Republication of "Osteochondral Lesions of the Talus: Current Concepts in Diagnosis and Treatment".

Osteochondral lesions of the talus (OLTs) are a difficult pathologic entity to treat. They require a strong plan. Lesion size, location, chronicity, and characteristics such as displacement and the presence of subchondral cysts help dictate the appropriate treatment required to achieve a satisfactory result. In general, operative treatment is reserved for patients with displaced OLTs or for patients who have failed nonoperative treatment for 3 to 6 months. Operative treatments can be broken down into cartilage repair, replacement, and regenerative strategies. There are many promising treatment options, and research is needed to elucidate which are superior to minimize the morbidity from OLTs.

Minimizing Costs for Dorsal Wrist Ganglion Treatment: A Cost-Minimization Analysis.

PURPOSE: Dorsal wrist ganglions are treated commonly with aspiration, or open or arthroscopic excision in operating room (OR) or procedure room (PR) settings. As it remains unclear which treatment strategy is most cost-effective in yielding cyst resolution, our purpose was to perform a formal cost-minimization analysis from the societal perspective in this context. METHODS: A microsimulation decision analytic model evaluating 5 treatment strategies for dorsal wrist ganglions was developed, ending in either resolution or a single failed open revision surgical excision. Strategies included immediate open excision in the OR, immediate open excision in the PR, immediate arthroscopic excision in the OR, or 1 or 2 aspirations before each of the surgical options. Recurrence and complications rates were pooled from the literature for each treatment type. One-way sensitivity and threshold analyses were performed. RESULTS: The most cost-minimal strategy was 2 aspiration attempts before open surgical excision in the PR setting ($1,603 ± 1,595 per resolved case), followed by 2 aspirations before open excision in the OR ($1,969 ± 2,165 per resolved case). Immediate arthroscopic excision was the costliest strategy ($6,539 ± 264 per resolved case). Single aspiration preoperatively was more cost-minimal than any form of immediate surgery ($2,918 ± 306 and $4,188 ± 306 per resolved case performed in the PR and OR, respectively). CONCLUSIONS: From the societal perspective, performing 2 aspirations before surgical excision in the PR setting was the most cost-minimal treatment strategy, although in reference to surgeons who do not perform this procedure in the PR setting, open excision in the OR was nearly as cost-effective. As patient preferences may preclude routinely performing 2 aspirations, performing at least 1 aspiration before surgical excision improves the cost-effectiveness of dorsal wrist ganglions treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic Decision Analysis II.

Humeral intramedullary nail placement through the rotator interval: an anatomic and radiographic analysis.

BACKGROUND: Antegrade humeral intramedullary nails are an effective fixation method for certain proximal humeral fractures and humeral shaft fractures. However, owing to potential rotator cuff damage during nail insertion, shoulder pain remains a common postoperative complaint. The purpose of this study was to provide quantitative data characterizing the anatomic and radiographic location of the rotator interval (RI) for an antegrade humeral intramedullary nail using a mini-deltopectoral approach. METHODS: Six consecutive fresh-frozen intact cadaveric specimens (mean age, 69 ± 12.8 years) were obtained for our study. Demographic data were collected on each specimen. A mini-deltopectoral approach was used, followed by placement of a guidewire in the RI. Quantitative anatomic relationships were calculated using a fractional carbon fiber digital caliper. Radiographic measurements were performed by 2 orthopedic residents and 1 practicing fellowship-trained orthopedic surgeon. In addition to re-measurement of similar anatomic relationships on radiographs, the ratio of the distance from the lateral humeral edge to the starting point relative to the width of the humeral head on the anteroposterior (AP) view was calculated. Similarly, on the lateral view, the ratio of the distance from the anterior humeral edge to the starting point relative to the humeral head width was calculated. RESULTS: In all cases, the described approach allowed for preservation of the biceps tendon and access to the RI for guidewire insertion, with no subsequent rotator cuff or humeral articular cartilage damage identified following nail insertion. The ratio of the distance from the lateral humeral edge to the starting point relative to the humeral head width on the AP view was 0.4 ± 0.0. The ratio of the distance from the anterior humeral edge to the starting point relative to the humeral head width on the lateral view was 0.3 ± 0.0. CONCLUSION: This study demonstrates the clinical feasibility of a mini-deltopectoral approach and shows that the ideal starting point through the RI radiographically lies along the medial aspect of the lateral third of the humeral head on the AP view and along the posterior aspect of the anterior third of the humeral head on the lateral view.

Complications of Low-Profile Plate Fixation in Metacarpal Fractures.

High complication rates have been reported using conventional plating systems to treat metacarpal fractures. This study investigated complication rates in metacarpal fractures treated with low-profile anatomic plates. A retrospective chart review was performed of patients with metacarpal fractures who were treated with open reduction and internal fixation using low-profile anatomic plates at a single institution from January 2010 to February 2017. Patients with concomitant tendon injury, open fractures, prior same metacarpal fracture, or thumb metacarpal fracture were excluded. A total of 79 patients with 110 metacarpal fractures were included. The primary outcome was the presence of a complication, defined as superficial or deep infection, delayed wound healing, delayed union, nonunion, major or minor extensor lag or stiffness 90 days postoperatively, or return to the operating room. Eleven fractures (10%) had 1 or more complications. Complications included 6 fractures (5%) with major extensor lag or stiffness, 4 fractures (4%) with minor extensor lag or stiffness, 1 fracture (1%) with delayed radiographic union that did not require operative intervention, and 1 fracture (1%) with return to the operating room for removal of hardware. In this retrospective study, treatment of metacarpal fractures with low-profile plate fixation resulted in a 10% overall complication rate and a 1% reoperation rate; this rate is significantly less than reported in previous literature prior to the widespread use of low-profile plates. This study suggests treatment of patients with metacarpal fractures using low-profile plating systems provides a reliable solution with acceptable complication rates. [Orthopedics. 2021;44(1):e91-e94.].

Complications of Low-Profile Plate Fixation of Phalanx Fractures.

Background: Phalanx fractures are common, and plate fixation can be used to treat difficult fractures. Major complications have been reported in up to 64% of phalanx fractures treated with plate fixation, with stiffness being the most common. Low-profile anatomic plates (LPAP) have been designed to decrease soft tissue irritation and postoperative stiffness. The objective of this study was to determine whether the use of LPAP has decreased complications in plate fixation of phalanx fractures. Methods: A retrospective chart review was performed of patients with phalanx fractures treated with open reduction and internal fixation (ORIF) using LPAP at a single institution from January 1, 2010, to January 25, 2018. Twenty-three patients with 23 phalanx fractures treated with LPAP were included. The primary outcome was the presence of a complication. Results: Of the 23 patients, 12 patients (52.2%) had a postoperative complication. Nine patients (39.1%) required return to the operating room, with 7 (30.4%) returning for removal of hardware and tenolysis/capsulotomy. Two patients (8.7%) had superficial infections, one requiring irrigation and debridement. The other infection resolved clinically after 2 courses of oral antibiotics, with the fracture going on to nonunion. One patient had delayed wound healing treated prophylactically with cephalexin; although the wound healed, the patient developed a boutonniere deformity requiring surgery. There were 2 malunions (8.7%), one requiring revision surgery and the other electing for nonoperative management. All but one fracture progressed to union. Conclusions: ORIF with LPAP consistently achieves fracture union for phalanx fractures, but it does not appear that LPAP reduce the high complication rate.

Increased Rate of Complications following Trigger Finger Release in Diabetic Patients.

BACKGROUND: The purpose of this study was to investigate the impact of diabetes on complications after open trigger finger release compared with a cohort matched for age, sex, race, and body mass index class. METHODS: A retrospective chart review was performed of diabetic patients who underwent trigger finger release at an academic institution within the past 10 years. Exclusion criteria included rheumatoid arthritis, malignancy, human immunodeficiency virus/acquired immunodeficiency syndrome, connective tissue disorders, or systemic steroid use. These patients were then matched by age, sex, race, and body mass index class to nondiabetic patients who underwent trigger finger release during the same period. One hundred thirty-seven patients met inclusion criteria and were matched with controls. Complications included superficial or deep infection, delayed wound healing, limited range of motion at 6 weeks, pain requiring medication at 6 weeks, and return to the operating room. RESULTS: In adjusted analyses, diabetic patients had a significantly higher rate of all-cause complication following trigger finger release compared with matched nondiabetic controls at an odds ratio of 2.1. Diabetic patients also had a significantly higher rate of limitation in postoperative range of motion compared to the controls with an odds ratio of 2.4. CONCLUSION: This retrospective case-control study identified that diabetic patients undergoing trigger finger release are at increased risk of all-cause postoperative complications and, specifically, range of motion limitation when compared with similar patients without diabetes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Metacarpal Position and Lunate Facet Screw Fixation in Dorsal Wrist-Spanning Bridge Plates for Intra-Articular Distal Radial Fracture: A Biomechanical Analysis.

BACKGROUND: A dorsal wrist-spanning plate (DWSP) can be affixed to the second or third metacarpal, depending on the morphology of the distal radial fracture (DRF) and on surgeon preference, but comparative biomechanical analyses between these methods are limited. This biomechanical study compared fixation to the second metacarpal versus the third metacarpal as measured by lunate facet fragment displacement in a cadaveric model of an axially loaded intra-articular DRF. The construct rigidity with the addition of an intrafragmentary lunate facet locking screw was also evaluated. METHODS: A sample size of 14 cadaveric matched pairs was calculated to achieve 81.7% power. The 28 limbs were randomized to DWSP fixation to the second metacarpal (Group 1) or third metacarpal (Group 2); each wrist underwent an osteotomy simulating an unstable intra-articular DRF. Limbs were tested at axial loads of 50, 100, 150, 200, 250, and 300 N. Lunate facet displacement from the metaphyseal fragment at each load was measured with use of differential variable reluctance transducers. After initial testing, a locking screw was placed through the plate into the lunate facet fragment in the third metacarpal group (Group 3). Displacement measurements were repeated for all loads. Paired 2-tailed t tests with Bonferroni correction (significance, p < 0.008) were performed to assess differences in fragment stability between groups. RESULTS: The average fracture displacement at 300 N was 0.8 mm in Group 1, 0.4 mm in Group 2, and 0.2 mm in Group 3. Plating to the third metacarpal more effectively resisted displacement compared with the second metacarpal at all axial loads (p < 0.008). The addition of a lunate facet screw further stiffened the construct at loads of ≥200 N (p < 0.008). CONCLUSIONS: Plate fixation to the third metacarpal with an intrafragmentary screw was the most biomechanically favorable construct, although other factors may favor an alternative distal fixation site. Mean displacement of the lunate facet fragment at 300 N was <1 mm in all groups. CLINICAL RELEVANCE: The present study demonstrated that a DWSP affixed to the third metacarpal with an intrafragmentary screw provides the most effective stabilization of the lunate facet fragment in intra-articular DRFs. This study validates the use of intrafragmentary screws to increase stability in DWSP fixation.

Open Reduction Internal Fixation With Transverse Volar Plating for Unstable Proximal Interphalangeal Fracture-Dislocation: The Seatbelt Procedure.

Background: Unstable intra-articular proximal interphalangeal (PIP) joint fracture-dislocations present a difficult problem that requires congruous joint reduction and stable internal fixation or distraction. Though fractures with limited articular involvement may be treated successfully with less invasive procedures, fracture-dislocations with a volar shear component may benefit from joint reduction with subchondral support for maintenance of stability. The purpose of this article is to describe a volar transverse plate and screw technique and report the short-term postoperative results. Methods: Seventeen patients with volar shear PIP dorsal fracture-dislocations were treated with transverse plate and screw constructs at an average of 21 days (range, 2-52) after injury. Information on postoperative stability, range of motion at PIP and distal interphalangeal (DIP) joints, and radiographic outcomes and complications were retrospectively collected. Results: At a mean of 7.3 months post-operation (range, 1.5-24), there were no recurrent dislocations and an average PIP arc of 77.4° and DIP arc of 61.5°. Sixteen of 17 patients had radiographically concentric joints, with 1 patient showing slight radiographic dorsal subluxation not apparent clinically. Two of 17 patients (11.8%) had revision surgery for tenolysis and removal of hardware to improve range of motion at 4 and 9 months post-operation. Conclusions: In the setting of PIP dorsal fracture-dislocations with volar shear component >40% of the articular surface, the Seatbelt procedure allows for concentric joint and articular surface reduction with subchondral support for maintenance of stability. This volar transverse plating technique allows for highly functional range of motion without PIP dorsal subluxation clinically in the setting of comminution and delayed presentation.

Determination of the Optimal Location for Bone Graft Harvest in the Distal Radius.

Background: The distal radius is commonly used as a bone graft donor site for surgery in the hand and wrist. The aim of this study was to evaluate the volume and relative density of cancellous bone in the distal radius. Methods: Thirty-four consecutive computed tomographic scans of the wrist in 33 patients without distal radius pathology were included. For each subject, 6 spherical regions of interest (ROIs) were identified within the distal radius. In each ROI, volumetric measurements and mean Hounsfield unit (HFU) values were recorded by 2 observers using a 3-dimensional imaging reconstruction software. Results: Compared with proximal bone, distal bone had larger volume (0.82 vs 0.27 cm3) and greater relative density (178 vs 152 HFU) on average. Among the 6 ROIs, the distal-central region had the largest average volume (1.20 cm3) and the distal-ulnar ROI had the greatest average relative density (193 HFU). Conclusion: Based on these results, we recommend performing cancellous autograft harvest relatively distal and ulnar within the distal radius.

Elevated Preoperative Hemoglobin A1c Associated with Increased Wound Complications in Diabetic Patients Undergoing Primary, Open Carpal Tunnel Release.

BACKGROUND: An increased rate of complications has been demonstrated with increasing hemoglobin A1c value for a variety of orthopedic procedures, including arthroplasty and spine surgery. The authors investigated the effects of elevated hemoglobin A1c value on postoperative complications at the time of carpal tunnel release. METHODS: This retrospective, cohort study evaluated all diabetic patients with a preoperative hemoglobin A1c value within 90 days of primary, open carpal tunnel release at a single academic institution within the past 10 years. Binary hemoglobin A1c thresholds were tested for association with outcomes of superficial or deep infection, delayed wound healing, and persistent symptoms using chi-square analysis. Multivariable models with adjustment for baseline and operative factors were then constructed. Odds ratios and 95 percent confidence intervals were displayed. RESULTS: Hemoglobin A1c value greater than or equal to 7.8 percent was most strongly associated with an increased risk of all-cause wound healing complications (p = 0.049) at an odds ratio of 4.2 (95 percent CI, 1.0 to 17.7) in adjusted analyses. Six patients (4 percent) experienced delayed wound healing and five patients (4 percent) developed a superficial infection. Six patients (4 percent) reported persistent carpal tunnel syndrome symptoms. CONCLUSIONS: Diabetic patients undergoing open, primary carpal tunnel release with a hemoglobin A1c value of 7.8 percent or higher had a higher rate of postoperative wound complications compared to diabetic patients with improved preoperative glucose control. Diabetics with poor glycemic control should be counseled that their risk of postoperative complication is higher. Further work is needed to determine whether delaying surgery to optimize glucose control could result in a reduction of wound healing complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.