Surgical Management of Swan Neck Deformity Following Mallet Finger Injury: A Review of 25 Patients Over 20 Years.

INTRODUCTION: Swan neck deformity develops as a sequela of chronic mallet finger. Surgical management can include soft tissue reconstruction or distal interphalangeal joint (DIPJ) fusion. Studies examining the incidence and management of posttraumatic swan neck deformity following mallet fracture are limited. METHODS: A retrospective, single-institution review of patients undergoing surgical management of swan neck deformity following a traumatic mallet finger from 2000 to 2021 was performed. Patients with preexisting rheumatoid arthritis were excluded. Injury, preoperative clinical, and surgical characteristics were recorded along with postoperative outcomes and complications. RESULTS: Twenty-five patients were identified who had surgical intervention for swan neck deformity. Sixty-four percent of mallet fingers were chronic. Median time to development of mallet finger was 2 months. Twelve (48%) mallet fingers were Doyle class I, 6 (24%) were class III, and 7 (28%) were class IVB. Forty percent of injuries failed nonoperative splinting trials. Sixteen (64%) underwent primary DIPJ arthrodesis, 8 (32%) underwent DIPJ pinning, and 1 underwent open reduction and internal fixation of mallet fracture. The complication rate was 50% overall, and 33% of surgeries experienced major complications. The overall reoperation rate was 33%. Proximal interphalangeal joint hyperextension improved by 11° on average. Median follow-up was 61.2 months. CONCLUSIONS: The development of symptomatic swan neck deformity following traumatic mallet finger injury is rare. All patients warrant an attempt at nonsurgical management. Attempts at surgical correction had a high rate of complications, and DIPJ fusion appeared to provide the most reliable solution.

Osteochondrolipoma of the Hand.

Lipoma is the most common type of benign soft tissue tumor and is composed of mature adipose tissue. A neoplasm of adipose tissue with admixed mature bone and cartilage, or osteochondrolipoma, is an extremely rare histologic variant. Most documented osteochondrolipomas have occurred in the soft tissues of the head and neck related to the oral cavity, and the tumor is seen involving the extremities. A fatty mass with nonlipomatous elements can present a diagnostic challenge. We present a rare case of osteochondrolipoma involving the wrist. The clinical presentation, radiographic images, histologic findings, and treatment are discussed in this case report.

Experience with Diagnosis and Management of Distal Radioulnar Joint Instability.

Objective The aim of this study is to review our cumulative experience with diagnosis and treatment of distal radioulnar joint (DRUJ) instability and to present our treatment algorithm. Materials and Methods Retrospective review identified 112 patients who had 126 episodes of care for DRUJ instability at a single institution over a 21-year period. Those diagnosed acutely or subacutely were treated with immobilization of the wrist and elbow for 6 weeks, while those with chronic instability had anatomic reconstruction of the dorsal and palmar radioulnar ligaments with tendon autograft or an alternative arthroscopic treatment with our thermal annealing technique. Short-term treatment failures and surgical complications were recorded. Nonparametric statistical tests were used to analyze key long-term outcome measures including ulnar wrist pain and DRUJ stability indicated by the dorsopalmar stress test. Results At mean 7-year follow-up, eight patients in the acute-injury cohort had statistically significant improvements in wrist pain and DRUJ instability ( p < 0.001). In both the 22-patient anatomic reconstruction cohort and the 37-patient arthroscopically treated group, there were also statistically significant improvements in wrist pain and DRUJ stability ( p < 0.001) at mean 9-year follow-up. The majority of patients in all three groups was satisfied with treatment outcome, though some required secondary procedures. Conclusion Early clinical diagnosis of DRUJ instability using the dorsopalmar stress test provides an opportunity for effective nonsurgical treatment. For chronic presentation, we recommend our arthroscopic thermal annealing technique for mild or moderate instability and open anatomic reconstruction of the radioulnar ligaments for severe instability. Level of Evidence This is a Level IV, therapeutic study.

Outcomes after anatomic reconstruction of the radioulnar ligaments for distal radioulnar joint instability.

This retrospective study investigated the clinical outcomes of patients treated for chronic distal radioulnar joint instability with open anatomic reconstruction of the palmar and dorsal radioulnar ligaments. After the midpoint of a tendon graft is anchored at the ulnar fovea, the two graft limbs traverse the distal radioulnar joint. One limb is woven into the palmar wrist capsule and the other is secured to the dorsal wrist capsule and retinaculum to stabilize the joint. Of 30 patients (31 wrists) treated with this technique, 19 were followed longitudinally for a mean of 10 years (range 3-21). In this long-term cohort, there were statistically significant improvements in ulnar-sided wrist pain on the visual analogue scale and in distal radioulnar joint stability on the dorsopalmar stress test. The modified Mayo Wrist Scores were classified as three excellent, 12 good, three fair and one poor. Of the 30 patients studied, failure occurred in four patients, two from graft rupture and two from distal radioulnar joint arthrosis. We conclude that anatomic reconstruction of the palmar and dorsal radioulnar ligaments is an effective treatment for distal radioulnar joint instability and is associated with high satisfaction and durable outcomes.Level of evidence: IV.

Arthroscopic thermal stabilization for distal radioulnar joint instability: 3 to 19 years follow-up.

This retrospective study investigated the clinical outcomes of patients treated for chronic distal radioulnar joint instability with arthroscopic thermal annealing of the superficial radioulnar ligaments, ulnar palmar wrist ligaments, and dorsoulnar wrist capsule using a radiofrequency probe. Sixty patients (62 wrists) were treated over an 18-year period. At mean follow-up of 10 years (range 3 to 19), 30 of 33 patients were satisfied with their surgical outcomes. There were statistically significant improvements in ulnar-sided wrist pain on a visual analogue scale and in distal radioulnar joint stability on the dorsopalmar stress test after surgery compared with preoperative status. The modified Mayo Wrist Score and Quick Disabilities of the Arm, Shoulder, and Hand score of the patients were favourable. Early failure occurred in 11 of 62 wrists. Nine of these 11 wrists needed a secondary procedure. We conclude that arthroscopic thermal shrinkage is effective for the majority of the patients with mild to moderate chronic distal radioulnar joint instability in long-term follow-up. Secondary open ligament reconstruction is an option in the case of early failure.Level of evidence: IV.

Short-Term Radiographic Evaluation of a Tri-Tapered Femoral Stem in Direct Anterior Total Hip Arthroplasty.

INTRODUCTION: Direct anterior approach (DAA) total hip arthroplasty (THA) has become increasingly popular, largely due to utilization of a true internervous and intermuscular plane. However, recent literature has demonstrated an increased rate of femoral implant subsidence with this approach. Hence, different femoral implants, such as the tri-tapered femoral stem, have been developed to facilitate proper component insertion and positioning to prevent this femoral subsidence. The purpose of this study was to evaluate the subsidence rate of a tri-tapered femoral stem implanted utilizing a DAA, and to determine if the proximal femoral bone quality affects the rate of subsidence. METHODS: A retrospective analysis of 155 consecutive primary THAs performed by a single surgeon was conducted. Age, gender, primary diagnosis, and radiographic measurements of each subject were recorded. Radiological evaluations, such as bone quality, femoral canal fill, and implant subsidence, were measured on standardized anteroposterior (AP) and frog-leg lateral radiographs of the hip at 6-week and 6-month postoperative follow-up evaluations. RESULTS: The average subsidence of femoral stems was 1.18 ± 0.8 mm. There was no statistical difference in the amount of subsidence based on diagnosis or proximal femora quality. The tri-tapered stem design consistently filled the proximal canal with an average of 91.9 ± 4.9% fill. Subsidence was not significantly associated with age, canal flare index (CFI), or experience of the surgeon. CONCLUSION: THA utilizing the DAA with a tri-tapered femoral stem can achieve consistent and reliable fit regardless of proximal femoral bone quality.

Nonsurgical Treatment for Acute Posttraumatic Distal Radioulnar Joint Instability: A Case Series.

Purpose: We investigated the clinical outcomes of patients with acute posttraumatic distal radioulnar joint (DRUJ) instability who were treated with our nonsurgical protocol. Methods: The electronic database of our community-based orthopedic practice was queried to identify patients with posttraumatic wrist pain and DRUJ instability who presented for treatment less than 6 weeks after injury. Medical records review defined a cohort of 16 patients treated between November, 2000 and December, 2016 with immobilization of the wrist and elbow for 6 weeks and gradual return to full activity at 6 months after injury. Data from the medical records were compiled and analyzed to assess short-term outcomes. Eight patients with a minimum 2-year follow-up completed questionnaires and underwent a wrist-focused examination to assess long-term outcomes. We used Wilcoxon signed-ranks exact test and McNemar chi-square exact test to confirm the statistical significance of observed trends in key outcome measures. Results: At a mean long-term follow-up of 6.7 years, there was statistically significant improvement in ulnar-sided wrist pain and all eight subjects examined demonstrated a negative dorsopalmar stress test indicating improved DRUJ stability. Analysis of the entire cohort showed that 11 of 16 patients (69%) were overall improved with respect to wrist pain and DRUJ stability at final follow-up evaluation. Ulnar-positive variance was a relative contraindication to nonsurgical treatment. Conclusions: Prompt above-elbow immobilization of patients with acute posttraumatic DRUJ instability may result in a good clinical outcome without operative treatment. Type of study/level of evidence: Therapeutic IV.

SCAPULAR SUBSTITUTION AFTER ROTATOR CUFF REPAIR CORRELATES WITH POSTOPERATIVE PATIENT OUTCOME.

BACKGROUND: Scapular substitution is an alteration of scapulohumeral kinematics that may occur when patients have shoulder pain or dysfunction. These abnormal scapular kinematic patterns have been recognized in patients with rotator cuff tears. It remains unknown if 1) normal scapular kinematics can be restored with rehabilitation after rotator cuff repair surgery and 2) abnormal scapular kinematics are associated with inferior patient-determined outcome scores, range of motion, or strength. PURPOSE: The purpose of this study was to determine 1) if scapular substitution can be decreased or improved with rehabilitation after rotator cuff repair surgery and 2) if the presence or amount of scapular substitution was correlated with patient-determined outcome scores, range of motion, or strength after rotator cuff repair surgery. STUDY DESIGN: Retrospective review of prospectively collected data (LOE IV). METHODS: Forty-eight patients who underwent post-operative rehabilitation after an arthroscopic rotator cuff repair were reviewed for this study. The outcomes measures of interest included: patient-determined outcome scores (WORC, Simple Shoulder Test, the ASES Score, the Shoulder Activity Score, and the SANE rating), identification and quantification of scapular substitution, active range of motion, and strength. Outcomes were prospectively collected up to 12 months after surgery and assessed retrospectively. RESULTS: As patients progress through their first year of rehabilitation from a rotator cuff repair, the amount of scapular substitution decreases but remains statistically significantly greater than the contralateral, asymptomatic side. At all post-operative time points, patients with scapular substitution, (determined subjectively by a physical therapist), had 1) inferior WORC, ASES, SANE, and SST scores, 2) inferior flexion, abduction, and external rotation range of motion, and 3) inferior scaption strength compared to those patients without subjective scapular substitution. CONCLUSIONS: Rehabilitation decreases but does not normalize the amount of scapular substitution up to one year after rotator cuff repair. Subjective identification of scapular substitution is associated with inferior patient-determined outcome scores, range of motion, and strength. LEVEL OF EVIDENCE: 4 - Prognosis study.

Painful Pseudotendon of the Flexor Carpi Radialis Tendon: A Literature Review and Case Report.

BACKGROUND: Flexor tendon ruptures in the wrist are uncommon. Flexor carpi radialis (FCR) tendon rupture can occur in rheumatoid patients, following cortisone injection for tenosynovitis, and following trauma. Following tendon rupture, tethering of the ruptured FCR tendon, or pseudotendon, can form which may or may not be symptomatic. METHODS: A literature review was done reviewing treatment and outcomes of FCR tendon lesions. A case report of painful FCR pseudotendon following a fall is presented. The patient presented 4 months after injury with a tender lump 6 cm proximal to the wrist joint with pain and weakness aggravated with wrist motion and gripping. RESULTS: The literature review reveals operative excision of a symptomatic FCR pseudotendon lesion results in great patient satisfaction with no morbidity. In this case report, in spite of conservative measures including cortisone injection and activity modification, the patient had persistent symptoms. The patient proceeded with surgery for complete excision of both the painful pseudotendon and retracted FCR tendon stump. Post-operatively, his wrist motion and grip strength returned to normal, and his Disabilities of the Arm, Shoulder, and Hand (DASH) score was significantly improved from 72 to 9. CONCLUSIONS: FCR pseudotendon is an uncommon condition and can be seen following trauma. Majority of FCR tendon ruptures resolve with non-operative treatment. Based on the excellent outcomes following complete FCR tendon harvest for thumb carpometacarpal (CMC) joint reconstruction, complete excision of a symptomatic pseudotendon results in excellent relief of symptoms with no long-term morbidity.

Are Pulley Exercises Initiated 6 Weeks After Rotator Cuff Repair a Safe and Effective Rehabilitative Treatment? A Randomized Controlled Trial.

BACKGROUND: There are few level 1 or 2 evidence studies that examine rehabilitation after rotator cuff repair. Pulleys have been used in postoperative shoulder rehabilitation with the intention of improving range of motion and developing strength. There is a concern that the use of pulleys in rehabilitation of rotator cuff repairs may contribute to excessive scapular motion (scapular substitution) and potentially inferior outcomes. HYPOTHESIS: Rotator cuff repair patients treated with pulley exercises would have increased scapular substitution and inferior patient-determined outcome scores, range of motion, and strength compared with patients treated with an alternative rehabilitation program without pulleys. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 27 patients who underwent rotator cuff repair were randomized to a rehabilitation group that used pulleys initiated 6 weeks postoperatively, and 26 patients followed a rehabilitation protocol without pulleys. Inclusion criteria were patients undergoing arthroscopic rotator cuff repair. Exclusion criteria were large to massive rotator cuff tears, revision rotator cuff repair, glenohumeral osteoarthritis, adhesive capsulitis, and a symptomatic contralateral shoulder. Outcomes of intervention were patient-determined outcome scores (Western Ontario Rotator Cuff Index [WORC], American Shoulder and Elbow Surgeons [ASES] Shoulder Score, Single Assessment Numeric Evaluation [SANE], Shoulder Activity Level, and Simple Shoulder Test [SST]), range of motion, scapular substitution, and strength. Outcomes were determined at 6, 12, 18, 26, and 52 weeks. A power analysis determined that 22 patients were needed per group to have a power of 0.80, α = 0.05, and effect size of f = 0.5. RESULTS: Both groups had statistically significant improvements in WORC, ASES Shoulder Score, SST, and SANE scores over time after rotator cuff repair (P < .0001). There were no differences between the interventions for WORC (P = .18), ASES Shoulder Score (P = .73), SANE (P = .5), Shoulder Activity Level (P = .39), or SST (P = .36). Both interventions demonstrated improvements in shoulder flexion (P = .002), abduction (P = .0001), external rotation (P = .02), strength (P ≤ .0002), and scapular substitution (P ≤ .07) over time after rotator cuff repair. However, there was no difference in range of motion (P ≥ .26), strength (P ≥ .20), or scapular substitution (P ≥ .17) between interventions. CONCLUSION: A rotator cuff repair rehabilitation program that uses pulleys does not result in inferior outcomes, as determined by patient-determined outcome scores, measurements of scapular substitution, range of motion, and scaption strength. REGISTRATION: ClinicalTrials.gov NCT01819909.

Does chondrolysis occur after corticosteroid-analgesic injections? An analysis of patients treated for adhesive capsulitis of the shoulder.

BACKGROUND: Clinical studies using continuous infusions of local anesthetics and basic science studies that model injections of local anesthetics have shown chondrotoxicity. However, clinical studies do not exist that have assessed for the risk of chondrolysis in nonarthritic joints exposed to single or intermittent corticosteroid or analgesic injections. Currently, there are no data available to guide the clinician on the safety of using these injections in clinical practice. MATERIALS AND METHODS: A retrospective review of patients treated for adhesive capsulitis of the shoulder with at least 1 intra-articular injection of a corticosteroid and anesthetic was performed. The inclusion criteria were a diagnosis of adhesive capsulitis and a minimum 2-year follow-up. Prospective follow-up was performed to obtain patient-determined outcome scores, range of motion, and radiographs to determine the presence of chondrolysis. RESULTS: Fifty-six patients with a mean age of 52.5 ± 7.2 years were enrolled at a mean follow-up of 54 months. The mean number of injections performed was 1.5 ± 0.7 (range, 1-4). At final follow-up, the mean Western Ontario Osteoarthritis of the Shoulder score was 91.4% ± 14.2%; Disabilities of the Arm, Shoulder and Hand score, 6.7 ± 9.6; Shoulder Pain and Disability Index score, 7.4 ± 11.4; and Single Assessment Numeric Evaluation score, 92.7% ± 10.1%. The Shoulder Activity Score was 8.3 ± 4.7. Passive and active forward elevation, external rotation, internal rotation, and cross-body adduction showed no significant differences compared with the unaffected contralateral shoulder. There was no radiographic evidence of chondrolysis in any patient. CONCLUSIONS: This study did not show chondrolysis in patients treated with an intra-articular corticosteroid and local anesthetic for adhesive capsulitis. The findings of this study do not support the cessation of using intra-articular analgesic-corticosteroid injections for the treatment of adhesive capsulitis. LEVEL OF EVIDENCE: Level IV; Case Series; Treatment Study.

Stress fracture of the hook of the hamate: a case report.

Hook of the hamate fractures are uncommon. This fracture is usually seen in sports involving a club or a racquet (i.e., baseball or golf) and is caused by blunt trauma. Stress fractures of the hamate are exceedingly rare. Because of its subcutaneous position and associated soft tissue structures, hook of the hamate fractures can be difficult to diagnosis. When treated early, conservative (non-operative) options can be used to successfully treat the fracture. When the diagnosis is delayed, nonunion of the fracture is common and is usually treated with surgery. This case represents a hook of the hamate stress fracture that healed with casting in spite of being seen two months from the onset of symptoms. Hamate fractures are reviewed, including the anatomy and treatment options for hook of the hamate fractures.