The V-shaped subscapularis tenotomy for anatomic total shoulder arthroplasty.

PURPOSE: Management of the subscapularis tendon during anatomic total shoulder arthroplasty (TSA) remains controversial. In our unit, subscapularis tenotomy is the preferred technique; however, the potential for tendon gapping and failure is recognised. The purpose of this study is to describe and provide early clinical results of a novel, laterally based V-shaped tenotomy (VT) technique hypothesised to provide greater initial repair strength and resistance to gapping than a transverse tenotomy (TT), with both clinically and radiologically satisfactory post-operative tendon healing and function. METHODS: A retrospective study of patients who underwent primary TSA with VT over a three year period was performed using shoulder and subscapularis-specific outcome scores, radiographs, and ultrasound. A separate cohort of patients who underwent TSA using a subscapularis sparing approach was also reviewed to provide comparative clinical outcomes of a group with TSA and an un-violated subscapularis. RESULTS: Eighteen patients were reviewed at mean 30.4 months (± 11.7). Constant (78.2 ± 12.3), UCLA (8.4 ± 1.5), pain VAS (2.3 ± 2.8), and strength in internal rotation were no different from the comparison group. Likewise, neither were the clinical outcomes of range-of-motion, belly-press, lift-off, and shirt-tuck tests. One patient (5.5%) was found to have a failed subscapularis repair on ultrasound. CONCLUSION: VT during TSA appears to provide healing rates at least equal to those reported for TT, and not dissimilar from those of lesser tuberosity osteotomy. Clinical outcomes are comparable to reported results in the literature for alternative techniques, and not different from those observed here in a comparison cohort with TSA performed without violating the subscapularis tendon. VT therefore potentially offers a more effective and secure tendon repair than a traditional TT, with at least comparable clinical outcomes.

Making Sense of Metal Allergy and Hypersensitivity to Metallic Implants in Relation to Hand Surgery.

All metals implanted into a biological system undergo some degree of corrosion depending upon its composition. The electrochemical process of corrosion produces free metal ions, which may activate the host's immune system through a variety of mechanisms. Whereas dermal metal hypersensitivity is common, affecting 10% to 15% of the population, the immune reaction from implanted metals is much less common (< 0.1%), but has been associated with metal allergy and hypersensitivity producing a multitude of patient symptoms. Superficial symptoms may be mild to severe forms of dermatitis, urticaria, pruritus, and vasculitis, whereas deep sequelae include metallosis-related pseudotumor, implant loosening, and joint stiffness. Currently, there are clinical tests to evaluate patients for metal hypersensitivity, but there is little agreement regarding the ideal timing and clinical situation prompting the work-up of a patient for a metal allergy or hypersensitivity. An understanding of the epidemiology, etiology, basic science, diagnostic testing, and treatment of patients with suspected metal allergy, as it pertains to the current literature, will aid orthopedic and plastic surgeons of all subspecialties in the management of patients requiring metallic implants.

The Influence of Microsurgical Training on the Practice of Hand Surgeons.

BACKGROUND: The study aims to determine the effect of formal training on the long-term practice of microsurgery. METHODS: Hand surgeons completing a 1-year hand fellowship and a 5-day microsurgery rat-model training course from a single institution over a 15-year period (1996-2011) were surveyed. Patency rates (at 24 hours), additional days spent in the laboratory, and training (orthopedic [OS] vs. plastic surgery [PS]) were correlated with the questionnaire responses regarding microsurgical confidence and practice spectrum. RESULTS: Data were obtained for 100% (61/61) of former fellows. PSs were 4.7 and 7.6 times more likely to perform replants and free flaps than OSs, respectively. Training patency rates and days in the laboratory were fair predictors of current practice of free flaps and replants. CONCLUSION: PSs are more likely to perform replants and free flaps than OSs. Successful completion of a microsurgical skills course can be used as a predictor of those who will ultimately practice microsurgery. Broader application of microsurgical skills labs may be a technique to increase the practice of microsurgery among all hand surgeons.

Feasibility of latissimus and teres major transfer to reconstruct irreparable subscapularis tendon tear: an anatomic study.

BACKGROUND: Several tendon transfers have been described to reconstruct irreparable subscapularis (SS) tears, but their outcomes are variable and unsatisfactory in the presence of anterior glenohumeral subluxation. We evaluated the anatomic feasibility of the latissimus dorsi (LD) or teres major (TM) muscle tendon transfer to reconstruct an irreparable SS tendon tear. MATERIALS AND METHODS: The dimensions of the LD and TM tendons and the distance between their insertion and the SS tendon insertion were determined In 20 cadaveric shoulders. Feasibility of the isolated LD and TM tendon transfer to 3 locations on the SS tendon insertion, transfer of the LD to the proximal half, TM to the lower half of the SS tendon, and combined transfer of the LD/TM tendon to the central aspect of the SS tendon was assessed. RESULTS: The LD and TM were an average length of 5.9 cm and 2.3 cm and an average width of 2.2 cm and 2.4 cm, respectively. The mean distances from the center of the LD and TM tendons insertion to the central aspect of the SS tendon insertion was 4.0 cm and 4.7 cm, respectively. All of the tendon transfers were feasible, and the risk of nerve compression was low, except for the combined tendon LD/TM transfer to the proximal third of the SS tendon. CONCLUSIONS: This study shows that transfer of the LD/TM to the lesser tuberosity to reconstruct an irreparable SS tear is feasible, with a low risk of nerve compression, with the exception of the combined LD/TM and more proximal TM tendon transfers.

Total Distal Radioulnar Joint Arthroplasty for Paget's Disease of Bone.

Background Distal radioulnar joint (DRUJ) and ulnocarpal pathology, such as ulnocarpal impaction, are relatively common causes of ulnar-sided wrist pain. We herein report a rare case of ulnocarpal impaction and DRUJ arthropathy due to Paget's disease of bone (PDB) in the ulna. Case Description A 65-year-old, right-hand-dominant male was diagnosed with right-sided ulnocarpal impaction secondary to PDB. While diagnosing the cause of this patient's ulnar wrist pain was relatively straightforward, the management of his pain and symptoms was less so. After a thorough discussion with the patient regarding medical versus surgical management, and after presenting all available surgical options, he opted for a total distal radioulnar joint arthroplasty (TDRUJA). At 3-year follow-up, his wrist is pain-free, has excellent functionality, near-normal motion, and he is highly satisfied. Literature Review Currently, there are no specific recommendations for surgical management of PDB in the ulna, causing ulnocarpal impaction. While resection of the pathologically enlarged ulnar head (Darrach procedure) and the Suavé-Kapandji (SK) procedure are standard surgical treatment options, a major known disadvantage of these procedures is painful ulnar impingement syndrome. TDRUJA, a relatively new treatment option, provides good long-term outcomes with high patient satisfaction and protects from ulnar impingement. Clinical Relevance Since recommendations are lacking for surgical management of PDB, we propose that the TDRUJA be considered as an effective surgical option for the management of PDB causing ulnocarpal impaction. Furthermore, this can reduce the incidence of ulnar impingement, especially for patients who have pathologically enlarged ulnas that are prone to impingement.

Natural history of anterior chest wall numbness after plating of clavicle fractures: educating patients.

OBJECTIVES: Improved patient outcomes after plating of displaced clavicle fractures have been demonstrated by recent clinical studies. Many of these patients, however, complain of anterior chest wall numbness after this procedure; we hypothesize that numbness likely persists long term for many patients, but without effect on shoulder function. DESIGN: Prospective observational cohort. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Adult patients undergoing plating of a displaced middle third diaphyseal clavicle fracture. INTERVENTION: Open reduction and internal fixation with superior clavicle plating. MAIN OUTCOME MEASUREMENTS: The primary outcome is anterior chest wall numbness size (in square centimeters) and location as measured with a numbness transparency grid. Secondary outcomes include Visual Analog scale, Disabilities of the Arm, Shoulder, and Hand, and Constant scores 1 year postoperatively. RESULTS: Twenty-five of 27 consecutive patients met inclusion/exclusion criteria, with 92% 1-year follow-up. Numbness at 2 weeks is very common, involving 83% of patients, with a mean area of 44 cm. Numbness at 1 year remains relatively common, involving 52% of patients, with a mean area of 15 cm (66% decrease in area from 2 weeks, P = 0.009). Numbness at 2 weeks predicted a 63% chance of continued 1-year numbness (37% resolved); Constant, Disabilities of the Arm, Shoulder, and Hand, and Visual Analog scale pain scores remained excellent in all patients at final follow-up, without correlation between numbness and outcome measures (r < 0.170). CONCLUSIONS: Anterior chest wall numbness after open reduction internal fixation of displaced clavicle fractures is very common in the early postoperative period and may remain high 1 year postoperatively. Numbness 1 year after surgery is not associated with poor clinical outcome measures. LEVEL OF EVIDENCE: Prognostic level IV. See instructions for authors for a complete description of levels of evidence.

Neuroforaminal chondrocyte metaplasia and clustering associated with recombinant bone morphogenetic protein-2 usage in transforaminal lumbar interbody fusion.

BACKGROUND CONTEXT: Recombinant human bone morphogenetic protein-2 (rhBMP-2) is commonly used to augment posterior and interbody spinal fusion techniques and has many reported side effects. Neuroforaminal heterotopic ossification (HO) is a known cause of postoperative leg pain, but the pathohistologic composition of this material is not well understood. PURPOSE: The purpose of this article was to report the histologic composition of a case of HO and lumbar radiculopathy after transforaminal lumbar interbody fusion with rhBMP-2. STUDY DESIGN/SETTING: This is a case report. PATIENT SAMPLE: This is a single patient case report. OUTCOME MEASURES: The outcomes considered were physician-recorded clinical, physiological, and functional measures. METHODS: A retrospective review of a single patient was performed. Clinical, radiographic, and pathologic specimens were reviewed and are reported. RESULTS: A 69-year-old woman presented with low back pain and right leg radicular pain associated with L4-L5 stenosis and a recurrent facet cyst. After attempted nonsurgical care, she underwent an L4-L5 revision decompression with interbody and posterolateral fusions including off-label rhBMP-2. Postoperatively, her symptoms resolved for approximately 7 months but then returned in association with right L4-L5 foraminal HO. The ectopic tissue was notably larger than suggested by preoperative computed tomographic scan. It was decompressed, which then improved her symptoms. Histologic examination of the specimen revealed three discrete tissue types: a nonspecific fibrovascular stroma; immature osteoid and woven bone; and chondrocyte metaplasia with chondrocyte clustering. CONCLUSIONS: Neuroforaminal HO formation is a reported side effect associated with the off-label use of rhBMP-2 for posterior lumbar interbody fusion. The mechanism of formation and the composition of this material are not well understood but may involve a chondrocyte differentiation pathway.

Lidocaine analgesia for removal of wound vacuum-assisted closure dressings: a randomized double-blinded placebo-controlled trial.

OBJECTIVES: Wound vacuum-assisted closure (VAC) is a technique used frequently by orthopedic surgeons to facilitate wound closure. Bedside VAC removal can be a source of great pain for patients, which we hypothesize can be decreased by topical lidocaine application. DESIGN: This was a prospective randomized double-blinded, placebo-controlled trial (registered on clinicaltrials.gov), utilizing the crossover intervention technique. SETTING: The study was carried out at a level 1 trauma center. PATIENTS/PARTICIPANTS: Nondiabetic, adult patients requiring at least 2 extremity wound VAC dressing changes were involved. INTERVENTION: In a double-blinded fashion, topical lidocaine (1%) was compared with topical normal saline (0.9% NaCl) after injection into the VAC sponge. The crossover intervention technique, wherein each patient received an independent VAC change with lidocaine and saline, served to control for all possible patient characteristics. Randomization determined which sample was given first or second. MAIN OUTCOME MEASUREMENTS: The patients were evaluated for visual analog pain scores, narcotic requirement, and wound characteristics. RESULTS: : A total of 11 patients were enrolled for a total of 21 VAC changes (mean wound size 133 cm); 1 patient withdrew after his first VAC dressing was changed with saline. Controlling for pre-VAC change pain, the lidocaine intervention was associated with 2.4 points less on the 0-10 visual analog scale for pain (P value <0.001, -3.0 to -1.7) and 1.7 mg less morphine-equivalents administered (P value <0.001, -2.3 to -1.1) during the VAC sponge removal. CONCLUSIONS: The patients undergoing an extremity wound VAC dressing removal at the bedside should be pretreated with topical lidocaine because it decreases pain and narcotic requirements. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.