Delayed debridement affects prognosis in patients with purulent flexor tenosynovitis: a retrospective cohort and multivariate analyses.

INTRODUCTION: Purulent flexor tenosynovitis (PFT) is a severe condition, and many patients report serious postoperative complications such as amputation, limited range of motion (ROM), or recurrence of symptoms. However, the ideal protocol for PFT treatment remains unknown owing to the limited number of studies. This retrospective cohort study aimed to identify prognostic factors for PFT treatment outcomes. MATERIALS AND METHODS: Sixty-six patients (46 men and 20 women) with PFT who underwent surgical debridement at our hospital between September 2005 and January 2023 were included in this study. We conducted multivariate linear regression analysis with permanent deficit as the primary outcome. We defined the number of operations, laboratory data, interval from onset to debridement, previous conservative treatment, aetiology, Kanavel's signs, and medical history of diabetes mellitus as possible prognostic factors. We also defined the interval from onset to debridement as a secondary outcome and performed logistic regression analysis. RESULTS: Overall, 25 (38%) patients had postoperative deficits. Longer interval from onset to surgery (odds ratio [OR]: 1.1, 95% confidence interval [CI]: 1.0-1.1) and polymicrobial infection (OR: 7.8, 95% CI: 1.56-38.8) were significant prognostic factors for unfavourable outcomes. Additional multivariate analysis showed that preoperative conservative treatment prolonged the interval to surgery (estimate, 16.4; standard error, 1.6; p < 0.05). CONCLUSIONS: The results of this study suggest that indications for nonoperative treatment of PFT are limited and that earlier surgical debridement is recommended.

An age-matched comparative study on intramedullary nailing and plate fixation of both-bone diaphyseal forearm fracture in adolescents.

OBJECTIVE: This study aimed to compare radiological and functional outcomes and complication rates between intramedullary nailing (IMN) and plate fixation for diaphyseal forearm fractures in adolescents via an age-matched analysis. METHODS: Data were collected from medical records at 11 hospitals from 2009 to 2019, and the age-matched study was conducted between IMN and plate fixation. Functional outcomes, radiographic outcomes, and postoperative complication rates were compared. RESULTS: The IMN group (Group N) and plate fixation group (Group P) each comprised 26 patients after age matching. The mean age after matching was 13.42 years old. Bone maturities at the wrist of the radius and ulna were not significantly different between the two groups (p = 0.764 and p = 1). At the last follow-up period, functional outcomes using the Price criteria were over 90% in both groups, and the rotational range of motion was comparable to that of the healthy side. Over 70% of cases in Group N were performed by closed reduction, and operation time was half that of Group P. Postoperative neurological symptoms and refractures were more common in Group P than in Group N, although not statistically significantly so. CONCLUSIONS: Treatment outcomes for age-matched adolescent diaphyseal forearm fractures were excellent with IMN, as well as with plate fixation in many cases despite fewer complications, better cosmesis, and shorter operative times with IMN. IMN for diaphyseal forearm fractures is a useful treatment option even in adolescents although the indications for the best procedure to perform should be considered depending on individual patient needs. LEVEL OF EVIDENCE IV: Multicenter retrospective study.

Are the Clinical Results of Locking Plate Fixation for Distal Radius Fractures Inferior in Patients over 80 Years of Age? A Multicentre (TRON Group) Study.

Introduction: With the aging of the population, the proportion of distal radius fracture patients who are > 80 years of age is increasing. In this study, we compared the postoperative clinical and radiographic outcomes between super-elderly patients (age: ≥ 80 years) and middle-elderly (age: 65-79 years) who were treated with volar locking plate (VLP) fixation for distal radius fractures. Patients and Methods: Patients of > 65 years of age with distal radius fractures treated by VLP fixation between 2015 and 2019, and who were followed for at least 6 months after surgery were included in our database (named TRON). Patients with open fractures, multiple-trauma, or who received fixation with implants other than a VLP were excluded. We evaluated postoperative complications, Mayo wrist score (MWS), and radiographic outcomes. Results: We identified 589 patients in this study; 452 were 65-79 years of age (Group A) and 137 were ≥ 80 years of age (Group B). After propensity score matching, we evaluated 309 patients in Group A and 103 patients in Group B. The mean follow-up period was 10.7 ± 4.6 months. Twenty-eight patients (9.1%) in Group A and 5 patients in Group B (4.9%) experienced post-operative complications (non-significant: p = 0.212). The postoperative MWS at 1, 3, and 6 months, respectively, was 65.4 ± 11.7, 75.2 ± 11.0, and 79.6 ± 10.5 in Group A and 67.1 ± 9.61, 75.7 ± 10.7, and 80.6 ± 9.7 in Group B (non-significant: p = 0.418, 0.893, 0.452, respectively). The differences in volar tilt, radial inclination, ulnar variance between the postoperative and last follow-up radiographs did not differ between the two groups to a statistically significant extent (p = 0.053, 0.437, 0.529, respectively). Conclusion: Our study showed that the clinical and radiographic outcomes of distal radius fractures treated with VLP in super-elderly patients were comparable to those in middle-elderly patients.

Prognostic factors for postoperative complications after K-wire fixation for paediatric forearm fractures: a multivariate analysis.

Although osteosynthesis using K-wires is a commonly performed procedure, the outcome is not always preferable. We aimed to identify the prognostic factors for postoperative complications in paediatric patients with both-bone forearm fractures. We reviewed 160 paediatric patients who underwent K-wire osteosynthesis for either distal or diaphyseal forearm fractures. We defined the occurrence rate of postoperative complications as the primary outcome and performed a multivariate logistic regression analysis. Variables such as age, sex, mechanism of injury, presence of an open fracture, ulnar or radial fracture and the associated procedure, the K-wire tip procedure and operation time, the duration from injury to operation and operation to implant removal, and duration of casting were included into the model as possible prognostic factors. The mean follow-up period was 51.2 weeks. The total number of complications was 43 (26.2%). Results of the logistic regression analysis indicated that a shorter duration from surgery to K-wire removal caused a significantly higher rate of postoperative complications [odds ratio (OR), 0.99; 95% confidence interval (CI), 0.97-1.0]. The subgroup analyses revealed that intramedullary K-wire fixation for radial fractures (OR, 1.07 × 10-5; 95% CI, 5.46 × 10-10 to 0.211) and a longer casting duration (OR, 0.84; 95% CI, 0.72-0.99) resulted in fewer postoperative infections. An exposed wire tip in the ulna contributed to more postoperative displacement (OR, 6.87; 95% CI, 1.76-26.9). To decrease the risk of postoperative complications, surgeons should bury the wire tip beneath the skin to facilitate a longer duration of K-wire placement.

Prognostic factors for outcomes of surgical mobilisation in patients with posttraumatic limited range of motion of the proximal interphalangeal joint: a multivariate analysis.

This study aimed to identify the prognostic factors for outcomes of surgical mobilisation in patients with posttraumatic limited range of motion (ROM) of the proximal interphalangeal (PIP) joint and determine which procedure actually improves the PIP joint ROM. A total of 71 fingers (57 patients: 49 men, 8 women; mean age, 41 years) with posttraumatic limited passive ROM of the PIP joint (<60°) who underwent surgical mobilisation were reviewed. Possible prognostic factors, including age, injury type, injured finger, injury in the adjacent finger, and procedure types, were assessed. We defined the PIP joint ROM improvement as the primary outcome in the linear regression analysis. To evaluate surgical efficacy, we classified the surgical treatment options into four categories (volar release, dorsal release, volar and dorsal release, and joint distraction with an external fixator) and compared their outcomes. The mean postoperative improvement in the PIP joint ROM was 12°. In the linear regression analysis, advanced age (estimate, -0.41; 95% confidence interval [CI], -0.76 to -0.06), open injury (estimate, -13.54; 95% CI -27.02 to -0.06), and skin defects (estimate, -23.22; 95% CI -34.83 to -11.61) were associated with worse outcomes; however, the volar approach was associated with favourable outcomes. Surgical mobilisation is strongly recommended when limited ROM of the PIP joint is caused by flexion site contracture. To improve the final outcome of fingers with complex injuries, a tailored treatment strategy is required to avoid dorsal release.

Volar plating versus external fixation for unstable dorsal fracture-dislocations of the proximal interphalangeal joint.

We retrospectively compared the results of volar plating and dynamic external fixation for acute unstable dorsal fracture-dislocations of the proximal interphalangeal joint with a depressed fragment. We treated 31 patients (31 fingers), 12 with volar buttress plating and 19 with dynamic external fixation. Follow-up averaged 35 and 40 months in the two groups, with a minimal 6-month follow-up. Average active flexion of the proximal interphalangeal joint was 95° after plate fixation and 87° after external fixation, with an active extension lag of -6° and -9°, respectively. Active flexion at the distal interphalangeal joint averaged 67° in the plate group and 58° in the external fixation group, with active extension lags of 0° and -5°, respectively. We conclude that both methods can obtain a good range of motion at the proximal interphalangeal joint. A limitation of the extension of the distal interphalangeal joint occurred with dynamic external fixation but not with volar buttress plating.Level of evidence: IV.

Outcomes of "Cross-Coupling Suture Button Suspensionplasty" for Thumb Carpometacarpal Joint Osteoarthritis: A Preliminary Report.

Thumb carpometacarpal joint osteoarthritis is a common condition that is treated nonsurgically. When conservative treatments fail, surgery is considered. Recently, suture button suspensionplasty has attracted attention and yielded good clinical results. We have developed a novel suture button suspensionplasty procedure called "cross-coupling suture button suspensionplasty" (CC-SBS) using a pair of suture button devices after a complete trapeziectomy. This retrospective study aimed to report the short-term clinical results of patients who underwent CC-SBS at our institution. We evaluated 10 hands of 10 patients (9 women and 1 man; average age, 67 years) who were refractory to conservative treatment and underwent CC-SBS at our institution between 2015 and 2017. We evaluated the preoperative Eaton stage and postoperative trapezial space height immediately after surgery and at the final visit; measured the trapezial space height, range of motion of the palmar and radial abduction of the carpometacarpal joint at the final visit; measured the preoperative and postoperative pinch strength; and recorded postoperative complications. The mean trapezial space height was 6.5 mm, and the mean radial and palmar abductions were 47° and 45°, respectively, at the final visit. The average pinch strength improved to 3.8 kg at the final visit compared to that pre-operation. In one case, a second metacarpal fracture occurred 2 weeks post-surgery, but no other complications were reported. Conclusion: CC-SBS showed short-term clinical outcomes similar to those of ligament reconstruction and tendon interposition and demonstrated faster overall recovery. Our procedure does not need a donor tendon for suspension and is technically simple and less invasive than ligament reconstruction tendon interposition. Thus, stronger initial fixation is obtained by using two suture button devices, and rehabilitation can be started from an early stage. We believe that this procedure is a good surgical option for carpometacarpal joint osteoarthritis.

Factors Affecting the Range of Motion of the Elbow after Open Reduction of Olecranon Fractures.

Background: Although postoperative outcomes of olecranon fractures are relatively favorable, postoperative stiffness of the elbow joint occurs occasionally. We aimed to identify negative prognostic factors for unfavorable outcomes following olecranon fractures. Methods: We retrospectively reviewed the records of 100 patients with olecranon fractures and collected data on the conducted procedures, age, fracture condition, postoperative reduced position, and postoperative active range of motion (AROM) of the elbow joint. The primary outcome was the regaining of an AROM of > 130° flexion and < -30° extension of the elbow joint at the final follow-up. We performed multivariate logistic regression analysis to identify the negative prognostic factors. Results: The mean follow-up period was 11 months. All patients regained an average AROM of 121 degrees. Eighty-one patients regained a favorable AROM of the elbow joint. On univariate logistic regression analysis, diabetes mellitus (OR, 8.2; 95%CI, 1.6-41.7), comminution of the fractured site (OR, 23.1; 95% CI, 13.2-165.0), and utilization of the tension band wiring (TBW) technique (OR, 7.5; 95% CI, 1.16-48.2) were significant factors in aggravating the final result of elbow AROM. On multivariate analysis, patients with diabetes mellitus (OR, 10.9; 95% CI, 2.83-41.9), comminuted fractures (OR, 11.4; 95% CI, 2.61-50.2), or undergoing the tension band wiring technique (TBW) (OR, 5.5; 95% CI, 1.35-50.2) showed reduced postoperative AROM of the elbow joint; postoperative malreduction of the articular surface was not a negative prognostic factor. Seven of 51 patients treated with TBW underwent revision surgery because of non-union or postoperative displacement. Conclusions: TBW for olecranon fractures is a simple and cost-effective procedure; however, negative effects could develop when regaining sufficient postoperative AROM of the elbow joint. Therefore, rigid fixation without reoperation may lead to a favorable outcome. Postoperative malreduction does not always worsen the postoperative AROM of the elbow joint, at least not in the early postoperative period.

Carpal Malalignment as a Predictor of Delayed Carpal Tunnel Syndrome after Colles' Fracture.

BACKGROUND: The present study aimed to clarify whether carpal malalignment associated with distal radius malunion after Colles' fracture is involved in the onset of delayed carpal tunnel syndrome (DCTS) in elderly women. METHODS: This retrospective case-control study was conducted in 40 female patients with Colles' fracture treated with a cast, including 10 patients (mean age, 71.6 years) who developed DCTS from 6 weeks to 6 months after injury (DCTS group) and 30 patients (mean age, 73.4 years) without DCTS (control group). Radiological parameters, including the radiocapitate distance (RCD), volar prominence height (VPH), and volar tilt (VT) were measured. Relationships between the RCD and both the VPH and VT were examined, and the involvement of the RCD in the onset of DCTS was analyzed. RESULTS: The RCD showed strong correlations with both the VPH and VT. The mean RCD was significantly lower in the DCTS group than in the control group (-12.8 mm versus -8.4 mm). Logistic regression analysis showed involvement of the RCD in the onset of DCTS, and the threshold value according to receiver operating characteristic curve analysis was -9.9 mm, with an odds ratio of 21. CONCLUSIONS: Dorsal displacement of the capitate due to Colles' fracture malunion is involved in DCTS accompanied with anatomical alteration of the carpal tunnel. When the center of the head of the capitate is located more than 1 cm dorsally behind the volar cortical line of the radius, careful follow-up should be performed as DCTS may occur within 6 months after injury.

Utility of early active motion for flexor tendon repair with concomitant injuries: A multivariate analysis.

INTRODUCTION: Flexor tendon injury often occurs with concomitant injuries such as fracture, vascular injury, and extensor tendon injury. These injuries are repaired independently, without a comprehensive strategy. We aimed to identify the effect of concomitant injuries and treatment choice on the outcome of flexor tendon repair. PATIENTS AND METHODS: We evaluated 118 fingers of 102 adult patients with zone 1-3 flexor digitorum profundus (FDP) tendon injuries who underwent primary surgery at our hospital between April 2009 and December 2017. The 2-strand pull-out, 4-strand Tsuge, 6-strand Lim & Tsai, and 8-strand cross-locked cruciate suturing techniques were used. We performed multivariate analyses, with the active range of motion (AROM) of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints as dependent variables, and age, existence of concomitant injuries, and their treatment as independent variables. RESULTS: The average AROM of the PIP + DIP joints was 130° at the last follow-up, and 'excellent' or 'good' function was obtained in 74 (63%) of 118 fingers by using the Strickland criteria. Old age, concomitant diaphyseal fractures, and specific methods of osteosynthesis, such as pinning, flexor digitorum superficialis injury, and immobilisation for 3 weeks, significantly worsened the results. However, wiring for osteosynthesis and early active motion protocol improved postoperative functional outcome. Although the outcome did not differ among the suture techniques, the 4-strand Tsuge procedure was performed for the two surgically confirmed ruptures of repair that occurred in our series. DISCUSSION: We clarified the superiority of early mobilisation protocols with rigid osteosynthesis procedure, other than pinning. To minimise tendon adhesion or joint stiffness, surgeons should repair the tendon and fractured bone appropriately, to ensure early mobilisation without serious complications.

Concomitant injuries affect prognosis in patients with central slip tear.

Central slip tears often occur with concomitant hand injuries. However, the outcome of a central slip tear and the effect of concomitant injuries are rarely reported. We evaluated 67 fingers in 63 patients with central slip tears who underwent primary surgery in our hospital between April 2009 and June 2017. We performed multivariate analyses, with proximal interphalangeal (PIP) joint active range of motion (AROM) and existing extension lag greater than 10° as dependent variables and age, existence of concomitant fractures, skin defects, collateral ligament injuries, ruptured lateral bands, ruptured flexor tendons or vascular injury in the injured finger as independent variables. Concomitant injuries of tendons in the adjacent fingers were also independent variables. The average AROM of the PIP joint was 62°, and extension lag occurred in 34 fingers (51%). Patients aged > 40 years with fractures of the injured finger or flexor tendon injuries in an adjacent finger had low decreases in AROM (partial regression coefficient [95% confidence interval, CI]: -13.7 [43-66], -31.6 [30-57], -34.5 [32-60] and -33.5 [10-43]). Extensor tendon injuries in an adjacent finger caused significantly more extension lag in the PIP joint (odds ratio [95% CI]: 3.2 [1.0-9.6]). The present study indicated the negative impact of a tendon injury on adjacent fingers, a circumstance widely known as the quadriga phenomenon. Ultimately, we can use these prognostic factors in surgical repair planning, particularly when comparing treatments such as central slip reconstruction and primary arthrodesis.

Progression from Injection to Surgery for Trigger Finger: A Statistical Analysis.

BACKGROUND: The purpose of this study was to identify predictive factors of poor response to intra-flexoral sheath corticosteroid injection, as well as to identify factors associated with patients' decisions to undergo surgical treatment. METHODS: Data from 112 patients who received steroid injection treatment for trigger finger were reviewed retrospectively. Logistic regression was used to assess the prognostic value of factors assumed to affect prognosis (age, sex, underlying disease, history of illness, presence of carpal tunnel syndrome, multiple digit involvement, and pre- and post-operative disability scores). RESULTS: Multiple digits were affected in 42 patients. Associated and underlying conditions were carpal tunnel syndrome (n = 36), hypertension (n = 23), hyperlipidemia (n = 14), and history of malignant tumor (n = 10). Logistic regression analysis showed that multiple digit involvement and Froimson clinical severity score were factors significantly associated with surgical treatment after intra-flexoral sheath corticosteroid injection treatment. These two factors were also found to be associated with the patients' decisions to undergo surgical treatment. CONCLUSIONS: Although local corticosteroid injection is useful in most cases, providers need to counsel patients with multiple digit involvement and/or severe cases about the possibility of requiring additional surgical treatment.

Eight-strand Cross-locked Cruciate Flexor Tendon Repair Using Double-stranded Suture: A Description of the Surgical Technique.

This article describes a technique for improved repair of digital flexor tendon laceration. Eight-strand cross-locked cruciate repair using 4-0 caliber double-stranded suture is not bulky and has a smooth configuration for tendon gliding. Additionally, it has sufficient strength for early postoperative active motion exercise.

The Optimal Rehabilitation Period for Patients with Distal Radius Fractures According to the MCID in DASH Scores; A Preliminary Study.

BACKGROUND: The statistical concept of minimal clinically important difference (MCID) enables the interpretation of small but meaningful changes that result from an intervention. This retrospective study aimed to examine the factors that influence the achievement of MCID after a distal radius fracture. METHODS: A total of 45 patients (mean age: 54.2 ± 16 years) were included. Of these, 27 patients started rehabilitation within 3 days of surgery (Early group), and 18 patients underwent immobilization for 2 weeks after surgery, before starting rehabilitation (Non-early group). Functional outcomes and DASH scores at 4 weeks (baseline) were compared with those measured at 8 and 12 weeks for both groups, to determine whether the MCID had been achieved. RESULTS: Our results showed that at 8 weeks after surgery in the early group, the grip strength, ulnar flexion, and baseline DASH score were significantly different between the groups that did and did not show an MCID ([Formula: see text]). There was also a significant difference in the baseline DASH score at 12 weeks after surgery ([Formula: see text]). None of these factors were significant in the non-early group. Logistic regression analysis revealed that the DASH score at 4 weeks (baseline) was an independent predictor for achieving a DASH MCID at 8 weeks postoperatively in the early group (odds ratio: 1.193). Those achieving a DASH MCID at 12 weeks postoperatively were completely separated by the baseline DASH score (≥ 29 points). CONCLUSIONS: If it is assumed that the effectiveness of rehabilitation depends upon achieving the DASH MCID by promoting functional recovery, early initiation might be recommended.

Pathological mechanism of musculoskeletal manifestations associated with CRPS type II: an animal study.

Patients with complex regional pain syndrome (CRPS) often complain of abnormal sensations beyond the affected body part, but causes of this spread of musculoskeletal manifestations into contiguous areas remain unclear. In addition, immobilization can predispose to the development of CRPS. We examined functional, biochemical, and histological alterations in affected parts, including contiguous zones, using an animal model. Ten-week-old male Wistar rats were assigned to 5 groups: a normal group receiving no treatment, a sham operation group with surgical exploration, an immobilization group with surgical exploration plus internal knee joint immobilization, a surgical neuropathy group prepared by spinal nerve ligation (SNL) of the left L5 nerve root, and a surgical neuropathy+immobilization group with simultaneous SNL and knee joint immobilization. Mechanical allodynia and knee contracture were compared between groups, and tissues were harvested for histological assessments and gene and protein expression analyses. Neither surgical procedures nor immobilization induced detectable mechanical sensitivity. However, the addition of nerve injury resulted in detectable mechanical allodynia, and immobilization not only accelerated hyperalgesia, but also resulted in muscle fibrosis. Nerve growth factor (NGF) and other mediators of neurogenic inflammation were highly expressed not only in denervated muscles, but also in innervated muscles in contiguous areas, suggesting the spread of NGF production beyond the myotome of the injured nerve. Transforming growth factor ß was involved in the development of contracture in CRPS. These findings imply that neuroinflammatory components play major roles in the progression and dispersion of both sensory pathologies and pathologies that are exacerbated by immobilization.

Targeting anti-inflammatory treatment can ameliorate injury-induced neuropathic pain.

Tumor necrosis factor-α plays important roles in immune system development, immune response regulation, and T-cell-mediated tissue injury. The present study assessed the net value of anti-tumor necrosis factor-α treatment in terms of functional recovery and inhibition of hypersensitivity after peripheral nerve crush injury. We created a right sciatic nerve crush injury model using a Sugita aneurysm clip. Animals were separated into 3 groups: the first group received only a skin incision; the second group received nerve crush injury and intraperitoneal vehicle injection; and the third group received nerve crush injury and intraperitoneal etanercept (6 mg/kg). Etanercept treatment improved recovery of motor nerve conduction velocity, muscle weight loss, and sciatic functional index. Plantar thermal and von Frey mechanical withdrawal thresholds recovered faster in the etanercept group than in the control group. On day 7 after crush injury, the numbers of ED-1-positive cells in crushed nerves of the control and etanercept groups were increased compared to that in the sham-treated group. After 21 days, ED-1-positive cells had nearly disappeared from the etanercept group. Etanercept reduced expression of interleukin-6 and monocyte chemotactic and activating factor-1 at the crushed sciatic nerve. These findings demonstrate the utility of etanercept, in terms of both enhancing functional recovery and suppressing hypersensitivity after nerve crush. Etanercept does not impede the onset or progression of Wallerian degeneration, but optimizes the involvement of macrophages and the secretion of inflammatory mediators.

Mechanical advantages of a truss-structure-based fracture fixation system--a novel fracture fixation device "PinFix".

A small, light, ball-joint device called PinFix, which can instantly convert a simple percutaneous cross pin fracture fixation system into a rigid external fracture fixation system based on truss structure, was developed. The purpose of this study was to compare the mechanical load and breaking strength of this truss-structure-based fixation system to that of the conventionally used external cantilever structure-based fixation system. Three types of mechanical loading tests, axial, bending, and torsion, were performed on an artificial fractured bone treated with either three-dimensional PinFix fixation, two-dimensional PinFix fixation, or conventional external fixation. The three- and two-dimensional PinFix fixations showed significantly more stiffness than conventional fixation on all three loading tests. Finite element analysis was next performed to calculate the stress distribution of the parts in PinFix and in the conventional fixator. The applied stress to the rod and connectors of PinFix was much less than that of the conventional external fixator. These results reflected the physical characteristic of truss structure in which applied load is converted to pure tension or compression forces along the members of the PinFix. In conclusion, PinFix is a simple fracture fixation system that has a truss-structure with a high rigidity.