Wagner, Eric R.

We retrospectively reviewed and compared the outcomes and complications associated with 81 single digit and 168 multi-digit proximal interphalangeal joint arthroplasties performed from 1998 to 2012 in 136 patients. Clinical outcomes were assessed with an average follow-up of 5.3 years for single digit and 5.9 years for multi-digit proximal interphalangeal joint arthroplasty. Comparing single versus multi-digit proximal interphalangeal joint arthroplasty, the reoperation-free survival was 67% and 68% at 5 years and 56% and 67% at 10 years, respectively. Furthermore, in comparison of single versus multi-digit proximal interphalangeal joint arthroplasty, the revision-free survival was 80% and 86% at 5 years and 80% and 85% at 10 years, respectively. Given the similar, or even slightly improved, rates of complications, reoperation, and revision surgery, proximal interphalangeal joint arthroplasty performed on multi-digits results in no worse outcomes compared with single digit proximal interphalangeal joint arthroplasty. Level of evidence: IV

Purpose: A biomechanical functional assessment was performed on a newly designed wrist hemiarthroplasty implant with aimed to identifying differences between the native wrist and wrist following the hemiarthroplasty procedure with [Formula: see text] and without a proximal row carpectomy (Hemi). Methods: Six cadaveric wrists were mounted on a custom testing fixture and underwent a series of functional tests to investigate differences in range of motion, muscles moment arms, and axis of rotation between the intact and post-operative wrists. The tested movements included manually-driven flexion-extension, radial-ulnar deviation, dart throwers motion, and circumduction. Results: The only significant change in range of motion was a decrease in flexion between the intact [Formula: see text] and both the Hemi [Formula: see text] and [Formula: see text] [Formula: see text] conditions. Minor differences in the mean position and variability of the axis of rotation’s piercing point were identified. A statistically significant decrease in the flexion moment arm of the flexor carpi radialis was identified between the intact ([Formula: see text][Formula: see text]mm) and [Formula: see text] ([Formula: see text][Formula: see text]mm) conditions. Statistically significant decreases were also identified in the radial deviation moment arms of the extensor carpi radialis brevis’ between the intact ([Formula: see text][Formula: see text]mm) and [Formula: see text] ([Formula: see text][Formula: see text]mm) conditions and the flexor carpi radialis’ between the intact ([Formula: see text][Formula: see text]mm) and Hemi ([Formula: see text][Formula: see text]mm) conditions as well as in the ulnar deviation moment arm of the extensor carpi ulnaris between the intact ([Formula: see text][Formula: see text]mm) and Hemi ([Formula: see text][Formula: see text]mm) conditions. Conclusions: While some statistically significant functional changes were identified between the native and hemiarthroplasty wrist, the findings suggest that post-operative function is equally acceptable in hemiarthroplasty with and without resection of the proximal carpal row.

Background: This study reviews long-term outcomes of partial wrist denervation focusing on need for and time to revision procedure. Methods: A retrospective study was conducted of all patients undergoing partial wrist denervation between 1994 and 2014. At average latest follow-up of 6.75 years (range, 1-21 years), clinical and radiographic data and need for revision surgery were recorded. Results: There were 100 wrists in 89 patients (61 male, 28 female) with average age at surgery of 54 years (range, 26-80). Principal diagnoses were arthritis (58%), inflammatory (19%), and posttraumatic arthritis (7%). Average flexion-extension arc was 83% and grip strength 75% of unaffected extremity. Average Mayo Wrist Scores improved from 48 preoperatively to 77 postoperatively. Sixty-nine percent of patients did not undergo other procedures during the time interval studied. Thirty-one percent underwent revision at an average of 26 months following denervation (range, 2-165). Conclusions: Partial wrist denervation is a motion-preserving procedure for patients with refractory wrist pain with 69% in this series requiring no further procedures. The remaining 31% experienced average symptom relief for 2 years prior to ultimately undergoing revision operation.

Abstract The arthroscopic Latarjet procedure is challenging because it can be difficult to place 2 screws parallel to the glenoid surface and a medial portal (dangerous for the brachial plexus) is mandatory. In addition, precise positioning of the coracoid bone block flush with the joint line and in a subequatorial position as recommended is troublesome without the use of a guiding system because of the arthroscopic lens distortion. To improve the reproducibility of the arthroscopic Latarjet procedure and to minimize the risk of nerve complications, we developed a guiding system to optimize the positioning of the coracoid bone block and 2 cortical buttons to facilitate its fixation. Four portals are used: a posterior standard portal and 3 anterior portals, all lateral to the conjoint tendon. The anterior rim of the glenoid and the coracoid process are prepared. Two holes are drilled in the glenoid and in the coracoid process with 2 specific guides. The subscapularis is then split, and 2 cortical buttons are passed from posterior to anterior through the tunnels with a shuttle relay. The coracoid process undergoes osteotomy and is guided through the split in the subscapularis to the anteroinferior rim of the glenoid by pulling on the cortical buttons. Technique Video video See video under supplementary data.

Background: Allograft-prosthetic composite (APC) reconstruction of the humerus represents an appealing surgical technique when implantation of a reverse prosthesis is considered in the setting of substantial proximal humeral bone loss 1–4 . Humeral APCs have been successfully performed in the past with a non-reverse shoulder prosthesis 4,5 . Reconstruction of the proximal part of the humerus with an allograft provides adequate support and fixation for the humeral component, allows restoration of length and lateral offset, and provides an opportunity for soft-tissue reattachment when needed. On the basis of the available peer-reviewed data, healing at the allograft-host junction is reliable, and complication rates, including instability, are relatively low 3,6 . Description: Once the glenoid reverse component has been implanted, a proximal humeral allograft is prepared to receive the humeral component of a reverse arthroplasty. The allograft is procured by our institutional bone and tissue bank, purchased from a number of vendors. The graft is selected after review of the description and radiographs provided by the vendor. The priority is to obtain a graft with sufficient length and soft tissues attached. If possible, the graft selected should have a diameter close to the diameter of the humerus of the recipient. The desired allograft length is selected on the basis of preoperative planning and intraoperative measurements, and the distal portion of the allograft is resected accordingly. Depending on the length of the defect, host bone quality, and surgeon preferences, the humeral component may or may not bypass the host-graft junction. The stem bypasses the host-graft junction for shorter APCs, as well as when the bone quality of the native humerus is compromised. Cemented fixation into the graft is universally used. Compression plating is used for graft-to-host fixation, supplemented by implantation of the stem across the junction in selected cases. Care is taken during the freehand cut to obtain optimal contact and compression. Once the ideal humeral bearing thickness has been selected, the polyethylene bearing is implanted and the joint relocated. If the posterior cuff can be repaired to cuff allograft, sutures are placed prior to relocation and are tied after relocation. Other musculotendinous units, such as the deltoid or pectoralis major, are repaired to the allograft if needed. Alternatives: Implantation of a reverse prosthesis with a proximal humeral metal body (a so-called tumor prosthesis) is the main alternative to proximal humeral APC reconstruction. In patients with shorter defects, adequate soft-tissue tension may be obtained by implanting a glenosphere with a large inferior eccentricity and cementing the humeral component in a more proximal position than is usually performed. Alternatively, when implantation of the glenoid component of a reverse prosthesis is not possible, a hemiarthroplasty-APC construct may be performed 1,4,5,7–10 , adding a synthetic sleeve such as an aortic Dacron graft to enhance soft-tissue stability if needed. Rationale: When reverse arthroplasty is performed in the setting of substantial humeral bone loss, the humeral component may be poorly supported and at risk for loosening. In addition, the absence of proximal humeral bone stock may lead to shortening and/or loss of lateral offset. Finally, the posterosuperior cuff, subscapularis, deltoid, and pectoralis tendons may remain detached. The potential consequences of humeral bone loss in the setting of reverse arthroplasty include humeral loosening, dislocation, and poor active motion (particularly poor active elevation). Allograft reconstruction of the proximal part of the humerus provides an opportunity for better support of the component, restoration of humeral length and lateral offset, and attachment sites for the musculotendinous structures around the shoulder, if needed.

Background: Reverse total shoulder arthroplasty (RTSA) performed in the setting of massive proximal humeral bone loss often requires special reconstructive techniques. Restoration of the proximal part of the humerus with an allograft provides a number of theoretical benefits, including implant support, restoration of humeral length, deltoid tensioning, and an opportunity to repair the posterior aspect of the cuff to improve strength in external rotation and repair of the subscapularis to improve stability. However, reverse allograft-prosthesis composites (APCs) are costly, are technically demanding to use, and can be compromised by progressive allograft resorption. Methods: Between 2005 and 2012, the lead author used an APC reconstruction in 8 primary and 18 revision RTSAs (26 patients; mean age, 62 years; mean body mass index, 27.9 kg/m 2 ). The indications for the primary RTSAs included severe proximal humeral bone loss after trauma (n = 5) and tumor resection (n = 3). The indications in the revision setting were failed hemiarthroplasty (n = 11), anatomic total shoulder arthroplasty (n = 4), and reverse arthroplasty (n = 3). The most common reason for revision was instability (n = 10). A compression plate was used for graft-to-host fixation in all shoulders. Shoulders were assessed for pain, motion, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST) score, Neer score, revision or reoperation, radiographic evidence of graft union or resorption, and implant fixation. The mean duration of follow-up was 4 years (range, 2 to 10 years). Results: RTSA using an APC construct resulted in substantial improvements in pain scores (p < 0.0001), elevation (p < 0.0001), and external rotation (p = 0.004). With the numbers available, there were no significant differences in clinical outcomes between primary and revision cases. No patients required revision surgery for nonunion at the host-allograft junction. The mean time to union was 7 months, with 1 patient requiring bone-grafting for delayed union. Other complications included dislocation, deep infection, graft fracture, and periprosthetic fracture distal to the previous APC construct in 1 patient each. The 2 and 5-year revision-free survival rate was 96%. Conclusions: Reconstruction of proximal humeral bone loss with an APC at the time of primary or revision RTSA is safe and effective, with acceptable functional outcomes and complication rates. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background: Nonvascularized bone grafting (NVBG) and vascularized bone grafts (VBGs) have been used to treat scaphoid nonunions. A comparison of a single institution’ s experience using structural iliac crest bone graft (ICBG), 1,2-intercompartmental supraretinacular artery (1,2-ICSRA), and medial femoral condyle (MFC) grafts to treat scaphoid nonunions was undertaken. Methods: Thirty-one patients underwent ICBG, 33 patients underwent 1,2-ICSRA, and 45 patients underwent MFC grafting. Mean time to follow-up was 16 months (range, 2-153). Twenty-three percent used tobacco products. Mean age was 24 years (range, 11-66), with 86% male patients. Outcomes included union rate, time to healing, range of motion, complications, and reoperations. Results: Union rates and mean time to union were 71% and 19 weeks for the ICBG group, 79% and 26 weeks for the 1,2-ICSRA group, and 89% and 16 weeks for the MFC group, respectively. Failure of union was associated with tobacco use but not with age, gender, time from injury to surgery, or type of fixation. There was no significant difference between the groups regarding range of motion or strength. Conclusions: These findings demonstrate the need for careful patient selection. In patients with the most complicated scaphoid nonunions (avascular necrosis, carpal collapse, and previous surgeries), the MFC group had the highest union rate and fastest time to union. Patients with risk factors for failure should be counseled on the outcomes and possible need for salvage fusion surgery.

The purpose was to determine if smartphone photography is a reliable tool in measuring wrist movement. Smartphones were used to take digital photos of both wrists in 32 normal participants (64 wrists) at extremes of wrist motion. The smartphone measurements were compared with clinical goniometry measurements. There was a very high correlation between the clinical goniometry and smartphone measurements, as the concordance coefficients were high for radial deviation, ulnar deviation, wrist extension and wrist flexion. The Pearson coefficients also demonstrated the high precision of the smartphone measurements. The Bland–Altman plots demonstrated 29–31 of 32 smartphone measurements were within the 95% confidence interval of the clinical measurements for all positions of the wrists. There was high reliability between the photography taken by the volunteer and researcher, as well as high inter-observer reliability. Smartphone digital photography is a reliable and accurate tool for measuring wrist range of motion. Level of evidence: II

Background Proper soft tissue balance is paramount to maintaining stability and a functional arc of motion in shoulder arthroplasty but is impaired in patients with prior glenohumeral (GH) dislocations. The purpose of this study was to determine the clinical outcomes, revisions, and complications of reverse shoulder arthroplasty (RSA) in patients with a history of glenohumeral dislocation. Methods Twenty-four patients with a history of GH dislocations that developed arthropathy underwent primary RSA from 2007 to 2013 were retrospectively reviewed. Mean follow-up was 3.3 years (2–7 years). Mean age was 70 years. Eight patients (33%) and 7 patients (29%) had complete or partial subscapularis deficiency, respectively. Results Twenty-two patients (92%) had little to no pain at final follow-up. Mean shoulder elevation improved from 48° to 120° ( P < .001) and mean external rotation increased from 13.2° to 48° ( P < .001). There were trends toward less complete pain relief and poorer motion in those with complete subscapularis deficiency. None of the patients experienced a postoperative dislocation or evidence of glenoid loosening at final radiographic follow-up, but 1 patient (4.2%) underwent early revision to a hemiarthroplasty for glenoid loosening. Conclusion RSA provides patients with prior glenohumeral dislocations a stable, pain-free arc of motion. Postoperative instability was not identified as a major failure mode at short-term follow-up. Complete subscapularis deficiency is a risk factor for poorer clinical outcome.