Hypothesis and background Coracoacromial ligament (CAL) excision and acromioplasty increase superior and anterosuperior glenohumeral translation. It is unknown how much of an increase in rotator cuff force production is required to re-establish intact glenohumeral biomechanics after these surgical procedures. We hypothesized that, after CAL excision and acromioplasty, an increase in rotator cuff force production would not be necessary to reproduce the anterosuperior and superior translations of the intact specimens. Methods Nine cadaveric shoulders were subjected to loading in the superior and anterosuperior directions in the intact state after CAL excision, acromioplasty, and recording of the translations. The rotator cuff force was then increased to normalize glenohumeral biomechanics. Results After CAL excision at 150 and 200 N of loading, an increase in the rotator cuff force by 25% decreased anterosuperior translation to the point where there was no significant difference from the intact specimen's translation. After acromioplasty (and CAL excision) at 150 and 200 N, an increase in the rotator cuff force of 25% and 30%, respectively, decreased superior translation to the point where there was no significant difference from the intact specimen's translation. Conclusions At 150 to 200 N of loading, CAL excision and acromioplasty increase the rotator cuff force required to maintain normal glenohumeral biomechanics by 25% to 30%. Clinical relevance After a subacromial decompression, the rotator cuff has an increased force production requirement to maintain baseline glenohumeral mechanics. Under many circumstances, in vivo force requirements may be even greater after surgical attenuation of the coracoacromial arch. Level of evidence Basic Science Study; Biomechanics

PURPOSE:The purpose of this biomechanical study was to compare the ultimate failure strength, stiffness, cyclic displacement, and failure displacement of 5 different proximal biceps tenodesis fixation techniques, specifically comparing wedge tenodesis with the other 4 techniques.METHODS:Forty cadaveric shoulders underwent 1 of 5 long head of the biceps tenodesis techniques and were cyclically tested to failure by use of tensile forces applied parallel to the longitudinal axis of the humerus. A preload at 5 N was applied for 2 minutes, followed by cyclical loading for 500 cycles from 5 to 70 N at 1 Hz and a pull-to-failure test at 1 mm/s. The techniques studied were wedge tenodesis, suture anchor fixation, suprapectoral interference screw fixation, T-wedge tenodesis, and the percutaneous intra-articular transtendon (PITT) technique. Cyclic displacement, failure displacement, and stiffness were calculated.RESULTS:The wedge tenodesis technique had an ultimate failure load similar to interference screw fixation and a greater ultimate failure load and stiffness than the suture anchor, PITT, and T-wedge techniques (P < .05).CONCLUSIONS:In this biomechanical study, wedge tenodesis was found to have an ultimate failure load similar to interference screw fixation and a greater ultimate failure load and stiffness than the suture anchor, PITT, and T-wedge techniques.CLINICAL RELEVANCE:On biomechanical testing, wedge tenodesis compares favorably with other techniques and may be a useful clinical option for proximal biceps tenodesis.

Coronoid fractures are rarely isolated injuries; they are most commonly encountered in association with other elbow injuries as part of 3 major instability patterns. Type 1 fractures are usually associated with terrible triad injuries. Type 2 fractures are associated with varus posteromedial rotatory instability. Type III fractures are associated with transolecranon fracture-dislocations. Current recommendations are to repair all coronoid fractures associated with elbow instability, regardless of fragment size. Surgical techniques are described in detail. (J Hand Surg 2012;37A:2418-2423. Copyright (C) 2012 by the American Society for Surgery of the Hand. All rights reserved.)

PURPOSE:To compare the biomechanical characteristics of screw versus plate versus both screw and plate fixation for large, type 3 O'Driscoll coronoid fractures. METHODS:Synthetic ulnas had 70% of their coronoids cut. Fixation was performed with either a cannulated screw, a plate, or both a screw and a plate. Energy to failure, force at failure, first cycle stiffness, and stiffness at failure were measured on a servohydraulic testing machine under cyclic posterior axial loading. RESULTS:The combination of a plate and screw had significantly greater energy to failure (83 Nm), force required to cause failure (634 N), and stiffness at failure (387 N/mm) compared to either an isolated plate (38 Nm, 474 N, 237 N/mm, respectively) or a screw (10 Nm, 279 N, 149 N/mm, respectively). For energy to failure and force required to cause failure, the plate group significantly outperformed the screw group. There was no significant difference in stiffness at the time of failure between the plate and screw groups. CONCLUSIONS:For type 3 O'Driscoll coronoid fractures or nonunions when both a screw and a plate can be placed, the combination of these 2 fixation devices appears to produce significantly greater biomechanical stability than either fixation device alone.

Purpose To determine whether there is any motion loss associated with the 1,2 intracompartmental supraretinacular artery (ICSRA) bone graft to the dorsal scaphoid. The null hypothesis is that placement of a vascularized bone graft in the dorsal scaphoid does not lead to a significant change in range of motion. Methods Seven fresh-frozen cadaveric upper extremities were examined. Simulated 1,2 ICSRA bone grafts were harvested and placed into a dorsal trough made in the proximal scaphoid. Wrist motion measurements were performed before and after 1,2 ICSRA bone graft implantation. Results There were no significant changes in wrist motion following 1,2 ICSRA bone graft implantation. Conclusions Properly placed 1,2 ICSRA vascularized bone grafts for treatment of proximal scaphoid nonunions do not by themselves cause loss of wrist motion. Clinical Relevance Loss of motion following the treatment of proximal scaphoid nonunions with properly placed 1,2 ICSRA vascularized bone grafts are due to factors other than the bone graft itself. (J Hand Surg 2011;36A:583-586. Copyright (c) 2011 by the American Society for Surgery of the Hand. All rights reserved.)

To determine whether there is any motion loss associated with the 1,2 intracompartmental supraretinacular artery (ICSRA) bone graft to the dorsal scaphoid. The null hypothesis is that placement of a vascularized bone graft in the dorsal scaphoid does not lead to a significant change in range of motion.Seven fresh-frozen cadaveric upper extremities were examined. Simulated 1,2 ICSRA bone grafts were harvested and placed into a dorsal trough made in the proximal scaphoid. Wrist motion measurements were performed before and after 1,2 ICSRA bone graft implantation.There were no significant changes in wrist motion following 1,2 ICSRA bone graft implantation.Properly placed 1,2 ICSRA vascularized bone grafts for treatment of proximal scaphoid nonunions do not by themselves cause loss of wrist motion.Loss of motion following the treatment of proximal scaphoid nonunions with properly placed 1,2 ICSRA vascularized bone grafts are due to factors other than the bone graft itself.

Purpose: To compare the effects of different-sized anterosuperior and posterosuperior rotator cuff tears (RCTs) and the effects of long head of the biceps tendon (LHB) loading on posterosuperior glenohumeral translation. Methods: Ten cadaveric shoulders were subjected to posterosuperior loading in the intact state and with sequentially larger anterosuperior and posterosuperior RCTs. Glenohumeral translation was measured with and without LHB loading. Results: At 50 N of force, cutting the superior half of the infraspinatus led to significantly greater posterosuperior translation than did cutting the superior half of the subscapularis (8.9 mm v 5.9 mm, P = .0179), and cutting the entire infraspinatus led to significantly greater posterosuperior translation compared with cutting the entire subscapularis (12.7 mm v 8.0 mm, P = .0003). Fifty newtons of LHB loading reduced posterosuperior translation in the intact specimen, as well as for all sizes of anterosuperior and posterosuperior RCTs (P < .05). The percentage decrease in posterosuperior glenohumeral translation with LHB loading increased as the size of the RCT increased, varying from 16% to 43%. Comparing these results with those previously published, we found that for anterosuperior RCTs, loading the LHB decreased translation significantly more in the anterosuperior direction than the superior and posterosuperior directions for supraspinatus and 2-tendon tears. For posterosuperior RCTs, there was no difference in the effect of LHB loading between anterosuperior and posterosuperior translation. Conclusions: The infraspinatus is a major dynamic restraint against posterosuperior glenohumeral translation, especially its inferior half. The LHB is less effective in constraining posterosuperior translation than anterosuperior translation.

BACKGROUND:Lateral ulnar collateral ligament (LUCL) reconstruction using a tendon graft is a well-accepted procedure used in the treatment of posterolateral rotatory instability. However, unlike most other ligament reconstructions, anatomical guidelines for the isometric points for tunnel placement of LUCL reconstruction have not been defined.PURPOSE:To determine if isometric points exist for tunnel placement for LUCL reconstruction and, if so, to determine their anatomical guidelines.STUDY DESIGN:Controlled laboratory study.METHODS:A series of 1.8-mm drill holes was placed in potential ligament reconstruction origin and insertion sites in 13 normal cadaveric elbows along the supinator crest of the ulna and in the lateral epicondyle of the humerus. The prepared specimens were mounted in a plastic test frame with electromagnetic sensors inserted into the drill holes. The distance between each potential pair of insertion sites was measured throughout the arc of elbow motion to determine the most isometric combinations of humeral and ulnar insertion sites.RESULTS:We could not locate truly isometric points for tunnel placement for LUCL reconstruction. For LUCL reconstruction, the position of most isometric tunnel placement was on the supinator crest 16 to 20 mm distal to the proximal margin of the radial head for the proximal wall of the ulnar tunnel, and between the 3:00 and 4:30 o'clock positions on the lateral epicondyle for the posterior/distal wall of the humeral tunnel.CONCLUSION:Similar to the native LUCL, there is no truly isometric location for LUCL tendon graft reconstruction tunnels. Also similar to the native LUCL, the distance between the optimal tunnel position decreases in elbow extension and often increases in elbow flexion.CLINICAL RELEVANCE:The most isometric position for LUCL reconstruction tunnel placement was defined using anatomical references.

PURPOSE:To investigate the biomechanical effects of posterosuperior rotator cuff tear (RCT) size and of loading the long biceps tendon in the presence of various-sized RCTs.METHODS:Ten cadaveric shoulders were subjected to loading in the superior and anterosuperior directions in the intact state and with sequentially larger RCTs. Glenohumeral translation was measured with and without biceps tendon loading.RESULTS:As long as the inferior infraspinatus remained intact, there was no significant difference in glenohumeral translation for any load studied. Once the supraspinatus and the entire infraspinatus were released, 50 N of load led to significantly increased translation in both directions. When we compare the results of this study with those of a previous study, the subscapularis appears to be more effective than the infraspinatus in constraining both anterosuperior and superior translation. For the intact specimens and for all sizes of RCTs, biceps loading led to a significant decrease in both anterosuperior and superior glenohumeral translation. Depending on the size of the RCT and the direction of loading, this decrease in glenohumeral translation varied from 19% to 53%.CONCLUSIONS:Tears of the subscapularis have greater biomechanical consequences than do tears of the infraspinatus. Loading the long biceps tendon led to a significant decrease in anterosuperior and superior glenohumeral translation for all sizes of RCTs, with a greater decrease in the percentage of glenohumeral translation noted for larger tears.CLINICAL RELEVANCE:Knowledge of the biomechanics of posterosuperior RCTs enhances our ability to treat them. Surgeons should be aware that, although biceps tenotomy or tenodesis may provide pain relief in shoulders with RCTs, there are biomechanical consequences to these procedures.

I read the article on mucous cysts by Jeffrey E. Budoff.1Budoff J.E. Mucous cysts.J Hand Surg. 2010; 35A (quiz 830): 828-830Google Scholar Dr. Budoff quoted incompletely from our article.2Kasdan M.L. Stallings S.P. Leis V.M. Wolens D. Outcome of surgically treated mucous cysts of the hand.J Hand Surg. 1994; 19A: 504-507Google Scholar He stated that we removed 113 cysts, when the correct number was 191 mucous cysts removed in 178 patients. Of the 191 mucous cysts excised, 113 had at least 6 months of follow-up time. The 2 recurrences occurred more than 40 months after surgery. Mucous CystsJournal of Hand SurgeryVol. 35Issue 5PreviewA 62-year-old, right-handed woman presents with a bump on the dorsum of her distal interphalangeal joint that she first noted 9 months ago. There is a slight groove of her nail, which she finds unsightly. The skin overlying the cyst is slightly thinned. Radiographs reveal mild osteoarthritis of her distal interphalangeal (DIP) joint, with osteophyte formation. The digit has full range of motion. She requests treatment to remove the cyst. Full-Text PDF In ReplyJournal of Hand SurgeryVol. 35Issue 10PreviewI thank Dr. Kasdan for his clarification. In my review,1 I was listing the reported results following treatment of mucous cysts. Table 1 from Dr. Kasdan's article2 is titled “Results of 113 cases with a 6-month or longer follow-up period.” This table lists the percentage of cases with postoperative pain, tenderness, stiffness, nail deformity, increased arthritic symptoms, infections, and recurrences. When discussing his article, I reported the results provided by this table. Results from the other 78 cases were not reported in his article, and so they could not be included in my review. Full-Text PDF

Purpose To determine which currently commercially available saw blades could be held at 45 degrees to the bone to reproducibly provide 2.0, 2.5, and 3.0 mm of ulna or radius shortening. Methods Commercially available saw blades were tested for their ability to achieve the osseous shortening at a 45 degrees angle cut. Results When held at a 45 degrees angle to the bone, 2 Stryker 0.64-mm-thick blades achieved a mean shortening of 2.0 mm. A single Linvatec 1.2-mm-thick blade achieved a mean osseous shortening of 2.1 mm. Two Dyonics 0.65-mm-thick blades achieved a mean osseous shortening of 2.7 mm. Two Dyonics 0.89-mm-thick saw blades achieved a mean osseous shortening of 3.1 mm. Three Stryker 0.38-mm-thick saw blades mounted with the middle blade "upside down" with regard to the 2 outer blades achieved a mean osseous shortening of 3.2 mm. Two Linvatec 0.8-mm-thick saw blades achieved a mean osseous shortening of 3.1 mm. Conclusions The findings of this study can help guide surgeons who desire to reproducibly shorten the ulna or radius by 2.0, 2.7, or 3.2 mm using a single saw cut to ensure a parallel osteotomy gap. (J Hand Surg 2009;34A:.1248-1251. (C) 2009 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.)

Purpose To determine the effect of coracoacromial ligament (CAL) resection and subacromial decompression (SAD)/acromioplasty on humeral head translation under anterosuperior and superior loading in a cadaveric model with an intact rotator cuff. Methods Six cadaveric shoulders were tested in the intact state, following CAL resection and following SAD. Results Excision of the CAL led to a significant increase in anterosuperior humeral translation of 2.1 mm (17%). SAD led to a significant increase in superior humeral translation of 2.5 mm (28%). Conclusions The results of this cadaveric study showed that resection of the CAL led to a 2.1-mm increase in anterosuperior translation and that SAD led to a 2.5-mm increase in superior translation. Clinical Relevance CAL resection and SAD are common surgical procedures, which may lead to increases in anterosuperior and superior glenohumeral instability.

PURPOSE:To examine the biomechanical effects of triquetral and scaphoid excision on wrist motion and radiolunate contact characteristics in a cadaveric model after simulated 4-corner arthrodesis with rigid internal fixation. METHODS:Ten fresh-frozen cadaveric upper extremities were studied. For all surgical manipulations, the motion was measured and contact characteristics were assessed using ultralow prescale pressure-sensitive film. RESULTS:Compared with the intact specimen, simple 4-corner arthrodesis with scaphoid retention led to a significant decrease in flexion (-23%), extension (-69%), radial deviation (-129%), and ulnar deviation (-25%), but no significant change in radiolunate contact characteristics. After 4-corner arthrodesis with scaphoid excision, there was a significant increase in radial deviation (+213%) without significant change in radiolunate contact characteristics, but average radial deviation was still less than in the intact specimen. After further excision of the triquetrum, radial deviation increased significantly (+238%), to a mean value 5% greater than that of the intact state, but at the cost of a significant increase in mean radiolunate contact pressure (+44% compared to the intact state). CONCLUSIONS:When performing 4-corner arthrodesis, scaphoid and triquetrum excision may improve motion at the cost of increased mean radiolunate contact pressure.

Commendably, the Journal of Hand Surgery continues to evolve and improve the quality of its articles. Recent enhancements include the designation of clinical studies by levels of evidence ranging from the highest (ie, high-quality randomized control trials) to the lowest (ie, expert opinion) (see http://www.jhandsurg.org/authorinfo). Even the Review Section has sought improvement with articles on Current Concepts, Surgical Technique, and Evidence-Based Medicine.Although I applaud these changes, I am concerned by this statement in Budoff's recent technique article.1Budoff J.E. Treatment of acute lunate and perilunate dislocations.J Hand Surg. 2008; 33A: 1424-1432Google Scholar It says:Although closed reduction with percutaneous pinning and immobilization may have been previously recommended for definitive treatment, better results have been achieved with open reduction, ligament repair, and internal fixation, which is now the current standard of care.2Grabow R.J. Catalano III, L. Carpal dislocations.Hand Clin. 2006; 22: 485-500Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 3Herzberg G. Forissier D. Acute dorsal trans-scaphoid perilunate fracture dislocations: medium-term results.J Hand Surg. 2002; 27B: 498-502Google Scholar [Emphasis mine].This statement is unsupported by any data. Rather, it references 2Grabow R.J. Catalano III, L. Carpal dislocations.Hand Clin. 2006; 22: 485-500Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar other technique articles neither of which reports even level IV evidence and is reminiscent of the Hans Christian Andersen story about the emperor's new clothes.Editors should be extremely wary of allowing the phrase “the current standard of care” in a peer-reviewed journal because in our litigious society, this is like filling a room with flammable gas in which a match will later be lit. Pity the poor hand surgeon whose patient receives less than an optimal result after treatment for a perilunate dislocation if he did not follow Budoff's recommendation and later has to explain this suboptimal result to a jury.4Freshwater M.F. “Standard of care” for immediate breast reconstruction.Plast Reconstr Surg. 2001; 107: 1612PubMed Google ScholarDid Budoff really mean to use the phrase “standard of care” or did he mean to say “state of the art”? There is a world of difference between the two: the first is a legal term, whereas the second implies the “latest available.” If indeed the Journal's editors continue to allow authors to state that a given diagnosis or treatment is the “standard of care,” then the editors have a duty to the readers to issue a disclaimer such as the one that prefaces the American Society for Surgery of the Hand Self-Assessment Examinations:The material is not intended to represent the only, or necessarily best, methods or procedures appropriate for the medical situation discussed. Rather it is intended to present an approach, view, statement or opinion of the authors … which may be helpful, or of interest, to other practitioners.5American Society for Surgery of the Hand2008 Self-Assessment Examination Book 1. American Society for Surgery of the Hand, Rosemont, IL2008Google ScholarIf Budoff did not mean to use the term “standard of care,” then he should clearly state that this was not his intention in responding to this letter.It appears that the Scientific Article section of the Journal mandates that any level IV paper include in its discussion the fact that its conclusions were limited by the quality of the data. On the other hand, the Review Section of the Journal seems to allow level V opinions with neither question nor critique. The policy disconnect between the Journal's sections recalls the old saying about the right hand not knowing what the left hand is doing—the ultimate irony for a hand journal. Commendably, the Journal of Hand Surgery continues to evolve and improve the quality of its articles. Recent enhancements include the designation of clinical studies by levels of evidence ranging from the highest (ie, high-quality randomized control trials) to the lowest (ie, expert opinion) (see http://www.jhandsurg.org/authorinfo). Even the Review Section has sought improvement with articles on Current Concepts, Surgical Technique, and Evidence-Based Medicine. Although I applaud these changes, I am concerned by this statement in Budoff's recent technique article.1Budoff J.E. Treatment of acute lunate and perilunate dislocations.J Hand Surg. 2008; 33A: 1424-1432Google Scholar It says: Although closed reduction with percutaneous pinning and immobilization may have been previously recommended for definitive treatment, better results have been achieved with open reduction, ligament repair, and internal fixation, which is now the current standard of care.2Grabow R.J. Catalano III, L. Carpal dislocations.Hand Clin. 2006; 22: 485-500Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 3Herzberg G. Forissier D. Acute dorsal trans-scaphoid perilunate fracture dislocations: medium-term results.J Hand Surg. 2002; 27B: 498-502Google Scholar [Emphasis mine]. This statement is unsupported by any data. Rather, it references 2Grabow R.J. Catalano III, L. Carpal dislocations.Hand Clin. 2006; 22: 485-500Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar other technique articles neither of which reports even level IV evidence and is reminiscent of the Hans Christian Andersen story about the emperor's new clothes. Editors should be extremely wary of allowing the phrase “the current standard of care” in a peer-reviewed journal because in our litigious society, this is like filling a room with flammable gas in which a match will later be lit. Pity the poor hand surgeon whose patient receives less than an optimal result after treatment for a perilunate dislocation if he did not follow Budoff's recommendation and later has to explain this suboptimal result to a jury.4Freshwater M.F. “Standard of care” for immediate breast reconstruction.Plast Reconstr Surg. 2001; 107: 1612PubMed Google Scholar Did Budoff really mean to use the phrase “standard of care” or did he mean to say “state of the art”? There is a world of difference between the two: the first is a legal term, whereas the second implies the “latest available.” If indeed the Journal's editors continue to allow authors to state that a given diagnosis or treatment is the “standard of care,” then the editors have a duty to the readers to issue a disclaimer such as the one that prefaces the American Society for Surgery of the Hand Self-Assessment Examinations: The material is not intended to represent the only, or necessarily best, methods or procedures appropriate for the medical situation discussed. Rather it is intended to present an approach, view, statement or opinion of the authors … which may be helpful, or of interest, to other practitioners.5American Society for Surgery of the Hand2008 Self-Assessment Examination Book 1. American Society for Surgery of the Hand, Rosemont, IL2008Google Scholar If Budoff did not mean to use the term “standard of care,” then he should clearly state that this was not his intention in responding to this letter. It appears that the Scientific Article section of the Journal mandates that any level IV paper include in its discussion the fact that its conclusions were limited by the quality of the data. On the other hand, the Review Section of the Journal seems to allow level V opinions with neither question nor critique. The policy disconnect between the Journal's sections recalls the old saying about the right hand not knowing what the left hand is doing—the ultimate irony for a hand journal. In ReplyJournal of Hand SurgeryVol. 34Issue 3PreviewThank you for the opportunity to reply to the letter by Dr. Freshwater. Dr. Freshwater takes exception to the phrase “standard of care” in the following passage: While closed reduction with percutaneous pinning and immobilization may have been previously recommended for definitive treatment, better results have been achieved with open reduction, ligament repair and internal fixation, which is now the current standard of care. Full-Text PDF

Overhead boom traction is commonly used in shoulder arthroscopy. In this article, we describe using overhead boom traction in wrist arthroscopy. The advantages are circumferential fluoroscopic access; lack of central post interference with instrumentation; and continuous, uninterrupted traction without need for frequent "dialing up" of traction tower height.