The onset, progress and factors influencing degenerative arthritis of the wrist following scaphoid fracture non-union.

BACKGROUND/AIMS: Scaphoid non-union causes osteoarthritis but factors associated are poorly understood. We investigated the rate of osteoarthritis after scaphoid fracture non-union, and if duration and fracture location influenced arthritis and its severity. METHODS: This retrospective cross-sectional observational study of 278 consecutive cases with scaphoid fracture non-union retrieved data on demographics, non-union duration, fracture location, dorsal intercalated segment instability (DISI), severity and distribution of wrist arthritis. Patient Evaluation Measure (PEM) and Quality of Life assessed impact on patients. Regression models investigated prediction of osteoarthritis by different variables. Time-to-event analysis investigated osteoarthritis evolution. Missing (MAR) data for the PEM and QoL was imputed and analysed. RESULTS: 278 patients, 246 males, aged 27.9 years (range 11 to 78 years), with a scaphoid fracture non-union confirmed on computed tomography (CT) scans (243) and plain radiographs (35) were reviewed. The interval between injury and imaging was 3.3 years (SD 5.9 years; range 0.1-45). The fracture was proximal to the ridge in 162, distal to the ridge in 83 and in the proximal 20% in 33. DISI (RLA ≥ 10°) occurred in 93.5% (260/278). Osteoarthritis was identified in 62.2% (173/278), and we classified a SNAC pattern in 93.6% (162/173). Of these, 100 (61.7%) had SNAC 1, 22 (13.6%) SNAC 2, 17 (10.5%) SNAC 3, and 23 (14.2%) SNAC 4. The mean duration in years for SNAC 1, 2, 3 and 4 were 2.5, 6.0, 8.2, and 11.3 years respectively. In fractures proximal to the ridge, 50% had arthritis in 2.2 years. Whereas in proximal pole, and distal to the ridge, 50% developed in 3.8 and 6.6 years, respectively. The PEM score was 42.8% (SD 18.9%) in those without arthritis and 48.8% (SD 21.5%) in those with arthritis. The mean QoL was 0.838 in patients without SNAC and 0.792 with SNAC. CONCLUSION: Scaphoid fracture non-union caused early carpal collapse, majority had osteoarthritis usually observed within a year following injury and occurred earliest in proximal waist fractures. Distribution of osteoarthritis (SNAC stage) may not always follow a distinctive pattern, as previously described.

Evidence-based quality leadership in orthopaedics.

There is a paucity of literature analysing the importance of leadership within trauma and orthopaedics. However, such skills are essential to make an orthopaedic surgeon proficient in their various roles. This literature review on leadership within orthopaedics enables an understanding of current issues. A narrative literature review was conducted using Pubmed, Medline and The National Centre for Biotechnology databases. The search string used to conduct the narrative literature review was (orthopaedic) and (leadership[Title]). The articles were screened by title, abstract and full text. A reference search was subsequently conducted on these papers using the same inclusion and exclusion criteria. The papers then underwent a thematic analysis to understand the issues surrounding leadership in orthopaedics. The critical themes recognised were quality improvement, training, women in leadership, inequality and traits of a leader. Through reviewing the themes in this article, a framework was developed to identify the current issues and potential avenues of advancing orthopaedic leadership. This narrative literature review has demonstrated a paucity of research in orthopaedic leadership. Further work would create a robust evidence base, outline ideal orthopaedic leadership and standardise training to create better orthopaedic leaders.

Venous thromboembolic events in hand surgery.

The risks of venous thromboembolism (VTE) following total hip and knee arthroplasty have been widely published. Our aim was to investigate the recorded incidence of VTE events at the time of elective and trauma hand surgery. The UK National Hospital Episode Statistics (HES) data linking VTE events with hand surgery for the financial years 2010-2012 were analysed. The local VTE rates following hand surgical procedures were also analysed. Finally, a cost assessment of VTE thromboprophylaxis was performed according to the British Society for Surgery of the Hand (BSSH) guidelines. 334,211 hand surgical procedures were performed throughout England of which there were 13 DVT and 27 PE events. These events were seen in patients with pre-existing comorbidities. The annual incidence of VTE is 0.006% at most in hand surgical patients in England. The cost of implementing mechanical VTE thromboprophylaxis to all patients having hand surgery would amount to £6,336,641 over 2 years. The cost of treatment for all VTE events would amount to £20,418. VTE prophylaxis is probably not necessary in patients undergoing isolated elective or trauma hand surgical procedures.

Cat bite: an injury not to underestimate.

Domestic cat bites are common and are often treated by simple wound care with good outcome. However, delayed presentation may lead to significant morbidity or even mortality. Twenty cases of cat bites to the hand and wrist were retrospectively reviewed between 2014 and 2018. Data included patient demographics, anatomical site of injury, microbiology results, method of treatment and surgical outcome. The subjects were 18 females and two males aged 27-86 years (mean age of 58 years). Eleven patients (Group A) were presented within 48 hours of their injury. Nine patients (Group B) presented later than 48 hours. Of these, 78% (n = 7) underwent multiple operations secondary to septic arthritis, osteomyelitis, necrotising fasciitis and deep collection. Mean length of hospital stay was 3.4 days in Group A, and 9.2 days in Group B, (p < .01). Four patients underwent digital or ray amputations. The index finger was the most common site of injury (45%). Almost 40% of cases had flexor tendon sheath infection of the fingers. Pasteurella species was isolated from 35% of infected wounds. Mean duration of antibiotic treatment and length of hospital stay were significantly longer in Group B (p < .05). Delayed presentation of infected cat bites increased the likelihood of more complicated surgeries such as amputation. Diabetic fingers with established peripheral neuropathy were more likely to undergo amputation. We recommend that any symptomatic cat bites to the upper limb, especially hand and wrist, must be treated promptly, essentially within 48 hours of injury, particularly in immunocompromised population.

A review of common practice in Dupuytren surgery.

Aspects of decision making, postoperative management, and complications routinely discussed with patients were investigated using a questionnaire completed by 141 hand surgeons of various grades who regularly manage Dupuytren disease. This account presents the results of this questionnaire study, and the literature is discussed in context. A brief description of operative technique in fasciectomy and dermofasciectomy is included. Thresholds for surgery did not differ greatly among the surgeons who completed the questionnaire. The training background and the number of operations performed by surgeons also did not generally influence surgical decision making. Postoperative care regimens were very similar. However, there was great variation in the complications routinely included in discussions with patients undergoing surgery for Dupuytren contracture. Recurrence and nerve damage were the only 2 mentioned by almost all surgeons. There was also diversity in what rates were quoted for complications, particularly recurrence (median 33%, range 0%-100%) and stiffness (median 10%, range 0%-100%).