Good morning. It's a pleasure to be with you today, finally in the real world. I drove up this morning from Providence and a lot of traffic at 5 a.m. on Highway 95, so happy to make it here. So I'm looking forward to talking with you about some of the complications, errors, and complaints in peripheral nerve surgery. There may be many of you, if you don't do peripheral nerve surgery, who think that it's one big complaint, but I really enjoy it, and it's one of my passions, and I've found that in my career, it's been one of the most rewarding things that I've done. So what is an error versus a complication? Errors are failure of your planned action to be completed as intended, or the use of a wrong plan to achieve the aim, or an unintended act, or one that doesn't achieve its outcome. And a complication is the unanticipated problem arising from the procedure. So an error in nerve surgery could be an incomplete release of a carpal tunnel, or lack of recovery over repair. However, that's kind of an interesting thing with a nerve surgery, because it can take so long. Our expectations are that we're only going to get about half of normal recovery expected, and so what truly is an error when you look at recovery? And then complications are if you have a wound infection, or if you inadvertently transect a nerve. What about things like new neuropathic pain of the same nerve, or even of a different nerve at a different site? So is lack of recovery always an error? Nerve surgery is a little bit less predictable than some other procedures, because you are operating on pain for hopefully the relief of some pain. And I was taught in medical school and residency that never operate on pain, which is kind of silly, because an ankle fracture, uh-oh, any thoughts? Because ankle surgery is going to be a painful condition, and nobody would say don't fix the broken ankle. So in my world I'm fixing the broken nerve. Who is running this, because it's not me. Let's try again. Okay, so now you're up, Sonu. Uh-oh, I think that all the times you hit it, it's now coming back to haunt you. Okay, all right, why don't you go back, and then I'll bounce back. Okay, so let's see if the computer is, there we go, and we're good. So last year at this similar conference, I presented a five-year experience, ending prior before, on 209 of my patients that had undergone nerve repair, reconstruction, or decompression, or a selective denervation. My age range was four to 90. I had about 50% more males, and about 80% of people were improved or improving or resolved, because nerve recovery and improvement can take a while. About 8% of people were far enough out that I thought that had minimal improvement. 2% were worse, and about 10% had complications, and 5% lost to long-term follow-up. Oh, there are a few chairs up here if anyone wants to come up. So I updated to the last three and a half years, during which time I had 186 people, patients, about equal gender distribution, age range, again, six to 85. For the 221 cases, 87% improvement, 5% mixed, 3% were lost to follow-up, 3% no change, and about 2% were worse. So my rates for, you know, over the past about eight years are fairly similar, that about 80% to 90% of people are probably going to do well with nerve surgery. When I broke it down to look at my results based on type of nerve compression, or type of nerve decompression, I had 60 carpal tunnels, 33 people with pronator releases, and smaller numbers with radial, guillans, cubital, and combination. So about 91% of my patients with carpal tunnel and pronator improved, improving, or resolved. Minimal people, about 5% for both of those. Worse, about 2%. And then lost to follow-up about 3%. I also did numerous combination cases. Most frequently it was carpal tunnel, pronator, but also pronator, radial tunnel, guillans, cubital, and one gentleman with a quadriparesis did, you know, got the full thing of carpal tunnel, pronator, cubital, and guillans. 91% resolved, 9% mixed recovery. It is also safe to operate on people who have an active diagnosis of CRPS. Three-quarters of them resolved improved, one-quarter were worse. For reconstruction, I've done about 29 selective denervations over the past three-and-a-half years, 83% resolved improved. For nerve repairs, 9 out of 17 were improving. Major nerve, 8 out of 13 were resolved or improving. So the main thing is, for nerves especially, who am I making worse, or who has complications, and how are they doing? So about 27% of my people had some sort of problem or issue after surgery. They could be as small as a yeast infection of the skin, a recurrent occipital neuralgia on a patient for whom I did a nerve release, or hypertrophic scar. One person had a transient radial nerve irritation after a guillans release, and I really can't explain that one. And then one person had no recovery after a perineal nerve repair in the setting of postoperative radiation, and he was almost 70 years old, so I wasn't quite surprised about that. The nerve had been inadvertently transected. These were people for whom their problems after surgery, they were kind of okay about it. They said, things happen. It's just going to be a little bit of a prolonged recovery. I'm fine with this. I understand. You explained it to me that this might happen. So who are my cranky patients? About 5% total are people who were just unhappy. And I've seen them many, many times, and their happiness is not really improving. Aside from this one woman for whom I repaired an MABC, she saw me once one year post-op, and I can't get her to come back in. So when she came in, she said, yeah, it's not better, and then she left again. And she seems like a normal person, so I don't know what the deal is with her. But I've had very strange things, like increased pain in the neck and the back after a pronator release. My entire hand became numb after initially improving with normal SEMS-Weinstein tests. One person, non-native English speaking, doesn't want to return to work. She's very anxious. I don't know if I'm communicating with her appropriately. Other people are getting new pains in different sites that I can't explain anatomically. And so these people spend, you know, I spend a lot of time talking with them in my office, but I don't know if there's anything that I could have done differently necessarily, other than maybe not operate on them. But that is something that, you know, I don't know that I could have predicted that these people would have gone south on me. So some key elements of this. You need to have full preoperative discussions, including the lack of predictability of nerve recovery. And one of my nurses actually gave me a little pin that said nerves are weird, because nerves are. It's not as linear a recovery process as, say, a fracture or even a tendon repair. You can have improvement. You can have worsening. If you live in Minnesota, everyone in October starts to, you know, have cold intolerance, and that can happen for years. And so we quote the Swedish study, saying that cold intolerance should improve over time. But you need to tell people this, and you need to document it. If people have any proximal pain, if I do, you know, axial loading, if I do a tennels over the brachial plexus and they spark, they go off to get neck therapy, see the spine clinic, anything else. But if you touch somebody who has preoperative pain up here, then you likely may have ongoing pain, because they may not have as good a result as you could have expected, because the pain still is generating more proximally. Having patients work with our hand therapists is invaluable, because our hand therapists are psychologists. They're wonderful. They help people get desensitized after surgery, and I think make them a lot happier. And you have to be accepting of the fact that some people are going to have postoperative courses that you can't explain. But as long as you are with the patient in every way and, you know, try to reassure them, things should be fine. So how do you optimize your patient outcomes if you're working on peripheral nerve patients? You need to set realistic expectations. So if you're doing something like brachial plexus surgery or proximal reconstruction, the patient cannot have the expectation that they are going to have 5 out of 5 flexion strength. I have had some really amazing results from motion, say, on elbow reconstruction with an Oberlin transfer. Three months, the person had 5 out of 5 elbow flexion. But the farther out you go, the more difficult that will be as an expectation. And sensory recovery, we know, you know, inch a month, it may be 2 years, 3 years, 20 years before you actually get decent sensation, and especially if you're starting when you're young. The older you are when you start, the less recovery you may get. And, you know, again, cold intolerance and weird feelings and mismatch and all of these other things. And so talking with patients about this has to be in your plan. And then balancing hope with realism. So you need to set expectations. Yet, if you feel that the patient is going to get some, has some chance of meaningful recovery, you don't want to, you know, make them depressed beforehand and potentially not undergoing a surgery that could be beneficial. And you need to engage your colleagues. Having somebody to refer them to for a pain team. Occupational therapists, occupational medicine physicians, or physiatrists can all work as a team together. I use diagrams, drawings, metaphors. You know, everybody goes away with, you know, someday if I become a famous artist, you'll have my first drawing of, you know, of this thing. So I just rip off paper toweling and I use the big operative marker and make big drawings that they can go home with so that they can get a feeling that, okay, I can pull it out and understand that this is what you're doing. So education is crucial. Remember that people only remember a third of what you tell them. If they have a family member with them and it's a crucial thing, they may remember a half of what you tell them. So I like to use a lot of educational material. That's a problem because the educational material is mostly at a 12th grade and I'm working with prisoners, foreign language speaking patients, and people whose health literacy is quite low. So I can't use a lot of the stuff that's out there. EPIC does have some good patient information in several languages. But two-thirds of our surgical patients have adequate health literacy and I think that's optimistic depending on where you are. But the Department of Health and Human Services had estimated the proficiency at about 12%. And when our patients don't understand what we're talking about, they're going to have poor compliance with the care plan. Older people may have less of good understanding. They may have problems with hearing. COVID has not helped with the masks and understanding what we're saying and we still have to wear masks in all of our clinic settings. If they're not English speaking, that's a problem. Low socioeconomic status, low education, and everything is too complex. So it's a challenge and it does take a long time. So you want to do these things to minimize your errors and I'll go through them. You want to find the right patient. If you feel that you are not communicating appropriately with the patient. If the patient has anxiety that's mixed with anger. There's anxiety that's mixed with sadness because nobody's listened to them. But there's anxiety that's mixed with anger and you want to avoid the angry patient. If their psychiatric disease is poorly controlled, no. History of poor compliance with every other thing. A history of substance misuse. If people say that you gave me a nerve block and it made my pain worse, I don't know what that means but it means I'm not operating on you. Because if I can't block a nerve, then I don't know what's going on with your central and peripheral nervous system that may be responding differently to local anesthetic. If somebody is in the middle of a legal battle, that's a problem. If they have unrealistic expectations and if the exam is just all over the place. One time one nerve is hurting, the next exam that you do it's completely different. If they don't have a consistent problem, then you should avoid operating on these folks. So diagnosing, where is the nerve compressed? Most of my people who come back and had a carpal tunnel release done someplace else also have pronator syndrome that was unrecognized. And in the textbooks we're still being told, oh, it's really rare. It's not really rare. It's very common. And so if you actually examine the person, palpate where it's painful, then you can actually find that they do have it. I do the scratch collapse test on everybody. Jay, oh, my God, a friend of mine, taught me to do an exam of the FTP of the index finger, Jay Erickson, with the wrist in slight flexion to put the patient farther down on the Blix curve so that you can actually detect weakness. And so you actually do have to do a very specific exam and be very clear about what you're finding. Because we have limitations. If we have never been taught to do a certain exam, we're not going to do it. We may miss findings. You may have excessive trust in your pre-visit diagnosis. Somebody comes in and like, oh, yeah, they got trigger fingers. Just saw this yesterday. My medical student came in and said, and he's got another trigger finger on his other hand. I said, is he diabetic? No. But one finger is really stuck. I said, he's got Dupuytren's disease. And yes, indeed, he come in and he's got dupes. So you can't really trust what other outside physicians are telling you. And so you have to do the whole exam and repeat everything. And I'm not really a big electrodiagnostic person. I rarely get them unless I feel that there's something going on systemically. Because history and physical can diagnose 90% of problems. Correct timing. Nerve transfers versus tendon transfers. Both have their indications. One of the biggest caveats is one that I learned where you have to be careful with nerve transfers more than seven months after an injury. People say, oh, you got 18 months. No, you don't. If you start operating on them at nine months, you're not going to really get good recovery, especially middle-aged or older. Cross C7s may be very good for tiny, tiny people. But they're not good for big, bulky Americans. Because those few little nerve fibers are not going to elevate your arm. And intercostal transfers, three nerves alone may not be enough. You may need four or five to do this. Interoperatively, good care. Postoperatively, get them moving within two weeks. And complications. You can have complications of commission, omission, or just regular garden variety ones. I do a pre-op, pre-prep block for everybody. I don't wait until the operating room. Because you can see with people, if you're doing the block and they're already under anesthesia, general anesthesia, and they're still wiggling, that means that their brain still knows that they're being attacked by a knife. And so block them beforehand so that they have a chance to actually get the anesthetic going. And then massage the area so that the block kicks in faster. Interoperatively, I ask our anesthesia colleagues to dose either dexmedetomidine. I got that tip from Susan McKinnon. I've been doing that since about 2007. Half a micro-kilo. Or ketamine. And then postoperatively, ice elevation routine postoperative things. I've started using meloxicam more. And other medications like immediate Toradol. I have a very short course of opioids. Mixilatine and minocycline. So your classic complaints after nerve surgery. Pain. Worsened pain. More pain. Pain. Pain. Pain limiting my function. And then numbness, weakliness, and general poor function. So approaching these, as I mentioned before, clear communication. Multimodal communication strategies. See them again and again and again. OT. And if their pain appears disproportionate, see the pain team. And then preoperative discussion of expectations. And then continuing to clarify that during the time. So in summary, nerve surgery can be done safely and effectively in the majority of patients. It does take a lot more talk time than maybe for some of the other things. The patients who are unhappy will require a disproportionate amount of your time. And optimal patient selection and good pre-op education are your best friends. So thank you very much. Thank you for that wonderful talk, Dr. Kellyanne. And we're going to go to our next speaker, Dr. Stern. And let's see if we can ‑‑ I'll let you take it over here. If we can pull up this one, the third one right there. This one? Yeah. One second. Is this it? in the next 15 minutes or so is to talk about errors, complications, and complaints in hand fracture surgery. This is a great quote over 50 years ago, Al Swanson. Does anybody here know Al Swanson? Yeah, amazingly egocentric guy, but very insightful. So he said, hand fractures can be complicated by deformity from no treatment, stiffness from overtreatment, and both deformity and stiffness for poor treatment, and that holds true today. So I'll go through a bunch of caveats of things that I've learned over the years. Malrotation for finger and metacarpal fractures is poorly tolerated. This is particularly true for spiral and oblique fractures, and I think it is critical not to treat X-rays but to treat the patient. So I always, particularly for isolated, simple injuries, one or two fractures, always ask the patient, ask her to make a fist and see if there's malrotation. You can use a metacarpal block if the patient is reluctant to move her finger. Secondly, caveat number two, fractures at the base of P1, particularly for the ulnar digits, can be easily missed. The problem is that when you take a lateral X-ray and they all, all of these fractures, pancreas fractures, have an apex palmar angulation, because the phalanges are overlapping each other, you can't get a good view. Also, oblique views are critical. This is just an example of somebody who had three P1 base fractures treated with closed reduction of percutaneous pinning. Number three, this is something actually that Dr. Jupiter, your next speaker, taught me, is that conular fractures, the head of the proximal phalanx or middle phalanx, are usually unstable. So these are bad actors. And the uniconular fracture, the fracture fragment, tends to migrate proximally and palmarly. And radiographically, that can be a little difficult to interpret. In the case to the right, the fracture fragment's actually rotated 180 degrees. But most of these need an operative procedure with usually one or two pins or screws to stabilize. Corollary, as I just mentioned, a single pin or screw for a conular fracture is inadequate. Here's somebody who had a single pin, it slipped, and you have a incongruent articular space. This plate fixation, in my opinion, in my opinion, for phalangeal fractures, is rarely indicated. Definitely sexy. And if you go to the exhibit hall, you'll see all kinds of fancy plates. But it's not always what it's cracked up to be. So here's a patient who had a couple P1 fractures treated with plate fixation. Looks pretty good radiographically. But here's the patient with me after surgery. She cannot flex at the IP joints at all. Why can't she flex? Well, we've gummed up her dorsal apparatus. She's got tons of adhesion. She's not a happy camper. So she needed a second operation, a tenolysis. And perhaps in retrospect, if we treated this with closed reduction percutaneous pinning, she might have done okay. Corollary, percutaneous fixation of unstable phalangeal fractures. It's not sexy, but it often does the job. And if I wanted to leave you with one message as I ride into the sunset, it'd be that sometimes K-pins have a role in fracture surgery, and fancy fixation may not. Not always, but something to think about. So this guy came in, he had some kind of auger injury, and he's a farmer, he wants to get back to work, et cetera, et cetera. We treated all of his fractures with just IND and percutaneous pins. His fracture's healed. I know it's not anatomic alignment. I'm an examiner for the board. You flunked, you didn't get these fractures reduced. But the bottom line is function in hand fractures. And at eight weeks, he's got excellent range of motion. He's back to work and doing fairly well. Caveat number five. Direct dorsal plating of phalangeal fractures can be risky. Well, why is that? If you look at an anatomic specimen of the anterior surface of the phalanges, they're kind of cup-shaped. And if you put a screw in from dorsal to palmar, because of these overlying lateral lips, the screw may penetrate into the flexor tendon sheath and cause a tendon rupture. Here's a very, very, very, very old slide of a patient who had a P1 fracture. Screws are too long. He presented to me, I did not do the case, of a FDS and FTP rupture. Caveat number six. No heroics. Gunshot injuries that take out the metacarpal head and base of P1 of the border digits should be strongly considered for amputations. I know patients don't like that, but sometimes it's the best thing to do. Salvage is a multiple step procedure and often results in short, stiff, and painful fingers. So here's a guy who is very unhealthy. He takes care of an unhealthy wife. He had a self-accidental inflicted gunshot injury to the head of his metacarpal. The joint is essentially destroyed. His soft tissues are not in good shape, but he does have decent circulation. We treated him with an immediate ray resection. Here he is at two weeks post-operatively. We're sure you lost a finger, but you saved him a lot of time, a lot of expense, a lot of anxiety, et cetera, et cetera. So again, as I ride into the sunset, border fingers sometimes do better with amputation than they do with multistage reconstruction. Caveat number seven. External fixation of comminuted open fractures of phalanges and metacarpals is frequently a better part of valor. This is something also that Dr. Jupiter has written about and reported very good results. So here's a patient that has fractures of the distal phalanx, proximal phalanx, metacarpal, intraarticular, et cetera, et cetera. Sure, you start into practice, you wanna put on fancy plates, et cetera, et cetera. Keep it simple, put on an external fixture, and they may do okay, particularly in the thumb. Caveat number eight. Phalangeal shortening is poorly tolerated and is underrated. So if you end up with a P1 or P2 fracture and it's short, they're gonna have extensor lags every time. Metacarpal shortening, on the other hand, up to probably five millimeters, excluding the small finger, is overrated and is generally well tolerated. And Hill Hastings and Dr. Vahey pointed this out. So remember that for each millimeter shortening of a P1 fracture, you get about a 10 degree PIPJ extensor lag. Caveat number nine. Consider Wollant, with or without sedation, for fixation of phalangeal fractures. And the beauty of Wollant is that you can do, if the patient's awake, you can ask her to make a fist. And so it's a great way of testing for malrotation, as I've noted in the slide. Here I'm with a patient that had Wollant, and we're putting our heads together. He actually was a tenolysis patient, great technique. He's making a complete fist. You can see his smile, he's a happy camper. Caveat number 10. A quote from a highly respected AO surgeon and friend regarding K-pins. So I'll slam K-pins a little bit. Actually, this isn't from Lee Osterman, but Al Freeland, who passed away, wonderful person. Pins penetrate, incinerate, irritate, and incarcerate. But in my opinion, pin fixation is not a sign of weakness. Pins are forgiving, versatile, and minimally damage soft tissue. And again, in my opinion, in the hand and fingers particularly, less so in metacarpals. If you do big operations, the soft tissues are gonna bite you in the end, and the patient's gonna end up with less flexion. And as my dear friend Dr. Osterman said, K-wires can be your best friend more often than not. I think that's very true. Number 11. Inter-frag fixation of spiral fractures and metacarpal fractures. Number one, if you do inter-frag fixation, which is fun to do, don't forget to countersink. If you have prominent screw heads, you're gonna have attritional ruptures or adhesions. In my opinion, doing lagging, which is what the AO principle is teaching, to get compression is dangerous. You've only got a few little threads on the far cortex, and if you strip them, you're not gonna have very good fixation. If you're inserting the screw and it's not perfect, remember you're dealing with pretty small screws, 1.5, 1.1, and it hits the far endosteal cortex, you're gonna explode the fracture apart, you should stop. And if possible, this is difficult in adults, easy in adolescents, et cetera, close the periosteum. Infected fractures. Another thing Dr. Jupiter's written on. Eliminate sepsis, debris, cultures, antibiotics, and remove implants, especially if loose. Secure union, often this requires staged treatment, excision of the dead bone, some type of spacer, antibiotic impregnated, et cetera, so-called Mascalet technique, and hopefully restore function. So here's a patient. This is young in my career, but it's very illustrative. This is the typical Friday afternoon phone call of Dr. Stern, I'm going out of town and I've got a patient that I think has an infection. Well, pus is draining out everywhere. Do you mind taking care of it? Sure, great, send it in. So, right or wrong, I removed the hardware, irrigated the fracture site out. The patient was placed in some type of skeletal traction. This is what we have, but there's still drainage. I then resected the fracture, hoping to do a PIP-DIP fusion after the spacer was removed. Stabilized this with an external fixer. Here she is, maybe six months after lots of surgeries with an atrophic, mal-rotated, totally non-functional finger. Six months later, she has an amputation. I think sometimes things are so bad that amputation, again, is a reasonable thing to do. We did an article 20 years ago looking at osteomyelitis of the tubular bones to the hand. The bottom line in this is that if you have to do more than three procedures and it's in Cincinnati, Ohio, there's a 75% amputation rate. So, in my opinion, one, two, three strikes, you're out. I think that's still true today. Caveat number 12, new technology. So, Dr. Jupiter and I were walking up to the lecture hall and talking about intramedullary fixation. So, intramedullary fixation has become incredibly popular. It is heavily, heavily, heavily pushed by industry. And I can say this because I've been retired for two months. I can say inflammatory statements. So, anybody, while I'm not, I think, except for my wife, I'm not known for being an obnoxious person, highly critical, et cetera, et cetera. But I truly believe that intramedullary fixation for a lot of metacarpal and phalangeal fractures is overdone. It's terribly simple to do. Yes, you can get the patient moving, but here's a few cases that came to me that didn't do quite that well. Here's a broken implant on the left. Here's a, this is called an A-frame fixation of the proximal phalanx. Yeah, it looks great. Destroy the articular surface of the P1, put these screws in, you got a crooked finger. And another one on the left, same thing. This is, and that patient, I'm sorry, on the right had a 90 degree flexing contracture from insertion of a screw through the PIP joint. So, I would plead with you to examine a patient first and not operate on every single one. I know we're surgeons and stuff like that, but anyway, enough. So, finally, Bill Burkhalter. How many people knew Bill Burkhalter? Great, Nash knew him. So, he's a great guy. He's a military surgeon. He ran the Jackson Memorial, he was chair of Jackson Memorial down in Miami, Florida, and they have kind of a wild patient population, and he was a big believer in non-surgical treatment, and this is a slide that Dr. Burkhalter gave me. So, you look at those x-rays and you say, God, this is gonna be great. I'm gonna get to do lots of osteotomies, probably soft tissue procedure, et cetera, et cetera, but you look functionally at how this character's doing, he's got nearly full extension, and he can make a great fist. And so, his quote, it seems that skeletal stability and not skeletal rigidity is necessary for functional use. So, treat the patient, not the fracture. Thank you. Okay. Good morning, everyone. Here's my disclosures currently. I'll give you a minute. First of all, what are we dealing with when we talk about errors and complications with distal radius fracture? And then I asked the question, is the surgeon view of what has developed to be a complication the same as a patient? Ask that. Is that always the same? Well, they did this study some years ago looking at that, looking at a checklist and surveyed the patients. And as it turned out, 27% of physicians, 235, felt the problem was a complication, whereas patients, substantially less. In fact, patients may be more focused on symptoms rather than diagnoses. And what they looked at was you may have a mild issue that's resolved with just some therapy or elevation or co-band wrapping. A moderate one that will require therapy, splints, but should resolve. And then finally, one that needs intervention. The fact is, with distal radius fractures, these could be existing before, median nerve at pre-surgery status. Or you may have post-op swelling that can be resolved. But if it gets on to a malunion, then that's obviously defined as a complication. But look at this study that they reported 41 patients treated with a volar plate for dorsally displaced. They had nine substantial complications. I consider a wound dehiscent substantial complications. But if you looked at the patient-rated outcome, there was a very high degree of patient satisfaction, supporting the idea that what a patient sees, what the physician or surgeon sees, may not be exactly the same. So let's try to go through quickly some of these problems that may occur with distal radius fractures. I won't be able to cover all of these problems, but as you know, they do exist. Loss of reduction. We've become quite familiar now with the volar side of the end of the radius and the volar lunate facet. And failure to, A, appreciate that there is a separate component and, B, adequately support it, may present three or four or five weeks later with a wrist looking like this. This is a very difficult problem. The fracture fragment has now been unloaded. It's atrophic and may be very hard to correct. So first problem is beware of this. If you see a volar shearing fracture, it's more likely than not more than one fragment. We reported this a number of years ago. We looked at, my colleague Diego Fernandez and I, looked at experience with volar shearing fractures, and actually a two-part fracture was the most common thing, and multiple fracture, multiple component. I think CT scan on a volar shearing fracture is very important pre-op. If you think about it, be wary of it. This is what the patient looks like. And to reconstruct this is exceedingly difficult to do. Not only is it necessary to release the contracture and release the soft tissue adhesions, but to bring this back and stabilize the wrist while this is healing. And that will require a temporary K-wire into the lunate, perhaps a spanning plate as well. And patient may end up with adequate function, but it's yet another operation to do this. Sometimes the volar lunate facet is not as appreciated, and it heals like this involving both the radiocarpal and radioulnar joint, and treated with combined arthrodesis, salve cupondria, and radioulnate fusion with adequate restoration of function. I saw this on one of my patients and then a second patient. I thought, this is a problem. We collected some cases from others, and Neil Harness was a resident and reported it. Four of these seven had to have a second operation to try to restore the anatomy. And if you look at the average wrist extension and flexion, it's certainly not what you would expect from a primary treatment. And some had, will end up with arthrodesis of sorts. So what does this tell us? Number one is understand the fracture pattern. The placement of your implant needs to be as close to the subchondral bone as possible. And now there's a number of ways to handle that volar lunate facet. But this has been shown in biomechanical studies and clinically. Understand the fracture pattern. For me personally, I can't stress that enough. It's very easy now to get CT scans and you can get CT scans and image them, remove the radial carpal joint, and you can really appreciate the magnitude of the problem. A radial view lifting the x-ray beam or the wrist up about 20 degrees will show you the lunate facet. And that's why if you're going to put a plate on, if possible, always try to put the ulnar screws first, ulnar side of screws first, because the styloid will cover that. And if you have screws in the styloid, you won't be able to appreciate the lunate side. So simple thing to do if you can, but realize that that's an issue. Understand well where the plate can go. If we have to extend the fixation beyond that watershed line, that's okay. But take the plate out before tendon problems arise. Understand the fracture pattern as well. For these small volar fragments are hallmark of very complex fractures. These are radiocarpal fracture dislocations and failure to recognize this, failure to repair the volar capsule and capsular ligaments, as illustrated in this case, look what happens. There's ulnar translation of the carpus and that's very, very difficult for the wrist. It tends to wear out and this patient ends up with an arthrodesis. The radiocarpal fracture dislocations is a very complex injury and the volar side needs to be repaired as well. There are alternative methods of fixation of these small lunate facet fractures. Move the plate to the more ulnar woods, move the plate more distally. If you do that, you can capture most of those fragments, but it presents a potential problem with flexor tendons. A simple way to do these is take a tension wire through a drill hole in the distal radius and through the capsule. And you can capture even the smallest little fragment this way and add this to your plate as well if you're doing a plating. And it's a very simple technique. Or these small custom-designed plates strategically placed over the fracture fragments. Delayed union nonunion may occur over distraction, devascularization during surgery, inadequate period of mobilization. Nonunions, although not common in the endoradius, do occur and they can be problematic because the distal fragment may be osteoporotic and small. One study, this group suggested to do a wrist arthrodesis. We looked at it again with my colleague, Diego Fernandez, and found that I think it's worthwhile trying to fix them, but be careful about the ulnar side. It may require a secondary procedure as well. So here's a case like that. And it's gone on to a major nonunion. But mobilizing this back, restoring the radio ulnar articulation and with a bone graft should be reasonably predictable. The size of the fragment presents a problem. If it's too small, maybe that requires arthrodesis. But we also looked at this, adding Provenzberger, who's in Germany, his experience. And we were able to find in 22 cases that you can restore this anatomy without the need for arthrodesis. So here's another example with it. It's a relatively small distal fragment, but bringing it back with an intercalary graft seemed to work very well. And here's the healing. Notice that these plates are taken out. Sometimes patients request, sometimes because they're too distal. And it's easier to take the plate out than to repair ruptured flexor pollicis longus. And the last thing is malunion. And look at decision-making. First of all, we realized a long time ago that patients who had interarticular fractures that were not treated well didn't do so well, young patients. And in this series we reported almost 45% were unsatisfactory. Let's see. If you didn't restore it, all of the patients went on to arthritis. If articular congruity was restored, most patients did well. So a patient like this or this, the question comes up is can you do this? Can you do an intraarticular osteotomy? The problems arise. If not, the patient will likely have problems. Is it feasible? Will it heal? What's the risk of osteonecrosis? First of all, the fracture pattern. If it's a difficult fracture pattern that you can't figure out, it's probably not amenable to intraarticular osteotomy. Now with virtual planning, that may be somewhat overcome in terms of that. I think better to have a well-defined deformity with good hand function, good compliance soft tissue, minimal cartilage injury. Timing therefore may not be as important. You can do it later. But these problems probably are contraindications for this. We looked at a series with a group in Germany and in Argentina. We followed the patients for 22 months on average. And interestingly enough, all healed. And the results were generally good. Avascular acrosis did not occur. And the radiographic appearance, there wasn't a progression of arthritis. There were some complications. All of these reconstructions may have some potential complications. And lastly, the combined intra and extraarticular malunion as seen in this patient four months after a fracture. This is a general surgeon I took care of over 30 years ago. And he's got combined intra and extra. And at that time, we were able to make using CAD-CHEM technology, life like models of the fracture, the opposite side to compare and we could work on it in the lab to try to figure out how to do it, where to do it and then go to the OR with a little bit greater sense of confidence. So here he is and now we're elevating that lunate facet component and then we did an osteotomy of the extraarticular component and it went reasonably well. One thing is when you're dealing with this and understand the fracture pattern, it may turn out to be a little easier than the fracture itself. You can define the component parts, bring back the articular surface first and then do the extraarticular osteotomy and complete it. And the implants you need don't have to be as robust and can be placed strategically for that. And here's 11-year follow-up. So given the interest of time, I think I'll stop there and address any questions you have along the way with your iPhone. Thank you. Next speaker will be Dr. Harry Hoan. Whenever I think of really bad elbows and shoulders, I think of Harry. So bear with us. I think it's just really, really slow this morning. That's what we're told. So I'm just going to click on it once and let it do its thing. Oh, there you go. Now it's fast. Good morning. I want to say this. We've seen some masterful reconstructions on some of these very difficult cases. And I don't know if I could handle necessarily all those. But I was tasked for elbow complications, problems, and maybe some prevention. It's a huge topic. So I decided to narrow it down a little bit. But here's an injury that gets taken care of. Here's the problem. Once it's sort of fixed and we all recognize there's continued subluxation, there's some fracture displacement, there's a few things. And like Dr. Jupiter, there are some solutions. And some can be simple. Some can be more complex. And that's for fracture. So in any elbow surgery, we'll narrow it down to trauma to a certain extent, is that there's recurrent instability or fracture failure. Functional limitation of motion, it sounds a little better than stiffness. Heterotopic ossification and post-traumatic arthritis. It's probably 15 minutes for each one of these in an hour symposium. So I decided to maybe focus on something that is hard for us and we see, though, is recurrent instability and fracture failure and understanding a little bit of the mechanisms of why we have persistent instability, some of the reconstructive methods of fixation, ligament reconstruction, and potentially external or internal fixation. And when Dr. Jupiter was on the panel, I said, well, I've got to find something here. I still refer to this. Jesse, this is a pretty old picture. I've sort of colorized it and fixed it a little bit. But it is really good. And I think about this a lot, because this is the ring of stability like it is for the ankle. And each one of those boxes has a bone and soft tissue component. And as I look at the procedure, I think to myself, what's injured, and then what do I have to fix? And I think the ring needs to be half-completed, but it really needs to be 3 quarters of the way completed at the end of your treatment, operative or non-operative. And the classic fracture dislocation in pathoanatomy, and let me see if this plays. And this is obviously an intraoperative case, but that's the forearm in pronation. This is the forearm coming up in neutral. And you can see how it falls into the defect or how it starts. And this is then in supination. Obviously, the ligament's been elevated, but you can see the concept of maybe this posterior lateral rotatory instability. And once that is freed up, loosened, they then go back and put it back together. And if it doesn't work, what happens? And this is the importance of the lateral column. This is the radial head fracture. And I include this because we're not going to discuss this, but there's forearm problems, and this can go all the way to the wrist. And I still get wrist x-rays on every elbow patient. Especially if they're shortening of the very, very important lateral column. And when it comes to fixation of the lateral column, one of the problems, pearls, and errors, and solutions is that we have this safe zone, right? There's an articular zone that articulates with the PRUJ, and we can't have fixation in that area. It's not allowed because it has to be completely buried. And the difficulty, as you can see on this x-ray, and you can see on the video we just showed, is that the fractures are often critical in that area. As you fall in a pronated wrist, and then you supinate around your pronated arm, the anterior part of the radial head, the important lateral column, one of those boxes in the ring, gets disrupted. So getting fixation there is difficult, and this is just in the cadaver. And it was actually a little bit hard to get this picture. Maybe some of the fellows in the audience that have done this with me, we do this every year, and we try to define the safe zone when you look at the oval part of the radial head, and where the fractures occur, and how it relates to the safe zone. So here's a 33-year-old gentleman, young, instability. This is a week. The evidenced fracture fragment in the posterolateral corner. This is the fracture again, as you can see. There's a ligament avulsion from the lateral epicondyle as well, a little bit of a minimal exposure. And there is the safe zone, and applying the implants below the articular surface for the critical fracture fragments, and then spanning the deficit in the safe zone is, and I think, Dr. Stern, sort of high-risk-reward here, right? If it all goes well, it goes great. If it doesn't, you get some of the stiffness in the issues that we saw, and I'll go back here. This is what it looks like, and then, and here it is. Now, all this has to move in concert with the annual ligament over it having stability. We can't wait to move these, right? They have to get moving early, so the fixation has to be robust enough. That's pretty small plate. The ligament repair has to be robust enough, and I use a combination of, Dr. Stern, some K-wires in there, right? So no, not always fancy screw. They do have a plate in there, but some K-wires to hold the critical fracture fragments, and then backed up with the plate. So I feel pretty good about these, and here's a case. It's a four-week-old injury, and there is some shortening of the distal radius, and here's this clinical picture, and I'm sort of true to the word. It's a couple K-wires, a small screw, but look what happens here one month after surgery, and I underestimated that metadiaphysial combination, and now ended up with radial hydroplasty. So my pearls for fixation of the ORIF is really acutely done. If anything is delayed, it's a bit difficult. Fractures that occur outside the safe zone are problematic, and it's much better when there's an intact portion of the radial head for fixation, something to build to, and I might even argue in some of these, if there's an intact portion of the radial head, the rest of the radial head can be managed non-operatively, and that's been borne out in the literature. It's only when the entire radial head's unstable is that you get a break in the ring that results in those problems. So each part of this ring has an opportunity for treatment as well as complication. Here's a gentleman that was referred in, 53-year-old, three months after this, let's say a Montesia variant, and he's had fixation of the proximal ulna, and something has occurred at the radial head, treated non-operatively. It's sort of fallen into that same position which we saw previously. So this is hard, right? This gets into the meat of this complications talk and everything else, and here's his problems. Recurrent instability, he already has instability. Range of motion's incredibly limited. There is heterotopic ossification. There's most likely, if not, articular damage and some post-traumatic arthritis. I'll go back. Here's his lateral part of his CT scan. Just to, you know, the good news is there's some relative stability of the ulna-humeral joint. So there's a strategy for each one of these. Capsulectomy for the range of motion loss, and I think Dr. Drupal alluded to all these. The soft tissue component of your wrist and your elbow is just as important. Restore the stability of the ring for his instability. Excise the blocking bone if possible. And then arthroplasty when necessary if the articular surface can't be reconstructed. And so this was a posterior approach, an elevation of the lateral fracture fragment with the ligament, excision of the capsule bone blocking. The radial head was not reconstructable. It has to have some stability. So resection in this situation would be problematic. It would give a better range of motion, but we know the wrist is already short, so that lateral column needs to be reestablished for the forearm as well as the wrist. And then maintenance of some of the hardware for stability of a fracture that wasn't quite healed. And here he is two months post-op, you know, doing reasonably well. Here's one year after hardware and plate removal, and they're not perfect by any stretch of the imagination. All right, so it's reasonably functionable. You can get up to his face. His supination's pretty good here. I'm giving him a little helping hand. No pun intended, ha ha. But his pronation's good, and he's got a relatively normal side. So he's gone from a stiff ankylosed elbow to something that's at least functional. People ask about hinged external fixation. It comes up a lot. I think there's some maybe better techniques, but it's for persistent instability, acute instability without ligament repair, or for late reconstruction, or fascial allograft, or interposition arthroplasty. It becomes very difficult. There's a big learning curve. The axis pin is hard to find. We've actually done some research in trying to help people, help myself find that perfect articular axis. You know, here's a case that was sent in, and this is the intraoperative, and they ended up excising the radial head, fracture fragments. And so we actually took a graft and rebuilt his radial head because of his age. Then it was still unstable. So this is classic sort of multi-planar external fixation. It works great. When it works, you can see our axis is pretty good. We took it off at six to eight weeks in fluoro, and he's done pretty good. The articular reconstruction's not perfect, but again, there was an intact part there. So I think that that's a take-home point today, that an intact part of the radial head's very important, and he's got unbelievable outcome, and certainly not all of these are like that. We'll sort of end with this case, and these are hard. 72-year-old referred for persistent dislocations over a month times six. And she presents with, this is the x-ray I took in the office with the cast on, and she's already hyperflexed. So this becomes a problem. She's on HOMO2, she's morbid obesity, colon problems, and she asked me, am I gonna make it through this? And I said, your elbow. She goes, no, am I going to make it through this? And I go, boy. But she needs her arms, because she ambulates with her upper extremities. Yeah, so this is hard. External fixation, transarticular K-wires, which I would, or pins, I'd probably not recommend. I have done some bridge plate fixation in very dire situations across the elbow, a large fragment, and then internal joint stabilization with ligament reconstruction. So I went through all these, and we ended up doing this. And this is, again, a high-risk reward. If all goes well, it goes well. If it doesn't, then you're in trouble. And you may end up with a resection arthroplasty or a persistent instability of the elbow. And she really couldn't tolerate external fixation here. She is at one week. And it's very important to get the access pin the best you can. And here we tried to reconstruct the intercapsule. We're luckily just stuck on the edge of the periosteum. In all these cases, there's a part for error in every single one of these. You're concentrating on this, and then you think the easy part is putting the anchor in, and it just sort of skies off the intercortex. No harm here, it held. And here she is at now six months. She has nice calcification of the medial collateral ligament. That's what you wanna see, because it's going to heal. And now the discussion is at six months, we take it off, and she's got a functional elbow. She's, it's going to break at some point, mostly because it's not anatomic, but she's concerned if it comes out, or elbow comes out. I don't think at this point, but her range of motion isn't great, but at least it's 90 degrees of flexion. She can weight bear using her walker. Sometimes they're all combined. And this was an intraoperative photo that was sent to me. It's a case that's a bit old. And they just couldn't get things the way they wanted. So they sort of closed up. I sent it, and here I've combined all sorts of things. Radial head, ligament reconstruction, an X-fix that backs it. Reconstruction of the articular surface with a bigger plate. And here she is four months post-operatively. Old case monoblock radial head. You can see how the radial head tilted and found its own little home as it healed, and something reasonably functional. So I'll go back to this, because I keep, in my mind, when I look at one of these and I sort of think about it, where do I need to get to from exposure and what needs to be stabilized or reconstructed? Thank you.

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