Management of complications with hand fractures.

Both operative and nonoperative treatment of hand fractures can result in numerous complications, including stiffness, malunion, nonunion, arthritis, infection, and complex regional pain syndrome. These complications are frequently encountered and are often challenging to treat. This article systematically outlines the diagnosis and treatment of each of these complications to achieve the best possible outcome for the patient's overall hand function.

Terrible triad elbow fracture-dislocation with triceps and flexor-pronator mass avulsion.

Terrible triad elbow injuries, consisting of fractures of the radial head and coronoid with ulnohumeral dislocation, are challenging to treat. They require a comprehensive understanding of the complex anatomy of the elbow to effectively treat all of the pathology and create a stable, congruent joint. The authors present a case of a terrible triad injury with avulsion of the triceps and flexor-pronator mass after a low-energy fall in a young patient. Although most terrible triad fracture-dislocations can be successfully treated with coronoid fixation, radial head fixation or replacement, and repair of the lateral collateral ligament complex, this case involved a completely circumferential injury to the elbow. The coronoid and anterior capsule were disrupted anteriorly, the radial head and lateral collateral ligament complex were disrupted laterally, the triceps was disrupted posteriorly, and the flexor-pronator mass was disrupted medially. Although the authors prefer to address most terrible triad injuries through a lateral approach, they suspected a circumferential injury preoperatively and elected to use a single posterior incision to address all of the pathology conveniently. This injury required treatment of all disrupted structures, because the elbow remained unstable until the triceps and flexor-pronator mass avulsions were ultimately repaired. With any elbow fracture-dislocation, surgeons should look for evidence of additional injuries that do not fit the commonly described patterns, because they may necessitate modifications to the treatment plan. Given the relatively common complications of stiffness and instability despite modern surgical techniques, additional injuries may further compromise functional outcomes unless they are addressed properly.

Multiple collagenase injections are safe for treatment of Dupuytren's contractures.

The authors report the case of a 65-year-old, right-hand-dominant man who had severe Dupuytren's disease with multiple cords and flexion contractures of the metacarpophalangeal and proximal interphalangeal joints of both hands and underwent repeated collagenase injections for treatment. Collagenase has been shown to be safe and effective in the treatment of Dupuytren's contractures when administered as a single dose, but the results of multiple injections over a prolonged period are unknown. Antibodies to collagenase develop in all patients after several treatments, raising concerns about safety and efficacy as a result of sensitization from repeated exposures. The antibodies generated as a result of repeated exposure to collagenase could theoretically render it less effective with time and could also lead to immune reactions as severe as anaphylaxis. The authors present the case of a single patient who experienced continued correction of his contractures with only minor and self-limited adverse reactions after administration of 12 collagenase doses through 15 injections during a 4-year period. Over time, the injections continued to be effective at correcting metacarpophalangeal joint contractures, but less effective at correcting proximal interphalangeal joint contractures. The patient did eventually require a fasciectomy, but the safety and modest success of the repeated collagenase injections shows promise for a less invasive treatment with a better risk profile than open fasciectomy. Although further studies are needed, repeated administration of collagenase appears to be safe and modestly effective for severe Dupuytren's contractures, although a fasciectomy may ultimately be required in the most severe cases.

Surgical technique: Methods for removing a Compress® compliant prestress implant.

BACKGROUND: The Compress® device uses a unique design using compressive forces to achieve bone ingrowth on the prosthesis. Because of its design, removal of this device may require special techniques to preserve host bone. DESCRIPTION OF TECHNIQUES: Techniques needed include removal of a small amount of bone to relieve compressive forces, use of a pin extractor and/or Kirschner wires for removal of transfixation pins, and creation of a cortical window in the diaphysis to gain access to bone preventing removal of the anchor plug. METHODS: We retrospectively reviewed the records of 63 patients receiving a Compress® device from 1996 to 2011 and identified 11 patients who underwent subsequent prosthesis removal. The minimum followup was 1 month (average, 20 months; range, 1-80 months). The most common reason for removal was infection (eight patients) and the most common underlying diagnosis was osteosarcoma (five patients). Three patients underwent above-knee amputation, whereas the others (eight patients) had further limb salvage procedures at the time of prosthesis removal. RESULTS: Five patients had additional unplanned surgeries after explantation. Irrigation and débridement of the surgical wound was the most common unplanned procedure followed by latissimus free flap and hip prosthesis dislocation. At the time of followup, all patients were ambulating on either salvaged extremities or prostheses. CONCLUSION: Although removal of the Compress® device presents unique challenges, we describe techniques to address those challenges.

Is the fibronectin-aggrecan complex present in cervical disk disease?

OBJECTIVE: To investigate the presence of inflammatory cytokines and the fibronectin-aggrecan complex (FAC) in persons undergoing surgical treatment for cervical radiculopathy caused by disk herniation. DESIGN: Single-center, prospective, consecutive case series. SETTING: A single large academic institution. PATIENTS: A total of 11 patients with radiculopathic pain and magnetic resonance imaging findings positive for disk herniation elected to undergo single-level cervical diskectomy. METHODS OR INTERVENTIONS: Lavage was performed by needle injection and aspiration upon entering the disk space for fluoroscopic localization before diskectomy. MAIN OUTCOME MEASUREMENTS: The lavage fluid was assayed for pH and the FAC, as well as for the cytokines interleukin-6 (IL-6), interferon-γ, monocyte chemotactic protein (MCP), and macrophage inhibitory protein-1ß. RESULTS: The subjects were 7 women and 4 men with a mean age of 50.6 years (SE 9.7; range, 36-70 years). The mean concentrations (SE; range) in picograms per milliliter were 7.9 (4.4; 0-44) for IL-6, 25.3 (15.5; 0-159) for interferon-γ, 16.1 (11.9; 0-121) for MCP, and 6.1 (2.8; 0-29) for macrophage inhibitory protein-1ß. The optical density of the FAC at 450 nm was 0.151 (0.036; 0.1-0.32), and the pH was 6.68 (0.1; 6.10-7.15). Statistically significant correlations were found between MCP and FAC (P = .036) and between FAC and pH (P = .008). CONCLUSIONS: Biochemical analysis of injured cervical intervertebral disks reveals the presence of inflammatory markers such as MCP, fragments of structural matrix proteins such as FAC, and a correlation with pH. Further evaluation of the FAC as a potential diagnostic biomarker or therapeutic target is warranted in the cervical spine.

Biomechanical comparison of double-row locking plates versus single- and double-row non-locking plates in a comminuted metacarpal fracture model.

PURPOSE: Open or unstable metacarpal fractures frequently require open reduction and internal fixation. Locking plate technology has improved fixation of unstable fractures in certain settings. In this study, we hypothesized that there would be a difference in strength of fixation using double-row locking plates compared with single- and double-row non-locking plates in comminuted metacarpal fractures. METHODS: We tested our hypothesis in a gap metacarpal fracture model simulating comminution using fourth-generation, biomechanical testing-grade composite sawbones. The metacarpals were divided into 6 groups of 15 bones each. Groups 1 and 4 were plated with a standard 6-hole, 2.3-mm plate in AO fashion. Groups 2 and 5 were plated with a 6-hole double-row 3-dimensional non-locking plate with bicortical screws aimed for convergence. Groups 3 and 6 were plated with a 6-hole double-row 3-dimensional locking plate with unicortical screws. The plated metacarpals were then tested to failure against cantilever apex dorsal bending (groups 1-3) and torsion (groups 4-6). RESULTS: The loads to failure in groups 1 to 3 were 198 +/- 18, 223 +/- 29, and 203 +/- 19 N, respectively. The torques to failure in groups 4 to 6 were 2,033 +/- 155, 3,190 +/- 235, and 3,161 +/- 268 N mm, respectively. Group 2 had the highest load to failure, whereas groups 5 and 6 shared the highest torques to failure (p < .05). Locking and non-locking double-row plates had equivalent bending and torsional stiffness, significantly higher than observed for the single-row non-locking plate. No other statistical differences were noted between groups. CONCLUSIONS: When subjected to the physiologically relevant forces of apex dorsal bending and torsion in a comminuted metacarpal fracture model, double-row 3-dimensional non-locking plates provided superior stability in bending and equivalent stability in torsion compared with double-row 3-dimensional locking plates, whereas single-row non-locking plates provided the least stability.

Unusual Variant of the Nutcracker Fracture of the Calcaneus and Tarsal Navicular.

A 62-year-old woman with severe seizure disorder presented with right ankle and foot pain after being found down, presumably following a seizure recurrence. Imaging showed an acute comminuted fracture of the anterolateral aspect of the right calcaneus, as well as an acute avulsion fracture of the right navicular tuberosity at the site of insertion of the tibialis posterior tendon. This fracture pattern suggests forced abduction of the midfoot or forefoot with severe compression of the lateral column and failure of the medial column under tension, an entity that has previously been described as the nutcracker fracture. This mechanism of injury should prompt particularly careful evaluation of the navicular, cuboid, and calcaneus for any signs of injury. Subtle fractures of the navicular and calcaneus may be overlooked in the emergency setting, leading to a delay in surgical treatment and ultimately chronic foot deformities that can result in significant functional disability.

Long-term outcomes of dorsal intercarpal ligament capsulodesis for chronic scapholunate dissociation.

PURPOSE: Chronic scapholunate dissociation is the most common cause of symptomatic wrist instability. In an attempt to restore normal carpal mechanics and prevent wrist arthrosis, we developed and tested biomechanically the dorsal intercarpal ligament capsulodesis (DILC). Previously, we reported good early clinical results for this procedure at an average follow-up period of 25 months. Here, we report on the functional and radiographic outcomes at a longer follow-up period of a minimum of 5 years. METHODS: Records of patients undergoing the DILC for chronic (greater than 6 weeks), flexible, static scapholunate dissociation were reviewed. Only patients with follow-up evaluation of greater than 60 months were included. Physical examination, radiographs, and validated outcome instruments were used to evaluate the patients. RESULTS: Twenty-one patients (22 wrists) met the inclusion criteria. Fifteen of 21 patients (16 wrists) were available for follow-up evaluation. Average follow-up period was 86 months. Physical examination revealed average wrist flexion and extension of 50 degrees and 55 degrees , respectively, radial and ulnar deviation of 17 degrees and 36 degrees , respectively, and grip strength of 43 kgf. Disabilities of the Arm, Shoulder and Hand, Short Form-12, and Mayo wrist scores averaged 19, 78, and 78, respectively. Radiographs revealed an average scapholunate angle and gap of 62 degrees and 3.5 mm, respectively. Eight of the 16 wrists in our study demonstrated arthritic changes on radiographs. CONCLUSIONS: The DILC does not consistently prevent radiographic deterioration and the development of arthrosis in the long-term; however, the level of functionality and patient satisfaction remained relatively high in 58% of our patients, suggesting a lack of correlation between the radiographic findings and development of arthrosis and the functional outcomes and patient satisfaction. We believe that the DILC is still a reasonable option for treating flexible static scapholunate dissociation in patients without radiographic signs of arthritis presenting with wrist pain despite conservative treatment. Prevention of radiographic deterioration and arthrosis remains an unsolved problem.

An application of bioinformatics and text mining to the discovery of novel genes related to bone biology.

The treatment and management of complex genetic diseases such as osteoporosis can greatly benefit from the integration of relevant research across many different disciplines. We created a text mining tool that analyzes the PubMed literature database and integrates the available genomic information to provide a detailed mapping of the genes and their interrelationships within a particular network such as osteoporosis. The results obtained from our text mining program show that existing genomic data within the PubMed database can effectively be used to predict potentially novel target genes for osteoporosis research that have not previously been reported in the literature. To filter the most significant findings, we developed a ranking system to rate our predicted novel genes. Some of our predicted genes ranked higher than those currently studied, suggesting that they may be of particular interest from a therapeutic standpoint. A preliminary analysis of the current biomedical literature in our research area using our tool suggests that S100A12, as well as a group of SMAD genes previously unstudied in relation to osteoporosis, may be highly relevant to the mechanism of action of bisphosphonates, that the function of osteocytes may be influenced by a family of important interleukins and interleukin-related molecules, and that the FYN oncogene may play an important role in regulating the apoptosis of bone cells in the context of degenerative bone diseases. An evaluation of our tool's predictive ability with an analysis of PubMed literature published before the year 2000 in the area of osteoporosis research shows that many of its top-rated novel target genes from that analysis were later studied and shown to be relevant to osteoporosis in the period between 2000 and 2006. We believe that our tool will be beneficial to researchers in the field of orthopaedics seeking to identify novel target genes in their research area, and it will allow them to delve deeper into the complex interplay between genes, biological systems and diseases.

Testicular cancer patterns in African-American men.

OBJECTIVES: To compare the testicular cancer incidence, pathologic grade, stage, and survival between African Americans and whites. African Americans had a worse outcome relative to whites with regard to a number of different malignancies. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database, we extracted all testicular cancer cases among white and African-American males for 1985 to 2000. Baseline demographic data included age at diagnosis, year of diagnosis, stage at diagnosis, and histologic type. Survival was examined using the Kaplan-Meier method and Cox proportional hazards modeling. RESULTS: The incidence of testicular cancer among African Americans was one fourth that observed among whites. However, African-Americans presented with a higher disease stage at diagnosis. African Americans also presented with significantly lower proportions of embryonal cell carcinoma. Overall survival among African-Americans was significantly worse at both 5 and 10 years. When overall survival was adjusted for stage at presentation and histologic type, the observed survival differences disappeared. CONCLUSIONS: African Americans appear to present with a higher disease stage than do whites. Observed differences in survival for the African-American group relative to whites appear to be primarily due to delayed presentation. Cultural perceptions of malignancy and understanding of cancer screening may be an important determinant of later presentation. Healthcare access and education issues, rather than inherent biologic differences, appear to be the primary underlying factor for the observed survival differences in African-American males.