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Dorsal distraction plating of complex distal radius fractures yields good radiographic results with minimal complications. In cases of complex distal radius fractures including dorsal marginal impaction where volar plating is not considered adequate, a dorsal distraction plate should be considered as an alternative to external fixation due to reduced risk for infection and better control of volar tilt.

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United States had a prescription for opioids, such as oxycodone and hydrocodone, for chronic pain. 1 In 2011, opioid overdoses caused more deaths than heroin and cocaine overdoses combined. 2 Kenan et al 1 showed that, from 2000 to 2010, the number of opioid prescriptions written increased by 35%, and the average dosage (in morphine mil-ligram equivalents daily [MMED]) for oxycodone and hydrocodone increased by more than 69%.Identification of patients who are at risk for long-term opioid use after surgery is important. Long-term exposure to opioids can result in structural and functional damage to the central nervous system 3 and can lead to dependence, tolerance, and a reduction in the pain threshold, which may complicate postoperative pain regimens and rehabilitation protocols. 4,5 Patients who had been taking 20 or more MMED for 6 weeks or longer before undergoing total knee arthroplasty had lon-

Background: Despite the increasing use of biceps tenodesis, there is a lack of consensus regarding optimal implant choice (suture anchor vs interference screw) and implant placement (suprapectoral vs subpectoral). Purpose/Hypothesis: The purpose was to determine the associations of procedural parameters with the biomechanical performance of biceps tenodesis constructs. The authors hypothesized that ultimate failure load (UFL) would not differ between sub- and suprapectoral repairs or between interference screw and suture anchor constructs and that the number of implants and number of sutures would be positively associated with construct strength. Study Design: Meta-analysis. Methods: The authors conducted a systematic literature search for studies that measured the biomechanical performance of biceps tenodesis repairs in human cadaveric specimens. Two independent reviewers extracted data from studies that met the inclusion criteria. Meta-regression was then performed on the pooled data set. Outcome variables were UFL and mode of failure. Procedural parameters (fixation type, fixation site, implant diameter, and numbers of implants and sutures used) were included as covariates. Twenty-five biomechanical studies, representing 494 cadaveric specimens, met the inclusion criteria. Results: The use of interference screws (vs suture anchors) was associated with a mean 86 N–greater UFL (95% CI, 34-138 N; P = .002). Each additional suture used to attach the tendon to the implant was associated with a mean 53 N–greater UFL (95% CI, 24-81 N; P = .001). Multivariate analysis found no significant association between fixation site and UFL. Finally, the use of suture anchors and fewer number of sutures were both independently associated with lower odds of native tissue failure as opposed to implant pullout. Conclusion: These findings suggest that fixation with interference screws, rather than suture anchors, and the use of more sutures are associated with greater biceps tenodesis strength, as well as higher odds of native tissue failure versus implant pullout. Although constructs with suture anchors show inferior UFL compared with those with interference screws, incorporation of additional sutures may increase the strength of suture anchor constructs. Supra- and subpectoral repairs provide equivalent biomechanical strength when controlling for potential confounders.

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A 68-year-old right hand dominant female sustained a direct trauma to her right wrist during a motorcycle accident resulting in an open right index finger proximal interphalangeal (PIP) joint laceration, small finger metacarpophalangeal (MCP) joint collateral ligament injuries with a stable metacarpal shaft fracture, and a transscaphoid, transtriquetral perilunate fracture dislocation with the lunate rotated 180°on the volar aspect of the distal radius and the carpus and hand translated volarly (Fig. 1a, b).The patient was brought to the operating room on the day of injury for irrigation and debridement and a plan for open reduction and internal fixation (ORIF) of the carpus. After extending the dorsal wrist laceration and releasing the extensor retinaculum with an ulnarly based flap, a traumatic dorsal wrist capsulotomy along the dorsal intercarpal ligament was visible with multiple extruded bony fragments from the triquetrum and scaphoid. The remainder of the capsule was divided via a ligament sparing capsulotomy. The lunate, scaphoid, and triquetrum were dislocated volarly. The lunate remained attached only by a small portion of the short radiolunate ligament with the long radiolunate ligament completely avulsed. The scaphoid was free floating with only minor attachments to the intact trapezium. The triquetrum was still attached to the hamate but was fractured dorsally and volarly with significant comminution. The scapholunate ligament was ruptured. Attempts were made to reduce the scaphoid and lunate together, but after appreciating the gross instability from ligamentous disruption and the severity of articular injury, a decision was made to perform an acute salvage procedure. Based on the significant articular damage to the cartilage on the radiolunate side of the lunate but preservation of the articular surface of the capitate and lunate fossa of the distal radius, a proximal row carpectomy (PRC) was performed.The scaphoid, lunate, and triquetrum were removed with minimal dissection, and the remaining small proximal carpal fragments were debrided. The capitate was then seated into the lunate fossa and given significant laxity of the radiocapitate articulation temporarily secured with two 0.045 Kwires. Instability was attributed to the loss of support of the volar extrinsic ligaments, in particular the long radiolunate ligament, which was completely avulsed from the lunate. For this reason, the radiolunate ligament was repaired directly to the capitate with suture anchors via a separate volar approach. Care was taken to preserve the remaining radioscaphocapitate ligament. Dorsally, avulsion of the hamate at the capitohamate ligament insertion was identified and repaired using a suture anchor. A sagittal split fracture of the dorsal nonarticular capitate was noted with ligamentous attachment to the trapezoid which was also reduced and secured with a suture anchor. Once the carpal injuries were addressed, the other injuries were treated, including repair of the small finger MCP ulnar and radial collateral lig...