Concomitant latissimus dorsi tendon transfer during reverse total shoulder arthroplasty does not improve active external rotation or clinical outcomes in patients with external rotation deficit.

BACKGROUND: To assess the role of latissimus dorsi tendon transfer (LDT) concomitant with reverse total shoulder arthroplasty in patients with external rotation (ER) deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis. METHODS: Patients with a positive external lag sign and <10° of active external rotation (aER) treated with reverse shoulder arthroplasty at a single institution with a minimum 12-month follow-up were retrospectively identified from a prospective database. Basic demographic information along with preoperative and postoperative range of motion (ROM) measures, American Shoulder and Elbow Surgeons score (ASES), Visual Analog Scale (VAS) pain, and Subjective Shoulder Value scores were obtained. Statistical analysis was performed to compare ROM and functional outcomes between patients who underwent concomitant LDT and those with no transfer (NT). RESULTS: The LDT (n = 31) and NT (n = 33) groups had similar age, sex distributions, and follow-up length average (24 vs. 30 months). No differences were found between groups at baseline, final follow-up, or magnitude of change for ASES, VAS pain, and Subjective Shoulder Value scores. Baseline ROM measures were similar, except for the LDT group having slightly less aER (-8° vs. 0°; P = .004). In addition, all postoperative ROM measures including aER were similar, except for a slight improvement in active internal rotation in the NT group. The majority of patients were satisfied with their outcome (LDT 84% (n = 26); NT 87% (n = 27); P = .72). CONCLUSION: Patients with ER deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis undergoing reverse total shoulder arthroplasty do not have significantly improved ER or patient-reported outcome measures with LDT.

Local and Systemic In Vivo Responses to Osseointegrative Titanium Nanotube Surfaces.

Orthopedic implants requiring osseointegration are often surface modified; however, implants may shed these coatings and generate wear debris leading to complications. Titanium nanotubes (TiNT), a new surface treatment, may promote osseointegration. In this study, in vitro (rat marrow-derived bone marrow cell attachment and morphology) and in vivo (rat model of intramedullary fixation) experiments characterized local and systemic responses of two TiNT surface morphologies, aligned and trabecular, via animal and remote organ weight, metal ion, hematologic, and nondecalcified histologic analyses. In vitro experiments showed total adherent cells on trabecular and aligned TiNT surfaces were greater than control at 30 min and 4 h, and cells were smaller in diameter and more eccentric. Control animals gained more weight, on average; however, no animals met the institutional trigger for weight loss. No hematologic parameters (complete blood count with differential) were significantly different for TiNT groups vs. control. Inductively coupled plasma mass spectrometry (ICP-MS) showed greater aluminum levels in the lungs of the trabecular TiNT group than in those of the controls. Histologic analysis demonstrated no inflammatory infiltrate, cytotoxic, or necrotic conditions in proximity of K-wires. There were significantly fewer eosinophils/basophils and neutrophils in the distal region of trabecular TiNT-implanted femora; and, in the midshaft of aligned TiNT-implanted femora, there were significantly fewer foreign body giant/multinucleated cells and neutrophils, indicating a decreased immune response in aligned TiNT-implanted femora compared to controls.

Operating Room Intervention Rates After Orthopaedic Resident-reduced Pediatric Both-Bone Forearm Fractures Relative to the Academic Calendar.

BACKGROUND: The purpose of this study was to evaluate the operating room (OR) intervention rates and quality of fracture reductions for pediatric diaphyseal both-bone forearm fractures performed by orthopaedic residents relative to the academic year. OR intervention was defined as any procedure performed in the OR, including closed reduction and casting, and was used to identify fractures that required secondary intervention after initial closed reduction performed by an orthopaedic resident in the emergency department. METHODS: A retrospective analysis identified pediatric patients presenting at our institution with both-bone forearm fractures from July 2010 to June 2016. Emergency-room sedation time, highest experience of orthopaedic resident documented to be present at the time of sedation (in postgraduate months), and frequencies of OR intervention were obtained by chart review. Fracture characteristics were determined by radiographic review. Immediate postreduction radiographs were used to measure cast indices, and adequacy of reduction was determined by postreduction angulation and translation. RESULTS: During the time period studied, 470 both-bone forearm reductions under sedation were performed by an orthopaedic resident at our institution. Of these, 41 fractures (41 patients) required 42 OR interventions (40 involved surgical fixation and 2 were repeat closed reductions). The academic year was divided into quartiles. The April to June quartile had the highest overall percentage of OR intervention (10.6%), followed by July to September (8.6%); however, there was no significant difference between quartiles in the percentages of reductions that needed OR intervention (P=0.553). There was also no correlation between the experience level of the resident performing the reduction (based on postgraduate months) and the frequency of OR intervention (P=0.244). The anteroposterior (AP) and lateral reduction grades did not vary based on quarters (P=0.584; 0.353). The ability to obtain adequate reduction and the rate of unacceptable cast index were also not significantly different between quarters (P=0.347 and 0.465). CONCLUSIONS: We found no significant difference in rates of OR intervention or the quality of reduction for pediatric both-bone diaphyseal forearm fractures treated by orthopaedic residents relative to the academic year. LEVEL OF EVIDENCE: Level III-comparative cohort study.

Titania nanotube morphologies for osseointegration via models of in vitro osseointegrative potential and in vivo intramedullary fixation.

As total joint replacements increase annually, new strategies to attain solid bone-implant fixation are needed to increase implant survivorship. This study evaluated two morphologies of titania nanotubes (TiNT) in in vitro experiments and an in vivo rodent model of intramedullary fixation, to simulate joint arthroplasty conditions. TiNT surfaces were prepared via an electrochemical etching process, resulting in two different TiNT morphologies, an aligned structure with nanotubes in parallel and a trabecular bone-like structure. in vitro data showed bone marrow cell differentiation into osteoblasts as well as osteoblastic phenotypic behavior through 21 days. In vivo, both TiNT morphologies generated greater bone formation and bone-implant contact than control at 12 weeks, as indicated by µCT analyses and histology, respectively. TiNT groups also exhibited greater strength of fixation compared to controls, when subjected to wire pull-out testing. TiNT may be a promising surface modification for promoting osseointegration.

Posttraumatic Bifid Ulna in a Pediatric Galeazzi-Equivalent Forearm Fracture.

We report an unusual clinical presentation and surgical treatment of a Galeazzi-equivalent fracture in which initial closed treatment failed. This case was unique and challenging secondary to the formation of a neoulna volar to an unreduced periosteal sleeve injury, resulting in a bifid radiographic appearance.

Plate Osteosynthesis of Patella Fractures-A Video Case Report.

Operative management of patella fractures continues to be associated with poor outcomes and high reoperation rates. Traditionally, tension band fixation has been used for more simple fracture patterns; however, fixation remains a challenge particularly for comminuted fractures. More recently, various types of plate fixation have been used and reported in the literature. Earlier mobilization after plate osteosynthesis of patella fractures is possible because of a more robust construct, with the potential for decreased knee stiffness and improved functional outcomes. We present a video case of a 79-year-old man who sustained a displaced patella fracture treated with an anterior mesh plate.

Novel Anterior Plating Technique for Patella Fracture Fixation.

Patella fracture fixation remains a significant challenge for orthopedic surgeons. Although tension band fixation allows for reliable osseous union, especially in simple fracture patterns, it still presents several problems. Plate fixation of patella fractures is a method that allows for more rigid stabilization and earlier mobilization. At the authors' level 1 trauma center, one fellowship-trained trauma surgeon has transitioned to using a novel anterior, low-profile mesh plate construct for all types of patella fractures. This construct allows for stable fixation, osseous union, and neutralization of the inferior pole for even the most comminuted of patella fractures. [Orthopedics. 2017; 40(4):e739-e743.].

Intravenous tranexamic acid reduces total blood loss in reverse total shoulder arthroplasty: a prospective, double-blinded, randomized, controlled trial.

BACKGROUND: Patients undergoing reverse total shoulder arthroplasty (RTSA) are at risk of significant perioperative blood loss. To date, few studies have examined the effectiveness of tranexamic acid (TXA) to reduce blood loss in the setting of RTSA. METHODS: In a prospective, double-blinded, single-surgeon trial, we analyzed 102 patients undergoing primary RTSA who were randomized to receive intravenous TXA (n = 53) or placebo (n = 49). Calculated total blood loss, drain output, and hemoglobin (Hb) drop were measured. Postoperative transfusions were recorded. Complications were assessed out to 6 weeks postoperatively. RESULTS: Total blood loss was less for the TXA group (1122.4 ± 411.6 mL) than the placebo group (1472.6 ± 475.4 mL, P < .001). Total drain output was less for the TXA group (221.4 ± 126.2 mL) than the placebo group (371.9 ± 166.3 mL , P < .001). Total Hb loss was less in the TXA group (154.57 ± 60.29 g) compared with the placebo group (200.1 ± 65.5 g, P = .001). Transfusion rates differed significantly at postoperative day 1; however, overall transfusion rates did not vary significantly. Seven patients (14.3%) and 12 units were transfused in the placebo group compared with 3 patients (5.7%) and 3 units in the TXA group. DISCUSSION: In this cohort of patients undergoing primary RTSA, TXA was effective in reducing total drain output, total Hb loss, and total blood loss compared with a placebo control.

Video Recording With a GoPro in Hand and Upper Extremity Surgery.

Video recordings of surgical procedures are an excellent tool for presentations, analyzing self-performance, illustrating publications, and educating surgeons and patients. Recording the surgeon's perspective with high-resolution video in the operating room or clinic has become readily available and advances in software improve the ease of editing these videos. A GoPro HERO 4 Silver or Black was mounted on a head strap and worn over the surgical scrub cap, above the loupes of the operating surgeon. Five live surgical cases were recorded with the camera. The videos were uploaded to a computer and subsequently edited with iMovie or the GoPro software. The optimal settings for both the Silver and Black editions, when operating room lights are used, were determined to be a narrow view, 1080p, 60 frames per second (fps), spot meter on, protune on with auto white balance, exposure compensation at -0.5, and without a polarizing lens. When the operating room lights were not used, it was determined that the standard settings for a GoPro camera were ideal for positioning and editing (4K, 15 frames per second, spot meter and protune off). The GoPro HERO 4 provides high-quality, the surgeon perspective, and a cost-effective video recording of upper extremity surgical procedures. Challenges include finding the optimal settings for each surgical procedure and the length of recording due to battery life limitations.

Stenosing synovitis of the extensor pollicis longus tendon.

There are only a few published cases of extensor pollicis longus (EPL) tenosynovitis in patients without rheumatoid arthritis. Even less common are cases of stenosing tenosynovitis of the EPL associated with triggering. This article presents 2 cases of EPL stenosing tenosynovitis with triggering of the thumb in the area of Lister's tubercle and addresses how to treat them.