Perilunate Dislocations and Perilunate Fracture Dislocations in the U.S. Military.

Background Perilunate dislocations and perilunate fracture dislocations (PLDs/PLFDs) are rare and often associated with poor outcomes. Heretofore, these outcomes have not been evaluated in a high-demand military population. Questions/Purpose The purpose of this study was to evaluate the outcomes in a young, active population after sustaining PLD/PLFD injuries. Patients and Methods We retrospectively reviewed the U.S. military service members who underwent surgical treatment for a PLD/PLFD (Current Procedural Terminology codes 25695 and 25685) between June 1, 2010, and June 1, 2014 through the Military Health System Management Analysis and Reporting Tool (M2) database, capturing patients with a minimum 2-year follow-up. Patient characteristics and outcomes were gathered; however, radiographic analysis was not possible. Results In this study, 40 patients (40 wrists) were included with an average follow-up of 47.8 months. The average age was 28.8 years. Twenty-two injuries (55%) were PLFD and 22 (55%) cases involved the nondominant extremity. On initial presentation, 11 (27.5%) were missed and 50% of patients were presented with acute carpal tunnel syndrome. Range of motion (ROM) was 74% and grip strength was 65% compared with the contralateral wrist; 78% reported pain with activity and only 55% remained on active duty status at final follow-up. Injuries to the nondominant extremity were significantly more likely to experience a good to excellent outcome and regained a more ROM. Patients with ligamentous PLD had less pain at rest and were more likely to return to sport. Conclusion Worse outcomes can be expected for PLD/PLFD of the dominant extremity, transscaphoid PLFD, greater arc injuries, and those undergoing pinning alone. A high-demand patient may expect worse functional results with a higher degree of limitation postoperatively. Level of Evidence The level of evidence is therapeutic IV.

An advanced simulator for orthopedic surgical training.

PURPOSE: The purpose of creating the virtual reality (VR) simulator is to facilitate and supplement the training opportunities provided to orthopedic residents. The use of VR simulators has increased rapidly in the field of medical surgery for training purposes. This paper discusses the creation of the virtual surgical environment (VSE) for training residents in an orthopedic surgical process called less invasive stabilization system (LISS) surgery which is used to address fractures of the femur. METHOD: The overall methodology included first obtaining an understanding of the LISS plating process through interactions with expert orthopedic surgeons and developing the information centric models. The information centric models provided a structured basis to design and build the simulator. Subsequently, the haptic-based simulator was built. Finally, the learning assessments were conducted in a medical school. RESULTS: The results from the learning assessments confirm the effectiveness of the VSE for teaching medical residents and students. The scope of the assessment was to ensure (1) the correctness and (2) the usefulness of the VSE. Out of 37 residents/students who participated in the test, 32 showed improvements in their understanding of the LISS plating surgical process. A majority of participants were satisfied with the use of teaching Avatars and haptic technology. A paired t test was conducted to test the statistical significance of the assessment data which showed that the data were statistically significant. CONCLUSION: This paper demonstrates the usefulness of adopting information centric modeling approach in the design and development of the simulator. The assessment results underscore the potential of using VR-based simulators in medical education especially in orthopedic surgery.

Current Evidence Regarding Routine Antibiotic Prophylaxis in Hand Surgery.

Background: Although routine antibiotic prophylaxis immediately preceding an orthopedic surgery has become the standard of care in most cases, this practice is poorly defined in hand surgery. The purpose of this analysis is to review the most current literature of antibiotic use in hand surgery. Methods: A careful review of the literature regarding routine antibiotic prophylaxis in hand surgery was made. Current relevant resources were used in the construction of this review. Results: There is a mixed consensus on the role for prophylactic antibiotics in hand surgery with some resources and data showing support and others opposed. Conclusions: Based on the current literature, the authors recommend the following patient characteristics not receive antibiotics: clean hygienic patients, without autoimmune disease, and those not taking steroid medication. Surgical characteristics that would render prophylaxis unnecessary include those without hardware, those without reasonable risk of hematoma formation, or those performed at an ambulatory surgery center as opposed to a large hospital. However, the decision should be made on a case-by-case basis weighing the evidence presented.

Outcomes Following Isolated Posterior Interosseous Nerve Neurectomy: A Systematic Review.

BACKGROUND: Posterior interosseous nerve neurectomies (PINN) are an option in the treatment of chronic dorsal wrist pain. However, the literature describing PINN consists primarily of small case series, and the procedure is typically done as an adjunct treatment; therefore, the outcomes of the PINN itself are not well known. We performed a systematic review of the literature to provide characteristics of patients following a PINN. METHODS: A systematic review of the literature was performed. Papers published in the PubMed database in English on isolated PINN were included. Articles in which a PINN was performed as an adjunct were excluded. Primary outcomes were return to work, patient satisfaction, pain/function scores, wrist range of motion, complications, and pain recurrence. Weighted averages were used to calculate continuous data, whereas categorical data were noted in percentages. RESULTS: The search yielded 427 articles including 6 studies and 135 patients (136 cases). The average age was 43.6 years (range, 17-75), and most patients were female (54.1%). At an average final follow-up of 51 months, 88.9% of patients were able to return to work. After initial improvement, a recurrence of pain occurred in 25.5% of patients at an average of 12.3 months. Excluding recurrence of pain, the complication rate was 0.9%, including 1 reflex sympathetic dystrophy. Overall, 88.4% of patients experienced a subjective improvement and were satisfied with the procedure. CONCLUSIONS: Isolated PINN have shown excellent clinical outcomes, with few patients experiencing recurrent pain at long-term follow-up. PINN can provide relief in patient's chronic wrist pain.

The Deltoid Lift: A Comparison Study of Exposure Area in Proximal Humeral Approaches.

BACKGROUND: Adequate exposure of the proximal humerus is necessary to address atypical or complex proximal humerus fractures and orthopedic tumors. Surgical management may be difficult through existing approaches due to their limited nature and the delicate neurovascular anatomy of the shoulder. The deltoid lift, a previously described extensile approach, can be incorporated into the surgeon's armamentarium as an alternative exposure to the proximal humerus. The objective of this study was to quantify and compare the humeral exposure achieved through the deltoid lift with the standard direct lateral deltoid-splitting, anterolateral acromial, and deltopectoral approaches in terms of surface area and exposure of key anatomic landmarks. METHODS: Each approach was performed a minimum of 8 times on 18 cadaveric specimens. After identifying landmarks, exposure area of exposed humerus was quantified using digital images and ImageJ software. RESULTS: The deltoid lift yielded an average exposure area of 46 cm2. Comparison of the exposure area for the deltoid lift against each of the other approaches yielded statistical significance ( P < .01). The exposure provided was 2-folds greater than that of the next most extensive approach. All anatomic landmarks were directly visible through the deltoid lift as compared with the remaining approaches, through which only 1 landmark was directly visualized and only 2 of the 3 remaining were palpable through the approach. CONCLUSIONS: The deltoid lift extensile surgical exposure to the proximal humerus provides the largest humeral exposure with the greatest visibility of landmarks relative to the 3 most widely utilized standard approaches.

Multicenter trial of an internal joint stabilizer for the elbow.

BACKGROUND: Our primary efficacy objective was to evaluate the effectiveness of the internal joint stabilizer of the elbow (IJS-E) in maintaining concentric location of the elbow during and after removal of the device in the treatment of persistent or recurrent instability after elbow fracture or dislocations, or both. The secondary study objectives were to assess range of motion, Broberg-Morrey functional score, Broberg-Morrey categorical rating, the Disabilities of the Arm, Shoulder and Hand score, and the rate of complications and adverse events after the use of IJS-E. METHODS: Twenty-four patients were studied in a multicenter, nonrandomized, prospective, single-arm study. The IJS-E was used to provide temporary stabilization of the elbow joint and allow a functional range of motion while ligaments and fractures healed. RESULTS: The elbow remained concentrically aligned in 23 of 24 patients. One coronoid-deficient elbow did not maintain concentric reduction. At the last evaluation a minimum of 6 months after device removal, the mean arc of elbow flexion was 119° (range, 80°-150°; standard deviation [SD], 18°), and the mean arc of forearm rotation was 151° (range, 90°-190°; SD, 24°). The mean and median Broberg-Morrey scores were 93 and 97, respectively. Categorically the results were excellent in 14, good in 8, fair in 1, and poor in 1. The mean Disabilities of the Arm, Shoulder and Hand score was 16 (range, 0-68; SD, 18). CONCLUSION: The IJS-E maintains concentric reduction, allows elbow motion, and avoids the inconveniences and pin problems of percutaneous fixation.

Surgical correction of distal radius malunions using an anatomic radial locking plate.

BACKGROUND: Correction of a distal radius fracture malunion is challenging technically. These malunions most classically deform dorsally, but often the deformity involves three planes. METHODS: Using an anatomically designed radial plate that takes into consideration the three planes, correction of the deformity can be obtained. In this video we see a patient with a classic dinner fork deformity that is associated with a dorsal malunion involving the distal radius. Correction of a distal radius malunion can be performed using a radial approach and an anatomic radial plate. RESULTS: The authors have used this technique for difficult distal radius fracture malunions and have achieved superb correction, returning patients to early range of motion and an active lifestyle. CONCLUSIONS: Careful mobilization of the branches of the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve is required. This technique affords the surgeon excellent access to three sides of the radius to help perform this complex surgery.

Surgical Management of Symptomatic Extensor Digitorum Brevis Manus: A Proposed Algorithm for Treatment.

First described in 1734, the extensor digitorum brevis manus (EDBM) is an anomalous extensor muscle found in the dorsum of the wrist and hand. Extensor muscle variants of the hand are not uncommon, and EDBM has an estimated reported incidence of approximately 2%. Although few extensor muscle variants become clinically significant, there is a paucity of literature discussing these anatomic variants, with most reports arising from cadaveric studies or isolated case series. Similarly, there are few established indications for surgical treatment of EDBM. In this case report, we describe the successful treatment of a young patient with persistently symptomatic anomalous extensor tendon with surgical excision and propose an algorithm for management after failure of conservative measures.

The Deltoid Lift: A Cadaveric Analysis and the Literature Review of a Novel Surgical Approach to the Proximal Humerus.

Obtaining adequate exposure of the proximal humerus for anatomic reduction of complex intra-articular fractures or in the surgical treatment of tumor may be difficult. Here we describe a novel approach to the proximal humerus: the deltoid lift, and perform a cadaveric analysis objectively quantifying the exposure. The deltoid lift offers significantly greater exposure to the proximal humerus as compared with the deltopectoral approach.

Dog bites to the upper extremity in children.

AIM: Dog bites are common injuries in children. A large percentage of these dog bites affect the upper extremity. There is little information describing the results of treatment of upper extremity injuries in children. METHODS: We retrospectively reviewed the medical records for all children less than 19 years old who presented to the emergency department in our level one trauma centre because of dog bites from 2005 to 2011. RESULTS: During the study period, there were 254 paediatric emergency department visits for animal bites, among these there were 118 dog bites, two were excluded because of inadequate documentation leaving 116 patients; 26 of them (22.4%) had bites to the upper extremity. Among the 26 children with dog bites to the upper extremity, 6 (23.1%) were admitted to the hospital for surgery (four patients) or parenteral antibiotics (two patients). Among the four surgeries, two were for extensive laceration and two were for abscess debridement. Of the 41 who presented with bites to the lower extremities, none were admitted to the hospital (P = 0.002). Compared with those who presented the same day they were injured, the relative risk of hospitalization or surgery in patients who presented 1 and 2 days after their injury was 3.5 and 7.0, respectively. CONCLUSION: Dog bites at the upper extremity are more prone to require surgical intervention and develop infection than those at the lower extremity, and delayed presentation of these injuries is associated with higher incidence of developing infection.

Acute Limb Shortening for Major Near and Complete Upper Extremity Amputations with Associated Neurovascular Injury: A Review of the Literature.

In the setting a near or complete upper extremity amputations with significant soft tissue loss and neurovascular compromise, upper extremity surgeons are faced with the challenge of limb salvage. There are a multitude of treatment options for managing skeletal and soft tissue injuries including provisional fixation, staged reconstruction, and an acute shortening osteotomy with primary rigid internal fixation. However, many complications are associated with these techniques. Complications of provisional fixation include pin tract infection and loosening, tethering of musculotendinous units, nonunion, and additional surgeries. Staged reconstruction includes a variety of techniques: distraction osteogenesis, bone transport, or vascularized and non-vascularized structural autograft or allograft, but the risks often outweigh the benefits. Risks include nonunion, postoperative vascular complications necessitating reoperation, and the inability to return to the previous level of function at an average of 24 months. Acute shortening osteotomy with internal fixation offers the advantage of a single-stage procedure that provides for decreasing the soft tissue loss, provides a rigid platform to protect the delicate neurovascular repair, and alleviates unwanted tension at the repair sites. This review discusses the literature on the surgical treatment of severe upper extremity trauma with associated neurovascular injury over the past 75 years, and aims to evaluate the indications, surgical techniques, clinical and functional outcomes, and complications associated with acute shortening osteotomy with rigid internal fixation. Although this technique is not without risks, it is well-tolerated in the acute setting with a complication profile comparable to other techniques of fixation while remaining a single procedure.

Distal humeral hemiarthroplasty: indications, results, and complications. A systematic review.

BACKGROUND: Distal humeral hemiarthroplasty (DHH) is a treatment option for unreconstructable intra-articular distal humerus fractures. DHH may also be used in the setting of rheumatoid arthritis, orthopaedic tumor with significant bone loss, malunion, or osteomyelitis. DHH has specific advantages over other, more common, treatment modalities: total elbow arthroplasty (TEA) and open reduction internal fixation (ORIF). DHH is especially a reasonable option in younger patients to preserve bone stock, avoid significant weight restrictions, and limit loosening. METHODS: The literature was reviewed for all cases of DHH for fracture and non-fracture indications between 1947 and 2014. Two hundred thirty-six papers were identified; 4 studies including 17 patients met criteria for non-fracture indications and 13 studies including 116 patients were identified for fracture indications. A systematic review was generated; patient indications, outcomes, and complications were recorded. RESULTS: For non-fracture indications, good to excellent results were achieved in 76.5 % of patients with a mean arc of motion of 62° at mean follow up of 46.3 months. Half of the patients experienced a complication, most commonly stiffness. Loosening of the prosthesis was not noted in any patient. For fractures, good to excellent results were achieved in 67.4 % of patients with a mean arc of motion of 98.3° at a mean follow up of 42.2 months. One third of the patients experienced a complication but only 1.7 % experienced loosening of the prosthesis. CONCLUSION: Here, we present the first review of the indications for DHH. DHH is a reasonable treatment option for older patients with unreconstructable intra-articular fractures of the distal humerus as well as younger patients with rheumatoid arthritis, orthopaedic tumor with significant bone loss, malunion, or osteomyelitis.

Correction of extra-articular distal radius malunions using an anatomic radial plate.

Malunion is a debilitating complication of a distal radius fracture. The malunion often requires a corrective osteotomy to restore the stability and joint congruity about the distal radius, a procedure which offers tremendous benefits in terms of pain, strength, and functionality. Here we describe a unique technique to address the malunion of an extra-articular distal radius fracture using a radial anatomic plate. This is a simple and reproducible method of fixation involving straightforward anatomy, which does not require excessive radiography, and which represents an excellent choice of fixation in the distal radius malunion.

Blunt traumatic bladder rupture: a 10-year perspective.

The purpose of this study was to determine the incidence, features, and associated injuries of intraperitoneal (IP) and extraperitoneal (EP) bladder rupture (BR) resulting from blunt trauma. A retrospective study from September 2001 to August 2011 was performed for blunt traumatic BR in adults. Demographics, mean Injury Severity Score (ISS), mean length of stay (LOS), incidence, mortality, operative repair, and associated injuries were evaluated. Of 15,168 adult blunt trauma admissions over 10 years, 54 patients had BR (EP = 22, IP = 27, EP + IP = 5; incidence = 0.36%). Sixty-three per cent were male. The mean age, ISS, and LOS were 40 years, 29, and 15 days, respectively. The mortality rate was 11 per cent. Fifty-two per cent of BR was the result of a motor vehicle crash. Most BRs were diagnosed by computed tomography cystogram. Eighty per cent had pelvic fracture. Hollow viscus injury was present in 34.5 per cent of patients. Colonic injury was seen in 24 per cent and 9.3 per cent had a rectal injury. Although BR is rare in adult blunt trauma, it is associated with high ISS, LOS, and mortality. Pelvic fractures are essentially present in all patients with EP BR. Hollow viscus injuries, especially colonic and rectal injuries, are more prominent in IP BR.

Exposure of distal radius fractures using a direct radial approach with mobilization of the superficial branch of the radial nerve.

Extraarticular and simple intraarticular fractures and malunions of the distal radius can be addressed through a direct radial approach that entails careful and meticulous handling of the soft tissues. This approach involves mobilization of the superficial branch of the radial nerve (SBRN) and extensor tendons of the first dorsal compartment. A Type I SBRN pattern is when the nerve presents as a single bundle. In Type II pattern, there are 2 major nerve groups present. With Type II branching patterns of the SBRN, careful intraneural dissection is required to mobilize the nerve branches into a safe location during surgery. The primary advantage of this approach is the ease of surgical dissection and avoidance of the flexor tendons of the fingers during surgery.

Soft tissue coverage of the elbow in a developing country.

Two cases that required soft tissue coverage to the anterior aspect of the elbow are presented. A fasciocutaneous intercostal perforator chest wall flap was used for one patient when only skin and fascia coverage was required. A latissimus dorsi myocutaneous flap was used to provide soft tissue coverage and supply motor power for elbow flexion after contracture release in the other. The surgical techniques for each of these flaps are discussed in the context of addressing soft tissue traumatic injuries about the elbow in a developing country with limited resources.

Computer assisted orthopaedic surgery -- CAOS.

The use of computer navigation in orthopedic surgery allows for real time intraoperative feedback resulting in higher precision of bone cuts, better alignment of implants and extremities, easier fracture reductions, less radiation and better documentation than what is possible in classical orthopaedic procedures. There is no need for direct and repeated visualization of many anatomical landmarks (classical method) in order to have good intraoperative orientation. Navigation technology depicts anatomy and position of "smart tools" on the screen allowing for high surgical precision (smaller number of outliers from desired goal) and with less soft tissue dissection (minimally invasive surgery - MIS). As a result, there are more happy patients with less pain, faster recovery, better functional outcome and well positioned, long lasting implants. In general, navigation cases are longer on the average 10 to 20 minutes, special training is required and equipment is relatively expensive. CAOS applications in knee and hip joint replacement are discussed.

A case study of negative pressure wound therapy to manage acute necrotizing fasciitis.

Acute necrotizing fasciitis is a devastating infectious process that requires immediate surgical debridement. Intravenous antibiotic treatment, hyperbaric oxygen therapy, and wound management are considered the standard of care. Subsequent wound closure is achieved with split-thickness skin grafting, delayed surgical closure, or healing by secondary intention. When a patient refuses additional surgical treatment or is no longer a surgical candidate, as was the case with a patient who presented with acute necrotizing fasciitis caused by Clostridium perfringens in the upper extremity, secondary intention healing is the only treatment option. Following surgery and intravenous antibiotic treatment, her wounds were managed with topical negative pressure wound therapy. No adverse events occurred and the wounds were almost completely healed 63 weeks following surgery. Research to develop evidence-based protocols of care for the closure of these wounds is needed.

Updates in flexor tendon repair at zone ii.

This article reviews the history and current management concepts of flexor tendon lacerations. Classic and contemporary repair techniques are discussed. The most popular rehabilitation protocols are also reviewed.

Distraction lengthening of the thumb following replantation.

Distraction lengthening is one of several surgical reconstructive methods used to obtain length of an amputated digit and to improve function. However, the use of this technique following replantation is a relatively new concept. A case of a 32-year-old male who sustained a traumatic amputation of his left nondominant thumb and index finger is described. The injury and the replantation surgery each resulted in a significant amount of bone loss from the thumb. Nine months following the replantation, distraction osteogenesis was utilized to lengthen the thumb and to improve both function and cosmesis.