Use of electrocautery devices for suture passage through the greater tuberosity: a biomechanical study.

BACKGROUND: The use of electrocautery to facilitate passage of a suture needle through bone without the aid of a drill or burr is a novel technique that has potential utility in orthopedic procedures, but there is a scarcity of research to support its utility. The specific aims of this cadaveric biomechanical study were to evaluate (1) the axial force reduction during suture passage using electrocautery when applied to rotator cuff repair, (2) the temperature change caused while using electrocautery, and (3) the failure loads and failure modes of this technique. METHODS: Five matched pairs of fresh frozen humeri were used, classified into 2 groups: with electrocautery on needle (study group) and without electrocautery on needle (control group). Four individual osseous tunnels were made on the greater tuberosity around the insertion of the supraspinatus tendon. Each specimen was sequentially tested in 2 parts: a needle penetration test (part I) to measure the peak axial force and temperature change and a single load-to-failure test (part II) to measure the maximum load to failure as well as the mechanism of failure. A No. 2 FiberWire suture with a straight needle was used. RESULTS: In part I, the mean peak axial force was lower in the study group compared with the control group for all osseous tunnels but was not statistically significant for individual tunnels. However, there was a significant decrease in peak axial force in the study group of 36% compared with the control group overall (P = .033). There was no significant change in temperature of the tunnel site with the use of electrocautery (mean: 0.2 ± 0.3°C, P = .435). In part II, 100% of the samples from each study group experienced bone tunnel failure. Forty percent of the trials in the study group found lower ultimate failure loads compared with the control group (reduction range: 7%-38%). There was no statistically significant difference in the ultimate failure load between either the loop tested or between the 2 study groups (loop 1: P = .352; loop 2: P = .270). CONCLUSION: Suture passage using electrocautery does significantly decrease the peak force needed to pass a needle directly through the greater tuberosity. This technique does not appear to burn the bone or weaken the bone tunnels. This technique may be useful during open rotator cuff repair or shoulder arthroplasty, although clinicians should be cautious when using this technique as its utility depends on bone quality and cortical thickness, and in vivo results may differ.

Use of Electrocautery to Facilitate Suture Passage Through the Greater Trochanter of the Femur: A Biomechanical Study.

Introduction: The specific aims of this study were to evaluate (1) the axial force reduction of suture passage utilizing electrocautery when applied to the greater trochanter of the femur, (2) the temperature change caused while using electrocautery for suture passage, and (3) the failure loads and failure modes utilizing this technique. Methods: Five matched pairs of fresh-frozen femurs were used and classified into two groups: with electrocautery on needle (study group) and without electrocautery on needle (control group). Two bicortical, osseous tunnels were made around the insertion of the gluteus medius tendon. Each specimen was sequentially tested in a needle penetration test and a single load-to-failure test. A #5 Ethibond suture with a straight needle was used. Results: Electrocautery reduced the peak axial force for bone penetration in 40% (near cortex) and 70% (far cortex) of the trials, and no significant difference was detected between groups or between two osseous tunnels. The average peak force was significantly higher for the far cortex for both groups and for both osseous tunnels compared to the near cortex. There was no significant change in temperature of the tunnel site with electrocautery. Ninety percent of the samples experienced bone tunnel failure for the study group compared to 70% in the control group. The average ultimate failure load for the study group was lower compared with the control group, but this finding was not statistically significant (range: 6%-15%). Conclusions: Suture passage using electrocautery may not significantly decrease the peak force needed to pass a needle directly through the greater trochanter.

A Mini-Open, Dorsal Approach for Scaphoid Fracture Fixation With a Ligament Sparing Arthrotomy.

There are several surgical approaches that are currently used to address nondisplaced scaphoid waist fractures, including percutaneous fixation, limited exposure fixation, and traditional open techniques through a volar or dorsal approach. Although percutaneous fixation has some theoretical advantages, it is much more difficult to achieve an accurate starting point for a headless compression screw. The purpose of this paper is to describe a simple, dorsal, mini-open approach to the scaphoid that minimizes incision size, extensor tendon dissection, capsular trauma, and vascular disruption, while still allowing for direct visualization of the proximal pole and optimal exposure for accurate screw placement. As a case report, we retrospectively evaluated 80 consecutive patients with closed scaphoid fractures. There were 2 groups, with 44 patients (age: 24±10 y) receiving a percutaneous dorsal approach and 36 patients (age: 30±16 y) treated with a mini-open approach. All scaphoid fractures were acute or fibrous nonunions (<6 mo from injury, except for one) treated with cannulated headless compression screws. Intraoperative and postoperative complications were measured and evaluated for each group to assess for differences between the percutaneous approach and the mini-open technique. We found no significant difference in complication rate with the mini-open dorsal technique compared with the dorsal percutaneous approach (8.3% vs. 4.5%, respectively). Therefore, we suggest consideration of this mini-open dorsal approach for scaphoid fracture fixation as a useful and safe technique.

Radiographic Assessment of First Tarsometatarsal Joint Shape and Orientation.

BACKGROUND: Hypermobility within the first tarsometatarsal (TMT) joint is a predisposing factor for hallux valgus. The purpose of this study was to assess whether the shape and angulation of the first TMT joint are affected by the positioning of the foot in radiographs. METHODS: Ten adult above-knee fresh-frozen cadaveric specimens were placed into a radiolucent apparatus that allowed controlled angulation of each foot at 0, 5, 10, 15, and 20 degrees in dorsiflexion, plantarflexion, inversion, and eversion. For each specimen, the first TMT joint angle (1TMTJA), shape of the distal articular surface of the medial cuneiform (flat or curved), and image quality of the first TMT joint were measured. RESULTS: The mean value for 1TMTJA was 22.9 degrees (95% confidence interval [CI] 21.9-24). Individual anatomical variations of the specimens as well as the different angulations due to foot positioning significantly influenced the 1TMTJA (both P < .001). Joints that were found to have a flat configuration showed significantly increased 1TMTJA on average when compared to the ones with curved articular surface, 25.9 (95% CI 24.4-27.4) and 20.8 degrees (95% CI 19.5-22.0) (P < .001), respectively. Image quality for visualization of the first TMT joint was progressively better for increased angles of dorsiflexion and inversion. CONCLUSION: The shape and angulation of the first TMT joint on radiographic evaluation are affected by the positioning of the foot. CLINICAL RELEVANCE: Clinical usefulness of these radiographic characteristics is limited and should not influence operative planning in patients with possible instability of the first TMT joint.

Capillary Hemangioma of the Finger in an Adult after a Burn: A Unique Case Mimicking Pyogenic Granuloma.

INTRODUCTION: Capillary hemangiomas and pyogenic granulomas are benign vascular neoplasms that are usually identified clinically by their characteristic features. Capillary hemangiomasmost commonly develop in infancy on the head and neck and nearly all spontaneously ingress by the teenage years. Pyogenic granulomas, however, typically present in adults and can be induced by trauma. It is exceedingly rare for capillary hemangiomas to present in adulthood or after trauma. We present an extremely unusual case of capillary hemangioma on the tip of the finger of an adult male presenting immediately after a burn. The mass was clinically diagnosed as pyogenic granuloma but histopathologically diagnosed as a capillary hemangioma. To our knowledge, this is the only presentation of its kind. CASE REPORT: A 29-year-old African American, right-hand-dominant male laborer presented to the outpatient orthopedic hand clinic with a 2--week-old growing mass on the tip of the right small finger. A clinical diagnosis of pyogenic granuloma was made. Silver nitrate therapy was ineffective, though surgical excision resulted in complete resolution of the mass. Surprisingly, the histopathological diagnosis was instead consistent with capillary hemangioma. CONCLUSION: Clinicians should maintain a high clinical suspicion for both pyogenic granulomas and capillary hemangiomas in children and adults with a vascular soft tissue mass, even after trauma. With this in mind, health-care providers should maintain a low clinical threshold to send soft tissue masses for histopathology to obtain an accurate diagnosis and to provide the best care possible.

Cadaveric study of the infrapatellar branch of the saphenous nerve: Can damage be prevented in total knee arthroplasty?

BACKGROUND: The infrapatellar branch of the saphenous nerve (IPBSN) is a purely sensory nerve innervating the anteromedial aspect of the knee and anteroinferior knee joint capsule. Total knee arthroplasty (TKA) is commonly used to treat end-stage arthritis, but the IPBSN is often injured and results in numbness around the anteromedial knee. The aim of this cadaveric study was to describe the course and variability of the IPBSN and to assess whether it is possible to preserve during a standard midline surgical approach in TKA. METHODS: Ten fresh-frozen cadaver legs were dissected using a midline approach to the knee. Skin and subcutaneous flap were reflected to expose both the saphenous nerve and its branches. The branches of the IPBSN were identified, and their vertical distances above the tibial tuberosity (TB) were recorded: TB to inferior branch, to middle branch, and to superior branch. RESULTS: There were 10 left-sided specimens (6 female, 4 male) with a mean age of 79.9 ±â€¯9.8 years. 8 (80%) specimens had 2 branches of IPBSN while 2 (20%) specimens had 3 branches. The average distance from TB to the inferior branch was 16.8 ±â€¯8.3 mm (3.0-28.0); middle branch, 24.0 ±â€¯1.4 mm (23.0-24.9); and superior, 45.9 ±â€¯7.7 mm (32.0-54.5). CONCLUSION: Our cadaveric study found no consistent way to preserve the IPBSN using a standard midline approach in TKA. It is important to provide proper patient education on this complication, and surgeons should be aware of approximate locations and variations of IPBSN while performing other knee procedures.

A systematic review and meta-analysis of complications in conversion arthroplasty methods for failed intertrochanteric fracture fixation.

BACKGROUND: Conversion arthroplasty for failed primary fixation of intertrochanteric fractures can be achieved using various methods, including cemented total hip arthroplasty, uncemented total hip arthroplasty, hybrid total hip arthroplasty, and hemiarthroplasty. Complication rates vary between each conversion method. The purpose of this paper is to examine the effect of conversion method on total conversion complication rates. METHODS: We performed a meta-analysis of five studies with sufficient data for analysis. We created a null hypothesis stating that the expected distribution of complications across conversion methods would reflect the distribution of conversion method used for failed primary fixation. Using a z test, we compared proportions of the expected distribution of complications to the observed distribution of complications. RESULTS: A total of 138 cases of conversion arthroplasty with 49 complications were available for analysis. The mean age was 73 (range, 32-96) years. 19 males and 48 females were included, with one study not including patient gender. The mean time from primary fixation failure to conversion was 11 months, and the mean duration of conversion surgery was 132 min. Expected and observed complication rate distributions were as follows: cemented total hip arthroplasty, 6.5% versus 4.1% (p = 0.79); uncemented total hip arthroplasty, 77.5% versus 81.6% (p = 0.69); hybrid total hip arthroplasty, 2.9% versus 2.0% (p = 1); and hemiarthroplasty, 13% versus 12.2% (p = 1). CONCLUSIONS: Our findings suggest that the method of conversion arthroplasty following failed primary intertrochanteric femur fracture fixation does not influence complication rate.

Clinical Outcomes of Cervical Facet Fractures Treated Nonoperatively With Hard Collar or Halo Immobilization.

STUDY DESIGN: Retrospective review. OBJECTIVES: To evaluate the rate of nonoperative treatment failure for cervical facet fractures while secondarily validating computed tomography-based criteria proposed by Spector et al for identifying risk of failure of nonoperative management. METHODS: Single-level or multilevel unilateral cervical facet fractures from 2007 to 2014 were included. Exclusion criteria included spondylolisthesis, dislocated or perched facets, bilateral facet fractures at the same level, floating lateral mass, thoracic or lumbar spine injuries, or spinal cord injury. Patients were placed into 3 groups for evaluation: immediate operative management, successful nonoperative management, and failed nonoperative treatment requiring surgical intervention. RESULTS: Eighty-eight patients (106 facets) were included. Twenty-one patients underwent operative treatment with anterior cervical discectomy and fusion or posterior spinal instrumentation and fusion without any failures. Sixty-seven of these patients were treated nonoperatively with either a hard collar (n = 62) or halo vest (n = 5). Eleven patients failed nonoperative treatment (16.4%), all with an absolute fracture height of at least 1 cm and 40% involvement of the absolute height of the lateral mass. Of the 56 patients successfully treated through nonoperative measures, 8 (14.3%) had fracture measurements exceeding both operative parameters. CONCLUSION: We conclude that it is safe and appropriate for patients with unilateral cervical facet fractures to receive a trial period of nonoperative management. However, patients who weigh over 100 kg, have comminuted fractures, or have radiographic measurements outside of the proposed computed tomography criteria for nonoperative treatment should be educated on the risks of treatment failure.

Soft Tissue Structures at Risk With Percutaneous Posterior to Anterior Screw Fixation of the Talar Neck.

BACKGROUND: Fractures of the talar neck and body can be fixed with percutaneously placed screws directed from anterior to posterior or posterior to anterior. The latter has been found to be biomechanically and anatomically superior. Percutaneous guidewire and screw placement poses anatomic risks for posterolateral and posteromedial neurovascular and tendinous structures. The objective of this study was to determine the injury rate to local neurovascular and tendinous structures using this technique in a cadaveric model. In addition, we aimed to determine the number of attempts at passing the guidewires required to achieve acceptable placement of 2 parallel screws. METHODS: Eleven fresh frozen cadaver limbs were used. Two 2.0-mm guidewires were placed under fluoroscopic guidance, posterior to anterior centered within the talus. The number of attempts required was recorded. A layered dissection was then performed to identify injury to any local anatomic structure. The shortest distance between the closest guidewire and the soft tissue structures was measured. RESULTS: The mean total number of guidewires passed to obtain optimal placement of 2 parallel screws was 2.9 ± 0.7. Direct contact between the guidewire and the sural nerve was seen in 100% of the specimens, with the nerve impaled by the guidewire in 3 of 11 (27.2%) cases. The peroneal tendons were impaled in 1 of 11 (9%) specimens and the Achilles tendon was in contact with the guidewire in 8 of the 11 (72.7%) specimens, and impaled at its most lateral border with the guidewire in 2 specimens (18.2%). CONCLUSION: The placement of posterior to anterior percutaneous screws for talar neck fixation is technically demanding, and multiple guidewires are needed. Our cadaveric study showed that important tendinous and neurovascular structures were in proximity with the guidewires and that the sural nerve was injured in 100% of the cases. CLINICAL RELEVANCE: Given the risk of injury to these structures, we recommend a formal posterolateral incision for proper visualization and retraction of the anatomic structures at risk.

Reconstruction for chronic Achilles tendinopathy: comparison of flexor hallucis longus (FHL) transfer versus V-Y advancement.

BACKGROUND: Several operative techniques exist for Achilles tendinopathy. The purpose of our study was to compare the clinical and functional outcomes of flexor hallucis longus (FHL) transfer and V-Y advancement for the treatment of chronic insertional Achilles tendinopathy. METHODS: Retrospective chart review from 2010 to 2016 of patients that underwent FHL transfer or V-Y advancement for chronic insertional Achilles tendinopathy. Outcome measures were compared for these two procedures. RESULTS: In total, 46 patients (49 ankles) with a mean age of 55.0 (range 33-73) years. Mean follow-up time 44.7 +/- 25.5 months. FHL group had 21 patients (21 ankles) with 89% satisfaction, 14% complication rate, final VAS of 0.4, final VISA-A of 89.1, subjective strength improvement following surgery of 78%, and 94% would recommend the procedure. V-Y group had 25 patients (28 ankles) with 74% subjective satisfaction, 21% complication rate, final VAS of 1.4, final VISA-A of 78.4, subjective strength improvement following surgery of 67%, and 84% would recommend the procedure. There was no significant difference in any of the results rates between the two groups (p > .05). CONCLUSION: V-Y advancement is comparable to FHL transfer for the operative management of insertional Achilles tendinopathy. Though our results trend towards less satisfactory results following V-Y advancement, we found high satisfaction rates with similar functional outcomes and complication rates in both operative groups. We suggest considering V-Y advancement as a viable option for the primary treatment of chronic insertional Achilles tendinopathy in patients who may not be an ideal candidate for FHL transfer.

First Metatarsophalangeal Joint Arthrodesis: Does the Addition of a Lag Screw to a Dorsal Locking Plate Influence Union Rate and/or Final Alignment after Fusion.

First metatarsophalangeal (MTP-1) joint fusion is a reliable method for the correction of various deformities, including hallux valgus and hallux rigidus. Ideal constructs provide high rates of fusion in the desired alignment. The present study examined the union rates and the change in dorsiflexion angle during the follow-up period in patients who had undergone MTP-1 fusion with a dorsal locking plate and a lag screw compared with patients who had undergone fusion with a dorsal locking plate alone. We performed a retrospective review of 99 feet undergoing MTP-1 fusion. The joints were fused using either a dorsal locking plate alone or a lag screw plus a dorsal locking plate. Union was determined radiographically during the follow-up period. Suspected nonunions were confirmed by computed tomography. The dorsiflexion angles were radiographically measured at the first postoperative visit and at the final follow-up visit. Of the 99 feet, 36 (36.4%) were in the lag screw plus dorsal plate group and 63 (63.6%) in the dorsal plate group. The mean follow-up period was 12.9 (range 12 to 33.5) months. The dorsal plate plus lag screw group had a significantly lower change in the mean dorsiflexion angle (0.57° ± 5.01°) during the postoperative period compared with the dorsal plate group (6.73° ± 7.07°). The addition of a lag screw to a dorsal locking plate for MTP-1 arthrodesis might offer improved stability of the joint in the sagittal plane over time compared with a dorsal plate alone.