A Surgical Approach to a Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injury without Dividing the Adductor Aponeurosis.

An injury to the ulnar collateral ligament (UCL) of the metacarpophalangeal joint (MCPJ) of the thumb is a common injury, widely referred to as a skier's thumb. The rupture usually occurs at the distal insertion. In the classical technique, the adductor aponeurosis is divided to access the torn UCL and the MCPJ and repaired after ligament repair/reinsertion. We describe a surgical approach to the UCL that does not require division of the adductor aponeurosis. Level of Evidence: Level V (Therapeutic).

Clinical and radiological results of distal radioulnar joint arthroplasty with the Aptis prosthesis.

We report the results of the treatment of disorders of the distal radioulnar joint with the semi-constrained Aptis prosthesis. Nineteen patients were assessed at a mean follow-up of 7 years. All patients had been operated on previously at the wrist, forearm or elbow. The Disabilities of Arm, Shoulder and Hand score had a mean value of 40, the Patient-Rated Wrist Evaluation score had a mean of 49 and the visual analogue scale for pain had a mean of 3.9. The mean ranges of pronation, supination, wrist flexion and wrist extension were 78°, 76°, 60° and 51°, respectively. The mean grip strength was 23 kg. Complications were noted in ten patients. Eighteen patients would undergo the operation again. The 10-year cumulative survival rate was 84%. The Aptis prosthesis may be a solution to treat patients in whom previous surgery at the distal radioulnar joint has failed.Level of evidence: IV.

Which Fracture Types Are Associated with Widening of the Scapholunate Distance? A CT-Scan Study of Acute Intraarticular Distal Radius Fractures.

Background: Scapholunate injuries in distal radius fractures may frequently be overlooked. The aims of this study were to measure the scapholunate distance in intraarticular distal radius fractures and to find out which fracture types were associated with an increased scapholunate width. Methods: Measurements of the scapholunate distance were performed on computed tomography scans of 143 intraarticular distal radius fractures in 140 patients. The fractures were classified according to the AO classification. The morphology of AO type B fractures was further analysed according to the Bain classification. Results: In 43 AO type B fractures mean scapholunate distance measured 2.1 mm and in 100 type C fractures 1.6 mm. The difference between partial and complete intraarticular fractures was significant. A trend towards a greater scapholunate distance was found in AO type B1 and radial styloid oblique fractures. Conclusions: In this study, partial intraarticular distal radius fractures, especially with a sagittal split, had a greater scapholunate distance and may be at risk for ligamentous injury.

Results of treatment of trapeziometacarpal osteoarthritis with trapeziectomy and tendon allograft interposition.

The aim of the study was to evaluate the results of treatment of osteoarthritis of the carpometacarpal joint of the thumb with tendon allograft interposition. Fifty-three patients (61 hands), 13 men and 40 women, were operated on at a mean age of 61 years. A partial trapeziectomy with tendon interposition was performed in 19 hands and with suspension arthroplasty in 24. Seventeen thumbs underwent a total trapeziectomy with suspension arthroplasty. Patients were evaluated at a mean follow-up of 4 years. In 34 patients (41 hands), a mean disability of arm, shoulder and hand score of 19 was found and a mean visual analogue scale for pain of 1.3. The satisfaction rate was 83 %. Revision operations were performed in 8 out of 61 hands. Four of those thumbs had been operated on previously or did not have primary osteoarthritis. No revisions were needed after partial trapeziectomy and tendon allograft interposition with suspension arthroplasty. In conclusion, tendon allograft interposition can be considered as one of the treatment options for osteoarthritis of the carpometacarpal joint of the thumb.

Ten-year outcomes of the Arpe prosthesis for the treatment of osteoarthritis of the trapeziometacarpal joint.

Outcomes of 66 Arpe prostheses in 50 patients treated for osteoarthritis of the trapeziometacarpal joint were investigated with a mean follow-up of ten years. Ten-year survival was 87% when failure was defined as implant removal followed by trapeziectomy and tendon interposition. Ten-year survival was 82% when revision of the cup was also considered as failure and it was 80% when replacement of the neck alone was also chosen as an endpoint. Of the 52 prostheses that were not revised mean DASH score was 11, mean pain score 1.2 and mean score for satisfaction 9.5. It can be concluded that the majority of patients who did not underwent revision surgery were satisfied and had little or no pain. However, long-term survival of the Arpe prosthesis was moderate and patients should be warned that after ten years the risk for reoperation might be up to 20%.

Involvement of the palmar lunate facet in intra-articular distal radius fractures.

BACKGROUND: Small fracture fragments of the palmar lunate facet of the distal radius can be difficult to stabilize and may cause loss of reduction and even subluxation of the radiocarpal joint. MATERIAL & METHODS: The aims of the study were to investigate fracture patterns of the intermediate column in 101 intra-articular distal radius fractures with three-dimensional computed tomography, and to determine the prevalence of palmar lunate facet fracture fragments. The size of the fragments was measured to find out how many fragments were small. RESULTS: The palmar lunate facet fragment was present in 61 fractures. Mean length of the palmar cortex measured 13.5mm (range: 3 to 26.9) and mean area of the lunate facet 115 mm2 (range: 31 to 267). Seventeen percent of intra-articular distal radius fractures had a palmar lunate facet fragment with a short palmar cortex. CONCLUSION: With accurate analysis of the preoperative computed tomography scans the typical fracture patterns of the palmar lunate facet are recognisable and adequate fixation technique can be chosen to avoid loss of reduction. LEVEL OF EVIDENCE: IV.

Treatment of distal radius fractures with palmar plates and locking screws. Comparisson of two different types of plate.

Various plating systems are available to fix distal radius fractures, each with a specific design. The purpose of this study was to compare radiological outcome and complications of the Variable Angle LCP Plate 2.4-mm (DePuy Synthes) with the VariAx volar locking plate (Stryker). One hundred patients (103 wrists) operated on for a distal radius fracture were retrospectively reviewed with a mean follow-up of 3.5 years. Seventy-three wrists were treated with a DePuy Synthes plate and 30 with a VariAx plate. The overall complication rate was 32%. Nineteen cases underwent revision surgery, 18 had malunion and 3 complex regional pain syndrome. Complicaton rate was 43% with DePuy Synthes plates and 27% with Variax plates, but the difference was not significant.

Non-traumatic primary and secondary osteoarthritis of the distal radioulnar joint.

A retrospective radiographic study was conducted to determine the prevalence and severity of non-traumatic primary and secondary osteoarthritis of the distal radioulnar joint in a group of 718 patients. Non-traumatic primary and secondary osteoarthritis was found in 77 patients (11%) with a mean age of 63 years. In 34 cases it was bilateral. Mild signs of osteoarthritis were present in 53, moderate in 17 and severe in seven patients. The prevalence of primary osteoarthritis was 8.2% and 2.5% had secondary non-traumatic osteoarthritis. The prevalence and severity of the osteoarthritis were similar in women and men. Ulnar wrist pain was associated with osteoarthritis of the distal radioulnar joint in 13% of patients with mild, 35% with moderate and 43% with severe radiological degeneration. Level of evidence: IV.

Results of ulnar shortening osteotomy in patients with ulnar wrist pain. A retrospective study.

The aim of the study was to find out if ulnar shortening is effective to treat ulnar wrist pain and which factors influence outcome. Thirty-seven patients were evalua- ted with a mean follow-up of 4.5 years. Thirty patients (81%) would undergo the same operation again although 21 (57%) had residual ulnar wrist pain. Mean disabilities of arm, shoulder and hand (DASH) score was 22 and mean patient rated wrist evaluation score (PRWE) was 33. DASH and PRWE scores were better in smokers, in patients operated on the non- dominant side and when follow-up was longer. PRWE score was worse in posttraumatic cases. Age, gender and type of osteotomy did not influence outcome. Three patients (8%) needed an additional operation for nonunion and in 17 (46%) plate and screws had to be removed. It can be concluded that ulnar shortening can be proposed to treat ulnocarpal wrist pain, but complete pain relief cannot be guaranteed and additional surgery may be required.

Limits Of Indications Of The Morrison Wrap-Around Procedure In Thumb Reconstruction.

The thumb contributes approximately 40 percent of hand function. In the case of an amputation, where replantation/revascularisation is impossible, a reconstruction should be planned as the second best treatment. Morrison described in 1980 the technique of a wrap-around partial great toe transfer. According to Morrison, the technique is best suited for reconstruction of the thumb distal to the metacarpophalangeal joint (MCPJ). In this study, we retrospectively report on 10 thumb reconstructions using the wraparound flap from the great toe. Functional results according to the level of amputation are compared. We found in our limited series, that although better results are achieved when the amputation was distal to the MCPJ, the 'wraparound' reconstruction technique still yielded acceptable functional results and outcome in amputation levels through or proximal to the MCPJ.

Prophylactic use of levofloxacin during medicinal leech therapy.

BACKGROUND: Medicinal leech therapy is effective in establishing venous outflow in congested flaps and replants. However, its use is also associated with infections, especially from Aeromonas species. To prevent this nosocomial infection, levofloxacin has been established as prophylaxis during leech therapy in our hospital. OBJECTIVES: To study the implementation rate of a guideline, to study the effect of levofloxacin on possible Aeromonas infections, and to evaluate the financial impact of this preventive measure. SETTING: A retrospective analysis on all patients treated with Hirudo medicinalis between July 2007 and March 2011 was performed at the Ghent University Hospital, Belgium. METHOD: A list of patients treated with leeches was retrieved from the pharmacy database. Patient characteristics, date of start and stop of leech therapy were collected. Data on routine diagnostic cultures during leech therapy, date and type of clinical sample, while cultivated micro-organism with antibiotic susceptibility were obtained from the laboratory database. MAIN OUTCOME MEASURE: percentage implementation rate of a guideline, presence of Aeromonas infections, financial impact of levofloxacin prophylaxis. RESULTS: Fifty-one patients were treated with leeches. Forty-six (90.2 %) patients were treated according the guideline. Fourteen out of 51 patients (27.5 %) were suspected for postoperative wound infections. From them, 60 clinical samples were sent for microbiological analysis. These included exudates (26.7 %), peroperative samples (5.0 %), puncture fluid (1.7 %), blood cultures (3.3 %) or smears from burns (63.3 %). No Aeromonas species were cultivated. Comparison between period before and after implementation of levofloxacin prophylaxis revealed that levofloxacin prevents colonization or infection with Aeromonas species in relation to leech therapy. The direct cost for levofloxacin prophylaxis in the current study was 2,570 euro. Based on data obtained in a previous study, we presume that a minimum cost-saving of 20,500 euro was realised during the current study period by implementation of antimicrobial prophylaxis. CONCLUSIONS: This study demonstrates successful implementation of a guideline for levofloxacin prophylaxis during leech therapy. Following its introduction, no Aeromonas species related to the use of leeches were isolated as compared to 8.5 % in the baseline period.

Which patients undergo a surgical reintervention following a distal radius fracture?

Not all malunited distal radius fractures cause pain or functional impairment, and only few patients require a surgical correction or a salvage procedure. The purpose of this retrospective study was to investigate differences between 38 patients who underwent a reintervention and 65 patients who did not. The only discriminative variable in the current study was age : 46 years in the reintervention group versus 59 years in the non-reintervention group (p < 0.0001). Differences in gender or type of malunion were not significant, and thus not discriminative. It can be concluded that patient age may be more often associated with a reintervention than gender or radiological characteristics of wrist fractures.

Trapeziometacarpal joint replacement with the Arpe prosthesis.

The purpose of the study was to assess the subjective outcome and five-year survival of non-cemented total joint replacement of the trapeziometacarpal joint with the Arpe prothesis. Forty-nine hands were operated on. Outcome scores were obtained with a mean follow-up of 6 years (range: 3-11 years) for 35 prostheses. Mean disability of the arm, shoulder and hand (DASH) score was 8, mean visual analogue scale for pain 1, for satisfaction 9.6 and for willingness to have the same operation again 9.8. Six patients were lost to follow-up. Two prostheses (5%) dislocated and four implants were removed. At five years the prosthesis was still in place in 33 out of 34 hands. The overall mid-term results of the Arpe prosthesis were satisfactory. Five-year survival was 97%.

Percutaneous K-wire fixation versus palmar plating with locking screws for Colles' fractures.

Different methods exist to treat distal radius fractures. A prospective randomized study was conducted to establish whether palmar plate fixation with locking screws gave better results than percutaneous K-wire fixation in patients over 50 years of age. Only fractures with dorsal displacement after a simple fall were included in the study. Twenty wrists were treated with K-wires and 20 with a plate. Radiological parameters were measured on preoperative radiographs and at five weeks postoperatively. Clinical results and DASH scores were determined at three months postoperatively and at more than one year. No significant difference in radial inclination, palmar tilt, clinical outcome and DASH score was found between plating and K-wires, but the mean difference in ulnar variance between pre- and postoperative radiographs was significantly better with plates. It can be concluded that plates were superior to K-wires in restoring ulnar variance, but functional outcome was similar with both techniques.

Interfacial synthesis of hollow metal-organic framework capsules demonstrating selective permeability.

Metal-organic frameworks (MOFs) are a class of crystalline materials that consist of metal ions and organic ligands linked together by coordination bonds. Because of their porosity and the possibility of combining large surface areas with pore characteristics that can be tailored, these solids show great promise for a wide range of applications. Although most applications currently under investigation are based on powdered solids, developing synthetic methods to prepare defect-free MOF layers will also enable applications based on selective permeation. Here, we demonstrate how the intrinsically hybrid nature of MOFs enables the self-completing growth of thin MOF layers. Moreover, these layers can be shaped as hollow capsules that demonstrate selective permeability directly related to the micropore size of the MOF crystallites forming the capsule wall. Such capsules effectively entrap guest species, and, in the future, could be applied in the development of selective microreactors containing molecular catalysts.

Treatment of chronic wounds at the olecranon.

Surgical resection of the olecranon bursa may be complicated by wound healing problems. Treatment with debridement and primary skin closure can be attempted. We reviewed eight patients in whom this approach had failed. In four patients we achieved wound healing with a pedicled flap (three antecubital fasciocutaneous island flaps and one radial forearm flap). In three patients the wound healed after closure of the skin and immobilization of the elbow in extension. In one elderly patient with diabetes and rheumatoid arthritis an antecubital fasciocutaneous island flap failed. It can be concluded that the antecubital fasciocutaneous island flap and primary closure of the skin followed by immobilization of the elbow in extension can be used to treat chronic wounds at the olecranon.