Bridge Plating for Distal Radius Fractures in Low-Demand Patients With Assist Devices.

Bridge plate fixation has traditionally been described for the treatment of high-energy distal radius fractures with extensive comminution, associated instability, and polytrauma with the need for immediate upper extremity assisted weight bearing. Certain patient populations who may similarly benefit from such effective and expedient stabilization include patients with multiple comorbidities who may have lower-energy fractures, poor bone quality, and a baseline reliance on ambulatory assist devices. This article reviews treatment considerations for distal radius fractures in low-demand patients and explores the rationale and technique of bridge plate fixation in this population.

Bedside Procedures in Hand Surgery.

Many conditions presenting to the hand surgeon are amenable to a bedside procedure rather than a formal operating room setting. With proper patient, room, and surgeon preparation, bedside procedures can provide an efficient and effective treatment for infection, trauma, and foreign bodies. Key differences from the operating room environment include patient expectations, analgesia, room setup, instrumentation, and surgical technique. This article provides a detailed primer for performing bedside procedures in the emergency department, outpatient clinic, and inpatient hospital room.

Screw Fixation Alone for Scaphoid Fracture Nonunion.

Scaphoid fracture nonunion can often lead to pain, arthrosis, and disability. While typically the result of delayed diagnosis or inadequate treatment, it can sometimes occur even if the initial care was timely and appropriate. Whereas early recognition of acute fractures allows for nonoperative management, nonunions frequently require surgical treatment. Traditionally, this has involved open debridement and bone grafting. However, some publications suggest that certain stable nonunions may be amenable to percutaneous debridement and fixation without formal bone grafting. Although certain characteristics appear to be appropriate indications for such management, well-designed clinical studies are needed to better define them.

Surgical Techniques for Correction of Traumatic Hyperextension Instability of the Proximal Interphalangeal Joint: A Biomechanical Study.

PURPOSE: To compare the biomechanical strengths of 5 surgical techniques for treatment of traumatic hyperextension instability of the proximal interphalangeal (PIP) joint. METHODS: Thirty-six cadaveric fingers were randomly assigned to 6 groups: normal control, volar plate repair, flexor digitorum superficialis tenodesis (FDST), single lateral band transfer (SLBT), double lateral band transfer, and dual split lateral band transfer. For each experimental specimen, the volar plate and accessory collateral ligaments were transected, the PIP joint was hyperextended to 90°, and a PIP joint stabilizing procedure was completed. The ultimate strength of each procedure was ascertained by loading to failure, and the fingers were dissected to determine the pathoanatomy of failure. Force-displacement curves were used to estimate the stiffness of each group, and multiple pairwise statistical comparisons were performed. RESULTS: The mean PIP joint stiffness in the control group was significantly greater than the mean PIP joint stiffness in the FDST and SLBT groups, but not significantly different from the mean PIP joint stiffness in the other 3 groups. There were no significant differences in the mean PIP joint stiffness between the 5 joint stabilizing techniques. The SLBT, double lateral band transfer, and dual split lateral band transfer repairs all failed by massive disruption of the flexor tendon sheath, whereas the volar plate repairs and FDST repairs failed by either suture anchor pullout or suture breakage. CONCLUSIONS: The stiffness of 5 surgical techniques to stabilize a traumatic hyperextensible PIP joint did not vary significantly. CLINICAL RELEVANCE: The 5 described techniques to stabilize a posttraumatic PIP joint hyperextension deformity may provide for equal restraint to PIP joint hyperextension instability in the early postoperative period. The choice of procedure should take into consideration other factors not studied, including the potential for PIP joint flexion contracture and long-term durability.

Hemophilic arthropathy of the elbow: prophylaxis, imaging, and the role of invasive management.

Hemophilia is an X-linked recessive deficiency of clotting factor VIII (hemophilia A) or IX (hemophilia B) that can result in hemarthrosis of various joints, including the elbow. Left unchecked, this can lead to progressive joint destruction and significant morbidity. Appropriate management of the elbow joint through prophylactic measures, accurate imaging, and timely intervention is essential. Replacing or supplementing deficient factor with a plasma-derived or recombinant factor concentrate can minimize bleeding episodes. Joints should be routinely monitored for damage. Plain films offer an inexpensive window into bone disease and joint space changes but lack soft tissue detail and may not detect early changes. Magnetic resonance imaging provides a high level of detail but may be limited by its cost and need for sedation in younger patients. Ultrasound may not achieve the same level of resolution as magnetic resonance imaging, but it is increasingly used as a convenient, effective, and relatively inexpensive alternative. Patients who experience hemarthrosis of the elbow with joint damage often require more invasive treatment. Radiosynovectomy and arthroscopic synovectomy are effective at minimizing pain and preventing future bleeding episodes, whereas extensive joint damage may necessitate total elbow replacement.

Understanding readmission after primary total hip and knee arthroplasty: who's at risk?

Readmission has been cited as an important quality measure in the Patient Protection and Affordable Care Act. We queried an electronic database for all patients who underwent Total Hip Arthroplasty or Total Knee Arthroplasty at our institution from 2006 to 2010 and identified those readmitted within 90 days of surgery, reviewed their demographic and clinical data, and performed a multivariable logistic regression analysis to determine significant risk factors. The overall 90-day readmission rate was 7.8%. The most common readmission diagnoses were related to infection and procedure-related complications. An increased likelihood of readmission was found with coronary artery disease, diabetes, increased LOS, underweight status, obese status, age (over 80 or under 50), and Medicare. Procedure-related complications and wound complications accounted for more readmissions than any single medical complication.

Bridge plating in the setting of radiocarpal instability: Does distal fixation to the second or third metacarpal matter? A cadaveric study.

BACKGROUND: Radiocarpal dislocations are rare but potentially devastating injuries. Poorer outcomes are associated with inadequate or lost reduction, such as ulnar translocation, but no consensus exists on the ideal fixation technique. Dorsal bridge plate fixation has been described for various settings in the treatment of complex distal radius fractures and can be fixed distally to the second or third metacarpal, but its application for radiocarpal dislocations has not been established. AIM: To determine whether distal fixation to the second or third metacarpal matters. METHODS: Using a cadaveric radiocarpal dislocation model, the effect of distal fixation was studied in two stages: (1) A pilot study that investigated the effect of distal fixation alone; and (2) a more refined study that investigated the effect of described techniques for distal and proximal fixation. Radiographs were measured in various parameters to determine the quality of the reduction achieved. RESULTS: The pilot study found that focusing on distal fixation alone without changing proximal fixation results in ulnar translocation and volar subluxation when fixing distally to the second metacarpal compared with the third. The second iteration demonstrated that anatomic alignment in coronal and sagittal planes could be achieved with each technique. CONCLUSION: In a cadaveric radiocarpal dislocation model, anatomic alignment can be maintained with bridge plate fixation to the second metacarpal or the third metacarpal if the described technique is followed. When considering dorsal bridge plate fixation for radiocarpal dislocations, the surgeon is encouraged to understand the nuances of different fixation techniques and how implant design features may influence proximal placement.

Providing Orthopaedic Care to Vulnerably Underserved Patients: AOA Critical Issues.

ABSTRACT: Implementation of the Affordable Care Act has increased the number of Americans with health insurance. However, a substantial portion of the population is still considered underserved, including those who are uninsured, underinsured, and those who are enrolled in Medicaid. The patients frequently face substantial access-to-care issues. Many underlying social determinants of health impact this vulnerable, underserved population, and surgeons must understand the nuances of caring for the underserved. There are numerous opportunities to engage with this population, and providing care to the indigent can be rewarding for both the vulnerably underserved patient and their surgeon.

Providing Hand Surgery Care to Vulnerably Uninsured Patients.

Economically vulnerable US patients are at risk for undertreatment of hand-related conditions as well as poorer outcomes. The cost of indigent care can be substantial to both the patients and their communities. Caring for these patients in a system that depends on inconsistent coverage requires a network of safety-net hospitals. To ensure that patients have access to care, the protection of safety-net hospitals should be prioritized when discussing federal and state funding allocation. On an individual scale, surgeons can also make changes in their practices to help find sustainable ways to care for indigent patients.

First carpometacarpal arthroplasty with ligamentous reconstruction: a long-term follow-up.

BACKGROUND: The purpose of the present study is to evaluate a single surgeon's short, intermediate, and long-term clinical, functional, and radiographic outcomes with a trapeziectomy with flexor carpi radialis (FCR) suspension arthroplasty without tendon interposition (LRSA). METHODS: Twenty-one patients underwent 26 FCR suspension arthroplasties without tendon interposition by a single senior surgeon. All patients had Eaton stage III and IV carpometacarpal (CMC) osteoarthritis. The Patient-Rated Wrist and Hand Evaluation (PRWHE) and Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) were used to evaluate functional outcomes. A comprehensive strength and range of motion evaluation was performed to evaluate clinical outcomes. Plain radiographs at rest and with maximal pinch were performed to evaluate for arthroplasty space subsidence. RESULTS: The LRSA exhibited consistent clinical and functional outcomes throughout postoperative follow-up. As the average patient age and time from surgery increased, range of motion (ROM) and PRWHE scores stayed relatively constant, while lateral tip and tip pinch strength deteriorated with time. The LRSA prevented the proximal migration of the first metacarpal in all but one patient. No patients required revision arthroplasty following LRSA. CONCLUSIONS: This study demonstrates the consistent short, intermediate, and long-term clinical, functional, and radiographic outcomes following a trapeziectomy with FCR suspension arthroplasty.