Volar Plate Advancement and Abductor Pollicis Brevis Tenodesis for Thumb Metacarpophalangeal Joint Hyperextension Correction.

First carpometacarpal (CMC1) osteoarthritis can be accompanied by the collapse of the first ray, with hyperextension of the first metacarpophalangeal (MCP1) joint. It is suggested that failure to address substantial MCP1 hyperextension during CMC1 arthroplasty may diminish post-operative capability and increase collapse reoccurrence. An arthrodesis is recommended in case of severe MCP1 joint hyperextension (>400). We describe a novel combination of a volar plate advancement and abductor pollicis brevis tenodesis to address MCP1 hyperextension at the time of CMC1 arthroplasty as an alternative to joint fusion. In 6 women, mean MCP1 hyperextension with pinch before surgery was 450 (range 300-850) and improved to 210 (range 150-300) of flexion with pinch six months after surgery. No revision surgery has been necessary to date, and there were no adverse events. Long-term outcome data is needed to establish the longevity of this procedure as an alternative to joint fusion, but early results are promising.

Distal Radius Fractures in Patients Aged 50 Years or Older: Obstacles to Bone Health Analysis and Follow-Up in a Community Setting.

Purpose: To determine barriers to implementing an osteoporosis protocol in a community institution following distal radius (DR) fragility fracture to help prevent subsequent fragility fractures. Methods: This cross-sectional study included elderly patients with DR fractures that occurred between 2016 and 2018. Exclusion criteria were age under 50 years, high-energy mechanism, and inability to follow-up locally. Patients were directed to follow-up with the hospital's osteoporosis center (OC) or an endocrinologist. Patients were contacted to identify if care was established with the OC and screened for potential barriers in evaluation for bone health. Primary outcomes included the completion of a follow-up visit with an osteoporosis care provider and identification of barriers for patients who did not complete this visit. Secondary outcomes included whether or not patients obtained bone health labs, dual-energy x-ray absorptiometry (DEXA) scans, and/or underwent medical treatment for osteoporosis. Results: One hundred seventy-five patients met final inclusion criteria and were contacted after discharge. Fifty patients agreed to follow-up with the OC, voicemails were left for 66 patients, only 70 (60.3%) patients actually followed up for bone health analysis. Patients were lost to follow-up due to lack of accessibility (32 patients; death, incorrect phone number, no voicemail, or impaired cognition), and lack of interest (27 patients). Ninety-six (54.9%) patients received appropriate treatment based on bone health labs and/or DEXA scan. Ninety (51.4%) patients had chemical treatment for osteoporosis. Fifty-five patients underwent DEXA scans with equal distribution of patients with normal, osteopenic, and osteoporotic bone. Forty-three (78%) patients who had DEXA scans underwent treatment. Conclusions: Establishing a protocol for follow-up for bone health assessment following a DR fracture is challenging. Only half of the patients underwent evaluation and management of their bone health. It is imperative to understand the barriers for at-risk patients to provide them with care that will improve their quality of life. Type of study/level of evidence: Diagnostic III.

Radiographic Outcomes in Treatment of Thumb Basal Joint Arthritis: Does Interposition of Acellular Dermal Allograft Prevent Metacarpal Settling?

Background Osteoarthritis at the thumb carpometacarpal joint can have a profound impact on quality of life. Here, we evaluate radiographic outcomes in patients who have had open complete trapeziectomy, ligament reconstruction with tendon interposition, and acellular dermal matrix (GraftJacket) interposition-Group A, and compare them with those without GraftJacket interposition-Group B. Materials and Methods Thirty patients who had undergone operative treatment for thumb basal joint arthritis by a single surgeon from 2009 to 2016 were identified, and charts were retrospectively reviewed for demographic data, surgical and radiographic outcomes, and complications. Results There was no significant difference in pre- and postoperative radial abduction or pre- and postoperative palmar abduction. The difference in intraoperative joint space was significant ( p = 0.006), but the difference in postoperative joint space was not ( p = 0.310). The average amount of metacarpal settling was 6.9 versus 3.7 mm ( p = 0.035) (Groups A and B, respectively). Three patients in Group A developed an inflammatory reaction to the GraftJacket, and one required reoperation for allograft removal. Conclusion This study suggests that thumb basal joint arthroplasty with GraftJacket interposition does not lead to more favorable radiographic outcomes at long-term follow-up. The increased costs associated with GraftJacket use may not be justified in light of these outcomes.

Perihamate-Peripisiform-Transtriquetrum Axial Ulnar Fracture Dislocation of the Hand With an Associated Perilunate Injury.

Axial fracture-dislocations are rare, high-energy injuries. Although cases of axial fracture-dislocations are reported in the literature, there are few reports of a patient who suffered a combined perilunate injury with an ulnar axial dislocation of the hand. This case report describes the anatomical injury and operative treatment of a patient who suffered this injury and discusses the importance of associated soft tissue management.

Fracture of the Distal Ulna Metaphysis in the Setting of Distal Radius Fractures.

BACKGROUND: Fracture of the metaphyseal region of the distal ulna is an uncommon injury that has been reported to occur concomitantly with distal radius fracture. We aimed to report the incidence and types of distal ulnar head and neck fractures associated with distal radius fractures and compare outcomes in operatively versus non-operatively treated patients. METHODS: Over a 5-year period a distal radius fracture registry was maintained at our institution. Eleven of 512 consecutive patients had metaphyseal distal ulna fractures in association with distal radius fractures and at least 1-year follow-up. Baseline radiographs and functional data were obtained, and patients were followed at 1-week, 2-week, 3-week, 6-week, 3-month, 6-month, 1-year, and 2-year intervals. Patients were split into two treatment groups: Group 1 consisted of five non-operatively treated patients, and Group 2 consisted of six operatively treated patients. RESULTS: Four separate fracture patterns were observed: simple transverse or oblique fracture of the ulnar neck just proximal to the ulnar head, fracture of the neck region with concomitant fracture of the tip of the ulnar styloid, simple fracture of the ulnar head, and comminuted fracture of the ulnar head. There were no statistical differences between the two groups with regard to flexion, extension, supination, pronation, and functional outcomes. CONCLUSIONS: Ulnar fracture patterns observed did not easily fall into previously described categories, and we have proposed a new classification system. Simple fractures of the ulnar neck or head often do not require operative fixation.

Similar Function and Improved Range of Shoulder Motion is Achieved Following Repair of Three- and Four-Part Proximal Humerus Fractures Compared with Hemiarthroplasty.

BACKGROUND: In order to compare open reduction and internal fixation (ORIF) with locked plating to hemiarthroplasty for the treatment of three- and four-part proximal humerus fractures, we compared two groups of patients treated during the same time period. MATERIALS AND METHODS: Sixty-five patients who underwent repair of a three- or four-part proximal humerus fracture with locked plates (Group A) were identified in a prospective database and were compared to 29 patients who underwent hemiarthroplasty for similar injuries (Group B). Data was collected for both groups. Shoulder motion was measured and functional outcomes were obtained using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: The mean length of follow-up for the ORIF group was 16 months compared to 44 months for the hemiarthroplasty group. The average postoperative forward flexion for patients in Group A was 131.1° and 110.4° for Group B (p < 0.047). There were no differences in DASH scores at latest follow-up (p = 0.64). Two patients in Group A had radiographic signs of osteonecrosis but had elected for no further surgery. One patient in Group A and two patients in Group B underwent a conversion to total shoulder arthroplasty. There was no difference in the rate of secondary surgery (p = 0.98). CONCLUSIONS: The results of this study suggest that ORIF using locked plates leads to similar postoperative function compared to hemiarthroplasty. Patients who underwent ORIF did achieve greater forward shoulder flexion. Neither strategy leads to a higher reoperation rate.

Total Hip Arthroplasty for Posttraumatic Osteoarthritis of the Hip Fares Worse Than THA for Primary Osteoarthritis.

We conducted a study to evaluate differences between patients who had total hip arthroplasty (THA) for posttraumatic osteoarthritis (OA) and patients who had THA for primary OA. Using a prospective database, we followed 3844 patients who had THA for OA. Those who had THA for secondary causes of hip OA, developmental hip dysplasia, or inflammatory processes were excluded. Of the remaining 1199 patients, 62 (63 fractures) had THA for posttraumatic OA after previous acetabular or proximal femur fracture fixation, and 1137 had THA for primary OA and served as the control group. In the posttraumatic OA group, mean time between fracture repair and conversion to THA was 74 months. Compared with the control patients, the posttrauma patients lost more blood, were transfused more units of blood, had longer operating room times, and had more complications (all Ps < .001). Posttrauma patients had a mean follow-up of 4.44 years and a mean postoperative modified Harris Hip Score of 81.3 at latest follow-up. Of these patients, 12.5% required revision a mean of 3.5 years after initial arthroplasty. THA in patients with posttraumatic hip OA after an acetabular or proximal femur fracture is a longer and more complicated procedure with a higher rate of early failure.

Operative treatment of nonunion following distal fibula and medial malleolar ankle fractures.

BACKGROUND: The purpose of this study was to evaluate the outcomes following operative treatment of nonunited rotational distal fibula and medial malleolar ankle fractures. METHODS: Seventeen patients were identified as having a nonunion of a rotational ankle fracture. All patients were evaluated clinically, radiographically, and functionally with the Short Musculoskeletal Functional Assessment (SMFA) questionnaire. They were divided into lateral and medial malleolus groups and compared with 44 patients following a nonoperative (SE2/3) ankle fracture and 25 patients who underwent operative fixation of their SE4 ankle fracture for functional comparison. RESULTS: Two of the 17 patients were excluded. The patients in the medial malleolar group were notably older than those in the other groups. Nonunions included 12 distal fibulas and 3 medial malleoli. All patients were treated with open reduction with plate and screw fixation or screw fixation alone. Adjunctive grafting was performed in all but 2 cases. The average time to healing was 5.2 months post surgery. At latest follow-up, mean 33.9 months, all nonunions had resolved. Standardized SMFA scores differed notably among the groups in the Bothersome, Emotional, and Mobility categories. There was no difference between lateral malleolar nonunion patients and surgically treated SE4 patients. CONCLUSIONS: Reports of nonunions of fractures of lateral and medial malleoli have been rarely reported. Operative treatment of these nonunions in this study led to reliable bony healing. Patients who underwent surgery for these nonunions ultimately had similar outcomes and range of motion compared with patients who underwent operative treatment for acute ankle fractures. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Results following operative treatment of tibial plateau fractures.

A total of 96 displaced tibial plateau fractures in 94 patients (average age, 48 years) were treated with open reduction and internal fixation. At 12 months postoperatively, mean range of knee motion was 126 degrees and 10 (10%) of the patients had required a secondary surgery. Using a binary regression model, no demographic variable such as age, gender, smoking history, diabetes, BMI; or fracture characteristic such as mechanism of injury, initial plateau depression, Schatzker classification was identified that correlated with short-term functional outcome such as a complication, range of motion, healing time, or residual depression. We determined that radiographic fracture reduction was not superior following fractures with less initial displacement, and increased plateau collapse at 12 months postoperatively was not indicative of decreased function. However, an increased postoperative articular step-off was found to be associated with an increased risk of plateau collapse (p < 0.01). Furthermore, at 12 months, 76% of the patients had returned to their preinjury employment and the overall complication rate was 13%.

Prevention of atrophic nonunion by the systemic administration of parathyroid hormone (PTH 1-34) in an experimental animal model.

OBJECTIVES: Recombinant human parathyroid hormone (PTH 1-34) has been previously shown to enhance fracture healing in animal models. Here, we sought to determine whether the systemic administration of PTH 1-34 is effective in preventing atrophic fracture nonunion in a murine, surgical nonunion model. METHODS: We used an established reproducible long-bone murine fracture nonunion model by generating a midshaft femur fracture, followed by fracture distraction using an intramedullary pin and custom metallic clip to maintain a fracture gap of 1.7 mm. Mice were randomized to receive either daily intraperitoneal injections of 30 µg/kg PTH 1-34 for 14 days or saline injections. At 6 weeks after the procedure, radiographic and histologic assessment of fracture healing was performed. RESULTS: At 6 weeks after surgery, the group treated with PTH showed higher rates of bony union (50% vs 8%; P < 0.05) as assessed by radiographic analysis. Mean gap size was also significantly lower in the PTH group (1.42 vs 0.36 mm in the control group; P < 0.05). Histologic analysis of atrophic nonunions in the control group revealed a persistent fracture gap with intervening fibrous tissue. In contrast, healed subjects in the PTH-treated group had cortical bridging with mature bone and relatively little callus, which is consistent with primary intramembranous ossification. CONCLUSIONS: Daily systemic administration of recombinant PTH 1-34 increased the rate of union in a mouse atrophic nonunion model. This may have important implications for the potential clinical role of PTH 1-34 in the treatment of atrophic fracture nonunions.