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Vascular injury in orthopedic trauma is challenging. The risk to life and limb can be high, and clinical signs initially can be subtle. Recognition and management should be a critical skill for every orthopedic surgeon. There are 5 types of vascular injury: intimal injury (flaps, disruptions, or subintimal/intramural hematomas), complete wall defects with pseudoaneurysms or hemorrhage, complete transections with hemorrhage or occlusion, arteriovenous fistulas, and spasm. Intimal defects and subintimal hematomas with possible secondary occlusion are most commonly associated with blunt trauma, whereas wall defects, complete transections, and arteriovenous fistulas usually occur with penetrating trauma. Spasm can occur after either blunt or penetrating trauma to an extremity and is more common in young patients. Clinical presentation of vascular injury may not be straightforward. Physical examination can be misleading or initially unimpressive; a normal pulse examination may be present in 5% to 15% of patients with vascular injury. Detection and treatment of vascular injuries should take place within the context of the overall resuscitation of the patient according to the established principles of the Advanced Trauma Life Support (ATLS) protocols. Advances in the field, made mostly during times of war, have made limb salvage the rule rather than the exception. Teamwork, familiarity with the often subtle signs of vascular injuries, a high index of suspicion, effective communication, appropriate use of imaging modalities, sound knowledge of relevant technique, and sequence of surgical repairs are among the essential factors that will lead to a successful outcome. This article provides a comprehensive literature review on a subject that generates significant controversy and confusion among clinicians involved in the care of trauma patients. [Vascular injury in orthopedic trauma is challenging. The risk to life and limb can be high, and clinical signs initially can be subtle. Recognition and management should be a critical skill for every orthopedic surgeon. There are 5 types of vascular injury: intimal injury (flaps, disruptions, or subintimal/intramural hematomas), complete wall defects with pseudoaneurysms or hemorrhage, complete transections with hemorrhage or occlusion, arteriovenous fistulas, and spasm. Intimal defects and subintimal hematomas with possible secondary occlusion are most commonly associated with blunt trauma, whereas wall defects, complete transections, and arteriovenous fistulas usually occur with penetrating trauma. Spasm can occur after either blunt or penetrating trauma to an extremity and is more common in young patients. Clinical presentation of vascular injury may not be straightforward. Physical examination can be misleading or initially unimpressive; a normal pulse examination may be present in 5% to 15% of patients with vascular injury. Detection and treatment of vascular injuries should take place within the context of the overall resuscitation of the patient according to the established principles of the Advanced Trauma Life Support (ATLS) protocols. Advances in the field, made mostly during times of war, have made limb salvage the rule rather than the exception. Teamwork, familiarity with the often subtle signs of vascular injuries, a high index of suspicion, effective communication, appropriate use of imaging modalities, sound knowledge of relevant technique, and sequence of surgical repairs are among the essential factors that will lead to a successful outcome. This article provides a comprehensive literature review on a subject that generates significant controversy and confusion among clinicians involved in the care of trauma patients. [Orthopedics.2016; 39(4):249–259.]

Previously published studies reported variable results using various suture techniques and reconstruction options for massive rotator cuff tears. Therefore, the current authors retrospectively studied 21 consecutive patients/shoulders with massive rotator cuff tears treated from January 2005 to October 2011 with a human dermal allograft through a mini-open approach. Mean patient age was 58 years (range, 33–72 years). Mean follow-up was 29 months (range, 18–52 months). Ten patients underwent revision repair for a failed rotator cuff repair. The authors measured the tendon gap (mean, 1.7 cm) and acromiohumeral interval (mean, 6.5 mm). They evaluated pain, shoulder range of motion (ROM) and function, patient satisfaction with the operation and outcome, and complications. At last follow-up, all patients experienced significant pain relief (Previously published studies reported variable results using various suture techniques and reconstruction options for massive rotator cuff tears. Therefore, the current authors retrospectively studied 21 consecutive patients/shoulders with massive rotator cuff tears treated from January 2005 to October 2011 with a human dermal allograft through a mini-open approach. Mean patient age was 58 years (range, 33–72 years). Mean follow-up was 29 months (range, 18–52 months). Ten patients underwent revision repair for a failed rotator cuff repair. The authors measured the tendon gap (mean, 1.7 cm) and acromiohumeral interval (mean, 6.5 mm). They evaluated pain, shoulder range of motion (ROM) and function, patient satisfaction with the operation and outcome, and complications. At last follow-up, all patients experienced significant pain relief (P=.001) and improved ROM (P=.001) and American Shoulder and Elbow Surgeons (ASES) score (P=.001). Eighteen patients reported that they were satisfied or very satisfied and 3 reported that they were not satisfied with the operation and outcome. Comparison of outcomes between patients who underwent primary repair and those who underwent revision repair and between patients who had muscle atrophy and fatty infiltration grades 0 to II and those who had grades III to IV showed no statistically significant differences. A statistically significant correlation was observed between the size of the tendon gap and postoperative pain, ROM (except external rotation), and ASES score (P<.050). No significant correlation was observed between postoperative pain, ROM, and ASES score and the acromiohumeral interval (P>.050). Complications related to the dermal human allograft were not observed. [Orthopedics.2014; 37(12):e1108–e1116.]

Case reports and small series have reported variable results regarding the treatment of choice for patients with triceps brachii tendon ruptures. Early surgical repair has been recommended for acute complete ruptures of the triceps brachii distal tendon to prevent late functional disability. However, controversy exists regarding the optimum surgical technique of reattachment. In addition, various attachment techniques have been described, with none shown clinically to be superior. Therefore, the authors present a technique for triceps brachii distal tendon reattachment following acute complete ruptures and evaluate their results in a series of patients.

Several surgical techniques have been described for the treatment of posterior shoulder dislocation depending on the time elapsed between injury and surgery and the size of the humeral head impression fracture. When the bone defect is between 25% and 50% of the articular surface of the head, the procedures of choice are autologous bone graft or allograft or subscapularis tendon or lesser tuberosity transfer. In neglected cases in which patients undergo surgery more than 3 weeks after injury, no standard accepted treatment for this injury exists.This article presents a modification of the McLaughlin technique for patients with neglected locked posterior dislocation of the shoulder. Using this technique, the shape of the humeral head was nearly restored with impaction of morselized bone allograft; two suture anchors were inserted into the defect, and the lesser tuberosity with the attached sub-scapularis tendon was transferred into the defect and secured with sutures. Postoperative rehabilitation included immobilization of the shoulder with an external rotation brace for 6 weeks followed by progressive passive, active-assisted, and active range of motion and rotator cuff strengthening exercises for another 6 weeks. This technique resulted in pain-free range of motion, a stable shoulder, and good joint congruency.

Posterior dislocation of the shoulder is an uncommon injury. Diagnosis is difficult and often missed. Once diagnosed, management must be individualized depending on the amount of the defect of the humeral head and the time from injury. This article presents a case of a 40-year-old man with a 4-month history of bilateral locked posterior fracture–dislocation of the shoulders after a grand mal seizure. Imaging showed loss of the glenohumeral joint lines congruency, reverse Hill-Sachs lesions, and articular defects of 35% and 40% of the humeral heads. A modified McLaughlin technique was performed in both shoulders in a single stage. Through the standard deltopectoral approach, the lesser tuberosity was osteotomized with the subscapularis and capsule attached and elevated to expose the humeral head and glenoid. The shape of the humeral head was restored by packing the defect with morselized bone allograft. Before packing the allograft into the defect, 2 absorbable suture anchors were inserted at the bottom of the defect; the lesser tuberosity was transferred into the defect, and fixed with 2 transosseous horizontal mattress sutures. Stable fixation was evaluated intraoperatively, and the wound was closed in layers. Postoperatively, both shoulders were immobilized with external rotation braces for 6 weeks, followed by passive, active-assisted, and progressively active range of shoulder motion and rotator cuff strengthening exercises for the next 6 weeks. At 12 weeks postoperatively, full range of motion was accomplished, and full activity was allowed. At 22-month follow-up, the patient was satisfied with his level of function; both shoulder joints were painless and stable without apprehension or recurrence of instability. Radiographs showed congruent joints and complete incorporation of the allograft into the defect with restoration of the shape of the humeral head.

One hundred fourteen patients (66 men and 48 women; mean age, 49 years) underwent spine stabilization using a dynamic neutralization system between January 1999 and August 2010 for degenerative disk disease, spinal instability, or spinal stenosis. Mean follow-up was 6.8 years (range, 1–11 years). Seven patients were lost to follow-up. Radiological examination and clinical evaluation, including the Oswestry Disability Index, the Roland-Morris Disability Questionnaire, and patient satisfaction, were performed.Mean Oswestry Disability Index score improved from 57% (severe disability) preoperatively to 22% (moderate disability) postoperatively. Mean Roland-Morris Disability Questionnaire score improved from 52% preoperatively to 35% postoperatively; 79 (74%) patients declared themselves very satisfied with the end result of the operation. Postoperatively, 27 (25%) patients experienced complications, including screw loosening (n=22), infection (n=2), back (n=5) and leg (n=2) pain, and endplate vertebral fracture (n=1). Three patients with screw loosening, 2 with deep infection, and 1 with severe persistent back and leg pain underwent rigid spine arthrodesis.Dynamic neutralization systems can be considered for degenerative disk disease, spinal instability, and stenosis. Patient satisfaction with the procedure is excellent. However, in the long term, the complication rate, most commonly screw loosening, is high and reoperations are common. In this setting, long-term follow-up is recommended, and the use of this system should be reconsidered.

This article describes a case of a 58-year-old man with no significant underlying disease who had chronic pain due to osteonecrosis of the hamate. Following physical examination, imaging, and laboratory findings, he underwent surgical exploration via a limited dorsal approach. The hamate bone did not have a normal anatomical appearance or structure. It was marble-like in appearance, soft, friable, and lacking physiologic contour and bone strength. We removed the dorsal aspect of the hamate piecemeal. The articular surfaces of the adjacent carpal bones (capitate and lunate) were excised, and the lesion was packed with iliac autograft. Three months postoperatively, fusion of the remaining hamate and the adjacent capitate and lunate carpal bones was evident, and the patient reported mild wrist pain, moderate grip strength improvement, and mild improvement of wrist range of motion and stiffness.Currently, no standard treatment algorithm exists for patients with avascular necrosis of the hamate. However, delayed diagnosis of this clinical entity can be debilitating. A high index of clinical suspicion and an early course of treatment offers considerable benefits to patients with osteonecrosis of the hamate.

Elbow extension is important for the elbow joint, and it is more difficult to restore with microsurgery than elbow flexion. The purpose of this article is to describe the experience of the authors with elbow extension reconstruction in obstetric brachial plexus palsy patients. The outcomes were analyzed in relation to the type of brachial plexus lesion, timing of surgery, and the type of nerve reconstruction.

Ligament reconstruction tendon interposition arthroplasty is currently the preferred technique for carpometacarpal joint arthritis of the thumb by most surgeons. Despite its efficacy, morbidity has been associated with the harvest of the flexor carpi radialis tendon. Using an allograft as material for arthroplasty, donor site morbidity is avoided. In this report, we present our surgical technique to perform ligament reconstruction tendon interposition arthroplasty using an acellular dermal matrix allograft (GraftJacket) in patients with Eaton stages II, III, and IV symptomatic first carpometacarpal arthritis.

Large experience in Asia has shown that the contralateral C7 nerve transfer has proved one of the major treatments for brachial plexus root avulsions. The authors report their experience in North America using the selective contralateral C7 transfer for neurotization of multiple targets.

In this study, children with obstetrical brachial plexus palsy who underwent various secondary reconstructions for shoulder stability and function were studied. The outcomes were analyzed in relation to the type of injury, the timing of surgery, and the type of secondary reconstruction.

In obstetrical brachial plexus palsy, suprascapular nerve reinnervation is a priority. For the most favorable outcomes in shoulder function, it is the authors’ policy to also reconstruct the axillary nerve with intraplexus donors to the posterior cord (early cases) or directly with intraplexus or extraplexus motor donors (late cases).

The authors' experience in the management of late ulnar nerve injuries is presented.

In children with global obstetric brachial plexus palsy, prioritization should be first focused on hand reinnervation and then directed to shoulder and elbow function. In this study, the surgical strategy for restoration of hand function and the methods and outcomes are analyzed.