Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Acrometastasis of Occult Renal Cell Carcinoma: A Case Report.

Renal cell carcinoma is a common malignancy with 30,000 new cases reported annually in the U.S. While bone is one of the most common sites of metastases of renal cell carcinoma, acrometastases are rare with an estimated incidence of 0.1 percent among patients with malignant disease. We present an 89-year-old white male who presented with a painful mass of the left thenar eminence. A preoperative medical evaluation revealed metastatic renal cell carcinoma with lytic infiltration of the diaphysis of the left thumb metacarpal with soft tissue involvement. The patient was treated with two intralesional currettage procedures and later radiation therapy. This approach allowed the patient to maintain functional use of the thumb for activities of daily living.

Wide-Awake Hand Surgery Has Its Benefits: A Study of 1,011 Patients.

Purpose: Wide-awake local anesthesia with no tourniquet has dramatically changed hand surgery practice. Using lidocaine with epinephrine and no tourniquet has allowed many procedures to be moved from the main operating room to an in-office procedure room. Previous studies have shown that using local anesthesia is safe and cost effective, with high patient satisfaction. This study evaluated patient satisfaction and complications for the first 1,011 elective hand surgeries performed using wide-awake anesthesia in an in-office procedure room. Methods: The first 1,011 patients who underwent elective hand surgery in an in-office procedure room were surveyed regarding their satisfaction. The patients were monitored for postoperative complications. Patient survey results and complications were logged in a database and analyzed. Results: Single-digit trigger finger release was the most common procedure performed (n = 582), followed by mass excision (n = 158), multiple-digit trigger finger releases (n = 109), and carpal tunnel release (n = 41). There were 43 (4.3%) superficial skin infections, with the majority seen in single-digit trigger finger releases (n = 27). There were no deep wound infections. All infections were managed nonsurgically with oral antibiotics and local wound care. Ninety-nine percent of the patients rated the in-office procedure room experience as the same as or better than a dental visit, would recommend wide-awake anesthesia to a friend or family member, and would undergo the procedure again. Using "lean and green" hand packs saved our institution more than $65,000 and saved 18.4 tons of waste during this study period. Conclusions: Surgical procedures performed with wide-awake local anesthesia with no tourniquet in an in-office procedure room can be performed safely with a low infection rate, are cost effective, and have high patient satisfaction. Clinical relevance: Minor hand surgery done in an in-office procedure room is safe, is cost effective, and has high patient satisfaction.

Fracture of the Volar Ulnar Index Metacarpal Base: Literature Review.

Information regarding the management of intra-articular base fractures of the index metacarpal is scarce. Fractures of the base of the index metacarpal are rare because of the inherent stability of the joint. Of the handful of case reports on this injury, there appear to be 2 main patterns: fractures of the dorsal radial condyle and fractures of the volar ulnar condyle, which are attached to the extensor carpi radialis longus and flexor carpi radialis tendons, respectively. Although majority of previously reported volar fragment fractures were treated with Kirschner wire stabilization, we reported a case that was managed nonsurgically. The case presented is of a 70-year-old man with a fracture of the volar ulnar condyle of the base of the index metacarpal. Although he initially struggled with swelling of the hand and mobility of the fingers, he did well with nonsurgical management and regained full strength in his hand.

Erosive Tophaceous Gouty Arthropathy of the Hand: A Case Report.

The presence of tophaceous gout in the hand is a classic finding seen in uncontrolled gout. Occasionally gouty tophi can be the initial physical finding in asymptomatic hyperuricemia. Composed of monosodium urate (MSU) crystals, gouty tophi can cause significant soft tissue and joint pathology. In addition, tophaceous gout and hyperuricemia are associated with increased mortality. We present a patient with tophaceous gout causing erosive arthropathy of the proximal interphalangeal (PIP) joint. The diagnosis and treatment for tophaceous gout is reviewed.

Acute Calcific Tendinitis of the Flexor Carpi Ulnaris Tendon Treated with Lavage and Steroid Injection: A Case Report.

Acute calcific tendinitis (ACT) is a relatively uncommon disorder that can involve the hand and wrist. ACT is frequently misdiagnosed due to a lack of familiarity with the condition and the clinical presentation that can be confused with other conditions. We report a case of acute calcific tendinitis of the flexor carpi ulnaris (FCU) tendon in a 68-year-old woman. She presented with acute left volar wrist pain, erythema, swelling, and restricted range of motion. Due to her inability to take nonsteroidal anti-inflammatory drugs (NSAIDs) and oral prednisone, she was treated with lavage and steroid injection of the calcified mass. Following the injection, there was dramatic improvement in her symptoms. Cortisone injection with lavage is an accepted treatment for rotator cuff calcific tendinitis and is another treatment option for ACT involving the hand and wrist.

Time to Stop Routinely Prescribing Opiates after Carpal Tunnel Release.

BACKGROUND: North American surgeons continue to routinely order narcotic medication for postoperative pain relief after carpal tunnel surgery. For some patients, this instigates persistent use. This double-blind, multicenter trial investigated whether over-the-counter medications were inferior to opioid pain control after carpal tunnel release. METHODS: Patients undergoing carpal tunnel release in five centers in Canada and the United States (n = 347) were randomly assigned to postoperative pain control with (opioid) hydrocodone/acetaminophen 5/325 mg versus over-the-counter ibuprofen/acetaminophen 600/325 mg. The two primary outcome measures were the Numeric Pain Rating Scale (0 to 10) and the six-item Patient-Reported Outcome Measurement Information System Pain Interference T-score. Secondary outcome measures were total medication used and overall satisfaction with pain medication management. RESULTS: The authors found no significant differences between opioid and over-the-counter patients in the Numeric Pain Rating Scale scores, Pain Interference T-scores, number of doses of medication, or patient satisfaction. The highest Numeric Pain Rating Scale group difference was the night of surgery, when opiate patients had 0.9/10 more pain than over-the-counter patients. The highest group difference in Pain Interference T-scores (2.1) was on the day of surgery, when the opiate patients had more pain interference than the over-the-counter group. Patient nationality or sex did not generate significant pain score differences. CONCLUSIONS: Pain management is not inferior for patients managed with over-the-counter acetaminophen/ibuprofen versus opioids. This study provides high-quality evidence that U.S. and Canadian surgeons should stop the routine prescription of narcotics after carpal tunnel surgery for patients who are not taking pain medicines daily before surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Osteochondrolipoma of the Hand.

Lipoma is the most common type of benign soft tissue tumor and is composed of mature adipose tissue. A neoplasm of adipose tissue with admixed mature bone and cartilage, or osteochondrolipoma, is an extremely rare histologic variant. Most documented osteochondrolipomas have occurred in the soft tissues of the head and neck related to the oral cavity, and the tumor is seen involving the extremities. A fatty mass with nonlipomatous elements can present a diagnostic challenge. We present a rare case of osteochondrolipoma involving the wrist. The clinical presentation, radiographic images, histologic findings, and treatment are discussed in this case report.

Thumb and Index Finger Amputation after Radial Artery Occlusion in a Patient with COVID-19.

The pathophysiology and predictability of radial artery thromboembolic events in patients with COVID-19 is not fully understood. We report a case of thumb and index finger gangrene and multiple digit amputations secondary to digital artery occlusion after radial artery cannulation in a patient admitted with COVID-19 pneumonia and encephalopathy. The exact association, causality, and potential hand manifestations in this patient population is unclear at this time, but is of particular interest in the current state of the pandemic.

Phentolamine Rescue for Digital Ischemia Following Lidocaine with Epinephrine Local Anesthesia: Case Presentation, Review of the Literature and Treatment Options.

The use of low-dose 1 percent lidocaine with epinephrine (1:100,000) has changed the practice of hand surgery. The safety of lidocaine and epinephrine in hand surgery has been well documented. Although rare, epinephrine-induced digital vasospasm can occur leading to tissue necrosis and amputation. Fortunately, digital ischemia can be reversed with phentolamine. We present a case of epinephrine-induced vasospasm following the use of 1 percent lidocaine with 1:100,000 epinephrine injected for a small finger flexor tendon and nerve repair. The multiple risk factors for digital ischemia and the role of phentolamine as an antidote to reverse epinephrine-induced ischemia are reviewed. Reversal of epinephrine-induced vasospasm using phentolamine rescue should be available to any provider using lidocaine with epinephrine in the hands and digits. Additionally, in more rural healthcare areas, a prophylactic post-procedure phentolamine injection might be considered in patients with multiple comorbidities which may predispose them to epinephrine-induced vasospasm.

Effect of dislocation timing following primary total hip arthroplasty on the risk of redislocation and revision.

INTRODUCTION: There is little data regarding timing of index dislocation in patients who undergo primary total hip arthroplasty (THA) and subsequent risk of redislocation and revision. METHODS: Between 1992 and 2013, 21,490 primary THAs were performed at a single institution. 189 patients (190 hips) had a first episode of dislocation within one year of index surgery (0.9 %). 32 patients (32 hips) were excluded for the following reasons: complex THA secondary to fracture malunion, Crowe III/IV developmental hip dysplasia, periprosthetic fracture, prior hip surgery, incomplete information, and hip abductor avulsion. The final cohort consisted of 157 patients (158 hips) who experienced dislocation within 1 year of primary non-complex THA. 88 patients were female (56%), mean age was 61 years (SD = 14), and mean follow-up was 76 months (range 0-229). Multivariable Cox proportional-hazards regression models with fractional polynomial models were used to estimate the association between timing of index dislocation and subsequent redislocation and revision surgery. RESULTS: 69 patients (44%) redislocated at final follow-up. Revision for any cause occurred in 26 out of 157 hips (17%). Time lapse from index THA to first dislocation was significantly associated with the risk of redislocation (p = 0.004) and with the risk of revision (p = 0.04). For every additional 7 days from surgery, risk of redislocation increased by a factor of 1.1 and risk of revision was increased by a factor of 1.13. CONCLUSION: This study demonstrates there is a lower risk of redislocation and revision in patients who have a first episode of dislocation closer to primary THA.

Delayed Rupture of the Flexor Pollicis Longus After Volar Plating for a Distal Radius Fracture: A Case Report.

Distal radius fractures account for 18 percent of all fractures in the elderly age group. It is estimated that the yearly cost of treatment for distal radius fractures approaches $240 million. The frequency of fractures will continue to increase with the aging population. The operative treatment of distal radius fractures has changed dramatically with the advent of the fixed-angle volar plate. Volar plating allows stable internal fixation which permits early return of function. A common and serious complication of volar plating of distal radius fractures is rupture of the flexor pollicis longus tendon. We report a case of a late rupture of the flexor pollicis longus tendon six years following plating of a distal radius fracture. The pathology and treatment options for flexor tendon ruptures are discussed. Guidelines for patient surveillance following distal radius plating are reviewed.

Discovering an Anatomic Variant of the Palmaris Profundus during Open Carpal Tunnel Release.

A 46-year-old female presented after 3 years of steadily increasing numbness in her hands bilaterally with worse symptoms in her right hand. She reported nighttime paresthesia and exacerbation of her symptoms while writing, typing, and driving. Tinel's and carpal tunnel compression test were positive bilaterally. During the right hand carpal tunnel release, a layer of synovium was present deep to the carpal ligament with a tendinous portion running midline longitudinally along the median nerve. This layer was an anomalous palmaris profundus (PP) tendon within the carpal tunnel, which inserted distally in the palmar fascia. The PP tendon was freed and released. The PP is a rare muscle variation of the forearm and wrist, and although it has no function, it has been reported as a cause of median nerve compression at the wrist. More commonly, it is an incidental finding during carpal tunnel surgery. Because of its close association with the median nerve, it can cause confusion when encountered during carpal tunnel surgery. Clinicians should be aware of this rare finding, which may be present during carpal tunnel surgery. We present a case, with intraoperative photographs, of a PP tendon that was encountered during a carpal tunnel release.

Lean and Green Hand Surgery.

Health care in the United States is both expensive and wasteful. The cost of health care in the United States continues to increase every year. Health care spending for 2016 is estimated at $3.35 trillion. Per capita spending ($10,345 per person) is more than twice the average of other developed countries. The United States also leads the world in solid waste production (624,700 metric tons of waste in 2011). The health care industry is second only to the food industry in annual waste production. Each year, health care facilities in the United States produce 4 billion pounds of waste (660 tons per day), with as much as 70%, or around 2.8 billion pounds, produced directly by operating rooms. Waste disposal also accounts for up to 20% of a hospital's annual environmental services budget. Since 1992, waste production by hospitals has increased annually by a rate of at least 15%, due in part to the increased usage of disposables. Reduction in operating room waste would decrease both health care costs and potential environmental hazards. In 2015, the American Association for Hand Surgery along with the American Society for Surgery of the Hand, American Society for Peripheral Nerve Surgery, and the American Society of Reconstructive Microsurgery began the "Lean and Green" surgery project to reduce the amount of waste generated by hand surgery. We recently began our own "Lean and Green" project in our institution. Using "minor field sterility" surgical principles and Wide Awake Local Anesthesia No Tourniquet (WALANT), both surgical costs and surgical waste were decreased while maintaining patient safety and satisfaction. As the current reimbursement model changes from quantity to quality, "Lean and Green" surgery will play a role in the future health care system.

Osteomyelitis Pubis Treated with Wedge Resection: A Case Report with 26-Year Follow-up and Literature Review.

Osteomyelitis pubis is a rare orthopedic infection, accounting for less than 1-2 percent of all hematogenous osteomyelitis. Osteomyelitis pubis generally affects children, elderly patients who have undergone genitourinary procedures, and parenteral drug users. Interestingly, cases of acute osteomyelitis pubis have also been documented in previously young, healthy athletes. The diagnosis is often difficult to differentiate from osteitis pubis, which is a self-limiting, painful inflammatory condition affecting the symphysis pubis. The authors report what is to our knowledge the first case of osteomyelitis pubis in a baseball player and provide a brief review of the literature. The patient was a previously healthy 18-year-old baseball player who presented with left groin pain after presumably straining his groin during a baseball game. Over the next 24 hours, he developed fever, chills, and left lower quadrant pain. He received IV antibiotics and was discharged from the hospital after clinical improvement. However, he returned six weeks later with increased groin pain, a 20-pound weight loss, and an inability to bear weight. Laboratory studies revealed an elevated white blood cell count and a bone scan demonstrated increased uptake at the symphysis pubis. The patient was taken to the operating room where a wedge-resection was performed and tissue cultures grew Staphylococcus aureus, confirming the diagnosis of osteomyelitis pubis. The patient recovered without complication postoperatively and played four years of college baseball. He was seen at a follow-up appointment 26 years later and demonstrated a normal physical exam with radiographic evidence of regeneration of the symphysis pubis without SI joint instability.

Wide-Awake Anesthesia in the In-Office Procedure Room: Lessons Learned.

BACKGROUND: Wide-awake local anesthesia and no tourniquet (WALANT) has become more popular in hand surgery. Without a tourniquet, there is no need for preoperative testing or sedation. The use of lidocaine with epinephrine has allowed a larger variety of cases to be done safely in an outpatient setting instead of the hospital. "Minor field sterility," which uses fewer drapes and tools to accomplish the same procedures, is a concept that is also gaining recognition. METHODS: Investigation of hand surgeons performing a majority of cases using WALANT and minor field sterility was the beginning of seeing its potential at our institution. Administration was concerned about patient safety, cost-effectiveness, and patient satisfaction of the proposed changes. Analysis of our institution to determine location of these procedures was also imperative to using WALANT. RESULTS: An in-office procedure room was built to allow for WALANT and minor field sterility. The requirements and logistics of developing an in-office procedure room for wide-awake surgery are reviewed in this article. CONCLUSIONS: The concurrent use of WALANT and minor field sterility has created a hand surgery practice that is cost-effective for the patient and the facility and resulted in excellent patient outcomes and satisfaction.

The Opioid Epidemic in 2017: Are We Making Progress?

With the emphasis on pain control (i.e., pain as the fifth vital sign) starting in the late 1990s and the increased prescribing of opioids, the opioid epidemic began. With the expanding misuse of opioids a new emphasis has been given for more responsible management of opioid prescribing by health care providers in all specialties. Since the pain experienced by patients with chronic musculoskeletal pain and acute postoperative pain can be severe, specific attention must be given to these patients who may be at increased risk for opioid abuse. We review the opioid epidemic and the impact of the epidemic on physicians and patients. As a result of this epidemic, several intraoperative techniques have been developed to decrease the need for postoperative pain medication. In addition, we identify several key features of a patient's background and their behavior that can indicate a potential for opioid abuse or misuse. Treatment strategies for providers including opioid prescribing guidelines are also discussed.