International consensus on periprosthetic joint infection.

The purpose of this manuscript is to document results and complications of use of a regenerative dermal matrix skin substitute for coverage of extremity wounds. A retrospective review at 3 institutions identified 28 patients and 34 wounds who had undergone use of this material (Integra). Complications included failure in two patients (4 wounds). However, overall "take" of the regenerative matrix was 86.1%. In most cases, a split thickness skin graft was applied on average at 25 days following the initial procedure. Failures were associated with infection and irradiation of the surgical field. In this series, use of the dermal regenerative matrix was associated with a high rate of success for wound coverage, obviating the need for flap coverage or prolonged dressing changes in most cases. Further series are likely to refine the known indications and contraindications to use of this method.

The effect of rotational malalignment on X-rays of the wrist.

This study evaluates the effect of rotational malposition of the wrist on measured radiographic parameters of the distal radius and carpus. Ten wrists from five healthy volunteers were imaged in varying degrees of rotation. The wrists were placed in a custom, calibrated jig and images were taken in 5 degrees increments to a maximum pronation and supination of 20 degrees . The results demonstrate the following: a steady decrease in the scapholunate and radioscaphoid angles with extremes of supination; an increase in palmar tilt with supination and a decrease in palmar tilt with pronation. The palmar tilt varied from -4 degrees to 15 degrees and the scapholunate angle ranged from 48 degrees to 29 degrees at the extremes of rotation. These results demonstrate how malrotation in X-ray positioning can have a significant effect on the apparent alignment of the distal radius and carpal bones. Measurements taken from poor X-rays typically fall outside the normal range and could adversely effect treatment decisions.

Corrective osteotomy for symptomatic increased ulnar tilt of the distal end of the radius.

Twelve wrists in 10 patients with a mean age of 23.6 years were treated for symptomatic increased ulnar inclination of the joint surface with corrective osteotomy of the radius. Diagnoses included mild ulnar dysplasia, posttraumatic deformity, Madelung's disease, and multiple hereditary exostosis. All patients had radial-sided wrist pain and an ulnarly displaced arc of radioulnar deviation. Preoperative radiographs showed excessive ulnar inclination of the distal radius, ulnar carpal translation, adaptive carpal malalignment, and frequent distal radioulnar joint incongruency. The patients had decreased pain and improved wrist function at a mean of 5.1 years (range, 2-10 years) after surgery. Average radial deviation changed from 3 degrees to 16 degrees and ulnar deviation from 48 degrees to 29 degrees; flexion/extension and pronosupination remained unchanged. Realignment of the wrist was shown radiographically by a change of ulnar inclination of the radius from 33 degrees to 21 degrees, an increase in scaphoid height from 16.4 to 20.4 mm, and reversal of ulnar carpal translation as shown by an increase in lunate-covering ratio of 64% to 77%. Reduction of the ulnar inclination to normal values by corrective radial osteotomy restores a more physiologic range of motion, decreases symptomatic wrist pain, reverts adaptive carpal changes to normal, increases lunate coverage, and may prevent abnormal cartilage overload in the ulnar compartment of the wrist.

Metacarpal and phalangeal fractures in athletes.

The high demands placed on the upper extremity in sporting activities subject the competitive athlete to common injuries of the hand. Treatment options are based on the fracture configuration, associated extremity injuries, and status of the surrounding soft tissue. Metacarpal and phalangeal fractures may usually be treated by closed, nonoperative methods, and most athletes may quickly return to play with a protective orthosis. Supplemental methods of fixation, such as percutaneous pins and tension-band wires, may be used for unstable fractures. When required, open reduction and internal fixation can provide optimum stability to the fracture, which allows immediate range-of-motion and early return to play.

Percutaneous pinning of proximal humerus fractures: a biomechanical study.

Mechanical testing of two-part surgical neck fractures fixed with four different pin configurations was performed. Ten fresh, frozen, unembalmed humeri stripped of all soft tissues were used; the surgical neck was osteotomized perpendicular to the humerus long axis. Terminally threaded 2.5-mm AO pins were used to fix the fracture. Humeri then were tested in both torsion and bending on a custom-made jig using Instron 1331 to assess the rigidity of pinning constructs. In torsion, two lateral pin construct was significantly less rigid than all other pin configurations. The addition of an anterior pin to two lateral pins did not increase bending rigidity, but significantly increased torsional stiffness. The addition of two bicortical tuberosity pins or two bicortical tuberosity pins and one anterior pin to two lateral pins significantly increased rotational and bending rigidity. Results confirm clinical data, and the authors conclude that multiplanar pins are needed to augment torsional stiffness, and that the addition of two bicortical tuberosity pins enhances bending rigidity.

Percutaneous pinning of distal radius fractures: a biomechanical study.

Mechanical testing of extra-articular distal radius fractures stabilized with percutaneous pins was performed. Twelve fresh-frozen unembalmed radii stripped of all soft tissues were used. An osteotomy with dorsal comminution was made 2.5 cm proximal to the radial styloid. Three pin sizes and four pin configurations were used to fix the fracture, and the constructs were mechanically tested. Results show that at least a .062-inch pin was required for any significant changes in rigidity of the four pin configurations tested to be discerned. Cross-pinning with two radial styloid pins and placement of a pin from the ulnar corner of the radius as the most rigid construct in both torsion and cantilever bending.