"Management of early deep infection after rotator cuff repair surgery"Kwon, Young W; Kalainov, David M; Rose, Howard A; Bisson, Leslie J; WEILAND, ANDREW J
Deep soft-tissue infection occurs infrequently after rotator cuff repair surgery. We retrospectively reviewed the clinical presentation in 14 patients whose rotator cuff repair was complicated by an early deep infection (<6 weeks). The functional outcome after treatment in 12 of these patients was analyzed at a mean follow-up of 37.5 months (range, 11-122 months). The diagnosis of infection was most often made within 3 weeks from the date of surgery (mean, 18 days; range, 3-41 days). Common presenting symptoms included localized wound erythema and drainage. The blood leukocyte counts were usually normal, but the erythrocyte sedimentation rates and C-reactive protein levels were elevated. A mean of 2.6 surgical debridements were required to clean the wound effectively in each case. Eight of twelve patients were dissatisfied at final assessment. Most patients reported reasonably good relief of pain, but they had residual shoulder stiffness and weakness. Retention of suture anchors in the humeral head did not preclude successful eradication of the infection.
"The V-sling: a modified medial intermuscular septal sling for anterior transposition of the ulnar nerve"Tan, Virak; Pope, Jeff; Daluiski, Aaron; Capo, John T; WEILAND, ANDREW J
Subcutaneous anterior ulnar nerve transposition has been advocated by many surgeons as simple and effective. Techniques to maintain the nerve anterior to the medial epicondyle include subcutaneous pocket, subcutaneous-fascia tunnel, and fascial and fasciodermal sling. We describe a modified technique that uses the medial intermuscular septum as a sling to allow a more gentle transition of the ulnar nerve as it enters into the flexor carpi ulnaris muscle belly..
"Bilateral Monteggia fractures"Kloen, Peter; Rubel, Ivan F; Farley, Timothy D; WEILAND, ANDREW J; Helfet, David L
The current concepts of anatomic and stable fixation followed by early mobilization in Monteggia fractures have clearly resulted in improvements in treatment and outcome. Bilateral Monteggia fractures are unusual and to the best of our knowledge have not been the subject of any reports in the literature. In this case report, we describe the operative technique for treating bilateral Monteggia fractures and the common pitfalls associated with this treatment. Despite the surgical and rehabilitative challenges posed by our patient's case, excellent results were obtained for both elbows.
"Fractures of the distal aspect of the radius: changes in treatment over the past two decades"Simic, Paul M; WEILAND, ANDREW J
Fractures of the distal end of the radius are among the most common orthopaedic injuries, and treatment of these fractures has changed over the course of time. Many fractures of the distal radius are in fact relatively uncomplicated and are effectively treated by closed reduction and casting. However, fractures that are either unstable and/or involve the articular surfaces can jeopardize the integrity of the articular congruence and/or the kinematics of these articulations. The goal of the treating physician should then be to restore the functional anatomy by a method that does not compromise hand function. The fracture pattern, degree of displacement, the stability of the fracture, and the age and physical demands of the patient determine the best treatment option. Over the past 20 years, there has been a development of more sophisticated internal and external fixation techniques and devices for the treatment of displaced fractures of the distal radius. The use of percutaneous pin fixation, external fixation devices that permit distraction and palmar translation, low profile internal fixation plates and implants, arthroscopically-assisted reduction, and bone grafting techniques including bone graft substitutes all have contributed to improving fracture stability and outcome.
"Magnetic resonance imaging of triangular fibrocartilage complex lesions" [Letter]Potter, Hollis G; WEILAND, ANDREW J
"Interosseous-lumbrical adhesions of the hand: contribution of magnetic resonance imaging to diagnosis and treatment planning"Tan, Virak; Rothenfluh, Dominique A; Beredjiklian, Pedro K; Potter, Hollis G; WEILAND, ANDREW J
Previous investigators have not found magnetic resonance imaging (MRI) to be helpful in the diagnosis of interosseous-lumbrical tendon adhesions of the hand. We present 2 cases in which preoperative magnetic resonance images correlated with the clinical diagnosis and intraoperative finding of adhesions between the interosseous-lumbrical tendons at the level of the metacarpal head. Because there are no specific signs for the diagnosis, no palpable lesion, and no specific provocative test, the MRI acted to confirm the diagnosis in the presence of vague, nonspecific symptoms and provide objective evidence of the source of the patient's discomfort. This finding preserved surgery as a definite therapeutic rather than exploratory procedure, raising the confidence level of the operating surgeon as well as the patient. We believe that an MRI is beneficial in narrowing the differential diagnosis of interosseous-lumbrical adhesions, especially in difficult cases in which other underlying pathology may exist.
"Role of ancillary procedures in surgical management of carpal tunnel syndrome: epineurotomy, internal neurolysis, tenosynovectomy, and tendon transfers"Ting, Jess; WEILAND, ANDREW J
The role of ancillary procedures in the treatment of carpal tunnel syndrome is controversial, especially with regard to internal neurolysis and epineurotomy. At present, there are little to no data to support their routine use in the treatment of primary carpal tunnel syndrome. Similarly, the use of tenosynovectomy in carpal tunnel surgery should be limited to those patients with clear underlying rheumatologic or inflammatory risk factors, or with gross synovitis incidentally noted at surgery. The Camitz transfer is uniquely suited to treating the thenar wasting seen in advanced carpal tunnel syndrome. It can be performed concurrently with open carpal tunnel release with minimal additional dissection and morbidity.
"Intraneural ganglion cyst of the peroneal nerve accompanied by complete foot drop. A case report"Coleman SH; Beredjeklian PK; WEILAND AJ
"Minimally invasive reduction and osteosynthesis of articular fractures of the distal radius"Duncan SF; WEILAND AJ
Treatment of displaced fractures of the distal radius has changed over the course of time. For many years, closed reduction with plaster immobilization was considered the treatment of choice. Subsequent use of pins and plaster, percutaneous pin fixation, and the development of external fixation devices all contributed to improving fracture stability. More recently a new generation of external fixation devices has been developed to permit distraction and palmar translation. In addition, over the past twenty years, we have seen the development of more sophisticated internal fixation devices for the treatment of displaced fractures of the distal radius. The indications for open reduction and internal fixation have been defined largely on the basis of numerous studies which support the concept that articular malreduction is predictive of traumatic arthritis and poor functional result. Knirk and Jupiter have reported poor results for intra-articular fractures of the distal radius having an articular step-off greater than 2 mm. More recently, wrist arthroscopy has been used to improve visualization of articular surfaces and aid fracture reduction. In addition, bone grafting techniques have been employed more frequently to accelerate fracture healing. With improvement in techniques, we are able to provide our patients with better functional results and return them to their activities of daily living and vocation more rapidly.
"Vascular pathology in the throwing athlete"Dugas JR; WEILAND AJ
Vascular pathology in the upper extremity of a throwing athlete comprises a spectrum of serious disorders apt to threaten the patient's career and the viability of the involved parts. Such pathology includes digital vessel thrombosis, proximal thrombosis with distal embolization, vessel aneurysm, and vessel compression, such as in thoracic outlet syndrome and quadrilateral space syndrome. This article provides a description of vascular disorders prone to result from sports activities and a review of published data relevant to throwing athletes. Recognition of vascular compromise as a cause for dead arm syndrome or painful digital dysfunction among athletes is essential to prevent the grave consequences of progressive ischemia.
"Intra- and interobserver reliability of sensibility testing in asymptomatic individuals"Rozental TD; Beredjiklian PK; Guyette TM; WEILAND AJ
Threshold and innervation density tests are common clinical tools used in the evaluation of peripheral nerve injuries and compression syndromes. The purpose of this study is to determine the inter- and intraobserver reliability of Semmes-Weinstein monofilaments and static and moving two-point discrimination in 48 volunteers. Kappa coefficients of inter- and intraexaminer agreement were generated for each test and investigator. The interexaminer reliability for the Semmes-Weinstein monofilaments ranged from fair to moderate in the ulnar and median nerve distributions, and slight to moderate in static and moving two-point discrimination testing. Intraobserver reliability for Semmes-Weinstein monofilaments and static and moving two-point discrimination was slight to fair for both examiners. Our data indicate that Semmes-Weinstein monofilaments and two-point discrimination tests yield unreliable measurements in asymptomatic individuals. Although useful in monitoring neurological function in pathological states, threshold and innervation density measurements from an unaffected digit or extremity may not represent a reliable standard for comparison of abnormal values.
"The challenges of genetic advances"WEILAND AJ
"Quadrilateral space syndrome: diagnosis, pathology, and treatment"Lester B; Jeong GK; WEILAND AJ; Wickiewicz TL
Quadrilateral space syndrome is an infrequent, recently established neurovascular compression syndrome affecting young active adults. With this syndrome, the neurovascular bundle, consisting of the posterior humeral circumflex artery (PHCA) and the axillary nerve, is compressed by fibrotic bands as it traverses the quadrilateral space. Symptoms result from compression of the axillary nerve, not from PHCA occlusion. Because of the vague, often nonspecific, clinical presentation of patients with quadrilateral space syndrome, diagnosis is challenging and requires a high index of suspicion from the orthopedist. Subclavian arteriography confirms the diagnosis. Treatment is usually conservative; operative management is reserved for selected patients. A posterior approach with detachment of the deltoid and teres minor muscles is recommended for surgical decompression and for lysis of fibrous tissue. We report two cases of persistent quadrilateral space syndrome in young adults, treated surgically, with 2-year follow-up. In the present report, diagnostic criteria, pathology, management, operative technique, and recent literature are also reviewed.
"Failure of the hinge mechanism of a trispherical total wrist arthroplasty: a case report and review of the literature"O'Flynn HM; Rosen A; WEILAND AJ
We report a patient with rheumatoid arthritis who developed late catastrophic failure of the hinge mechanism of her trispherical total wrist arthroplasty. This was associated with synovitis secondary to wear debris from Titanium, cement, and polyethylene which produced exuberant flexor and extensor tendon synovitis and median nerve compression.
"An aneurysm involving the axillary artery and its branch vessels in a major league baseball pitcher. A case report and review of the literature"Schneider K; Kasparyan NG; Altchek DW; Fantini GA; WEILAND AJ
Baseball pitchers appear to be prone to aneurysms of the axillary artery and its branches. The cause is probably related to repetitive compression of or tension on the vessels at the level of the pectoralis minor muscle and the humeral head, which is exacerbated by the pitching motion. The incidence of aneurysms of the axillary artery and its branches among pitchers and other athletes is not known, nor is it clear whether pitchers who are at high risk of vascular injury can be identified before irreversible damage to the vessels has occurred. Perhaps patients who have documented compression or occlusion of the vessel with the arm in the abducted, externally rotated position are at higher risk. Screening pitchers to identify those with axillary artery compression, aneurysm, or thrombosis has also not been shown to be effective. Certainly, many pitchers will have some level of compression of the axillary artery with their arm in the pitching position but will never develop any clinical abnormality requiring treatment. Screening would therefore probably lead to a high false-positive rate. It is clear, however, that pitchers who complain of ischemia-type symptoms such as early fatigue or who have evidence of emboli require a complete evaluation to rule out any abnormality of the axillary artery or one of its branches. Orthopaedic surgeons who see pitchers and other athletes involved in repetitive overhead motions need to be aware of this disorder so that they order the appropriate tests and obtain a vascular consultation--and make a prompt diagnosis. Treatment will vary depending on the type of lesion and on which vessel or vessels are involved, and should be decided on by the team of surgeons treating the patient.
"External fixation, not ORIF, as the treatment of choice for fractures of the distal radius"WEILAND AJ
"Mycotic aneurysm in a free flap"Kalainov DM; Gerwin M; Gayle LB; WEILAND AJ
A 41-year-old man developed a 3 x 4 cm wound after corrective osteotomies of his distal tibia and fibula. The wound was debrided and covered with a free gracilis muscle flap. Seven days after flap transfer, the arterial pedicle ruptured adjacent to the anastomosis. Attempted repair of the aneurysm failed and the graft was subsequently debrided. Intraoperative wound cultures grew Pseudomonas and Enterobacter cloacae, which were attributed to formation of the aneurysm.
"Rheumatoid arthritis of the wrist and hand"Rosen A; WEILAND AJ
A complete assessment of the entire patient along with a clear understanding of the progression of rheumatoid deformities is the key to success when contemplating surgical intervention for rheumatoid arthritis of the hand. The decision to perform surgery must be made following careful evaluation of the patient's signs and symptoms weighed against the potential benefits likely to be gained. The surgical plan will vary from patient to patient and should be tailored accordingly. Early in the disease process, conservative measures including pharmacologic intervention, steroid injections, and hand therapy, including splinting and wrist use modification, are indicated. Surgical intervention, however, should not be avoided for so long that the benefit of successful intervention is diminished. Hand surgery has proven to be effective in correcting deformity and maintaining or increasing function in patients with rheumatoid arthritis. The indications for synovectomy, tenosynovectomy, tendon repair or realignment, arthroplasty, and arthrodesis have been well established. Superior results are possible when surgical reconstruction is performed before tendon rupture, severe fixed contractures, subluxation, or dislocation.