Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Osteochondrolipoma of the Hand.

Lipoma is the most common type of benign soft tissue tumor and is composed of mature adipose tissue. A neoplasm of adipose tissue with admixed mature bone and cartilage, or osteochondrolipoma, is an extremely rare histologic variant. Most documented osteochondrolipomas have occurred in the soft tissues of the head and neck related to the oral cavity, and the tumor is seen involving the extremities. A fatty mass with nonlipomatous elements can present a diagnostic challenge. We present a rare case of osteochondrolipoma involving the wrist. The clinical presentation, radiographic images, histologic findings, and treatment are discussed in this case report.

Delayed Presentation of a Flexor Digitorum Profundus Avulsion Injury: A Case Report.

Avulsion of the flexor digitorum profundus (FDP) tendon is a relatively common injury in athletes. Also known as "jersey finger," it can also occur in nonathletes, and is often not initially diagnosed. Early diagnosis and repair are essential to regaining optimum return of function. We report a case of a 37-year-old woman who was seen six weeks following an undiagnosed FDP avulsion injury. Due to finger stiffness and the delayed diagnosis, she was treated with occupational therapy to maximize finger range of motion. The anatomy, classification, diagnosis, and treatment options for FDP avulsion injuries are discussed. The goal of this paper is to increase awareness for this injury, resulting in early diagnosis and prompt treatment.

Thumb and Index Finger Amputation after Radial Artery Occlusion in a Patient with COVID-19.

The pathophysiology and predictability of radial artery thromboembolic events in patients with COVID-19 is not fully understood. We report a case of thumb and index finger gangrene and multiple digit amputations secondary to digital artery occlusion after radial artery cannulation in a patient admitted with COVID-19 pneumonia and encephalopathy. The exact association, causality, and potential hand manifestations in this patient population is unclear at this time, but is of particular interest in the current state of the pandemic.

Acute Calcific Tendinitis of the Flexor Carpi Ulnaris Tendon Treated with Lavage and Steroid Injection: A Case Report.

Acute calcific tendinitis (ACT) is a relatively uncommon disorder that can involve the hand and wrist. ACT is frequently misdiagnosed due to a lack of familiarity with the condition and the clinical presentation that can be confused with other conditions. We report a case of acute calcific tendinitis of the flexor carpi ulnaris (FCU) tendon in a 68-year-old woman. She presented with acute left volar wrist pain, erythema, swelling, and restricted range of motion. Due to her inability to take nonsteroidal anti-inflammatory drugs (NSAIDs) and oral prednisone, she was treated with lavage and steroid injection of the calcified mass. Following the injection, there was dramatic improvement in her symptoms. Cortisone injection with lavage is an accepted treatment for rotator cuff calcific tendinitis and is another treatment option for ACT involving the hand and wrist.

Erosive Tophaceous Gouty Arthropathy of the Hand: A Case Report.

The presence of tophaceous gout in the hand is a classic finding seen in uncontrolled gout. Occasionally gouty tophi can be the initial physical finding in asymptomatic hyperuricemia. Composed of monosodium urate (MSU) crystals, gouty tophi can cause significant soft tissue and joint pathology. In addition, tophaceous gout and hyperuricemia are associated with increased mortality. We present a patient with tophaceous gout causing erosive arthropathy of the proximal interphalangeal (PIP) joint. The diagnosis and treatment for tophaceous gout is reviewed.

Acrometastasis of Occult Renal Cell Carcinoma: A Case Report.

Renal cell carcinoma is a common malignancy with 30,000 new cases reported annually in the U.S. While bone is one of the most common sites of metastases of renal cell carcinoma, acrometastases are rare with an estimated incidence of 0.1 percent among patients with malignant disease. We present an 89-year-old white male who presented with a painful mass of the left thenar eminence. A preoperative medical evaluation revealed metastatic renal cell carcinoma with lytic infiltration of the diaphysis of the left thumb metacarpal with soft tissue involvement. The patient was treated with two intralesional currettage procedures and later radiation therapy. This approach allowed the patient to maintain functional use of the thumb for activities of daily living.

Phentolamine Rescue for Digital Ischemia Following Lidocaine with Epinephrine Local Anesthesia: Case Presentation, Review of the Literature and Treatment Options.

The use of low-dose 1 percent lidocaine with epinephrine (1:100,000) has changed the practice of hand surgery. The safety of lidocaine and epinephrine in hand surgery has been well documented. Although rare, epinephrine-induced digital vasospasm can occur leading to tissue necrosis and amputation. Fortunately, digital ischemia can be reversed with phentolamine. We present a case of epinephrine-induced vasospasm following the use of 1 percent lidocaine with 1:100,000 epinephrine injected for a small finger flexor tendon and nerve repair. The multiple risk factors for digital ischemia and the role of phentolamine as an antidote to reverse epinephrine-induced ischemia are reviewed. Reversal of epinephrine-induced vasospasm using phentolamine rescue should be available to any provider using lidocaine with epinephrine in the hands and digits. Additionally, in more rural healthcare areas, a prophylactic post-procedure phentolamine injection might be considered in patients with multiple comorbidities which may predispose them to epinephrine-induced vasospasm.

Opioid Prescribing and Patient Satisfaction Scores Across Practice Types.

US physicians prescribe opioids at a high rate relative to other countries. Of the US physicians surveyed, almost half report having prescribed an inappropriate opioid due to concerns about patient satisfaction scores. We investigated patterns in controlled substance prescribing practices, patient risk factors, and associated Press Ganey patient satisfaction scores at a sample of orthopaedic surgery and primary care clinics over a 6month time period. Primary care practices had higher proportions of prescriptions, and patient risk profiles varied across sites. However, overall satisfaction was high, with little variation between sites (78.3 81.3%). Satisfaction with pain control was lower and more varied (67.1 78.0%). A total of 4,229 Press Ganey survey responses were received, including 7,232 comments, of which only 10 (0.1%) expressed frustration for not receiving opioids. Opioid prescriptions had minimal association with Press Ganey scores among varied practices and patient populations. Prescribers should prescribe opioids appropriately without fear that this will negatively impact their satisfaction scores. (Journal of Surgical Orthopaedic Advances 29(1):59, 2020).

A Distal Radius Nonunion Treated with A Dorsal Spanning Distraction Plate: A Case Report.

Distal radius fractures are one of the most common orthopedic injuries, particularly in the elderly population. Distal radius nonunions are rare and are usually associated with a patient's underlying health conditions. We present a patient who developed a distal radius nonunion following treatment of an open wrist fracture with an external fixation frame. This nonunion was successfully treated with a dorsal spanning distraction plate. The etiology of distal radius nonunions and treatment options are reviewed.

Delayed Rupture of the Flexor Pollicis Longus After Volar Plating for a Distal Radius Fracture: A Case Report.

Distal radius fractures account for 18 percent of all fractures in the elderly age group. It is estimated that the yearly cost of treatment for distal radius fractures approaches $240 million. The frequency of fractures will continue to increase with the aging population. The operative treatment of distal radius fractures has changed dramatically with the advent of the fixed-angle volar plate. Volar plating allows stable internal fixation which permits early return of function. A common and serious complication of volar plating of distal radius fractures is rupture of the flexor pollicis longus tendon. We report a case of a late rupture of the flexor pollicis longus tendon six years following plating of a distal radius fracture. The pathology and treatment options for flexor tendon ruptures are discussed. Guidelines for patient surveillance following distal radius plating are reviewed.

Lean and Green Hand Surgery.

Health care in the United States is both expensive and wasteful. The cost of health care in the United States continues to increase every year. Health care spending for 2016 is estimated at $3.35 trillion. Per capita spending ($10,345 per person) is more than twice the average of other developed countries. The United States also leads the world in solid waste production (624,700 metric tons of waste in 2011). The health care industry is second only to the food industry in annual waste production. Each year, health care facilities in the United States produce 4 billion pounds of waste (660 tons per day), with as much as 70%, or around 2.8 billion pounds, produced directly by operating rooms. Waste disposal also accounts for up to 20% of a hospital's annual environmental services budget. Since 1992, waste production by hospitals has increased annually by a rate of at least 15%, due in part to the increased usage of disposables. Reduction in operating room waste would decrease both health care costs and potential environmental hazards. In 2015, the American Association for Hand Surgery along with the American Society for Surgery of the Hand, American Society for Peripheral Nerve Surgery, and the American Society of Reconstructive Microsurgery began the "Lean and Green" surgery project to reduce the amount of waste generated by hand surgery. We recently began our own "Lean and Green" project in our institution. Using "minor field sterility" surgical principles and Wide Awake Local Anesthesia No Tourniquet (WALANT), both surgical costs and surgical waste were decreased while maintaining patient safety and satisfaction. As the current reimbursement model changes from quantity to quality, "Lean and Green" surgery will play a role in the future health care system.

Osteomyelitis Pubis Treated with Wedge Resection: A Case Report with 26-Year Follow-up and Literature Review.

Osteomyelitis pubis is a rare orthopedic infection, accounting for less than 1-2 percent of all hematogenous osteomyelitis. Osteomyelitis pubis generally affects children, elderly patients who have undergone genitourinary procedures, and parenteral drug users. Interestingly, cases of acute osteomyelitis pubis have also been documented in previously young, healthy athletes. The diagnosis is often difficult to differentiate from osteitis pubis, which is a self-limiting, painful inflammatory condition affecting the symphysis pubis. The authors report what is to our knowledge the first case of osteomyelitis pubis in a baseball player and provide a brief review of the literature. The patient was a previously healthy 18-year-old baseball player who presented with left groin pain after presumably straining his groin during a baseball game. Over the next 24 hours, he developed fever, chills, and left lower quadrant pain. He received IV antibiotics and was discharged from the hospital after clinical improvement. However, he returned six weeks later with increased groin pain, a 20-pound weight loss, and an inability to bear weight. Laboratory studies revealed an elevated white blood cell count and a bone scan demonstrated increased uptake at the symphysis pubis. The patient was taken to the operating room where a wedge-resection was performed and tissue cultures grew Staphylococcus aureus, confirming the diagnosis of osteomyelitis pubis. The patient recovered without complication postoperatively and played four years of college baseball. He was seen at a follow-up appointment 26 years later and demonstrated a normal physical exam with radiographic evidence of regeneration of the symphysis pubis without SI joint instability.

The Opioid Epidemic in 2017: Are We Making Progress?

With the emphasis on pain control (i.e., pain as the fifth vital sign) starting in the late 1990s and the increased prescribing of opioids, the opioid epidemic began. With the expanding misuse of opioids a new emphasis has been given for more responsible management of opioid prescribing by health care providers in all specialties. Since the pain experienced by patients with chronic musculoskeletal pain and acute postoperative pain can be severe, specific attention must be given to these patients who may be at increased risk for opioid abuse. We review the opioid epidemic and the impact of the epidemic on physicians and patients. As a result of this epidemic, several intraoperative techniques have been developed to decrease the need for postoperative pain medication. In addition, we identify several key features of a patient's background and their behavior that can indicate a potential for opioid abuse or misuse. Treatment strategies for providers including opioid prescribing guidelines are also discussed.

Opioid Analgesics for Chronic Non-Cancer Pain: A Guideline on Opioid Prescribing.

INTRODUCTION: Over the past decade, the use of opioid analgesics has risen dramatically both in the U.S. and South Dakota. Opioids have been increasingly used to treat chronic non-cancer pain; however, the utilization of opioids for this role has limited and questionable utility. The U.S. has also seen a rise of opioid abuse, addiction, misuse, and overdose. The various pharmacological and non-pharmacological strategies to help physicians manage chronic non-cancer pain and a guideline on appropriate opioid prescribing are presented. DISCUSSION: Before the decision is made to begin opioid therapy for chronic non-cancer pain, other pharmacological and non-pharmacological therapeutic strategies should be explored. The schema for responsible opioid prescribing can be dived into the following: the initial assessment, initiating opioid therapy, maintenance therapy, and the discontinuation of opioid treatment. These categories are explored, and a general approach to prescribing opioids for chronic non-cancer pain is presented. CONCLUSION: The Centers for Disease Control and Prevention (CDC) has declared opioid prescription abuse an "epidemic." There are a variety of methods clinicians can utilize to relieve chronic non-cancer pain. If opioid therapy is sought, clinicians should be mindful of the current state of opioid abuse and misuse. This guideline may aid clinicians in appropriate opioid prescribing.

Intraoperative Periprosthetic Fractures in Proximal Interphalangeal Joint Arthroplasty.

PURPOSE: To examine the frequency, risk factors, and postoperative outcomes associated with intraoperative periprosthetic fractures during proximal interphalangeal (PIP) joint arthroplasty. METHODS: We examined 382 consecutive PIP joint arthroplasties in 205 patients. Procedures were performed from 1998 to 2012. The patients were identified and outcomes were collected through a single institution's total joints registry, collecting additional information not contained in the prospectively collected registry through medical record examination. Multiple outcomes were analyzed relating to the fractures, the hard surgical outcomes, finger function, and radiographic findings. Statistical analysis was performed utilizing Kaplan-Meier survival models, log-rank tests, univariate analysis, Student t test and Fisher exact test. RESULTS: Intraoperative periprosthetic fracture occurred in 5% (n = 20) of 383 PIP joint arthroplasties. All of the patients who had an intraoperative fracture were women. Lower body mass index and a diagnosis of rheumatoid arthritis were associated with a significantly higher risk of intraoperative fracture. The use of pyrocarbon implants also significantly increased fracture risk. At a median follow-up of 5.3 years, there were no refractures in the patients who sustained an intraoperative fracture. Six patients underwent revision surgery, with a 2- and 5-year survival rate free of revision surgery of 76% and 64%, respectively. These rates were not significantly different from those without intraoperative fractures. There was no significant difference in the incidence of postoperative complications between patients with or without an intraoperative fracture. CONCLUSIONS: Intraoperative fractures occur in about 5% of PIP joint arthroplasties. These periprosthetic fractures do not appear to influence outcomes, including revision surgery, refracture rate, or other early complications. Female sex, lower body mass index, rheumatoid arthritis, and the use of pyrocarbon implants were associated with increased risk for intraoperative fractures. CLINICAL RELEVANCE: This information may help decrease fracture risk and help surgeons identify and treat the fractures when they do occur. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Stress fracture of the hook of the hamate: a case report.

Hook of the hamate fractures are uncommon. This fracture is usually seen in sports involving a club or a racquet (i.e., baseball or golf) and is caused by blunt trauma. Stress fractures of the hamate are exceedingly rare. Because of its subcutaneous position and associated soft tissue structures, hook of the hamate fractures can be difficult to diagnosis. When treated early, conservative (non-operative) options can be used to successfully treat the fracture. When the diagnosis is delayed, nonunion of the fracture is common and is usually treated with surgery. This case represents a hook of the hamate stress fracture that healed with casting in spite of being seen two months from the onset of symptoms. Hamate fractures are reviewed, including the anatomy and treatment options for hook of the hamate fractures.