The rate of nonunion in the MRI-detected occult scaphoid fracture.

Aims: There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures. Methods: This multicentre cohort study at eight centres in the UK included all patients with an acute scaphoid fracture diagnosed on MRI having presented acutely following wrist trauma with normal radiographs. Data were gathered retrospectively for a minimum of 12 months at each centre. The primary outcome measures were the rate of acute surgery, delayed union, and nonunion. Results: A total of 1,989 patients underwent acute MRI for a suspected scaphoid fracture during the study period, of which 256 patients (12.9%) were diagnosed with a previously occult scaphoid fracture. Of the patients with scaphoid fractures, six underwent early surgical fixation (2.3%) and there was a total of 16 cases of delayed or nonunion (6.3%) in the remaining 250 patients treated with cast immobilization. Of the nine nonunions (3.5%), seven underwent surgery (2.7%), one opted for non-surgical treatment, and one failed to attend follow-up. Of the seven delayed unions (2.7%), one (0.4%) was treated with surgery at two months, one (0.4%) did not attend further follow-up, and the remaining five fractures (1.9%) healed after further cast immobilization. All fractures treated with surgery had united at follow-up. There was one complication of surgery (prominent screw requiring removal). Conclusion: MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion of scaphoid fractures diagnosed only after MRI seen in over 6% despite appropriate initial immobilization, with most of these patients with nonunion requiring surgery to achieve union. This study adds weight to the evidence base supporting the use of early MRI for these patients.

Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial.

BACKGROUND: Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. The use of immediate surgical fixation to manage this type of fracture has increased, despite insufficient evidence of improved outcomes over non-surgical management. The SWIFFT trial compared the clinical effectiveness of surgical fixation with cast immobilisation and early fixation of fractures that fail to unite in adults with scaphoid waist fractures displaced by 2 mm or less. METHODS: This pragmatic, parallel-group, multicentre, open-label, two-arm, randomised superiority trial included adults (aged 16 years or older) who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear bicortical fracture of the scaphoid waist on radiographs. An independent remote randomisation service used a computer-generated allocation sequence with randomly varying block sizes to randomly assign participants (1:1) to receive either early surgical fixation (surgery group) or below-elbow cast immobilisation followed by immediate fixation if non-union of the fracture was confirmed (cast immobilisation group). Randomisation was stratified by whether or not there was displacement of either a step or a gap of 1-2 mm inclusive on any radiographic view. The primary outcome was the total patient-rated wrist evaluation (PRWE) score at 52 weeks after randomisation, and it was analysed on an available case intention-to-treat basis. This trial is registered with the ISRCTN registry, ISRCTN67901257, and is no longer recruiting, but long-term follow-up is ongoing. FINDINGS: Between July 23, 2013, and July 26, 2016, 439 (42%) of 1047 assessed patients (mean age 33 years; 363 [83%] men) were randomly assigned to the surgery group (n=219) or to the cast immobilisation group (n=220). Of these, 408 (93%) participants were included in the primary analysis (203 participants in the surgery group and 205 participants in the cast immobilisation group). 16 participants in the surgery group and 15 participants in the cast immobilisation group were excluded because of either withdrawal, no response, or no follow-up data at 6, 12, 26, or 52 weeks. There was no significant difference in mean PRWE scores at 52 weeks between the surgery group (adjusted mean 11·9 [95% CI 9·2-14·5]) and the cast immobilisation group (14·0 [11·3 to 16·6]; adjusted mean difference -2·1 [95% CI -5·8 to 1·6], p=0·27). More participants in the surgery group (31 [14%] of 219 participants) had a potentially serious complication from surgery than in the cast immobilisation group (three [1%] of 220 participants), but fewer participants in the surgery group (five [2%]) had cast-related complications than in the cast immobilisation group (40 [18%]). The number of participants who had a medical complication was similar between the two groups (four [2%] in the surgery group and five [2%] in the cast immobilisation group). INTERPRETATION: Adult patients with scaphoid waist fractures displaced by 2 mm or less should have initial cast immobilisation, and any suspected non-unions should be confirmed and immediately fixed with surgery. This treatment strategy will help to avoid the risks of surgery and mostly limit the use of surgery to fixing fractures that fail to unite. FUNDING: National Institute for Health Research Health Technology Assessment Programme.

Outcomes and Early Recurrence Following Enzymatic (Collagenase) Treatment of Moderate and Severe Dupuytren Contractures.

PURPOSE: We offer collagenase Clostridium histolyticum (CCH) injections to all patients with a Dupuytren contracture and a palpable cord. We assessed whether more severe contractures respond less well or recur more frequently. METHODS: From a database of 502 CCH injections, 386 (77%) had a complete dataset with minimum 1-year face-to-face follow-up. Contracture severity was assessed using the Tubiana system: grade 1 (27%), grade 2 (49%), grade 3 (19%), and grade 4 (5%). Patients received a single intralesional injection of 0.58 mg CCH followed by manipulation. Finger position was measured at 6 to 12 weeks, 6 months, and 1 year. Failure to break the cord, skin tears, and any adverse events were noted. Recurrence was defined as a failure to maintain any prior correction to within 20°. RESULTS: There were 17 failures (4%) and 6 allergic reactions (1%). We found 31% corrected completely, with approximately half remaining corrected at 1 year. We achieved 43° (95% confidence interval, 40°-46°) correction of combined deformity, with 11° (95% confidence interval, 9°-13°) correction attrition over 1 year. Sixteen percent of treated digits experienced a recurrence with no difference between Tubiana grades, and one-third chose further treatment. Following treatment, Tubiana grade 1 contractures improved by 78% in comparison with higher grade contractures (55%-67% relative correction). By 1 year, all grades had a similar mean 46% relative correction. A complete correction was seen in 61% of grade 1 contractures, with more severe contractures less likely to correct completely (9%-24%). A 31% skin tear rate had no impact on outcome, recurrence, or long-term morbidity. CONCLUSIONS: CCH may treat any Dupuytren cord regardless of severity. Although contracture may recur, few patients pursue further treatment within 1 year. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Three Year Review of Dorsal Plating for Complex Intra-Articular Fractures of the Distal Radius.

BACKGROUND: The volar approach is commonly used for plating intra-articular fractures of the distal radius. Despite this, certain fracture configurations are more suitable for dorsal plate fixation. This technique has not gained favour due to the reported high incidence of extensor tendon irritation and attrition ruptures. With the advent of lower profile plates this risk has decreased. METHODS: We report on forty-six cases performed in a tertiary hand centre between January 2011 and May 2014. Patients were identified from a database of distal radius fractures treated with open reduction and internal fixation. Pre-operative radiographs and computed tomogram (CT) scans were reviewed to classify fractures and evaluate fracture configurations. Dorsal displacement of fracture fragments was present in all cases. Records and imaging were reviewed to assess bony union and complications including tendon irritation, rupture and need for further surgery. RESULTS: Plate placement was dependent on the degree of comminution in each fracture component. The combination of a dorsal and radial styloid plate was used in 52% of cases. There were no cases of tendon rupture and one case of post-operative loss of reduction. Removal of metal was performed in ten patients, mainly to improve motion and for tendon irritation (four cases each). CONCLUSIONS: Even though technically challenging, dorsal plating is useful in cases of dorsal fragment displacement and comminution, as well as complex AO-23C3 fractures with involvement of the lunate fossa. It allows stable reduction of the dorso-ulnar fragment which is important to restore DRUJ anatomy. The rate of tendon irritation and rupture is lower when compared to earlier plate designs, and removal of metal is only necessary in a few cases.

Four corner fusion using a multidirectional angular stable locking plate.

AIM: To review the results of our experience with the Medartis Aptus plating system for four corner arthrodesis of the wrist, which uses a combination of compression screws and variable angle locking screws. METHODS: We reviewed the results of 17 procedures in 16 patients that underwent scaphoid excision and four corner fusion using the Medartis Aptus system between May 2010 and June 2014. The primary outcome measure was radiographic and clinical union. RESULTS: The mean clinical follow up time was 20.6 mo. The mean union time was 6 mo. Two non-unions required revision procedures. The mean disabilities of the arm, shoulder and hand score taken after union was 36. The mean final grip strength was 27 kg. The mean final range of movement was 30° flexion and 31° of extension. All patients had a restored scapholunate angle on postoperative radiographs. There were no incidences of dorsal impingement. CONCLUSION: Overall our experience with the Aptus plating system shows comparable results to other methods of fixation for four corner fusion, in the short to medium term.

Treatment of Scaphoid Nonunion: A Systematic Review of the Existing Evidence.

PURPOSE: To determine by systematic review the optimal treatment of scaphoid nonunion. METHODS: We conducted a systematic review of the literature with a meta-analysis of proportions to investigate the comparative effectiveness of different surgical techniques. RESULTS: A total of 48 publications (1,602 patients) met the eligibility criteria. Vascularized and nonvascularized bone grafts had an estimated union incidence of 92% and 88%, respectively. Distal radius and iliac crest bone grafts had similar union rates (89% and 87%, respectively) but harvesting of iliac crest bone grafts had more complications. Both screw and K-wire fixation had a higher incidence of union (88% and 91%, respectively) than no fixation (79%). No approach was statistically different. Patients fixed with screws were mobilized earlier than those with K-wire fixation. CONCLUSIONS: Current evidence does not demonstrate a significantly superior method for the treatment of scaphoid nonunion. A multicenter randomized trial would be ideal but the large numbers that would be required may make this unrealistic. We recommend the continued reporting of series with specific assessments and outcome measures to optimize future comparisons in an attempt to determine the best management of scaphoid nonunion. CLINICAL RELEVANCE: The use of bone grafts and the methods of their fixation for scaphoid nonunion are debated issues in hand and wrist surgery, with multiple methods employed. There is no current consensus on optimal treatment. A meta-analysis of proportions of available data from recent studies was deemed the most appropriate way to assimilate the available evidence with the view to inform surgeons of the optimal treatment according to the evidence base.

An unusual presentation of aplastic anaemia: compartment syndrome.

This is a case of a previously fit and healthy 17-year-old man presenting with atraumatic forearm compartment syndrome. On his initial blood film, he was found to have a pancytopenia and was subsequently diagnosed with aplastic anaemia. His compartment syndrome was treated with urgent fasciotomy after correction of his pancytopenia. He made a good functional recovery with only a very minor deficit, and no recurrence of his compartment syndrome. He has undergone a successful bone marrow transplant for treatment of his aplastic anaemia.

A comparison of complications requiring return to theatre in hip and knee arthroplasty patients taking enoxaparin versus rivaroxaban for thromboprophylaxis.

BACKGROUND: There is no consensus on the optimal form of venous thromboembolic prophylaxis treatment in hip and knee arthroplasty patients, or on the safety and complication profile of the available chemical prophylaxis modalities. In this study we aimed to measure the return to theatre rate for any cause related to wound complications in patients undergoing total hip replacement and total knee replacement, and compare these rates between patients on oral Rivaroxaban 10mg OD and subcutaneous Enoxaparin 40mg OD in our department. MATERIAL AND METHODS: There were a total of 387 patients included in the study; 227 patients in group 1, who received Enoxaparin 40mg OD, and 160 patients in group 2, who received Rivaroxaban 10mg OD. RESULTS: The primary outcome measure was re-operation rate due to wound complications. Secondary outcome measures were infection rate, incidence of deep vein thrombosis, pulmonary emboli, duration of hospital stay, change in haemoglobin and haematocrit and blood transfusion rate. In this retrospective cohort study we found that patients who received Rivaroxaban were more than twice as likely to return to theatre for wound complications compared to patients receiving Enoxaparin. Although not statistically significant, this increase is in line with previous studies. Infection rates increased from 0.9% to 1.9% after the introduction of Rivaroxaban and microbiologically confirmed superficial infections rose from 1.3% to 3.1% after Rivaroxaban was introduced in our unit. These rises were not statistically significant. CONCLUSION: Our study highlights the need for large randomised controlled trials to assess post-operative complications following the introduction of Rivaroxaban for post-arthroplasty thromboprophylaxis.

Area variations in health: a spatial multilevel modeling approach.

Both space and membership in geographically-embedded administrative units can produce variations in health, resulting in geographic clusters of good and poor health. Despite important differences between these two types of dependence, one is easily mistaken for the other, and the possibility that both are at work is commonly ignored. We fit a series of hierarchical and spatially-explicit multilevel models to a U.S. county-level life dataset of life expectancy in 1999 to demonstrate approaches for data analysis and interpretation when multiple sources of area-clustering are present. We demonstrate the methods to detect, interpret, and differentiate evidence of spatial and geographic membership effects and discuss key considerations for analyzing data with spatial or/and membership dimensions. We find evidence that life expectancy is driven by both within-state geographic process, and by spatial processes. We argue that considering spatial and membership processes simultaneously yields valuable insights into the patterning of area variations in health.

Volar locking plates versus K-wire fixation of dorsally displaced distal radius fractures--a functional outcome study.

BACKGROUND: Fractures of the distal radius are common. As the population of the western world ages, their incidence is set to increase further. There are various methods of treating these fractures, but optimal management remains controversial. In the United Kingdom, the most common surgical treatment of closed distal radius fractures is by Kirschner-wires (K-wires) or volar locking plate. In this study, we compared long-term functional outcomes of volar locking plates with those of K-wires. METHODS: A retrospective comparative study of 71 patients with dorsally displaced distal radius fractures treated contemporaneously in two independent hospitals was performed. One group was treated with a volar locking plate (n = 36) and the other group with manipulation and K-wire fixation (n = 35). There was no difference between the two groups in terms of demographics or grade of fracture. Outcome was measured 15 months to 27 months post surgery using the Disabilities of the Arm, Shoulder and Hand score and the Patient-Rated Wrist Evaluation score. RESULTS: We found no statistical difference between the two groups in the Patient-Rated Wrist Evaluation score or Disabilities of the Arm, Shoulder and Hand score at 1 year to 2 years postsurgery. CONCLUSION: We have been unable to demonstrate a clinically relevant advantage of using volar locking plates over K-wires at 1 year to 2 years postoperatively.

Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield better functional results? A systematic review of the literature.

As first metatarsophalangeal joint arthrodesis is generally considered to be a successful procedure for the treatment of hallux rigidus, many surgeons question the usefulness of total joint replacement. In an effort to elucidate the clinical evidence, we undertook a systematic review of the literature comparing the functional outcomes of arthrodesis and joint replacement in first metatarsophalangeal surgery. Using multiple search engines and medical subject headings, 10 articles were eligible for inclusion: 5 featured arthrodesis and 5 featured total joint replacement. The American Orthopaedic Foot and Ankle Society-Hallux metatarsophalangeal-interphalangeal score was used in all articles. The mean age at operation was 53 years for joint replacement patients and 55 for those undergoing joint arthrodesis. Most patients in all studies were female. There was a significant increase from pre- to postoperative scores in both procedures. The median postoperative score for joint replacement was 83/100 (range 74-95) and 82/100 (range 78-89) for arthrodesis. The median revision rate in joint replacements was 7% (range 0%-10%) and 0% (range 0%-12%) for arthrodesis. This systematic review reveals that arthrodesis achieves better functional outcomes than total joint replacement. The operative techniques and prostheses for joint replacements are however still in an early stage of development and advances still need to be achieved to produce a more successful and anatomical prosthesis that could be functionally superior to an arthrodesis.

Iatrogenic pancreatic cyst perforation successfully managed by a minimally invasive combined endoscopic­laparoscopic approach.

Endoscopic treatment of walled-off pancreatic necrosis is becoming more prevalent in clinical practice, although perforation may complicate 5% of cases, and efficient management of this complication is imperative. In this report, we present a case of necrosis cavity perforation successfully managed by a combined laparoscopic­endoscopic approach, with a novel method of luminal defect closure.

Moje first metatarsophalangeal replacement--a case series with functional outcomes using the AOFAS-HMI score.

We report the functional results of a case series of Moje first metatarsophalangeal total joint replacements carried out between February 2001 and November 2006. All patients who underwent Moje arthroplasty under the care of a single surgeon were included; outcome scores and complications were recorded annually. A total of 32 joints in 29 consecutive patients were followed for a mean duration of 34 (range 6 to 74) months, and the mean patient age at the time of operation was 56 (range 38 to 79) years. Hallux rigidus was the primary diagnosis in 28 (87.5%) of the cases. The mean American Orthopaedic Foot & Ankle Society Hallux-Metatarsophalangeal-Interphalangeal score at final follow-up was 74/100 (range 9 to 100), with 13 (40.63%) joints rated good to excellent. Two (6.25%) joints were revised to arthrodesis at a mean of 52 (range 41 to 63) months following the arthroplasty procedure, and the overall prevalence of postoperative complications was 6 (18.75%). Based on these results, we concluded that first MTPJ total joint replacement with the Moje device remains promising, but still has room for improvement before the results match those obtained with larger joint (knee, hip) arthroplasty.