Diagnostic Accuracy of Point-of-Care Ultrasound Versus Radiographic Imaging for Pediatric Distal Forearm Fractures: A Randomized Controlled Trial.

STUDY OBJECTIVE: In patients aged 5 to 15 years with a clinically nondeformed distal forearm injury presenting to the emergency department (ED), we examined whether point-of-care ultrasound or radiographic imaging had better diagnostic accuracy, with the reference diagnosis determined by an expert panel review. METHODS: This multicenter, open-label, diagnostic randomized controlled trial was conducted in South East Queensland, Australia. Eligible patients were randomized to receive initial imaging through point-of-care ultrasound performed by an ED clinician or radiograph. Images were defined as "no," "buckle," or "other" fracture by the treating clinician. The primary outcome was the diagnostic accuracy of the treating clinician's interpretation compared against the reference standard diagnosis, which was determined retrospectively by an expert panel consisting of an emergency physician, pediatric radiologist, and pediatric orthopedic surgeon, who reviewed all imaging and follow-up. RESULTS: Two-hundred and seventy participants were enrolled, with 135 randomized to each initial imaging modality. There were 132 (97.8%) and 112 (83.0%) correctly diagnosed participants by ED clinicians in the point-of-care ultrasound and radiograph groups, respectively (absolute difference [AD]=14.8%; 95% confidence interval [CI] 8.0% to 21.6%; P<.001). Point-of-care ultrasound had better accuracy for participants with "buckle" fractures (AD=18.5%; 95% CI 7.1% to 29.8%) and "other" fractures (AD=17.1%; 95% CI 2.7% to 31.6%). No clinically important fractures were missed in either group. CONCLUSION: In children and adolescents presenting to the ED with a clinically nondeformed distal forearm injury, clinician-performed (acquired and interpreted) point-of-care ultrasound more accurately identified the correct diagnosis than clinician-interpreted radiographic imaging.

BMP2 and GDF5 for Compartmentalized Regeneration of the Scapholunate Ligament.

Background Chronic injuries to the scapholunate ligament (SLIL) alter carpal kinematics and may progress to early degenerative osteoarthritis. To date, there is no consensus for the best method for SLIL reconstruction. This study aims to assess the use of growth factors (bone morphogenetic protein [BMP]2 and growth and differentiation factor 5 [GDF5]) for compartmentalized regeneration of bone and ligament in this multiphasic scaffold in a rabbit knee model. Case Description A total of 100 µg of BMP2 and 30 µg of GDF5 were encapsulated into a heparinized gelatin-hyaluronic acid hydrogel and loaded into the appropriate compartment of the multiphasic scaffold. The multiphasic scaffold was implanted to replace the native rabbit medial collateral ligament ( n = 16). The rabbits were randomly assigned to two different treatment groups. The first group was immobilized postoperatively with the knee pinned in flexion with K-wires for 4 weeks ( n = 8) prior to sacrifice. The second group was immobilized for 4 weeks, had the K-wires removed followed by a further 4 weeks of mobilization prior to sample harvesting. Literature Review Heterotopic ossification as early as 4 weeks was noted on gross dissection and confirmed by microcomputed tomography and histological staining. This analysis revealed formation of a bony bridge located within and over the ligament compartment in the intra-articular region. Biomechanical testing showed increased ultimate force of the ligament compartment at 4 weeks postimplantation consistent with the presence of bone formation and higher numbers of scaffold failures at the bone-tendon junction. This study has demonstrated that the addition of BMP2 and GDF5 in the bone-ligament-bone (BLB) scaffold resulted in heterotopic bone formation and failure of the ligament compartment. Clinical Relevance The implantation of a three-dimensional-printed BLB scaffold alone demonstrated superior biomechanical and histological results, and further investigation is needed as a possible clinical reconstruction for the SLIL.

Current rehabilitation recommendations following primary triangular fibrocartilage complex foveal repair surgery: A survey of Australian hand therapists.

BACKGROUND: Following injury to the Triangular Fibrocartilage Complex (TFCC), foveal repair surgery may be indicated to restore joint stability and function. Protection of the repaired ligament is a clinical consideration during post-surgical rehabilitation, although no "gold standard" rehabilitation protocol currently exists. PURPOSE: To describe the professional opinions of Accredited Hand Therapists (AHT) regarding post-operative rehabilitation recommendations following TFCC foveal repair surgery. STUDY DESIGN: Cross-sectional descriptive study. METHODS: All Australian AHTs were invited to complete a quantitative, online, 10-item survey between December 2019 and March 2020. The survey included questions regarding clinical recommendations for wrist and forearm immobilization, range of motion and exercise methods, and timeframes. AHT characteristics and experience of patients sustaining a TFCC re-rupture were also collected. Categorical and nominal survey responses were reported descriptively and effects of AHT characteristics on survey responses were assessed using Pearson Chi2, with significance set to <0.05. RESULTS: Survey responses were received from 135 AHTs or approximately 37% of the available population at the time of completion (March 2020). Recommendations for post-surgery immobilization ranged from "not required" to 8 weeks, 6 weeks representing the most common answer. Wrist and forearm range of motion commencement time ranged from "immediately" to "later than 8 weeks," with 6 weeks also the most common answer. When asked whether post-surgery rupture had been experienced in their respective patient groups, 15 therapists (11%) indicated "Yes." The most recommended thermoplastic orthosis was a Sugartong orthosis (41%) followed by a Muenster orthosis (30%), both of which immobilizes the wrist and forearm. CONCLUSIONS: Rehabilitation varied widely between AHTs. Further prospective research is recommended to explore whether patient-related or rehabilitation factors influence outcomes following TFCC repair.

Biomechanical analysis of three techniques of suspensionplasty after trapeziectomy: a cadaveric study.

The aim of the present cadaveric study was to assess resistance to first metacarpal subsidence of three techniques of suspensionplasty after trapeziectomy. In total, 18 forearms (mean age 60 years [range 20-89]) were used with six specimens per surgical technique: palmar oblique ligament reconstruction with tendon interposition (LRTI), abductor pollicis longus (APL) suspensionplasty, or suture suspensionplasty. There was no significant difference in mean trapezial space height after trapeziectomy and suspensionplasty compared to the preoperative trapezial height. However, after simulation of physiological lateral pinch, there was a significant (p < 0.05) difference in mean trapezial space height between the APL suspensionplasty and the suture suspensionplasty compared to the LRTI group. After axial loading, there was significantly greater metacarpal subsidence in the LRTI group compared to the APL and suture suspensionplasty groups but no statistically significant difference between the suture suspensionplasty and the APL suspensionplasty groups.Level of evidence: V.

Ultrasonography or Radiography for Suspected Pediatric Distal Forearm Fractures.

BACKGROUND: Data on whether ultrasonography for the initial diagnostic imaging of forearm fractures in children and adolescents is noninferior to radiography for subsequent physical function of the arm are limited. METHODS: In this open-label, multicenter, noninferiority, randomized trial in Australia, we recruited participants 5 to 15 years of age who presented to the emergency department with an isolated distal forearm injury, without a clinically visible deformity, in whom further evaluation with imaging was indicated. Participants were randomly assigned to initially undergo point-of-care ultrasonography or radiography, and were then followed for 8 weeks. The primary outcome was physical function of the affected arm at 4 weeks as assessed with the use of the validated Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) score (range, 8 to 40, with higher scores indicating better function); the noninferiority margin was 5 points. RESULTS: A total of 270 participants were enrolled, with outcomes for 262 participants (97%) available at 4 weeks (with a window of ±3 days) as prespecified. PROMIS scores at 4 weeks in the ultrasonography group were noninferior to those in the radiography group (mean, 36.4 and 36.3 points, respectively; mean difference, 0.1 point; 95% confidence interval [CI], -1.3 to 1.4). Intention-to-treat analyses (in 266 participants with primary outcome data recorded at any time) produced similar results (mean difference, 0.1 point; 95% CI, -1.3 to 1.4). No clinically important fractures were missed, and there were no between-group differences in the occurrence of adverse events. CONCLUSIONS: In children and adolescents with a distal forearm injury, the use of ultrasonography as the initial diagnostic imaging method was noninferior to radiography with regard to the outcome of physical function of the arm at 4 weeks. (Funded by the Emergency Medicine Foundation and others; BUCKLED Australian New Zealand Clinical Trials Registry number, ACTRN12620000637943).

Redefining radiocarpal fracture-dislocations with injury specific management and a clinical classification system: a retrospective review.

BACKGROUND: Unlike articular shear fractures of the distal radius, radiocarpal fracture-dislocations defined as complete dislocation of the lunate from its articular facet of the radius are relatively uncommon. The management principles of these fractures have not been defined and there is no consensus on approach to management of these injuries. The aim of this study is to review our series of radiocarpal fracture-dislocations and propose a radiographic classification to guide surgical management. METHODS: This study is reported based on STROBE guidelines. A total of 12 patients underwent open reduction and internal fixation. All the fracture-dislocations were dorsal and satisfactory objective outcomes achieved were comparable to literature. Injury morphology-specific management approach was used based on the size of dorsal lip fragment and the volar teardrop fragment attached to the short radiolunate ligament assessed by preoperative CT scans. RESULTS: All patients with known outcome (n = 10) went on to resume their prior occupation and hobbies that included high-demand activities and manual labour at mean follow-up of 27 weeks. Average wrist flexion was 43° and wrist extension was 41° while radial and ulnar deviation were 14° and 18° respectively. Average forearm pronation was 76° and supination was 64° at final follow-up. CONCLUSION: We describe four injury patterns of radiocarpal fracture-dislocations based on preoperative CT scans that guide fixation. We believe that early recognition of radiocarpal fracture-dislocations and appropriate management can yield satisfactory outcomes.

Additively manufactured polyethylene terephthalate scaffolds for scapholunate interosseous ligament reconstruction.

The regeneration of the ruptured scapholunate interosseous ligament (SLIL) represents a clinical challenge. Here, we propose the use of a Bone-Ligament-Bone (BLB) 3D-printed polyethylene terephthalate (PET) scaffold for achieving mechanical stabilisation of the scaphoid and lunate following SLIL rupture. The BLB scaffold featured two bone compartments bridged by aligned fibres (ligament compartment) mimicking the architecture of the native tissue. The scaffold presented tensile stiffness in the range of 260 ± 38 N/mm and ultimate load of 113 ± 13 N, which would support physiological loading. A finite element analysis (FEA), using inverse finite element analysis (iFEA) for material property identification, showed an adequate fit between simulation and experimental data. The scaffold was then biofunctionalized using two different methods: injected with a Gelatin Methacryloyl solution containing human mesenchymal stem cell spheroids (hMSC) or seeded with tendon-derived stem cells (TDSC) and placed in a bioreactor to undergo cyclic deformation. The first approach demonstrated high cell viability, as cells migrated out of the spheroid and colonised the interstitial space of the scaffold. These cells adopted an elongated morphology suggesting the internal architecture of the scaffold exerted topographical guidance. The second method demonstrated the high resilience of the scaffold to cyclic deformation and the secretion of a fibroblastic related protein was enhanced by the mechanical stimulation. This process promoted the expression of relevant proteins, such as Tenomodulin (TNMD), indicating mechanical stimulation may enhance cell differentiation and be useful prior to surgical implantation. In conclusion, the PET scaffold presented several promising characteristics for the immediate mechanical stabilisation of disassociated scaphoid and lunate and, in the longer-term, the regeneration of the ruptured SLIL.

The onset, progress and factors influencing degenerative arthritis of the wrist following scaphoid fracture non-union.

BACKGROUND/AIMS: Scaphoid non-union causes osteoarthritis but factors associated are poorly understood. We investigated the rate of osteoarthritis after scaphoid fracture non-union, and if duration and fracture location influenced arthritis and its severity. METHODS: This retrospective cross-sectional observational study of 278 consecutive cases with scaphoid fracture non-union retrieved data on demographics, non-union duration, fracture location, dorsal intercalated segment instability (DISI), severity and distribution of wrist arthritis. Patient Evaluation Measure (PEM) and Quality of Life assessed impact on patients. Regression models investigated prediction of osteoarthritis by different variables. Time-to-event analysis investigated osteoarthritis evolution. Missing (MAR) data for the PEM and QoL was imputed and analysed. RESULTS: 278 patients, 246 males, aged 27.9 years (range 11 to 78 years), with a scaphoid fracture non-union confirmed on computed tomography (CT) scans (243) and plain radiographs (35) were reviewed. The interval between injury and imaging was 3.3 years (SD 5.9 years; range 0.1-45). The fracture was proximal to the ridge in 162, distal to the ridge in 83 and in the proximal 20% in 33. DISI (RLA ≥ 10°) occurred in 93.5% (260/278). Osteoarthritis was identified in 62.2% (173/278), and we classified a SNAC pattern in 93.6% (162/173). Of these, 100 (61.7%) had SNAC 1, 22 (13.6%) SNAC 2, 17 (10.5%) SNAC 3, and 23 (14.2%) SNAC 4. The mean duration in years for SNAC 1, 2, 3 and 4 were 2.5, 6.0, 8.2, and 11.3 years respectively. In fractures proximal to the ridge, 50% had arthritis in 2.2 years. Whereas in proximal pole, and distal to the ridge, 50% developed in 3.8 and 6.6 years, respectively. The PEM score was 42.8% (SD 18.9%) in those without arthritis and 48.8% (SD 21.5%) in those with arthritis. The mean QoL was 0.838 in patients without SNAC and 0.792 with SNAC. CONCLUSION: Scaphoid fracture non-union caused early carpal collapse, majority had osteoarthritis usually observed within a year following injury and occurred earliest in proximal waist fractures. Distribution of osteoarthritis (SNAC stage) may not always follow a distinctive pattern, as previously described.

Effect of K-wire Reuse and Drill Mode on Heat Generation in Bone.

BACKGROUND: We examined the effect of Kirschner wire (K-wire) reuse and use of oscillating mode on heat generation within cortical bone. METHODS: Two trocar-tipped K-wires were drilled through the diaphysis of each of 30 human metacarpals and phalanges: one K-wire was inserted in rotary mode and another in oscillating mode. Each wire was reused once. Thermocouples placed within the dorsal and volar bone adjacent to the K-wire drill path measured temperatures throughout each test. RESULTS: Peak cortex temperatures were 25°C to 164°C. Rotary drilling achieves peak temperatures quicker (31 ± 78 seconds vs 44 ± 78 seconds, P = .19) than oscillating drilling, but insertion time is also less, resulting in lower overall heat exposure. This effect is also seen when the K-wire is reused (34 ± 70 seconds vs 41 ± 85 seconds, P = .4). The length of time that cortical bone was exposed to critical temperatures (47°C or more) was significantly higher when a wire was reused (36 ± 72 seconds vs 43 ± 82 seconds, P = .008). Peak temperatures greater than 70°C (a temperature associated with instantaneous cell death) were observed on many occasions. CONCLUSIONS: Overall heat exposure may be higher if a K-wire is reused or inserted in oscillating mode. In the absence of external cooling, K-wire insertion into cortical bone can easily expose bone to temperatures that exceed 70°C and may increase the risk of osteonecrosis.

Wrist and forearm range of motion commencement time following primary triangular fibrocartilage complex foveal repair surgery: A scoping review.

STUDY DESIGN: Scoping review. BACKGROUND: Rehabilitation guidelines following triangular fibrocartilage complex (TFCC) foveal repair surgery have been inconsistently reported in the published literature, with no consensus regarding wrist or forearm range of motion (ROM) commencement time. PURPOSE OF THE STUDY: To scope the available literature to identify the extent and strength of the evidence supporting the clinical guidelines for wrist and forearm ROM commencement time following primary TFCC foveal repair surgery. METHODS: A systematic search produced 26 studies (3 retrospective cohort studies, 1 prospective cohort study, 1 retrospective comparative study, and 21 retrospective case series) that described specific rehabilitation protocols following TFCC foveal repair surgery. RESULTS: No supporting evidence was identified regarding rehabilitation protocol recommendations across all the included studies. Postsurgery wrist ROM commencement ranged from 2 to 8 weeks; forearm ROM commencement ranged from 2 to 12 weeks. ROM commencement times did not appear to systematically influence the rate of adverse events, although adverse events were poorly reported. CONCLUSIONS: TFCC rehabilitation protocols were poorly reported and varied widely between the included studies. Additional research is recommended to comprehensively evaluate the association between wrist and/or forearm ROM and the rate of adverse events for this complex and multifaceted condition.

A comparison of early fixation of distal radius fractures versus late corrective osteotomy of distal radius malunion.

BACKGROUND: Fractures of the distal radius are common. Closed reduction and moulded casting is often the first line treatment. Malunion after casting is not uncommon and can lead to discussion on acute surgical fixation versus delayed corrective osteotomy if symptomatic. However, it is unclear if late surgery will provide similar outcomes as early intervention. METHODS: We performed a single centre, age matched, case series comparison study, comparing outcomes of patients who had undergone early fixation (ORIF) versus those who had undergone late corrective osteotomy (CO) following distal radius fracture. RESULTS: Twenty-six patients were available for review, 13 in each group. Fracture patterns were similar. Reviewing CO versus ORIF; patients achieved a mean DASH; 22 versus 18 (P = 0.355), PRWE; 35 versus 26 (P = 0.237), and VAS 2 versus 2 (P = 0.490). Grip strength was significantly better in those who had undergone ORIF; 2% versus -22% (P ≤ 0.001). Range of motion was generally better with primary fixation but of doubtful clinical importance, reviewing CO versus ORIF; Flexion 46° versus 60° (P = 0.045), extension 55° versus 64° (P = 0.137), pronation 73° versus 85° (P = 0.078), supination 84° versus 84° (P = 0.747), flexion/extension arc 101 versus 124 (P = 0.017), ulnar/radial deviation arc 42° versus 59° (P = 0.01), pronation/supination arc 157° versus 168° (P = 0.118). Ulnar variance was significantly improved in the ORIF group; +0.5 mm versus +2 mm in the CO group (P = 0.023). Radial inclination, radial height and volar tilt were not significantly different between either group. CONCLUSION: Our findings suggest that patient measured outcome of corrective osteotomy is not inferior to early internal fixation. LEVEL OF EVIDENCE: III (Case Series Comparison).

Histological, immunohistochemical, and morphometric analysis of negative pressure-assisted in-vivo nerve stretch-growth.

Axons respond well to mechanical stimuli and can be stretched mechanically to increase their growth rate. Although stretch growth of axons and their transient lengthening ex-vivo has been discussed in literature extensively, however, real applications of this phenomenon are scarcely found. This work presents a technique to translate ex-vivo axonal stretch growth to in-vivo nerve stretch growth. By establishing a rat model of completely transected sciatic nerve injury, the regrowth rate of the proximal nerve stump was examined under the effect of a stretching force developed by negative pressure. In this manuscript, results have been presented based on quantitative and qualitative analysis of the stained nerve tissues. Gross observations have explicitly confirmed that the proximal stump of a whole sectioned sciatic nerve of a Wistar rat stretched in a T-shaped nerve prosthesis using a controlled amount of negative pressure displayed a better outcome in terms of an increase in the total length of proximal nerve stump post-treatment and a higher number of blood vessels with respect to control. The histological and morphometric analyses confirmed that negative pressure-assisted nerve growth provides an alluring control over nerve's regrowth rate. Immunohistochemical staining also supported the existence of a positive correlation between nerve growth and in-vivo application of axial stress on it. This work presents the first holistic evidence on growing nerves in the continuum of in-vivo nerve stretch growth using negative pressure and concludes that systematic and controlled negative pressure applied directly to the resected ends of a sciatic nerve resulted in the enhanced growth rate of regenerating nerve fibres.

Negative Pressure Neurogenesis: A Novel Approach to Accelerate Nerve Regeneration after Complete Peripheral Nerve Transection.

Various modalities to facilitate nerve regeneration have been described in the literature with limited success. We hypothesized that negative pressure applied to a sectioned peripheral nerve would enhance nerve regeneration by promoting angiogenesis and axonal lengthening. METHODS: Wistar rats' sciatic nerves were cut (creating ~7 mm nerve gap) and placed into a silicone T-tube, to which negative pressure was applied. The rats were divided into 4 groups: control (no pressure), group A (low pressure: 10 mm Hg), group B (medium pressure: 20/30 mm Hg) and group C (high pressure: 50/70 mm Hg). The nerve segments were retrieved after 7 days for gross and histological analysis. RESULTS: In total, 22 rats completed the study. The control group showed insignificant nerve growth, whereas the 3 negative pressure groups showed nerve growth and nerve gap reduction. The true nerve growth was highest in group A (median: 3.54 mm) compared to group B, C, and control (medians: 1.19 mm, 1.3 mm, and 0.35 mm); however, only group A was found to be significantly different to the control group (**P < 0.01). Similarly, angiogenesis was observed to be significantly greater in group A (**P < 0.01) in comparison to the control. CONCLUSIONS: Negative pressure stimulated nerve lengthening and angiogenesis within an in vivo rat model. Low negative pressure (10 mm Hg) provided superior results over the higher negative pressure groups and the control, favoring axonal growth. Further studies are required with greater number of rats and longer recovery time to assess the functional outcome.

Finite element analysis of the performance of additively manufactured scaffolds for scapholunate ligament reconstruction.

Rupture of the scapholunate interosseous ligament can cause the dissociation of scaphoid and lunate bones, resulting in impaired wrist function. Current treatments (e.g., tendon-based surgical reconstruction, screw-based fixation, fusion, or carpectomy) may restore wrist stability, but do not address regeneration of the ruptured ligament, and may result in wrist functional limitations and osteoarthritis. Recently a novel multiphasic bone-ligament-bone scaffold was proposed, which aims to reconstruct the ruptured ligament, and which can be 3D-printed using medical-grade polycaprolactone. This scaffold is composed of a central ligament-scaffold section and features a bone attachment terminal at either end. Since the ligament-scaffold is the primary load bearing structure during physiological wrist motion, its geometry, mechanical properties, and the surgical placement of the scaffold are critical for performance optimisation. This study presents a patient-specific computational biomechanical evaluation of the effect of scaffold length, and positioning of the bone attachment sites. Through segmentation and image processing of medical image data for natural wrist motion, detailed 3D geometries as well as patient-specific physiological wrist motion could be derived. This data formed the input for detailed finite element analysis, enabling computational of scaffold stress and strain distributions, which are key predictors of scaffold structural integrity. The computational analysis demonstrated that longer scaffolds present reduced peak scaffold stresses and a more homogeneous stress state compared to shorter scaffolds. Furthermore, it was found that scaffolds attached at proximal sites experience lower stresses than those attached at distal sites. However, scaffold length, rather than bone terminal location, most strongly influences peak stress. For each scaffold terminal placement configuration, a basic metric was computed indicative of bone fracture risk. This metric was the minimum distance from the bone surface to the internal scaffold bone terminal. Analysis of this minimum bone thickness data confirmed further optimisation of terminal locations is warranted.

Case series of: Iatrogenic digital compression ischaemic injury in the emergency department.

This brief report is a retrospective review of three cases of iatrogenic digital ischemia and clinical outcome at six months. Hand injuries are one of the most common injuries that occur in the working population. Iatrogenic digital ischemia is a rare condition that can be avoided by proper wound management. After the correct initial treatment is provided, it is important to apply the wound dressing correctly to avoid iatrogenic trauma or ischemia. Currently, there is no consensus regarding the best treatment for these injuries. Our aim is to remind clinicians of this rare condition, and to highlight prevention and treatment strategies.

Multiphasic scaffold for scapholunate interosseous ligament reconstruction: A study in the rabbit knee.

Scapholunate interosseous ligament tears are a common wrist injury in young and active patients that can lead to suboptimal outcomes after repair. This research aims to assess a multiphasic scaffold using 3D-printing for reconstruction of the dorsal scapholunate interosseous ligament. The scaffold was surgically implanted in vivo in the position of the native rabbit medial collateral ligament. Two branches of treatment were implemented in the study. In the first group, the rabbits (n = 8) had the knee joint fixed in flexion for 4 weeks using 1.4 mm K-wires prior to sample harvesting. The second group (n = 8) had the rabbit knee joint immobilized for 4 weeks prior to K-wire removal and mobilization for an additional 4 weeks prior to sample harvesting. Overall, samples were harvested at 4 weeks post-surgery (immobilized group) and eight weeks post-surgery (mobilized group). Mechanical tensile testing (n = 5/group) and histology (n = 3/group) of the constructs were conducted. Tissue integration and maturation were observed resulting in increased mechanical strength of the operated joint at 8 weeks (P < .05). Bone and ligament tissues were regenerated in their respective compartments with structural and mechanical properties approaching those reported for the human dorsal SLIL ligament. Clinical Significance: This proof of concept study has demonstrated that the synthetic multiphasic scaffold was capable of regenerating both bone and ligament while also withstanding the physiological load once implanted in the rabbit knee. The artificial scaffold may provide an alternative to current techniques for reconstruction of scapholunate instability or other ligament injuries in the hand and wrist.

Open Reduction of Neglected Dislocations of the Proximal Interphalangeal Joint.

Chronic unreduced dislocations of the proximal interphalangeal joint are uncommon and management principles for these injuries have not been defined. The dislocation can be volar or dorsal and closed reduction is rarely successful owing to soft tissue contractures. We describe an extensile midaxial approach to the proximal interphalangeal joint for release of contractures, open reduction, and repair of critical structures. A smaller contralateral incision can be made if needed for additional soft tissue release. Using illustrative cases, we discuss technical points that are essential for a successful outcome and common pitfalls that could lead to complications. A functional range of motion with a stable joint can be achieved as long as articular cartilage is relatively preserved.

Vitamin D deficiency in proximal femur fracture patients of South-East Queensland.

OBJECTIVES: To determine the incidence of hypovitaminosis D in proximal femur fracture (PFF) patients and investigate whether sociodemographic factors or radiographic parameters are associated with vitamin D levels. METHODS: This is a consecutive case series of South-East Queensland patients presenting with low-energy PFFs. Vitamin D levels and sociodemographic factors (age, sex, postcode, medications and type of residence) were collected from medical records. Radiographic parameters included PFF type and cortical thickness of the femur. RESULTS: A total of 313 patients were included (mean age = 79.5 years), and 105 (34%) were deficient in vitamin D (<50 nmol/L). There was no association between vitamin D levels and sociodemographic factors or radiographic parameters. Eighty-four (84%) of vitamin D-deficient patients were not taking vitamin D supplements. CONCLUSIONS: Social and demographic factors are not correlated with vitamin D levels in this cohort. Routine vitamin D supplementation may be indicated in ageing patients although it is not always protective of low-energy fractures.

Surgical applications of intracorporal tissue adhesive agents: current evidence and future development.

Introduction: Traditional mechanical closure techniques pose many challenges including the risk of infection, tissue reaction, and injury to both patients and clinicians. There is an urgent need to develop tissue adhesive agents to reform closure technique. This review examined a variety of tissue adhesive agents available in the market in an attempt to gain a better understanding of intracorporal tissue adhesive agents as medical devices.Areas covered: Fundamental principles and clinical determinants of the tissue adhesives were summarized. The available tissue adhesives for intracorporal use and their relevant clinical evidence were then presented. Lastly, the perspective of future development for intracorporal tissue adhesive were discussed. Clinical evidence shows current agents are efficacious as adjunctive measures to mechanical closure and these agents have been trialed outside of clinical indications with varied results.Expert opinion: Despite some advancements in the development of tissue adhesives, there is still a demand to develop novel technologies in order to address unmet clinical needs, including low tensile strength in wet conditions, non-controllable polimerization and sub-optimal biocompatibility. Research trends focus on producing novel adhesive agents to remit these challenges. Examples include the development of biomimetic adhesives, externally activated adhesives, and multiple crosslinking strategies. Economic feasibility and biosafety are limiting factors for clinical implementation.

Long term outcomes of open reduction internal fixation versus external fixation of distal radius fractures: A meta-analysis.

Distal radius fractures are among the most common fractures encountered in the clinical setting. Of these common fractures, it has been said that up to 60% are intraarticular in nature. Intra-articular or unstable and comminuted fractures represent severe and high energy injuries. Despite a large amount of literature, it is surgeon preference which determines the fixation method employed. There are only a few randomised control trials that report 2-year outcomes. There has yet to be a meta-analysis comparing the long-term outcomes of open reduction internal fixation (ORIF) and external fixation (EF). The aim of this metaanalysis is to identify any difference in the outcomes of either fixation method in the long term. We pooled the data of all the available randomised control trials that followed the patients for a minimum of 2 years and compared outcomes of ORIF against EF of distal radius fractures as per PRISMA guidelines from inception of the databases to December 2016. We then performed our meta-analysis using RevMan 5.3 software. Flexion/extension arcs were significantly improved in ORIF, and 7 of the 10 analysed outcomes supported ORIF, although most not to a significant degree. The meta-analysis indicated that there is no difference in outcomes with either form of treatment. Even though the flexion extension arc was statistically better in the ORIF group, the difference is not clinically meaningful.