Accuracy of acromioclavicular joint injections.

BACKGROUND: Injection to the acromioclavicular (AC) joint can be both diagnostic and therapeutic. PURPOSE: The purpose of this study was to evaluate the accuracy of in vivo AC joint injections. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty patients with pain localized to the AC joint were injected with 1 mL of 1% lidocaine and 0.5 mL of radiographic contrast material (Isovue). Radiographs of the AC joint were taken after the injection. Each radiograph was reviewed by a musculoskeletal radiologist and graded as intra-articular, extra-articular, or partially intra-articular. RESULTS: Of the 30 injections performed, 13 (43.3%) were intra-articular, 7 (23.3%) were partially articular, and 10 (33.3%) were extra-articular. When the intra-articular and the partially articular groups were combined, 20 patients (66.7%) had some contrast dye in the AC joint. CONCLUSION: This study demonstrates that despite the relatively superficial location of the AC joint, the clinical accuracy of AC joint injections remains relatively low.

Zone-II flexor tendon repair: a randomized prospective trial of active place-and-hold therapy compared with passive motion therapy.

BACKGROUND: In order to improve digit motion after zone-II flexor tendon repair, rehabilitation programs have promoted either passive motion or active motion therapy. To our knowledge, no prospective randomized trial has compared the two techniques. Our objective was to compare the results of patients treated with an active therapy program and those treated with a passive motion protocol following zone-II flexor tendon repair. METHODS: Between January 1996 and December 2002, 103 patients (119 digits) with zone-II flexor tendon repairs were randomized to either early active motion with place and hold or a passive motion protocol. Range of motion was measured at six, twelve, twenty-six, and fifty-two weeks following repair. Dexterity tests were performed, and the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome questionnaire and a satisfaction score were completed at fifty-two weeks by ninety-three patients (106 injured digits). RESULTS: At all time points, patients treated with the active motion program had greater interphalangeal joint motion. At the time of the final follow-up, the interphalangeal joint motion in the active place-and-hold group was a mean (and standard deviation) of 156 degrees +/- 25 degrees compared with 128 degrees +/- 22 degrees (p < 0.05) in the passive motion group. The active motion group had both significantly smaller flexion contractures and greater satisfaction scores (p < 0.05). We could identify no difference between the groups in terms of the DASH scores or dexterity tests. When the groups were stratified, those who were smokers or had a concomitant nerve injury or multiple digit injuries had less range of motion, larger flexion contractures, and decreased satisfaction scores compared with patients without these comorbidities. Treatment by a certified hand therapist resulted in better range of motion with smaller flexion contractures. Two digits in each group had tendon ruptures following repair. CONCLUSIONS: Active motion therapy provides greater active finger motion than passive motion therapy after zone-II flexor tendon repair without increasing the risk of tendon rupture. Concomitant nerve injuries, multiple digit injuries, and a history of smoking negatively impact the final outcome of tendon repairs.

Work of flexion related to different suture materials after flexor digitorum profundus and flexor digitorum superficialis tendon repair in zone II: a biomechanical study.

PURPOSE: Repair of both flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons is commonly performed in zone II flexor tendon injuries; however, the bulk of the repair may impair tendon gliding. We evaluated whether repairing 1 slip of FDS tendon and resecting the other would significantly decrease work of flexion and whether suture material affected this interaction in an in vitro study. METHODS: The index, middle, and ring fingers from 10 fresh-frozen human cadaveric hands were disarticulated and their tendon sheaths opened. Baseline work of flexion was tested. Lacerations were made in zone II, and then the FDP tendon was repaired with 3 different suture materials: FiberWire, Ticron, and prolene. Work of flexion was again measured and the percentage increase calculated. Further iterations were performed with both slips of FDS tendon repaired and with one slip of FDS tendon repaired and the other resected. RESULTS: There was no significant difference in the work of flexion after repairs done with FiberWire, Ticron, or Prolene. Work of flexion after repair of both FDP and FDS tendons increased 51% compared with an increase of 21% after FDP-only repair and an increase of 9% after repair of one and resection of the other slip of FDS. Repair of both FDP and FDS tendons significantly increased work of flexion. CONCLUSIONS: Resection of 1 slip of FDS tendon significantly reduces work of flexion in zone II flexor tendon repair. Suture material had no effect on this interaction.

Brachial plexus birth palsy: an overview of early treatment considerations.

Since the description by Smellie in 1764, in a French midwifery text, that first suggested an obstetric origin for upper limb birth palsy, great strides have been made in both diagnosis and early and late treatment. This report presents an overview of selected aspects of this complex and extensive subject. Early treatment options are reviewed in the context of the present controversies regarding the natural history and the indications for and timing of microsurgical intervention in infants with brachial plexus birth injuries.

The detailed anatomy of the 1,2 intercompartmental supraretinacular artery for vascularized bone grafting of scaphoid nonunions.

PURPOSE: To describe the configuration of the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA), including the location of the perforators, and to discuss the clinical use of the 1,2 ICSRA for vascularized bone grafting of scaphoid nonunions. METHODS: Thirteen fresh-frozen cadaveric forearms were used to evaluate the variations in the anatomy of the 1,2 ICSRA. After injection of red latex, the 1,2 ICSRA and its perforators were characterized and measured. Pedicle length and distal reach of the transposed 1,2 ICSRA pedicle was evaluated. We noted the relationship of the 1,2 ICSRA to the dorsal scaphoid branch of the radial artery. Another 10 specimens were injected, frozen, and sectioned to evaluate vascular penetration into the dorsal distal radius. RESULTS: The 1,2 ICSRA branched from the radial artery 1.9 mm proximal to the tip of the radial styloid (range -6.3-3.2 mm), on average. The average pedicle length was 22.5 mm (range 15-31 mm), which permits its application for both dorsal and volar scaphoid. The relationship between the origin of the 1,2 ICSRA and the dorsal scaphoid branch was categorized into 3 types, including--separate, combined, and shared. The average number of perforating vessels arising from the pedicle was 5.5 (range 3-7), with an average of 2.75 (range 1-7) perforators overlying a 1 by 0.5 cm block of the distal radius bone graft. A graft located between 8-18 mm proximal to the articular surface of distal radius would incorporate the greatest numbers of perforators. The most notable vascular penetration of the distal radius was demonstrated at 10.0 mm proximal to the radial styloid. CONCLUSIONS: The detailed anatomy of the 1,2 ICSRA presented in this study may guide in planning and dissection to maximize the vascularity of a pedicled bone graft based on this vessel for the management of scaphoid nonunions.

Calculation of rotational deformity in pediatric supracondylar humerus fractures.

OBJECTIVE: Supracondylar humerus fractures (SCHF) are common in the pediatric population. Cubitus varus deformity (CVD) is the most common long-term complication of SCHFs and may lead to elbow instability and deficits in throwing or extension. Distal fragment malrotation in the axial plane disposes to fragment tilt and CVD; however, no simple method of assessing fracture malrotation exists. This study tested a mathematical method of measuring axial plane malrotation in SCHFs based on plain radiographs. DESIGN: A pediatric SCHF model was made, and x-rays were taken at known intervals of rotation. Five independent, blinded observers measured these films. Calculated rotation for each data set was compared to the known rotation. The identical protocol was performed for an aluminum phantom. RESULTS: The reliability and agreement of the rotation values were good for both models. CONCLUSIONS: This method is a reliable, accurate, and cost-effective means of calculating SCHF distal fragment malrotation and warrants clinical application.

"Floating total knee": ipsilateral periprosthetic fractures of the distal femur and proximal tibia after total knee arthroplasty.

UNLABELLED: Currently, there are more than 300000 primary total knee arthroplasty (TKA) performed annually in the United States. It is estimated that 0.3% to 2.5% of these patients will sustain a periprosthetic fracture in association with a TKA [Haidukewych GJ, Jacofsky DJ, Hanssen AD. Treatment of periprosthetic fractures around a total knee arthroplasty. J Knee Surg 2003;16:111]. The first report of a periprosthetic fracture involving a TKA occurred in 1977 [Callaghan JJ. Periprosthetic fractures of the acetabulum during and following total hip arthroplasty. Instr Course Lect 1998;47:231]. The majority of periprosthetic fractures associated with a TKA are distal femoral fractures [Berry D. EPIDEMIOLOGY: hip and knee. In: Callaghan J, Duncan C, editors. Periprosthetic fractures after major joint replacement. Philadelphia: WB Saunders; 1999. p. 183]. Periprosthetic tibial fractures are rare and usually involve the medial tibial plateau in the presence of a loose component [Rand JA, Coventry MB. Stress fractures after total knee arthroplasty. J Bone Joint Surg Am 1980;62:226, Hanssen AD, Stuart MJ]. Treatment of periprosthetic tibial fractures. Clin Orthop 2000; p. 91]. The following case report describes the management of simultaneous ipsilateral distal femoral and proximal tibial periprosthetic fractures associated with a TKA. The patient was informed that data concerning the case would be submitted for publication. To our knowledge, this "floating total knee" injury has not been previously reported.