Technologic Advances and the Upper Extremity

Contents

Preface xi

Asif M. Ilyas

The Role of Locking Technology in the Hand 307

David E. Ruchelsman, Chaitanya S. Mudgal, and Jesse B. Jupiter

Locked fixed-angle plating in the hand and wrist helps to optimize outcomes follow-ing surgical fixation of select acute fractures and complex reconstructions. Selectindications include unstable distal ulna head/neck fractures, periarticular metacarpaland phalangeal fractures, comminuted/multifragmentary diaphyseal fractures withbone loss (ie, combined injuries of the hand), osteopenic/pathologic fractures, non-unions and corrective osteotomy fixation, and small joint arthrodesis. Locked platingtechniques in the hand should not be seen as a panacea for wrist and digital acutetrauma and delayed reconstructions. An understanding of the biomechanics offixed-angle plating and proper technical application of locking constructs will opti-mize outcomes and minimize complications. As clinical experience with lockingtechnology in hand trauma broadens, new indications and applications will emerge.Currently, several systems are available. The specific implants share common fea-tures in their protocols for insertion, but unique differences in their design (ie, individ-ual locking mechanisms, uniaxial vs polyaxial locking capability, metallurgy, andplate profiles) must be appreciated and considered preoperatively.

Intramedullary Nail Fixation for Metacarpal Fractures 321

Philip E. Blazar and Dante Leven

Metacarpal fractures are common, especially in men, and account for about 10% ofall fractures in patients. The fracture pattern and location, and the degree of angu-lation are important in determining the optimal treatment approach. Although meta-carpal fractures can be treated nonsurgically, certain indications such as irreduciblefractures, malrotations, and open fractures may necessitate surgery. Intramedullarynail fixation has been successful in treating metacarpal fractures. Complications canbe minimized by taking appropriate precautions and care in performing the surgery.

Implant Arthroplasty of the Carpometacarpal Joint of the Thumb 327

David J. Bozentka

Resection arthroplasty with or without ligament reconstruction for thumb trapezio-metacarpal arthritis can be complicated by thumb shortening and pinch-strengthweakness. Implant arthroplasties have been developed to limit loss of thumb length,improve strength, and limit postoperative convalescence. The ideal thumb carpo-metacarpal implant should be strong and stable, provide full range of motion, andprevent loosening. Unfortunately, no current prosthesis accomplishes all of thesegoals. Until the ideal implant is developed, clinical acumen must be used to deter-mine appropriate patients and implants.

Interposition Arthroplasty Options for Carpometacarpal Arthritis of the Thumb 339

Nathan D. Bodin, Ryan Spangler, and Joseph J. Thoder

Carpometacarpal (CMC) arthritis of the thumb affects half of postmenopausalwomen and up to 25% of elderly men. This disease can cause significant disability

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in affected patients often necessitating surgical intervention. Various surgical op-tions have been used to treat refractory CMC arthritis. Any successful surgical inter-vention must address three goals: removal of diseased joint surfaces, reconstructionof ligamentous stabilizers, and preservation of the joint space. In this article we willdiscuss various interposition arthroplasty options for CMC arthritis of the thumb.

Headless Compression Screw Fixation of Scaphoid Fractures 351

John R. Fowler and Asif M. Ilyas

Scaphoid fractures carry significant long-term morbidity and short-term socioeco-nomic difficulty in the young and active patient population in which they most com-monly occur. While cast immobilization results in high rates of radiographic union innondisplaced scaphoid fractures, internal fixation with headless compression screwshas been recommended in cases of displaced fractures. Internal fixation has led tohigh rates of union in both nondisplaced and displaced fractures with the added ben-efits of earlier mobilization and return to work and sports. Multiple manufacturers arenow offering ‘‘second generation’’ headless compression screws for the internal fix-ation of scaphoid fractures. The few biomechanical studies that exist demonstrate im-proved compression forces and load to failure for the newer generation of headlesscompression screws when compared with the first generation headless compressionscrew, although it is unclear if these differences are clinically significant.

Intramedullary Fixation of Distal Radius Fractures 363

Kevin Harreld and Zhongyu Li

Intramedullary fixation is the latest in a variety of techniques that have been devel-oped to manage distal radius fractures. Intramedullary nailing of these fracturescombines the soft-tissue advantages of a less invasive surgical approach with thebiomechanical advantages of locking screw technology. These features may enablean accelerated postoperative rehabilitation and quicker return to function. Disadvan-tages associated with the intramedullary technique include the necessity of a closedor percutaneous reduction and the inability of the implant to adequately stabilizeintraarticular or highly comminuted fractures. Consequently, intramedullary implantsare primarily indicated for fixation of extra-articular or simple intraarticular split pat-terns and should not be employed for management of volar or dorsal shear fractures.Preliminary clinical data is emerging in the form of short-term follow-up studies withlimited numbers of study participants.

Variable-Angle Locking Screw Volar Plating of Distal Radius Fractures 373

Jung H. Park, Jennifer Hagopian, and Asif M. Ilyas

Surgical treatment options for distal radius fractures are many and commonlyinvolve volar locked plating. More recently, newer volar locking plates have beenintroduced to the market that allow the placement of independent distal subchondralvariable-angle locking screws to better achieve targeted fracture fixation. This articlereviews this new technology and presents the authors’ experience with the Aptus(Medartis, Kennett Square, Pennsylvania) variable-angle volar locking plates.

Nonbridging External Fixation of Distal Radius Fractures 381

Matthew D. Eichenbaum and Eon K. Shin

Surgical management of distal radius fractures continues to evolve because of theirhigh incidence in an increasingly active elderly population. Traditional radiocarpal

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external fixation relies on ligamentotaxis for fracture reduction but has several draw-backs. Nonbridging external fixation has evolved to provide early wrist mobility in thesetting of anatomic fracture reduction. Several studies of the nonbridging techniquehave demonstrated satisfactory results in isolated nonbridging external fixation se-ries and in comparison with traditional spanning external fixation. Nonbridging exter-nal fixation for surgical treatment of distal radius fractures can be technicallydemanding and requires at least 1 cm of intact volar cortex in the distal fracture frag-ment for successful implementation.

Intramedullary Fixation of Forearm Fractures 391

Saqib Rehman and Gbolabo Sokunbi

Plate fixation remains the primary surgical treatment option for most adult forearmfractures. However, intramedullary nailing can be successful and might be prefera-ble in cases of massive soft-tissue injury and burns, certain segmental fractures,pathologic fractures, and skeletally immature adolescent patients. Furthermore,the risk for refracture after plate removal is decreased with fixation by intramedullarynailing. The history, indications, surgical technique, and results of intramedullary fix-ation of forearm fractures are described in this article.

Radial Head Arthroplasty 403

James T. Monica and Chaitanya S. Mudgal

Radial head arthroplasty remains an encouraging treatment option for comminutedradial head fractures in an unstable elbow or forearm. This article discusses the sur-gical considerations related to radial head arthroplasty, including anatomy, indica-tions, and surgical technique. Radial head arthroplasty outcomes literature anda review of current implant options are also discussed.

Use of Orthogonal or Parallel Plating Techniques to Treat Distal Humerus Fractures 411

Joshua M. Abzug and Phani K. Dantuluri

Distal humerus fractures continue to be a complex fracture to treat. This article de-scribes two surgical techniques that can be used to tackle these difficult fractures:Parallel plating and orthogonal plating. Both techniques have yielded excellent out-comes after open reduction and internal fixation; yet each has its own set of uniqueconsiderations. However, the key to successful treatment of these difficult fracturesregardless of technique remains obtaining anatomic reduction with stable fixationand the implementation of early motion.

Hinged External Fixation of the Elbow 423

Neal C. Chen and Abhishek Julka

Hinged external fixation of the elbow provides the advantages of static fixation withthe benefits of continued motion through the joint. Indications for the use of thismethod of fixation include traumatic instability, distraction interposition arthroplasty,instability after contracture release, and instability after excision of heterotopic ossi-fication. Orthopedic surgeons should be familiar with hinged fixators and their appli-cation when faced with an unstable ulnohumeral joint.

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The Role of Nerve Allografts and Conduits for Nerve Injuries 435

Michael Rivlin, Emran Sheikh, Roman Isaac, and Pedro K. Beredjiklian

Nerve repair after transection has variable and unpredictable outcomes. In additionto advancements in microvascular surgical techniques, nerve allografts and con-duits are available options in peripheral nerve reconstruction. When tensionlessnerve repair is not feasible, or in chronic injuries, autografts have been traditionallyused. As substitute to autografts, decellularized allografts and conduits have be-come available. These conduits can reduce donor site morbidity, functional lossat the donor area in cases where autografts are used, and immune reaction fromtransplants or unprocessed allografts. The development of new biomaterials foruse in conduits, as well as use of cytokines, growth factors, and other luminal fillers,may help in the treatment of acute and chronic nerve injuries. The indications andproperties of nerve conduits and allografts are detailed in this article.

Three-Dimensional Computed Tomographic Imaging and Modeling in theUpper Extremity 447

Thierry G. Guitton and David Ring

Technologic advances in imaging of the upper extremity have taken an immenseleap in the last decade. So has the amount of research that has been publishedon this subject. Three-dimensional (3D) reconstructions, in particular, have improvedidentification of fracture characteristics, such as fragments, fracture edges, and ar-ticular surfaces. Three-dimensional physical models can even increase the advan-tages of the 3D reconstructions. Together, 3D reconstructions and physicalmodeling may outweigh the disadvantages of increased cost, resource usage,and additional time, as research has shown that it can benefit both the surgeonand the patient significantly.

Index 455