Hemi-hamate arthroplasty provides functional reconstruction of acute and chronic proximal interphalangeal fracture-dislocations.

PURPOSE: Hemi-hamate resurfacing arthroplasty is a treatment alternative for the management of severe acute and chronic dorsal proximal interphalangeal (PIP) fracture-dislocations. This study was designed to determine whether this procedure would successfully restore function after such injuries. METHODS: Hemi-hamate reconstructions were performed on 33 patients (mean age, 34 years) who presented to 1 hand surgery practice with dorsal PIP fracture-dislocations. Eligible patients experienced unstable dislocations with comminuted metaphyseal fractures involving at least 50% of the volar middle phalangeal surface that was not amenable to open reduction and internal fixation. We evaluated 22 patients with 14 acute (<6 weeks) and 8 chronic (mean, 30 weeks) injuries at a mean of 4.5 years (range, 1-7 years). Functional outcomes were assessed by objective and subjective measures: joint alignment/motion/stability, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and visual analog scales (VAS) of pain and function. RESULTS: After hemi-hamate reconstruction, active PIP motion averaged 70 degrees (acute 71 degrees , chronic 69 degrees ) with a mean flexion contracture of 19 degrees (range, 0 degrees to 80 degrees ). Active distal interphalangeal motion averaged 54 degrees (acute 56 degrees , chronic 51 degrees ). The mean VAS score for digit pain was 1.4 (acute 0.7, chronic 2.5). The mean DASH score of 5 (acute 2, chronic 9) and VAS functional score of 1.9 (acute 1.4, chronic 2.6) indicated little functional impairment (acute 2, chronic 9). Grip strength averaged 95% of the opposite hand. Mean coronal plane angulation at the PIP joint was 3 degrees . Ten patients reported aching with cold temperatures. One dissatisfied patient underwent revision surgery. Chronic reconstructions were associated with increased VAS pain ratings (p = .02) and higher DASH scores (p = .06). CONCLUSIONS: Hemi-hamate reconstruction represents a valuable surgical procedure to address severe PIP joint fracture-dislocations. Reconstruction of chronic injuries by this method restores PIP function, albeit with more modest outcome performance. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias. According to high-quality guidelines: (1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options; (2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation; (3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and (4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation. Ten guidelines were of high methodological quality, but updating and some methodological improvements are needed. Overall, most guidelines target nonspecific LBP and recommend education, staying active/exercise, manual therapy, and paracetamol or NSAIDs as first-line treatments. The recommendation to use paracetamol for acute LBP is challenged by recent evidence and needs to be revisited. SIGNIFICANCE: Most high-quality guidelines recommend education, staying active/exercise, manual therapy and paracetamol/NSAIDs as first-line treatments for LBP. Recommendation of paracetamol for acute LBP is challenged by recent evidence and needs updating.

Skeletal tissue responses to thermal injury: an experimental study.

Skeletal changes occurring secondary to burn injuries were studied in an experimental animal model for thermal injury. One hindlimb of female Sprague-Dawley rats (200-250g) was subjected to a standardized thermal injury; the other hindlimb was left untreated. Control animals received no experimental treatment. Effects on skeletal architecture were studied at the proximal tibial metaphysis and tibial diaphysis using static histomorphometry. Bone formation dynamics were studied from a series of bone fluorochrome labels administered before the experiment began, early (days 8, 9) postburn treatment (PBT) and late PBT (days 17, 18). Animals were sacrificed on day 21 PBT. In proximal tibial metaphyses of burn-treated limbs, trabecular bone area (TBA) and trabecular number in all regions except the primary spongiosa, were significantly reduced. TBA was also decreased, but not significantly in nontreated limbs. Longitudinal growth rate, growth plate thickness and growth cartilage cell production rate are greater in burn-treated than in nonburned and control bones. Burn-treated diaphyses showed extensive woven bone formation at periosteal surfaces, and corresponding increases of bone areas and periosteal perimeters. Endocortical surfaces showed only typical occasional resorption areas. No intracortical changes were observed. Mineral appositional rate (MAR) and bone formation rate (BFR) at endocortical surfaces were markedly depressed after thermal injury, significant changes were noted in both limbs of treated animals. Among burned limbs, the early PBT label was absent from all specimens, indicating a virtual shutdown of osteoblast activity and recruitment. Similarly in nonburned limb bone, the label was absent from 50% of the specimens; in those bones in which the label was present, label lengths, appositional and bone formation rates were significantly reduced relative to the control specimens. Comparison of average bone formation dynamics for the total PBT interval indicates that MAR and BFR in burned treated tibiae were reduced to approximately 25% of control values. MAR and BFR from the nonburned side of treated animals were significantly reduced as well, to about 55% of control values. These data indicate that the principal metaphyseal effects of thermal injury are stimulation of growth cartilage proliferation, and depression of ossification and osteoblast activity. In diaphyses, thermal injury causes extensive local periosteal woven bone proliferation and a dramatic depression of endosteal bone formation. The latter effect, while more severe locally, is also evident systemically.

Acute management of severe hand injuries.

Mutilating hand injuries are extraordinarily complex, involving all structures of the hand. Immediate treatment priorities are described, and planning for staged reconstruction is formulated, based on the most reasonable and realistic goals involved in restoration of use for the patient.

Severe open fractures of the tibia.

Sixty-two Type-III open fractures of the tibial shaft are reported on. Eleven were Type IIIA, and three of them had non-union while none were associated with deep infection or required secondary amputation. Forty-two were Type IIIB, and fifteen of them had non-union, twelve were associated with deep infection, and seven required secondary amputation. However, in the twenty-four Type-IIIB fractures that were treated with early restoration of the damaged soft tissue by local flaps or free tissue transfer, the rate of complications was significantly reduced to five non-unions, two deep infections, and two secondary amputations. Unfortunately, of the nine Type-IIIC injuries, seven ultimately required secondary amputation, from two days to sixty-three months after the initial injury, because of pain, sepsis, non-union, or failure of the vascular repair. Only two patients who had a Type-IIIC fracture have avoided amputation to date, and their results were poor.

The latissimus dorsi flap for reconstruction of the brachium and shoulder.

The latissimus dorsi was transferred on its neurovascular pedicle to reconstruct the shoulder or brachium in nineteen patients. Group I consisted of seven patients in whom transfer of the latissimus dorsi was used only to obtain active flexion of the elbow. Although there was complete necrosis of the transferred muscle in one patient, six patients achieved an average of 111 degrees of active flexion and full extension of the elbow. There was only a modest gain in active supination because of pre-existing pronation contractures. The three patients in Group II had sustained loss of the flexor muscles of the elbow and the overlying soft tissue as a result of trauma. After the latissimus dorsi musculocutaneous flexorplasty, an average of 135 degrees of active flexion of the elbow was restored, but there was an average loss of 12 degrees of extension. The three patients in Group III had a large, noninfected defect of the soft tissue over the shoulder or brachium; the bone, shoulder joint, or neurovascular structures were exposed in each patient. Transfer of the latissimus dorsi with the overlying skin provided satisfactory coverage of the defect. The six patients in Group IV had chronic osteomyelitis or septic arthritis of the glenohumeral joint. Treatment consisted of radical débridement of the infected soft tissue and bone followed by transfer of the latissimus dorsi. This provided satisfactory coverage for subsequent osteosynthesis of the humerus or arthrodesis of the shoulder when one of these procedures was indicated. At the time of writing, an average of 2.3 years after the latissimus dorsi transfer, none of the patients in this group (including one who died nine months post-operatively of unrelated causes) had drainage.

Osteonecrosis after renal transplantation in children.

Osteonecrosis occurred in nine of thirty-six children following renal transplantation. The distal femoral condyle was the most common location but the femoral head was the most symptomatic and required total hip replacement in three of five patients. Total steroid dosage did not correlate with the development of osteonecrosis. There were no cases of osteonecrosis in patients under the skeletal age of ten years or in patients who did not have rejection reactions. In three children non-progressive focal lesions developed, similar to those of osteochondritis dissecans.

Thumb carpometacarpal osteoarthritis: arthrodesis compared with ligament reconstruction and tendon interposition.

BACKGROUND: There has been considerable controversy regarding the procedure of choice for treatment of any given stage of osteoarthritis of the thumb carpometacarpal joint. This study was designed to directly compare the clinical results of two common surgical procedures for this condition, trapeziometacarpal arthrodesis and trapezial excision with ligament reconstruction and tendon interposition, in similar patient populations. METHODS: Between 1988 and 1998, 109 patients (141 thumbs) who were less than sixty years old were treated with one of the two procedures. In a retrospective review, forty-two patients (fifty-eight thumbs) treated with arthrodesis completed an outcome questionnaire and twenty-nine patients (forty-four thumbs) treated with arthrodesis completed the questionnaire and were examined. In the group treated with trapezial excision with ligament reconstruction and tendon interposition, thirty-nine patients (forty-nine thumbs) completed the questionnaire and thirty patients (thirty-eight thumbs) completed the questionnaire and were examined. The average duration of follow-up was sixty-nine months. The groups were similar with regard to age, gender, hand dominance, and duration of follow-up. RESULTS: Subjective evaluation of pain, function, and satisfaction demonstrated no significant difference between the two groups, with >90% of patients satisfied following either procedure. Although grip strength did not differ between the groups, the arthrodesis group had significantly stronger lateral pinch (p < 0.001) and chuck pinch (p < 0.01). The group treated with ligament reconstruction and tendon interposition had a better range of motion with regard to opposition (p < 0.05) and the ability to flatten the hand (p < 0.0001). There was a higher complication rate in the arthrodesis group, with nonunion of the fusion site accounting for the majority of the complications. However, despite a persistent nonunion in six thumbs, those thumbs and the thumbs in which union was obtained did not differ with regard to pain; all of the patients with nonunion had improvement in their pain status compared with preoperatively, and all were very satisfied with the outcome. Peritrapezial arthritis developed in nine patients (fourteen thumbs). This finding was not related to age and did not affect overall pain, function, or satisfaction. CONCLUSIONS: Although traditionally arthrodesis and ligament reconstruction and tendon interposition have been indicated in two different patient populations, we compared them in a homogeneous group and found that the two procedures had similar results with regard to pain, function, and satisfaction despite minimal differences in strength and motion. Although complications were more frequent following arthrodesis, most did not affect the overall outcome.

Intramedullary fixation of humeral shaft fractures.

In this paper we document seventy fractures of the humeral shaft that were treated by intramedullary fixation between 1970 and 1981. Complications developed in forty-seven (67 per cent) of the fractures, and forty-five (64 per cent) required at least one additional operative procedure. Of the sixty fractures that were internally fixed within six weeks after injury, nine (15 per cent) had a delayed union and five (8.3 per cent) had a non-union, two of which persisted despite subsequent surgery. Three of the ten fractures that were internally fixed more than six weeks after injury never united despite additional procedures that were done to secure union. Delayed union and non-union were more common in open fractures (33 per cent) than in closed fractures (21 per cent), and with open reduction (39 per cent) than with closed or so-called semi-open reduction (9 per cent). Deep infection occurred in three (5 per cent) of the fractures and was more common in open (17 per cent) than in closed fractures (2 per cent). One of the three open fractures that were treated by immediate fixation became infected, as compared with only one of the nine open fractures treated by delayed fixation. Painful adhesive capsulitis of the shoulder developed in thirty-four (56 per cent) of the patients who had fractures treated with distally directed pins, but motion of the elbow was not restricted in the nine patients with fractures treated with proximally directed pins.

Complications of scaphoid silicone arthroplasty.

Between 1971 and 1982, thirty-three patients underwent scaphoid silicone arthroplasty, and twenty-three of them were available for review after an average of three years of follow-up. Radiographically, there was evidence of carpal collapse with a progressive decrease in carpal height and a progressive increase in the scapholunate angle in thirteen wrists. Subluxation of the spacer occurred in thirteen patients, and nine of them also had dislocation of the trapezial stem. Clinically, grip strength did not improve and wrist motion increased only slightly. There were complaints of pain associated with subluxation of the spacer in more than half of the patients. Ten patients, eight of whom had a subluxated spacer, underwent thirteen secondary surgical procedures.

Functional reconstruction of an extremity by free tissue transfer of the latissimus dorsi.

Fifteen lower extremities with large traumatic defects in the soft tissues were resurfaced by free microvascular transfer of the latissimus dorsi muscle and overlying skin. This procedure was particularly useful in four patients in whom a portion of the extremity had been acutely denuded of its soft-tissue sleeve, leaving exposed bone, joint, or tendon. It was also effective in eleven patients with chronic lesions who required additional reconstructive procedures (arthrodesis, internal fixation, bone-grafting, or tendon-grafting), and in the treatment of chronic osteomyelitis when infected bone and soft tissue had to be liberally debrided. In the eleven patients who had chronic osteomyelitis at the time of the transfer (five with infected, unstable tibial fractures), no subsequent drainage was evident at an average of twenty-two months' follow-up.

Deep venous thrombosis after spinal surgery.

Eighty-six consecutive patients undergoing spinal surgery were studied with preoperative and postoperative compression ultrasonography of the lower extremities to identify acute deep venous thrombosis. Compression stockings were the only method of prophylaxis. Postoperative deep venous thrombosis developed in five patients (6%). Serial ultrasound scanning revealed propagation of the thrombus proximal to the knee in one patient, who was the only patient to be anticoagulated. There were no statistically significant differences in the incidence of deep venous thrombosis compared to the type of procedure, age, sex, length of operation, or duration of bed rest. In conclusion, deep venous thrombosis distal to the inguinal ligament is unusual after spinal surgery. Given the potential complications of anticoagulation, we recommend only mechanical prophylaxis.

Acute management of thermal and electrical burns of the upper extremity.

Acute management of upper extremity thermal and electrical injuries requires an aggressive treatment protocol which combines meticulous wound care, intensive hand therapy, and early stable wound coverage to salvage upper extremity function. Electrical injuries inflict severe deep-tissue destruction that frequently results in major limb amputation.

Early joint and tendon reconstruction for a degloving injury to the dorsum of the hand.

Primary insertion of inert material into an open wound to expedite joint and tendon reconstruction can be safely accomplished if the wound is thoroughly debrided and the material is covered with a well-vascularized flap. In this case, metacarpophalangeal mobility and extensor tendon function were largely preserved by early insertion of silicone spacers and rods in the reconstruction of a severe degloving injury to the dorsum of the hand.

The inhibition of skeletal changes in a rat burn model with a local muscle flap.

The effects of early wound closure using a local muscle flap on the development of periosteal new bone formation in a rat burn model were studied. Following a full-thickness burn to one hind limb, periosteal new bone formation along the tibial diaphysis was measured by the use of the fluorochrome agent calcein and an image-analysis system. Prostaglandin E levels, a known inflammatory mediator, from the bone beneath the burn also were measured. Periosteal new bone formation was inhibited by 50 percent in animals that had debridement and wound closure with a gastrocnemius muscle flap and skin graft on postburn day 2 compared to untreated controls or animals closed with skin grafts only. There was a trend toward reduced prostaglandin E measurements from tibial sections in the early closure group compared to untreated controls. This study demonstrates that early wound closure using a local muscle flap inhibits the periosteal new bone formation which is possibly associated with the inflammation in a rat burn model.

Surgical treatment of elbow contractures in postburn children.

One-hundred and forty-six postburn elbow contractures in children were classified into four categories--simple band, complex band (crosses shoulder and/or wrist joint), diffuse scar, and limited scar--to assess the results of surgical treatment. The best results were seen in children less than 5 years of age and in children with less than 50 percent third-degree total body surface area burns. Types of release included skin grafts, local flaps (with or without graft), and deep releases. Generally, good to excellent results were seen regardless of technique of release, and in no case was the postoperative contracture worse than the preoperative contracture. Full extension was restored in 82 percent of contractures that were less than 50 degrees and in 50 percent of contractures greater than 50 degrees. Major complications were uncommon, with 4 of 171 elbows requiring reoperation because of skin-graft or flap loss. Repeat releases were of minimal functional benefit.

Complications of muscle-flap transposition for traumatic defects of the leg.

A careful study of 95 consecutive muscle-flap procedures performed on 71 patients with traumatic soft-tissue defects of the leg was carried out. Although there were only 5 cases of total muscle-flap necrosis, major and minor complications were found in 31 patients, requiring additional surgery for coverage. Technical errors resulted in partial split-thickness skin-graft loss or hematoma and were responsible for the 10 minor complications. Inadequate debridement of necrotic soft tissue and bone, the use of diseased or traumatized muscle, and unrealistic objectives for the muscle-flap coverage were the source of 21 major complications. We feel fewer complications would result with more careful preoperative evaluation and surgical planning, adequate debridement of bone and soft tissue, and the transfer of healthy, nontraumatized muscle.

Skeletal changes after burn injuries in an animal model.

Musculoskeletal deformities can develop after burn injuries. Seventy-five skeletally immature Sprague-Dawley rats were examined after infliction of full-thickness lower extremity scald burns to assess longitudinal growth, joint integrity, and bone composition. Longitudinal bone growth in the immediate postburn period was depressed. However, with the resumption of feeding and activity, normal growth ensued, unless the epiphyseal cartilage had been damaged by septic extension of the wound. Degenerative joint changes occurred in the burned limbs of six animals. Significant soft tissue contractures and collapse of the supporting subchondral bone were present in each of the affected knee joints. There was no evidence of joint sepsis. Large amounts of periosteal new bone consistently formed along the tibia beneath the burn wound. Sequential injections of fluorescent bone markers demonstrated that the stimulus for new bone formation corresponded with the presence of an open granulating burn wound. No further pathologic new bone formed after the wound had healed fully.

Complications following mucous cyst excision.

Eighty-six mucous cysts in 79 patients were surgically excised. Follow-up was carried out at an average of 2.6 years. Fifteen digits (17%) had a residual loss of extension of 5 to 20 degrees at the IP or DIP joints. One patient developed a superficial infection and two developed a DIP pyarthrosis, which eventually required DIP arthrodesis. Nail deformities were present in 25 of 86 digits preoperatively (29%), 15 of which resolved after surgery (60%). Four of 61 digits developed a nail deformity which was not present preoperatively (7%). Three of 86 digits (3%) developed recurrence. Other complications included persistent swelling, pain, numbness, stiffness, and radial or ulnar deviation at the DIP joint. We recommend that patients be informed preoperatively of the potential risks of decreased range of motion, persistent swelling and pain, infection, recurrence, and persistent or postoperatively acquired nail deformity.

The Sauve-Kapandji procedure and the Darrach procedure for distal radio-ulnar joint dysfunction after Colles' fracture.

This retrospective study evaluated the results of the Darrach procedure and the Sauve-Kapandji procedure for the treatment of distal radio-ulnar joint derangement following malunion of dorsally displaced, unstable, intraarticular fractures of the distal radius in patients under 50 years of age. Twelve of 18 possible patients in the Sauve-Kapandji group completed the disabilities of the arm, shoulder, and hand survey at a mean of 4 years postoperatively and nine of the 18 returned for a follow-up examination at a mean of 2 years. Twenty-one of 30 possible patients in the Darrach group completed the disabilities of the arm, shoulder, and hand survey at a mean of 6 years postoperatively and 13 of these 30 returned for follow-up examination at a mean of 4 years. The Darrach procedure and the Sauve-Kapandji procedure yielded comparable and unpredictable results with respect to both subjective and objective parameters.