All-Inside Versus Outside-in Repair of Triangular Fibrocartilage Complex Peripheral Tears.

PURPOSE: Triangular fibrocartilage complex (TFCC) peripheral tears with persistent wrist pain can be treated with arthroscopic surgical repair owing to vascularization of the peripheral region. The safety and efficacy of all-inside repair has been shown in prior case series. The purpose of this study was to compare two methods of arthroscopic peripheral TFCC repair: all-inside vertical mattress and outside-in horizontal mattress. METHODS: A 5-year retrospective review was performed on patients treated from 2016 to 2021 with wrist arthroscopy and TFCC repair for Palmer 1B tears. Patients with ulnar extrinsic ligament repair, distal radioulnar joint instability, concomitant ulnar shortening osteotomy, and extensor carpi ulnaris instability were excluded. Patient therapy and office visit records were reviewed. Outcomes including Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH); range of motion; grip strength; immobilization time; complications; and need for revision procedures were compared. RESULTS: Fifty-two patients were included in the study, 32 in the outside-in group and 20 in the all-inside group. The average follow-up length was 24.8 weeks, with similar range of motion and strength in both groups. The average postoperative QuickDASH score was 13 in the outside-in group and 9 in the all-inside group at 43.5 months, compared with the preoperative QuickDASH scores of 47 and 50, respectively. Mean immobilization time was longer for outside-in than for all-inside (5.25 vs 2.0 weeks, respectively). CONCLUSIONS: All-inside arthroscopic peripheral TFCC repair showed range of motion, grip strength, complications, revisions, and postoperative improvement in QuickDASH scores similar to those with the outside-in technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV; retrospective comparative study.

Smart fracture plate for quantifying fracture healing: Preliminary efficacy in a biomechanical model.

The diagnosis of fracture nonunion following plate osteosynthesis is subjective and frequently ambiguous. Initially following osteosynthesis, loads applied to the bone are primarily transmitted through the plate. However, as callus stiffness increases, the callus is able to bear load proportional to its stiffness while forces through the plate decrease. The purpose of this study was to use a "smart" fracture plate to distinguish between phases of fracture healing by measuring forces transmitted through the plate. A wireless force sensor and small adapter were placed on the outside of a distal femoral locking plate. The adapter converts the slight bending of the plate under axial load into a transverse force which is measurable by the sensor. An osteotomy was created and then plated in the distal femur of biomechanical Sawbones. Specimens were loaded to simulate single-leg stance first with the osteotomy defect empty (acute healing), then sequentially filled with silicone (early callus) and then polymethyl methacrylate (hard callus). There was a strong correlation between applied axial load and force measured by the "smart" plate. Data demonstrate statistically significant differences between each phase of healing with as little as 150 N of axial load applied to the femur. Forces measured in the plate were significantly different between acute (100%), early callus (66.4%), and hard callus (29.5%). This study demonstrates the potential of a "smart" fracture plate to distinguish between phases of healing. These objective data may enable early diagnosis of nonunion and enhance outcomes for patients.

Diagnostic Performance and Advanced Imaging Reduction With Digital Tomosynthesis in Scaphoid Fracture Management.

BACKGROUND: Management of scaphoid fractures often requires advanced imaging to achieve accurate diagnoses and appropriate treatment. Digital tomosynthesis (DTS) is a cross-sectional imaging modality that may be used to substitute magnetic resonance imaging or computed tomographic scans. The purpose of this study is to: (1) determine the diagnostic accuracy of DTS in occult scaphoid fractures; and (2) report on the reduction of other advanced imaging when using DTS. METHODS: From May 2014 to October 2017, the charts of all patients who underwent scaphoid tomogram were retrospectively reviewed. The diagnostic accuracy of DTS for occult fracture was compared with 2-week follow-up plain films. To measure the reduction in utilization of advanced imaging, it was determined whether DTS eliminated the need for advanced imaging by providing adequate information regarding the clinical question. RESULTS: A total of 78 patients underwent scaphoid tomography in this time frame: 39 for occult fracture, 33 for fracture union, 5 for fracture morphology, and 1 for hardware positioning. For the detection of occult fracture, DTS had a sensitivity of 100%, specificity of 83%, positive predictive value of 64%, and negative predictive value of 100%. Advanced imaging was not used in 35 of the remaining 39 patients based on the results obtained by DTS. In patients who did receive advanced imaging, 83% of tomograms provided conclusive diagnostic information. CONCLUSIONS: Digital tomosynthesis increases the diagnostic sensitivity of occult scaphoid fractures, reducing unnecessary immobilization and advanced imaging. Digital tomosynthesis provides clinical detail beyond plain film, which reduces the need to obtain advanced imaging when assessing union, fracture pattern, and hardware placement.

An Analysis of Complications and Bone Defect Length With the Use of Induced Membrane Technique in the Upper Limb: A Systematic Review.

Background: The induced membrane technique was originally described as a technique for the reconstruction of long bone defects. The authors performed a systematic review to determine whether the use of the induced membrane technique is effective in large bony defects in the upper extremity. Methods: A qualitative systematic review was conducted using PubMed, EBSCO, and Google Scholar databases to record all studies reporting on complications of the induced membrane technique in the upper extremity. Studies written after 1990 in English language journals met the inclusion criteria. Exclusion criteria were non-English language publications, animal studies, failure to identify the location of the bone defect, failure to identify whether complications were associated with the procedure, and failure to define the length of bone defect. Results: A total of 1422 studies were identified in the original search. Twelve studies satisfied the criteria for inclusion. A total of 70 patients with 83 upper extremity cases were reported: 1 proximal interphalangeal joint, 22 phalanges, 8 metacarpals, 37 forearms, 14 humeri, and 1 clavicle. The mean bone defect size was 4.0 cm (SD, 1.5). The most common complication was infection. We found that complication rates were independent of the location of the bone defect. Complication rates in the upper extremity ranged from 0% to 100%, with a total weighted mean of 10%. Conclusion: The induced membrane technique is an emerging possible treatment of large bone defects in the upper extremity. More research is needed to determine the outcomes of the induced membrane technique in the upper extremity.

Comprehensive Review of Rock Climbing Injuries.

Increasing numbers of people are participating in the sport of rock climbing, and its growth is expected to continue with the sport's Olympic debut in 2020. Extreme loading of the upper extremities, contorted positioning of the lower extremities, rockfall, and falling from height create an elevated and diverse injury potential that is affected by experience level and quantity of participation. Injuries vary from acute traumatic injuries to chronic overuse injuries. Unique sport-specific injuries to the flexor tendon pulley system exist, but the remaining musculoskeletal system is not exempt from injury. Orthopaedic evaluation and surgery is frequently required. Understanding the sport of rock climbing and its injury patterns, treatments, and prevention is necessary to diagnose, manage, and counsel the rock-climbing athlete.

Propionibacterium acnes Osteomyelitis after Intraosseous Cannulation in a Child.

Propionibacterium acnes osteomyelitis secondary to intraosseous (IO) cannulation is not well documented in literature. We report here an extremely rare incident of P. acnes tibial osteomyelitis at the IO access site, in a 4-year-old child, who presented 3 months after an episode of fluid resuscitation for streptococcal toxic shock syndrome necessitating irrigation and debridement and prolonged antibiotic therapy. We advocate for heightened awareness of osteomyelitis in patients with continued pain after IO cannulation. Low-grade persistent symptoms may be caused by less virulent organisms and may dictate need for early magnetic resonance imaging studies for diagnosis and treatment planning.

Bilateral native knee septic arthritis due to Propionibacterium acnes; a case report and review of literature.

Propionibacterium acnes should be considered in any case of indolent septic arthritis. Cultures should be followed for 2 weeks as our cultures were negative for 7 days before growing P. acnes. Irrigation and debridement followed by antibiotics is the standard of care.

Prostheses for reverse total shoulder arthroplasty.

INTRODUCTION: Historically, patients with rotator cuff arthropathy had limited reconstructive options. The early generations of reverse total shoulder arthroplasty (rTSA) designs had increased failure rates due to loosening of glenoid baseplates secondary to excessive torques. In 1985, Paul Grammont introduced a prosthetic design changing the center of rotation that addressed this major complication. The Grammont principles remain the foundation of modern reverse total shoulder prostheses, although the original design has undergone several adaptations. We reviewed here the various aspects of prosthetic designs including baseplates, glenospheres, humeral components, and polyethylene bearing interfaces. AREAS COVERED: We discuss the evolution, biomechanics, prosthetic options, and future direction for rTSA. A literature search using the PubMed database including review articles, biomechanical studies, and clinical trials pertaining to rTSA prothesis and outcomes. EXPERT COMMENTARY: Despite an expansion in the understanding of the biomechanics of the rotator cuff deficient shoulder and its effect on the reverse total shoulder prostheses, Grammont principles remain the foundation of contemporary rTSA designs. Further clinical studies are needed to assess how modern prosthetic modifications effect clinical and radiographic outcomes. Additionally, implants are being used in younger individuals with expanded indications, therefore, close clinical monitoring is needed to better evaluate their prosthetic longevity.

Tissue expanders with a focus on extremity reconstruction.

INTRODUCTION: Acute traumatic or surgical wounds that cannot be primarily closed often cause substantial morbidity and mortality. This often leads to increased costs from higher material expenses, more involved nursing care, and longer hospital stays. Advancements in soft tissue expansion has made it a popular alternative to facilitate early closure without the need for more complicated plastic surgical procedures. AREAS COVERED: In this review, we briefly elaborate on the history and biomechanics of tissue expansion and provide comprehensive descriptions of traditional internal tissue expanders and a variety of contemporary external tissue expanders. We describe their uses, advantages, disadvantages, and clinical outcomes. The majority of articles reviewed include case series with level IV evidence. Outcome data was collected for studies after 1990 using PubMed database. EXPERT COMMENTARY: An overall reduction in cost, time-to-wound closure, hospital length-of-stay, and infection rate may be expected with most tissue expanders. However, further studies comparing outcomes and cost-effectiveness of various expanders may be beneficial. Surgeons should be aware of the wide array of tissue expanders that are commercially available to individualize treatment based on thorough understanding of their advantages and disadvantages to optimize outcomes. We predict the use of external expanders to increase in the future and the need for more invasive procedures such as flaps to decrease.