Shin, Alexander Y.

Arthroscopic dorsal wrist ganglionectomy is demonstrably a safe procedure with recurrence rates comparable to open surgery. We present a patient with wrist pain following arthroscopic ganglion excision. MRI and arthroscopic findings showed a large dorsal capsular defect, synovial fistula to the fourth extensor compartment, and dorsal radiocarpal ligament resection. Ligament reconstruction and capsular imbrication resolved her symptoms. We postulate that this complication resulted from a large capsular resection. Because we feel that it can be difficult to judge the size of the debridement through an arthroscope, the need for adequate capsular resection in dorsal wrist ganglionectomy needs to be balanced by consideration of potential complications from more aggressive capsular debridement, and thus we feel that capsular resection should be limited to no more than 1 cm2.

AbstractBackgroundA bridging nerve autograft is the gold standard for the repair of segmental nerve injury that cannot be repaired directly. However, limited availability and donor site morbidity remain major disadvantages of autografts. Here, a nerve allograft decellularized with elastase was compared with an autograft regarding functional motor outcome in a rat sciatic segmental nerve defect model. Furthermore, the effect of storage on this allograft was studied.MethodsSixty‐six Lewis rats (250–300 g) underwent a 10‐mm sciatic nerve reconstruction using either a cold‐ (n = 22) or frozen‐stored (n = 22) decellularized nerve allograft or an autograft (n = 22). Sprague–Dawley rats (300–350 g) served as full major histocompatibility complex‐mismatched donors. Functional motor outcome was evaluated after 12 and 16 weeks. Ankle angle, compound muscle action potential (CMAP), isometric tetanic force, wet muscle weight, and histomorphometry were tested bilaterally.ResultsFor CMAP and isometric tetanic force, no significant differences were observed between groups. In contrast, for ankle angle, histomorphometry and muscle weight, the cold‐stored allograft performed comparable to the autograft, while the frozen‐stored allograft performed significantly inferior to the autograft. At week 16, ankle angle was 88.0 ± 3.1% in the cold‐stored group, 77.4 ± 3.6% in the frozen‐stored group, and 74.1 ± 3.1% in the autograft group (P < .001); At week 16, the muscle weight showed a recovery up to 71.1 ± 4.8% in the autograft group, 67.0 ± 6.6% in the cold‐stored group, and 64.7 ± 3.7% in the frozen‐stored group (P < .05).ConclusionsA nerve allograft decellularized with elastase, if stored under the right conditions, results in comparable functional motor outcomes as the gold standard, the autograft.

* Rates of opioid use and abuse continue to rise in the United States, as do opioid-related deaths. Many patients who misuse opioids receive their first exposure in the perioperative setting. * Postoperative opioid use reduction in patients who have undergone an upper-extremity procedure can be difficult secondary to the often-painful nature of orthopaedic procedures. Postoperative pain can prevent timely discharge from hospitals and is a major cause for emergency medicine visits following outpatient upper-extremity surgical procedures. * Utilization of a multidisciplinary, multimodal, home-going continuous peripheral nerve block catheter protocol may be able to comfortably allow patients to recover in an outpatient setting after an upper-extremity surgical procedure, with a diminished opioid requirement.

Background: The medial femoral condyle free vascularized bone flap is a valuable alternative to other types of vascularized bone grafts. The donor-site morbidity and functional outcomes after flap harvest have not been fully appreciated. The authors report the postoperative outcomes and analyze the impact of increasing the size of the flap on knee donor-site morbidity. Methods: A retrospective chart review of patients who underwent medial femoral condyle flap surgery between 2001 and 2012 at their institution was performed. The size of the flap was stratified, based on the largest dimension, into three groups. Demographics, outcomes, and complications related to the flap donor site were recorded and analyzed. Subsequently, functional status was assessed by administering a validated condition-specific measure. A univariate logistic regression analysis was performed, and results were analyzed. Results: A total of 75 patients were identified. Average age was 29.5 ± 15.2 years. Average follow-up time was 13 months. The overall complication rate was 18.6 percent. Paresthesia in the saphenous nerve distribution was the most common complication. Increasing the size of the flap resulted in a significant elevation in complication risk (p < 0.05). A total of 47 patients completed the Lower Extremity Functional Scale questionnaire. The average Lower Extremity Functional Scale score was 72.12 ± 14.18. Fifty-one percent (n = 24) scored 80 points, indicating a normal level of function on average. Conclusions: The medial femoral condyle flap has overall acceptable donor-site morbidity, with a good level of function postoperatively. Larger flaps are associated with a greater number of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background: Outcomes following revision surgery for scaphoid nonunions with osteonecrosis are guarded. We hypothesized that use of free vascularized medial femoral condyle (MFC) bone grafts can lead to healing of the nonunion, increase vascularity of the proximal pole, and restore scaphoid architecture, resulting in acceptable functional outcomes. Methods: We performed a retrospective review of 49 patients who were treated with an MFC bone graft, between May 2005 and September 2016, after prior failure of operative treatment for scaphoid nonunion. The mean time from the injury to the revision surgery with the MFC bone graft was 24 months, and the mean time from the prior, failed surgery was 15 months. Thirty-six of the 49 patients had had a prior bone graft procedure and 6 patients had had 2 previous surgical procedures for the nonunion. The initial internal fixation of the scaphoid fracture was with a scaphoid screw in 43 patients. All patients had documented osteonecrosis of the proximal pole at the time of our surgery. Carpal indices, time to union, pain scores, functional outcomes, and complications were recorded. Results: Forty-one (84%) of the 49 previously operated on scaphoid nonunions healed at a mean of 16 weeks (range, 9 to 31 weeks) after the MFC bone-grafting as confirmed on computed tomography (CT). Radiographs demonstrated significant improvement in carpal alignment following the surgery with the MFC bone graft. Comparison between preoperative and postoperative values showed a trend toward improved grip strength and no important change in total wrist range of motion. Subsequent procedures were performed in 29 patients, 21 of whom had planned Kirschner wire removal. All 24 patients in whom scaphoid union had been achieved and who were available for follow-up were able to work or attend school full-time, and 88% were satisfied or very satisfied with their wrist function. Age, smoking status, body mass index, time to surgery, and preoperative radiographic findings were not found to be significant predictors of failure. Conclusions: MFC grafts increase vascularity and restore scaphoid architecture, promoting union in most patients with the combination of proximal pole osteonecrosis, carpal collapse, and failed prior scaphoid nonunion surgery. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background: The purpose of this study was to determine whether prominent radial shaft screws in volar locked plating of distal radius fractures increase the risk of tendon irritation, tendon rupture, or hardware removal. Methods: Patients who underwent volar locked plating of distal radius fractures from April 2002 to March 2016 with at least 6 months of follow-up were evaluated. Variables examined included demographics, extensor tendon irritation, extensor tendon rupture, and hardware removal. The most prominent cortical screws on postoperative lateral radiographs were identified and measured from the dorsal cortex of the radial shaft to the tip of the screw. Results: In all, 261 distal radius fractures in 255 patients were identified. Thirty-nine patients (14.9%) underwent subsequent hardware removal at a mean 15.8 ± 18.6 months. Nine patients (3.45%) were found to have clinically significant extensor tendon irritation including one patient (0.38%) with extensor tendon rupture. The average screw was 1.48 mm proud of the dorsal radial cortex. In all, 22.6% of screws were greater than 2 mm proud. Comparing patients who underwent hardware removal with those who did not, there was no statistically significant difference in mean screw prominence or proportion of patients with screws greater than 2 mm. There was no statistically significant difference between shaft screw prominence and extensor tendon irritation. Conclusions: The effect of dorsal screw prominence of radial shaft screws is not significant. This study does not support the downsizing of prominent screws 2 mm or less.

This study aimed to determine the outcome of free vascularized medial femoral condyle bone grafts in the primary treatment of scaphoid nonunions with scaphoid foreshortening or carpal collapse and intraoperatively documented avascular necrosis. Thirty-two patients (28 male, four female) met the inclusion criteria. Median time from injury to surgery was 70 weeks. Thirty of 32 patients healed at a median of 12 weeks. There was significant improvement from preoperative to postoperative lateral intrascaphoid angle, scapholunate angle, and radiolunate angle. Two scaphoids failed to unite; one patient underwent scaphoidectomy and four-corner fusion 15 months postoperatively after suffering a subsequent injury. Another patient underwent 1,2-intercompartmental supraretinacular artery-based vascularized bone grafting at 4 months postoperatively and then scaphoid excision with four-corner fusion 4 years later. The free vascularized medial femoral condyle bone graft restores scaphoid vascularity and architecture while promoting union in a subset of scaphoid nonunions that has historically been a clinical challenge. Level of evidence: IV

Background: Distal radius fractures are common, and the trend in fixation has included the use of locked volar plating. The duration of splinting required after surgery and the effect splinting has upon outcome of the wrist are not clear. Our aim was to compare outcome of patients treated with early versus late motion protocol after volar plating. Methods: Thirty-three patients with distal radius fractures were prospectively and randomly enrolled into an early versus late motion study including volar plating of the distal radius fracture. Early motion included an active and passive wrist motion protocol by 14 days after surgery and delayed motion was initiated at 5 weeks. Fractures were defined as intra-articular and extra-articular, and those with, and without, ulnar styloid fracture. Motion and outcome scores (Disabilities of the Arm, Shoulder and Hand [DASH]/patient-rated wrist evaluation [PRWE]), and strength were measured through 1 year. Results: Wrist motion, DASH, and PRWE scores were only significantly different at 6 weeks with no significant differences at any later time points up to 1 year. One patient had complex regional pain syndrome (CRPS) and one had adhesive capsulitis in the late motion group. Conclusions: Following locked volar plating of distal radius fractures, early motion favored earlier return of motion along with lower DASH, PRWE, and pain scores within first 6 weeks. Although the late motion group had delayed recovery, there were no long-term significant differences in motion, strength, outcome, or pain scores. The 2 cases with complications (CRPS and adhesive capsulitis) did occur in the late motion group and may implicate late motion with these problems.

Background: Traumatic brachial plexus injury (BPI) in patients with complete spinal cord injury (SCI) such as paraplegia or tetraplegia is a very rare and debilitating combined injury that can occur in high-energy traumas. Management of a BPI should be aimed at regaining strength for self-transfers and activities of daily living to restore independence. However, brachial plexus reconstruction (BPR) in this unique patient population requires considerable planning due to the combined elements of upper and lower motor neuron injuries. Methods: We present 2 cases of traumatic complete SCI with concomitant BPI with mean follow-up of 42 months after BPR. The first patient had a left C5-7 BPI with a T2 complete SCI. The second patient sustained a left C5-8 BPI with complete SCI at C8. Results: The first patient underwent BPR including free functioning muscle, intra- and extraplexal nerve transfers, and tendon transfers resulting in active elbow flexion and active elbow, finger, and thumb extension, but no recovery of shoulder function. While the second patient underwent extra-plexal nerve transfer to restore elbow flexion yet did not recover any function in the left upper extreimty. Conclusions: Because extensive upper and lower motor neuron injuries are present in these combined injuries, treatment strategies are limited. Expectations should be tempered in these patients as traditional methods to reconstruct the brachial plexus may result in less than ideal functional outcomes due to the associated upper motor neuron injury.

A simple, reproducible technique for assessing the scaphotrapeziotrapezoid joint radiographically is described. In addition to its diagnostic value, the technique is simple to perform with a minifluoroscopy unit, allowing for image-guided injections of the scaphotrapeziotrapezoid joint.