Does achieving clinically important thresholds after first shoulder arthroplasty predict similar outcomes of the contralateral shoulder?

BACKGROUND: Patients are increasingly undergoing bilateral total shoulder arthroplasty (TSA). At present, it is unknown whether success after the first TSA is predictive of success after contralateral TSA. We aimed to determine whether exceeding clinically important thresholds of success after primary TSA predicts similar outcomes for subsequent contralateral TSA. METHODS: We performed a retrospective review of a prospectively collected shoulder arthroplasty database for patients undergoing bilateral primary anatomic (aTSA) or reverse (rTSA) total shoulder arthroplasty since January 2000 with preoperative and 2- or 3-year clinical follow-up. Our primary outcome was whether exceeding clinically important thresholds in the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score for the first TSA was predictive of similar success of the contralateral TSA; thresholds for the ASES score were adopted from prior literature and included the minimal clinically important difference (MCID), the substantial clinical benefit (SCB), 30% of maximal possible improvement (MPI), and the patient acceptable symptomatic state (PASS). The PASS is defined as the highest level of symptom beyond which patients consider themselves well, which may be a better indicator of a patient's quality of life. To determine whether exceeding clinically important thresholds was independently predictive of similar success after second contralateral TSA, we performed multivariable logistic regression adjusted for age at second surgery, sex, BMI, and type of first and second TSA. RESULTS: Of the 134 patients identified that underwent bilateral shoulder arthroplasty, 65 (49%) had bilateral rTSAs, 45 (34%) had bilateral aTSAs, 21 (16%) underwent aTSA/rTSA, and 3 (2%) underwent rTSA/aTSA. On multivariable logistic regression, exceeding clinically important thresholds after first TSA was not associated with greater odds of achieving thresholds after second TSA when success was evaluated by the MCID, SCB, and 30% MPI. In contrast, exceeding the PASS after first TSA was associated with 5.9 times greater odds (95% confidence interval 2.5-14.4, P < .001) of exceeding the PASS after second TSA. Overall, patients who exceeded the PASS after first TSA exceeded the PASS after second TSA at a higher rate (71% vs. 29%, P < .001); this difference persisted when stratified by type of prosthesis for first and second TSA. CONCLUSIONS: Patients who achieve the ASES score PASS after first TSA have greater odds of achieving the PASS for the contralateral shoulder regardless of prostheses type.

Establishing the diagnosis of radial tunnel syndrome: a systematic review of published clinical series.

PURPOSE: Radial tunnel syndrome (RTS) is a controversial diagnosis due to non-specific exam findings and frequent absence of positive electromyography (EMG) and nerve conduction study (NCS) findings. The purpose of this study was to identify the methods used to diagnose RTS in the literature. METHODS: We queried PubMed, Embase, Web of Science, and Cochrane databases per PRISMA guidelines. Extracted data included article and patient characteristics, diagnostic assessments utilized and their respective findings, and treatments. Objective data were summarized descriptively. The relationship between reported diagnostic findings (i.e., physical exam and diagnostic tests) and treatments was assessed via a descriptive synthesis. RESULTS: Our review included 13 studies and 391 upper extremities. All studies utilized physical exam in diagnosing RTS; most commonly, patients had tenderness over the radial tunnel (381/391, 97%). Preoperative EMG/NCS was reported by 11/13 studies, with abnormal findings in 8.9% (29/327) of upper extremities. Steroid and/or lidocaine injection for presumed lateral epicondylitis was reported by 9/13 studies (46/295 upper extremities, 16%), with RTS being diagnosed after patients received little to no relief. It was also common to inject the radial tunnel to make the diagnosis (218/295, 74%). The most common reported intraoperative finding was narrowing of the PIN (38/137, 28%). The intraoperative compressive site most commonly reported was the arcade of Frohse (142/306, 46%). CONCLUSIONS: There is substantial heterogeneity in modalities used to diagnose RTS and the reported definition of RTS. This, in conjunction with many patients having concomitant lateral epicondylitis, makes it difficult to compare treatment outcomes for RTS. LEVEL OF EVIDENCE: Level III. Systematic review of retrospective and prospective cohort studies.

Study Design and Analysis in Hand Surgery Research: Tips for Success.

Hand surgeons are constantly faced with evaluation of new evidence to identify best practices in clinical care. However, even the most rigorous study designs have limitations due to biases, generalizability, and other flaws. Here, we highlight seven common aspects of study design and analysis that should be considered by hand surgeons when interpreting findings. The evaluation of these practices can optimize the peer-review process and assess the value of evidence to be incorporated into clinical practice.

The association between humeral lengthening and clinical outcomes after reverse shoulder arthroplasty: a systematic review and meta-analysis.

BACKGROUND: The purpose of this study was to evaluate the relationship between humeral lengthening and clinical outcomes after reverse shoulder arthroplasty (RSA) with stratification based on measurement method and implant design. METHODS: This systematic review was performed using PRISMA-P guidelines. PubMed/Medline, Cochrane Trials, and Embase were queried for articles evaluating the relationship between humeral lengthening and clinical outcomes inclusive of range of motion (ROM), strength, outcome scores, and pertinent complications (acromial and scapular spine fractures, nerve injury) after RSA. The relationship between humeral lengthening and clinical outcomes was reported descriptively overall and stratified by measurement method and implant design (globally medialized vs. lateralized). A positive association was defined as increased humeral lengthening being associated with greater ROM, outcome scores, or a greater incidence of complications, whereas a negative association denoted that increased humeral lengthening was associated with poorer ROM, outcome scores, or a lower incidence of complications. Meta-analysis was performed to compare humeral lengthening between patients with and without fractures of the acromion or scapular spine. RESULTS: Twenty-two studies were included. Humeral lengthening was assessed as the acromiohumeral distance (AHD), the distance from the acromion to the greater tuberosity (AGT), the acromion to the deltoid tuberosity (ADT), and the acromion to the distal humerus (ADH). Of 11 studies that assessed forward elevation, a positive association with humeral lengthening was found in 6, a negative association was found in 1, and 4 studies reported no association. Of studies assessing internal rotation (n = 9), external rotation (n = 7), and abduction (n = 4), all either identified a positive or lack of association with humeral lengthening. Studies assessing outcome scores (n = 11) found either a positive (n = 5) or no (n = 6) association with humeral lengthening. Of the studies that assessed fractures of the acromion and/or scapular spine (n = 6), 2 identified a positive association with humeral lengthening, 1 identified a negative association, and 3 identified no association. The single study that assessed the incidence of nerve injury identified a positive association with humeral lengthening. Meta-analysis was possible for AGT (n = 2) and AHD (n = 2); greater humeral lengthening was found in patients with fractures for studies using the AGT (mean difference 4.5 mm, 95% CI 0.7-8.3) but not the AHD. Limited study inclusion and heterogeneity prohibited identification of trends based on method of measuring humeral lengthening and implant design. CONCLUSION: The relationship between humeral lengthening and clinical outcomes after RSA remains unclear and requires future investigation using a standardized assessment method.

Two-year outcomes of the reverse humeral reconstruction prosthesis.

BACKGROUND: Extensive proximal humeral bone loss in the setting of shoulder arthroplasty represents a difficult challenge for the treating surgeon. Achieving adequate fixation with standard humeral prostheses can be problematic. Allograft-prosthetic composites are a viable solution for this problem; however, high rates of complications have been reported. Modular proximal humeral replacement systems are another potential solution, but there is a paucity of outcome data on these implants. This study reports the 2-year minimum follow-up outcomes and complications of a single system reverse proximal humeral reconstruction prosthesis (RHRP) for patients with extensive proximal humeral bone loss. METHODS: We retrospectively reviewed all patients with minimum 2-year follow-up who underwent implantation of an RHRP for either (1) failed shoulder arthroplasty or (2) proximal humerus fracture with severe bone loss (Pharos 2 and 3) and/or sequelae thereof. Forty-four patients met inclusion criteria (average age 68.3 ± 13.1 years). The average follow-up was 36.2 ± 12.4 months. Demographic information, operative data, and complications were recorded. Pre- and postoperative range of motion (ROM), pain, and outcome scores were assessed and compared to the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for primary rTSA where available. RESULTS: Of the 44 RHRPs evaluated, 93% (n = 39) had undergone prior surgery and 70% (n = 30) were performed for failed arthroplasty. ROM improved significantly in abduction by 22° (P = .006) and forward elevation by 28° (P = .003). Average pain on a daily basis and pain at worst improved significantly, by 2.0 points (P < .001) and 2.7 points (P < .001), respectively. Mean Simple Shoulder Test score improved by 3.2 (P < .001), Constant score by 10.9 (P = .030), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score by 29.7 (P < .001), University of California, Los Angeles (UCLA), score by 10.6 (P < .001), and Shoulder Pain and Disability Index score by 37.4 (P < .001). A majority of patients achieved the MCID for all outcome measures assessed (56%-81%). The SCB was exceeded by half of patients for forward elevation and the Constant score (50%), and exceeded by the majority of patients for the ASES score (58%) and UCLA score (58%). The complication rate was 28%; the most common complication was dislocation requiring closed reduction. Notably, there were no occurrences of humeral loosening requiring revision surgery. DISCUSSION: These data demonstrate that the RHRP resulted in significant improvements in ROM, pain, and patient-reported outcome measures, without the risk of early humeral component loosening. RHRP represents another potential solution for shoulder arthroplasty surgeons when addressing extensive proximal humerus bone loss.

Glenoid component placement accuracy in total shoulder arthroplasty with preoperative planning and standard instrumentation is not influenced by supero-inferior glenoid erosion.

PURPOSE: Accurate glenoid component placement in total shoulder arthroplasty (TSA) remains challenging even with preoperative planning, especially for variable glenoid erosion patterns in the coronal plane. METHODS: We retrospectively reviewed 170 primary TSAs in which preoperative planning software was used. After registration of intraoperative bony landmarks, surgeons were blinded to the navigation screen and attempted to implement their plan by simulating placement of a central-axis guide pin: 230 screenshots of simulated guide pin placement were included (aTSA = 66, rTSA = 164). Displacement, error in version and inclination, and overall malposition from the preoperatively-planned target point were stratified by the Favard classification describing superior-inferior glenoid wear: E0 (n = 89); E1 (n = 81); E2 (n = 29); E3(n = 29); E4(n = 2). Malposition was considered > 10° for version/inclination errors or > 4 mm displacement from the starting point. RESULTS: Mean displacement error was 3.5 ± 2.7 mm (aTSA = 2.7 ± 2.3 mm, rTSA = 3.8 ± 2.9 mm), version error was 5.7 ± 4.7° (aTSA = 5.8 ± 4.4°, rTSA = 5.7 ± 4.8°), inclination error was 7.1 ± 5.6 (aTSA = 4.8 ± 4.8°, rTSA = 8.1 ± 5.7°), and malposition rate was 53% (aTSA = 38%, rTSA = 59%). When compared by Favard classification, there were no differences in any measure; when stratified by TSA type, version error differed for rTSAs (P = .038), with E1 having the greatest version error (6.9 ± 5.2°) and E3 the least (4.2 ± 3.4°). When comparing glenoids without wear (E0) and glenoids with superior wear (E2 and E3), the only difference was greater version error in glenoids without wear (6.0 ± 4.9° vs. 4.6 ± 3.7°, P = .041). CONCLUSIONS: Glenoid malposition did not differ based on coronal glenoid morphology. Although, malposition was relatively high, suggesting surgeons should consider alternate techniques beyond preoperative planning and standard instrumentation in TSA. LEVEL OF EVIDENCE III: Retrospective Cohort Study.

How to Shoot and Edit High-Quality Surgical Videos for Hand and Upper Extremity Surgery.

A surgical video can improve patient care, surgical education, as well as scientific presentations and publications. Previous authors have outlined a basic understanding of how to produce high-quality surgical videos. With continuous technological improvements in video-filming hardware and editing software, multiple options for producing high-quality surgical videos are available. This article described important aspects of filming and editing videos to create a video that the surgeon can watch before performing the procedure. The authors reviewed camera terminology, including resolution, optical and digital zoom, shutter speed, and frame rate, as well as equipment options or setup for recording high-quality surgical videos. We provided information regarding computer requirements and editing on Windows and Macintosh operating systems, optimizing educational value for the viewer.

Rotator Cuff Repair and Reconstruction.

Rotator cuff pathology is the most common shoulder condition for which patients seek treatment. Schmidt et al covered the relevant anatomy, natural history, nonsurgical and surgical treatment, biological augmentation, and postoperative rehabilitation in their comprehensive review published in 2015. This current review builds upon the last update, discussing the most recent evidence-based medicine regarding rotator cuff repair: primary repair, revision repair, and reconstructive techniques for superior capsular reconstruction, subacromial balloon spacers, tendon transfer options (pectoralis major, latissimus dorsi, and lower trapezius), and reverse total shoulder arthroplasty.

Forearm Nonunion: Characterization and Management.

Adult forearm nonunion should be investigated prior to developing a treatment strategy: "Why did the fracture not heal?" Optimizing the patient's biology and the stability at the nonunion site are critical for a successful outcome. This review concisely discusses the initial work-up, including history, physical examination, imaging, and laboratory testing, as well as available surgical techniques-irrigation and debridement with deep cultures, revision open reduction internal fixation with or without biological adjuvant therapies, cancellous autograft, tricortical iliac crest, reamer/irrigator/aspirator, allograft, vascularized free-fibula and induced-membrane technique.

Distal Biceps Tendon Repair and Reconstruction.

Distal biceps tendon ruptures can result in functionally significant loss of supination and flexion strength, as well as decreased resistance to fatigue. Although the diagnosis of distal biceps tendon ruptures remains straightforward, substantial debate continues with regards to surgical indications, pertinent surgical anatomy, single- versus double-incision surgical technique, and fixation options. This review discusses the latest evidence-based literature regarding distal biceps tendon repair/reconstruction including types of tears, demographics, clues for diagnosis, surgical indications, anatomy with special attention to how the distal tendon inserts distally and the relevant tuberosity anatomy (height and cam effect), common reconstruction techniques (single- vs double-incision and single-incision power optimizing cost-effective technique), fixation techniques (bone tunnels, distal biceps button, interference screw, button plus screw), surgical technique pearls, postoperative rehabilitation, postoperative outcomes, as well as the treatment of chronic tears with special reconstruction techniques including Achilles allograft, pedicled latissimus transfer, and the use of a free innervated gracilis.

In Situ Venous Bypass for Chronic Hand Ischemia: A Review of 25 Cases in 23 Patients.

BACKGROUND: Chronic ischemia of the hand in the setting of atherosclerotic disease is a challenging problem that leads to serial amputations and significant morbidity. Salvage using an in situ venous bypass has been described. In selected cases, leaving the vein in situ for bypass allows a good size match for anastomosis at the wrist or palmar arch. Due to the rarity of the condition, there is a paucity of data regarding the efficacy of this technique. METHODS: Outcomes in 23 consecutive patients that underwent a total of 25 in situ vein grafts over a 16-year period were retrospectively reviewed. RESULTS: Eighteen were men and 5 were women with a mean age of 61 years. Target vessels at the wrist or palmar arch were identified on preoperative vascular imaging. The cephalic vein (n = 19, 76%) was most commonly used followed by the basilic vein (n = 6, 24%). Overall patency rate at a mean follow-up period of 12.1 months was 92%. Success as determined by both symptomatic improvement and resolution of the ischemic changes or toleration of revision amputation was achieved in 16 (64%) cases. Postoperative complications occurred in ten cases (40 %). Progression of ischemia occurred in 7 cases (28 %) and 3 (12 %) of these cases required a hand amputation. CONCLUSIONS: In situ vein grafts in the upper extremity offer good short-term patency rates and can be used for salvage of chronic hand ischemia.

Functional outcomes and height restoration for patients with multiple myeloma-related osteolytic vertebral compression fractures treated with kyphoplasty.

STUDY DESIGN: A retrospective review of pathologic vertebral fractures related to multiple myeloma. OBJECTIVE: To report the functional status and height restoration of 32 patients treated with kyphoplasty for multiple myeloma-related vertebral compression fractures. SUMMARY OF BACKGROUND DATA: Multiple myeloma can cause significant bony resorption, and vertebral involvement is extremely common. Compression fractures due to myelomatous vertebral metastases result in significant pain and can lead to kyphosis and sagittal imbalance. Nonoperative treatment can result in deformity and continued pain, and large surgical procedures have significant morbidity. Percutaneous cement augmentation (kyphoplasty and vertebroplasty) is a minimally invasive technique that can improve pain in these patients. Kyphoplasty also has the potential to provide mild deformity correction in addition to fracture stabilization. METHODS: Study participants were patients with biopsy-proven multiple myeloma presenting with compression fracture treated with kyphoplasty. Data were compiled from patient charts and preoperative and postoperative radiographs. Patient self-reported functional status were obtained through the use of the Oswestry Disability Index. The degree of vertebral body collapse and deformity was evaluated using the method of Genant and analyzed using paired Student t test. RESULTS: Thirty-two consecutive patients who underwent kyphoplasty at a total of 76 levels for myelomatous vertebral compression fractures were identified. Sixteen fractures were at the thoracolumbar junction. The mean age was 64.3 years. The average Genant grade for the involved levels improved from 1.9 preoperative to 1.53 postoperative, which was statistically significant (P<0.0001). The postoperative Oswestry Disability Index score was obtained at a mean of 24 months, with a mean of 29.6%. Complications occurred in 12 (37.5%) patients, all consisting of minimal intraoperative cement extravasation without clinical sequelae. No changes in the neurological status were observed. The average hospital stay was 1.34 days postprocedure. CONCLUSION: Kyphoplasty for vertebral compression fractures due to multiple myeloma is a safe and effective procedure that can lead to pain relief and vertebral height restoration.

Salvage of distal radius nonunion with a dorsal spanning distraction plate.

Treatment of nonunion after previous instrumentation of distal radius fractures represents a reconstructive challenge. Resultant osteopenia provides a poor substrate for fixation, often necessitating wrist fusion for salvage. A spanning dorsal distraction plate (bridge plate) can be a useful adjunct to neutralize forces across the wrist, alone or in combination with nonspanning plates to achieve union, salvage wrist function, and avoid wrist arthrodesis in distal radius nonunion.

A Review of 1228 In-Office Hand Surgery Procedures With Wide Awake Local Anesthesia No Tourniquet (WALANT) at a Single Private Practice.

BACKGROUND: This study examined the complication rate of Wide Awake Local Anesthesia No Tourniquet (WALANT) technique in the clinic setting with field sterility at a single private practice. We hypothesized that WALANT is safe and effective with a low complication rate. METHODS: This retrospective chart review included 1228 patients who underwent in-office WALANT hand procedures at a single private practice between 2015 and 2022. Patients were divided into groups based on type of procedure: carpal tunnel release, A1 pulley release, first dorsal compartment release, extensor tendon repair, mass excision, foreign body removal, and needle aponeurotomy. Patient demographics and complications were recorded; statistical comparisons of cohort demographics and risk factors for complications were completed, and P < .05 was considered significant for all statistical comparisons. RESULTS: The overall complication rate for all procedures was 2.77% for 1228 patients including A1 pulley release (n = 962, 2.7%), mass excision (n = 137, 3.7%), extensor tendon repair (n = 23, 4.3%), and first dorsal compartment release (n = 22, 8.3%). Carpal tunnel release, foreign body removal, and needle aponeurotomy groups experienced no complications. No adverse events (e.g. vasovagal reactions, digital ischemia, local anesthetic toxicity, inadequate vasoconstriction) were observed in any group. Patients with known autoimmune disorders and those who were currently smoking had a statistically significant higher complication rate. CONCLUSIONS: Office-based WALANT procedures with field sterility are safe and effective for treating common hand maladies and have a similar complication profile when compared to historical controls from the standard operating room in an ambulatory center or hospital.

Physician self-referral: frequency of negative findings at MR imaging of the knee as a marker of appropriate utilization.

PURPOSE: To determine whether ownership of magnetic resonance (MR) imaging equipment by ordering physicians affects the likelihood of positive findings at MR imaging of the knee and to evaluate rates of knee abnormalities seen at MR imaging as a metric for comparison of utilization. MATERIALS AND METHODS: The institutional review board approved this retrospective HIPAA-compliant study and waived the need for informed consent. A retrospective review was performed of consecutive diagnostic MR images of the knee interpreted by one radiology practice between January and April 2009 for patients who had been referred by two separate physician groups serving the same geographic community: one with financial interest (FI) in the MR imaging equipment used and one with no FI (NFI) in the MR imaging equipment used. The percentage of examinations with negative results was tabulated for both groups, and the relative frequency of each abnormality subtype was calculated among the studies with positive findings in each group. To examine frequency differences among groups, χ(2) tests were used, and to examine mean differences among groups, t tests were used. RESULTS: Of 700 examinations, 205 had negative results (117 of 350 in the FI group and 88 of 350 in the NFI group, P = .016). Among the examinations with positive results, the mean total number of positive abnormality subtypes per image did not significantly differ between groups: 1.52 for the FI group and 1.53 for the NFI group (P = .96). CONCLUSION: MR images of the knee among patients referred by the FI group were significantly more likely to be negative than those among patients referred by the NFI group. Frequency of abnormality subtype and distribution among examinations with positive results suggests a highly similar distribution and severity of abnormalities between the two patient groups.

Structural and functional analysis of the semitendinosus tendon after harvest for soft tissue reconstructive procedures: a dynamic ultrasonographic study.

PURPOSE: To assess the potential for regeneration of the hamstring tendons after harvesting for various soft tissue reconstructive procedures, this study uses dynamic, high-resolution ultrasound to evaluate the presence of any tissue in the harvest gap and to characterize tissue functionality. METHODS: Patients who underwent ACL reconstruction using ipsilateral hamstring autograft were identified in the database of a single surgeon. Dynamic 12-MHz sonographic imaging was used to evaluate the ipsilateral and contralateral (control) semitendinosus tendons from their insertion sites to proximal muscle bellies. The presence or absence and echogenicity of tissue in the harvest defect, tissue appearance, degree of retraction of the proximal tendon stump, thickness of gap tissue, and motion of the proximal tendon stump were recorded. Data were analysed with Wilcoxon-Mann-Whitney, sign or binomial tests, with significance of P < 0.05. RESULTS: Eighteen knees in 15 patients (aged 17-51 years) were studied. The proximal amputated stump was retracted an average of 9.0 ± 7.6 cm (range, 0-18 cm; P = 0.0063). With dynamic testing, 9 of 15 knees demonstrated decreased excursion of the proximal tendon stump when compared to the native, contralateral muscle-tendon unit (P = 0.0039). Tissue was detected in the harvest gap in nine knees, five of which had harvest gap tissue with a disorganized appearance compared to the native tendon (P < 0.0001). Six of these nine knees had tissue in the gap demonstrating either less or no excursion with active knee flexion when compared to the native, contralateral side (P = 0.0313). CONCLUSIONS: The presence of tissue in the harvest gap after ACL reconstruction is variable. When tissue is present, there is proximal retraction of the musculotendinous junction and disorganized appearance of the tissue that does not demonstrate normal excursion or physiological function similar to the native muscle-tendon unit. LEVEL OF EVIDENCE: Case series, Level IV.

Isolated ulnar shortening osteotomy for the treatment of extra-articular distal radius malunion.

PURPOSE: To report the clinical outcomes and complications for a cohort of patients who had extra-articular distal radius malunions treated with isolated ulnar-shortening osteotomy (USO). A second purpose was to define the dorsal angulation limit that would still result in clinical and functional improvement after isolated USO for distal radius malunion. We postulated that patients with up to 20° dorsal or volar tilt could be successfully treated with isolated USO. METHODS: We conducted a retrospective chart review for all patients who had an isolated USO for the treatment of ulnar impaction syndrome after distal radius malunion between January 1990 and December 2011. A total of 18 patients underwent isolated USO after distal radius malunion. The mean age of the patients was 53 years and the mean duration of follow-up was 34 months. We used Wilcoxon signed-rank tests to compare preoperative and postoperative range of motion; pain; Quick Disabilities of the Arm, Shoulder, and Hand scores; and radiographic measurements. RESULTS: Average intraoperative ulna shortening was 5.6 mm. Average flexion-extension arc improved from 79° preoperatively to 105° postoperatively. Average pronation-supination arc improved from 121° preoperatively to 162° postoperatively. Average visual analog scale pain score improved from 4.1 to 1.9. Average Quick Disabilities of the Arm, Shoulder, and Hand score improved from 43 to 11. CONCLUSIONS: This case series demonstrated a significant improvement in pain score and range of motion after isolated USO for distal radius malunion. Patients with up to 20° dorsal tilt and radial inclination as low as 2° demonstrated improved clinical and functional outcomes after isolated USO. Given the comparable functional outcomes with shorter operative times and lower complication rate requiring fewer secondary surgeries, isolated USO is an attractive alternative to distal radius osteotomy for the management of distal radius malunion in patients with up to 20° dorsal tilt. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Bridge plating in the setting of radiocarpal instability: Does distal fixation to the second or third metacarpal matter? A cadaveric study.

BACKGROUND: Radiocarpal dislocations are rare but potentially devastating injuries. Poorer outcomes are associated with inadequate or lost reduction, such as ulnar translocation, but no consensus exists on the ideal fixation technique. Dorsal bridge plate fixation has been described for various settings in the treatment of complex distal radius fractures and can be fixed distally to the second or third metacarpal, but its application for radiocarpal dislocations has not been established. AIM: To determine whether distal fixation to the second or third metacarpal matters. METHODS: Using a cadaveric radiocarpal dislocation model, the effect of distal fixation was studied in two stages: (1) A pilot study that investigated the effect of distal fixation alone; and (2) a more refined study that investigated the effect of described techniques for distal and proximal fixation. Radiographs were measured in various parameters to determine the quality of the reduction achieved. RESULTS: The pilot study found that focusing on distal fixation alone without changing proximal fixation results in ulnar translocation and volar subluxation when fixing distally to the second metacarpal compared with the third. The second iteration demonstrated that anatomic alignment in coronal and sagittal planes could be achieved with each technique. CONCLUSION: In a cadaveric radiocarpal dislocation model, anatomic alignment can be maintained with bridge plate fixation to the second metacarpal or the third metacarpal if the described technique is followed. When considering dorsal bridge plate fixation for radiocarpal dislocations, the surgeon is encouraged to understand the nuances of different fixation techniques and how implant design features may influence proximal placement.

Relative Increase in Distal Radius Exposure with Extension of the FCR Approach.

Objectives: Major surgical approaches for volar plating of the distal radius include the standard flexor carpi radialis (FCR) approach, the extended FCR (eFCR) approach, and the extended FCR approach combined with radial-sided carpal tunnel release (eFCR+CTR). The purpose of this study was to determine which of these three surgical approaches offers the greatest exposure and visualization of the distal radius. Methods: Sequential dissections were performed on each of 30 fresh frozen below elbow cadaveric samples in order to simulate the three surgical approaches for distal radius volar plating, starting with the standard FCR approach, advancing to eFCR, and finishing with eFCR+CTR. Prior to the initial dissection of each cadaveric sample, radiographs were taken in order to calculate the total area of the distal radius. Then, following each sequential dissection, photographs were taken of each specimen and analyzed with an image measuring software in order to obtain the area of distal radius exposed. The percentage of total distal radius exposure was then calculated for each of the three surgical approaches. Results: The eFCR+CTR approach offered the greatest average distal radius exposure at 87% of total distal radius visualized. The eFCR approach provided the next greatest exposure with an average of 73% visualized, followed by the standard FCR approach with an average of 61% visualized. Conclusion: The extended FCR approach with radial-sided carpal tunnel release is both safe and efficacious for osteosynthesis of distal radius fractures in the setting of concomitant carpal tunnel syndrome. This study demonstrates that an additional advantage of this approach includes improved surgical exposure and visualization of the distal radius. This surgical approach is a valuable addition to any upper extremity surgeon's armamentarium and should be considered when treating difficult distal radius fractures.

Allograft-Prosthetic Composite Reconstruction for Proximal Humerus Bone Loss: A Systematic Review and Meta-Analysis of Outcomes and Complications.

BACKGROUND: In smaller studies, allograft-prosthetic composite (APC) has been used for proximal humerus bone loss with some success, although with notable complication risk. This systematic review and meta-analysis sought to describe outcomes and complications after proximal humerus APC and how major APC complications are defined in the literature. METHODS: A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for articles on APC for proximal humeral bone loss secondary to tumor, fracture, or failed arthroplasty. Primary outcomes included postoperative range of motion, outcome scores (Musculoskeletal Tumor Society [MSTS], Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons [ASES], Constant, visual analog scale [VAS], and subjective shoulder value [SSV]), and complication incidence. We also described individual study definitions of APC malunion/nonunion, methods of postoperative evaluation, malunion/nonunion rates, allograft fracture/fragmentation rates, and mean union time, when available. Secondarily, we compared hemiarthroplasty and reverse total shoulder arthroplasty. RESULTS: Sixteen articles including 375 shoulders were evaluated (average age: 49 years, follow-up: 54 months). Fifty-seven percent of procedures were performed for tumors, 1% for proximal humerus trauma sequelae, and 42% for revision arthroplasty. Average postoperative forward elevation was 82° (69-94°), abduction 60° (30-90°), and external rotation 23° (17-28°). Average MSTS score was 82% (77%-87%), SST score 5.3 (4.5-6.1), ASES score 64 (54-74), Constant score 44 (38-50), VAS score 2.2 (1.7-2.7), and SSV 51 (45-58). There was a 51% complication rate with an 18% nonallograft surgical complication rate, 26% APC nonunion/malunion/resorption rate, and 10% APC fracture/fragmentation rate. Fifteen percent of nonunited APCs underwent secondary bone grafting; 3% required a new allograft; and overall revision rate was 12%. APC nonunion/malunion was defined in 2 of 16, malunion/nonunion rates in 14 of 16, fracture/fragmentation rates in 6 of 16, and mean union time (7 months) in 4 of 16 studies. CONCLUSION: APC reconstruction of the proximal humerus remains a treatment option, albeit with substantial complication rates. In addition, there is a need for APC literature to report institutional definitions of nonunion/malunion, postoperative evaluation, and time to union for a more standardized evaluation. LEVEL OF EVIDENCE: Level IV; systematic review. See Instructions for Authors for a complete description of levels of evidence.