Percutaneous Retrograde Technique Using Intramedullary Headless Compression Screws for Metacarpal Fractures Under Wide-Awake Local Anaesthesia No Tourniquet.

Background The common modality of treatment of metacarpal fractures is nonsurgical. There are, however, a subset of patients and fracture types that require surgical correction, but surgery comes with its own problems like stiffness and scarring. Therefore, surgical operations must be minimally invasive barring complications of anaesthesia and the procedure. Therefore, we conducted this study to assess patient outcomes following treatment with percutaneous intramedullary screw fixation via the wide-awake local anaesthesia no tourniquet (WALANT) approach for unstable metacarpal fractures. Methodology We retrospectively analysed the records of 21 patients who received metacarpal fixations with headless compression screws at two district general hospitals in the United Kingdom from 2018 to 2020. We used wide-awake anaesthesia with 10 mL (1% lidocaine and 1 mL 8.4% sodium bicarbonate as a buffer) infiltrated around the superficial tissues on the dorsal aspect of the metacarpal bone, including the periosteum. The Jahss manoeuvre was used to reduce the fracture under the guidance of a mini C-arm. All patients had 3-mm Medartis cannulated compression screws (Medartis AG, Basel, Switzerland) (self-tapping) inserted retroactively using a 5-mm skin incision. The range of movement of the metacarpophalangeal joint was checked intraoperatively and shown to the patient for optimal postoperative rehabilitation. Patients underwent a two-week follow-up wound check and examination for pain (using the visual analogue scale (VAS)) or stiffness requiring physiotherapy. We used the Manchester-modified (M2) disability of the arm, shoulder, and hand (DASH) score to scrutinize the fracture union and the functional outcome of the hand. We also assessed the time to return to work. Results The study included 18 men and two women with a mean age of 22.6 years (range, 18 to 40). The fifth (n=16), fourth (n=4), and second metacarpals (n=1) were involved, and we saw transverse (n=10) and short oblique (n=11) fractures. Fractures healed in five weeks (range, four to six weeks). The mean M2 DASH score was 0.8 (range, 0 to 6), and mean total active motion was 240° (range, 230° to 260°). At the final follow-up, the mean extensor lag for the metacarpophalangeal joint was 5° (range, 0° to 15°), 7° for the proximal interphalangeal joint (range, 0° to 15°), and no lag at the distal interphalangeal joint. The average VAS score at the end of two weeks was 8/10 (range, 7 to 9). The average time for the return to daily activities was 2.56 weeks. We found no intraoperative complications in any of the patients. All patients went home on the same day postoperatively and gave feedback that their experience with WALANT was good to excellent. All patients had a good range of motion at the two-week follow-up, and the mean time to return to normal work was two to three weeks. The M2 DASH score measured was satisfactory. Conclusions This retrospective study assessed patient outcomes following treatment with percutaneous intramedullary screw fixation via the WALANT approach for unstable metacarpal fractures. WALANT was a quick and reliable alternative to fix unstable metacarpal fractures, especially for high-demand patients requiring a short recovery period before returning to regular activity. Further research with a larger sample size and a longer follow-up to analyse the outcome is warranted before an actual guideline can be established.

Early Results of a Variable-Angle Volar Locking Plate for Distal Radius Fractures: A Bi-centre Study.

Purpose This study examines the clinical, functional and radiological outcomes of distal radius fracture fixation with the Aptus® (Medartis, Pennsylvania) locking plate in order to determine its efficacy and identify notable findings related to treatment variations. Methods This is a retrospective bi-centre study collecting patient details from a district general hospital and a regional hand unit. We assessed 61 consecutive patients with distal radius fractures (Arbeitsgemeinschaft für Osteosynthesefragen (AO) grade A=19, B=9, C=33) fixed using an Aptus® plate with a minimum of six months follow-up. Outcome measures included the DASH (Disabilities of the Arm, Shoulder and Hand) score, wrist range of movement and grip strength, and complications. Radiographs were reviewed to assess restoration of anatomy and union. Results All but two fractures united within six weeks. The mean ranges of movement were only mildly restricted compared to the normal wrist (flexion/extension = 102°; radial/ulna deviation = 53°; pronation/supination = 169°). Mean postoperative grip strength was 23.8 kg, which was comparable to the contralateral side at 31.5 kg. The mean DASH score was 18.2. Seven patients had screws misplaced outside the distal radius although three of these remained asymptomatic. Conclusion Variable-angle locking systems benefit from the flexibility of implant positioning and may allow enhanced inter-fragmentary reduction for accurate fixation of intra-articular fractures.

Does intraoperative tissue sample enrichment help or hinder the identification of microorganisms in prosthetic joint infection?

OBJECTIVES: Biofilm formation reduces the efficacy of standard microbiological techniques in prosthetic joint infection. This study aimed to investigate the sensitivity, specificity and predictive values of tissue sample enrichment as a means to increase diagnostic yield. METHODS: Patients undergoing revision arthroplasty surgery between May 2004 and January 2013 had intraoperative tissue samples cultured in standard media as well as enriched in brain heart infusion broth. Patients were separated into infected or non-infected groups according to modified criteria from the Musculoskeletal Infection Society. RESULTS: A total of 197 revision arthroplasties were included (non-infected, n = 165; proven infection, n = 32). The mean time until revision in non-infected and infected groups was 75.9 and 41.7 months, respectively. The commonest microorganisms cultured were coagulase-negative staphylococci (42.9 %) and Staphylococcus aureus (34.4 %). The sensitivity and specificity of standard tissue culture were 0.25 (CI 0.18-0.33) and 0.98 (CI 0.95-0.99), respectively. Including enrichment culture results increased the sensitivity to 0.45 (CI 0.37-0.54), but decreased specificity to 0.59 (CI 0.52-0.66). CONCLUSION: Any potential increase in the sensitivity is far outweighed by the extremely high false-positive rate. Results of tissue samples cultured by enrichment should be used with caution and may lead to a worse outcome if incorrectly interpreted.

A case series of 35 hip revisions for adverse reactions to metal debris following Cormet hip resurfacing.

The primary aim of this study was to analyse our painful metal-on-metal (MoM) hip resurfacing revisions with evidence of 'adverse reactions to metal debris' (ARMD). In our series of 35 revisions the median whole blood Cobalt levels were 58 nmols/l (range 12-1407 nmols/l), and whole blood Chromium levels were 73 nmols/l (range 2-353 nmols/l). Thirty-four of our 35 patients had abnormal imaging on Ultrasound scanning (USS). The mean histological Campbell grading of ARMD was 4, and ranged from 0-9. The mean Oxford Hip Score (OHS) increased from 19 pre-revision (range 4-46) to 33 post-revision surgery (range 23-47).We found no correlation between the preoperative metal ion levels, and the severity of the disease or the outcome.Pain following hip resurfacing may arise from a number of causes and when groin pain arises in conjunction with abnormal cross sectional imaging we have offered our patients revision surgery regardless of raised metal ions or grossly abnormal imaging, with good results.

The effect of anterior cruciate ligament reconstruction on the progression of osteoarthritis.

Anterior cruciate ligament rupture (ACL) is a common injury, particularly among young sporting adults. Early onset osteoarthritis (OA) can be a devastating and difficult to manage consequence of such an injury. The techniques for reconstructing the ACL are advancing all the time, but the effect that this has on the progression of OA is less well understood. Many factors affect the development of OA following an ACL injury, including direct and indirect trauma to the articular cartilage, associated meniscal injuries, chronic tibiofemoral joint instability, and multiple enzymatic pathways. This review will summarize the current evidence surrounding each of these areas, and describe some of the recent developments that may have an impact on the management of these injuries in the future.

Occurrence of secondary fracture around intramedullary nails used for trochanteric hip fractures: a systematic review of 13,568 patients.

INTRODUCTION: A sliding hip screw (SHS) is currently the treatment of choice for trochanteric hip fractures, largely due to the low incidence of complications. An alternative treatment is the use of intramedullary proximal femoral nails. Unfortunately these implants have been associated with a risk of later fracture around the implant. The aim of this study was to see if any improvements have been made to the current intramedullary nails, to reduce the incidence of secondary fracture around the distal tip of the nail. METHODS: We analysed data related to 13,568 patients from 89 studies, focusing on the incidence of post operative secondary femoral shaft fracture following the use of intramedullary nails in the fixation of trochanteric hip fractures. RESULTS: The overall reported incidence of secondary fracture around the nail was 1.7%. The incidence of fracture has reduced in the 3rd generation Gamma nails when compared to the older Gamma nail (1.7% versus 2.6%, p value 0.03). However, the incidence of secondary fracture in the 3rd generation Gamma nails is still significantly higher than the other brands of short nail (1.7% versus 0.7%, p value 0.0005). Long nails had a slight tendency towards a lower risk of fracture although the difference was not statistically significant (1.1% versus 1.7%, p value 0.28). There was a significantly lower risk of fracture for those nails with a biaxial fixation as opposed to uniaxial fixation (0.6% versus 1.9%, p value <0.0001). CONCLUSION: Secondary fracture around a proximal femoral nail is one of the most significant of fracture healing complications, and this study suggests that continuing design changes to this method of fixation has reduced the risk of this complication occurring.

Troponin T in hip fracture patients: prognostic significance for mortality at one year.

Hip fractures are common injuries in the elderly, with significant mortality and morbidity from several factors. Many of these patients have cardiac disease, and some develop cardiac complications which may increase mortality. Troponin T is a marker of myocardial injury but can be raised in other conditions. Patients over 60 years admitted with hip fracture during the study period had their troponin T measured on admission and postoperatively. Assay was performed after the patient had completed their treatment. We report the results of this study one year after the last patient was admitted. 108 patients were recruited. The average age was 84 years, 86% were female. The mean hospital stay was 20 days. This study found that 27% of hip fracture patients had some increase in the troponin T levels in the peri-operative period. This increase was not associated with an increase in early mortality, but there was an increase in one-year mortality for those with an increase in troponin T (45% versus 22%, p=0.03). These findings indicate that the routine measurement of troponin T does not correlate with acute mortality and is not necessary without evidence of an acute cardiac event.

Diabetes mellitus and hip fracture: a study of 5966 cases.

INTRODUCTION: Diabetes mellitus, and especially type II diabetes, is a widespread and increasing problem in the western world due to the high rates of obesity. It has also been shown in previous studies that diabetics have impaired fracture healing. The aim of this study was to see exactly what role diabetes plays in hip fracture because it is a partially modifiable disease, and to see whether there are any changes that we could make to our practice to improve patient outcome. METHODS: We analysed the characteristics and outcomes for 477 hip fracture patients who were known to be diabetic at the time of admission, against 5489 non-diabetic hip fracture patients. RESULTS: At the time of admission the diabetic patients were more likely to be using walking aids [268/477 (56%) versus 2455/5489 (45%), p<0.0001], have a more restricted walking ability and a higher mean ASA grade (2.9 versus 2.6, p<0.0001). Diabetics patients were more likely to develop cardiac post-operative complications [26/477 (5.5%) versus 146/5489 (2.7%), p=0.0008] and to develop pressure ulcers [34/477 (7.1%) versus 171/5489 (3.1%), p<0.0001]. Hospital stay was increased for those with diabetes (25 days versus 21 days, p 0.006). No difference in surgical complications was seen between groups. At one year, recovery of function was similar for diabetic patients compared to those without diabetes. CONCLUSION: These findings show diabetics are at an increased risk of specific complications and have a longer length of hospital stay but generally make a normal recovery thereafter.