Suture Button Repair for Lateral Ulnar Collateral Ligament in Terrible Triad Injuries: Surgical Technique.

Terrible triad injuries are typically treated surgically to restore elbow stability, as the radial head acts as a secondary stabilizer to valgus stress, while the coronoid provides stability against posterior elbow dislocations. The lateral ulnar collateral ligament (LUCL) is also commonly injured in terrible triad of the elbow injuries, and if not repaired, leads to posterolateral rotatory instability. Depending on the fracture pattern and size, the radial head fracture may be treated with open reduction internal fixation (ORIF), arthroplasty, or excision, whereas the coronoid fracture is most commonly treated with ORIF. If treated, these injuries are managed prior to LUCL fixation to avoid stressing the LUCL repair. We describe a technique for treatment of a LUCL injury with a suture button. When repairing the LUCL, a Kocher approach is used to visualize the LUCL footprint, which is then reattached to the insertion point on the lateral epicondyle using a suture button. The purpose of this study was to provide a step-by-step approach to using this surgical technique and an associated postoperative protocol.

Recurrence Rates of Dorsal Wrist Ganglion Cysts After Arthroscopic Versus Open Surgical Excision: A Retrospective Comparison.

BACKGROUND: This study directly compares the recurrence rates of dorsal wrist ganglion cysts in patients treated via open surgical excision versus arthroscopic surgical excision. We hypothesized that there would be no difference between recurrence rates with these 2 surgical options. METHODS: We retrospectively reviewed the charts of all patients with a dorsal ganglion cyst undergoing either open or arthroscopic surgical excision at a single academic center with 3 fellowship-trained attending hand surgeons from 2012 to 2017. Charts were identified using Current Procedural Terminology codes and were reviewed using postoperative office notes for preoperative and postoperative symptoms, episodes of recurrence, time at which recurrence occurred, subsequent operations, and outcome at final follow-up. RESULTS: The charts of 172 patients undergoing either arthroscopic or open dorsal ganglion excision were reviewed. Nine of 54 (16.7%) arthroscopic excisions resulted in cyst recurrence, while 8 of 118 (6.8%) open excisions resulted in cyst recurrence (P = .044). Two of 9 (22%) recurrences after arthroscopic ganglion excision versus 2 of 8 (25%) recurrences after open ganglion excision underwent repeat surgical intervention. Time to recurrence, as well as final follow-up, was not statistically different between groups. CONCLUSIONS: Dorsal wrist ganglion cysts are the most common benign soft tissue mass of the upper extremity, but it remains unknown whether arthroscopic or open surgical excision leads to lower recurrence rate. Scant literature exists directly comparing these 2 methods of surgical excision. This study suggests that open excision of dorsal wrist ganglia leads to a lower recurrence rate than does arthroscopic excision.

Economic Impact of Unused Surgical Instruments in an Orthopaedic Surgery Department at an Academic Medical Center: A Prospective Cross-sectional Study.

Orthopaedic surgical trays contain unused instruments, but we do not know which specific instruments go unused nor do we know the savings from eliminating them from a given tray. This was a single-site, observational study conducted at an academic medical center. The primary outcome was type of unused instruments and percentage of instruments used in two commonly used surgical trays. The secondary outcome was cost savings in United States dollars (USD) that could be attained by eliminating these instruments. In the first tray, five instruments (10.6%) were unused in any of 37 observed cases. In the second tray, nineteen instruments (19.6%) were unused in 37 observed cases. The total annual savings from replacement cost analysis and reprocessing cost analysis was $6,597.00 USD. Unused instruments are common in surgical trays. Eliminating unused instruments can result in immediate cost savings. (Journal of Surgical Orthopaedic Advances 30(3):131-135, 2021).

Subfascial-located contraceptive devices requiring surgical removal.

BACKGROUND: Subdermal etonogestrel implants are highly effective contraceptive methods. Despite standardization of insertion technique by the manufacturer, some implants are inadvertently placed too deeply within or below the plane of the biceps brachii fascia. Placement of these implants in a deep tissue plane results in more difficult removal, which is not always possible in the office setting. In rare cases, surgical removal by an upper extremity surgeon is warranted. CASE PRESENTATION: Here we present 6 cases of etonogestrel implants located in a subfascial plane requiring removal by an upper extremity surgeon. Implants were all localized with plain radiography and ultrasound prior to surgical removal. All cases had implants located in the subfascial plane and one was identified intramuscularly. The average age was 28 years (19-33) and BMI was 24.0 kg/m^2 (19.1-36.5), with the most common reason for removal being irregular bleeding. The majority of cases (5/6) were performed under monitored anesthesia care with local anesthetic and one case utilized regional anesthesia. All implants were surgically removed without complication. CONCLUSIONS: Insertion of etonogestrel contraceptive implants deep to the biceps brachii fascia is a rare, but dangerous complication. Removal of these implants is not always successful in the office setting and referral to an upper extremity surgeon is necessary to avoid damage to delicate neurovascular structures for safe removal.

Evaluation and Management of Hand, Wrist and Elbow Injuries in Ice Hockey.

Ice hockey continues to be a popular, fast-paced, contact sport enjoyed internationally. Due to the physicality of the game, players are at a higher risk of injury. In the 2010 Winter Olympics, men's ice hockey had the highest injury rate compared to any other sport. In this review, we present a comprehensive analysis of evaluation and management strategies of common hand, wrist, and elbow injuries in ice hockey players. Future reseach focusing on the incidence and outcomes of these hand, wrist and elbow injuries in ice hockey players is warranted.

Outerbridge-Kashiwagi Procedure for the Treatment of a Supracondylar Humerus Fracture Malunion (O-K Procedure).

The Outerbridge-Kashiwagi (O-K) procedure has conventionally been used for the treatment of osteoarthritis of the elbow and to treat posttraumatic sequelae including posttraumatic arthritis, stiffness, contracture, and ulnar neuritis. The procedure involves exposure of the posterior elbow joint as well creating a window posteriorly through the olecranon fossa to target anterior aspects of the elbow. Several case series have shown the O-K procedure to have good functional outcomes with minimal complications. Used mostly for the surgical treatment of adult osteoarthritis, the O-K procedure has not been previously described for the treatment of a pediatric supracondylar humerus fracture malunion. This article and accompanying video will present the pearls and discuss the technique of the O-K procedure used to treat the loss of elbow flexion as a sequelae of supracondylar humerus fracture malunion.

Combined Upper Extremity and Gluteal Compartment Syndrome Following Illicit Drug Abuse: A Retrospective Case Series.

INTRODUCTION: The purpose of this study was to describe four cases of patients who developed concomitant upper extremity and gluteal compartment syndrome in the context of substance abuse. In somnolent patients unable to provide a reliable physical exam, the healthcare provider must be aware of patients presenting with concomitant upper extremity and gluteal compartment syndrome. METHODS: Retrospective chart review identified cases of the combined upper extremity and gluteal compartment syndrome following illicit drug abuse at a single academic center during the years 2009-2019. RESULTS: During the 11-year period examined, a total of eight patients were diagnosed with compartment syndrome secondary to illicit drug use and prolonged immobilization. Four (50%) patients presented with combined upper extremity and gluteal compartment syndrome. All of these patients underwent prompt surgical release of the affected compartments. All eventually returned to normal activities of daily living. DISCUSSION: Compartment syndrome is primarily a clinical diagnosis, with physical exam being extremely important. In patients presenting with somnolence secondary to illicit drug use, physical exam may not be reliable. It is critical to have a high clinical suspicion in this patient population, understanding that these patients may present with concomitant upper extremity and gluteal compartment syndrome. LEVEL OF EVIDENCE: Level IV, case series.

Flexor Tenosynovitis of the Hand Caused by Mycobacterium tuberculosis.

Infectious tenosynovitis of the hand is a serious condition with a high risk of morbidity. Mycobacterium tuberculosis is a rare cause of tenosynovitis, especially in regions where tuberculosis is no longer endemic, and presents significant diagnostic challenges. We present the case of a 42-year-old woman with no known history of or exposure to tuberculosis and a medical history of systemic lupus erythematosus on chronic immunosuppressive therapy who presented with swelling and erythema in the fifth finger of the left hand of 1-month duration. She underwent tenosynovectomy, and intraoperative cultures grew M tuberculosis. The patient completed an appropriate antibiotic regimen, and systemic workup revealed ring-enhancing lesions on brain MRI consistent with tuberculoma. We review the literature and current trends in the management of mycobacterial tenosynovitis, as well as the important teaching points of the case.

Outpatient total shoulder arthroplasty: A cost-identification analysis.

BACKGROUND: As demand for total shoulder arthroplasty (TSA) rises, containing costs will become increasingly important. We hypothesize that performing ambulatory TSA procedures results in significant cost savings. METHODS: A model was created to evaluate cost savings. Hospital stay length and cost, pain control method and cost, and number of annual outpatient TSA procedures were estimated based on literature. RESULTS: Estimated cost savings per patient were $747 to $15,507 (base case $5594), total annual savings of $4.1M to $349M (base case $82M), and ten-year savings of $51M to $5.4B (base case $1.1B). CONCLUSION: Ambulatory TSA procedures result in significant cost savings.

Denervation of the Wrist Joint for the Management of Chronic Pain.

Wrist denervation for the management of chronic wrist pain is a safe and effective procedure that can delay or eliminate the need for more invasive and kinematically compromising salvage procedures. Wrist denervation has become increasingly popular since it was first described in 1959, and the technique has evolved from more extensive denervations to limited single-incision approaches. Many physicians have performed this procedure as a palliative approach to managing chronic wrist pain and as an adjunct to other procedures.

Adequacy of thyroid hormone replacement in a general population.

BACKGROUND: Suboptimal thyroid hormone replacement may carry harmful health consequences. AIMS: Our objectives were to determine the prevalence and factors associated with inadequate replacement in patients receiving treatment with levothyroxine. DESIGN: Retrospective general practice audit. METHODS: We identified levothyroxine users through electronic searches of primary care records in all 11 practices within a county borough. The adequacy of thyroid hormone replacement was determined from the current serum, serum thyrotropin (TSH) as: (i) adequate replacement (normal TSH; 0.4-4.0 mU/l); (ii) over replacement (low TSH; <0.4 mU/l); and (iii) under replacement (high TSH; >4.0 mU/l). RESULTS: Out of a registered patient population of 58 567, we identified 1037 patients who were first included in the hypothyroidism disease register between January 2004 and December 2009 (mean age 62.4 ± 15.9 years; female 85.9%, male 14.1%). Inadequate replacement was seen in 385 patients (37.2%), comprising 205 patients (19.8%) with over replacement and 180 patients (17.4%) with under replacement. Step-wise logistic regression showed that the factors associated with under replacement were male gender [odds ratio (OR) 2.85, confidence interval (CI) 1.86-4.38; P < 0.001 and younger age (OR 0.88, CI 0.80-0.98; P = 0.02 per 10 year increase in age) while longer duration of treatment was associated with over-treatment (OR 1.06, CI 1.01-1.10). A thyroid function test was performed in the preceding 12 months in 914 patients (88.1%) and appropriate dose adjustments had been made in 81.0% (312/385) of patients with abnormal results. CONCLUSION: Despite frequent monitoring and dose adjustment activities, inadequate thyroid hormone replacement remained a problem in over a third of levothyroxine users in this population.

Thyroid dysfunction in patients with diabetes: clinical implications and screening strategies.

BACKGROUND: Patients with diabetes mellitus are at an increased risk of thyroid disease. The frequency of thyroid dysfunction in diabetic patients is higher than that of the general population and up to a third of patients with type-1 diabetes (T1DM) ultimately develop thyroid dysfunction. Unrecognised thyroid dysfunction may impair metabolic control and add to cardiovascular disease risk in diabetic patients. AIMS: Our aims were to review the current literature on the association between thyroid dysfunction and diabetes mellitus, to highlight relevant clinical implications, and to examine present thyroid disease screening strategies in routine diabetes care. RESULTS: The pleiotropic effects of thyroid hormones on various metabolic processes are now better understood. Uncontrolled hyperthyroidism in diabetic patients may trigger hyperglycaemic emergencies while recurrent hypoglycaemic episodes have been reported in diabetic patients with hypothyroidism. Furthermore, thyroid dysfunction may amplify cardiovascular disease risk in diabetic patients through inter-relationships with dyslipidaemia, insulin resistance and vascular endothelial dysfunction. However, the significance of subclinical degrees of thyroid dysfunction remains to be clarified. While these developments have implications for diabetic patients a consensus is yet to be reached on optimal thyroid screening strategies in diabetes management. CONCLUSIONS: The increased frequency of thyroid dysfunction in diabetic patients and its likely deleterious effects on cardiovascular and metabolic function calls for a systematic approach to thyroid disease screening in diabetes. Routine annual thyroid testing should be targeted at diabetic patients at risk of thyroid dysfunction such as patients with T1DM, positive thyroid autoantibodies or high-normal TSH concentrations.

Can a random serum cortisol reduce the need for short synacthen tests in acute medical admissions?

BACKGROUND: Short synacthen tests (SSTs) are frequently performed in medical inpatients with suspected adrenocortical insufficiency. The utility of a random or baseline serum cortisol in this setting is unclear. We determined random cortisol thresholds that safely preclude SSTs in acute medical admissions. METHODS: We analysed SSTs in acute non-critically ill general medical patients (n = 166, median age 66, range 15-94 y; men 48%, women 52%). The SST was defined according to the 30-min cortisol as 'pass' (>550 nmol/L) or 'fail' (< or =550 nmol/L). Receiver operating characteristics (ROC) curves were generated to determine the predictive value of the basal cortisol for a failed SST. RESULTS: Of 166 SSTs, a pass was seen in 127 (76.5%) tests, while 39 (23.5%) tests failed the SST. ROC curves showed that no single cut-off point of the baseline cortisol was adequately both sensitive and specific for failing the SST despite a good overall predictive value (area under curve 0.94; 95% confidence interval 0.89-0.98). A basal cortisol <420 nmol/L had 100% sensitivity and 54% specificity for failing the SST, while a basal cortisol <142 nmol/L had 100% specificity and 35% sensitivity. Restricting the SST to patients with a basal cortisol <420 nmol/L would have prevented 44% of SSTs while correctly identifying all patients who failed the SST. CONCLUSION: A baseline serum cortisol may prevent unnecessary SSTs in medical inpatients with suspected adrenocortical insufficiency. However, SSTs are still indicated in patients with random cortisol <420 nmol/L, or where the suspicion of adrenal insufficiency is compelling.

The blood supply of the common peroneal nerve in the popliteal fossa.

We investigated the blood supply of the common peroneal nerve. Dissection of 19 lower limbs, including six with intra-vascular injection of latex, allowed gross and microscopic measurements to be made of the blood supply of the common peroneal nerve in the popliteal fossa. This showed that a long segment of the nerve in the vicinity of the fibular neck contained only a few intraneural vessels of fine calibre. By contrast, the tibial nerve received an abundant supply from a constant series of vessels arising directly from the popliteal and posterior tibial arteries. The susceptibility of the common peroneal nerve to injury from a variety of causes and its lack of response to operative treatment may be explained by the tenuous nature of its intrinsic blood supply.

Short-term outcomes after surgical treatment of traumatic posterior sternoclavicular fracture-dislocations in children and adolescents.

Posterior sternoclavicular joint (SCJ) dislocations and posteriorly displaced physeal fractures of the medial clavicle require prompt diagnosis and treatment to prevent persistent symptoms, recurrent instability, and potential complications. The purpose of this investigation was to review one institution's experience with these injuries. A retrospective review of 13 patients with posterior SCJ fracture-dislocations was performed. Average patient age was 14.6 years, and 85% of injuries were sustained during sporting activities. Patients with posterior dislocations underwent ligament repair and those with posteriorly displaced medial clavicular physeal fractures had open reduction and suture stabilization. At an average of 22.2 months follow-up, all patients had excellent functional outcomes. There were no respiratory or neurovascular complications. Skeletally immature patients may expect excellent functional outcomes following surgery for posterior SCJ dislocations or posteriorly displaced physeal fractures of the medial clavicle.

Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome.

Compartment syndrome can be difficult to diagnose in a child, with delays in diagnosis leading to disastrous outcomes. Thirty-six cases of compartment syndrome in 33 pediatric patients were treated at the authors' institution from January 1, 1992, to December 31, 1997. There were 27 boys and 6 girls, with nearly equal upper and lower extremity involvement. Approximately 75% of these patients developed compartment syndrome in the setting of fracture. Pain, pallor, paresthesia, paralysis, and pulselessness were relatively unreliable signs and symptoms of compartment syndrome in these children. An increasing analgesia requirement in combination with other clinical signs, however, was a more sensitive indicator of compartment syndrome: all 10 patients with access to patient-controlled or nurse-administered analgesia during their initial evaluation demonstrated an increasing requirement for pain medication. With early diagnosis and expeditious treatment, >90% of the patients studied achieved full restoration of function.

Upper extremity pediatric compartment syndromes.

Fractures are associated with the majority of compartment syndromes in children. Respect for associated soft-tissue injuries and recognition of specific fractures that can put a limb at risk for compartment syndrome are essential for prevention or successful treatment with early decompressive fasciotomies. In those limbs at risk for compartment syndrome, percutaneous pinning or intramedullary fixation provides fracture stabilization and prevents problems noted with standard cast treatment. Any condition that causes increased tissue pressure within a limited space can lead to compartment syndrome, however. It therefore is important to identify the injured, ill, or hospitalized child with unexplained changes in pain status or soft tissues. In particular, the agitated child with increasing analgesia requirements requires a thorough evaluation. The child's behavior should not be attributed to young age, fear, or fracture pain. This is a trap that must be avoided to prevent the disastrous outcomes of a missed compartment syndrome.

Radiographic assessment of the trapezial space before and after ligament reconstruction and tendon interposition arthroplasty.

A radiographic method was developed, the trapezial space ratio, for assessing the space occupied by the trapezium (a space defined by the distal scaphoid and thumb metacarpal base divided by the thumb proximal phalanx). This method was applied to 100 normal thumb radiographs and to the radiographs of 15 patients with symptomatic degenerative arthrosis of the thumb basal joint before and after operative treatment with ligamentous reconstruction and tendon interposition arthroplasty. The trapezial space ratio averaged 0.476 +/- 0.033 for radiographs of normal thumbs, 0.372 +/- 0.084 for the pre-operative radiographs of thumbs with symptomatic basal joint arthrosis, and 0.270 +/- 0.078 for the radiographs of thumbs following basal joint arthroplasty. A significant reduction in the trapezial space ratio was noted when values from arthritic thumbs were compared to those of normal thumbs (22%; P < 0.0001). A further reduction in the trapezial space ratio was noted when post-operative values were compared to pre-operative ones (27%; P < 0.0002). Comparing post-operative trapezial space ratio values to values obtained in normal thumbs, a reduction of 43% was found in those thumbs treated operatively. These finding indicate that the trapezial space is reduced significantly in thumbs with severe degenerative arthrosis compared to normal thumbs and that ligament construction tendon interposition arthroplasty is not entirely successful in either restoring or maintaining the length of the thumb ray.

Basal joint arthritis: trapeziectomy with ligament reconstruction and tendon interposition arthroplasty.

This article provides a qualitative and quantitative outcomes assessment of a consecutive series of 27 patients (30 thumbs) with basal joint arthritis of the thumb undergoing ligament reconstruction and tendon interposition arthroplasty. Outcome analysis revealed that 24 (89%) patients were satisfied with the relief of pain provided by the arthroplasty and 23 (87%) would undergo surgery again. Eighteen (67%) thumbs were noted to have improvement in the ability to perform activities of daily living. Significant improvements were noted in web space measurements and in grip and pinch strength determination. X-ray film assessment using the trapezial space ratio averaged 0.33 +/- 0.08 in preoperative x-ray films of thumbs with stage III and IV degenerative arthritis and 0.23 +/- 0.07 in thumbs following basal joint arthroplasty. This represents a total decrease of 51% in the trapezial space ratio following arthroplasty compared to the normal values obtained in previous studies and 33% compared to the preoperative values obtained in this study. Outcomes assessment at a mean of 42 months after surgery showed that there was no significant correlation between maintenance of trapezial height and both objective and subjective clinical outcomes. Although ligament reconstruction consistently failed to restore trapezial height, primary and secondary clinical outcomes following basal joint arthritis were almost uniformly satisfactory.

Molecular cloning and characterization of WP34, a phosphorylated human lymphocyte differentiation and activation antigen.

An absorbed antiserum was made by incubating a cytotoxic T lymphocyte immune antiserum with the T cell leukemia HPB-ALL, thus removing reactivity to known lymphocyte function-associated antigens. This antiserum was used to screen a cDNA expression library and isolate a novel human lymphocyte cDNA clone designated WP34, WP34 transcript is expressed in functional T cells and a variety of hematopoietic cell lines and tissues, including fetal liver and thymus, but not in HPB-ALL or any non-hematopoietic cell lines or tissues tested. The WP34 protein is an acidic, phosphorylated molecule with a pI of 4.5 and molecular mass of 50 kDa. WP34 protein expression is absent in resting peripheral blood lymphocytes but can be induced with antigen stimulation, while the transcript is constitutively expressed. Sequence analysis indicates that WP34 is the human homologue of the recently described murine molecule LSP1.