Restoring Functionality: Humeroradial Total Elbow Revision for Salvaging Total Elbow Arthroplasty Failure and Ulnar Bone Loss.

As the number of total elbow arthroplasty (TEA) continues to increase worldwide, one might predict the number of revision TEA would rise as well. The most common indications for revision TEA include (a) loosening, (b) infection, and (c) periprosthetic fracture. Although the rate of revision TEA procedures continues to rise due to the infrequency in which they are performed compared to other arthroplasty surgeries, no gold standard algorithm or procedure for managing severe ulnar bone loss in revision TEA has been determined. Various surgical techniques and strategies including allograft-prosthesis composite, custom long prosthesis with or without allograft, and resection arthroplasty have all been employed in attempting to address severe ulnar bone loss in revision TEA. Though the reported outcomes are mixed at best between each treatment strategy with similar complication rates. Another option is implanting the ulnar component into the radius. In those patients with severe ulnar bone loss, a humeroradial TEA revision can provide stability, restore range of motion, and provide pain relief.

Wide-Awake Local Anesthesia for a Proximal Humerus Fracture: A Case Report.

Introduction: Over the past two decades, wide-awake local anesthesia no-tourniquet (WALANT) surgery has gained substantial popularity, challenging conventional assumptions regarding the safety of epinephrine. This report investigates the unprecedented expansion of the wide-awake local anesthesia technique beyond hand surgeries. It meticulously documents its successful application in a peri-implant proximal humerus fracture, presenting a fresh perspective on its safety and viability for managing intricate orthopedic injuries. Case Report: The subject of this study is a 61-year-old HIV-positive male with a history of recurrent falls, seeking treatment for a peri-implant proximal humerus fracture. Electing the wide-awake local anesthesia option due to financial constraints, the patient underwent a successful surgery. The technique employed involved precise administration of local anesthetic, facilitating fracture reduction, and plate replacement. Notably, the emphasis was placed on active patient participation during intraoperative assessment. Conclusion: This report extends the recognized utility of WALANT surgery beyond hand surgeries, demonstrating its versatility and potential transformative impact on health-care delivery. The study underscores the pivotal role played by wide-awake local anesthesia surgery in addressing challenges related to health-care accessibility. It presents a promising avenue for future orthopedic interventions and positions itself as a safe and viable option for patients in underserved areas globally.

The Integration of Foot and Ankle Instruments to Enhance Orthopedic Hand Surgery: Technical Note.

Introduction: The scaphoid fracture is the most common type of carpal fracture, and disruption of the proximal row of carpal bones alters wrist mechanics altering the stabilization that permits the wrist to work efficiently. When the displacement is at least 2 mm, the majority of surgeons would preferentially operatively intervene in this fracture. Non-union of the fracture will occur when left untreated. The gold standard for treatment is open reduction and internal fixation using autologous bone graft. This case report is the first to describe the integration of the Hintermann™ Distractor, used as an integral part of the surgery in scaphoid waist fracture fixation to improve fracture stabilization, preparation, and compression. Case Report: A 20-year-old male presented with a volar flexed scaphoid non-union, 4 months after the initial injury. Open reduction internal fixation, with the use of the Hintermann™ Distractor, facilitated ease of reduction and placement of Russe graft. Conclusion: Scaphoid waist non-unions with volar angulation and an associated DISI deformity can lead to a significant decrease in function. This case study is the first to describe the use of a foot and ankle instrument to assist with fracture preparation and distraction to place a corticocancellous strut graft in the scaphoid fracture efficiently. This case study demonstrates the efficiency of the technique.

The Role of the Hand Surgery Consultant in the Management of the High School and Collegiate Athlete.

For the purpose of this article, we will not use individual sports as the primary delineator; however, the two different levels of play: High School and Collegiate. We plan to share insight that we have gained through decades of practice treating High School sports and collegiate athletes. This article offers readers reliable guidance on not only treating the athlete's hand but understanding the person as a whole and the struggles at each level of play.

Incorporating Office-Based Surgery Into Your Practice With WALANT.

Office-based surgery (OBS) with wide-awake local anesthesia no tourniquet (WALANT) surgery is a safe and cost-effective care model that is convenient for patient and provider alike. Currently, the practice is growing, but in the majority of North America the ambulatory-care center is still the most common setting for hand surgery. This article discusses the practical issues of implementing OBS with WALANT including clinical setup and workflows for OBS, negotiating payor contracts, and managing liability.

Mimickers of Carpal Tunnel Syndrome.

Carpal tunnel syndrome is the most common compression neuropathy. Despite the prevalence of carpal tunnel syndrome, many other conditions present with similar symptoms (numbness, tingling, thenar atrophy, and weakness). Carpal tunnel syndrome is differentiated from other etiologies through a detailed history and physical examination, aided by electrodiagnostic and adjunctive imaging studies. Misdiagnosis can lead to unnecessary operative procedures and persistent symptoms.

Cue Ball Arthroplasty With Humeroradial Total Elbow Arthroplasty (TEA) Revision: An Approach to Managing Infection and Severe Ulnar Bone Loss in TEA.

Total elbow arthroplasties (TEA) have become more prevalent as indications expand. However, TEA complications remain a treatment conundrum. One such complication, periprosthetic joint infections (PJIs) have been reported to occur in up to 12% of all TEA procedures. Irrigation and debridement with retention of hardware and antibiotic suppression has a high failure rate. Two stage revisions of TEA, while more morbid, is an effective approach with previous studies showing a 79% eradication rate. These cases are often associated with periprosthetic bone loss, adding to the surgical complexity. In our case report, we present the case of a 59 year old diabetic male with a primary TEA secondary to a distal humerus fracture who developed a deep infection and was successfully treated with explantation, cue ball antibiotic cement arthroplasty, and humeroradial revision. This case report will discuss the cue ball antibiotic spacer technique and humeroradial revision as a salvage procedure in TEA revisions in the setting of extensive ulnar bone loss.

The Effect of Metal Instrumentation on Patient and Surgical Team Scatter Radiation Exposure Using Mini C-Arm in a Simulated Forearm Fracture Fixation Model.

INTRODUCTION: To our knowledge, no studies have studied the effect of metal instrumentation (MI) in the field of fluoroscopy regarding changes in the intensity, direction of scatter, and degree of radiation exposure to the patient and surgical team. The goal of this study was to determine whether the presence of MI increases scatter radiation exposure to the patient and surgical team when using a mini C-arm in the horizontal and vertical positions. METHODS: Four trials were conducted using a lamb limb specimen and a mini C-arm to simulate a forearm/wrist fracture fixation scenario. Radiation scatter percentages were measured with the mini C-arm in a vertical and horizontal position with and without the presence of MI (a six-hole 3.5-mm limited-contact dynamic compression plate attached to the specimen with six cortical screws and a self-retaining retractor) using a parallel plate radiation detector. RESULTS: The patient, scrub technician, circulating nurse, and anesthesiologist were exposed to no detectable radiation. In the horizontal position with the presence of MI, there was a 181-fold increase in scatter radiation exposure to the first assistant's eyes (0.016% versus 2.893%, 1.4 × 10-6 Sv/min versus 3.5 × 10-5 Sv/min) and increased exposure to the surgeon's hands compared with the horizontal position with no MI. In the vertical position, the scatter radiation received by the first assistant's eyes increased (zero versus 2.9 × 10-6 Sv/min) with MI present, whereas the only radiation measured for the surgeon was in the right hand which did not change with MI present (2.2 × 10-5 Sv/min). DISCUSSION: MI in the field of fluoroscopy increases scatter radiation exposure to a degree that may place the first assistant's yearly eye exposure in excess of the International Commission on Radiological Protection limit. Surgeons and their assistants should wear lead aprons, thyroid shields, and leaded glasses and minimize the usage of fluoroscopy with MI in the field.

Case Report of Diagnostic Evidence Depicting Palmaris Longus Origin Reversal: Ultrasound and MRI Evaluation.

INTRODUCTION: The palmaris longus (PL) is very prone to anatomical variance. It may exhibit agenesis, reversal, and duplication. The reversal variant presents with the PLtendinous aspect proximally and the muscle belly distally. It is an important finding, and it is important to consider when making a differential diagnosis. This is the only reported case of a left distal forearm PLmuscle variant with ultrasound and magnetic resonance imaging (MRI) in a Caucasian adult male. CASE REPORT: A 28-year-old Caucasian male presented to the clinic with an abnormal ultrasound finding of a left wrist mass. The patient was instructed to get an MRI, which demonstrated and further confirmed the reversed Plmuscle. CONCLUSION: Although rare, anatomic muscle variance may occur in many places of the body leading to symptoms that need attention. These variants should be considered in orthopedic differential diagnosis and ruled out appropriately with proper diagnostic techniques. By making the correct diagnosis, it leads to improved patient outcomes and satisfaction both conservatively and surgically.

Trends in the Surgical Treatment for Cubital Tunnel Syndrome: A Survey of Members of the American Society for Surgery of the Hand.

BACKGROUND: Cubital tunnel syndrome is the second most common compression neuropathy affecting the upper extremity. The aim of this study was to determine the preferred surgical treatment for cubital tunnel syndrome by members of the American Society for Surgery of the Hand (ASSH). METHODS: We invited members of the ASSH research mailing list to complete our online survey. They were presented with 6 hypothetical cases and asked to choose their preferred treatment from the following options: open in situ decompression, endoscopic decompression, submuscular transposition, subcutaneous transposition, medial epicondylectomy, and conservative management. This was assessed independently and anonymously through an online survey (SurveyMonkey). RESULTS: 1069 responses were received. Seventy-three percent of the respondents preferred to continue conservative management when a patient presented with occasional paresthesias for greater than 6 months with a normal electromyogram (EMG) or nerve conduction velocity (NCV). Sixty-five percent picked open in situ decompression if paresthesias, weakness of intrinsics, and EMG/NCV reports of mild to moderate ulnar nerve entrapment was present. More than 50% of respondents picked open in situ decompression, as their preferred treatment when sensory loss of two-point discrimination of less than 5 or more than 10 was present in addition to the findings mentioned above. Seventy-nine percent of the respondents said their treatment algorithm would change if ulnar nerve subluxation was present. CONCLUSIONS: Our survey results indicate that open in situ decompression is the preferred operative procedure, if there is no ulnar nerve subluxation, among hand surgeons for cubital tunnel syndrome.

Thumb Immobilization in the Treatment of an Acute Hook of Hamate Fracture: A Case Report.

A 65-year-old male presented with an acute nondisplaced hook of hamate fracture while lifting a suitcase. Conservative management was employed, and he was treated with a thumb spica cast. At the most recent follow-up, he demonstrated resolution of pain and restoration of motion. CT imaging confirmed osseous union. High nonunion rates following conservative management with short arm casting without thumb immobilization for hook of hamate fractures may be in part due to inadequate immobilization. Here, use of a thumb spica cast resulted in successful osseous union following an acute hook of hamate fracture.

Failure of Wrist Hemiarthroplasty.

BACKGROUND: Wrist hemiarthroplasty has emerged as a motion-sparing option for severe wrist arthritis. It is technically easy with advantages of limited bone resection and no risk of nonunion. Given the relative infancy of the procedure in clinical practice, there are limited data on patient outcomes. METHODS: Eleven patients were treated with wrist reconstructive hemiarthroplasty. Indications included 1 patient with scaphoid nonunion advanced collapse, 9 patients with scapholunate advanced collapse, and 1 patient with capitolunate arthritis. Average age was 63 years; average follow-up was 4 years. Objective parameters included Disabilities of the Arm Shoulder and Hand (DASH), grip strength, and range of motion. Implant failure defined by necessity of revision procedure. RESULTS: DASH scores initially improved postoperatively but were not statistically significant. Grip strength was 60% of contralateral side. Postoperative range of motion at 6 months was flexion 40.3°, extension 39.3°, supination 87.0°, pronation 77.8°, radial deviation 14.5°, and ulnar deviation 13.8°. A 45% failure rate was observed. Complications included failure with conversion to Total Wrist Arthroplasty (TWA; n = 2) or wrist fusion (n = 3) secondary to development of ulnar-sided wrist pain. One additional patient experienced severe wrist pain but declined additional surgery. CONCLUSIONS: Wrist hemiarthroplasty in our series had a significant failure rate. In each case of failure, the patient developed ulnar-sided wrist pain. In the presence of more reliable procedures, wrist hemiarthroplasty is not indicated in its current incarnation.

Scapula fractures: interobserver reliability of classification and treatment.

OBJECTIVES: There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment. DESIGN: Web-based reliability study. SETTING: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey. PARTICIPANTS: One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns. MAIN OUTCOME MEASUREMENTS: Fleiss kappa (κ) was used to assess the reliability of agreement between the surgeons. RESULTS: The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, κ = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, κ = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), κ = 0.79) was substantial and the agreement about a fractured body (Body (B), κ = 0.57) or process was moderate (Process (P), κ = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (κ = 0.57) with a 73% PA. CONCLUSIONS: The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions.

Dorsal dislocation of the distal interphalangeal joint and volar dislocation of the metacarpophalangeal joint in the same finger: a case report.

Double dislocations of the finger interphalangeal and/or metacarpophalangeal joints are a rare entity. Sixty-four cases of distal and proximal interphalangeal joint double dislocations have been previously reported. Five cases of metacarpophalangeal and interphalangeal double dislocations of the thumb have also been reported. Only one case has been reported in the English literature regarding simultaneous dislocations of the distal interphalangeal and metacarpophalangeal joints in the nonthumb digit. The directions of the dislocation were the same; both were dorsal. We report, to our knowledge, the first ever case of a double dislocation a non-thumb digit in opposing directions-volar at the metacarpophalangeal joint and dorsal at the distal interphalangeal joint.

Humeral shaft fractures and radial nerve palsy: to explore or not to explore...That is the question.

Humeral shaft fracture with radial nerve palsy has been a subject of debate since this entity was originally described by Holstein and Lewis in 1963. As the literature provides support for almost any approach in treating patients with this injury, surgeons have no definitive literary guidance. To clarify how physicians are actually treating these patients, we surveyed practice tendencies in observation versus exploration of the radial nerve. In addition, we have integrated our survey results with the current literature to propose an algorithm directing treatment of these patients.

Home treadmill injuries in infants and children aged to 5 years: a review of Consumer Product Safety Commission data and an illustrative report of case.

Approximately 8700 injuries from home exercise equipment occur annually in children in the United States. Home treadmills, which have been growing steadily in popularity during the past decade, pose a specific hazard to infants and children aged 5 years or younger, a population at increased risk of injury to the upper extremities (ie, arm, forearm, wrist, hand, and fingers). The authors also provide an illustrative report of case of a 2-year-old boy whose hand injury resulted from a home treadmill. Analysis and frequency reporting of United States Consumer Product Safety Commission data for home treadmill injuries in this demographic group are presented. From January 1, 1996, to September 30, 2000, the number of home treadmill injuries reported to the National Electronic Injury Surveillance System was 1009. Three hundred of these (29.7%) were in infants and children aged to 5 years. Abrasions or contusions (or both) of the upper extremities were the most common injury. Although the number of home treadmill injuries to children being reported is low, the potential for costly and serious complications has been demonstrated previously. The authors conclude that additional home treadmill safety measures and guidelines must be established.

Indications, alternatives, and complications of external fixation about the elbow.

External fixation around the elbow is a concept as complex as the pathology that it treats. A myriad of potential pitfalls await the surgeon who casually applies a frame to any extremity, let alone a portion of one as complicated as the elbow. A careful understanding of the anatomy, specific technique, applications of the various devices commercially available, and rational alternatives to each problem is crucial for the judicial use of external fixation around the elbow. The potential benefits of the external fixator, however, are worthy of the surgeon's time to understand and pass on to his or her next patient.