A Review on Volar Fracture-Dislocations of the Proximal Interphalangeal Joint.

Volar fracture-dislocations of the proximal interphalangeal joint are rare injuries caused by an axial force on a flexed digit resulting in an avulsion fracture of the dorsal lip of the middle phalanx with volar dislocation of the joint. This volar subtype is analogous to the more common dorsal subtype with a mirror image fracture on the dorsal lip of the middle phalanx. The main significance in this type of injury lies in the disruption of the extensor mechanism at the central slip. The goals of treatment, apart from restoring a congruent and stable joint, is to restore the extensor mechanism to prevent a boutonnière deformity. In this article, we summarise the current literature and discuss the principles for treatment of this uncommon injury. Level of Evidence: Level V (Therapeutic).

Comparing the torsional resistance of different fixation techniques for spiral metacarpal fractures.

This study aimed to compare the torsional resistance of three fixation techniques for spiral metacarpal fractures: screw-only fixation, screw plus neutralization plate fixation, and a locking plate construct. A spiral fracture was created on 18 cadaveric metacarpal bones by applying an axial and torsional loading force using an Instron 3343 mechanical tester. The failure strength was defined as the native torque strength. The fractures were divided into three groups and fixed using each of the three techniques. The repaired bones were loaded to failure to determine the post-repair strength. The neutralization plate group conferred a post-repair torque (278.6 Nmm) that was similar to the native torque (292 Nmm) with a diminution of only 4.5% and appeared to provide the best resistance to torsion.

Open Excision of Olecranon Melorheostosis to Relieve Elbow Extension Block.

We report a 34-year-old man who presented with hyperostosis of his right elbow associated with an inability to fully extend his elbow. The radiographic assessment revealed a classical dripping candle wax appearance of his proximal ulna suggestive of melorheostosis. Computed tomography was performed to identify the impingement point and aid in surgical planning. A targeted open excision biopsy via a Boyd incision was performed to excise the exophytic component that was causing the functional block. After surgery, he achieved full elbow extension and was able to return to his usual activity.

Clinical outcomes of an all-arthroscopic glenoid reconstruction using iliac crest bone graft with a double cannulated screw fixation technique.

INTRODUCTION: Significant glenoid bone loss contributes to recurrent anterior shoulder instability. Reconstruction using an iliac crest bone graft provides an anatomic restoration of the glenohumeral arc. We present a case series of an all-arthroscopic glenoid bone reconstruction using iliac crest bone graft (ICBG) with a double cannulated screw fixation technique. MATERIALS AND METHODS: This is a retrospective study from 2012 to 2017. Patient selection was based on Instability Severity Index Score (ISIS) of greater than 3 points and the presence of glenoid bone defect of more than 20% surface area. The ICBG was harvested from the ipsilateral hip and delivered arthroscopically to the deficient glenoid. The bone graft was then fixed with two cannulated screws. All patients were evaluated at 0, 6, 12 and 24 months for range of motion, isometric strength, pain score, and functional outcome scores: Constant-Murley Score (CMSO), Oxford Shoulder Score (OSS), and UCLA Shoulder Score. RESULTS: 7 patients (6 males, 1 female) with the mean age of 40.2 years and mean glenoid bone loss of 41.8% were included. At 24 months, the mean active flexion improved from 119 to 143° (p = 0.128) and active abduction improved from 112 to 138° (p = 0.063). Isometric strength increased from 14.7 to 17.6lbs (p = 0.345). All functional scores showed significant improvement (p < 0.05), where CMSO increased from 66.9 to 81.4; OSS 17.4 to 31.4, and UCLA score 23.5 to 32.1. Pain score improved from 4 to 0.5. Bone graft incorporation was confirmed for all the cases and none had recurrent instability. One patient required screw removal for screw cutout. CONCLUSION: Our mid-term results for an all-arthroscopic glenoid reconstruction using ICBG demonstrated good clinical result with minimal complications.

The strengths of one-, two-, and three-weave Pulvertaft tendon repairs.

We tested the tensile strength of the proximal juncture of tendon grafts with Pulvertaft tendon repairs in 18 cadaveric digital flexor tendons. These tendons were divided into three groups of six: single, two, or three weaves. Each of the interlacing weaves was secured with eight anchoring sutures. The specimens were loaded in a biomechanical tester until failure. The ultimate tensile strength did not show any significant differences across all three groups with statistical power of 0.77. The mean tendon elongation before repair failure showed significant difference at 10 mm (standard deviation (SD) 2), 16 mm (SD 3), and 15 mm (SD 3), respectively. All specimens failed by intra-tendinous pull-out of the weaves. We conclude that the two-weave Pulvertaft construct demonstrated comparable tensile strength to three weaves and tendon elongation was similar when two or three weaves were used.

Biomechanical comparison of monocortical and bicortical plate fixation for rib fractures in a cadaveric model using a locking plate system.

BACKGROUND: Surgical stabilization of rib fractures is an established form of treatment for complex rib fractures. Plate fixation with bicortical screws placement can cause injury to intra-thoracic organs and pleural irritation from protruding screw tips. The aim of this study is to compare the biomechanical properties of monocortical and bicortical plate fixation for rib fractures using a locking plate system. METHODS: Ten pairs of fresh-frozen cadaveric ribs were harvested. Native ribs were mounted onto a biomechanical tester and statically loaded to failure to induce a rib fracture. The native stiffness of the rib was measured. Next, the ribs were stabilized using the Synthes MatrixRIB (Johnson & Johnson, USA) locking plate. Left-sided ribs were fixed in a bicortical manner and right-sided ribs were fixed in a monocortical manner. The repaired ribs were subjected to cyclic loading of 50,000 cycles between 2 to 6 N to simulate physiological respiration, followed by static loading at a rate of 10 N/min until failure. The pre and post-repaired stiffness were measured. A high-speed camera was used to record the mechanism of failure. RESULTS: One left-sided rib was omitted from the study because the fracture occurred at the drill hole site. Left-sided ribs demonstrated a mean native stiffness of 10.0 N/mm (SD 3.71) and right-sided 11.92 N/mm (SD 3.57). After plate fixation, pre and post cyclic stiffness was 3.32 N/mm (SD 1.21) and 4.41 N/mm (SD 3.29) for the bicortical group; 3.14 N/mm (SD 1.24) and 3.91 N/mm (SD 1.98) for the monocortical group. There is no statistical difference found between the two groups (P=0.872). CONCLUSIONS: Our results show that there is no difference in stability between monocortical and bicortical fixation for rib fractures using a locking plate system. Monocortical fixation is recommended to avoid potential complications.

Biobrane™ for burns of the pubic region: minimizing dressing changes.

BACKGROUND: The pubic region is often involved in accidental hot water or soup-spill burns. Most of these wounds are superficial partial thickness burns. Due to their proximity to the urinary system, as well as vaginal and anal openings, these burns are easily contaminated. Daily dressings are routinely prescribed as the sole treatment. The cumbersome dressing process is uncomfortable and embarrassing for patients. Biobrane™ is a bilayered biosynthetic dressing. Its coverage of superficial partial thickness burns promotes wound healing and allows one-time application. CASE PRESENTATIONS: We report two patients who suffered superficial dermal burns over their pubic region. One patient had 23% total body surface area (TBSA) burns over her lower abdomen, both thighs and pubic region. The second patient had 10% TBSA burns that involved her perineum and the medial sides of both thighs and buttocks. Both were managed with the standard resuscitation protocol in the initial phase. Their burn injuries were managed by shaving, Foley catheterization and Biobrane™ coverage. Their wounds healed uneventfully without complications. Full epithelization was achieved by post-operative day seven. Both patients consented to medical photography and academic publication. CONCLUSION: Shaving and catheterization improved the hygiene of the burns of the pubic area. The Biobrane™ method circumvents the need of regular dressing changes, eliminating the pain due to dressing changes and preserving patient dignity.

Restoring a functional and mobile shoulder following reconstruction of the sternoclavicular joint with a free vascularized fibular flap.

Infection of the sternoclavicular joint (SCJ) is rare and often missed at early stage. In extensive disease with bony and soft tissue destruction, radical excision is indicated. The loss of SCJ results in exposure of vital structures of the anterior mediastinum and instability of the shoulder girdle. SCJ reconstruction using locoregional muscle flaps like the pectoralis major or latissimus dorsi flap has been well described. While these options can provide soft tissue coverage, they do not restore the structural framework of the SCJ which is important for shoulder excursion and chest wall movement. We describe a case of SCJ reconstruction using a free vascularized fibular flap following the resection of sternoclavicular tubercular osteomyelitis. The fibula bone was used to restore the clavicular strut by anchoring it to the remaining manubrium with a steel wire and by plating the lateral end to the remnant clavicle. The steel wire served as a "defunctioning" cerclage that allowed motion of the joint to induce fibrous union. A strict post-operative rehabilitation protocol keeping the shoulder adducted at the initial phase was prescribed. At one year follow up, the patient achieved good shoulder function with 140 degrees of shoulder abduction and 110 degrees flexion.

Comparison of four measures in reducing length of stay in burns: An Asian centre's evolved multimodal burns protocol.

INTRODUCTION: Multidisciplinary burns care is constantly evolving to improve outcomes given the numerous modalities available. We examine the use of Biobrane, micrografting, early renal replacement therapy and a strict target time of surgery within 24h of burns on improving outcomes of length of stay, duration of surgery, mean number of surgeries and number of positive tissue cultures in a tertiary burns centre. METHODS: A post-implementation prospective cohort of inpatient burns patients from 2014 to 2015 (n=137) was compared against a similar pre-implementation cohort from 2013 to 2014 (n=93) using REDCAP, an electronic database. RESULTS: There was no statistically significant difference for comorbidities, age and percentage (%) TBSA between the new protocol and control groups. The protocol group had shorter mean time to surgery (23.5-38.5h) (p<0.002), 0.63 fewer operative sessions, shorter mean length of stay (11.8-16.8 days) (p<0.04), less positive tissue cultures (0.59-1.28) (p<0.03). DISCUSSION/CONCLUSION: The 4 measures of the new burns protocol improved burns care and validated the collective effort of a multi-disciplinary, multipronged burns management supported by surgeons, anesthetists, renal physicians, emergency physicians, nurses, and allied healthcare providers. Biobrane, single stage onlay micrograft/allograft, early CRRT and surgery within 24h were successfully introduced. These are useful adjuncts in the armamentarium to be considered for any burns centre.

Technical tips to enhance micrografting results in burn surgery.

The lack of autograft donor site is one of the greatest limiting factors for the treatment of extensive burn. Micrografting is an important revolution in burn surgery where autografts are cut into small pieces for wide and rapid coverage of burn wound. Our early experiences with the current standard micrografting technique were fraught with poor graft take as well being time and labor intensive. We have improvised our technique, where we combined the use of allograft to serve as a carrier for the micrograft. The objective of this paper is to share our experience in micrografting and several technical tips which had enhanced our micrografting results. The improvisation in our technique includes: (1) Single-stage 'micrograft-allograft sandwich method' where allograft served as a direct carrier for the micrografts. Micrografts were laid uniformly 1cm apart onto allograft sheets, creating a 1:9 expansion ratio. This technique replaced the original two stage method. (2) The use of the Meek device (Humeca, Netherlands) to prepare micrograft. The Meek device can rapidly produce 3mm micrografts for easy transfer with a fine forceps. (3) The use of slow-acting fibrin sealant to promote graft take and hemostasis. (4) A two-team approach for micrograft preparation where one team processes micrograft and another prepares the allograft sheets. This reduces the lag time between micrograft preparation and grafting, and reduces the overall surgery time. Micrografting remains an important treatment for major burn surgery. The aim of micro-allograft combination is to allow autografts re-epithelization under a reliable temporary skin coverage in a single stage procedure. A prospective study is warranted to measure the objective outcome of this renewed technique.