Intramedullary Plate Fixation and Viable Bone Allografting in a Complex Intra-articular Distal Radius Fracture Nonunion: A Case Report.

In this report, we detail a 69-year-old female who sustained a comminuted intra-articular left distal radius fracture that failed to heal with bridge plate fixation. Given the patient's poor subchondral bone stock and refusal of bone autograft, we designed a construct using a dorsal spanning plate and an intramedullary fragment-specific plate as a volarly placed strut in combination with viable bone allograft and cancellous bone chips to treat this nonunion. This case demonstrates an option for distal radius non-union treatment and highlights the importance of ingenuity that orthopedic surgeons should demonstrate when trying to accommodate patients' wishes.

A case report of a distal radius fracture treated with a dorsal spanning plate augmented with fragment specific fixation.

Dorsal spanning plates are frequently utilized to manage comminuted intra-articular distal radius fractures, but there is little literature on combining them with augmented fixation in complex cases. We present a 43-year-old man who fell 5 ft onto his outstretched right hand. On examination, there was gross swelling and tenderness of the right wrist with no neurovascular deficit. Radiographs confirmed a comminuted intra-articular displaced distal radius fracture. He was treated with a dorsal spanning plate fixation combined with radiostyloid and volar buttress plates. Follow-up at 2 months showcased intact hardware with good fracture healing. The dorsal spanning plate was removed 4 months after the procedure with radiographs demonstrating adequate alignment and healing without failure. The patient reported no complaints and minimal functional disability. We highlight a case of augmenting a dorsal spanning plate with fragment-specific plate fixation for a comminuted intra-articular displaced distal radius fracture.

Antineuropathic Pain Management After Orthopedic Surgery: A Systematic Review.

Background: The opioid crisis has become a present concern in the medical field. In an effort to address these complications, antineuropathic pain medications have been considered as alternatives to prescribed opioids. Objective: This review focuses on the analgesic effects of neuromodulators, such as gabapentin, duloxetine, and pregabalin, that provide room for less dependence on narcotic analgesics following orthopedic surgery. Methods: During the database searches, 1,033 records were identified as a preliminary result. After duplicates were removed, an initial screen of each article was completed which identified records to be removed due to absence of a full-text article. Articles were excluded if they were not either prospective or retrospective, showcased an irrelevant medication (such as tricyclic antidepressants) which are not pertinent to this review, or deemed to be unrelated to the topic. Results: Ultimately, 19 articles were selected. Three different drugs, gabapentin, pregabalin, and duloxetine, were analyzed to compile data on the effectiveness of preventing opioid overuse and addiction following hand surgery. This review identifies potential evidence that peri-operative gabapentin, pregabalin, and duloxetine administration decreases post-operative pain and lowers opioid dependency. Conclusion: Gabapentin, pregabalin, and duloxetine have potential to further decrease post-operative pain and lower opioid dependency. This review creates an opening for further research in hand surgery to assess an updated protocol for pain management to reduce opioid dependency.

Histopathologic Analysis of a Recalcitrant Calcaneal Wound Treated Using a Synthetic Hybrid-scale Fiber Matrix.

Traditionally, full-thickness wounds with exposed structures are treated with flap coverage or dermal regenerative templates. Most dermal regenerative templates are biologic in origin, but recently synthetic options have become available. One such product is a synthetic hybrid-scale fiber matrix (SHSFM). In this case, SHSFM was used to treat a recalcitrant calcaneal wound. After the wound granulated, it was biopsied, and histopathologic analysis was conducted. A 16-year-old woman involved in a motor vehicle collision sustained multiple traumatic injuries which were stabilized. Postoperatively, she developed a calcaneal infection and associated wound, which developed into a chronic, nonhealing wound. Failed treatments included removal of hardware, multiple debridements, and advanced wound therapies. An SHSFM was then trialed, which led to granulation of the wound without infection. Despite wound healing, the patient subsequently elected to undergo a below-the-knee amputation due to pain and functional disability from posttraumatic ankle arthritis. The heel was biopsied at the time of amputation for analysis. Pathologists noted excellent granulation tissue formation and complete coverage of the wound surface area and 75% of the wound depth, which included epithelialization and decreasing inflammation at wound edges. Collagen deposition and numerous interspersed blood vessels were present. Foreign material and bacteria were absent. No osteomyelitis was observed. This analysis provided the opportunity to investigate the in vivo regenerate from a novel synthetic SHSFM. Given the uniqueness and challenges presented in this case, the usage of this relatively new product warrants further investigation with larger populations and assorted wound etiologies.

The effect of smoking on open carpal tunnel release recovery.

INTRODUCTION: This study examines the relationship between smoking status and surgical outcomes in open carpal tunnel release. Smoking status has previously been correlated with orthopedic surgical complications unless smoking cessation occurs at least 4 weeks prior to surgery; however, the effect of smoking on open carpal tunnel release has not been specifically examined. METHODS: This study is a retrospective review of patient charts over the last 5 years (n = 131). Smoking status was determined at the time of carpal tunnel release from the patients' charts. Patients were dichotomized as smokers (n = 58) or non-smokers (n = 73). Data comprised preoperative pain, postoperative pain at 2 and 6 weeks, postoperative wrist stiffness, wound healing time, and infection status. Data were compared on chi square, Fisher exact, and one-sided Fisher exact tests. RESULTS: Infection rates were significantly higher in smokers. Postoperative numbness and wrist stiffness were also significantly higher in smokers. Smokers reported higher postoperative pain scores at 2 and 6 weeks. Non-smokers were also significantly more likely to report complete pain resolution at 6 weeks. DISCUSSION: In the present study smoking was associated with surgical outcome complications in open carpal tunnel release. This could be attributed to immune system suppression or to poor wound healing, both of which are known side-effects of smoking. Pain scores 6 weeks post-surgery were significantly higher in smokers than in non-smokers. Smokers undergoing open carpal tunnel release need to understand the risk of surgical complications and should consider smoking cessation to optimize their chances of successful surgery. CONCLUSION: Patients who were active smokers showed poorer recovery from open carpal tunnel surgery than non-smoking patients.

The Effect of Body Mass Index on Open Carpal Tunnel Release Recovery.

Purpose: The purpose of this study was to determine whether a relationship exists between body mass index (BMI), specifically obesity, and surgical outcomes for open carpal tunnel release. Obesity is correlated with increased incidence of carpal tunnel syndrome; however, the effect of obesity on after release recovery has not been examined. Methods: This study used a retrospective review of patient charts (n = 142). BMI was calculated based on height and weight measurements, and patients were grouped based on their BMI into the following categories: healthy BMI (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), obesity class one (30-34.9 kg/m2) (OB1), obesity class (2 35-39.9 kg/m2) (OB2), or obesity class three (40+ kg/m2) (OB3). Data were then complied on surgical outcomes by assessing preoperative pain, postoperative pain at 2 and 6 weeks, postoperative joint stiffness, wound healing time, and infection status. Data were analyzed using chi-square analyses and multivariable logistic regression to assess the differences in treatment outcomes while controlling for possible confounding variables. Results: Age at the time of release was found to be inversely correlated with BMI. Healthy BMI patients (n = 19) underwent release at an average age of 59.1 years, whereas OB3 (n = 30) underwent release at an average age of 46.9 years. The odds of improvement in pain were significantly lower in all three obesity groups when compared with healthy BMI at both 2 and 6 weeks after operation. Conclusions: Our results indicate that obesity may be positively correlated with earlier incidence of carpal tunnel syndrome requiring surgical intervention. These data also indicate the increased rates of postoperative complications in obese patients, particularly patients with OB3. Patients with OB3 need to understand these risks before undergoing open release. Further study should examine the impact of type 2 diabetes on carpal tunnel release recovery. Clinical relevance: The information included in this study may be used to guide surgeons and patients when considering the effect and potential improvement in outcomes that may come from addressing patient BMI before open carpal tunnel surgery.

Insufflation via a peritoneal dialysis catheter is a safe way to achieve pneumoperitoneum: a case report.

A 66-year-old female with a preoperative high index hostile abdomen was incidentally found to have a right T1a 16 mm renal cell carcinoma mass. She safely underwent robot assisted partial nephrectomy after her peritoneal dialysis catheter was alternatively used for insufflation. This adjustment in technique reduced risk related morbidity and possible conversion to open laparotomy.