Single minimal incision fasciotomy for the treatment of chronic exertional compartment syndrome: outcomes and complications.

INTRODUCTION: Chronic exertional compartment syndrome (CECS) is a common injury in young athletes, causing pain in the involved leg compartment during strenuous exercise. The gold standard treatment is fasciotomy, but most of the reports on its effectiveness include relatively small cohorts and relatively short follow-up periods. This study reports the long-term results of a large cohort of young athletes who underwent single-incision fasciotomy for CECS. MATERIALS AND METHODS: This a retrospective case-series study. All patients treated by fasciotomies performed for CECS between 2007 and 2011, in a tertiary medical institution. CECS was diagnosed following history taking and clinical evaluation, and confirmed by compartment pressure measurements. Ninety-five legs that underwent single-incision subcutaneous fasciotomy were included. Data on the numerical analog scale (NAS), Tegner activity score, and quality-of-life (QOL) as measured via the short form-12 (SF-12) were retrieved from all patients preoperatively and at the end of follow-up. RESULTS: The average time to diagnosis was 22 months and the mean follow-up was 50.1 months. Sixty-three legs underwent anterior compartment fasciotomy (an additional 30 legs also underwent lateral compartment release), and two legs underwent lateral and peroneal compartment releases. The average change in Tegner score was an improvement of 14.6 points. Similarly, the patients reported a significant improvement in the SF-12 and NAS scores. Satisfaction rates were high (average 75.5 %). The main complications were wound infection (2 patients) and nerve injuries (4 patients). Eight patients had recurrence. CONCLUSION: Single-incision fasciotomy leads to long-term improvement in the activity level and QOL of patients with CECS.

Norton scale scores and 1-year mortality in elderly patients following lower limb amputations.

BACKGROUND: The Norton scale is used for assessing the risk of pressure ulcers. The association between low admission Norton scale scores (ANSS), complications and mortality in elderly patients following lower limb amputations has never been studied until now. OBJECTIVES: The aim of this study was to investigate if low ANSSs are associated with complications the 30-day and 1-year mortality in elderly patients following lower limb amputations. MATERIALS AND METHODS: The medical charts of 104 elderly (≥ 65 years) patients following lower limb amputations were studied for the following measurements: ANSS, demographics, comorbidities, complications during hospitalization, 30-day mortality and 1-year mortality. Complications included acute coronary syndrome, major bleeding, stroke, systemic infections, organ failure and thromboembolism. An ANSS ≤ 14 was considered as being low. RESULTS: Overall 54 (51.9%) patients underwent below-knee amputations and 50 (48.1%) patients underwent above-knee amputations. Most (n = 78; 75.0 %) patients were men and the mean age was 78.5 ± 7.9 years. Following the amputation 46 (44.2%) patients had complications other than pressure ulcers, 24 (23.1%) patients died within 30 days and 63 (60.6%) patients died within 1 year. A total of 61 (58.7%) patients had a low ANSS. The incidence of complications other than pressure ulcers, 30-day and 1-year mortality rates were higher in patients with a low ANSS relative to patients with a high ANSS. A regression analysis showed that 1-year mortality was independently negatively associated with ANSS (t = 2.629; p = 0.010). CONCLUSION: The Norton scale can be used for predicting 1-year mortality in elderly patients following lower limb amputations.

Does neuromuscular electrical stimulation enhance the effectiveness of an exercise programme in subjects with knee osteoarthritis? A randomized controlled trial.

OBJECTIVE: To determine whether neuromuscular electrical stimulation applied to the quadriceps femoris muscle will enhance the effectiveness of an exercise programme in patients with knee osteoarthritis. DESIGN: A randomized trial with parallel intervention treatment groups. SETTING: Outpatient physical therapy clinic. SUBJECTS: Fifty participants (mean age (SD) 68.9 (7.7) years) with symptomatic idiopathic knee osteoarthritis and radiographic evidence (grade ≥ II Kelgren's classification). INTERVENTIONS: Participants were randomized into one of two groups receiving 12 biweekly treatments: An exercise-only group or an exercise combined with neuromuscular electrical stimulation group (biphasic pulses, at 75 Hz and 250 µs phase duration). MAIN MEASURES: Knee pain intensity; maximal voluntary isometric contraction and voluntary activation of the quadriceps femoris muscle; measures of functional performance. RESULTS: A significant interaction effect (P = 0.01) indicated greater improvement in pain for the electrical stimulation group. The mean (SD) change in pain intensity was from 7.5 ± 2 to 5 ± 2.2 and from 7.4 ± 1.9 to 3.3 ± 2.4 in the exercise and electrical stimulation groups, respectively. A significant treatment effect was also noted for the voluntary activation of the quadriceps femoris, which increased by 22.2% in the electrical stimulation group and by 9.6% in the exercise group (P = 0.045). Significant improvements were observed in both groups in all remaining measures, with no differences between groups. CONCLUSIONS: Electrical stimulation treatment to the quadriceps femoris enhanced the effectiveness of an exercise programme in alleviating pain and improving voluntary activation in patients with knee osteoarthritis, but did not enhance its effect on muscle strength or functional performance.

Usefulness of prophylactic antibiotics in preventing infection after internal fixation of closed hand fractures.

Prophylactic antibiotics (PA) have been shown to be ineffective in reducing the incidence of surgical site infection (SSI) in clean wounds associated with elective surgery of the hand. Routine administration of PA for internal fixation of hand fractures is a subject that has been scarcely studied. We hypothesized that PA do not reduce SSI incidence in fixation of closed hand fractures. We did a retrospective comparative study in patients who underwent open or closed reduction and internal fixation of a hand and carpus fracture. Patient demographics, past medical history, fracture characteristics and the type of internal fixation used were extracted from our electronic archives. Follow-up period lasted for 1 year, during which any form of clinically evident SSI, such as pus formation, wound dehiscence and positive bacterial culture was documented. A total of 107 patients met the inclusion criteria, 63 in the control group and 44 in the test group. The overall infection rate was 6.5%. All infections (3 in the control group and 4 in the test group) were pin-tract infections that resolved completely after pin extraction. Our study did not find significant differences between groups (P = 0.442). No specific fracture pattern was associated with increased total infection rate (p = 0.898). In this study, we found no support for routine administration of PA prior to internal fixation of closed fractures of the hand and carpus. PA should still be administered in selected patients, such as those with decreased immunity or open fractures. Further large-scale research is needed to establish proper guidelines, to reduce the adverse effects of antibiotic treatment.

Molten metal high pressure injection injury of the hand.

The second case of high temperature molten metal, high-pressure injection injury of the hand is reported here. Like in the previous case, there was an innocent-looking entry point with deep thermal injury to the flexor tendons and the digital nerves that appeared a few days after the injury and lead to finger amputation. LEVEL OF EVIDENCE: 5.

Internal fixation of metacarpal fractures using wide awake local anesthesia and no tourniquet.

We sought to report on the use of wide-awake local anesthesia and no tourniquet (WALANT) for internal fixation of metacarpal fractures. We retrospectively examined 10 patients with metacarpal fractures that required either closed reduction and internal fixation (CRIF) or open reduction and internal fixation (ORIF). WALANT was administered 20minutes before the surgery outside the operating room. Once the area was numb, an open or closed reduction was made followed by internal fixation of the fracture using plating, intramedullary screws or Kirshner wires (K-wires). We used intraoperative X-ray to confirm anatomic reduction and correct internal fixation. After proper reduction and fixation, the active range of motion (AROM) was assessed while the patient was awake. Patients were discharged the next day after evaluating their neurovascular status and establishing pain control. Follow-up evaluations were carried out at 2, 6 and 12 weeks postoperatively. All individuals underwent uneventful operations. No significant pain or bleeding was recorded during the operation. Nine out of ten patients regained full AROM at the 12-week follow-up visit in the outpatient clinic. One patient still had slight reduction of range of motion (ROM) of the 5th metacarpophalangeal joint. No neurovascular damage or surgical site morbidity was recorded. CRIF and ORIF of simple metacarpal fractures can be executed successfully using WALANT with good functional results without increased morbidity compared to monitored anesthesia care.

High-pressure injection injuries of the fingers: Long-term follow-up in patients after extensive debridement.

High-pressure injection injuries to the fingers resulting from the introduction of a foreign substance, such as oil or paint, through a minor puncture wound are rare but can have serious clinical consequences. The objective of this article was to examine the long-term outcomes after surgical debridement of these injuries. We present a retrospective case series of 8 adults who had a high-pressure injection injury to their hand and underwent surgical debridement in our facility. Data were extracted from our outpatient registry. Assessment included a full physical examination, grip strength, range of motion, two-point discrimination and Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. We followed 8 male patients for an average of 12.7 years. Their average age was 37 at time of injury and all had injured their right dominant hand. Seventy-five percent of the injuries were to the index finger. Seven out of the 8 patients returned to their pre-injury occupation, 4 out of 8 patients had reduced range of motion of the affected digit. Injury sequelae adversely affected activities of daily living (ADL) with an average QuickDASH score of 26. Grip strength in the injured hand was reduced by an average of 35% in 6 out of 8 patients compared with the uninjured hand. Sensation was also reduced in the affected digit in 7 out of 8 patients. All patients suffered from some level of neuropathic pain and/or cold intolerance. High pressure injection injury to the fingers is a serious event found amongst industrial laborers. In most patients, this injury will lead to long-term disability along with a negative impact on ADL. However, most patients eventually return to their pre-injury occupation. Extensive, single or repeat debridement of high-pressure injection injuries remains a valid treatment option with good long-term results.

Determinants of functional outcome after simple and complex acetabular fractures involving the posterior wall.

We have evaluated the functional, clinical and radiological outcome of patients with simple and complex acetabular fractures involving the posterior wall, and identified factors associated with an adverse outcome. We reviewed 128 patients treated operatively for a fracture involving the posterior wall of the acetabulum between 1982 and 1999. The Musculoskeletal Functional Assessment and Short-Form 36 scores, the presence of radiological arthritis and complications were assessed as a function of injury, treatment and clinical variables. The patients had profound functional deficits compared with the normal population. Anatomical reduction alone was not sufficient to restore function. The fracture pattern, marginal impaction and residual displacement of > 2 mm were associated with the development of arthritis, which related to poor function and the need for hip replacement. It may be appropriate to consider immediate total hip replacement for patients aged > 50 years with marginal impaction and comminution of the wall, since 7 of 13 (54%) of these required early hip replacement.

A new bromelain-based enzyme for the release of Dupuytren's contracture: Dupuytren's enzymatic bromelain-based release.

OBJECTIVES: Injectable Bromelain Solution (IBS) is a modified investigational derivate of the medical grade bromelain-debriding pharmaceutical agent (NexoBrid) studied and approved for a rapid (four-hour single application), eschar-specific, deep burn debridement. We conducted an ex vivo study to determine the ability of IBS to dissolve-disrupt (enzymatic fasciotomy) Dupuytren's cords. MATERIALS AND METHODS: Specially prepared medical grade IBS was injected into fresh Dupuytren's cords excised from patients undergoing surgical fasciectomy. These cords were tested by tension-loading them to failure with the Zwick 1445 (Zwick GmbH & Co. KG, Ulm, Germany) tension testing system. RESULTS: We completed a pilot concept-validation study that proved the efficacy of IBS to induce enzymatic fasciotomy in ten cords compared with control in ten cords. We then completed a dosing study with an additional 71 cords injected with IBS in descending doses from 150 mg/cc to 0.8 mg/cc. The dosing study demonstrated that the minimal effective dose of 0.5 cc of 6.25 mg/cc to 5 mg/cc could achieve cord rupture in more than 80% of cases. CONCLUSIONS: These preliminary results indicate that IBS may be effective in enzymatic fasciotomy in Dupuytren's contracture.Cite this article: Dr G. Rubin. A new bromelain-based enzyme for the release of Dupuytren's contracture: Dupuytren's enzymatic bromelain-based release. Bone Joint Res 2016;5:175-177. DOI: 10.1302/2046-3758.55.BJR-2016-0072.

Interleukin-6 modulates trabecular and endochondral bone turnover in the nude mouse by stimulating osteoclast differentiation.

A great deal of evidence has been accumulating that implicates the immune system in normal and pathological bone turnover. The objective of the present study was to examine the possible involvement of cytokines produced by T lymphocytes in bone metabolism. We have chosen the immunologically compromised athymic mouse, which demonstrate sclerotic features in its trabecular bone, as the animal model for assessment of possible modulation effects of interleukin-1alpha (IL-1alpha) and interleukin-6 (IL-6) on bone and cartilage metabolism. The cytokines were applied by daily subcutaneous injections for 3 consecutive days. Histomorphometry, measuring epiphyseal trabecular bone volume (ETBV), metaphyseal trabecular bone volume (MTBV), and the width of the growth plate, and tartrate-resistant acid phosphatase (TRAP) histochemistry were used to assess parameters of bone turnover in the proximal tibia. IL-6, but not IL-1alpha, reduced ETBV and MTBV. Both IL-6 and IL-1alpha reduced the width of the growth plate. IL-6, but not IL-1alpha, increased the number of chondroclasts and osteoclasts in the primary spongiosa of the proximal tibia, as well as the number of nuclei. The resultant bone resembled that of the wild-type mouse. The results point to IL-6 as a possible regulator of bone turnover in vivo. It is suggested that the athymic mouse has a deficiency somewhere in the cascade of events leading to the production of IL-6 or, alternatively, that IL-6 replaces other factors that are supplied by T lymphocytes directly or indirectly. As T lymphocytes interact with B lymphocytes it is suggested that the athymic mouse might be appropriate for studying the in vivo effects of the immune system on normal bone metabolism.

A peptide prodrug approach for improving bisphosphonate oral absorption.

This work was aimed at improving the absorption of bisphosphonates by targeting carrier systems in the intestine and the intestinal peptide carrier system (hPEPT1), in particular. (14)C-Labeled pamidronate and alendronate as well as radiolabeled and "cold" peptidyl-bisphosphonates, Pro-[(3)H]Phe-[(14)C]pamidronate, and Pro-[(3)H]Phe-[(14)C]alendronate were synthesized. In situ single-pass perfusion studies revealed competitive inhibition of transport by Pro-Phe, suggesting peptide carrier-mediated transport. Prodrug transport in the Caco-2 cell line was significantly better than that of the parent drugs, and the prodrugs exhibited high affinity to the intestinal tissue. Oral administration of the dipeptidyl prodrugs resulted in a 3-fold increase in drug absorption following oral administration in rats, and the bioavailability of Pro-Phe-alendronate was 3.3 (F(TIBIA)) and 1.9 (F(URINE)) times higher than that of the parent drug. The results indicate that the oral absorption of bisphosphonates can be improved by peptidyl prodrugs via the hPEPT1; however, other transporters may also be involved.

Ulnar nerve injury following midshaft forearm fractures in children.

We report three cases of ulnar nerve deficit in children following closed fractures of the forearm bones. Significant anterior angulation and displacement of the ulna was noted in all patients. Two patients were operated on at a later stage when no evidence of recovery was demonstrated; the ulnar nerve was found to be embedded in dense scar tissue. One patient was operated on at the time of injury; entrapment of the nerve on the anterior spike and partial transection was found. Early exploration is indicated in such cases and may result in full recovery.

Tension-band arthrodesis of the small joints of the hand.

A review of 72 cases of tension-band arthrodesis in the small joints of the digits was conducted. Fusion was achieved in all joints with no complications apart from 2 cases of superficial infection. No failure of the hardware was noted, although hardware was removed in 5 patients after fusion was attained due to technical failure or pain. This technique provides immediate skeletal stability, thereby facilitating early digital motion and recovery.

Quadriceps femoris muscle fatigue in patients with knee osteoarthritis.

The purpose of this study was to characterize quadriceps femoris muscle fatigue of both lower extremities in patients with knee osteoarthritis (OA). Sixty-two subjects (mean age 68.2 years, standard deviation [SD] ± 7.9 years) with knee OA participated in the study. Significantly higher knee pain was reported in the involved knee than in the contralateral knee, as determined by a visual analog scale. Significant differences were demonstrated between the lower extremities in terms of maximal voluntary isometric contraction, in favor of the less involved leg (P = 0.0001). In contrast, the degree of fatigue of the quadriceps femoris muscle, as measured by the decrement in force production following ten repeated contractions, was significantly higher in the contralateral leg (P = 0.0002). Furthermore, normalization of the fatigue results to the first contraction yielded a similar result (P < 0.0001). Similar results were noted when analysis was performed separately for subjects whose involvement was unilateral or bilateral. The results indicate that, irrespective of the initial strength of contraction, the rate of muscle fatigue in the contralateral leg is significantly higher than in the involved leg. Hypotheses for these unexpected results are suggested. Rehabilitation of patients with knee OA should focus on increasing quadriceps muscle strength and endurance for both lower extremities.

Gender differences in pain perception and functional ability in subjects with knee osteoarthritis.

Background. There is no consensus regarding gender-related differences in pain intensity and functional abilities among patients with knee osteoarthritis (OA). Objective. Determine gender-related differences in pain intensity and functional ability among subjects with knee OA, as assessed by a self-report questionnaire and by performance-based tests. Methods. Sixty-three subjects with symptomatic knee pain due to OA were included in this study. The outcome measures were self-reported knee pain intensity and physical function (WOMAC), as well as three performance-based functional assessments: time up and go test, a 10-meter walk test, and stair negotiation. Independent sample t-tests were performed to determine gender differences. Level of significance was set at P ≤ 0.05. Results. Female subjects reported higher levels of knee pain and lower functional performance. In contrast, no significant gender-related differences were determined in any of the performance-based measures. Conclusion. The results indicate that the two types of functional ability measures may address different constructs of functional ability. Self-reported ability, particularly in the female subjects, may be influenced by psychological aspects associated with chronic pain. Rehabilitation programs should consider the underlying mechanisms of the patients' performance limitations in order to address the specific needs of each individual patient.

Complications encountered while using thin-wire-hybrid-external fixation modular frames for fracture fixation. A retrospective clinical analysis and possible support for "Damage Control Orthopaedic Surgery".

One hundred ninety eight adult patients who had sustained long bone fractures were treated by external fixation from admission to bone healing and consolidation. Of these, 135 had sustained high-energy injuries, 39 of them had suffered multi-system injuries. Superficial pin track infection was the most common complication, occurring predominantly in pins located in the femur, upper tibia and upper humerus. There were no cases of deep infection or osteomyelitis. One patient with a femoral shaft fracture developed a DVT although he was on preventive low molecular weight heparin, i.e. sc Clexane 40 mg daily. There were no cases of PE or ARDS. External fixation systems are a minimal invasive surgical modality, which allow three-dimensional fracture fixation after closed or minimal open reduction. They require a good command of surgical anatomy, but provide an optimal preservation of the fracture's soft tissue envelope, the critical biological factor for new bone formation and fracture healing. Recent publications have suggested that in the critically ill patient, minimally invasive fracture fixation surgery may prevent the perpetuation of a reactive, life threatening inflammatory reaction (the "second hit") which may induce the development of multiple organ dysfunction (MODS).

Expression of vascular antigens by bone cells during bone regeneration in a membranous bone distraction system.

An in vivo system of membranous bone formation during distraction has been investigated in order to follow cells that express vascular markers with the objective of understanding the neovascularization process. Concomitantly, sustained proliferation of preskeletal cells was achieved through the application of mechanical force. New capillaries and leading edges that arose by angiogenesis from the periosteal and mucosal surfaces and invaded the central zone of the regenerating distraction tissue temporally preceded the growth of delicate woven bone trabeculae from both edges of the cut bone. Concentrically arranged 'onion-like' configurations were abundant in paracentral zones and in association with mesenchymal condensations, suggesting their de novo formation in situ. Vascular specific markers, the angiopoietin receptor Tie-2 and factor VIII-related antigen (FVIIIrAg), were localized immunohistochemically in order to follow cells of vascular origin. Endothelial cells of the new capillaries, centrally located cells of the concentric configurations, pericytes, and most of the adjacent polygonal mesenchymal cells stained positively with specific antibodies to both antigens. Moreover, preosteoblasts and osteoblasts that lie adjacent to or already embedded in the osteiod of the newly formed trabeculae were also FVIIIrAg and Tie-2 immunopositive. As the source of the bone-forming cells in regenerating tissue during distraction is not yet fully understood, this observation might support the possibility of their vascular origin.