Outcomes and Complications of Intramedullary Metacarpal Fixation.

BACKGROUND: Metacarpal fractures are common orthopedic injuries with potentially debilitating outcomes. Ideal surgical treatment remains a topic of debate, with intramedullary fixation becoming popular as a technique to allow for earlier mobilization with few reported complications. The aim of this study was to report observed outcomes and complications of intramedullary metacarpal fixation using the ExsoMed INnate metacarpal nail. METHODS: A retrospective chart review of 37 patients with 44 metacarpals treated with the ExsoMed INnate between July 2020 and December 2021 by a single fellowship-trained hand surgeon at a single level 1 trauma center was performed. Variables recorded included both patient and injury demographics, surgical complications, and postoperative outcomes. We also measured metacarpal isthmus diameter of the second to fifth metacarpals on all patients to determine the intramedullary canal diameter to assist in implant size selection. RESULTS: Average follow-up was 5.84 weeks with average time to radiographic healing of 5.5 weeks, and time to full activity 6.32 weeks. The mean postsurgical active total arc of motion was 250°, while passive total arc of motion was 259.74°. A total of 10 complications (22%) were identified, including 4 bent screws which occurred as a result of a punching event postoperatively. CONCLUSIONS: Intramedullary fixation of metacarpal fractures using the ExsoMed INnate metacarpal nail has shown to preserve range of motion and quick return to full activity, with a low rate of major complications. Our study highlights the potential major complication of the bent intramedullary screw and its association with an initial punching mechanism.

A Missed Case of Synovial Osteochondromatosis.

Synovial osteochondromatosis or synovial chondromatosis is a benign joint pathology characterized by the development of multiple cartilaginous nodules or loose bodies in the synovial membrane that typically arise in the larger joints of the body. It usually presents as joint pain and, as seen in the present case, can occasionally be missed. Diagnosis involves a combination of clinical evaluation, imaging studies, and histopathological evaluation (which is confirmatory). Treatment depends on the severity of the disease, symptoms, and the patient's social situation, and may include monitoring for asymptomatic cases, non-surgical management (pain medications and physical therapy), or surgical intervention. Surgical intervention may include arthroscopic removal of loose bodies, synovectomy, or reconstruction/replacement in severe situations. Prognosis has a direct relationship to how early the disease is diagnosed. Early intervention with appropriate management can help alleviate symptoms; however, if left unmanaged, it can lead to joint damage and osteoarthritis or very rarely, malignant transformation into chondrosarcoma. This report describes the case of a 62-year-old female with complaints of bilateral knee pain who was originally diagnosed with osteoarthritis based on clinical exam and X-rays. Two magnetic resonance imaging (MRI) scans were done three years apart, with synovial osteochondromatosis being on the differential after the second scan. A left knee major synovectomy was conducted after the second MRI reading, where rubbery masses of tissue along with loose fragments were removed. Fluid from the tissue masses was sent to culture and pathology for interpretation. Two weeks post the surgery, the patient's pain improved tremendously, with adequate ambulation independently. Histopathology came back positive for synovial osteochondromatosis. This case report highlights the importance of keeping this joint pathology on the differential when treating patients with joint pain and interpreting imaging.

Iliac Crest Bone Graft With Intramedullary Headless Implant for Metacarpal Bone Loss.

ABSTRACT: Metacarpal bone loss presents a challenging reconstructive dilemma for hand surgeons. While multiple bone grafting techniques have been described, complications including nonunion, graft resorption, fixation requiring prolonged immobilization, stiffness, and the need for multiple procedures are well-documented. We present a technique for managing metacarpal bone loss utilizing a tri-cortical iliac crest graft and an intramedullary metacarpal nail for the treatment of metacarpal fractures and nonunions that is technically simple, fast, and allows for early initiation of motion to decrease postoperative complications. LEVEL OF EVIDENCE: Level IV- Therapeutic.

Effects of Sterilization Techniques on Bioactivity of Polymethyl Methacrylate Antibiotic Beads Containing Vancomycin and Tobramycin.

OBJECTIVES: Prefabrication and storage of antibiotic beads may decrease surgical time and allow for use in other settings. This study investigated the effects of sterilization technique and storage time on the bioactivity of antibiotic polymethyl methacrylate (PMMA) beads. METHODS: Uniform beads of PMMA containing 1 g each of tobramycin and vancomycin were sterilized using autoclave, ethylene oxide (ETO), or ultraviolet (UV) light. Beads were made in a sterile fashion as a control. Disks containing eluted antibiotics from each of the 4 groups were placed onto agar plates inoculated with Staphylococcus aureus. Zones of inhibition, a measure of bioactivity for antibiotic eluted, were determined for the experimental groups and control. Repeat testing was performed for beads stored for 1 week, 1, 3, and 6 months. RESULTS: Beads sterilized using autoclave, ETO, and UV light showed similar ZOIs after 24 hours of and 1 week of elution compared with the control group. Beads stored for up to 6 months demonstrated similar bioactivity to beads made sterile and tested immediately. CONCLUSION: PMMA beads containing vancomycin and tobramycin made in a sterile fashion and stored for up to 6 months have the same efficacy as the current standard of beads made sterile and used immediately. The elution and bioactivity of vancomycin-tobramycin antibiotic beads are not negatively impacted by the sterilization methods of autoclaving, ETO gas, or UV light. Furthermore, nonsterile beads can be sterilized and stored up to 6 months with an expected efficacy comparable with beads made in a standard sterile fashion.

Laparoscopic Heller myotomy and Dor fundoplication in the same day surgery setting with a trained team and an enhanced recovery protocol.

BACKGROUND: The length of stay after Heller myotomy is 1-5 days. The aim was to report feasibility of the procedure as same day surgery (SDS). METHODS: Three steps of Enhanced Recovery After Surgery protocol: preoperatively, clear liquid diet for 24 hours, in preoperative area: antiemetics as dermal patch/IV form, 2: Intraoperatively, intubation in semi upright position, IV analgesics and antiemetics. 3: Postoperatively, clear liquid diet and discharge instructions. Patients were followed using a phone questionnaire. Values are median (interquartile range). RESULTS: Fifty-seven patients, 32 M (56%)/25F (44%), age 48 (35-59). First 45 were inpatient with LOS of 1 day. Last 12 were planned as same day surgery, 1/12 was discharged on POD#2, 11/12 (92%) were performed as same day surgery. The duration of operation: 139.5 min (114-163) inpatient: vs 123 (107-139) same day surgery, P < .01. Questionnaires were obtained in 78% inpatient at 40 months (25.6-67) vs 82% same day surgery at 8 (4-12). All were satisfied with the operation with no difference between the 2 groups. CONCLUSION: Heller myotomy can be planned as same day surgery and performed successfully in majority of patients with a trained team and an Enhanced Recovery After Surgery protocol focused on prevention of nausea, and pain control in perioperative period.