Distal Metaphyseal Osteotomy Allows for Greater Ulnar Shortening Compared to Diaphyseal Osteotomy for Ulnar Impaction Syndrome: A Biomechanical Study.

Purpose To compare the biomechanical characteristics between diaphyseal and metaphyseal ulnar-shortening osteotomy with respect to (1) maximal shortening achieved at each osteotomy site and (2) force required to achieve shortening at each site. Methods Nine fresh frozen cadaveric upper extremities were affixed through the proximal ulna to a wooden surgical board. A metaphyseal 20-mm bone wedge was resected from the distal ulna and sequential shortening was performed. A load cell was attached to a distal post that was clamped to the surgical board and used to measure the force required for each sequential 5-mm of shortening until maximal shortening was achieved. The resected bone was reinserted, and plate fixation was used to restore normal anatomy. A 20-mm diaphyseal osteotomy was performed, and force measurements were recorded in the same manner with (1) interosseous membrane intact, (2) central band released, and (3) extensive interosseous membrane and muscular attachments released. Results Metaphyseal osteotomy allowed greater maximal shortening than diaphyseal osteotomy with the interosseous membrane intact and with central band release but similar shortening when extensive interosseous membrane and muscle release was performed. Force at maximal shortening was similar between metaphyseal and diaphyseal osteotomy. Sequential soft tissue release at the diaphysis allowed for increased shortening with slightly decreased shortening force with sequential release. Conclusion Metaphyseal ulnar osteotomy allows greater maximal shortening but requires similar force compared with diaphyseal osteotomy. Sequential release of the interosseous membrane permits increased shortening at the diaphysis but requires extensive soft tissue release. Clinical Relevance Both sites of osteotomy can achieve sufficient shortening to decompress the ulnocarpal joint for most cases of ulnar impaction syndrome. The greater shortening from metaphyseal ulnar osteotomy may be reserved for severe cases of shortening, especially after distal radius malunion or in the setting of distal radius growth arrest in the pediatric population. Level of Evidence This is a Level V, basic science study.

Revision Total Wrist Arthroplasty Due to Polyethylene Wear, Metallosis-Induced Carpal Tunnel Syndrome, Distal Ulnar Impingement, and Fourth Carpometacarpal Joint Pain: Case Report and Pitfalls to Avoid.

Background: Total wrist arthroplasty (TWA) is indicated to alleviate pain secondary to arthritis while preserving wrist motion. Despite vigilant measures, TWAs are susceptible to complications. The current case illustrates an array of preventable complications which are addressed through operative technique in a revision setting. Case presentation: The patient was a 72-year-old man who presented with chronic pain at the fourth carpometacarpal joint (CMCJ) and distal radioulnar joint with paresthesias in the median nerve distribution. Surgery was undertaken to address the following complications secondary to a previous TWA: impingement of the native distal ulna on the prosthesis, carpal tunnel due to metallosis and polyethylene synovitis, loose carpal component, and prominent screw at the fourth CMCJ. Surgical correction included open carpal tunnel release with extensive flexor tenosynovectomy, distal ulna resection and implant arthroplasty with shortening, revision of carpal component with bone grafting, and shortening of the ulnar screw to avoid crossing the fourth CMCJ. Within 6 months of the procedure, the patient reported resolution of neuropathic symptoms and pain-free motion of the wrist. Discussion: Preventable complications associated with TWA are individually highlighted. In addition, we compare and contrast our approach and surgical technique to current reported literature. Overall, we provide education and guidance to avoid possible TWA pitfalls. Conclusion: With this case report, we hope to increase TWA knowledge with emphasis on the requirements of judicious patient selection, preoperative planning, meticulous surgical technique, and complication awareness for subsequent optimization of wrist function, stability, and durability.

Early Correction of Distal Radius Partial Articular Malunion Leads to Good Long-term Functional Recovery at Mean Follow-up of 4 Years.

Background: Distal radius articular step-off or deformity may cause posttraumatic arthritis and poor functional outcome. The purpose of this study was to evaluate pain and functional outcomes in patients with malunited partial articular distal radius fractures who underwent corrective osteotomy. We hypothesized that anatomic restoration of distal radius articular surface after a malunited partial articular distal radius fracture results in improvement in pain and functional measures and delays the development of posttraumatic arthritis. Methods: Seven consecutive patients with mean age of 38 years underwent corrective osteotomy via either a standard dorsal approach or combined dorsal and volar approach. Mean time from injury to corrective osteotomy was 10 weeks. Patients were assessed with respect to Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), forearm and wrist range of motion, pain, and grip strength. Results: At mean follow-up of 44 months, significant improvements in pain scores (7.1-0.9, P < .001), QuickDASH (38.7-11.6, P < .001), grip strength (21.4-30.0 kg, P = .01) were achieved. All range of motion measurements demonstrated significant improvements except forearm pronation. One patient demonstrated radiographic evidence of osteoarthritis but had no pain at final follow-up. No patients required secondary surgery for removal of symptomatic hardware. Conclusions: Based on these findings, we recommend that early corrective osteotomies should be considered in young patients with intra-articular distal radius malunions before considering salvage procedures such as partial or complete wrist arthrodesis.

Determinants of Pain and Predictors of Pain Relief after Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome.

Background The purpose of this study is to characterize patient- and surgery-specific factors associated with perioperative pain level in patients undergoing ulnar shortening osteotomy (USO) for ulnar impaction syndrome (UIS). We hypothesize that preoperative opiate consumption, tobacco utilization, and severity of ulnar variance will be associated with less postoperative pain relief. Methods All cases of USO between January 2010 and December 2016 for management of UIS were retrospectively reviewed. Patient demographics, smoking status, type of labor, and opioid utilization before surgery were recorded. Radiographic measurements for ulnar variance, radial tilt and inclination, as well as triangular fibrocartilage complex and distal radial-ulnar joint (DRUJ) morphology were assessed. Pre- and postoperative pain score were recorded. Regression analysis was performed to determine predictors of pain scores. Results A total of 69 patients were included for the final analysis with a mean age of 44 years (range 17-73 years). Seventeen patients reported use of daily opioid medications at the time of surgery (25%). Patients who used opioid analgesics daily, active laborers, smokers, and patients involved in worker compensation claims had significantly less pain relief after surgery. Patients with osteotomy performed at the metaphysis had significantly more pain relief than patients that had diaphyseal osteotomy. Regression analysis identified tobacco utilization and anatomic site of osteotomy as independent predictors of postoperative pain. Conclusion The results from this study identified smoking and location of osteotomy as independent predictors of postoperative pain relief. While smoking cessation is paramount to prevent delayed/nonunion it may also help improve pain relief following USO. The potential to achieve greater shortening with a metaphyseal osteotomy suggests that in addition to the mechanical unloading the carpus, pain relief after USO may also stem from tensioning the ulnar collateral ligaments of the wrist, the ECU subsheath, and the radioulnar ligaments. Level of Evidence This is a Level III, therapeutic study.

Chronic Longitudinal Instability of the Forearm Treated With a Combination of Ulnar Shortening Osteotomy, Pronator Teres Transfer, and Tightrope Technique.

Restoration of longitudinal stability of the forearm continues to pose a difficult challenge for the hand surgeon, and no technique has demonstrated success above others. Longitudinal stability to the forearm is conferred by 3 structures: the radial head, which acts as a primary stabilizer, the interosseous membrane, more specifically, the central band and, the distal radioulnar ligaments which are part of the triangular fibrocartilage complex. A combination of techniques is described in this article to address chronic longitudinal instability of the forearm: (1) ulnar shortening osteotomy to restore ulnar variance, (2) pronator teres transfer was used to reconstruct the central band of the interosseous membrane, and (3) tightrope augmentation was used to prevent elongation during the healing process.

Minimally Invasive Proximal Interphalangeal Joint Arthrodesis Using Headless Screw: Surgical Technique.

Proximal interphalangeal (PIP) joint arthritis causes debilitating hand pain and instability leading to significant functional impairment. Arthrodesis remains the gold standard for treatment of PIP arthritis. We present a minimally invasive PIP arthrodesis that provides rigid fixation with a headless compression screw. Seven patients who presented to the senior author with PIP joint arthritis underwent PIP arthrodesis by minimally invasive technique. A 1 cm transverse incision is made over the PIP joint, incising skin, central band, and articular capsule. PIP joint is flexed to expose the articular surface. Articular surfaces are prepared with a fine tipped rongeur, exposing subchondral bone until flat surfaces are obtained. Under fluoroscopy a guide wire for cannulated headless screw (3.0, 2.4, or 2.0 mm) is inserted in an antegrade manner. It progresses from the center of the proximal phalangeal articular surface until it exits through the dorsal cortex and the distal end lies within the subchondral bone. This is the most critical step of the procedure because the guide wire angle determines the degree of flexion of the fusion. A 5 mmincision is made over the guide wire and the wire is advanced through the center of the medullary canal of the middle phalanx. The wire is then overdrilled, length is measured, and a headless compression screws is inserted. Reevaluate alignment after insertion of the screws because malrotation may be induced by torque during compression. Six consecutive patients underwent the procedure by the senior author. All patients healed the arthrodesis without complications and hardware removal was not needed. Minimally invasive PIP joint arthrodesis is a safe and viable procedure. Critical portions of the procedure include placing the wire at the angle of the desired angle of fusion and avoiding malrotation during screw insertion.

Current Perspectives on Complex Wrist Fracture-Dislocations.

Although perilunate injuries represent only 5% of all carpal injuries, they compose a spectrum of devastating complex wrist injuries. Perilunate injuries result from high-energy trauma to the wrist and may be associated with multiple fractures, dislocations, and ligament injuries. Although the diagnosis of a perilunate injury is made via radiographic assessment, missed diagnosis occurs in 25% of patients with a perilunate injury. Immediate diagnosis of perilunate injuries is critical to optimize patient outcomes. Closed reduction of perilunate injuries is performed to avoid permanent damage to the median nerve and other compromised structures. As swelling subsides, open reduction is performed to restore anatomic alignment, attain stable fixation, and repair the ligaments. Despite optimal management of perilunate injuries, complications, including median nerve dysfunction, complex regional pain syndrome, carpal instability, and late posttraumatic arthritis, may occur. Satisfactory outcomes can be achieved in patients with a perilunate injury via prompt recognition and timely surgical management. Although radiographic signs of arthritis develop in many patients with a perilunate injury, these radiographic signs do not necessarily correlate with functional outcomes. Some patients with a perilunate injury require salvage procedures for the management of persistent complications. Radiocarpal fracture-dislocations are a complex wrist fracture-dislocation pattern. Radiocarpal fracture-dislocations generally result from high-energy trauma and are characterized by a carpal dislocation, which usually involves a small portion of the rim of the dorsal or volar aspect of the distal radius. Neurologic dysfunction and elevated intracompartment pressure may be present in patients with a radiocarpal fracture-dislocation. Wrist fracture-dislocations are associated with a number of complications, including intercarpal instability, later arthrosis, carpal nonunion, and loss of radiocarpal mobility.

Metaphyseal Versus Diaphyseal Ulnar Shortening Osteotomy for Treatment of Ulnar Impaction Syndrome: A Comparative Study.

PURPOSE: To compare the clinical and radiographic outcomes and complication rates of diaphyseal and metaphyseal ulnar shortening osteotomies for the treatment of ulnar abutment syndrome. METHODS: We performed a retrospective study comparing 35 patients who underwent either a metaphyseal (n = 14) or diaphyseal (n = 21) osteotomy. Radiographic and clinical outcomes were compared. Complication rates including infection, hardware removal, and reoperations were also assessed. RESULTS: There were no differences in patient characteristics, ulnar variance, or pain and functional scores between groups. Metaphyseal osteotomy surgery time was shorter (45.5 vs 71.7 minutes) and resulted in greater ulnar shortening (4.8 vs 3.4 mm) compared with diaphyseal osteotomies. At an average 19.2-month follow-up, metaphyseal osteotomies were associated with greater improvement in pain and Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire scores. The need for implant removal was the same in both groups. There were no complications in either group. CONCLUSIONS: Results from this study suggest that metaphyseal osteotomies are a safe and effective alternative to diaphyseal osteotomies for the management of ulnar abutment syndrome. Although improved surgical time and postoperative outcomes are encouraging, further large-scale and properly powered studies with long-term outcomes will help characterize the benefit of one technique over another. Ultimately, the decision between a metaphyseal and diaphyseal osteotomy may be surgeon preference. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Scaphocapitate Syndrome With Associated Trans-Scaphoid, Trans-Hamate Perilunate Dislocation: A Case Report and Description of Surgical Fixation.

Background: Perilunate fracture dislocations are often associated with fractures of the distal pole of the scaphoid or the proximal pole of the capitate. However, the combination of perilunate dislocation with multiple carpal fractures and associated scaphocapitate syndrome is very rare. Methods: We report a unique case of scaphocapitate fracture syndrome with perilunate dislocation and fracture of the hamate resulting from a high-energy injury to the wrist during a dirt-bike competition. Results: Open reduction and internal fixation of the scaphoid fracture with a 3.0-mm headless screw, the head of the capitate with a 1.5-mm lag screw, and the hamate fracture with a 1.3-mm lag screw was performed. The lunotriquetral dissociation was reduced, with the ligament repaired and the joint stabilized using a Kirschner wire. All screw heads are carefully buried under the articulate cartilage. Conclusions: Prompt anatomic reduction and stable osteosynthesis of all fractures in this patient resulted in successful healing and return to activity.

Single-Stage, Single-Incision Correction of Neuromuscular Hip Dysplasia: Surgical Technique.

Surgical correction of neuromuscular hip dysplasia is a common orthopaedic procedure that carries significant risk of complications. Reducing time of surgery, limiting incisions, and minimizing unnecessary surgical exposure are paramount in reducing complications. This article describes the use of a single-stage, single-surgical approach operation for the correction of neuromuscular hip dysplasia. The operation consists of a modified anterolateral approach to the hip joint (modified Watson-Jones approach) to perform a varus derotational proximal femur osteotomy, hinged acetabuloplasty, and soft tissue releases.

Arthroscopic Release of Adhesive Capsulitis of the Shoulder Complicated With Shoulder Dislocation and Brachial Plexus Injury.

The incidence of brachial plexus injury after shoulder dislocation or arthroscopic shoulder surgery is low. Complex regional pain syndrome (CRPS) is an uncommon but painful condition that can develop after nerve injury. Historically, CRPS has been difficult to treat and therapeutic efforts are sometimes limited to ameliorating symptoms. However, if a dystrophic focus can be identified, the condition can be addressed with surgical exploration for potential neurolysis or nerve repair. The present article reports on a case of type II CRPS that developed in the postoperative setting of arthroscopic shoulder surgery complicated with simple shoulder dislocation.

Hemodynamic recovery after hypovolemic shock with lactated Ringer's and keratin resuscitation fluid (KRF), a novel colloid.

Death after severe hemorrhage remains an important cause of mortality in people under 50 years of age. Keratin resuscitation fluid (KRF) is a novel resuscitation solution made from keratin protein that may restore cardiovascular stability. This postulate was tested in rats that were exsanguinated to 40% of their blood volume. Test groups received either low or high volume resuscitation with either KRF or lactated Ringer's solution. KRF low volume was more effective than LR in recovering cardiac function, blood pressure and blood chemistry. Furthermore, in contrast to LR-treated rats, KRF-treated rats exhibited vital signs that resembled normal controls at 1-week.

Distal ulna hook plate: angular stable implant for fixation of distal ulna.

Distal ulna fractures, especially styloid injuries, classically have not been repaired, and only recently have these injuries been considered important. Certain fracture patterns of the distal ulna contribute to distal radioulnar joint (DRUJ) incongruity and potential instability. Appropriate fixation of the distal ulna is frequently difficult for several reasons: (1) high incidence of osteoporois in the affected patient population, (2) proximity of the injury to articular surfaces, and (3) lack of a proper implant to treat these injuries. The 2.0-mm locking compression distal ulna plate (LC-DUP) is an anatomically contoured implant with a low profile and fixed angle that provides proper stability to treat injuries of the distal ulna. The plate was designed for the treatment of distal ulna fractures, but its success has led to an extension of its indications to be used in treating symptomatic basistyloid ulnar nonunions and in ulnar shortening osteotomy for ulnocarpal abutment syndrome. The authors' description of the techniques used for each indication as well as their perspectives in the treatment of distal ulna injuries are described in detail in this report.

Metaphyseal ulnar shortening osteotomy for the treatment of ulnocarpal abutment syndrome using distal ulna hook plate: case series.

PURPOSE: To determine the efficacy of a transverse ulnar-shortening osteotomy at the metaphysis in combination with osteosynthesis using a low-profile, 2.0-mm, locking compression distal ulna plate for the treatment of ulnocarpal abutment syndrome. METHODS: We enrolled into this prospective case series 6 patients with symptomatic ulnocarpal abutment syndrome without distal radioulnar joint ligamentous instability, who had previously failed conservative treatment. We recorded Quick Disability of Arm, Shoulder, and Hand score; wrist range of motion; and visual analog scale score for pain before and after surgery for statistical comparisons. RESULTS: All parameters improved after the surgery. The Quick Disabilities of the Arm, Shoulder, and Hand improved from a mean of 65 to 17, and the visual analog score improved from a mean of 7 to 2. No hardware removal was required and no complications were reported. CONCLUSIONS: Metaphyseal ulnar-shortening osteotomy provided the functional advantages of a midshaft ulnar-shortening osteotomy with the potential for improved bone healing and the reduced risk for complications. This technique was a useful alternative for treatment of ulnocarpal abutment syndrome, especially in patients with more than 2 mm ulnar positive variance. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.