Acromial Morphology Does Not Correlate with Age at Time of Rotator Cuff Tear: A Cross-Sectional Study.

Background: The purpose of this study was to determine if scapular anatomy differs between younger and older patients with atraumatic full-thickness supraspinatus tears. Methods: The critical shoulder angle, acromial index and lateral acromial angle were measured on standardized radiographs of two groups of patients who underwent arthroscopic repair of full-thickness degenerative supraspinatus tears. Group 1 included 61 patients under the age of 50 years while Group 2 included 45 patients over the age of 70 years. The mean critical shoulder angle, acromial index, and lateral acromial angle were then compared. Results: There was no significant difference between groups for the critical shoulder angle (p = .433), acromial index (p = .881) or lateral acromial angle (p = .263). Interobserver reliability for critical shoulder angle, acromial index, and lateral acromial angle was nearly perfect (interclass correlation coefficient 0.996, 0.996, 0.998, respectively). No significant correlation existed between age and critical shoulder angle (p = .309), acromial index (p = .484) or lateral acromial angle (p = .685). Discussion: While the critical shoulder angle and acromial index were found to be high and in the typical range for patients with rotator cuff tears in both groups, there were no significant differences in acromial morphology between Groups 1 and 2.

Arthroscopic Evaluation of the Long Head of the Biceps Tendon: Traditional Versus Allis Clamp Techniques.

Using a probe to retract the long head of the biceps tendon (LHBT) into the joint is common practice for visualizing the extra-articular portions during arthroscopy. However, extra-articular lesions may be missed in up to half of cases. Greater excursion of the LHBT may be achieved with an Allis clamp grasper. Our goal was to quantify portions of the extra-articular LHBT that could be visualized during shoulder arthroscopy with the Allis clamp and probe techniques. Shoulder arthroscopy was performed on 8 forequarter cadaveric specimens in the simulated beach chair position, and the most distal extent of the intra-articular LHBT was marked. The tendon was pulled into the joint with both techniques, and the additional exposed tendon portion was marked. An open approach was performed, and the locations of the 3 marks were assessed relative to total tendon length. Mean LHBT total length was 96.25 mm. Diagnostic arthroscopy allowed visualization of a mean of 21.75 mm of the intra-articular tendon (22.6% of the total length). The traditional probe technique provided visualization of 31.13 mm (32.8%). The Allis clamp technique provided visualization of 49.38 mm (52%) and increased visualization of the LHBT by 58.6% (P<.0001). A mean of 46.87 mm (48%) of the LHBT remained unvisualized. The Allis clamp technique maximizes arthroscopic visualization of extra-articular LHBT. The distal 48% eludes evaluation, but can be visualized when combined with an open technique without the need to divide the transverse humeral ligament. The Allis clamp technique facilitates additional identification of LHBT pathology that could otherwise remain hidden during shoulder arthroscopy. Because the LHBT is a major source of pain in the shoulder, this technique may improve outcomes of shoulder arthroscopy and reduce the need for revision because of remnant anterior shoulder pain. [Orthopedics. 2022;45(1):38-42.].

Editorial Commentary: Wrist Ulnar Impaction Syndrome: When I Use the Wafer Procedure and When I Do Not.

Ulnar impaction syndrome is fundamentally a clinical diagnosis, which can be confirmed by magnetic resonance imaging. All palmer stages are amenable to surgical treatment with either arthroscopic wafer procedure (AWP) or ulnar shortening osteotomy, and neither the absence of a triangular fibrocartilage complex perforation nor neutral or negative variance contraindicate either. Because of its minimally invasive value proposition and likely success, there are few clinical scenarios for which I do not perform AWP preferentially. Furthermore, AWP is always preferable in smokers and in wrists in which a divergent orientation of the sigmoid notch and ulnar articular surfaces portend arthritic complication after ulnar shortening.

In the Grip of Expertise.

Effective, collaborative leadership is one of the most credible and important predictors of team performance. This is relevant to us as surgeons because teamwork is now a common part of the vernacular in health care, we do not operate in a vacuum without a team, and we are well positioned to assume a leadership role on our teams. However, our standing as experts, our training and the way we were mentored, an insufficient concept of leadership as a process as opposed to a position, and inadequate nontechnical skills may disadvantage us as surgeons as collaborative members of teams. Liberation from the grip of expertise can be an inflection point for development.

Basal metacarpal osteotomy for osteoarthritis of the thumb.

Thumb metacarpal extension osteotomy provides effective treatment for the hypermobile trapeziometacarpal joint consistent with Eaton stage 1 disease. This procedure is a useful alternative to Eaton ligament reconstruction. Clinical outcomes are favorable and, should symptoms persist, the procedure does not jeopardize satisfactory execution of trapezial resection arthroplasty in the future.

Arthritis of the thumb basal joint: old and new treatments for a common condition.

Arthritis of the basal joint of the thumb is a condition that is becoming even more common as longevity increases and more people have active lifestyles in later life. The role of new hyaluronase-based injectable agents is evolving. A number of surgical procedures are effective in treating early-stage arthritis; the commonly performed trapezium resection and ligament reconstruction procedures have been modified by using limited-incision approaches, arthroscopic assistance, and bioengineered materials, as well as metacarpal repositioning osteotomy.

The emerging role for Uni-Elbow arthroplasty.

Uni-Elbow arthroplasty is an innovative alternative to radial head resection or implant removal in addressing painful radiocapitellar joint arthrosis. As an "arthroplasty" solution, it retains the biomechanical function of the elbow and obviates the potential complications of not having a radial head. Although its role is likely to evolve as clinical experience accumulates and reported outcomes increase in number, it may have a role in the setting of acute and chronic Essex-Lopresti lesions, and when previous radial head arthroplasty has resulted in capitellar arthrosis but when removal of the implant alone is felt to be contraindicated.

Thumb by metacarpal extension osteotomy: rationale and efficacy for Eaton Stage I disease.

This article describes the rationale and results of a "biomechanical" strategy to restore trapeziometacarpal (TM) stability when symptomatic Eaton Stage I disease exists. Though the author has performed TM arthroscopy, synovectomy, and capsular shrinkage for such cases in 10 patients, the author has been dissatisfied with the outcomes, particularly pain relief. The author currently relies exclusively on extension osteotomy as treatment for this subset of patients. Thumb metacarpal extension osteotomy remains an effective treatment alternative for the hypermobile TM joint consistent with Eaton Stage I disease. This procedure alters forces, shifts load away from the volar compartment, and further engages the dorsoradial ligament. Clinical outcomes are favorable, and no bridges are burned should arthritic changes develop in the future.

Suspensionplasty for basal joint arthritis: why and how.

Abductor pollicis longus suspensionplasty is a simple, effective treatment alternative forbasal joint arthritis. Use of a suspensionplasty technique acknowledges our current understanding of forces involved during pinch and grip, as well as the role of normal ligamentous anatomy. The primary rationale for performing suspensionplasty revolves around resisting the sagittal plane collapse that will occur when the thumb is loaded during pinch. In the absence of a volar-based suspension of the metacarpal, cantilever bending forces and axial force transmission will result in the dissipation of force along the thumb lever arm, and ultimately longitudinal collapse. Maximal grip and pinch strength require suspensionplasty, which can be performed using a variety of techniques. The author's current technique for suspensionplasty is described.

Finger metacarpophalangeal joint disease: the role of resection arthroplasty and arthrodesis.

When finger MP joint arthrosis exists, it is indeed infrequent that implant arthroplasty is not the most optimal treatment alternative. When post-traumatic bone loss or postinfectious dysfunction require surgical intervention, however, the hand surgeon may need to consider the options of resection arthroplasty and arthrodesis. So long as the MP joint is pain-free and relatively stable, most patterns of functional prehension can be maintained.

Distal interphalangeal joint arthrodesis with screw fixation: why and how.

Though DIP joint fusion can be successfully achieved with K-wires in both the osteoarthritic and rheumatoid patient, their use is often some-what of an inconvenience to the patient. They prohibit showering, may become infected, may back out and catch on clothing, and surely slowdown mobilization of the rest of the finger [1]. For optimal prehension, a modest amount of DIP joint flexion is required, however. Thus, one advantage of K-wires is that they allow fusion in 5 degrees to 10 degrees of flexion (Fig. 1). In the rheumatoid patient in particular, bone stock may be so com-promised that getting enough purchase with wires alone can be challenging. Since making the transition to the Herbert screw, hardware-related complications and patient dissatisfaction with obligatory postoperative functional limitations until union is achieved have been eliminated. Despite the fact that the fusion must occur without flexion-a necessity to ensure intramedullary placement of the screw-patients seem to adapt well (Fig. 2). One further potential disadvantage of screw fixation is the issue of size mismatch between phalanx and screw-especially in the small finger. Though cautious insertion is justified, precise technique allows use even in the small finger-a benefit when early motion is indicated; for example, when concomitant proximal interphalangeal (PIP) implant arthroplasty is performed in an adjacent digit. This device is contraindicated, obviously, if future PIP joint arthro-plasty is anticipated in the same finger (Fig. 3).

Reconstruction of the interosseous ligament unloads metallic radial head arthroplasty and the distal ulna in cadavers.

PURPOSE: Longitudinal radioulnar dissociation may result when a compressive load to the hand results in excessive proximal migration of the radius with interosseous ligament (IOL) disruption and radial head fracture. Interosseous ligament reconstruction has been proposed to restore more normal forearm mechanics. The objective of this study was to evaluate the effect of IOL reconstruction on compressive load transfer through the forearm after excision and metallic replacement of the radial head in cadavers. METHODS: In 8 cadaveric forearms, 138 N of compressive load was applied to the hand in neutral forearm rotation and neutral elbow varus-valgus alignment. We measured proximal radial migration and 3-dimensional force vectors acting on the distal radius, distal ulna, IOL, proximal radius, and proximal ulna. The experiment was repeated in order for 5 conditions: (1) with the IOL intact, (2) with the IOL reconstructed with a double-bundle flexor carpi radialis construct, (3) with the radial head excised, (4) after metallic radial head arthroplasty, and (5) after cutting the IOL reconstruction. Analysis of variance was used for statistical comparisons. RESULTS: With the IOL intact the resultant load in the distal radius was 94% +/- 3% of hand load, with 75% +/- 2% transmitted to the proximal radius. Double-bundle flexor carpi radialis reconstruction effectively restored this relationship. After radial head excision the resultant distal radius load decreased whereas great increases were seen in the resultant distal ulna load, the resultant load in the IOL reconstruction, the resultant load in the proximal ulna, and proximal radial migration. Force continued to transfer through the proximal radius transversely, with a 400% increase in transverse force, a consequence of abutment of the radial stump caused by proximal radioulnar convergence (there was no contact at the capitellum). After radial head arthroplasty loads transferred across the wrist remained closer to intact but the resultant load on the distal ulna and proximal radius remained increased. With cutting of the IOL reconstruction transverse forces in the forearm became negligible, the resultant distal ulna load increased by 50%, and the resultant radial head load increased by 25%. Proximal migration of the radius was small and was increased by 4.6 mm with radial head excision and by 1 mm after radial head replacement compared with the IOL-reconstructed, radial head-intact state. CONCLUSIONS: Interosseous ligament reconstruction may help improve treatment of longitudinal radioulnar dissociation but remains an experimental procedure.

Ulnar impaction syndrome.

Although Palmer's classification of TFCC lesions differentiates post-traumatic central perforations (IA tears) from degenerative tears secondary to ulnocarpal impaction (IIC) [3], the distinction is not always clear clinically. In the final analysis, the literature suggests that as many as 25% of wrists with TFCC tears have residual symptoms following arthroscopic debridement alone [23], and it is likely that static or dynamic ul-nar positive variance plays a role [2,5,17,25]. The authors' results suggest that combined arthroscopic TFCC debridement and wafer resection are feasible and efficacious as treatment for all stages of ulnar impaction syndrome. When class II A and B changes are observed, that is, when a TFCC perforation has not yet developed, the authors have observed favorable results in most patients following arthroscopic TFCC central disc excision and wafer resection as an alternative to ulnar shortening osteotomy [33] or open wafer excision [10].

Gene transfer to human joints: progress toward a gene therapy of arthritis.

This article describes the clinical application of gene therapy to a nonlethal disease, rheumatoid arthritis (RA). Intraarticular transfer of IL-1 receptor antagonist (IL-1Ra) cDNA reduces disease in animal models of RA. Whether this procedure is safe and feasible in humans was addressed in a phase I clinical study involving nine postmenopausal women with advanced RA who required unilateral sialastic implant arthroplasty of the 2nd-5th metacarpophalangeal (MCP) joints. Cultures of autologous synovial fibroblasts were established and divided into two. One was transduced with a retrovirus carrying IL-1Ra cDNA; the other provided untransduced, control cells. In a dose escalation, double-blinded fashion, two MCP joints were injected with transduced cells, and two MCP joints received control cells. One week later, injected joints were resected and examined for evidence of successful gene transfer and expression by using RT-PCR, ex vivo production of IL-1Ra, in situ hybridization, and immunohistochemistry. All subjects tolerated the protocol well, without adverse events. Unlike control joints, those receiving transduced cells gave positive RT-PCR signals. Synovia that were recovered from the MCP joints of intermediate and high dose subjects produced elevated amounts of IL-1Ra (P = 0.01). Clusters of cells expressing high levels of IL-1Ra were present on synovia of transduced joints. No adverse events occurred. Thus, it is possible to transfer a potentially therapeutic gene safely to human rheumatoid joints and to obtain intraarticular, transgene expression. This conclusion justifies additional efficacy studies and encourages further development of genetic approaches to the treatment of arthritis and related disorders.