Clinical Outcomes Following Surgical Management of Post-Traumatic Elbow Contractures in the Pediatric Age Group: A Meta-Analysis and Systematic Review.

PURPOSE: Post-traumatic elbow stiffness is a common occurrence resulting in potentially substantial functional limitations in both daily activities and recreational endeavors. In children, this can be particularly difficult given the early stages of childhood and development and the challenges of rehabilitation. Several studies have reported favorable results of elbow contracture releases in children, resulting in improvements in outcomes. This meta-analysis aimed to determine the efficacy and safety of elbow contracture releases in the pediatric population (<18 years), along with subgroup analyses comparing age groups, operative approach, and post-traumatic versus nontraumatic etiologies. METHODS: Meta-analysis was performed with a multidatabase search (PubMed, OVID, EMBASE, and Medline) according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines on September 25, 2020. Data from all published literature meeting inclusion criteria were extracted and analyzed. RESULTS: Seven studies were included, comprising 114 post-traumatic elbow contractures. Mean age was 13.7 years. Contracture releases of the elbow led to improvements in flexion-extension arc of motion by 48º, and pronosupination arc of motion by 22º. Subgroup analysis comparing age groups of <10, 10-14 and 15-18 years showed greater improvements in flexion-extension arc in the older age group, whereas subgroup analysis comparing injury patterns revealed a larger improvement in pronosupination motion for radial head fractures. Comparing open and arthroscopic procedures, open releases had greater improvement in both flexion-extension and pronosupination motion by 18º and 21º, respectively, although there were limited patients in the arthroscopy group. CONCLUSION: Operative management of pediatric elbow contractures is effective. Older children, children with radial head fractures, and those receiving open contracture releases may be more likely to have greater improvements. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Distal Biceps Tendon Repair Using a Double Intracortical Button Anatomical Footprint Repair Technique.

INTRODUCTION: Distal biceps tendon repair is usually performed via a double-incision or single-incision bicortical drilling technique. However, these techniques are associated with specific complications and usually do not allow for anatomical footprint restoration. It was the aim of this study to report the clinical results of a double intracortical button anatomical footprint repair technique for distal biceps tendon tears. We hypothesized that this technique would result in supination strength comparable to the uninjured side with a low re-rupture rate and minimal bony or neurological complications. MATERIAL AND METHODS: This was a retrospective, single-surgeon cohort study of a consecutive series of 22 patients with a mean (SD) age of 50.7 (9.4) years and at least 1-year follow-up after distal biceps tendon repair. At final follow-up, complications, range of motion (ROM), the Patient-rated Elbow Evaluation (PREE), Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, visual analog scale (VAS) for pain, patient satisfaction and supination strength in neutral as well as 60° of supination were analyzed. Radiographic evaluation was performed on a CT scan. RESULTS: One patient (4.5%) experienced slight paresthesia in the area of the lateral antebrachial cutaneous nerve. Heterotopic ossification was seen in one patient (4.5%). All patients recovered full ROM except for one who had 10° of loss of flexion and extension. Median PREE score was 4.6 (0-39.6), median MEP was 100 (70-100) and median DASH was 1.4 (0-16.7). All but one patient were very satisfied with the outcome. The affected arm had a mean of 98% (± 13) of neutral supination strength (p=0.633) and 94% (± 12) of supination strength in 60° (p=0.054) compared to the contralateral, unaffected side. There were four cases (18.2%) of cortical thinning due to at least one button and one case of button pull-out (4.5%). CONCLUSIONS: The double intracortical button anatomical footprint repair technique seems to provide reliable restoration of supination strength, excellent patient satisfaction while minimizing complications, particularly nerve damage and heterotopic ossification.

Biomechanical analysis of plating techniques for unstable lateral clavicle fractures with coracoclavicular ligament disruption (Neer type IIB).

BACKGROUND: Neer type IIB lateral clavicle fractures are inherently unstable fractures with associated disruption of the coracoclavicular (CC) ligaments. Because of the high rate of nonunion and malunion, surgical fixation is recommended; however, no consensus has been reached regarding the optimal fixation method. A new plating technique using a superior lateral locking plate with anteroposterior (AP) locking screws, resulting in orthogonal fixation in the lateral fragment, has been designed to enhance stability and reduce implant failure. The purpose of this study was to biomechanically compare 3 different clavicle plating constructs within a fresh frozen human cadaveric shoulder model. METHODS: Twenty-four fresh frozen cadaveric shoulders were randomized into 3 groups (n = 8 specimens): group 1, lateral locking plate only (Medartis Aptus Superior Lateral Plate); group 2, lateral locking plate with CC stabilization (No. 2 FiberWire); and group 3, lateral locking plate with 2 AP locking screws stabilizing the lateral fragment. All specimens were subject to cyclic loading of 70 N for 500 cycles. Data were analyzed for gap formation after cyclic loading, construct stiffness, and ultimate load to failure, defined by a marked decrease in the load displacement curve. RESULTS: After 500 cycles, there was no statistically significant difference between the 3 groups in gap formation (P = .179). No specimen (0/24) failed during cyclic loading. Ultimate load to failure was significantly higher in group 3 compared to group 1 (286 N vs. 167 N; P = .022), but not to group 2 (286 N vs. 246 N; P = .604). There were no statistically significant differences in stiffness (group 1: 504 N/mm; group 2: 564 N/mm; group 3: 512 N/mm; P = .712). Peri-implant fracture was the primary mode of failure for all 3 groups, with group 3 demonstrating the lowest rate of peri-implant fractures (group 1: 6/8; group 2: 7/8; group 3: 4/8; P = .243). CONCLUSION: Biomechanical evaluation of the clavicle plating techniques showed effective fixation across all specimens at 500 cycles. The lateral locking plate with orthogonal AP locking screw fixation in the lateral fragment demonstrated the greatest ultimate failure load, followed by the lateral locking plate with CC stabilization. This new plating technique showed compatible stiffness and gap formation when compared to conventional lateral locking plates as well as plates with CC fixation. The use of orthogonal screw fixation in the distal fragment may negate against the need for CC stabilization in these types of fractures, thus minimizing surgical dissection around the coracoid and potential complications.

Double-Screw Osteosynthesis in an Unstable Scaphoid Fracture Model: A Biomechanical Comparison of Two Screw Configurations.

PURPOSE: Although there is evidence that a single headless compression screw is sufficient for fixation of most scaphoid fractures, double-screw osteosynthesis has been shown to result in higher failure strength and stiffness than a single screw. However, the biomechanical effect of different screw configurations has not been determined. METHODS: A standardized unstable fracture model was produced in 28 cadaveric scaphoids. Specimens were randomly allocated to 1 of 2 fixation groups using 2 internal compression screws positioned in either the sagittal or coronal plane. A specimen-specific 3-dimensionally-printed customized screw placement and osteotomy device was developed using computer-aided design-generated models derived from computed tomography scan data of each individual scaphoid. Load to failure and stiffness of the repair constructs were evaluated using a mechanical testing system. RESULTS: There were no significant differences in size, weight, and density between the scaphoid specimens. The average distance between screws was significantly greater in the sagittal group than in the coronal group. There were no significant differences between the coronal and sagittal aligned double screws in load to 2 mm displacement (mean coronal 180.9 ± 109.7 N; mean sagittal 156.0 ± 85.8 N), load to failure (mean coronal 275.9 ± 150.6 N; mean sagittal 248.0 ± 109.5 N), stiffness (mean coronal 111.7 ± 67.3 N/mm; mean sagittal 101.2 ± 45.1 N/mm), and energy absorption (mean coronal 472.6 ± 261.4 mJ; mean sagittal 443.5 ± 272.7 mJ). CONCLUSIONS: There are no significant biomechanical differences between the sagittal or coronal aligned double headless compression screws in a scaphoid fracture model with bone loss. CLINICAL RELEVANCE: In cases where double-screw fixation of the scaphoid is being considered, the placement of double screws can be at the discretion of the surgeon, and can be dictated by ease of access, surgical preference, and fracture orientation.

A new all-suture tension band tape fixation technique for simple olecranon fractures versus conventional tension band wire fixation: a comparative biomechanics study.

HYPOTHESIS: Simple transverse or short oblique olecranon fractures without articular comminution are classified as Mayo type IIA fractures and are typically treated with a tension band wire construct. Because of the high reoperation rates, frequently because of prominent hardware, all-suture tension band constructs have been introduced. It was the purpose to compare the biomechanical performance of conventional tension band wire fixation with a new all-suture tension band tape fixation for simple olecranon fractures. METHODS: Mayo type IIA olecranon fractures were created in 20 cadaveric elbows from 10 donors. One elbow of each donor was randomly assigned to the tension band wire technique (group TBW) or tension band tape (Arthrex, 1.3-mm SutureTape) technique (group TBT). Both groups were cyclically loaded with 500 N over 500 cycles, after which a uniaxial displacement was performed to evaluate load to failure. Data were analyzed for gap formation after cyclic loading, construct stiffness, and ultimate load to failure, where failure was defined as fracture gap formation greater than 4.0 mm. RESULTS: There was no significant difference in gap formation after 500 cycles between the TBW (1.8 mm ± 1.3 mm) and the TBT (1.9 mm ± 1.1 mm) groups (P = .854). The TBT showed a tendency toward greater construct stiffness compared with the TBW construct (mean difference: 142 N/mm; P = .053). Ultimate load to failure was not significantly different comparing both groups (TBW: 1138 N ± 286 N vs. TBT: 1126 N ± 272 N; P = .928). In both groups, all repairs failed because of >4.0-mm gap formation at the fracture site and none because of tension band construct breakage. CONCLUSIONS: Our study shows that the TBT technique produces equivalent or superior biomechanical performance to the TBW for simple olecranon fractures. The TBT approach reduces the risk of hardware prominence and as a result mitigates against the need for hardware removal. The TBT technique offers a clinically viable alternative to TBW.

Reconstruction of the Proximal Scaphoid With a Medial Femoral Trochlea Osteochondral Graft: Minimum 2-Year Results.

PURPOSE: To report the clinical and radiological outcomes after medial femoral trochlear (MFT) osteochondral graft for the salvage of proximal scaphoid fractures with a minimum 2-year follow-up. METHODS: A retrospective review was performed of patients with comminuted fractures of the proximal scaphoid treated by excision of the proximal pole and replacement with free vascularized MFT osteochondral graft. Demographic data, objective and radiographic measurements, and patient-reported outcome measures of the upper limb and knee were collected. Pain was assessed by completion of a visual analog scale (VAS). RESULTS: Between February 2014 and May 2015, 12 MFT osteochondral grafts were performed. Eight patients were available for follow-up at a mean of 34 months (range, 28-39 months). The mean range of wrist flexion was 31° (range, 15°-60°), extension was 34° (range, 5°-60°), radial deviation was 9° (range, 0°-20°), ulnar deviation was 28° (range, 10°-45°) and grip strength was 42 kg (range, 25-53 kg). The median wrist pain, as measured by VAS, was 0.7 (mean, 1.3; range, 0-6). The average follow-up scapholunate, radiolunate, and radioscaphoid angles were 58.9° (range, 44°-93°), 12.9° (range, 0°-30°), and 46.0° (range, 35°-63°), respectively. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 13.9 (range, 3-43) and Patient Rated Wrist Evaluation (PRWE) score was 22.4 (range, 2-68). The mean postoperative Oxford Knee Score was 42 (range, 14-48). One patient suffered notable knee pain at 37-month follow-up. One patient suffered notable pain on the radial side of the wrist and underwent scaphoid excision and 4-corner arthrodesis. CONCLUSIONS: Replacement of the fragmented proximal scaphoid by MFT graft is an alternative to other salvage options and most patients can expect pain relief and acceptable wrist motion. These results need to be balanced against the potential for donor-site morbidity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Measurement of Scaphoid Bone Microarchitecture: A Computed Tomography Imaging Study and Implications for Screw Placement.

PURPOSE: High bone density and quality is associated with improved screw fixation in fracture fixation. The objective of this study was to assess bone density and quality in the proximal and distal scaphoid to determine optimum sites for placement of 2 screws in scaphoid fracture fixation. METHODS: Twenty-nine cadaveric human scaphoid specimens were harvested and scanned using micro-computed tomography. Bone density (bone volume fraction) and bone quality (relative bone surface area, trabecular number, and trabecular thickness) were evaluated in 4 quadrants within each of the proximal and distal scaphoid. RESULTS: The proximal radial quadrant of the scaphoid had significantly greater bone volume than the distal ulnar (mean difference, 33.2%) and distal volar quadrants (mean difference, 32.3%). There was a significantly greater trabecular number in the proximal radial quadrant than in the distal ulnar (mean difference, 16.7%) and in the distal volar quadrants (mean difference, 15.9%) and between the proximal ulnar and the distal ulnar quadrants (mean difference, 12%). There was a significantly greater bone surface area in the proximal radial and distal radial quadrants than in the distal ulnar and distal volar quadrants. There were no significant differences in trabecular thickness between the 8 analyzed quadrants CONCLUSIONS: Although there are differences in bone volume, trabecular number, and bone surface area between the proximal pole of the scaphoid and that of the distal pole, there were no significant differences in the bone quality (trabecular thickness, trabecular number, and relative bone surface area) and density (bone volume fraction) between the 4 quadrants of the proximal or distal pole of the cadaveric scaphoids studied. CLINICAL RELEVANCE: Insertion of 2 headless compression screws can be determined by ease of surgical access and ease of screw positioning and not by differences in bone quality or density of the proximal or distal scaphoid.

Fixation of the Fractured Lunate in Kienböck Disease.

PURPOSE: To describe an uncommon subset of fractured lunates in Kienböck disease that is salvageable by internal fixation. METHODS: We performed a retrospective review for patients with Kienböck disease treated by internal fixation. Demographic data, objective and radiographic measurements, patient-reported outcome measures (Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation) and pain (visual analog scale) scores were collected. RESULTS: Of the 7 patients treated, 5 were available for review. At an average follow-up of 7.1 years (range, 1.5-15 years), all patients had activity-related wrist pain but were pain-free at rest. Radiographic assessment showed union in all lunates and a normal radioscaphoid angle and Stahl index. The modified carpal height ratio was reduced in 4 patients and normal in one. There was no observed narrowing or irregularity of the radiocarpal or midcarpal joints. Patient-reported outcome measures in 2 patients were unsatisfactory. CONCLUSIONS: Computed tomography of the lunate in Kienböck disease is an important investigative tool. A coronal split fracture of these lunates can be salvageable by internal fixation. Revascularization of the lunate can be performed when the fragment is of sufficient size. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Surgical management of chronic high-grade acromioclavicular joint dislocations: a systematic review.

BACKGROUND: To date, no gold-standard technique exists for the treatment of chronic acromioclavicular joint (ACJ) instability. We systematically reviewed the clinical results of 3 main categories of ACJ reconstruction for high-grade chronic instability. METHODS: A literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The inclusion criteria were clinical studies involving patients with ACJ instability (Rockwood grades III-VI) for at least 6 weeks, managed with ACJ stabilization, with a minimum 1-year follow-up. Depending on the surgical technique, patients were divided into 1 of 3 groups: nonbiological fixation between the coracoid and clavicle, for example, suture loops and synthetic ligaments (group 1); biological reconstruction of the coracoclavicular ligaments, for example, allograft or autograft ligament reconstruction (group 2); and ligament and/or tendon transfer, for example, the Weaver-Dunn procedure (group 3). Patient demographic characteristics, functional scores, radiographic outcomes, and complications were compared. RESULTS: Two independent investigators reviewed 960 articles. A total of 27 studies met the inclusion criteria, comprising 590 patients divided into 1 of 3 groups. The complication rates were similar among the 3 groups: 15% for nonbiological fixation, 15% for biological reconstruction, and 17% for ligament and/or tendon transfer, with failure rates of 8%, 7%, and 5%, respectively. In terms of functional results, the mean Constant score was 87.2 points for nonbiological fixation (n = 89), 92.4 points for biological reconstruction (n = 86), and 87.4 points for ligament and/or tendon transfer (n = 49). CONCLUSION: On comparison of the results of 3 different ACJ reconstruction methods, all techniques showed similar complication rates. Among the level II studies, ACJ reconstruction with a tendon graft showed superior results.

Scaphoid Fracture Fixation in a Nonunion Model: A Biomechanical Study Comparing 3 Types of Fixation.

PURPOSE: Union of a scaphoid fracture after fixation is influenced by various factors, one of which is fracture stability. This study aims to compare the biomechanical stability of 3 different types of scaphoid fracture fixation in a scaphoid nonunion model. METHODS: Thirty cadaveric scaphoid specimens were assigned to one of 3 different fixation groups: (1) single 3.0-mm compression screw, (2) two 2.2-mm screws, and (3) scaphoid plate. A 3-mm volar wedge osteotomy was created at the scaphoid waist to simulate a nonunion model. The primary outcome measure was load to failure, whereas secondary outcome measures were load to 2-mm displacement, energy absorbed, stiffness, and mode of failure, recorded by video and retrieval analysis. RESULTS: There was a significantly lower load to failure in the single screw construct compared with that in the double screw (mean difference 187.2 N) and plate fixation constructs (mean difference 150.7 N). The mean load to 2-mm displacement in the single screw construct (91.5 N) was also significantly lower than that in the double screw (181.8 N) and plate fixation constructs (197.2 N). There was a significantly lower stiffness with the single screw fixation compared with that of the double screws (mean difference 85.4 N/mm), and lower energy absorbed with single screws when compared with that of double screws (mean difference 386.5 mJ) and when compared with plate fixation (mean difference 270.8 mJ). CONCLUSIONS: In this biomechanical study comparing fixation methods using a model of scaphoid nonunion with bone loss, we found that double screws or plate fixation demonstrated significantly greater stability, stiffness, and energy absorption when compared with a single compression screw. We found no discernible differences between double screw fixation and the plate groups. CLINICAL RELEVANCE: The use of double screws or plate fixation in a nonunion setting may allow accelerated rehabilitation without compromise to fracture stability.

Fixation of Ultrasmall Proximal Pole Scaphoid Fractures Using Bioabsorbable Osteochondral Fixation Nails.

Surgical treatment of ultrasmall proximal pole scaphoid fractures poses a number of challenges. The fragment may be too small to fix with conventional headless screw fixation owing to the high risk of fragmentation upon insertion. However, excision of the fragment risks compromising the scapholunate ligament complex and also exposes the radioscaphoid joint to potential degenerative changes. Under these circumstances, we describe the use of bioabsorbable osteochondral fixation nails that allows stable low-profile fixation while minimizing the risk of fracturing the proximal pole.

Propionibacterium Acnes Infection of a Metacarpophalangeal Joint Arthroplasty.

Neglected and underestimated in the past, Propionibacterium acnes is currently the most prevalent organism associated with deep prosthetic infections around the shoulder. Surprisingly, it has never been reported as a cause of infection in the hand. Here we report a case of a late presentation of a P. acnes infection in a metacarpophalangeal joint replacement, resulting in chronic low-grade pain with movement. The patient underwent a 2-stage revision, with initial removal of the prosthesis. Positive cultures for P. acnes required 15 days of extended incubation. The patient subsequently had 6 weeks of oral antibiotics followed by a second-stage revision with a Silastic implant.

Interobserver and intraobserver variability of glenoid track measurements.

BACKGROUND: A method of assessing combined glenoid and humeral bone loss in traumatic shoulder instability with an associated treatment protocol was recently published. The aim of this study was to investigate its reliability and reproducibility. METHODS: Seventy-one patients with unilateral anteroinferior shoulder instability underwent computed tomography scans, from which 3-dimensional images were derived. En face views of both glenoid fossae and with 3 views of the humeral head were provided to 4 assessors to determine interobserver reliability. From these measurements, the shoulder was assigned a treatment classification. Two observers repeated their assessments 1 month later to determine intraobserver reliability. For each measurement, the mean coefficient of variability was calculated. RESULTS: Assessment of glenoid bone loss showed good interobserver (4 observers agreeing in 90.1% of cases) and also good intraobserver agreement (94% and 96%). There was a poor level of interobserver reliability regarding the on-track or off-track classification (72%). Intraobserver reliability for this measurement was less variable (90% and 80%). There was a poor level of agreement between observers (65%) regarding treatment classification. The coefficient of variability for the Hill-Sachs lesion measured 19.2%, indicating a high level of variability for this measurement compared with <4% for all other measures. CONCLUSION: Linear bone loss on the glenoid can be measured reliably and reproducibly; however, evaluation of Hill-Sachs lesions demonstrates a high level of variability, and poor interobserver reliability.

Outcomes after operative treatment of elbow contractures in the pediatric and adolescent population.

BACKGROUND: The role of elbow contracture release in the very young is unclear, with existing studies reporting conflicting results. This study evaluated the long-term results after open elbow contracture release in patients aged younger than 18 years. METHODS: Between 1994 and 2012, 32 patients underwent open elbow contracture release at a mean age of 13.8 years (range, 5-18 years), and their outcomes were reviewed. The primary cause was traumatic in 30 patients (4 radial head/neck fractures, 5 intra-articular distal humeral fractures, 11 extra-articular distal humeral fractures, 10 complex fracture-dislocations), and the mean time from the index injury to contracture release was 16.3 months (range, 3-82 months). The cause in 2 patients was nontraumatic (1 osteochondritis dessicans, 1 congenital). The mean follow-up period was 66 months (range, 7-202 months). RESULTS: At the latest follow-up, total arc of motion improved from 69° to 123° (P <.0001), with a mean increase of 54° (P <.0001). The function arc was >100° in 28 patients (88%), and 29 patients (91%) achieved >20° of improvement in their arc. Twelve patients (38%) underwent a gentle manipulation under anesthesia at a mean of 2.7 weeks (range, 1-5 weeks) for early recurrence of stiffness. There were 3 complications (1 deep infection, 1 hematoma, 1 humeral fracture through the external fixator pin site). No patients lost motion after surgery. CONCLUSION: Elbow contracture release in the pediatric and adolescent population can provide significant improvements in range of motion similar to that achieved in adults. The improvements in motion are durable.

Conversion of stemmed hemi- or total to reverse total shoulder arthroplasty: advantages of a modular stem design.

BACKGROUND: If revision of a failed anatomic hemiarthroplasty or total shoulder arthroplasty is uncertain to preserve or restore satisfactory rotator cuff function, conversion to a reverse total shoulder arthroplasty has become the preferred treatment, at least for elderly patients. However, revision of a well-fixed humeral stem has the potential risk of loss of humeral bone stock, nerve injury, periprosthetic fracture, and malunion or nonunion of a humeral osteotomy with later humeral component loosening. QUESTIONS/PURPOSES: The purposes of this study were to determine whether preservation of a modular stem is associated with (1) less blood loss and operative time; (2) fewer perioperative and postoperative complications, including reoperations and revisions; and/or (3) improved Constant and Murley scores and subjective shoulder values for conversion to a reverse total shoulder arthroplasty compared with stem revision. METHODS: Between 2005 and 2011, 48 hemiarthroplasties and eight total shoulder arthroplasties (total=56 shoulders; 54 patients) were converted to an Anatomical™ reverse total shoulder arthroplasty system without (n=13) or with (n=43) stem exchange. Complications and revisions for all patients were tallied through review of medical and surgical records. The outcomes scores included the Constant and Murley score and the subjective shoulder value. Complete clinical followup was available on 80% of shoulders (43 patients; 45 of 56 procedures, 32 with and 13 without stem exchange) at a minimum of 12 months (mean, 37 months; range, 12-83 months). RESULTS: Blood loss averaged 485 mL (range, 300-700 mL; SD, 151 mL) and surgical time averaged 118 minutes (range, 90-160 minutes; SD, 21 minutes) without stem exchange and 831 mL (range, 350-2000 mL; SD, 400 mL) and 176 minutes (range, 120-300 minutes; SD, 42 minutes) with stem exchange (p=0.001). Intraoperative complications (8% versus 30%; odds ratio [OR], 5.2) and reinterventions (8% versus 14%; OR, 1.9) were substantially fewer in patients without stem exchange. The complication rate leading to dropout from the study was substantial in the stem revision group (six patients; 43 shoulders [14%]), but there were no complication-related dropouts in the stem-retaining group. If, however, such complications could be avoided, with the numbers available we detected no difference in the functional outcome between the two groups. CONCLUSIONS: Patients undergoing revision of stemmed hemiarthroplasty or total to reverse total shoulder arthroplasty without stem exchange had less intraoperative blood loss and operative time, fewer intraoperative complications, and fewer revisions than did patients whose index revision procedures included a full stem exchange. Therefore modularity of a shoulder arthroplasty system has substantial advantages if conversion to reverse total shoulder arthroplasty becomes necessary and should be considered as prerequisite for stemmed shoulder arthroplasty systems. LEVEL OF EVIDENCE: Level III, therapeutic study.

Latissimus Dorsi and Teres Major Transfer With Reverse Shoulder Arthroplasty Restores Active Motion and Reduces Pain for Posterosuperior Cuff Dysfunction.

BACKGROUND: In patients with rotator cuff dysfunction, reverse shoulder arthroplasty can restore active forward flexion, but it does not provide a solution for the lack of active external rotation because of infraspinatus and the teres minor dysfunction. A modified L'Episcopo procedure can be performed in the same setting wherein the latissimus dorsi and teres major tendons are transferred to the lateral aspect of proximal humerus in an attempt to restore active external rotation. QUESTIONS/PURPOSES: (1) Do latissimus dorsi and teres major tendon transfers with reverse shoulder arthroplasty improve external rotation function in patients with posterosuperior rotator cuff dysfunction? (2) Do patients experience less pain and have improved outcome scores after surgery? (3) What are the complications associated with reverse shoulder arthroplasty with latissimus dorsi and teres major transfer? METHODS: Between 2007 and 2010, we treated all patients undergoing shoulder arthroplasty who had a profound external rotation lag sign and advanced fatty degeneration of the posterosuperior rotator cuff (infraspinatus plus teres minor) with this approach. A total of 21 patients (mean age 66 years; range, 58-82 years) were treated this way and followed for a minimum of 2 years (range, 26-81 months); none was lost to followup, and all have been seen in the last 5 years. We compared pre- and postoperative ranges of motion, pain, and functional status; scores were drawn from chart review. We also categorized major and minor complications. RESULTS: Active forward flexion improved from 56° ± 36° to 120° ± 38° (mean difference: 64° [95% confidence interval {CI}, 45°-83°], p < 0.001). Active external rotation with the arm adducted improved from 6° ± 16° to 38° ± 14° (mean difference: 30° [95% CI, 21°-39°], p < 0.001); active external rotation with the arm abducted improved from 19° ± 25° to 74° ± 22° (mean difference: 44° [95% CI, 22°-65°], p < 0.001). Pain visual analog score improved from 8.4 ± 2.3 to 1.7 ± 2.1 (mean difference: -6.9 [95% CI, -8.7 to -5.2], p < 0.001), and Single Assessment Numeric Evaluation score improved from 28% ± 21% to 80% ± 24% (mean difference: 46% [95% CI, 28%-64%], p < 0.001). There were six major complications, five of which were treated operatively. Overall, three patients' latissimus and teres major transfer failed based on persistent lack of external rotation. CONCLUSIONS: In patients with posterior and superior cuff deficiency, reverse shoulder arthroplasty combined with latissimus dorsi and teres major transfer through a single deltopectoral incision can reliably increase active forward flexion and external rotation. Patients experience pain relief and functional improvement but have a high rate of complications; therefore, we recommend the procedure be limited to patients indicated for reverse who have profound external rotation loss and a high grade of infraspinatus/teres minor fatty atrophy. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Biomechanical Analysis of Scapholunate Ligament Repair Techniques.

PURPOSE: To evaluate the biomechanical properties of 3 scapholunate repair techniques. METHODS: In 51 cadavers, the scapholunate ligament was exposed through a dorsal approach, incised at its scaphoid insertion, and repaired using 1 of 3 techniques: 2 single-loaded suture anchors, 2 double-loaded suture anchors, or 2 transosseous sutures. Twenty-four repaired specimens underwent load to failure (LTF) testing using tensile distraction on a servo-hydraulic machine. Twenty-seven specimens underwent cyclical testing to measure gap formation at the scapholunate joint. RESULTS: The mode of failure was suture pullout through the substance of the ligament in 22 specimens, failure at the bone suture interface in 1, and anchor pullout in 1. Double-loaded anchor repairs demonstrated a significantly higher mean ultimate LTF compared with single-loaded anchor (91 N vs 35 N) and transosseous (91 N vs 60 N) repairs. Transosseous repairs demonstrated a higher mean ultimate LTF compared with single-loaded suture repairs (60 N vs 35 N). After 300 cycles, the average gap for the transosseous repair group was double that for the single- and double-loaded repairs, although not statistically significant. CONCLUSIONS: Primary scapholunate ligament repairs using double-loaded suture anchors demonstrated significantly higher strength compared with single-loaded anchors and transosseous repairs. On cyclic loading, transosseous repairs demonstrated the greatest gap formation with no measurable difference between single- and double-loaded repairs. CLINICAL RELEVANCE: In a cadaveric model for primary repairs, double-loaded suture anchors demonstrated the highest LTF and offer a similar but unproven performance in vivo.

Failure of the lesser tuberosity osteotomy after total shoulder arthroplasty.

BACKGROUND: Lesser tuberosity osteotomy (LTO) as an approach during total shoulder arthroplasty (TSA) is a reliable technique with strong biomechanical fixation and a low failure rate. Complications have been infrequently reported in the literature. METHODS: We report a case series of 5 patients who sustained failure of the LTO repair after primary TSA. The data on the patient demographic characteristics, surgical technique, postoperative care, revision surgery, and clinical outcomes are reported. RESULTS: The mean age of the 5 patients was 52 years, all patients were men, and the mean body mass index was 28 kg/m(2). They were followed up for a mean of 29 months (range, 24-38 months). The mean time from initial TSA to diagnosis of LTO failure was 9 weeks (range, 5-12 weeks). Two patients reported no trauma, 2 had minor trauma (using a pulley, rolling over in bed), and 1 sustained a fall. At the latest follow-up, the mean visual analog scale; Single Assessment Numeric Evaluation; University of California, Los Angeles; and American Shoulder and Elbow Surgeons scores were 4 (range, 0-6), 48 (range, 20-70), 19 (range, 11-22), and 63 (range, 48-83), respectively. Only 1 patient required no additional procedures beyond the revision LTO repair. Another patient required a second revision LTO repair. The remaining 3 patients either underwent or were recommended to undergo reverse arthroplasty. CONCLUSION: Failure of the LTO repair after TSA may possibly be an under-reported complication that is associated with poor clinical outcomes and limited options for revision surgery. In patients with a high risk of LTO failure, considerations should be made to augment the LTO repair during the index TSA procedure.

Vascular anomalies of the hand and wrist.

Vascular malformations of the hand and wrist are uncommon. They develop from aberrations in angiogenic signaling during vascular development. Unlike hemangiomas, which are characterized by biphasic growth and slow spontaneous involution, vascular malformations continue to grow proportionally with the child. Management is dictated by classification of the vascular malformations, which is based on flow characteristics (ie, low, high) and predominant cell type (ie, venous, lymphatic, capillary, combined, arteriovenous). Initial management is conservative, with the goal of providing relief from pain and swelling. Sclerotherapy, laser treatment, and arterial embolization may be beneficial in well-selected patients. Surgery is indicated in cases of persistent pain and uncontrolled limb swelling leading to functional impairment and/or neurologic compression. The goals of surgery are to excise as much of the lesion as possible while avoiding injury to adjacent nerves, minimizing blood loss, and preventing distal limb ischemia. This mandates careful preoperative planning and meticulous technique. Adjuvant treatments may be warranted, as in the case of preoperative embolization in patients with high-flow lesions.

Carpal fractures.

Carpal fractures are exceedingly rare clinical entities and are often associated with concomitant injuries. In this review, we focus on fractures of the carpus, excluding the scaphoid, and provide an update on the current consensus as to mechanism, diagnosis, management, outcomes, and complications after such injuries.