Proximal interphalangeal joint dislocations and fracture-dislocations.

Although proximal interphalangeal joint dislocations are generally straightforward to treat, fracture-dislocations are among the most difficult hand injuries to manage. Fracture patterns range from simple to treat palmar plate avulsion fractures to complex, unstable pilon fractures of the base of the middle phalanx, where achieving adequate reduction and fixation can be extremely difficult. Moreover, these fractures may present sub-acutely or chronically, which greatly adds to the complexity of the case. It is therefore no surprise that clinical results vary and are often difficult to predict. We will discuss the clinical presentations, the various dislocation and fracture-dislocation patterns, treatment options and the complications of these injuries.

Revision of Failed Radial Head Arthroplasty.

BACKGROUND: Revision of radial head arthroplasty (RHA) may be indicated in cases of prosthesis loosening and malposition. Inherent difficulties in revision surgery include poor bone stock and disrupted soft tissue envelope. Although cases of RHA used for revision of failed RHA are rare, there is reasonable expectation for increasing frequency of these cases due to the increasing incidence of primary RHA. Furthermore, there is an increasing demand for postoperative recovery of function; thus, surgeons may consider revising a failed RHA to a new RHA. We report on series of failed RHA which were revised to a new radial head prosthesis. METHODS: A retrospective review was performed at multiple institutions for a single radial head prosthesis used for revision of a failed radial head prosthesis. Clinical and radiographic outcomes were collected with a minimum of 1 year of follow-up. RESULTS: Across 11 patients at a mean follow-up of 45.1 months, the mean Mayo Elbow Performance Score was 81.7; mean Disabilities of the Arm, Shoulder, and Hand scores were 24.4; and mean Visual Analog Scale for pain was 0.6. Radiographic analysis yielded no evidence of capitellar wear or stem loosening. CONCLUSION: A radial head prosthesis can produce satisfactory results when used for revision of a failed prosthesis. Inherent difficulties in revision surgery include the potential for reduced bone stock and a disrupted soft tissue envelope. Elements of prosthesis design which may contribute to effectively managing revision surgery include a long stem with in-growth surface and prosthetic head alignment to the axis of forearm rotation.

Avascular Necrosis of the Scaphoid Preiser Disease.

No consensus regarding optimal treatment or etiology of Preiser disease exists. We described the epidemiology, classification and treatment characteristics of 18 patients with Preiser disease. Patients with changes related to previous trauma, and without radiographs were excluded. Based on the radiographs at diagnosis, we classified 13 scaphoids as Herbert Lanzetta stage II, four as stage III, and one as stage IV. In 12 patients nonspecific treatment was offered and only two patients received surgical treatment. We found that chosen treatment is not associated with the severity of Herbert Lanzetta stage and the outcome is not influenced by chosen treatment.

Diagnostic Wrist Arthroscopy for Nonspecific Wrist Pain.

Background: This study addresses the prevalence of discrete pathophysiology accounting for patients' symptoms during diagnostic wrist arthroscopy in individuals with wrist pain without a specific preoperative diagnosis. Secondarily, we determined the number and type of surgeries subsequent to diagnostic wrist arthroscopy. Methods: Between January 2000 and January 2015, 135 diagnostic wrist arthroscopies were performed by 12 surgeons in 3 urban academic hospitals. We recorded the diagnostic findings of diagnostic wrist arthroscopy and any subsequent surgeries. Results: One hundred and five patients had synovitis or a normal wrist (78%), 17 had likely age-appropriate changes (eg, central triangular fibrocartilage complex defects scapholunate changes) (13%), 8 (6%) were given uncommon diagnoses, and 5 (4%) had osteochondral defects. Sixteen patients (12%) had subsequent wrist surgery: 2 were for adverse events, 2 were carpal tunnel releases, and 12 were other surgeries. Conclusion: Diagnostic arthroscopy performed in the setting of an unclear preoperative diagnosis yielded limited diagnostic benefit.

Portal placement in elbow arthroscopy by novice surgeons: cadaver study.

PURPOSE: In this anatomical cadaver study, the distance between major nerves and ligaments at risk for injury and portal sites created by trainees was measured. Trainees, inexperienced in elbow arthroscopy, have received a didactic lecture and cadaver instruction prior to portal placement. The incidence of iatrogenic injury from novice portal placement was also determined. METHODS: Anterolateral, direct lateral, and anteromedial arthroscopic portals were created in ten cadavers by ten inexperienced trainees in elbow arthroscopy. After creating each portal, the trajectory of the portal was marked with a guide pin. Subsequently, the cadavers were dissected and the distances between the guide pin in the anterolateral, direct lateral, and anteromedial portals and important ligaments and nerves were measured. RESULTS: The difference between the distance of the direct lateral portal and the posterior antebrachial cutaneous nerve (PABCN) (22 mm, p < 0.001), the lateral antebrachial cutaneous nerve (4.0 mm, p < 0.001), and the radial nerve (25 mm, p < 0.001) was different from the average reported distances in the literature. A difference was found between the distance of the anterolateral portal and the PABCN (32 mm, p < 0.001) compared to previous studies. Three major iatrogenic complications were observed, including: laceration of the posterior bundle of the medial ulnar collateral ligament, lateral ulnar collateral ligament midsubstance laceration, and median nerve partial laceration. CONCLUSION: Surgeons increasingly consider arthroscopic treatment as an option for elbow pathology. In the present study a surgical complication rate of 30 % was found with novice portal placement during elbow arthroscopy. Furthermore, as the results from this study have indicated, accurate, precise, and safe portal placement in elbow arthroscopy is not easily achieved by didactic lecture and cadaver instruction session alone. Level of evidence V.

Current Trends in Treatment of Kienböck Disease: A Survey of Hand Surgeons.

BACKGROUND: The cause and treatment of Kienböck disease is controversial. No treatment algorithm has been accepted. We surveyed US hand surgeons to determine trends and attitudes regarding the treatment of Kienböck disease. METHODS: An online questionnaire was created focusing on specific treatments of Kienböck disease. The survey included 6 questions regarding the cause of disease, preferred vascularized bone grafting (VBG) procedure, and treatment of stages I, II, IIIA, and IIIB. Respondents were also asked to specify their geographic location of practice and the approximate number of years in practice. RESULTS: A total of 338 of the 2781 surgeons contacted completed the survey for a response rate of rate of 12%. The majority of respondents believe ulnar-negative variance alone contributes to the development of Kienböck disease. For treatment of a young ulnar-neutral male with stage I disease who had failed immobilization and nonsteroidal anti-inflammatory drugs, most hand surgeons chose distal radius core decompression. There was no preferred treatment among respondents for treatment of a young ulnar-neutral female with stage II disease. For treatment of a 40-year-old ulnar-negative male with stage IIIA disease, most hand surgeons chose a radial shortening osteotomy. The preferred treatment among respondents for treatment of stage IIIB disease is a proximal row carpectomy. CONCLUSIONS: Our study demonstrated that most hand surgeons believe ulnar-negative variance largely contributes to Kienböck disease and the most commonly preferred VBG technique utilizes the fourth and fifth extensor compartment arteries.

Partial Flexor Tendon Laceration Assessment: Interobserver and Intraobserver Reliability.

Accurate assessment of partial-thickness flexor tendon lacerations in the hand is difficult owing to the subjectivity of evaluation. In this study, we created 12 partial-thickness flexor tendon lacerations in a cadaveric hand, evaluated the accuracy of 6 orthopedic residents and 4 fellowship-trained hand surgeons in estimating the percentage thickness of each laceration, and assessed the groups' interobserver and intraobserver agreement. The 10 participants estimated each laceration independently and on 2 separate occasions and indicated whether they would repair it. The actual thickness of each laceration was calculated from measurements made with a pair of digital microcalipers. Overall estimates differed significantly from calibrated measurements. Estimates grouped by residents and fellowship-trained hand surgeons also differed significantly. Third-year residents were the most accurate residents, and fellowship-trained hand surgeons were more accurate than residents. Overall interobserver agreement was poor for both readings. There was moderate overall intraobserver agreement. Fellowship-trained hand surgeons and first-year residents had the highest intraobserver agreement. These results highlight the difficulty in accurately assessing flexor tendon lacerations. Accuracy appears not to improve with surgeon experience.

Union rate after operative treatment of humeral shaft nonunion--A systematic review.

INTRODUCTION: Humeral shaft nonunions can lead to morbidity from subsequent operations, complications and impaired function. Currently there is no evidenced-based consensus for treatment of humeral shaft nonunions. AIM: We aimed to summarize and analyze union rates and complications after operative treatment for humeral shaft nonunion. METHODS: Studies investigating operative treatment strategies for humeral shaft nonunion were identified by searching: EMBASE, MEDLINE, Ovid SP, Web of Science, Cochrane Central, PubMed and Google Scolar up to October 24, 2014. Studies were eligible if: (1) outcome of operative treatment for humeral shaft nonunion was reported; (2) at least ten adult patients with humeral shaft nonunion included; (3) full text article available; (4) written in English, German or Dutch; and (5) nonunion was defined as no bone-bridging between the fracture ends after 6 months. RESULTS: Thirty-six studies were included. A union rate of 98% was found in patients (n=672) who underwent plate fixation with autologous bone grafting (ABG), 95% in plate fixation without ABG (n=19), 88% in intramedullary nailing with ABG (n=164), 66% in intramedullary nailing without ABG (n=78), 92% in bone strut fixation (n=91) and 98% in external fixation (n=152). A total complication rate of 12% was found in patients treated with plate fixation combined with ABG, 15% in intramedullary nail with ABG and 8% intramedullary nailing without ABG, 20% in bone strut fixation and 22% in external fixation. CONCLUSION: Plate fixation with ABG was recommended for humeral shaft nonunion, since the union rate is highest and the complication rate is relatively low. LEVEL OF EVIDENCE: Level IV.

Plate and Screw Fixation of Bicolumnar Distal Humerus Fractures: Factors Associated With Loosening or Breakage of Implants or Nonunion.

PURPOSE: To identify factors associated with reoperation for early loosening or breakage of implants or nonunion after operative treatment of AO type C distal humerus fractures. METHODS: We retrospectively analyzed 129 adult patients who had operative treatment of an isolated AO type C distal humerus fracture at 1 of 5 hospitals to determine factors associated with reoperation for early loosening or breakage of implants or nonunion. RESULTS: Within 6 months of original fixation, 16 of 129 fractures (12%) required reoperation for loosening or breakage of implants (n = 8) or nonunion (n = 8). In bivariate analyses, the Charlson comorbidity index, smoking, a coded diagnosis of obesity, diabetes mellitus, and radiographic osteoarthritis were significantly associated with reoperation for early loosening or breakage of implants or nonunion. CONCLUSIONS: With the numbers available, patient factors rather than technical factors were associated with reoperation for loosening or breakage of implants and nonunion. Because of the relative infrequency of fixation problems and nonunion, a much larger study is needed to address technical deficiencies.

Harrington rod revision after failed total hip arthroplasty due to missed acetabular metastasis.

We report the case of a 61-year-old woman who was referred to our service after she received a total hip implant at another institution and was found to have a large acetabular defect from pulmonary metastasis. The patient elected to undergo palliative surgical curettage and fixation. We describe a technique to create a cement construct reinforced with Steinmann pins that reduces pain and offers improved mobility.

Pilot study for an orthopedic surgical training laboratory for basic motor skills.

The most effective way to teach and assess a resident's knowledge of musculoskeletal medicine, including orthopedic-specific surgical skills, remains unclear. We designed a surgical skills training session to educate junior-level orthopedic residents in 4 core areas: comfort with basic power equipment, casting/splinting, suturing, and surgical instrument identification. As part of the study reported here, 11 orthopedic residents (postgraduate year 1-3) completed a skills session and were evaluated with written examinations and an ankle fracture model before and after the session. Four other junior residents were unable to attend the session because of clinical responsibilities. For the group of 11 residents who completed the written examination, mean (SD) presession percentile was 87.3 (10.4), mean (SD) postsession percentile was 92 (8.4), median was 96, and mode was 96. There was a significant pre-post difference among all test takers, regardless of training level (P < .05). In the ankle fracture model, for the entire group, mean (SD) overall presession percentile was 68.6 (13.9), and mean (SD) overall postsession percentile was 95.2 (5.2). There was a significant pre-post difference among all test takers, regardless of training level (P = .03). An intensive laboratory has the potential to improve junior-level residents' basic surgical skills and knowledge.

Return to activity after medial patellofemoral ligament repair or reconstruction.

PURPOSE: This study aimed to determine the ability of patients to return to activity after medial patellofemoral ligament (MPFL) reconstruction or repair for patellar instability. METHODS: A systematic review was performed using multiple databases. Studies reporting outcomes with Tegner scores after repair or reconstruction of the MPFL were included. Surgical technique, Tegner scores, and episodes of recurrent patellar instability were recorded. RESULTS: Ten articles with a total of 402 patients were included. The mean preoperative Tegner score was 4.7 (2.9 to 7.5). The mean postoperative Tegner score was 5.8 (4.0 to 7.7). Forty-nine patients (12.2%) had a recurrent episode of instability, 11 of whom required additional corrective procedures. There was a statistically significant larger failure rate among those who underwent MPFL repair (26.9%) than those who underwent reconstruction (6.6%) or medial retinacular repair/plication (16.5%). CONCLUSIONS: Recurrent dislocation was higher in patients who underwent MPFL repair rather than reconstruction. However, repair and reconstruction had similar Tegner scores. Repair or reconstruction of the soft tissue structures contributing to patellofemoral instability is successful in returning patients to preinjury activity levels. LEVEL OF EVIDENCE: Level IV, systematic review of Level II, III, and IV studies.

Predictors of local recurrence in high-grade soft tissue sarcomas: hydrogen peroxide as a local adjuvant.

Soft tissue sarcomas have a mortality rate of 40% to 60%, with local recurrence being a poor prognostic factor for overall survival. Three-percent nondiluted hydrogen peroxide is hypothesized to be an effective local adjuvant. The purpose of this study was to identify risk factors for local recurrence in high-grade soft tissue sarcomas and to determine whether using hydrogen peroxide as a local adjuvant reduced the risks of local recurrence and surgical-site infection. Retrospective data were collected for 106 patients surgically treated for high-grade soft tissue sarcomas between 2002 and 2010. The primary endpoint was local recurrence. Eighteen (16.98%) cases of local recurrence occurred. Predictors of local recurrence were margin status, estimated blood loss, and histology (ie, malignant peripheral nerve sheath tumor), with hazard ratios of 4.44 (95% confidence interval [CI], 1.32-14.95), 1.19 (95% CI, 1.06-1.35), and 9.21 (95% CI, 2.11-40.16), respectively. Hydrogen peroxide yielded a statistically insignificant improvement in local recurrence, with a hazard ratio of 0.81 (95% CI, 0.27-2.48) and a reduced risk of surgical site infection, with a hazard ratio of 0.52 (95% CI, 0.15-1.81). Margin status, increased blood loss, and histologic subtype are associated with increased local recurrence risk. Using hydrogen peroxide improved local control and infection rates, but the difference was not statistically significant.

Preoperative MRI underestimates articular cartilage defect size compared with findings at arthroscopic knee surgery.

BACKGROUND: Magnetic resonance imaging (MRI) is widely used as a preoperative tool to estimate the size of articular cartilage defects to optimize treatment selection. However, the reliability of MRI sizing of cartilage defects is not well understood. Hypothesis/ PURPOSE: The purpose of this investigation was to compare the size of knee articular cartilage defects on MRI to arthroscopic visualization after debridement. It was hypothesized that MRI sizing would produce measurements that were no different than those made during arthroscopic knee surgery. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Seventy-seven patients (age [mean ± SD], 38 ± 10.7 years) who met inclusion criteria underwent preoperative knee MRI of at least 1.5 T within 1 year of arthroscopic knee surgery for a high-grade cartilage defect. Postdebridement defect sizes were obtained from intraoperative surgery notes and compared with retrospective MRI estimates. RESULTS: Ninety-two total cartilage defects were analyzed with an average of 1.2 high-grade defects per knee and average postdebridement defect area of 2.99 cm(2) per lesion (95% CI, 1.63-2.26 cm(2)). Preoperative MRI analysis estimated a lesion area that was an average of 1.04 cm(2) smaller (95% CI, 0.70-1.39 cm(2); P < .0001). In 74% of the lesions analyzed, defect size was larger on arthroscopic visualization than was estimated by MRI sizing. On average, MRI underestimated the defect area by 70% compared with arthroscopic visualization. CONCLUSION: Magnetic resonance imaging underestimates the size of articular cartilage defects compared with final postdebridement size as measured during arthroscopic knee surgery. Thus, before arthroscopic surgery, orthopaedic surgeons should consider treatment strategies that are appropriate for a larger defect than predicted by preoperative MRI.

Operative management of capitellar fractures: a systematic review.

PURPOSE: This study was conducted to evaluate reports of clinical outcomes of isolated capitellar fractures. MATERIALS AND METHODS: We conducted a systematic review of medical databases reporting clinical outcomes of patients undergoing nonoperative and operative management of isolated capitellar fractures. RESULTS: We identified 28 studies for inclusion comprising 174 patients. All included studies were level IV evidence. Capitellar fractures were more common among women than men and were more likely to involve the nondominant arm. Type I fractures (84%) were more common than type II (14%) and III fractures (2%). Operative and nonoperative management both led to satisfactory clinical outcomes. No significant difference in outcomes was observed in those undergoing operative management compared with those undergoing closed reduction and immobilization. CONCLUSIONS: Nonoperative and operative management of isolated capitellar fractures leads to satisfactory clinical outcomes as determined by postoperative range of motion, improvement in pain, and a return to previous levels of function. No statistical difference in outcomes was observed between those undergoing operative management compared with those treated with closed reduction and immobilization.