The flaws of laser Doppler in negative-pressure wound therapy research.

Recent studies, using modalities other than laser Doppler, have indicated that perfusion during negative-pressure wound therapy (NPWT) is reduced, contrary to world literature. The aim of the present study was to evaluate whether the measuring technique of the laser Doppler could be influenced by the compressive nature of NPWT dressings and whether this could explain the conflicting findings. A hypothesis that it may be possible for laser Doppler to record similar readings to those obtained during NPWT by merely compressing tissues manually was tested on 12 NPWT dressings, with each undergoing an alternating series of manual compressive forces and NPWT (-125 mmHg). During the periods of NPWT (n = 12), the mean perfusion recording increased in five experiments, reduced in six, and remained unchanged in one. During the period when manual pressure was applied (n = 12), there was a mean increase in perfusion in six experiments and a reduction in six. The type of change in perfusion (increase or decrease) was the same for both NPWT and manual pressure in 10 of the 12 experiments. In conclusion, laser Doppler can incorrectly record increased perfusion when tissues are compressed, implying that it is flawed in the field of NPWT research as tissues are always compressed to some degree by the NPWT dressing.

Syringomyelia-induced wrist Charcot neuroarthropathy.

We present a rare case of wrist Charcot neuroarthropathy secondary to post-tuberculosis syringomyelia.Level of evidence: V.

Explant analysis of a chromium nitride coated metal-on-metal total wrist replacement: A case study.

Explant analysis can provide important understanding of how artificial joints perform in the human body. The articulating surfaces of the metacarpal head and the radius cup from a chromium nitride coated metal-on-metal Motec wrist implant were analysed. Due to bone resorption and aseptic loosening, the implant was removed after 6 years in the patient, and metallosis was observed during removal. Visually, some areas of the articulating surfaces appeared polished, others were dulled. A chemical composition analysis of the metacarpal head showed that the polished surfaces were chromium rich, implying this surface was the original chromium nitride coating, whereas the dulled surfaces were cobalt rich, indicating the underlying cobalt chromium substrate. In addition, the underlying cobalt chromium substrate was an order of magnitude rougher than the polished surface, indicating the scale of damage to it. It is speculated that the loss of the coating, and the subsequent damage to the underlying substrate due to a third-body wear process, led to osteolysis and the metallosis seen at revision surgery.

Learning curves in Motec total wrist arthroplasty: an international cohort study.

We examined the learning curve of Motec total wrist arthroplasty (TWA) of six experienced surgeons in their first 30 cases. Three times more complications/revisions were encountered in the first half of the study compared with the second half. Motec TWA surgery should be concentrated in a smaller number of centres performing higher volumes.

Complication rates and modes of short and medium-term failure in Motec total wrist arthroplasty: an international cohort study.

The aim of this study was to analyse the short- and medium-term complications of the Motec total wrist arthroplasty (TWA). Identifying exact modes of failure and their causes should allow surgeons to avoid or mitigate these risks in the future. Retrospective analysis of prospectively collected data from six hand surgeons at five international centres provided details of 171 Motec TWAs. The mean follow-up was 5.8 years (range 18 months to 12 years). There were 33 (19%) complications within our cohort, with a revision rate of 8.2% (14 revisions). There was no difference in complication rates between metal-on-metal and metal-on-polymer articulations. Failure of osseointegration was the most common complication. Problems with soft tissue balancing, implant impingement related osteolysis, bony impingement and metacarpal fracture were found to be other preventable causes of failure in this series. Elimination of these preventable complications will improve survival rates for this implant.Level of evidence: IV.

Arthroplasty in the hand: what works and what doesn't?

This review describes the different possibilities for arthroplasties at the proximal interphalangeal joint, thumb carpometacarpal joint, distal radioulnar joint, metacarpophalangeal joint and the wrist. For each joint, the indication for arthroplasty is explained, the surgical technique with the suitable implant is described and a brief summary of the outcomes reported in the literature is given.

Surface Replacement Proximal Interphalangeal Joint Arthroplasty: A Case Series.

Background: In 2012, our unit published our experience with a pyrocarbon proximal interphalangeal joint (PIPJ) implant. Due to high subsidence rates, a decision was made to change to a cemented surface replacement proximal interphalangeal joint (SR-PIPJ) implant. The purpose of this study was to assess whether the change to a cemented implant would improve the subsidence rates. Methods: Retrospective review of all patients who had a cemented SR-PIPJ arthroplasty performed from 2011 to 2013 with at least 12 months follow-up. Results: A total of 43 joints were included with an average follow-up of 26.5 months. There was a significant (P = .02) improvement in arc of motion with an average satisfaction score of 3.3 (satisfied patient). Subsidence was noted in 26% of joints with a significant difference in range of motion (P = .003) and patient satisfaction (P = .001) between the group with and without subsidence. Conclusions: The change to a cemented implant resulted in satisfied patients with an improvement in range of motion. The rate of subsidence improved but remains unacceptably high.

A device for zone-II flexor tendon repair. Surgical technique.

BACKGROUND: The stainless-steel Teno Fix tendon-repair device has improved biomechanical characteristics compared with those of suture repair, and it was well tolerated in a canine model. The purpose of this study was to compare the Teno Fix with suture repair in a clinical setting. METHODS: Sixty-seven patients with isolated zone-II flexor tendon injury were randomized to be treated with a Teno Fix or a four-stranded cruciate suture repair. There were eighty-five injured digits: thirty-four were treated with the Teno Fix, and fifty-one served as controls. A modified leinert rehabilitation technique was employed, with active flexion starting at four weeks postoperatively. Patients were followed for six months by blinded observers who determined the range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) score, pinch and grip strength, and pain score on a verbal scale and assessed swelling and neurologic recovery. Adverse outcomes, including device migration and rupture, were monitored at frequent intervals. RESULTS: Nine of the fifty-one suture repairs ruptured, whereas none of the Teno Fix repairs ruptured (p < 0.01). Five of the nine ruptures were caused by resistive motion against medical advice. There were no differences between the two groups in terms of range of motion, DASH score, pinch and grip strength, pain, swelling, or neurologic recovery. The Teno Fix group had slightly slower resolution of pain and swelling compared with the control group. Of the patients who were available for follow-up at six months, sixteen of the twenty-four treated with a Teno Fix repair and nineteen of the twenty-seven treated with a control repair had a good or excellent result. One Teno Fix device migrated and extruded secondary to a wound infection. Of all eighty-five digits that were operated on, four were thought to have tendons of inadequate size to accommodate the device and nine were deemed to have inadequate exposure to allow placement of the anchors. CONCLUSIONS: The Teno Fix is safe and effective for flexor tendon repair if the tendon size and exposure are sufficient. Tendon repairs with the Teno Fix have lower rupture rates and similar functional outcomes when compared with conventional repair, particularly in patients who are non-compliant with the rehabilitation protocol.

Device for zone-II flexor tendon repair. A multicenter, randomized, blinded, clinical trial.

BACKGROUND: The stainless-steel Teno Fix tendon-repair device has improved biomechanical characteristics compared with those of suture repair, and it was well tolerated in a canine model. The purpose of this study was to compare the Teno Fix with suture repair in a clinical setting. METHODS: Sixty-seven patients with isolated zone-II flexor tendon injury were randomized to be treated with a Teno Fix or a four-stranded cruciate suture repair. There were eighty-five injured digits: thirty-four were treated with the Teno Fix, and fifty-one served as controls. A modified Kleinert rehabilitation technique was employed, with active flexion starting at four weeks postoperatively. Patients were followed for six months by blinded observers who determined the range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) score, pinch and grip strength, and pain score on a verbal scale and assessed swelling and neurologic recovery. Adverse outcomes, including device migration and rupture, were monitored at frequent intervals. RESULTS: Nine of the fifty-one suture repairs ruptured, whereas none of the Teno Fix repairs ruptured (p < 0.01). Five of the nine ruptures were caused by resistive motion against medical advice. There were no differences between the two groups in terms of range of motion, DASH score, pinch and grip strength, pain, swelling, or neurologic recovery. The Teno Fix group had slightly slower resolution of pain and swelling compared with the control group. Of the patients who were available for follow-up at six months, sixteen of the twenty-four treated with a Teno Fix repair and nineteen of the twenty-seven treated with a control repair had a good or excellent result. One Teno Fix device migrated and extruded secondary to a wound infection. Of all eighty-five digits that were operated on, four were thought to have tendons of inadequate size to accommodate the device and nine were deemed to have inadequate exposure to allow placement of the anchors. CONCLUSIONS: The Teno Fix is safe and effective for flexor tendon repair if the tendon size and exposure are sufficient. Tendon repairs with the Teno Fix have lower rupture rates and similar functional outcomes when compared with conventional repair, particularly in patients who are noncompliant with the rehabilitation protocol.

A prospective study to assess the outcome of steroid injections and wrist splinting for the treatment of carpal tunnel syndrome.

Surgery is the definitive treatment for carpal tunnel syndrome. Conservative treatments, such as wrist splinting and steroid injections, are also effective for the relief of carpal tunnel symptoms, but their use remains controversial because they only offer long-term relief in a minority of patients. A prospective study was performed to assess the role of steroid injections combined with wrist splinting for the management of carpal tunnel syndrome. A total of 73 patients with 99 affected hands were studied. Patients presenting with known medical causes or muscle wasting were excluded. Diagnosis was made clinically and electrodiagnostic studies were performed only when equivocal clinical signs were present. Each patient received up to three betamethasone injections into the carpal tunnel and wore a neutral-position wrist splint continuously for 9 weeks. After that period, symptomatic patients received an open carpal tunnel release, and those who remained asymptomatic were followed up regularly for at least 1 year. Patients who relapsed were scheduled for surgery. At a minimum follow-up of 1 year, seven patients (9.6 percent) with 10 affected hands (10.1 percent) remained asymptomatic. This group had a significantly shorter duration of symptoms (2.9 months versus 8.35 months; p = 0.039, Mann-Whitney test) and significantly less sensory change (40 percent versus 72 percent; p = 0.048, Fisher's exact test) at presentation when compared with the group who had surgery. It is concluded that steroid injections and wrist splinting are effective for relief of carpal tunnel syndrome symptoms but have a long-term effect in only 10 percent of patients. Symptom duration of less than 3 months and absence of sensory impairment at presentation were predictive of a lasting response to conservative treatment. It is suggested that selected patients (i.e., with no thenar wasting or obvious underlying cause) presenting with mild to moderate carpal tunnel syndrome receive either a single steroid injection or wear a wrist splint for 3 weeks. This will allow identification of the 10 percent of patients who respond well to conservative therapy and do not need surgery.

A Glomus Tumour of the Elbow: A Case Report and Review of the Literature.

Extradigital glomus tumours are relatively uncommon. We present a case report of a glomus tumour of the elbow and review of the literature with regards to the clinical features, work-up and management of these tumours, to highlight the importance of considering a glomus tumour as part of the differential diagnosis in patient with atypical pain around the elbow.

The influence manufacturers have on negative-pressure wound therapy research.

BACKGROUND: Studies investigating the effects of negative-pressure wound therapy using the Chariker-Jeter system (gauze-based interface) and the vacuum-assisted closure system often have outcomes that favor one particular system. This study attempts to examine whether manufacturer involvement could be related to the outcomes of these scientific studies. METHODS: A literature review was undertaken to identify a cohort of studies that compared these two forms of negative-pressure wound therapy. Clinical outcomes studies, basic research studies, and published conference abstracts were included. Allthe articles' abstracts and conclusions were given to five surgeons, who were blinded to the titles and authors. They were individually asked to record what they would consider to be the take-home message of each article (in terms of which system is superior). After categorizing each study according to the system that it appears to favor, the level of manufacturer involvement in each study was evaluated. The relationship between the outcome of a study and the level of manufacturer involvement in that study was then investigated. RESULTS: Of the total of 24 studies found to match the inclusion criteria, 22 were considered to favor a particular system (the other two were categorized as impartial). Of the 24 studies, 19 had some form of manufacturer involvement. Of the 19 that had some form of manufacturer involvement, 18 had outcomes that were deemed beneficial to the involved manufacturer, whereas one was deemed to have an impartial outcome. CONCLUSIONS: This study suggests that manufacturer involvement in these studies (regardless of level) correlates with the outcomes being beneficial to the involved manufacturer in almost all cases. Potential reasons for this and the implications thereof are discussed.

Conservative treatment of fractures of the proximal phalanx: an option even for unstable fracture patterns.

PURPOSE: The purpose of the study was to assess the efficacy of the conservative management of proximal phalangeal fractures in a dorsal plaster slab. METHODS: Twenty-three consecutive patients with extra-articular proximal phalangeal fractures were included in this prospective study. Fourteen patients (62%) presented with fractures considered unstable. The fractures were reduced and the position was held with a dorsal plaster slab for three weeks. The patients were followed up for an average of seven weeks (range 2 to 45) after the injury. Range of motion of the finger and radiological evidence of union, non-union or malunion was documented after removal of the plaster. RESULTS: Ninety-one percent of fractures maintained an acceptable reduction. All cases measured less than 15° of angulation. On average 1,1 mm of shortening was measured. In two (9%) cases the reduction was not accepted on follow up assessment and the fractures were managed surgically. CONCLUSION: Most extra-articular proximal phalanx fractures can be managed conservatively with acceptable results.