Scaphoid Nonunion Volar Plating with Pure Nonvascularized Cancellous Autograft.

BACKGROUND: Surgical treatment of scaphoid nonunion has evolved over the years to include a variety of procedures and techniques involving a number of vascularized and nonvascularized bone grafting options and fixation strategies. Volar plating of scaphoid nonunions with use of pure cancellous nonvascularized autograft is a safe and effective treatment method with good functional outcomes and union rates1. DESCRIPTION: Volar plating of the scaphoid nonunion is performed via a volar approach, with debridement and reduction of the nonunion site. A nonvascularized pure cancellous bone autograft is then harvested and impacted from the distal aspect of the ipsilateral radius or the olecranon. Finally, a low-profile volar locking plate is applied for fixation2. ALTERNATIVES: There is no consensus regarding the optimal treatment of scaphoid nonunion. Headless compression screws are currently popular, and advances have been made over time to include various nonvascularized and vascularized corticocancellous grafts. The advent of plate fixation of the scaphoid has enabled the surgical treatment of nonunion to better replicate scaphoid morphology, allowing for improved biomechanical stability and optimizing the biologic milieu for healing. RATIONALE: Headless compression screws, although a reasonable option for most acute scaphoid fractures, may not be the most appropriate application for nonunions. Compression, in itself, is not required for the surgical treatment of scaphoid nonunion, and can even prove detrimental by forcing the reduction into a malunion. The stability of headless compression screws must rely on a structural graft to resist the compression and create friction. The more structural the graft, however, the less biologically active it tends to be. Further, the simple placement of a metallic screw within the fracture site is counter to orthopaedic principles because it dramatically lowers the surface area available for union. Volar locking plates address the shortcoming of headless compression screws by (1) directly buttressing the deforming forces superior to headless screws3-6; (2) utilizing the most accessible, biologically active nonvascularized bone graft, which is pure cancellous graft; (3) allowing for maximal surface area contact for union; and (4) preserving the intraosseous vascular network within the scaphoid and its vascular supply at its dorsal ridge. EXPECTED OUTCOMES: Volar scaphoid plating with cancellous bone grafting is a reliable technique with excellent union rates and favorable functional outcomes. A review of 34 patients with scaphoid nonunions with segmental defects treated with volar plates and pure cancellous autograft demonstrated 100% union as verified by computed tomography scans postoperatively1. Average Disabilities of the Arm, Shoulder and Hand scores and grip strengths improved by final follow-up. Another series of 13 scaphoid nonunions with osteonecrosis treated with volar plating and pure cancellous autograft showed 100% union and good patient-reported and functional outcomes, despite smokers, proximal poles, and previous failed surgical procedures in the cohort2. These favorable results are consistent with earlier reports of the modern plating systems; however, concerns for hardware-related complications have been elucidated over the years, including symptomatic hardware impingement7. This risk can be mitigated by proper surgical technique and plate placement. IMPORTANT TIPS: Clear visualization of the entire volar surface of the scaphoid is crucial. Take care not to reflect too much capsule, so as to cause ulnar translation of the carpus.Thorough debridement of nonviable bone is paramount. Using a 2.0 or 3.0-mm low-speed burr with continuous irrigation can be helpful. We have had successful unions even in cases in which the remaining proximal pole was just a cortical shell and essentially a hollow vessel for graft.Err on the side of verticalization of the scaphoid, overextending and supinating the distal pole. Overstuffing the nonunion site with cancellous autograft aids in reduction and maximizes the osteoinductive and osteoconductive properties of the graft.Impaction of the graft is crucial, and the surgeon should harvest more autograft than one might initially anticipate.Secure the plate to the proximal portion of the scaphoid first. There is less room for error on the proximal portion where plate positioning is more critical.Do not cross the scaphoid "line in the sand"; to do so will result in plate impingement on the radius. Proper placement of the plate is just distal to the point at which the convex surface of the proximal pole transitions to become the concave surface of the scaphoid waist, as viewed from a volar approach.Plate modification for proximal pole fractures and nonunions: removal of the most proximal hole in the plate allows for improved fixation despite the plate itself remaining behind the scaphoid "line in the sand." In these cases, the locking screws must be directed so that they buttress the subchondral bone of each pole, especially the proximal pole.

A Comparison of Plate Versus Screw Fixation for Segmental Scaphoid Fractures: A Biomechanical Study.

BACKGROUND: Volar locking plate fixation may offer several advantages over headless screw fixation for scaphoid nonunion, or segmental or comminuted fractures: (1) increased surface area for bony healing; (2) preserved vascularity; and (3) maintenance of a gap for graft insertion. The purpose of this study is to compare headless screw and locking plate fixation of segmental scaphoid fractures and to determine whether either fixation provides a greater mechanical advantage in osteoporotic versus nonosteoporotic bone. METHODS: Sixteen matched-pair cadaver scaphoids were dissected from a range of osteoporotic and nonosteoporotic specimens. Scaphoids from each matched pair were randomly assigned to either volar locking plate or compression screw fixation. A 3-mm segment of bone was circumferentially excised from each scaphoid waist to simulate a segmental defect. Implants were applied, and each specimen was then loaded in axial compression. Load to failure was defined as the load required to achieve gap closure. Mechanism of failure, load to failure, and percent gap recovery were recorded for each trial. RESULTS: Gap closure occurred in all trials. Difference in load to failure was not statistically significant between plate and screw fixation in either nonosteoporotic or osteoporotic cadaver specimens. However, percent gap recovery was significantly higher for plate fixation than for screw fixation. CONCLUSIONS: In scaphoid fractures with segmental defect, plate and screw fixation demonstrate similar loads to failure, but plate fixation performs superiorly to screw fixation for gap recovery after an applied load to failure.

Outcomes of Unstable Scaphoid Nonunion With Segmental Defect Treated With Plate Fixation and Autogenous Cancellous Graft.

PURPOSE: Treatment of scaphoid nonunion with a segmental defect presents a challenging clinical problem. Various techniques have been proposed, often involving structural grafting with vascularized and nonvascularized bone. The authors hypothesize that satisfactory clinical and radiographic outcomes are possible with a relatively simplified technique of volar plate fixation with autogenous, purely cancellous graft. METHODS: The authors performed a retrospective review of 34 patients with scaphoid nonunions with segmental defects, treated with plate fixation and purely cancellous bone grafting. Cases with avascular necrosis were excluded. Surgical management included a volar incision, reduction, bone grafting from the ipsilateral distal radius and/or olecranon, and application of a volar locking plate. Postoperative outcome measures included time to union based on computed tomography, return to work and sports, patient-reported pain and disability scores, grip strength, and range of motion. RESULTS: Thirty-four patients with an average age of 31 years (range, 16-55 years) were treated with volar plate fixation and cancellous grafting, an average of 34 months after initial injury. Twenty-six patients (76%) were treated for nonunion at the scaphoid waist, 7 (21%) at the proximal pole, and 1 (3%) at the distal pole. Mean final follow-up was 18.7 months (range, 12-34 months). When union was defined by computed tomography evidence of healing, 2 (6%) scaphoids healed by 6 weeks after surgery, 28 (82%) healed by 12 weeks, and 100% healed by 18 weeks. Mean Disabilities of the Arm, Shoulder, and Hand score improved from 27.1 ± 7.3 before surgery to 11.8 ± 5.8 after surgery. Grip strength, corrected for hand dominance, improved from 77.5% of the nonsurgical side before surgery to 90.5% after surgery. All employed patients returned to work, although 3 (9%) did not return to full capacity. CONCLUSIONS: The combination of scaphoid plate fixation and pure cancellous bone grafting for scaphoid nonunion with segmental defects yields reliable union rates and good patient outcomes. Autogenous cancellous grafting may be an alternative to more technically demanding or morbid grafting procedures for the treatment of scaphoid nonunion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Plate Fixation With Cancellous Graft for Scaphoid Nonunion With Avascular Necrosis.

PURPOSE: Currently, there is no consensus on the optimal treatment for scaphoid nonunion with avascular necrosis (AVN). Various techniques, often involving vascularized corticocancellous bone grafting, have been proposed. The authors hypothesized that similar outcomes might be possible with volar plate fixation augmented with autogenous pure cancellous graft. METHODS: The authors performed a retrospective chart review of 13 cases of scaphoid nonunions with AVN in 12 patients treated with plate fixation and pure cancellous bone grafting. Surgical management included a volar incision, reduction, impaction of cancellous bone graft from the ipsilateral olecranon and/or distal radius, and application of a volar locking plate. Postoperative outcome measures included time to union based on computed tomography, patient-reported pain and disability scores, grip strength, range of motion, and return to work and sports. RESULTS: The average patient was 32 years old (range, 17-50 years) and treated an average of 18 months after initial injury (range, 6-49 months). Two of 12 patients (15.7%) were female, 3 of 12 patients (25%) were smokers, and 5 of 12 patients (41.7%) had failed union with previous screw fixation. Twelve scaphoids (92.3%) were treated for AVN associated with a proximal pole fracture, and 1 (7.7%) for AVN proximal to a scaphoid waist fracture. Mean follow-up was 19.5 months (range, 12-29 months). Union was achieved in all patients. Two scaphoids (15%) achieved union by 12 weeks, 7 scaphoids (54%) by 18 weeks, 2 scaphoids (15%) by 24 weeks, and 2 scaphoids (15%) by 30 weeks (range, 8.9-28 weeks). Mean Disabilities of the Arm, Shoulder, and Hand score improved from 30.6 ± 6.2 before surgery to 17.2 ± 6.5 after surgery. All 11 employed patients returned to work, although 3 (27.2%) did not return to full capacity. CONCLUSIONS: Scaphoid plate fixation and pure nonvascularized cancellous bone grafting for scaphoid nonunion with AVN yields excellent union rates and good patient-reported and functional outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Olecranon Osteotomy-Facilitated Elbow Release (OFER).

BACKGROUND: The olecranon osteotomy-facilitated elbow release (OFER) is a safe and effective method for releasing severe posttraumatic elbow contractures. The OFER procedure is easier, faster, and relatively less invasive, and appears to offer superior outcomes, compared with more traditional techniques. DESCRIPTION: An olecranon osteotomy provides a trapdoor through which the surgeon will have circumferential access to the joint and will be able to address all intrinsic and extrinsic causes of contracture. Access from the posterior to the anterior compartment is achieved by detaching the origin of the medial collateral ligament (MCL) and hinging the joint from medially to laterally, pivoting around the intact lateral collateral ligament. Once the olecranon and MCL are repaired, the elbow is stable enough for the patient to participate in intensive rehabilitation protocols. ALTERNATIVES: The first line of treatment for elbow contracture is physical therapy, focusing on range of motion and using modalities such as static-progressive and dynamic splinting protocols. In some select cases, there is also a role for manipulation under anesthesia. When nonoperative methods fail, elbow contractures may be treated surgically, using either open or arthroscopic techniques. Authors have described open release involving medial, lateral, and anterior approaches. The first outcome report of a posterior approach to treat elbow contractures has recently been published1. RATIONALE: An open approach usually utilizes 1 or possibly 2 large incisions and involves invasive dissection through muscle and nerve mobilization. This may result in a postoperative hematoma and usually substantial pain, posing a challenge for rehabilitation. Arthroscopic techniques are less invasive, with potentially fewer complications, but are far more technically challenging. Also, most extrinsic and some intrinsic causes cannot be adequately addressed through the arthroscope. The outcomes of OFER have been found to be superior to those reported after either arthroscopic or more conventional open procedures. In addition, we believe that the OFER procedure is substantially faster and technically easier than either other open or arthroscopic releases, although we are not aware of any studies addressing this topic.

The Olecranon Osteotomy-Facilitated Elbow Release (OFER).

BACKGROUND: Elbow contractures can cause functional limitation, and treatment can be challenging. The purpose of this article is to describe a novel technique that releases posttraumatic elbow contractures through an olecranon osteotomy and report the outcomes. METHODS: Thirty-five patients with refractory posttraumatic elbow contracture who underwent an olecranon osteotomy-facilitated elbow release (OFER) procedure were included in the study. The average patient age was 39.5 years (range, 18 to 63 years), and the mean duration of follow-up was 37.2 months (range, 24 to 72 months). Preoperative and postoperative data included age, sex, cause of contracture, previous surgical procedures, active elbow range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) scores, visual analog scale pain scores, and radiographs. Intraoperative tourniquet time and complications were recorded. RESULTS: The mean preoperative elbow motion arc was 33° (51° to 84° of flexion). Postoperatively, the motion arc improved significantly (p < 0.001) to 110° (16° to 126° of flexion). The mean visual analog pain scale score improved from 6.3 preoperatively to 1.4 at the time of follow-up (p < 0.001). The mean DASH score improved from 57.5 preoperatively to 10.9 postoperatively (p < 0.001). The maximal improvement in the motion arc occurred at a mean of 8.7 weeks. There was 1 postoperative ulnar neurapraxia that resolved spontaneously. The intraoperative tourniquet time averaged 27 minutes (range, 18 to 45 minutes). The average time until radiographic evidence of union of the olecranon osteotomy site was 6.6 weeks (range, 5.7 to 7.7 weeks). CONCLUSIONS: The OFER is a safe and effective means of treating posttraumatic elbow contractures, and is an alternative to traditional open or arthroscopic techniques. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Postoperative Complications Associated With Anesthetic Choice for Surgery of the Hand.

PURPOSE: There is a recent trend toward performing most hand surgery procedures under local and/or regional anesthesia without sedation. However, little evidence exists regarding the postoperative complications associated with local/regional anesthesia without sedation, especially compared with local/regional anesthesia with sedation or general anesthesia. METHODS: Patients who underwent hand procedures as part of the American College of Surgeons National Surgical Quality Improvement Program were identified. Thirty-day postoperative complications were compared among patients who received local/regional anesthesia without sedation, local/regional anesthesia with sedation, and general anesthesia with adjustment for patient and procedural factors. RESULTS: We identified 27,041 patients as having undergone hand surgery from 2005 to 2013. A total of 4,614 underwent local/regional anesthesia without sedation (17.1%), 3,527 underwent local/regional anesthesia with sedation (13.0%), and 18,900 underwent general anesthesia (69.9%). Overall, both local/regional anesthesia with and without sedation were associated with fewer postoperative complications compared with general anesthesia. In patients aged over 65 years, there was an additional benefit of avoiding all forms of sedation; these data showed that treatment with local/regional anesthesia without sedation decreased the odds of sustaining a postoperative complication compared with sedation and general anesthesia. CONCLUSIONS: Although the overall risk of postoperative complications remains small in hand surgery, these data suggest that avoiding general anesthesia may decrease the overall risk of sustaining postoperative complications. In addition, for patients aged over 65 years, avoiding any form of sedation may decrease the risk of postoperative complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients.

BACKGROUND: Elbow tenderness and pain with resisted wrist extension are common manifestations of lateral epicondylar tendinopathy, also known as tennis elbow. Previous studies have suggested platelet-rich plasma (PRP) to be a safe and effective therapy for tennis elbow. PURPOSE: To evaluate the clinical value of tendon needling with PRP in patients with chronic tennis elbow compared with an active control group. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: A total of 230 patients with chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at least 3 months of symptoms and had failed conventional therapy. There were no differences in patients randomized to receive PRP (n = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the point of care and contained both concentrated platelets and leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled with or without PRP. Patients and investigators remained blinded to the treatment group throughout the study. A successful outcome was defined as 25% or greater improvement on the visual analog scale for pain. RESULTS: Patient outcomes were followed for up to 24 weeks. At 12 weeks (n = 192), the PRP-treated patients reported an improvement of 55.1% in their pain scores compared with 47.4% in the active control group (P = .163). At 24 weeks (n = 119), the PRP-treated patients reported an improvement of 71.5% in their pain scores compared with 56.1% in the control group (P = .019). The percentage of patients reporting significant elbow tenderness at 12 weeks was 37.4% in the PRP group versus 48.4% in the control group (P = .143). Success rates for patients at 12 weeks were 75.2% in the PRP group versus 65.9% in the control group (P = .104). At 24 weeks, 29.1% of the PRP-treated patients reported significant elbow tenderness versus 54.0% in the control group (P = .009). Success rates for patients with 24 weeks of follow-up were 83.9% in the PRP group compared with 68.3% in the control group (P = .037). No significant complications occurred in either group. CONCLUSION: No significant differences were found at 12 weeks in this study. At 24 weeks, however, clinically meaningful improvements were found in patients treated with leukocyte-enriched PRP compared with an active control group.

Proximal forearm fractures.

Unfortunately, the literature has little guidance for revision elbow surgery. This article attempts to supplement what is known in the literature with the author's anecdotal experience. With this article, it is the author's hope that the reader may learn from his or her successes and his or her failures without having to discover them first hand. There is good reason for angst to overcome surgeons looking at radiographs depicting a traumatized proximal ulna or radius. Surgeons know that there is a good chance they will be seeing these patients for a long time.

Surgeon perceptions and patient outcomes regarding proximal ulna fixation: a multicenter experience.

BACKGROUND: Our objective was to determine surgeon- and patient-based perceptions concerning proximal ulna fixation, including rates of implant removal and overall satisfaction. METHODS: Orthopedic surgeons were surveyed about surgical experience managing proximal ulna fractures and their perception regarding implant removal/revision. A retrospective chart review identified all patients who underwent fixation for proximal ulna fractures and osteotomies between January 2004 and December 2008. RESULTS: In total, 583 surgeons responded to the survey (80%). Of these, 67% believed that their implant removal rate was the same as other surgeons whereas 31% believed that their rate was lower. Seventy-one percent believed that patients required hardware removal less than 30% of the time. Ninety-eight percent believed that they were the same surgeons to remove the implant. In total, 138 consecutive patients were surveyed about their proximal ulna implant. Plating was performed in 80 (58%), and tension banding was performed in 55 (40%). The overall rate of implant removal was 64.5% (89 of 138) at 18.8 months. A second surgeon performed the removal in 68 patients (76%). Of the 49 patients without implant removal, 11 (22%) reported satisfaction with the implant and 19 (39%) reported a functional impairment because of the implant. If guaranteed a safe surgery, 36 (73%) would have the implant removed. CONCLUSION: Surgeons underestimate the rates of proximal ulna implant removal and patient dissatisfaction. Because 76% of the implant removals were performed by a second surgeon, in sharp contrast to the surgeon-perceived rate of 2%, we challenge surgeons to become more aware of this problem in their practices.

Quantifying and comparing torsional strains after olecranon plating.

PURPOSE: Any torsion experienced at a fracture site will directly translate into shearing forces and has been regarded as detrimental to healing. The purpose of this study was to determine which plating system currently on the market controls torsional forces about comminuted olecranon fractures most effectively. METHODS: Five olecranon plates (Acumed, Synthes-SS, Synthes-Ti, ITS/US Implants and Zimmer) were implanted to stabilise a simulated comminuted fracture pattern in 50 fresh-frozen, cadaveric elbows. All specimens were evaluated by dual energy X-ray absorptiometry (DXA) scan to determine bone density. Three-dimensional displacement analysis was conducted to assess fragment motion through physiologic cyclic arcs of motion. The specimens were cycled through progressive physiologic loads (0.18-5.6 kg). Movements of the fragments were statistically compared amongst the different implants using one-way analysis of variance (ANOVA) and Tukey Honestly Significant Difference (HSD) post hoc comparisons with a critical significance level of α=0.05. RESULTS: DXA bone mineral densities (BMDs) ranged from 0.465 to 0.927, with an average of 0.714. The Acumed, Synthes-SS, Synthes-Ti and Zimmer plates allowed <1° of torsion up to 1.6 kg of load. The differences between these plates at this load were not statistically significant. The ITS/US Implants plate, however, allowed significantly more torsion above loads of 2.6 kg (p=0.045) compared with all other plates. The ITS/US Implants plate allowed over 2° of torsion at 2.6 kg (p=0.012), and nearly 3° at 3.6 kg (p=0.045). The Zimmer plate consistently allowed more torsion than the Acumed plate or either of the Synthes plates, but the differences were not statistically significant. CONCLUSION: Regardless of which olecranon plate is used, the authors recommend limiting postoperative rehabilitation loads to below 1.6 kg in an effort to minimise the detrimental effects of torsion on healing. If loads over 1.6 kg are anticipated, the authors recommend the use of the Acumed plate or either of the Synthes plates.

Management of comminuted proximal ulna fracture-dislocations using a multiplanar locking intramedullary nail.

Intramedullary nails have been used for the fixation of olecranon fractures in an attempt to reduce the soft tissue irritation and resulting need for hardware removal seen with plating and tension banding. Further benefits include preservation of vascular supply, and increase stability and improved compression over some alternative techniques. Most intramedullary nails have been limited to simple olecranon fractures or osteotomies. One novel multiplanar, locking intramedullary nail, however, is indicated to stabilize all fracture patterns of the proximal ulna, including the coronoid. This particular locking nail has screws that radiate in multiple planes and form a fixed-angle lattice throughout the bone. The nail also has fixed-angle screws dedicated to the 3 parts of the coronoid: process tip, medial facet, and medial wall. This allows the nail to secure multiple fragments regardless of the fracture pattern's extent of instability. The objective of this article is to illustrate the recommended steps in reducing and stabilizing a comminuted proximal ulna fracture-dislocation using this multiplanar locking intramedullary nail.

Comparison of olecranon plate fixation in osteoporotic bone: do current technologies and designs make a difference?

OBJECTIVES: The purpose of this study is to determine if recent innovations in olecranon plates have any advantages in stabilizing osteoporotic olecranon fractures. METHODS: Five olecranon plates (Acumed, Synthes-SS, Synthes-Ti, US Implants/ITS, and Zimmer) were implanted to stabilize a simulated comminuted fracture pattern in 30 osteoporotic cadaveric elbows. Specimens were randomized by bone mineral density per dual-energy x-ray absorptiometry scan. Three-dimensional displacement analysis was conducted to assess fragment motion through physiological cyclic arcs of motion and failure loading, which was statistically compared using one-way analysis of variance and Tukey honestly significant difference post hoc comparisons with a critical significance level of α = 0.05. RESULTS: Bone mineral density ranged from 0.546 g/cm to 0.878 g/cm with an average of 0.666 g/cm. All implants limited displacement of the fragments to less than 3 mm until sudden, catastrophic failure as the bone of the proximal fragment pulled away from the implant. The maximum load sustained by all osteoporotic specimens ranged from 1.6 kg to 6.6 kg with an average of 4.4 kg. There was no statistical difference between the groups in terms of cycles survived and maximum loads sustained. CONCLUSIONS: Cyclic physiological loading of osteoporotic olecranon fracture fixation resulted in sudden, catastrophic failure of the bone-implant interface rather than in gradual implant loosening. Recent plate innovations such as locking plates and different screw designs and positions appear to offer no advantages in stabilizing osteoporotic olecranon fractures. Surgeons may be reassured that the current olecranon plates will probably adequately stabilize osteoporotic fractures for early motion in the early postoperative period, but not for heavy activities such as those that involve over 4 kg of resistance.

Prospective outcomes of stage III thumb carpometacarpal arthritis treated with arthroscopic hemitrapeziectomy and thermal capsular modification without interposition.

PURPOSE: To prospectively evaluate the subjective and objective results of Eaton stage III thumb carpometacarpal arthritis treated with arthroscopic hemitrapeziectomy and thermal capsular modification without interposition. METHODS: Twenty-three patients with Eaton stage III thumb carpometacarpal arthritis had arthroscopic hemitrapeziectomy without interposition and were evaluated with regard to grip and pinch strength, digital and wrist motion, Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, analog pain scores, and radiographic findings before surgery, 3 months after surgery, and at a minimum of 4 years after surgery. RESULTS: At 3 months after surgery, average DASH score improved from 61 to 10, and pain scores decreased from 8.3 to 1.5. Grip and key pinch strength improved 6.8 kg and 1.9 kg, respectively, and wrist and digital motion were unchanged. Proximal migration of the first metacarpal averaged 3 mm, and translation decreased from 30% to 10%. Nineteen of 23 patients were pleased with their overall outcomes. After 3 months, DASH scores, grip and pinch strengths, motion, patient satisfaction, and radiographic subsidence and translation remained unchanged for a minimum of 4 years. CONCLUSIONS: Arthroscopic hemitrapeziectomy and thermal capsular modification offers patients with Eaton stage III arthritis a minimally invasive alternative that can provide increased function and decreased pain by 3 months after surgery. These results appear to last for a minimum of 4 years and are comparable to those reported for open techniques involving complete trapeziectomy. Substance interposition does not appear to be necessary.

Prospective outcomes and associations of wrist ganglion cysts resected arthroscopically.

PURPOSE: To prospectively evaluate objective and subjective outcomes of arthroscopic dorsal wrist ganglion cyst resection, and to identify and examine intra-articular pathologies associated with ganglion cysts. METHODS: We prospectively evaluated 55 patients with dorsal wrist ganglion cysts who underwent arthroscopic resection with a minimum follow-up of 24 months. Ten had recurrent ganglion cysts previously treated with open resection. Grip strength, wrist motion, and Disabilities of the Arm, Shoulder, and Hand questionnaire scores were evaluated preoperatively and at 6 weeks, 6 months, and 2 years postoperatively. Intraoperative findings were reviewed. RESULTS: In primary ganglion cysts a discrete stalk was present in 4 of 45 cases and diffuse cystic material and redundant capsular thickening were present in 38 of 45 cases. Cystic material appeared to arise from the radiocarpal joint exclusively in 11 of 42 cases, extended into the midcarpal joint in 29 of 42 cases, and arose exclusively from the midcarpal joint in 2 of 42 cases. The scapholunate joint demonstrated instability types I (2 of 45 cases), II (22 of 45 cases), III (20 of 45 cases), and IV (1 of 45 cases). The lunatotriquetral joint demonstrated instability types II (6 of 45 cases) and III (39 of 45 cases). At 6 weeks, average grip strengths increased by 5.9 kg and wrist flexion decreased 13 degrees . Preoperative Disabilities of the Arm, Shoulder, and Hand scores improved from 14.2 to 1.7 at 6 weeks and remained stable at 2 years. At 2 years, all patients demonstrated motion to within 5 degrees of preoperative measurements, and there were no recurrences. CONCLUSIONS: Patients experienced significant increases in function and decreases in pain within 6 weeks after arthroscopic ganglion cyst resection, and the recurrence and complication rates appear to be comparable to open resections. Ganglion cysts also have a high association with certain interosseous laxities, and recurrent ganglion cysts originating from the midcarpal joint are not contraindications for arthroscopic resection. Assessment of the midcarpal joint is necessary for complete resection of most ganglion cysts, and identification of a discrete stalk is an uncommon finding and not necessary for successful resection.

Complications related to simple dislocations of the elbow.

Simple elbow dislocations may present complications that are anything but simple. Although occurring less frequently, these complications are identical to those associated with more complex fracture-dislocations: contracture, heterotopic ossification, Essex-Lopresti injury, neurovascular injury, and residual instability. Each complication is discussed, including strategies for prevention, evaluation, and treatment.

Acromioclavicular stability: a biomechanical comparison of acromioplasty to acromioplasty with coplaning of the distal clavicle.

PURPOSE: The purpose of the study was to compare the laxity of the acromioclavicular (AC) joint in the superior, posterior, and anterior planes after isolated acromioplasty and after acromioplasty with inferior clavicular coplaning. TYPE OF STUDY: In vitro (cadaveric) analysis. METHODS: Eight fresh-frozen cadaveric shoulders were evaluated using a hydraulic actuator. While the scapula was stabilized, a 30-N force was applied to the distal clavicle perpendicular to the AC joint in the superoinferior plane and parallel to the joint in the anteroposterior plane. Laxity of the AC joint in the superior, anterior, and posterior directions was evaluated via load-displacement analysis after acromioplasty and after acromioplasty with coplaning. RESULTS: Coplaning the distal clavicle increased superior AC laxity by 53% compared with acromioplasty alone (P =.012). With regard to anteroposterior laxity, coplaning increased anterior translation by 19% (P =.047) and increased posterior translation by 16% (P =.237). Bony impingement was seen to limit posterior translation in 3 specimens. CONCLUSIONS: Acromioplasty with coplaning increases AC laxity significantly in the superior and anterior directions as compared with acromioplasty alone. A trend toward increased posterior translation was found; posterior bony impingement may limit posterior laxity.

Autologous blood injections for refractory lateral epicondylitis.

PURPOSE: Most nonsurgical treatments for lateral epicondylitis have focused on suppressing an inflammatory process that does not actually exist in conditions of tendinosis. An injection of autologous blood might provide the necessary cellular and humoral mediators to induce a healing cascade. The purpose of this study was to evaluate prospectively the results of refractory lateral epicondylitis treated with autologous blood injections. METHOD: Twenty-eight patients with lateral epicondylitis were injected with 2 mL of autologous blood under the extensor carpi radialis brevis. All patients had failed previous nonsurgical treatments including all or combinations of physical therapy, splinting, nonsteroidal anti-inflammatory medication, and prior steroid injections. Patients kept personal logs and rated their pain (0-10) and categorized themselves according to Nirschl staging (0-7) daily. RESULTS: The average follow-up period was 9.5 months (range, 6-24 mo). After autologous blood injections the average pain score decreased from 7.8 to 2.3. The average Nirschl stage decreased from 6.5 to 2.0. For the 9 patients receiving more than one blood injection the mean pain score and Nirschl stage before injection were 7.2 and 6.6, respectively. After the second blood injection the pain and Nirschl scores were both 0.9. Two patients received a third blood injection that brought both pain and Nirschl scores to 0. CONCLUSIONS: After autologous blood injection therapy 22 patients (79%) in whom nonsurgical modalities had failed were relieved completely of pain even during strenuous activity. This study offers encouraging results of an alternative minimally invasive treatment that addresses the pathophysiology of lateral epicondylitis that has failed traditional nonsurgical modalities.

Factors associated with Short Form-36 outcomes in nonoperative treatment for ipsilateral fractures of the clavicle and scapula.

Twenty consecutive patients with ipsilateral fractures of the clavicle and scapula were treated nonoperatively with immobilization and physical therapy. Results were evaluated using the Herscovici, Rowe, and Constant scoring systems and the Short Form-36 (SF-36) questionnaire. The average comprehensive SF-36 score was lower than the scores obtained using the other scoring systems. In the SF-36 questionnaire, physical scores were strongly associated with nonphysical scores (P<.001). No association was found between SF-36 physical scores and age (P=.37), fracture pattern (clavicle, P=.81; scapula, P=.18), fracture displacement (P=.18), or injury severity score (P=.52). Outcomes were found to relate more to nonphysical factors than to the physical injury.