Surgical Considerations for Osteoporosis, Osteopenia, and Vitamin D Deficiency in Upper Extremity Surgery.

Fragility fractures as a result of osteoporosis, osteopenia, or vitamin D deficiency are some of the most common injuries encountered in orthopedics and require careful consideration when determining the appropriate management and treatment options. A thorough perioperative evaluation can identify causes of low bone mineral density allowing for initiation of appropriate therapy. Surgical treatment of these fractures can be difficult, and techniques should be employed to ensure stable fixation. It is important to understand the potential pitfalls associated with treatment of fragility fractures to prevent avoidable complications. Postoperative management is key to preventing future injuries in this unique patient population.

Acute Carpal Tunnel Syndrome and Median Nerve Neurapraxia: A Review.

Prompt diagnosis and treatment of acute injury to the median nerve after wrist trauma are paramount to a successful outcome. Neuropathy can occur primarily at the time of injury, secondary to unreduced fracture fragments or callus, or from prolonged immobilization in palmar flexion. Acute carpal tunnel syndrome is a surgical emergency that requires decompression. Progressively worsening pain and sensory disturbances in the median nerve distribution are findings that will distinguish an acute carpal tunnel syndrome from the less severe median nerve neurapraxia. This article describes the key differences between neurapraxia and acute compartment syndrome and their respective treatment.

Scaphoid Fractures in Athletes.

Scaphoid fractures are common injuries in athletes. Most can be treated with cast immobilization, with an expected rate of union of 90% to 95%. Cast treatment, however, has the disadvantages of longer immobilization time, joint stiffness, reduced grip strength, and longer time to return to manual work or athletics. Closed reduction and percutaneous screw fixation generally are preferred in athletes to allow a quicker return to sport; if closed reduction cannot be obtained, open reduction and internal fixation may be required.

Tendon With Z-Lengthening Technique and Construct Assessment: A Biomechanical Study for Use in Tendon Reconstructions.

PURPOSE: Tendon reconstruction is frequently required under conditions of tendon deficiency. The authors sought a technique that could obviate the need for tendon harvest yet meet the minimum load of 45 N required for an early active motion protocol. This study was designed to determine the ideal suture construct utilizing the tendon with Z-lengthening (TWZL) technique. METHODS: Sixty fresh-frozen cadaveric flexor digitorum profundus tendons of the index, middle, and ring fingers were randomized into 5 different TWZL construct designs using 3-0 braided polyethylene suture. Constructs were tested on an electromechanical actuator until failure was observed on the load-elongation recording. Data points on maximum yield and load at 8% strain were recorded for each construct. RESULTS: The maximum yield data revealed the construct with a 4-core suture type configuration (construct #4) had the highest overall mean load to failure at 150 N compared with all other constructs. The construct with the highest mean load at 8% strain was that with a 4-core type repair (construct #4) at 59 N. The constructs with Krackow locking sutures (constructs #2, #3, and #4 were found to withstand a significantly higher mean load at 8% strain than those without Krackow sutures (#0 and #1). Comparison among constructs with Krackow locking sutures #2 (56 N), #3 (48 N), and #4 (59 N) did not show a significant difference in mean load at 8% strain. Construct #3, however, had an SD and 95% confidence interval that fell below the 45 N early active motion threshold, whereas both #2 and #4 had 95% confidence intervals that fell no lower than 50 N. CONCLUSIONS: This study provides evidence that the TWZL technique utilizing either construct #2 or #4 could provide sufficient strength and reproducibility for tendon reconstruction. CLINICAL RELEVANCE: The study describes the application of the TWZL technique for utilization in tendon reconstruction and quantifies differences in the yield strengths of the 5 proposed constructs.

Emerging Technologies in Upper Extremity Surgery: Polyvinyl Alcohol Hydrogel Implant for Thumb Carpometacarpal Arthroplasty and Processed Nerve Allograft and Nerve Conduit for Digital Nerve Repairs.

In the field of upper extremity surgery there are myriad new and developing technologies. The purpose of this article is to highlight a few of the most compelling new technologies and review their background, indications for use, and most recently reported outcomes in clinical practice.

Liposomal Bupivacaine Mixture Has Similar Pain Relief and Significantly Fewer Complications at Less Cost Compared to Indwelling Interscalene Catheter in Total Shoulder Arthroplasty.

BACKGROUND: The efficacy and costs of indwelling interscalene catheter (ISC) and liposomal bupivacaine (LBC), with and without adjunctive medications, in patients with primary shoulder arthroplasty are a source of current debate. METHODS: In 214 arthroplasties, 156 patients had ISC and 58 had LBC injections that were mixed with morphine, ketorolac, and 0.5% bupivacaine with epinephrine. Charts were reviewed for visual analog scale pain scores, oral morphine equivalent (OME) usage, major complications, and costs. RESULTS: Visual analog scale scores were not significantly different at 24 hours or at 2, 6, and 12 weeks. Average OME consumption at 24 hours was significantly more with LBC, but was not significantly different at 12 weeks. Relative risk of a major complication was nearly 4 times higher with ISC than with LBC. The average cost for the LBC mixture was $289.04, and for ISC, including equipment and anesthesia fees, was $1559.42. CONCLUSION: The intraoperative LBC mixture provided equivalent pain relief with significantly fewer major complications and at markedly lower cost than ISC. LBC required almost twice as much OME to attain the same level of pain relief at 24 hours, but there was no significant difference in the cumulative amount of outpatient narcotic use.