Reverse shoulder arthroplasty megaprosthesis for surgical management of severe proximal humeral bone loss.

BACKGROUND: Shoulder arthroplasty in the setting of severe proximal humerus bone loss can be challenging. The purpose of this study was to evaluate the outcomes of a modular segmental megaprosthesis when implanted in a reverse configuration for complex primary arthroplasty, reconstruction at the time of oncologic resection, and revision shoulder arthroplasty. MATERIALS AND METHODS: A Joint Registry Database was queried to identify all shoulder arthroplasties performed at a single institution using the Comprehensive Segmental Revision System reverse shoulder arthroplasty (SRS-RSA; Zimmer Biomet). A retrospective review of electronic medical records and radiographs was performed to record demographic data, indication, outcomes, complications, and revision surgery. RESULTS: Between February 2012 and October 2022, a total of 76 consecutive SRS-RSAs were implanted. An analysis of patients with minimum 12-month follow-up yielded 53 patients with a mean follow-up of 4.1 ± 2.43 years. Surgical complication rate in this cohort was observed in 41.5% (22 of 53) of cases. Overall, the revision rate at final follow-up was 26.4% (14 of 53), with a significant difference between the primary and revision cohorts. The number of prior surgeries was a significant risk factor for revision surgery, with a hazard ratio of 1.789 (95% confidence interval 1.314-2.436, P < .001). When analyzing aseptic humeral loosening rates across study cohorts, a significant difference was found between the primary arthroplasty (0%, n = 0) and the revision arthroplasty cohorts (22.2%, n = 6) (P = .04). DISCUSSION: Reverse shoulder arthroplasty using a modular segmental megaprosthesis remains a reasonable salvage option for shoulder reconstruction in the setting of proximal humeral bone loss. Because of the substantial bone loss and soft tissue deficiencies typically present in these cases, surgeons should educate patients on the relatively high complication rate, particularly when used in the setting of a previous failed arthroplasty.

Effect of Cervicothoracic Junction LIV Selection on Posterior Cervical Fusion Mechanical Failure: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and Meta-analysis. OBJECTIVE: Analyze and summarize literature evaluating the role of C7, T1, and T2 lowest instrumented vertebra (LIV) selection in posterior cervical fusion (PCF) and if this affects the progression of mechanical failure and revision surgery. SUMMARY OF BACKGROUND DATA: Literature evaluating mechanical failure and adjacent segment disease in the setting of PCF at or nearby the cervicothoracic junction (CTJ) remains limited with studies reporting conflicting results. MATERIALS AND METHODS: Two reviewers conducted a detailed systematic review using EMBASE, PubMed, Web of Science, and Google Scholar on June 28, 2021, for primary research articles comparing revision and complication rates for posterior fusions ending in the lower cervical spine (C7) and upper thoracic spine (T1-T2). The initial systematic database yielded 391 studies, of which 10 met all inclusion criteria. Random effects meta-analyses compared revision and mechanical failure rates between patients with an LIV above the CTJ and patients with an LIV below the CTJ. RESULTS: Data from 10 studies (total sample=2001, LIV above CTJ=1046, and LIV below CTJ=955) were meta-analyzed. No differences were found between the 2 cohorts for all-cause revision [odds ratio (OR)=0.75, 95% CI=0.42-1.34, P<0.0001] and construct-specific revision (OR=0.62, 95% CI=0.25-1.53, P<0.0001). The odds of total mechanical failure in the LIV below CTJ cohort compared with the LIV above CTJ cohort were significantly lower (OR=0.38, 95% CI=0.18-0.81, P<0.0001). CONCLUSION: The results show patients with PCFs ending below the CTJ have a lower risk of undergoing total mechanical failure compared with fusions ending above the CTJ. This is important information for both physicians and patients to consider when planning for operative treatment. LEVEL OF EVIDENCE: Level I.

Dorsal Impaction Injuries of the Distal Radius: Operative Technique Through Dorsal Approach to the Wrist.

SUMMARY: Distal radius fractures vary widely in fracture pattern and displacement. Impaction injuries involving the dorsal articular surface of the distal radius can present challenges when anatomic reduction and fixation is attempted through a standard volar approach. Dorsal approach to the distal radius can provide direct visualization of these fracture patterns, greatly facilitating anatomic reduction and stabilization. In this technique video, surgical approach, fracture reduction, and operative fixation of a dorsally impacted, intra-articular distal radius fracture through a dorsal approach is presented. Low-profile dorsal plating can be a safe and effective technique in treating amenable distal radius fractures, with satisfactory radiographic and clinical outcomes. Although this technique provides excellent exposure and facilitates anatomic reduction, surgeons should be aware of associated risks of wrist stiffness and extensor tendon irritation and select low-profile constructs to mitigate these risks.

Fracture Dislocations of the Glenohumeral Joint.

PURPOSE OF REVIEW: Proximal humerus fracture dislocations typically result from high-energy mechanisms and carry specific risks, technical challenges, and management considerations. It is vital for treating surgeons to understand the various indications, procedures, and complications involved with their treatment. RECENT FINDINGS: While these injuries are relatively rare in comparison with other categories of proximal humerus fractures, fracture dislocations of the proximal humerus require treating surgeons to consider patient age, activity level, injury pattern, and occasionally intra-operative findings to select the ideal treatment strategy for each injury. Proximal humerus fracture dislocations are complex injuries that require special considerations. This review summarizes recent literature regarding the evaluation and management of these injuries as well as the indications and surgical techniques for each treatment strategy. Thorough pre-operative patient evaluation and shared decision-making should be employed in all cases. While nonoperative management is uncommonly considered, open reduction and internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder replacement are at the surgeon's disposal, each with their own indications and complication profile.

Management of Shoulder Instability in Patients with Seizure Disorders.

PURPOSE OF REVIEW: Patients with seizure disorders commonly suffer shoulder dislocations and subsequent instability. Due to high rates of recurrence and bone loss, management of this instability and associated pathology has proven to be more complex than that of patients without seizure disorders. The ultimate goal of this review is to outline the various treatment modalities and their respective outcomes in this complex patient population. RECENT FINDINGS: Optimization of medical management of seizure disorders is imperative. However, despite these efforts, the incidence of post-operative seizure activity continues to be a concern. These subsequent episodes increase the risk of further instability and failure of surgical procedures. Overall, the use of soft tissue procedures has proven to result in increased recurrence of instability compared to bone-block augmenting and grafting procedures. There are a variety of bone-block procedures that have been described for anterior and posterior instability. Despite their success in decreasing further instability, they are associated with several complications that patients should be informed of. There is no consensus regarding the optimal surgical management of shoulder instability in patients with seizure activity. A multidisciplinary approach to the management of the seizure activity is paramount to the success of their treatment. Further studies are required to evaluate the optimal timing and type of surgical intervention for individualized cases.

Injury Pattern Recognition and Surgical Technique of Pilon Fracture Reduction With Posterior Tibial Tendon Incarceration.

SUMMARY: Pilon fractures occur over a broad spectrum of injury severity and soft-tissue compromise. This article will review a distinct pilon injury variant characterized by posterior tibial tendon incarceration in posteromedial pilon fracture propagation. This injury pattern is vital to recognize preoperatively because failure to mobilize the entrapped posterior tibial tendon (PTT) will result in fracture malreduction and postoperative loss of PTT excursion. In addition, the authors' preferred surgical technique for PTT mobilization and anatomic fracture reduction is described.

Bridge Plate Fixation of Distal Radius Fractures: Indications, Techniques, and Outcomes.

Distal radius fractures are among the most commonly encountered injuries treated by orthopedic surgeons. The incidence of distal radius fractures appears to be on the rise. Although this injury is usually treated nonoperatively, surgical management is often indicated and involves several options, including percutaneous pinning, fragment-specific fixation, volar/dorsal/radial locked plating, intramedullary fixation, and external fixation. More recently, dorsal spanning bridge plating has been introduced for certain fracture patterns and patient circumstances. This article reviews the indications, surgical techniques, outcomes, and potential complications associated with bridge plating of distal radius fractures. The authors believe that this article will familiarize surgeons with an additional surgical technique that can be used to treat complex presentations of a common orthopedic injury. [Orthopedics. 2021;44(4):e620-e625.].

Exposure Provided by the Gibson Versus the Kocher-Langenbeck Approaches With and Without Trochanteric Osteotomy: A Cadaveric Mapping Study.

OBJECTIVE: To determine if prevalent approaches in acetabular fracture surgery provide enhanced anterior and cranial exposure in a cadaveric model. METHODS: A Kocher-Langenbeck (K-L) approach (followed by a Gibson approach on the contralateral hip) was performed in the lateral position on 8 cadavers. A Steinmann pin was used to create holes outlining the bony surfaces available for instrumentation before and after a trochanteric osteotomy. All soft tissue was then removed from the pelvis, and a calibrated digital picture was taken. The surface area of the pelvis visualized through each approach was calculated and compared with the contralateral side to assess for a difference in exposure between the Gibson approach and the K-L approach. An increase in exposure of greater than 10% was considered significant. The extent of anterior exposure (with and without a trochanteric osteotomy) was then measured from the greater sciatic notch. RESULTS: In 2 of 8 cadavers (25%), the Gibson approach yielded an increase in exposure when compared with a K-L approach. The addition of a trochanteric osteotomy yielded on average 1.6 cm (range, 0.7-2.6 cm) of increased anterior exposure in the K-L approaches and 1.5 cm (range 0.9-3.1 cm) in the Gibson approaches. CONCLUSION: The Gibson approach did not reliably provide increased anterior exposure compared with a K-L approach in a cadaver model. A trochanteric osteotomy can be expected to add 1-2 cm of increased anterior exposure in both approaches.

Factors influencing management of bilateral femur fractures: A multicenter retrospective cohort of early versus delayed definitive Fixation.

INTRODUCTION: The purpose of our study was to evaluate the factors that influence the timing of definitive fixation in the management of bilateral femoral shaft fractures and the outcomes for patients with these injuries. METHODS: Patients with bilateral femur fractures treated between 1998 to 2019 at ten level-1 trauma centers were retrospectively reviewed. Patients were grouped into early or delayed fixation, which was defined as definitive fixation of both femurs within or greater than 24 hours from injury, respectively. Statistical analysis included reversed logistic odds regression to predict which variable(s) was most likely to determine timing to definitive fixation. The outcomes included age, sex, high-volume institution, ISS, GCS, admission lactate, and admission base deficit. RESULTS: Three hundred twenty-eight patients were included; 164 patients were included in the early fixation group and 164 patients in the delayed fixation group. Patients managed with delayed fixation had a higher Injury Severity Score (26.8 vs 22.4; p<0.01), higher admission lactate (4.4 and 3.0; p<0.01), and a lower Glasgow Coma Scale (10.7 vs 13; p<0.01). High-volume institution was the most reliable influencer for time to definitive fixation, successfully determining 78.6% of patients, followed by admission lactate, 64.4%. When all variables were evaluated in conjunction, high-volume institution remained the strongest contributor (X2 statistic: institution: 45.6, ISS: 8.83, lactate: 6.77, GCS: 0.94). CONCLUSION: In this study, high-volume institution was the strongest predictor of timing to definitive fixation in patients with bilateral femur fractures. This study demonstrates an opportunity to create a standardized care pathway for patients with these injuries. LEVEL OF EVIDENCE: Level III.

Single-Stage Versus 2-Stage Bilateral Intramedullary Nail Fixation in Patients With Bilateral Femur Fractures: A Multicenter Retrospective Review.

OBJECTIVE: To evaluate rates of complications in patients with bilateral femur fractures treated with intramedullary nailing (IMN) during either 1 single procedure or 2 separate procedures. DESIGN: A multicenter retrospective review of patients sustaining bilateral femur fractures, treated with IMN in single or 2-stage procedure, from 1998 to 2018 was performed at 10 Level-1 trauma centers. SETTING: Ten Level-1 trauma centers. PATIENTS/PARTICIPANTS: Two hundred forty-six patients with bilateral femur fractures. INTERVENTIONS: Intramedullary nailing. MAIN OUTCOME MEASURES: Incidence of complications. RESULTS: A total of 246 patients were included, with 188 single-stage and 58 two-stage patients. Gender, age, injury severity score, abbreviated injury score, secondary injuries, Glasgow coma scale, and proportion of open fractures were similar between both groups. Acute respiratory distress syndrome (ARDS) occurred at higher rates in the 2-stage group (13.8% vs. 5.9%; P value = 0.05). When further adjusted for age, gender, injury severity score, abbreviated injury score, Glasgow coma scale, and admission lactate, the single-stage group had a 78% reduced risk for ARDS. In-hospital mortality was higher in the single-stage cohort (2.7% compared with 0%), although this did not meet statistical significance (P = 0.22). CONCLUSIONS: This is the largest multicenter study to date evaluating the outcomes between single- and 2-stage IMN fixation for bilateral femoral shaft fractures. Single-stage bilateral femur IMN may decrease rates of ARDS in polytrauma patients who are able to undergo simultaneous definitive fixation. However, a future prospective study with standardized protocols in place will be required to discern whether single- versus 2-stage fixation has an effect on mortality and to identify those individuals at risk. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Lowest Instrumented Vertebra Selection in Posterior Cervical Fusion: Does Cervicothoracic Junction Lowest Instrumented Vertebra Predict Mechanical Failure?

STUDY DESIGN: Retrospective. OBJECTIVE: The purpose of this study is to evaluate the effect of posterior cervical fusion lowest instrumented vertebra (PCF LIV) selection on incidence of mechanical failure, revision surgery, and patient-reported outcomes (PROs). SUMMARY OF BACKGROUND DATA: Recent studies indicate that the LIV in PCF may contribute to the risk of mechanical failure. To date, the evidence available to guide spine surgeons in the selection of PCF LIV remains limited. METHODS: All patients undergoing PCF at a single institution were prospectively entered into a spine registry which was retrospectively queried. Data collection included demographics, pathology, operative variables, construct LIV, outcomes of mechanical failure, revision surgery, and patient-reported disability, pain, and quality of life. RESULTS: Of 438 patients undergoing PCF from 2006 to 2019, 106 patients had an LIV of C7, T1, or T2, a minimum of 1-year follow-up, and met all study inclusion criteria. LIV cohorts were C7 LIV (36), T1 LIV (42), and T2 LIV (28). There were no between-group differences in patient demographics, operative variables, or postoperative follow-up across the three LIV cohorts. Mechanical failure rates for C7, T1, and T2 LIV were 30.6%, 23.8%, and 0%, respectively (P = 0.007). Revision rates for C7, T1, and T2 LIV were 25.0%, 11.9%, and 0%, respectively (P = 0.013). No difference was noted in average time to revision/failure between C7 (39.68 months) and T1 (29.85 months) LIV cohorts. No differences in baseline, 3-month, and 12-month postoperative PRO measures were noted in the C7 and T1 LIV cohort when compared to the T2 LIV cohort. CONCLUSION: The findings in this study indicate that PCF LIV selection may play a significant role in the development of mechanical complications and need for revision surgery. T2 LIV selection demonstrated a significantly lower rate of mechanical failure and revision surgery. Postoperative PROs up to 36 months are needed to evaluate effect of LIV selection on PROs.Level of Evidence: 3.

Augmented intramedullary screw tension band construct for olecranon fracture reduction and fixation: a review of literature and surgical technique.

Olecranon fractures, which make up 10% of upper extremity fractures in adults, often require anatomic reduction and stable internal fixation. Successful olecranon fracture osteosynthesis has classically been achieved via tension band wiring or plate fixation. This article reviews the indications, outcomes, and a surgical technique as an alternative construct for tension band wiring of olecranon fractures. The technique involves placement of an ulnar intramedullary partially threaded screw that is used as a proximal point of attachment for tension band wiring of the olecranon. Although infrequently used by orthopedic surgeons, this construct has been shown to be biomechanically and clinically superior to classic Kirschner wire tension banding techniques. This review is intended to familiarize surgeons with a surgical technique that can be applied to a variety of proximal ulna fractures.

Symptomatic Radial Neck Nonunion Following Traumatic Impacted Radial Neck Fracture.

PURPOSE: Minimally displaced or impacted radial neck fractures are commonly sustained after elbow trauma, although few require surgical treatment or result in lasting complications. Whereas they are rare, radial neck nonunion after this injury can have adverse implications for patient function and quality of life. The current study presents a case series of 8 radial neck nonunions after minimally displaced or impacted radial neck fractures. METHODS: Using our institution's electronic medical record database, referred to as the Synthetic Derivative database, we performed a retrospective review of all radial neck fractures that presented to our institution over 15 years. RESULTS: Of 472 minimally displaced or impacted radial neck fractures, 8 progressed to symptomatic nonunion. Average age of these patients was 54 ± 9.3 years. One patient presented with bilateral radial neck nonunions. CONCLUSIONS: Nonunion after an impacted radial neck fracture is a rare yet frustrating outcome for patients and providers alike. Our results estimate the rate of symptomatic radial neck nonunion after minimally displaced or impacted radial neck fractures to be 1.7%. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Touch Surgery: Analysis and Assessment of Validity of a Hand Surgery Simulation "App".

BACKGROUND: Surgical educators are increasingly exploring surgical simulation and other nonclinical teaching adjuncts in the education of trainees. The simulators range from purpose-built machines to inexpensive smartphone or tablet-based applications (apps). This study evaluates a free surgery module from one such app, Touch Surgery, in an effort to evaluate its validity and usefulness in training for hand surgery procedures across varied levels of surgical experience. METHODS: Participants were divided into 3 cohorts: fellowship-trained hand surgeons, orthopedic surgery residents, and medical students. Participants were trained in the use of the Touch Surgery app. Each participant completed the Carpal Tunnel Release module 3 times, and participants' score was recorded for each trial. Participants also completed a customized Likert survey regarding their opinions on the usefulness and accuracy of the app. Statistical analysis using a 2-tailed t test and analysis of variance was performed to evaluate for performance within and between cohorts. RESULTS: All cohorts performed better on average with each subsequent simulation attempt. For all attempts, the experts outperformed the novice and intermediate participants, while the intermediate cohort outperformed the novice cohort. Novice users consistently gave the app better scores for usefulness as a training tool, and demonstrated more willingness to use the product. CONCLUSIONS: The study confirms app validity and usefulness by demonstrating that every cohort's simulator performance improved with consecutive use, and participants with higher levels of training performed better. Also, user confidence in this app's veracity and utility increased with lower levels of training experience.

Perioperative Pain Control in Upper Extremity Surgery: Prescribing Patterns, Recent Developments, and Opioid-Sparing Treatment Strategies.

Background: Perioperative pain management in hand and upper extremity surgery has become increasingly challenging following recent efforts to accelerate postoperative recovery, decrease length of stay, and maximize the number and complexity of surgical interventions provided in an ambulatory setting. This issue has been further complicated by the growing opioid epidemic in the United States and increasing insights into its detrimental effects on society. Practicing hand surgeons must acknowledge this ongoing public health crisis and adapt their clinical practices to minimize and optimize distribution of prescription opioids. Methods/Results: This review outlines current opioid prescribing patterns, recent developments, and treatment strategies designed to maintain effective perioperative analgesia in orthopedic upper extremity surgery while minimizing opioid delivery available for diversion, misuse, and abuse. Conclusions: The authors advise hand surgeons to utilize the strategies discussed in this review to assist in forming a unique, patient-specific postoperative analgesic regimen.

Critical ischemia and myonecrotic sepsis following scapulothoracic dissociation in the setting of apparent hand perfusion: A case report.

Scapulothoracic dissociation is a rare and devastating injury to the shoulder girdle. It is often caused by traction or severe blunt trauma injury to the upper extremity and is associated with both neurologic and vascular injuries. Scapulothoracic dissociation is a highly morbid and rare injury pattern that is often seen in conjunction with other traumatic injuries. The authors describe a case of scapulothoracic dissociation with associated complete brachial plexus injury and subclavian artery injury that was complicated by hypoperfusion, myonecrosis, and subsequent polymicrobial infection of the affected limb in the setting of a warm hand with brisk capillary refill. While capillary refill and hand warmth in the setting of a pulseless extremity have been used in previous cases of scapulothoracic dissociation as an indication for limb perfusion and nonoperative management, these markers cannot reliably be used to evaluate collateral circulation as exemplified in this case report. This case highlights multiple important aspects of the evaluation and management of scapulothoracic dissociation that orthopaedic surgeons and vascular surgeons should be familiar with and utilize when dealing with these challenging injuries. Level of Evidence: V.

Preemptive Analgesia in Thumb Basal Joint Arthroplasty: Immediate Postoperative Pain with Preincision versus Postincision Local Anesthesia.

Purpose Currently no guidelines exist for the timing of the injection of anesthetics in surgeries performed under general anesthesia to minimize postoperative pain. To better understand the role of timing of the injection of local anesthesia in hand surgery performed under general anesthesia, we evaluated the effect of pre- versus postincisional local analgesic injection on immediate postoperative pain experience. We hypothesize that the preincisional (preemptive) injection will result in decreased immediate postoperative pain experience and analgesic use when compared with postincisional injection. Methods Consecutive cases of thumb basal joint arthroplasty performed over a 4-year period were retrospectively reviewed. During the first half of the study period, the surgical site was infiltrated with 0.5% bupivacaine at the completion of surgery following closure. During the second half of the study period, the surgical site was infiltrated with 0.5% bupivacaine prior to skin incision. Data collected included patient demographics, immediate postoperative recovery room (PACU) pain scores, and postoperative opioid consumption in morphine equivalents. Results Two-tailed t -test identified no significant difference between the pre- and postincision cohorts relative to PACU entrance pain scores and time spent in the PACU. PACU exit pain scores were significantly lower in the preincision cohort. The mean PACU pain score was also significantly lower in the preincision cohort. PACU opioid consumption, converted into morphine equivalents, was found to be 211 mg in the preincision versus 299 mg in the postincision cohort. Conclusion The preincisional (preemptive) injection of local anesthesia was found to result in lower pain scores during and upon exit of the PACU as compared with the postclosure group. In addition, the preincision cohort also trended toward lower opioid consumption while in the PACU. Consideration should be given to the routine use of preincision injection of local anesthesia to maximize pain relief in a multimodal pain strategy in hand surgical patients. Level of Evidence Therapeutic level III.