Distal Radius Hemiarthroplasty.

INTRODUCTION: Due to a higher risk for implant loosening, particularly of the distal component, patients with physically demanding lifestyles are infrequently considered for total wrist arthroplasty (TWA). A distal radius hemiarthroplasty may obviate the need for the strict restrictions recommended for patients treated by TWA, thus providing another surgical option for active patients with severe wrist arthritis, especially those with articular degeneration of the lunate facet of the radius, capitate head, or combination of both, who are not typically candidates for traditional motion-preserving procedures. MATERIALS AND METHODS: Eight fresh-frozen cadaver limbs (age range, 43-82 years) with no history of rheumatoid arthritis or upper extremity trauma were used. Radiodense markers were inserted in the radius and hand. Posteroanterior (PA) fluoroscopic images with the wrist in neutral, radial deviation, and ulnar deviation, and lateral images with the wrist in neutral, flexion, and extension were obtained for each specimen before implantation, after distal radius hemiarthroplasty, and after combined hemiarthroplasty and PRC. RESULTS: On the PA images, the capitate remained within 1.42 and 2.21 mm of its native radial-ulnar position following hemiarthroplasty and hemiarthroplasty with PRC, respectively. Lateral images showed the capitate remained within 1.06 mm of its native dorsal-volar position following hemiarthroplasty and within 4.69 mm following hemiarthroplasty with PRC. Following hemiarthroplasty, capitate alignment changed 2.33 and 2.59 mm compared with its native longitudinal alignment on PA and lateral films, respectively. These changes did not reach statistical significance. As expected, significant shortening in longitudinal alignment was seen on both PA and lateral films for hemiarthroplasty with PRC. CONCLUSION: A distal radius implant hemiarthroplasty with or without a PRC provides good static alignment of the wrist in a cadaver model and thus supports the concept as potential treatment alternatives for advanced wrist arthritis; however, combined hemiarthroplasty with a PRC has more clinical relevance because it avoids the risk of proximal carpal row instability and eliminates the commonly arthritic radioscaphoid joint.

Efficacy of an online education program for ultrasound diagnosis of pneumothorax.

BACKGROUND: Experienced ultrasonographers can rule out pneumothorax reliably. The authors hypothesized that with basic training, anesthesia residents and faculty can also reliably rule out pneumothorax when presented with an optimal ultrasound image of the chest. METHODS: The study investigators created a library of 99 ultrasound video images of the chest with or without pneumothorax obtained from 53 patients undergoing elective thoracic surgery. After a 5-min tutorial, the physicians were invited to take a quiz based on 20 ultrasound videos randomly selected from the library. Sensitivity and specificity were calculated for overall performance, and a generalized estimating equations model was created to identify significant independent covariates affecting performance. To detect the retention rate for this skill, participants were asked to take the quiz again 6 months later. RESULTS: Seventy-nine anesthesia residents and faculty took part in the study. The sensitivity and specificity for ruling out pneumothorax was 86.6% and 85.6% respectively. On generalized estimating equation model, participants were significantly less likely to identify ultrasound features of pneumothorax if there was probe movement (P value = 0.002; OR 2.69; 95% CI 1.61-4.5) or heartbeat (P < 0.001; OR 3.54; 95% CI 2.27-5.51) on the ultrasound video. The median and interquartile ranges for scores (90%, and 80-95% respectively) did not change from the first to the second quiz. CONCLUSION: After viewing a 5-min online training video, physicians can reliably rule out pneumothorax on an optimal ultrasound image. They are also able to retain this skill for up to 6 months.

Five to ten-year outcomes of the Universal total wrist arthroplasty in patients with rheumatoid arthritis.

BACKGROUND: Implant arthroplasty of the wrist offers pain relief with preservation of motion to patients with rheumatoid arthritis, although few studies have investigated the long-term results of this procedure. The purpose of the present study is to report the prospective results of total wrist arthroplasty with use of the Universal wrist prosthesis in a consecutive series of patients with rheumatoid arthritis who were managed by a single surgeon. METHODS: Twenty-four wrist arthroplasties in twenty patients with rheumatoid arthritis were followed prospectively. Nineteen wrists in fifteen patients were followed clinically and radiographically for a mean of 7.3 years (range, 5.0 to 10.8 years) after the index procedure. Outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, wrist range of motion, and standard radiographic findings. RESULTS: The average DASH score improved from 62 points preoperatively to 40 points at the time of the latest follow-up. The mean wrist flexion and extension at the time of the latest follow-up were 42° and 20°, respectively, for a mean improvement in the total flexion-extension arc of 14°. A total of nine wrists (45%) in eight patients underwent revision surgery because of a loose carpal component at the time of the latest follow-up. One patient underwent wrist arthrodesis because of recurrent wrist instability. Two additional wrists in two patients had radiographic evidence of carpal component subsidence at the time of the latest follow-up. The implant survival rates at five and seven years for the original prosthetic components were 75% and 60%, respectively. CONCLUSIONS: The results for the Universal wrist prosthesis at a minimum of five years of follow-up include a high rate of failure, most often because of carpal component loosening, resulting in revision of ten (50%) of twenty wrists at the time of the latest follow-up (with the inclusion of one revision in a patient who died before five years). Patients with a stable prosthesis maintained a functional range of motion and had improvement in patient-reported outcome measures.

Mediastinal approach to the placement of tunneled hemodialysis catheters in patients with central vein occlusion in an outpatient access center.

OBJECTIVES: Endovascular therapy for hemodialysis (HD) access is now performed in outpatient centers in a growing number of cities in the US. As patients live longer, we are facing a growing number of patients with central venous occlusion. We report our first three cases of mediastinal tunneled dialysis catheter placement in a clinic setting. METHODS: Between 15 November 2009 and 1 April 2010, three patients with central vein occlusion required tunneled HD catheter placement. Case #1 was a 60-year-old male with left subclavian and innominate vein occlusion from a defibrillator pacemaker and two previous right internal jugular tunneled dialysis catheters with occlusion of the right internal jugular vein. He lost right arm access after two failed arteriovenous fistulas (AVF) and an occluded upper arm AV graft. His last right external jugular catheter was removed for infection. Case #2 was a 72-year-old female with a thrombosed left upper arm and a right basilic vein AV access. She had a history of left leg deep vein thrombosis (DVT) and a vena cava filter. The left and right internal jugular veins were occluded as well as the left subclavian vein after stent placement. She required a tunneled HD catheter after a failed attempt at endovascular salvage of her right basilic AVF. Case #3 was a 78-year-old female who had been on HD for 4 yr. She refused AVF surgery and had four tunneled HD catheters removed for infection. She presented with bilateral internal jugular vein thrombosis and the removal of an infected right subclavian tunneled HD catheter. THE TECHNIQUE: The dialysis catheters were placed using standard C-arm fluoroscopy. We accessed the right femoral vein to pass a Berenstein catheter (Cordis, Inc, Warren, NJ) into the right innominate-subclavian vein junction. Using the catheter as a fluoroscopic target, a micropuncture needle was guided into the right innominate vein and a standard J-guidewire was used to dilate the mediastinal tract and place a new tunneled dialysis catheter. RESULTS: In all three cases, the tunneled dialysis catheters were placed under local anesthesia with no intravenous sedation. No pneumothorax occurred and all three catheters were used for HD within 24 hr. Two catheters were removed at 3 and 4 months for infection. One catheter continues to function well. CONCLUSIONS: As the lifespan of our dialysis patient population continues to improve, we will see an increasing need to perform complicated access procedures to maintain HD support. These three cases emphasize the value of the transmediastinal technique using basic C-arm fluoroscopy and a limited stock of basic catheters and guidewires.

Early complications of volar plating of distal radius fractures and their relationship to surgeon experience.

BACKGROUND: Fractures of the distal radius are among the most common fractures in adults. Recently, there has been a trend towards open reduction and internal fixation of these fractures through a volar approach. The purpose of this study was to assess the early complications of volar locking plate fixation of distal radius fractures with an emphasis on defining the relationship between surgeon experience and incidence of complications. MATERIALS AND METHODS: Following IRB approval, we conducted a retrospective chart review of the initial 96 distal radius fractures (92 patients) treated by open reduction and internal fixation of distal radius fracture using a volar locked plate. Our outcome measurements were incidence of postoperative complications and radiographic loss of reduction. RESULTS: Twenty-two complications occurred in 21 patients. Of these, five complications (5%) required surgical treatment or hospitalization. Seventeen complications (18%) required no surgical intervention or hospitalization. Transient nerve dysfunction was the most common complication, accounting for 12 of 22 complications. The first 30 patients experienced significantly more complications than those treated later in the series (p = 0.03). There was a trend towards increased incidence of complications in cases where more than 10 days elapsed between injury and surgery or where supplementary Kirschner wire fixation was used. There was no correlation between patient age, sex, severity of fracture, or presence of ulnar styloid fracture and the development of complications or loss of reduction. DISCUSSION: The incidence of complications decreased significantly with increased surgeon experience, suggesting that many of these early complications are avoidable.

Comparison of the native ulnar head and a partial ulnar head resurfacing implant.

PURPOSE: To assess the match in size and shape between the native ulnar head and a partial ulnar head implant in cadaver specimens. METHODS: Ten fresh-frozen cadaver arms (6 male, 4 female, age range 79-91 years) with no history of previous distal radioulnar joint surgery were used. Radiographic measurements before and after implantation were used to compare ulnar head articular height, width, offset, and ulnar variance. Head diameter was measured using photographs of the resected ulnar heads. RESULTS: The partial ulnar head implant consistently reproduced the natural anatomic size and shape for all variables except ulnar head height and ulnar variance. Head height was greater with the implant, but the additional height extended proximally into the distal radioulnar joint synovial recess, which is unlikely to have adverse affects. Ulnar variance match was technique dependent, with a tendency to place the implant in more neutral variance when positive variance was present before surgery. CONCLUSIONS: Our study demonstrated that a partial ulnar head implant, which replaces the articular surfaces, can closely re-create the ulnar head anatomy. By virtue of restoring the anatomy without an extensive dissection, the clinical results should be expected to at least match the functional results of total head replacement, reduce the rehabilitation, and possibly reduce the risk of joint instability.

Early outcome of spherical ceramic trapezial-metacarpal arthroplasty.

PURPOSE: A retrospective review of 50 ceramic, spherical implants for the treatment of trapezial-metacarpal osteoarthritis in 49 patients assessed clinical and radiographic outcome. METHODS: Thirty-five patients returned for a clinical examination and completed an outcome survey at a mean follow-up of 3 years. A radiographic review was available for all 50 implants with a mean follow-up of 3 years. Average patient age at surgery was 59 years (35 women and 15 men). Twenty-five patients were retired and 24 were regularly employed preoperatively. RESULTS: Overall satisfaction was between "very satisfied" and "satisfied" for 32 patients, and none were dissatisfied. Twenty-nine patients rated both frequency and severity of pain as "less than before surgery" or "much less than before surgery." Average rating for thumb and hand strength was the "same as before surgery." Thumb pinch strength averaged 40 N (91% that of the opposite thumb). Postoperative thumb opposition was Kapandji stage 8 or better in 34 of 50 thumbs and stage 6 or better in patients who had an interphalangeal joint or metacarpophalangeal joint fusion. All 24 employed patients returned to work, but 2 required substantial modifications of pinch and grasp movements. Implant subsidence occurred in 47 of 50 thumbs, ranging from 1 to 13 mm. Trapezium fractures occurred in 15 thumbs. Eleven additional thumbs showed erosions and cystic changes within the trapezium or metacarpal. There was no evidence of arthritis developing in surrounding joints. In addition to adverse radiographic changes, there were 10 complications in 10 patients, including implant subluxation in 7 patients. CONCLUSIONS: Although most patients were satisfied with their function and pain relief, adverse radiographic findings were nearly universal. Implant subsidence, especially into the trapezium, was often severe, with some resulting in a trapezium fracture. Based on the radiographic outcome at this medium-term follow-up, we no longer use this implant. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.