Anatomic total shoulder arthroplasty with a nonspherical humeral head and inlay glenoid: 90-day complication profile in the inpatient versus outpatient setting.

BACKGROUND: Total shoulder arthroplasty (TSA) with a nonspherical humeral head component and inlay glenoid is a successful bone-preserving treatment for glenohumeral arthritis. This study aimed to describe the 90-day complication profile of TSA with this prosthesis and compare major and minor complication and readmission rates between inpatient- and outpatient-procedure patients. METHODS: A retrospective review was performed of a consecutive cohort of patients undergoing TSA with a nonspherical humeral head and inlay glenoid in the inpatient and outpatient settings by a single surgeon between 2017 and 2022. Age, sex, body mass index, American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), and 90-day complication and readmission rates were compared between inpatient and outpatient groups. RESULTS: One hundred eighteen TSAs in 111 patients were identified. Mean age was 64.9 years (range, 39-90) and 65% of patients were male. Ninety-four (80%) and 24 (20%) patients underwent outpatient and inpatient procedures, respectively. Four complications (3.4%) were recorded: axillary nerve stretch injury, isolated ipsilateral arm deep venous thrombosis (DVT), ipsilateral arm DVT with pulmonary embolism requiring readmission, and gastrointestinal bleed requiring readmission. There were no reoperations or other complications. Outpatients were younger with lower ASA and CCI scores than inpatients; however, there was no difference in complications (1/24 vs. 3/94, P=1.00) or readmissions (1/24 vs. 1/94, P=0.37) between these two groups. CONCLUSIONS: TSA with a nonspherical humeral head and inlay glenoid can be performed safely in both inpatient and outpatient settings. Rates of early complications and readmissions were low with no difference according to surgical setting. Level of evidence: IV.

Variation in radial head fracture treatment recommendations in terrible triad injuries is not influenced by viewing two-dimensional computed tomography.

BACKGROUND: We analyzed association between viewing two-dimensional computed tomography (2D CT) images in addition to radiographs with radial head treatment recommendations after accounting for patient and surgeon factors in a survey-based experiment. METHODS: One hundred and fifty-four surgeons reviewed 15 patient scenarios with terrible triad fracture dislocations of the elbow. Surgeons were randomized to view either radiographs only or radiographs and 2D CT images. The scenarios randomized patient age, hand dominance, and occupation. For each scenario, surgeons were asked if they would recommend fixation or arthroplasty of the radial head. Multi-level logistic regression analysis identified variables associated with radial head treatment recommendations. RESULTS: Reviewing 2D CT images in addition to radiographs had no statistical association with treatment recommendations. A higher likelihood of recommending prosthetic arthroplasty was associated with older patient age, patient occupation not requiring manual labor, surgeon practice location in the United States, practicing for five years or less, and the subspecialties "trauma" and "shoulder and elbow." CONCLUSIONS: The results of this study suggest that in terrible triad injuries, the imaging appearance of radial head fractures has no measurable influence on treatment recommendations. Personal surgeon factors and patient demographic characteristics may have a larger role in surgical decision making. Level of evidence: Level III, therapeutic case-control study.

Measurement of the gluteal compartment pressures: A cadaveric study describing safety and reproducibility of two methods.

INTRODUCTION: Gluteal compartment syndrome is an uncommon entity and physicians may use intracompartmental pressure measurements for confirmation of the clinical diagnosis, or in cases where the physical exam is indeterminate. However, there is a paucity of literature describing a safe and reproducible technique to measure gluteal intracompartmental pressures during the diagnosis of gluteal compartment syndrome. The purpose of this cadaveric study is to evaluate the sole previous technique described in the literature to measure gluteal intracompartmental pressures and provide a modified technique which can be safely and reliably utilized clinically. METHODS: A cadaveric study with three phases was performed in 16 gluteal regions in 8 cadavers. In the first phase, the previously described technique was assessed. In the second phase, a modified set of techniques was created and evaluated. In the third phase, inter-user reliability of the modified set of techniques was assessed and calculated using Cohen's ĸ coefficient. In all three phases, methylene blue was injected through pressure monitoring needles into the gluteus maximus (GMax), gluteus medius/minimus (GMM), and the tensor fascia lata (TFL) compartments. Following dissection, rate of successful penetration into each targeted compartment and distance from the neurovascular structures was recorded. RESULTS: The previously described set of techniques was found to be variable. The modified set of techniques was effective, successfully reaching the GMax, GMM, and TFL compartments in 100%, 100%, and 81% of attempts, respectively. Inter-user reliability was excellent (ĸ = 1) for the techniques to reach both the GMax and GMM compartments, and moderate (ĸ = 0.54) for the technique to reach the TFL compartment. Within the GMax, the pressure monitoring needle was at a mean of 5.4±0.6 cm, 4.1±0.7 cm, 6.4±0.5 cm from the sciatic nerve (SN), superior gluteal nerve (SGN), and inferior gluteal nerve (IGN), respectively. Within the GMM, the pressure monitoring needle was at a mean of 9.7±1.4 cm, 7.4±1.3 cm, 11.1±1.7 cm from the SN, SGN, and IGN, respectively. CONCLUSION: The modified set of techniques presented allows the three gluteal compartments to be safely and reproducibly reached to measure intracompartmental pressures during the diagnosis of gluteal compartment syndrome.

CT Scan versus Saline Load Test for Detection of Traumatic Wrist Arthrotomy.

Background Traumatic arthrotomy of the wrist is most commonly detected using the saline load test (SLT); however, little data exists on the effectiveness of the SLT to this specific joint. The use of computed tomography (CT) scan has been validated as an alternative method to detect traumatic arthrotomy of the knee, as the presence of intra-articular air can be seen when there is violation of the joint capsule. Question/Purpose The purpose of this study was to determine the ability of CT scan to identify arthrotomy of the wrist capsule and compare the diagnostic performance of CT versus traditional SLT. Materials and Methods Ten fresh frozen cadavers which had undergone transhumeral amputation were initially used in this study. A baseline CT scan was performed to ensure no intra-articular air existed prior to intervention. After baseline CT, an arthrotomy was created at the 6R radiocarpal portal site. The wrists then underwent a postarthrotomy CT to identify the presence or absence of intra-articular air. Following CT, the wrists were subjected to the SLT to detect the presence of extravasation from the arthrotomy. Results Nine cadavers were included following baseline CT scan. Following arthrotomy, intra-articular air was visualized in eight of the nine cadavers in the postarthrotomy CT scan. Air was seen in the radiocarpal joint in eight of the nine wrists; midcarpal joint in seven of the nine wrists; and distal radioulnar joint in six of the nine wrists. All wrists (nine of the nine) demonstrated extravasation during the SLT. The mean volume of extravasation occurred at 3.7 mL (standard deviation = 2.6 mL), with a range of 1 to 7 mL. Conclusion CT scan correctly identified eight of the nine simulated traumatic arthrotomies. Injection of 7 mL during the SLT was necessary to identify 100% of the arthrotomies. Clinical Relevance CT scan is a sensitive modality for detection of traumatic arthrotomy of the wrist in a cadaveric model.

Diagnostic Performance and Advanced Imaging Reduction With Digital Tomosynthesis in Scaphoid Fracture Management.

BACKGROUND: Management of scaphoid fractures often requires advanced imaging to achieve accurate diagnoses and appropriate treatment. Digital tomosynthesis (DTS) is a cross-sectional imaging modality that may be used to substitute magnetic resonance imaging or computed tomographic scans. The purpose of this study is to: (1) determine the diagnostic accuracy of DTS in occult scaphoid fractures; and (2) report on the reduction of other advanced imaging when using DTS. METHODS: From May 2014 to October 2017, the charts of all patients who underwent scaphoid tomogram were retrospectively reviewed. The diagnostic accuracy of DTS for occult fracture was compared with 2-week follow-up plain films. To measure the reduction in utilization of advanced imaging, it was determined whether DTS eliminated the need for advanced imaging by providing adequate information regarding the clinical question. RESULTS: A total of 78 patients underwent scaphoid tomography in this time frame: 39 for occult fracture, 33 for fracture union, 5 for fracture morphology, and 1 for hardware positioning. For the detection of occult fracture, DTS had a sensitivity of 100%, specificity of 83%, positive predictive value of 64%, and negative predictive value of 100%. Advanced imaging was not used in 35 of the remaining 39 patients based on the results obtained by DTS. In patients who did receive advanced imaging, 83% of tomograms provided conclusive diagnostic information. CONCLUSIONS: Digital tomosynthesis increases the diagnostic sensitivity of occult scaphoid fractures, reducing unnecessary immobilization and advanced imaging. Digital tomosynthesis provides clinical detail beyond plain film, which reduces the need to obtain advanced imaging when assessing union, fracture pattern, and hardware placement.

An Analysis of Complications and Bone Defect Length With the Use of Induced Membrane Technique in the Upper Limb: A Systematic Review.

Background: The induced membrane technique was originally described as a technique for the reconstruction of long bone defects. The authors performed a systematic review to determine whether the use of the induced membrane technique is effective in large bony defects in the upper extremity. Methods: A qualitative systematic review was conducted using PubMed, EBSCO, and Google Scholar databases to record all studies reporting on complications of the induced membrane technique in the upper extremity. Studies written after 1990 in English language journals met the inclusion criteria. Exclusion criteria were non-English language publications, animal studies, failure to identify the location of the bone defect, failure to identify whether complications were associated with the procedure, and failure to define the length of bone defect. Results: A total of 1422 studies were identified in the original search. Twelve studies satisfied the criteria for inclusion. A total of 70 patients with 83 upper extremity cases were reported: 1 proximal interphalangeal joint, 22 phalanges, 8 metacarpals, 37 forearms, 14 humeri, and 1 clavicle. The mean bone defect size was 4.0 cm (SD, 1.5). The most common complication was infection. We found that complication rates were independent of the location of the bone defect. Complication rates in the upper extremity ranged from 0% to 100%, with a total weighted mean of 10%. Conclusion: The induced membrane technique is an emerging possible treatment of large bone defects in the upper extremity. More research is needed to determine the outcomes of the induced membrane technique in the upper extremity.

Patient Positioning for Proximal Femur Fracture Fixation: a Review of Best Practices.

PURPOSE OF REVIEW: Proximal femur fractures are common traumatic injuries treated by orthopedic surgeons. Preparation and positioning for surgical intervention are critical in the proper management of proximal femur fractures. The purpose of this study was to review the current evidence on the various positioning options for patients and to highlight the principles and emerging techniques to help orthopedic surgeons treat this common injury. RECENT FINDINGS: Strategic patient positioning is key to the reduction and fixation of proximal femur fractures without complications. The use of intramedullary devices for the fixation of proximal femur fractures has led to an increased use of the modern fracture table. The fracture table should be used when surgeons are facile with its use to avoid significant complications. Recent best available evidence has suggested increased risk of malrotation associated with the use of the fracture table. The use of the radiolucent table offers the most flexibility, but limits surgeons as multiple assistants are needed to maintain reduction during fixation. Positioning for proximal femur fractures is an important technique for general and trauma orthopedic surgeons. Surgeons need to be aware of the various techniques for positioning of proximal femur fractures due to the diversity of injury patterns and patient characteristics. Each positioning technique has it benefits and potential complications that every orthopaedic surgeon should be familiar with while treating these injuries.

Surgical Management of a Pediatric Cuboid Nutcracker Fracture: A Case Report.

CASE: Cuboid impaction fractures (nutcracker fractures) result from high-energy trauma and are exceedingly rare in children. We present a case of an 8-year-old boy who sustained a comminuted cuboid nutcracker fracture after a fall from height. The patient underwent open reduction and internal fixation with a locking plate. At 1 year postoperatively, lateral column length and articular congruency were maintained, and the patient return to full function and activity. CONCLUSION: Cuboid nutcracker fractures in children are rare and can be successfully treated with open reduction and internal fixation with locking plates, with excellent radiographic and functional outcomes.

Current management of pediatric chiari type 1 malformations.

OBJECTIVES: Pediatric Chiari Type 1 Malformations (CM1) are commonly referred for neurosurgical opinion. The ideal management in children regarding surgical and radiographic decision making is not clearly delineated. PATIENTS AND METHODS: We retrospectively reviewed our cohort of patients age 18 years and younger referred to a single neurosurgeon for CM1. Baseline MRIs of the spine were obtained. Non-operative patients had repeat imaging at 6-12 months. Patients who underwent an operation (decompression with/without duraplasty) had repeat imaging at 6 months. RESULTS: One hundred and thirty-two patients with mean age of 10 years met inclusion criteria. All patients had post-operative symptomatic improvement. We identified 26 patients with syrinx, 8 with scoliosis, 3 with hydrocephalus, and one had tethered cord. The average tonsillar descent was 8.1 mm in the non-operative group and 11.9 mm in the operative group. Ninety-five patients were managed conservatively (72%). Thirty-seven were offered surgery (28%), and 33 patients underwent intervention; 21 with duraplasty (64%) and 12 without (36%). CONCLUSIONS: Pediatric patients with CM1 require both clinical and radiographic follow-up. Duraplasty may be performed if decompression fails to relieve symptomatology, but is not always needed. CM1 continues to present a challenge in surgical decision making. Adhering to a treatment paradigm may help alleviate difficult decision-making.

Efficacy of intraoperative ultrasonography in neurosurgical tumor resection.

OBJECTIVE Intraoperative ultrasonography (IOUS) is a widely accessible imaging modality that provides real-time surgical guidance with minimal identified risk or additional operative time. A recent study by the authors found a strong correlation between IOUS and postoperative MRI findings when evaluating the extent of tumor resection, suggesting that IOUS might have significant clinical implications. The objective of this study was to expand on results from the previous study in order to provide more evidence on the usage of IOUS in the determination of gross-total resection (GTR) in both adult and pediatric patients with brain tumors. METHODS This study consisted of a retrospective review of adult and pediatric neurosurgical patients who were treated at Albany Medical Center between August 2009 and March 2016 for a tumor of the brain. All patients were treated with IOUS and then underwent postoperative MRI (with and without contrast) within 1 week of surgery. RESULTS A total of 260 patients (55% of whom were males) met inclusion criteria for the study (age range 3 months to 84 years). IOUS results showed a strong association with postoperative MRI results (φ = 0.693, p < 0.001) and an 81% intended GTR rate. In cases in which GTR was pursued, 19% had false-negative results. IOUS was able to accurately identify residual tumor in 100% of subtotal resection cases where resection was stopped due to invasion of tumor into eloquent locations. Cases involving gliomas had a 75% intended GTR rate and a 25% false-negative rate. Cases involving metastatic tumors had an 87% intended GTR rate and a 13% false-negative rate. The sensitivity, specificity, negative predictive value, and positive predictive value are reported for IOUS in all included tumor pathologies, glioma cases, and metastatic tumor cases, respectively. CONCLUSIONS The use of IOUS may allow for a reliable imaging modality to achieve a more successful GTR of brain tumors in both adult and pediatric neurosurgical patients. When attempting GTR, the authors demonstrated an 81% GTR rate. The authors also report false-negative IOUS results in 19% of attempted GTR cases. The authors support the use of IOUS in both adult and pediatric CNS tumor surgery to improve surgical outcomes. However, further studies are warranted to address existing limitations with its use to further improve its efficacy and better define its role as an intraoperative imaging tool.