Excision of Hook of Hamate Fractures in Elite Baseball Players: Surgical Technique and Return to Play.

Background: Hook of hamate fractures are relatively common in baseball players, but the proper diagnosis and surgical technique can be challenging. Outcomes after surgical excision, as well as optimal surgical technique, in elite baseball players have not been clearly established. Hypothesis: Excision of hook of hamate fractures with a technique tailored to elite professional and collegiate baseball players will lead to high rates of return to play within a short time. Study Design: Case series; Level of evidence, 4. Methods: We reviewed the cases of 42 elite athletes who underwent surgical excision of 42 hook of hamate fractures at a single academic hand surgery practice from 2006 to 2020. The athletes competed at the professional (n = 20) or varsity collegiate (n = 22) baseball levels and were treated using the same surgical technique tailored toward the elite athlete. The clinical history, timing of surgery, complications, and time to return to play were recorded for each patient. Results: All 42 patients underwent an excision of their hook of hamate fracture at a mean of 7.2 weeks (range, 0.5-52 weeks) from the onset of symptoms. All but one patient were able to return to full preinjury level of baseball participation within 6 weeks from the date of surgery, with a mean return to sport of 5.4 weeks (range, 3-8 weeks). Two patients returned to the operating room-1 for scar tissue formation causing ulnar nerve compression and 1 for residual bone fragment causing pain and ulnar nerve compression. Conclusion: Surgical excision of hook of hamate fractures in elite baseball players showed a very high rate of return to play within 6 weeks. Meticulous adherence to the described surgical technique tailored to athletes optimizes clinical outcomes and avoids complications.

Dual Mobility for Monoblock Metal-on-Metal Revision-Is It Safe?

BACKGROUND: Revision of monoblock metal-on-metal (MoM) total hip arthroplasty (THA) is associated with high complication rates. Limited revision by conversion to a dual mobility (DM) without acetabular component extraction may mitigate these complications. However, the concern for polyethylene wear and osteolysis remains unsettled. This study investigates the results of DM conversion of monoblock MoM THA compared to formal acetabular revision. METHODS: One hundred forty-three revisions of monoblock MoM THA were reviewed. Twenty-nine were revisions to a DM construct, and 114 were complete revisions of the acetabular component. Mean patient age was 61, 54% were women. Components used, acetabular cup position, radiographic outcomes, serum metal ion levels, and HOOS Jr clinical outcome scores were investigated. RESULTS: At 3.9 years of follow-up (range 2-5), there were 2 revisions (6.9%) in the DM cohort, 1 for instability and another for periprosthetic fracture. Among the formal acetabular revision group there was a 20% major complication rate (23/114) and 16% underwent revision surgery (18/114) for aseptic loosening of the acetabular component (6%), deep infection (6%), dislocation (4%), acetabular fracture (3%), or delayed wound healing (6%). In the DM cohort, there were no radiographic signs of aseptic loosening, component migration, or polyethylene wear. One DM patient had a small posterior metadiaphyseal femur lesion that will require close monitoring. There were no other radiographic signs of osteolysis. There were no clinically significant elevations of serum metal ion levels. HOOS Jr scores were favorable. CONCLUSION: Limited revision with conversion to DM is a viable treatment option for failed monoblock MoM THA with lower complication rates than formal revision. Limited revision to DM appears to be a safe option for revision of monoblock MoM THA with a cup in good position and an internal geometry free of sharp edges or articular surface damage. Longer follow-up is needed to demonstrate any potential wear implications of these articulations.

Efficacy of manipulation under anesthesia beyond three months following total knee arthroplasty.

BACKGROUND: Stiffness after total knee arthroplasty (TKA) is often treated with manipulation under anesthesia (MUA) to improve range of motion (ROM). However, many authors recommend against MUA beyond 3 months after TKA. This study investigates the timing of MUA for stiffness after TKA, focusing on MUA performed at >12 weeks. METHODS: In total, 142 MUAs were retrospectively reviewed. "Early" MUAs were at <12 weeks after TKA; "Late" MUAs were >12 weeks. MUAs were further subdivided into 4 groups: 83 "Group I" cases at <12 weeks, 34 "Group II" between 12 and 26 weeks, 12 "Group III" between 26 and 52 weeks, and 13 "Group IV" at >52 weeks. Gains in ROM were compared between groups. RESULTS: Gains in flexion and overall ROM were statistically equivalent in Early vs Late MUA when controlling for pre-MUA ROM. ROM gains between the early Group I and the later Groups II-IV were also statistically comparable. Overall ROM gain in Group I was 24.1°, 17.9° in Group II, 20.8° in Group III, and 11.1° in Group IV. There were no significant complications. CONCLUSIONS: Early and late MUA resulted in statistically equivalent gains in ROM, regardless of timing after TKA. All groups showed an average improvement in ROM of ≥11°. MUA performed beyond 3 months, and even beyond 1 year, appears to be safe and may improve ROM and allow select patients to avoid revision surgery.

Total Hip Intraoperative Femur Fracture: Do the Design Enhancements of a Second-Generation Tapered-Wedge Stem Reduce the Incidence?

BACKGROUND: Intraoperative femur fracture (IFF) is a well-known complication in primary uncemented total hip arthroplasty (THA). Variations in implant instrumentation design and operative technique may influence the risk of IFF. This study investigates IFF between a standard uncemented tapered-wedge femoral stem and its second-generation successor with the following design changes: size-specific medial curvature, proportional incremental stem growth, modest reduction in stem length, and distal lateral relief. METHODS: A single experienced surgeon's patient database was retrospectively queried for IFF occurring during primary uncemented THA using a standard tapered-wedge femoral stem system or a second-generation stem. All procedures were performed using soft tissue preserving anatomic capsule repair and posterior approach. The primary outcome measure was IFF. A z-test of proportions was performed to determine significant difference between the 2 stems with respect to IFF. Patient demographics, Dorr classification, and implant characteristics were also examined. RESULTS: Forty-one of 1510 patients (2.72%) who received a standard tapered-wedge femoral stem sustained an IFF, whereas 5 of 800 patients (0.63%) using the second-generation stem incurred an IFF. No other significant associations were found. CONCLUSION: A standard tapered-wedge femoral stem instrumentation system resulted in greater than 4 times higher incidence of IFF than its second-generation successor used for primary uncemented THA. Identifying risk factors for IFF is necessary to facilitate implant system improvements and thus maximize patient outcomes.

Unintended Change of Physiological Lumbar Lordosis and Pelvic Tilt After Posterior Spinal Instrumentation and Fusion for Adolescent Idiopathic Scoliosis: How Much Is Too Much?

STUDY DESIGN: Retrospective review of prospective multicenter adolescent idiopathic scoliosis (AIS) database. OBJECTIVES: To investigate the effect of decreased lumbar lordosis (LL) on measured pelvic tilt (PT) after posterior spinal instrumentation and fusion for AIS and to test the hypothesis that lumbar spinal fusion resulting in mismatched LL is associated with increased PT. SUMMARY OF BACKGROUND DATA: Interaction between the spine and pelvis highly influences global sagittal alignment (GSA). In adults, correlation between health-related quality of life measures and LL proportional to a patient-specific pelvic incidence (PI) has been established, although the implications of poor sagittal alignment are less well-defined in AIS. This observation warrants further examination of regional spine contour and its relation to the pelvis in AIS. METHODS: The authors queried a prospective multicenter database for AIS patients who underwent posterior spinal instrumentation and fusion with lowest instrumented vertebra between L2 and L5 and identified 155 patients with minimum 2 years' follow-up. Lumbar lordosis (T12-S1), LL within fusion, LL below fusion, GSA, PT, and PI were measured preoperatively and at 2 years. Change in PT was compared between patients with matched or mismatched LL based on a common clinical definition (LL = PI + 10) and a research-driven model (LL = 0.56 PI + 33.43). RESULTS: Thirty-eight percent of patients had decreased LL from before surgery to 2 years after surgery. These patients had significantly higher rates of increased PT (73%) than patients without decreased LL (40%). Multivariate regression demonstrated that change in LL, LL within fusion, and GSA had a significant predictive effect on PT (p < .001). Using either definition of LL, patients with LL less than 2 standard deviations from predicted values were more likely to have increased PT. CONCLUSIONS: Iatrogenic loss of LL commonly occurs in spine fusion for AIS and is associated with a reciprocal increase in PT. As such, spinal fusion in AIS can have unintended effects on sagittal alignment with currently uninvestigated potential consequences in the future.

Flatback Revisited: Reciprocal Loss of Lumbar Lordosis Following Selective Thoracic Fusion in the Setting of Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective review of prospective multicenter adolescent idiopathic scoliosis (AIS) database. OBJECTIVE: To investigate the relationship between iatrogenic loss of thoracic kyphosis (TK) after selective thoracic posterior spinal instrumentation and fusion (PSIF) for AIS with straightening of lumbar lordosis (LL). SUMMARY OF BACKGROUND DATA: Segmental PSIF has become the standard of care for surgical treatment of severe AIS. Studies show that adults with flattening of TK and LL can develop pain and dysfunction associated with flatback syndrome. Analysis of post-fusion sagittal alignment is lacking in the AIS population. METHODS: Query of prospective multicenter database for AIS patients with Lenke 1, 2, or 3 curves who underwent selective thoracic PSIF (lowest instrumented vertebra equal or cephalad to L1) identified 123 patients with a minimum of 2 years' follow-up. Thoracic kyphosis (T5-T12), LL (T12-S1), and global sagittal alignment were measured preoperatively and at 2 years postoperatively. Health-related quality of life measures were examined. RESULTS: A total of 31% of patients had loss of TK and 42% lost LL. Patients with decreased TK had significantly higher rates of decreased LL (68%) than patients without decreased TK (31%). Multivariate regression confirmed that TK had significant predictive effect on LL (p < .001). Specifically, change in TK of 2° was associated with roughly 3° change in LL. There were no significant associations between changes in TK or LL and health-related quality of life. CONCLUSIONS: Loss of TK occurs commonly in selective fusion for AIS. This loss of kyphosis is strongly associated with reciprocal loss of LL. Spinal fusion can have unintended effects on sagittal alignment; these effects may have consequences that remain to be fully elucidated.

Risk Factors for Coronal Decompensation After Posterior Spinal Instrumentation and Fusion in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective review of multicenter data set with adolescent idiopathic scoliosis (AIS) patients with at least 2 years of follow-up after posterior spinal instrumentation and fusion (PSIF). OBJECTIVES: The purpose of this study is to investigate risk factors for coronal decompensation 2 years after PSIF for AIS. SUMMARY OF BACKGROUND DATA: Coronal decompensation is a potential complication of spinal instrumentation for AIS. This can result in problems requiring revision surgery. METHODS: Demographic, clinical, and radiographic measures were reviewed on 890 identified patients. Coronal decompensation was defined as a change farther away from midline from 6 weeks postoperatively to 2 years in any one of the following radiographic parameters: change in coronal balance >2 cm; change in coronal position of the lowest instrumented vertebra (LIV) >2 cm; change in thoracic trunk shift >2 cm; or change in LIV tilt angle >10°. Patients with decompensation were compared to those without. The relationship between the LIV and lowest end vertebra (LEV) was examined as an independent variable. RESULTS: Two years postoperation, 6.4% (57/890) of patients exhibited coronal decompensation. Multivariate regression revealed that decompensated patients were twice as likely to be male, have lower preoperative Risser score, and lower percentage major curve correction. The relationship between the LIV and LEV as well as quality of life surveys were not significantly different between decompensated and nondecompensated patients at 2 years. CONCLUSIONS: Two years after PSIF, 6.4% of patients with AIS exhibit radiographic coronal decompensation. Although this study did not demonstrate a significant association between the relationship of LIV and LEV and decompensation 2 years postoperation, results of this study indicate that skeletal immaturity, male gender, and less correction of the major curve may be related to higher rates of coronal decompensation.