Background It has been over 100 years since the initial description of avascular necrosis of the lunate. Over the last two decades, there has been the introduction of advanced information regarding the etiology, natural history, classification, and treatment options for lunate osteonecrosis. There have been new classifications developed based on advanced imaging, perfusion studies of lunate viability, and arthroscopic assessment of the articular cartilage. Purpose This article brings together a new treatment algorithm, incorporating the traditional osseous classification system (Lichtman) with the perfusion/viability classification (Schmitt) and the articular cartilage classification (Bain). Methods We have developed a new algorithm to manage Kienböck avascular necrosis of the lunate. This new algorithm incorporates the current concepts of the diseased lunate and its effects on the remainder of the wrist. Conclusion For patients with a good prognosis and in the earliest stages, the "intact lunate" is initially protected utilizing nonoperative measures. If this fails, then appropriate lunate unloading procedures should be considered. If the lunate is "compromised" then it can be reconstructed with a medial femoral condyle graft or proximal row carpectomy (PRC). With the further collapse of the lunate, the wrist is then also compromised, with the development of secondary degeneration of the central column articulation. The "compromised wrist" will have functional articulations, which allows motion-preserving procedures to be utilized to maintain a functional wrist. With advanced disease (Kienböck disease advanced collapse), the wrist is not reconstructable, so only a salvage procedure can be performed. Other than these objective pathoanatomical factors, the final decision must accommodate the various patient factors (e.g., age, general health, lifestyle, financial constraints, and future demands on the wrist) and surgeon factors (skill set, equipment, and work environment).
Background: Little is known regarding the effect timing of repair has on extensor tendon repair results. The purpose of this study is to determine if a relationship exists between the time of extensor tendon injury to extensor tendon repair and patient outcomes. Methods: A retrospective chart review was conducted on all patients that underwent extensor tendon repair at our institution. The minimum time to final follow-up was 8 weeks. Patients were then divided into two cohorts for analysis; those that underwent repair less than 14 days after injury and those that underwent extensor tendon repair at or greater than 14 days after injury. These cohorts were further sub-grouped by zone of injury. Data analysis was then completed using a two-sample t-test assuming unequal variance and ANOVA for categorical data. Results: A total of 137 digits were included in final data analysis, with 110 digits repaired less than 14 days from injury and 27 digits in the greater than or equal to 14 days to surgery group. For zones 1–4 injuries, 38 digits were repaired in the acute surgery group and eight digits in the delayed surgery group. There was no significant difference in final total active motion (TAM) (142.3° vs. 137.4°). Final extension was also similar between the groups (2.37° vs. 2.13°). For zones 5–8 injuries, 73 digits were repaired acutely, and 13 digits were repaired in delayed fashion. There was no significant difference in final TAM (199.4° vs. 172.7°). Final extension was also similar between the groups (6.82° vs. 5.77°). Conclusions: We found time from extensor tendon injury to surgical repair did not affect final range of motion when comparing acute repair within 2 weeks from injury or delayed repair greater than 14 days from injury. Additionally, there was no difference in secondary outcomes, such as return to activity or surgical complications. Level of Evidence: Level IV (Therapeutic)
K-wires used in the fixation of fractures of the proximal aspect of the humerus may migrate into the thoracic cavity. No modification of this technique, including the use of threaded, terminally bent, or external pins that are visibly secured, eliminates the potential for devastating complications.
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