The tangential view described by Moneim to demonstrate scapholunate dissociation: an update

PURPOSE

Scapholunate dissociation is a common and significant injury to the wrist. Radiographs are important in the diagnosis of this injury and in the planning of treatment. The tangential radiograph view was described almost 40 years ago as a method for accurately measuring scapholunate gaps. The hand is positioned on a 20° foam rubber block and the thumb on the cassette, which positions the scaphoid and lunate articular surfaces parallel, without patient discomfort or effort. The goal of this study was to review this method with more recent data and in a larger group of patients.

METHODS

Radiographs of 31 patients who had scapholunate interosseous ligament tears and surgical repair over a 9 year period were retrospectively evaluated. Each of the four authors independently measured scapholunate gaps for posteroanterior and tangential views.

RESULTS

The tangential view gaps were significantly greater than the posteroanterior gaps overall. Similar results were found for borderline cases where the posteroanterior gap was less than 3 mm. Every tangential view gap measurement was greater than its respective posteroanterior gap with good inter-rater reliability.

CONCLUSION

The tangential view is a reliable radiographic method to identify scapholunate gaps. It should be obtained when there is clinical concern for scapholunate dissociation, especially in patients with borderline posteroanterior gaps.

Return to Sport After Multiligament Knee Injury in Young Athletes

Background

While return to sport (RTS) in young athletes after anterior cruciate ligament (ACL) reconstruction has been well studied, little is known regarding their rate of RTS after multiligament knee injury (MLKI).

Purpose

To assess the level of and factors associated with RTS after MLKI in young athletes.

Study Design

Case series; Level of evidence, 4.

Methods

We retrospectively identified 116 patients aged ≤23 years who had sustained an injury to ≥2 knee ligaments and undergone operative reconstruction or repair of ≥1 ligament. Our primary outcome was self-reported RTS at the preinjury level or higher. We estimated the likelihood of RTS using binomial logistic regression. Secondary variables included the 2000 International Knee Documentation Committee Subjective Knee Form (IKDC-SF), ACL-Return to Sport after Injury (ACL-RSI), and 12-Item Short Form Health Survey (SF-12) physical and mental health summaries.

Results

A total of 30 (25.9%) patients (24 men, 6 women; mean age, 18.1 ± 2.5 years) completed patient-reported outcome surveys at a mean follow-up of 7.8 years (median, 6.6 years [range, 1.1-19.5 years]). A total of 28 patients underwent surgical treatment of ≥2 ligaments. RTS was achieved by 90% of patients, and 43.3% returned to their preinjury level or higher. Patients who had played sports at a higher level before injury were more likely to RTS at their preinjury level or higher (odds ratio [OR], 3.516 [95% CI, 1.034-11.955]; P = .044), while those who played cutting sports were less likely to do so (OR, 0.013 [95% CI, 0.000-0.461; P = .017). Patients who achieved RTS at their preinjury level or higher had significantly higher IKDC-SF and ACL-RSI scores versus patients who did not (P = .001 and P = .002, respectively). The number of ligaments injured, age, mental health diagnosis, and SF-12 scores were not associated with the ability to RTS at the preinjury or higher levels.

Conclusion

Most young athletes who sustained MLKI were able to return to play at some level, but a minority returned to their preinjury level. Patients who did return at preinjury or higher levels had higher IKDC-SF and ACL-RSI scores than those who did not. Performance in cutting and/or pivoting sports was negatively associated with RTS.

Plating of Proximal Ulna Fractures Using Posterolateral Distal Humerus Plates: Surgical Technique and Case Series

Precontoured olecranon plates are frequently used in the management of proximal ulna fractures. Occasionally, in comminuted proximal ulna fractures or segmental ulna fractures, available precontoured olecranon plates are too short for the management of these fractures. The authors have utilized posterolateral distal humerus plates in these instances. The coronal bend in some posterolateral distal humerus plates anecdotally fits well to the proximal ulna, despite being designed for the distal humerus. We sought to measure the coronal angulation of precontoured posterolateral distal humerus plates from various companies and compare these to established proximal ulna angles. Case examples are also provided.

Review of surgical treatment for chronic scapholunate ligament reconstruction: a long-term study

PURPOSE

Scapholunate dissociation (SLD) is a common entity encountered by hand surgeons. While multiple methods for surgical treatment exist, there is little agreement on the best surgical techniques to treat chronic, static SLD. Our study's goal was to assess the long-term (greater than five years), clinical and radiologic outcomes of the currently recommended treatment options for chronic, static SLD.

METHODS

We performed a review of the literature to assess outcomes after surgical treatment of chronic, static SLD with long-term follow-up of greater than five years.

RESULTS

We found only six studies that encompassed the modified Brunelli tenodesis, capsulodesis, scapholunate arthrodesis, and bone-ligament-bone graft using the modified Cuenod procedure. All were level of evidence IV. Many patients went back to some form of work. Tenodesis showed less development of arthritis and greater improvement in scapholunate gap, while capsulodesis showed greater postoperative flexion and extension. Of note, study size varied with 67 combined patients in the capsulodesis studies and 30 patients in the tenodesis studies.

CONCLUSION

There was no clear superiority of one procedure over the others. More long-term data are needed to identify the best surgical treatment of chronic, static SLD.

A Rare Case of Metallosis Co-occurring With Chronic Prosthetic Joint Infection in Total Hip Arthroplasty

Prosthetic joint infection (PJI) and metallosis are known complications of total hip arthroplasty (THA) and are causes for revision surgeries. Articulating metal surfaces in total hip arthroplasty with corrosion at modular junctions can lead to the release of metal ions that can cause an immune-mediated biological reaction. There are few cases in the literature of both coinciding together. We describe a case of chronic Cutibacertium acnes PJI and metallosis co-occurring in a 64-year-old female after THA with a dual mobility construct. After undergoing uncomplicated left THA through a modified Hardinge approach, the patient dislocated anteriorly after four weeks and required revision of her acetabular component to a less anteverted position. Nine months later, she presented with hip pain and was found to have medial wall fragmentation and cystic changes around the greater trochanter on radiographs, elevated serum cobalt and chromium levels, and a benign noninfected hip aspiration. During her revision procedure, intraoperative histopathology showed over 20 neutrophils per high power field in multiple samples and fluid aspirates demonstrating Gram-positive rods. She was also found to have pseudotumor formation with the erosion of the anterior and posterior capsules with black debris on the femoral stem trunnion and the backside of the modular dual mobility liner. An antibiotic spacer was placed and her cultures grew into C. acnes. She completed six weeks of intravenous ceftriaxone and, during her "drug holiday," she dislocated her spacer and was found to have a lateral femoral diaphyseal stress fracture at the distal end of her spacer. She underwent stage II of her revision, and while the plan was to continue her antibiotics, she had an adverse reaction and was transitioned to oral antibiotics for six months. Due to delayed healing, she underwent additional irrigation and debridement with head and liner exchange. Her wound then healed, and at her one-year final follow-up, she was able to ambulate without pain, and her serum inflammatory and metal ion levels were within normal limits. Concurrent PJI and metallosis from articulating metal interfaces can occur, and a high index of suspicion is necessary to properly manage both conditions.

Initial Evaluation and Classification of Knee Dislocations

The traumatic knee dislocation (KD) is a complex condition resulting in injury to >1 ligament or ligament complexes about the knee, termed multiligament knee injuries. Typically, KDs result in injury to both cruciate ligaments with variable injury to collateral ligament complexes. Very rarely, KD may occur with single cruciate injuries combined with collateral involvement but it is important to understand that not all multiligament knee injuries are KDs. Patients can present in a wide spectrum of severity; from frank dislocation of the tibiofemoral joint to a spontaneously reduced KD, either with or without neurovascular injury. The initial evaluation of these injuries should include a thorough patient history and physical examination, with particularly close attention to vascular status which has the most immediate treatment implications. Multiple classification systems have been developed for KDs, with the anatomic classification having the most practical application.

Minimally Invasive Versus Open Laminectomy/Discectomy, Transforaminal Lumbar, and Posterior Lumbar Interbody Fusions: A Systematic Review

Minimally invasive spine surgeries (MISS) are becoming increasingly favored as alternatives to open spine procedures because of the reduced blood loss, postoperative pain, and recovery time. Studies have shown mixed results regarding the efficacy and safety of minimally invasive procedures compared to the traditional, open counterparts. The objectives of this systematic analysis are to compare clinical outcomes between the three MISS and open procedures: (1) laminectomy/discectomy, (2) transforaminal lumbar interbody fusion (TLIF), and (3) posterior lumbar interbody fusion (PLIF). The Cochrane and PubMed databases were queried according to the preferred reporting items for systematic review and meta-analyses (PRISMA) statement. The primary outcome measures included the visual analog scale (VAS), the Oswestry disability index (ODI), and blood loss. A total of 32 studies were included in the analysis. Of the three procedures investigated, only MISS TLIF showed significantly improved VAS for leg pain (p = 0.02), ODI (p = 0.05), and reduced blood loss (p = 0.005). MISS-laminectomy/discectomy, TLIF, and PLIF appear to be similar in terms of postoperative pain and perioperative blood loss. MISS TLIF is perhaps more effective in specific outcome measures and results in less intraoperative blood loss than open TLIF.