Citations

Posttraumatic elbow stiffness is common with the primary indication for contracture release being limited motion that affects functional activities which has not adequately improved after intensive therapy and rehabilitation. Preoperative evaluation focuses on the history of previous nonoperative and/or operative treatment, physical exam with particular attention paid to the status of the ulnar nerve, and imaging consisting of radiographs and computed tomography. There are multiple intrinsic and extrinsic causes of posttraumatic contracture. In general, limitation of motion in one direction can be attributed to a mechanical block and/or opposing contracture or tightness. Open elbow contracture release has been shown to improve motion, patient health status and disability scores with the specific surgical approach based upon the contracture pathology and surgeon preference. A step-wise algorithm is presented for open osteocapsular release. An anterior and posterior release is performed first through a lateral approach with the addition of a medial approach if ulnar nerve dysfunction exists or inadequate release has been obtained from the lateral approach. A previous posterior incision can be utilized by raising full thickness flaps. After release, gentle manipulation is performed and intraoperative stability is assessed with stress testing under fluoroscopy. Postoperatively, pain is managed with an in-dwelling nerve catheter and rehabilitation commences immediately. Significant improvement in range of motion can be expected with adequate surgical release and postoperative rehabilitation.

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.

Background: Trapeziectomy with ligament reconstruction tendon interposition (LRTI) or suspensionplasty is an effective treatment in older patients with end-stage thumb basilar arthritis. However, the survivability of this procedure is unknown in younger patients who may impart more stress on their thumbs. Methods: A retrospective review was performed on all patients who underwent trapeziectomy and LRTI or suspensionplasty at 55 years of age or younger from 1992 to 2008. Objective clinical outcome measures included preoperative to postoperative changes in thumb range of motion, grip and pinch strength, a study-specific thumb function score, and the Buck-Gramcko subjective outcome score. Progressive metacarpal subsidence was evaluated on radiographs. Survivorship free from revision surgery was calculated with a Kaplan-Meier analysis. Results: A total of 57 wrists underwent trapeziectomy and LRTI (n = 18) or suspensionplasty (n = 39). The mean patient age at the time of surgery was 49.6 years (range: 38-55 years). Mean clinical and radiographic follow-up were 10.2 and 6.4 years, respectively. Overall, there were significant improvements in pain and grip strength despite progressive and metacarpal subsidence. Survivorship was 100% and 86% free from revision surgery at 10 and 15 years, respectively (n = 2 failures). Conclusions: Trapeziectomy and LRTI or suspensionplasty in patients less than or equal to 55 years of age can result in considerable improvements in pain and grip strength with a 10-year survivorship free from revision.

Most distal radius fractures are the result of low-energy mechanisms that can be successfully treated either non-operatively or with a variety of operative techniques if indicated. Complex distal radius fractures occur most commonly in high-energy injuries with extensive comminution or bone loss and associated soft tissue or vascular injuries. These high-energy fractures can present many challenges in reconstructing the distal radius. Effective restoration of the bony architecture requires a thorough knowledge of distal radius anatomy, understanding of the goals of treatment, versatility in surgical approaches, and familiarity with multiple fixation options.

The purpose of this study is to evaluate the rate of union after four-corner arthrodesis with a locking, dorsal circular plate comprised of polyether-ether-ketone. A retrospective review was conducted of all patients who underwent four-corner arthrodesis with a locking, dorsal circular plate at our institution from January 2005 to May 2009. The primary outcome measure was radiographic and clinical union. During the study period, 26 consecutive wrists underwent four-corner arthrodesis with a locking, dorsal circular plate. Twenty-three wrists were included. The mean clinical follow-up was 16 months (range 3–37). Union was achieved in 22 of 23 wrists at a mean time of 3 months (range 1–12). There was one partial union that underwent successful revision arthrodesis. In summary, four-corner fusion with a polyether-ether-ketone locking, dorsal circular plate results in high union rates. The use of a radiolucent plate allows for more accurate assessment of union with the biomechanical advantages of a fixed angle construct.

AbstractPurposeThe purpose of this study is to determine whether the RetroScrew tibial fixation system offers a biomechanical advantage over the Delta screw for anterior cruciate ligament (ACL) reconstruction in cadaveric tibias with low bone mineral density (BMD).MethodsTen matched pairs of osteoporotic cadaveric tibiae underwent simulated ACL reconstruction using quadrupled hamstring grafts with one of the two tibial fixation constructs. Group 1 was fixed with the Delta screw (DS; 35‐mm antegrade biointerference screw), and group 2 was fixed with the RetroScrew system (RSS; 20‐mm retrograde and 17‐mm antegrade biointerference screws). Each construct was cyclically loaded (50–200 N, 1 Hz, 500 cycles) and subsequently loaded to failure (20 mm/s).ResultsAll specimens were osteoporotic without significant segmental (proximal, middle, and distal) BMD differences between groups by quantitative computed tomography (P = n.s.). A trend was noted for more construct failures due to graft slippage in the DS group (n = 3) over the RSS group (n = 1). There were no significant differences in cyclic displacement (P = n.s.), maximum cyclic stiffness (P = n.s.), maximum load at failure (P = n.s.), or pullout stiffness (P = n.s.) between groups.ConclusionsIn an osteoporotic cadaveric model, there was no significant biomechanical advantage of the RetroScrew system versus the Delta screw for tibial fixation in soft tissue graft ACL reconstruction. However, a trend toward lower graft fixation failure to cyclic loading was noted with the RetroScrew system.Level of evidenceBiomechanical comparative study, Level II.

AbstractPurposeThe purpose of this study is to determine the effect of bioabsorbable interference screw (BIS) tibial fixation with the Delta screw (antegrade) and RetroScrew (retrograde) on initial (time zero) intra‐articular graft tension in soft tissue anterior cruciate ligament (ACL) reconstruction in a cadaveric model.MethodsTen matched pairs of cadaveric tibias received one of two tibial fixation constructs using quadrupled hamstring grafts, Delta screw (antegrade) or the RetroScrew (retrograde). Each specimen was mounted to the materials testing device with the displacement force vector in line with the tibial tunnel. The construct was pre‐tensioned (10–30 N, 0.1 Hz, 10 cycles), a baseline tension of 25 N was introduced, and the change in intra‐articular graft tension before and after screw insertion was recorded.ResultsSegmental (proximal, middle, distal) BMD was utilized to assess BMD using quantitative computed tomography (qCT). The Delta screw had a higher maximum insertion torque (P = 0.03) and exhibited a larger increase in intra‐articular graft tension as compared to the RetroScrew (38.3 ± 17.9 N, 7.6 N ± 14.4, P = 0.004), respectively. There were no significant correlations between intra‐articular graft tension increase to maximum insertion torque (P = NS) or corresponding segmental BMD (P = NS).ConclusionsDelta screw tibial fixation (antegrade) in soft tissue ACL reconstruction significantly increases the initial intra‐articular graft tension as compared to RetroScrew screw fixation (retrograde) in this cadaveric model. Delta screw (antegrade) tibial fixation may increase initial quadrupled hamstring graft intra‐articular tension with currently accepted insertion techniques.