The Greco-Nice-Lag: Lag Screw and Double Nice Knot Fixation for Spiral Proximal Phalanx Fractures-Connecting the Shoulder to the Finger.

A colorful array of fixation options exists for the management of operative long oblique or spiral proximal phalanx fractures. These include lag screws, intramedullary devices, Kirschner wires, dorsal or lateral plating, and cerclage wiring. The "Nice double-suture knot," described by Boileau and colleagues, is a sliding, self-stabilizing knot initially created for tuberosity fixation in the shoulder. Nice knot cerclage has been described in shoulder arthroplasty, as well as for comminuted patella fractures. Here we describe a technique utilizing a single lag screw with 2 Nice knot cerclage sutures for the treatment of a spiral proximal phalanx fracture in a 65-year-old active smoker with osteopenia.

Evaluation of Mid-term Outcomes Following Shoulder Hemiarthroplasty for Avascular Necrosis of the Humeral Head in Patients 40 Years and Younger.

In order to evaluate postoperative function and failure rates among younger patients undergoing hemiarthroplasty for humeral head avascular necrosis (AVN), data from patients < 40 years treated between December 2008 - January 2018 was retrospectively analyzed. Pain was assessed preoperatively and at final follow up using a visual analogue scale (VAS). The American Shoulder and Elbow Surgeons (ASES) standardized assessment, single assessment numeric evaluation (SANE) score, and patient satisfaction were assessed at final follow up, as well as surgical revision rates. In total, eight shoulders were included in the final analysis, with a follow up of 6.6 + 3.6 years. Analysis indicated a statistical improvement in VAS pain (p = 0.001), while comparison of postoperative function between surgical and non-surgical limbs did not demonstrate statistical differences in SANE or ASES averages (p > 0.05). At final follow up, 25% of patients expressed dissatisfaction; however, there were no cases of revision surgery. In conclusion, younger patients undergoing hemiarthroplasty for humeral head AVN experienced pain improvement and no revisions at short-to-mid-term follow up, but one-in-four indicated dissatisfaction. Level of evidence: IV, case series. (Journal of Surgical Orthopaedic Advances 32(2):118-121, 2023).

Patient Risk Factors Associated With Postoperative Complications After Common Hand Procedures.

BACKGROUND: Carpal tunnel syndrome (CTS), trigger finger (TF), and De Quervain tenosynovitis (DQ) are 3 common pathologies of the hand often treated with relatively simple surgical procedures. However, outcomes from these procedures can be compromised by postoperative complications. The aim of this study was to evaluate the association between diabetes, tobacco use, and obesity and the incidence of postoperative complications. METHODS: We reviewed 597 patients treated surgically for CTS, TF, or DQ from 2010 to 2015. We used bivariate and multivariate analyses to assess independent associations between diabetes, tobacco use, obesity, and surgical complications and compared the incidences with healthier patients without these comorbidities. We also looked at patients with overlapping diagnoses of these comorbidities. RESULTS: Bivariate analysis showed that patients with diabetes and smokers were more likely to have a surgical complication. Multivariate analysis showed diabetes and tobacco use as independent predictors of complications. The disease states or combinations placing patients at the highest risk of a postoperative complication were the diabetic-smoker-obese, diabetic-smoker, diabetic-obese, diabetic, and smoker-obese groups. The diabetic-smoker-obese patient population had a 42.02% predicted rate of postoperative complications. CONCLUSIONS: Diabetes and tobacco use are independent risk factors for complications after operative treatment of CTS, TF, and DQ. Obesity when coexisting with diabetes mellitus (DM) and/or tobacco use increased the risk of complications. When the 3 patient factors evaluated, DM, obesity, and tobacco use, were present, the rate of complications was 42.02%. Careful assessment and discussion should occur before proceeding with operative treatment for simple hand conditions in patients with the risk factors studied.

Early to midterm radiographic loosening of the press fit radial head prosthesis.

BACKGROUND: Radiographic loosening is frequently seen around the radial head (RH) implant. The hypothesis of this study was that radiographic loosening will be more frequent in patients in which the RH prosthesis was implanted due to elbow trauma leading to instability that required lateral collateral ligament repair (LCL). MATERIALS AND METHODS: A retrospective review of the patients who had RH implantation between 2012 and 2019 was performed. Evaluation included evidence of radiographic loosening, stress shielding, formation of heterotopic ossification, and rate of removal of the implant. Range of motion of the elbow at the latest follow up was also recorded. RESULTS: At a mean follow up of 18 months (range 1.4 - 80) eight out of 25 patients had radiographic loosening around the implant. The radial head implant was removed in 8 patients (in 3 due to painful radiographic loosening, in 4 due pain without radiographic loosening and in 1 due to infection). Radiographic loosening around the RH implant had no association with LCL repair (p=0.18) or future removal of implant (p=0.18) or the diagnosis of Monteggia lesion (p=0.68). In addition, removal of the RH implant had no association with prior LCL repair (p=0.60) or the diagnosis of Monteggia lesion (p=0.15). Stress shielding was seen in 5 patients and was of no clinical significance. Heterotopic ossification was seen in 12 patients and was classified as Class I in 3, IIA in 3, IIC in 6, according to the Hastings Classification. The average flexion-extension arc was 23° to 130°, and average pronation-supination was 76° to 69°. CONCLUSION: One third of the patients had radiographic loosening around the RH implant at a mean follow up of 18 months. Pain with or without radiographic loosening were the main reasons for removal of the implant. No associations were found between the development of radiographic loosening and LCL repair at the time of RH replacement. Limitations of this study are: (a) the retrospective design (b). the small sample size and the possibility of a type II statistical error.

Anatomic Reconstruction of the Anterior Oblique and the Dorsoradial Ligaments for Painful Subluxating Carpometacarpal Joint of the Thumb.

Thumb carpometacarpal osteoarthritis (CMC OA) is a common pathology of the hand that is characterized by pain, loss of grip and pinch strength, and deformity. Although conservative management is often preferred in earlier stage of CMC OA, surgical techniques can be used when symptoms are not fully relieved, especially with subluxation. We report a case series of 26 patients (32 operations) with Eaton stage I and II CMC OA who underwent a novel surgical technique that anatomically restores the CMC joint with autologous double ligament reconstruction. All cases were retrospectively reviewed as a prospective study and performed at a single regional health system from 2012 to 2016. Preoperative and postoperative radiographs, grip and pinch strength measurements, and DASH scores were collected to evaluate the outcomes. The mean CMC subluxation ratio decreased from 0.59±0.14 to 0.35±0.21 (P<0.0001). The mean grip strength increased from 44.34±17.36 pounds to 52.97±18.92 pounds (P=0.017), and the mean pinch strength increased from 10.16±4.59 pounds to 12.75±4.52 pounds (P=0.00027). The mean DASH scores decreased from 42.32±14.99 to 19.94±14.47 (P<0.0001). The average follow-up period was 39.44±14.94 months. Three patients had postoperative thumb stiffness that resolved with physical therapy. One patient had postoperative pain, attributed to carpal tunnel syndrome. One surgery required revision. All other patients (84.38%) reported significant improvement in pain and the ability to return to previous levels of work. This surgical technique is therefore a feasible option for patients with Eaton stage I or II CMC OA, and should be recommended for wider surgical use.

Ulnar Nerve Enlargement at the Medial Epicondyle Negatively Correlates With Nerve Conduction Velocity in Cubital Tunnel Syndrome.

Background: In cubital tunnel syndrome (CuTS), chronic compression often occurs at the origin of the flexor carpi ulnaris at the medial epicondyle. Motor nerve conduction velocity (NCV) across the elbow is assessed preoperatively to corroborate the clinical impression of CuTS. The purpose of this study was to correlate preoperative NCV to the direct measurements of ulnar nerve size about the elbow at the time of surgery in patients with clinical and/or electrodiagnostic evidence of CuTS. Methods: Data from 51 consecutive patients who underwent cubital tunnel release over a 2-year period were reviewed. Intraoperative measurements of the decompressed nerve were taken at 3 locations: at 4 cm proximal to the medial epicondyle, at the medial epicondyle, and at the distal aspect of Osborne fascia at the flexor aponeurotic origin. Correlation analysis was performed comparing nerve size measurements to slowing of ulnar motor nerve conduction velocities (NCV) below the normal threshold of 49 m/s across the elbow. Results: Enlargement of the ulnar nerve at the medial epicondyle and nerve compression at the flexor aponeurotic origin was a consistent finding. The mean calculated cross-sectional area of the ulnar nerve was 0.21 cm2 above the medial epicondyle, 0.30 cm2 at the medial epicondyle, and 0.20 cm2 at the flexor aponeurotic origin (P < .001). There was an inverse correlation between change in nerve diameter and NCV slowing (r = -0.529, P < .001). Conclusions: For patients with significantly reduced preoperative NCV and clinical findings of advanced ulnar neuropathy, surgeons can expect nerve enlargement, all of which may affect their surgical decision-making.

Peripheral Nerve Injury After Elbow Arthroscopy: An Analysis of Risk Factors.

PURPOSE: To identify risk factors associated with peripheral nerve injury after elbow arthroscopy and provide an updated incidence of those complications. METHODS: The elbow arthroscopies that were performed at our institution between 2006 and 2016 were identified. Over a 10-year period, 253 elbow arthroscopies were performed at our institution. Two hundred twenty-seven cases had a minimum follow-up of 4 weeks, and were included in our analysis. Minor and major nerve-related complications were recorded. The surgeon's experience and training, body max index of the patients, surgical tourniquet time, type of anesthesia or surgery, radiographic appearance of the elbow, diagnosis at the time of surgery, and presence of diabetes were analyzed. RESULTS: There were 12 reported peripheral nerve injuries, 10 minor (4.4%) and 2 major complications (0.9%). The risk factors examined in this study were not correlated with a higher rate of complications. CONCLUSIONS: The minor nerve-related complication rate was 4.4%, with a 0.9% incidence of major peripheral nerve injury. Based on these findings, we conclude that elbow arthroscopy is a relatively safe procedure. The risk factors examined in this study had no association with the rate of complications. This finding could be potentially related to type II or beta error in the analysis of risk factors for nerve injury. The exact reasons for nerve injury are not known from this study. LEVEL OF EVIDENCE: Level IV, retrospective case series.

A randomized trial of diagnostic ultrasound to improve outcomes in focal neuropathies.

INTRODUCTION: Neuromuscular ultrasound is valid, reliable, and accurate, but it is not known whether combining it with electrodiagnostic studies leads to better outcomes in individuals with focal neuropathies. METHODS: One hundred twenty individuals with focal neuropathy, based on history, examination, and electrodiagnosis, were enrolled in this study. All patients underwent neuromuscular ultrasound and were randomized to either have their ultrasound results sent to the referring physician or not have them sent. Outcomes were assessed at 6 months by evaluators blinded to group assignment. RESULTS: The Overall Disability Sum Score and 7 of 8 domains of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) showed more improvement in the "report sent" group, although only the general health perception domain was significant (P = 0.005). CONCLUSIONS: Most 6-month outcomes did not reach statistical significance between the 2 groups. However, the "report sent" group had trends toward better outcomes, with significance being reached in the general health perception domain of the SF-36.

Morphometric analysis of distal interphalangeal joint and implications for arthrodesis with a headless compression screw.

Using radiographs of a cross section of patients, measurements of phalanges were done to aid in surgical planning for distal interphalangeal joint (DIPJ) arthrodesis using a headless compression screw. Measurements were performed of the distal and middle phalanx of all fingers and the proximal and distal phalanx of the thumb. Three independent reviewers measured 50 patients. The average measurements (in mm) of anteroposterior (AP) dimensions were as follows: for the thumb P1 and P2: 5.7 and 5.5, lateral 4.2 and 3.5; for the index P2 and P3 AP: 4.2 and 3.3, lateral 2.1 and 1.8; for the long P2 and P3 AP: 4.5 and 3.5, lateral 2.2 and 1.8; for the ring P2 and P3 AP: 4.3 and 3.1, lateral 1.8 and 1.7; and for the small P2 and P3 AP: 3.7 and 2.2, lateral 1.8 and 1.5. Careful surgical planning by measuring the involved digit and knowledge of screw size is paramount to avoid complications from DIPJ arthrodesis with a compression screw.

Randomized comparison of volar locking plates and intramedullary nails for unstable distal radius fractures.

PURPOSE: To compare minimally invasive intramedullary nails (IMN) and volar locking plates (VLP) for the treatment of unstable distal radius fractures by evaluating postoperative subjective, radiographic, and functional outcomes. The hypothesis was that IMN patients would have less pain and required less pain medication in the early postoperative period and returned to work earlier than VLP patients. METHODS: Sixty patients with closed, displaced, unstable, extra-articular, metaphyseal fractures of the distal radius were randomized to receive a VLP or an IMN for internal fixation. Functional outcomes (Quick Disabilities of the Arm, Shoulder, and Hand, Michigan Hand Questionnaire), radiographic measurements (ulnar variance, radial height, inclination, and volar tilt), and range of motion were assessed until final follow-up at 2 years after surgery. Narcotic pain medication use was documented for 5 weeks following surgery. RESULTS: There were 2 groups of 30 patients with IMN (mean age, 55 ± 14 y) or VLP (mean age, 55 ± 16 y) with similar demographics and comorbidities. Patients with IMN regained extension earlier but had similar range of motion to patients with VLP at final follow-up. There was similar improvement in Michigan Hand Questionnaire, Quick Disabilities of the Arm, Shoulder, and Hand, and strength between groups. Five weeks after surgery, fewer IMN patients required narcotic pain medication (13%) than VLP patients (33%). Radiographic outcomes were similar at final follow-up. There were 3 failures with IMN versus 1 failure with VLP. All 10 employed patients with IMN returned to previous work compared with 10 of the 12 employed patients with VLP. Time to return to work was similar for both groups. CONCLUSIONS: In a cohort of similar patients, IMN and VLP provided comparable improvement in functional and radiographic outcomes. Patients with IMN required less narcotic pain medication after surgery than VLP patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Nonspecific wrist pain in gymnasts and cheerleaders.

Participation in gymnastics and other upper extremity weight-bearing sports frequently requires athletes to bear significant loads through their wrists. This requirement makes wrist pain and injury of significant concern to competitive gymnasts. Athletes' wrist pain, and their ultimate evaluation and treatment, are subject to many variables. Diagnosing the cause of wrist pain in a gymnast requires understanding of the interplay between sport-specific mechanics imparted to the wrist and the individual athlete's characteristics. Treatment entails the appropriate use of conservative measures or surgical intervention with an emphasis on collaborating with all members of the patient's treatment and training team.

Attrition tendinitis of long head of biceps brachii in relation to humeral head osteonecrosis: case report.

This case report identifies a 41-year-old male patient who developed anterior shoulder pain in the setting of humeral head osteonecrosis. As a consequence of the cartilage degeneration, multiple loose bodies formed and migrated into the bicipital tendon sheath, causing attrition tendinitis, which was a feature of the clinical presentation. The patient was treated by a combination of arthroscopic glenohumeral joint debridement and open tenodesis of the biceps using a suture anchor. Follow-up revealed asymptomatic shoulder function by 18 months. This is the first report in the literature of bicipital tendinitis in the context of avascular necrosis of the shoulder.

Median nerve changes following steroid injection for carpal tunnel syndrome.

INTRODUCTION: Neuromuscular ultrasound is a painless, radiation-free, high-resolution imaging modality for assessment of the peripheral nervous system. The purpose of this study was to use neuromuscular ultrasound to assess the changes that occur in the median nerve after steroid injection for carpal tunnel syndrome (CTS). METHODS: Ultrasound and nerve conduction studies were performed at baseline and 1 week, 1 month, and 6 months after steroid injection in 19 individuals (29 wrists) with CTS. RESULTS: Significant changes were noted in median nerve cross-sectional area (P < 0.001), mobility (P = 0.001), and vascularity (P = 0.042) at the distal wrist crease after steroid injection, and the nerve cross-sectional area correlated with symptom score and electrodiagnostic parameters. Changes in the ultrasonographic parameters were seen within 1 week of injection. CONCLUSIONS: These findings suggest neuromuscular ultrasound is potentially helpful for the assessment of individuals undergoing treatment for CTS, as typical changes can be expected after successful treatment injection.

Consensus statement on shoulder instability.

The understanding and treatment of shoulder instability comprise a rapidly evolving area of interest in orthopaedics. Evaluation methods are becoming more specific in showing the exact pathologies causing the symptoms. Magnetic resonance arthrography and arthroscopy have contributed to this development. The patient with an unstable shoulder should be thoroughly evaluated through their history and specific clinical tests of the shoulder as well as the scapulothoracic joint. Often, shoulder instability can be classified after this primary evaluation. Magnetic resonance arthrography and arthroscopy are the gold standards in soft-tissue evaluation, whereas specialized radiographic examinations and computed tomography scans are used to assess bony defects. Patients are treated according to the pathology found on preoperative or pretreatment evaluation. Multiple factors need to be considered before the treatment program is instituted, including the patient's age, activity demands, associated pathology and dysfunction, soft-tissue pathology, degree of instability, direction, frequency, and etiology. Treatment can be nonoperative or arthroscopic or open repair. Soft-tissue pathology and bony defects should be addressed, and the surgeon's preferred method and skills are important in choosing the right treatment for the patient. The patient should be informed about possible complications, restrictions during the treatment period, and the prognosis for the particular type of instability. To improve progress in shoulder orthopaedics, one of the most important factors can be a universal agreement on an outcome measurement tool that is well designed and validated.

Traumatic valgus instability of the elbow: pathoanatomy and results of direct repair. Surgical technique.

BACKGROUND: The medial collateral ligament provides valgus stability to the elbow. The purpose of the present study was to describe the pathoanatomy of acute traumatic medial collateral ligament ruptures and to report the rationale and results of direct repair. METHODS: Between 1996 and 2006, eleven athletes presented with acute rupture of the medial collateral ligament of the elbow and no history of dislocation. Three patients had received steroid injections for the treatment of medial epicondylitis, but none had a history of medial elbow insufficiency. All patients demonstrated gross valgus instability on clinical examination and medial joint space widening on valgus stress radiographs. Complete avulsion of the medial collateral ligament from its humeral origin was documented with magnetic resonance imaging in all patients. Operative findings uniformly demonstrated avulsion of the flexor-pronator muscles with distal retraction. The underlying medial collateral ligament was avulsed in a sleeve-like fashion from the denuded medial epicondyle. The ligament was directly reattached to its footprint. The avulsed flexor-pronator tendon was repaired to the residual tendon with use of interrupted figure-of-eight nonabsorbable sutures. All patients were followed for a minimum of sixteen months with serial clinical examinations, radiographs, and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS: Full active range of motion was achieved in ten patients; the remaining patient had a 20 degrees flexion contracture. Three patients had acute ulnar nerve palsies at the time of the injury, and all three recovered complete motor and sensory function by six months after the injury. Nine of the eleven patients returned to competitive college athletics between four and six months. The mean DASH score at the time of the most recent follow-up was 6. CONCLUSIONS: Direct repair of an acute traumatic medial collateral ligament avulsion of the elbow reliably restores valgus stability, even in throwing athletes.