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In patients with segmental nonunion of the distal radius, the distal ulna and distal radioulnar joint may not be salvageable. As an alternative to a vascularized free fibula, a pedicled distal ulna vascularized graft is a useful salvage technique. The procedure relies on the vascular bundle of the pronator quadratus and the dorsal oblique arterial anastomosis between the anterior and posterior interosseous arteries running along the interosseous membrane as the pedicle. We present 3 patients who received a distal ulna vascularized graft with concomitant wrist arthrodesis for distal radius segmental nonunion after complex distal radius fracture. This technique provides a local pedicled graft that may be a simpler, more reliable, and less technically demanding alternative., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Rehabilitation after rotator cuff repair surgery has been the focus of several clinical trials in the past decade. Many illuminate new evidence with regard to the prognosis of structural and functional success after surgery., Methods: A selective literature search was performed and personal physiotherapeutic and surgical experiences are reported., Results: Post-operative rehabilitation parameters, namely the decision to delay or allow early range of motion after surgery, play a large role in the overall success after surgery. Using a prognosis driven rehabilitation program offers clinicians a means of prescribing optimal rehabilitation parameters while ensuring structural and functional success. This commentary aims to synthesize the evidence in a spectrum of prognostic factors to guide post-operative rehabilitation., Conclusion: The optimal rehabilitation program after rotator cuff repair surgery is debatable; therefore, we suggest using a spectrum of prognostic factors to determine a rehabilitation program suited to ensure structural and functional success, quickly and safely.

Purpose: To compare the clinical outcomes in patients with grade III acromioclavicular (AC) joint injuries in whom nonoperative therapy was successfully completed and those who had nonoperative therapy failure and who proceeded to undergo surgical reconstruction., Methods: Forty-nine patients were initially treated nonoperatively for grade III AC joint injuries with physical therapy. Patients completed questionnaires at initial presentation and after a follow-up period of 2 years. Outcome measures included the Short Form 12 Physical Component Score; American Shoulder and Elbow Surgeons score; Quick Disabilities of the Arm, Shoulder and Hand score; and Single Assessment Numeric Evaluation score. Failure of nonoperative treatment occurred when a patient underwent AC reconstruction before final follow-up., Results: Forty-one patients with a mean age of 39 years (range, 18 to 79 years) were included. In this cohort, 29 of 41 patients (71%) successfully completed nonoperative therapy whereas 12 of 41 (30%) had nonoperative therapy failure at a median of 42 days (range, 6 days to 17.0 months). Of the 41 patients, 39 (95.3%) were contacted to determine treatment success. Of the 12 patients who had nonoperative therapy failure, 11 (92%) had sought treatment more than 30 days after the injury. Subjective follow-up data were available for 10 of 12 patients (83.3%) who had nonoperative therapy failure and for 23 of 29 patients (79.3%) who were successfully treated nonoperatively. The mean length of follow-up was 3.3 years (range, 1.8 to 5.9 years). Although there were no statistically significant differences in outcome scores between groups, those who sought treatment more than 30 days after their injury showed decreased postoperative Single Assessment Numeric Evaluation scores (P = .002) and Short Form 12 Physical Component Scores (P = .037)., Conclusions: According to our results, (1) a trial of nonoperative treatment is warranted because successful outcomes can be expected even in patients who eventually opt for surgery and (2) patients who presented more than 30 days after their injury were less likely to complete nonoperative treatment successfully., Level of Evidence: Level III, retrospective comparative study., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to evaluate (1) patient preferences regarding iPad and paper-based questionnaires, (2) the efficacy of iPad and paper questionnaires in a hand surgery practice, (3) the influence of questionnaire length on patient preferences and data collection, and (4) patient characteristics associated with a preference for iPad-based questionnaires., Methods: Two hundred total patients in a single hand surgery practice were randomly assigned to one of four groups. Each group completed either the Michigan Hand Questionnaire (MHQ) or QuickDASH (QD) using either an iPad or pen and paper. Patient preferences, questionnaire completion and timing, and demographic data were analyzed., Results: The use of an iPad was associated with a statistically stronger preference for the same delivery format in the future compared to paper for the MHQ (93.9 vs 52.1 %, p < 0.001) and QD (90.0 vs 41.7 %, p < 0.001). The MHQ iPad group found the survey "physically easy" more often compared to the MHQ paper group, while no difference was found among QD groups. Questionnaire timing between iPad and paper groups was similar for the MHQ but statistically longer with the iPad for QD. A significantly higher proportion of patients who preferred the iPad were under the age of 50 compared to those who preferred paper., Conclusions: The addition of an iPad is an efficient and preferable questionnaire format for functional outcome assessment in a hand and upper extremity surgery practice setting. The iPad is particularly preferable for longer outcome questionnaires and for patients under the age of 50.

Unlabelled: The literature describing the characteristic features of femoroacetabular impingement (FAI) has been on the rise, increasing awareness of this pathology in the young, active population. The physical therapist should consider FAI as a contributing factor to anterior hip pain, impairments, and functional deficits of the lower quarter. The dynamic interplay of anatomical variations, pain, and muscle function and their effects on gait in patients with FAI, however, is poorly understood. Small sample populations and variability in radiological, demographic, and clinical presentations in those with FAI have precluded meaningful insight into gait analysis and FAI, reiterating the need for further research in this domain. The purpose of this clinical commentary is to review the literature that defines normal gait at the hip joint and abnormal gait as a result of FAI and labral pathology or surgery aimed at correcting it. Secondarily, the authors aim to offer clinicians a strategy to progress the post-surgical patient to normal, unassisted gait while reducing the risk for anterior hip pain. Lastly, the authors of this commentary aim to identify specific areas for future research directed at therapeutic interventions in patients with FAI and those who have undergone surgery to correct it., Level of Evidence: 5.

Purpose: To provide an overview of the characteristics and timing of rotator cuff healing and provide an update on treatments used in rehabilitation of rotator cuff repairs. The authors' protocol of choice, used within a large sports medicine rehabilitation center, is presented and the rationale behind its implementation is discussed., Background: If initial nonsurgical treatment of a rotator cuff tear fails, surgical repair is often the next line of treatment. It is evident that a successful outcome after surgical rotator cuff repair is as much dependent on surgical technique as it is on rehabilitation. To this end, rehabilitation protocols have proven challenging to both the orthopaedic surgeon and the involved physical therapist. Instead of being based on scientific rationale, traditionally most rehabilitation protocols are solely based on clinical experience and expert opinion., Methods: A review of currently available literature on rehabilitation after arthroscopic rotator cuff tear repair on PUBMED / MEDLINE and EMBASE databases was performed to illustrate the available evidence behind various postoperative treatment modalities., Results: There is little high-level scientific evidence available to support or contest current postoperative rotator cuff rehabilitation protocols. Most existing protocols are based on clinical experience with modest incorporation of scientific data., Conclusion: Little scientific evidence is available to guide the timing of postsurgical rotator cuff rehabilitation. To this end, expert opinion and clinical experience remains a large facet of rehabilitation protocols. This review describes a rotator cuff rehabilitation protocol that incorporates currently available scientific literature guiding rehabilitation.

Alpine skiing is a high-risk sport for injuries to the anterior cruciate ligament (ACL). While descending a hill, a skier must resist large centrifugal forces at a high velocity, while the knees are positioned in postures that place the ACL at risk of injury. Skiers who undergo ACL reconstructive surgery are prone to a high rate of reinjury to the same knee and even ACL injury in the uninjured knee. A rehabilitation program that integrates the best current evidence of ACL rehabilitation and the science of skiing is essential to a successful return to alpine skiing. Unlike rehabilitation programs developed for court or field athletes, a skiing program must place a large emphasis on slow eccentric-loading and weight-bearing (closed-chain) power and endurance. The purpose of this clinical commentary is to provide the rehabilitation specialist such a program directed toward safely returning the athlete to alpine skiing.

Pathologic conditions in the shoulder of a throwing athlete frequently represent a breakdown of multiple elements of the shoulder restraint system, both static and dynamic, and also a breakdown in the kinetic chain. Physical therapy and rehabilitation should be, with only a few exceptions, the primary treatment for throwing athletes before operative treatment is considered. Articular-sided partial rotator cuff tears and superior labral tears are common in throwing athletes. Operative treatment can be successful when nonoperative measures have failed. Throwing athletes who have a glenohumeral internal rotation deficit have a good response, in most cases, to stretching of the posteroinferior aspect of the capsule.

The thiazolidinedione class of antidiabetic drugs, including troglitazone, has an insulin-sensitizing effect for patients with type 2 diabetes. However, in some tissues, studies have shown that troglitazone also has an acute insulin-independent effect on glucose uptake. To determine the extent of this acute action of troglitazone, the effect of troglitazone on 2-deoxyglucose (2DG) uptake in L929 fibroblast cells was measured. Troglitazone stimulated 2DG uptake in a dose dependent manner with a maximum stimulation of >300% at 5-10 microM. In addition, nitric oxide has been shown to stimulate glucose uptake in peripheral muscle tissue. Therefore, the effect of nitric oxide on 2DG uptake in L929 cells was also investigated using the nitric oxide donor, sodium nitroprusside (SNP). SNP stimulated 2DG uptake by >200% with a maximally effective concentration of 5 mM. The combined effect of maximally effective concentrations of both stimulants (10 microM troglitazone + 5 mM SNP) was not additive suggesting a shared pathway for 2DG uptake. However, the nitric oxide synthase inhibitor, N(G)-monomethyl-L-arginine (L-NMMA, 50 microM) had no effect on troglitazone stimulated 2DG uptake, indicating that the troglitazone and nitric oxide pathways converge after nitric oxide production. In addition, 12.5 microM dantrolene was shown to have no effect on either troglitazone or SNP stimulated 2DG uptake suggesting that these stimulatory effects are independent of changes in calcium ion concentrations. These data provide important evidence for the acute regulation of glucose transport through GLUT 1 transporters.