Modes of failure following locking plate fixation of the distal radius: a thematic analysis of 517 fractures.

Anterior locking plate fixation of the distal radius is a common procedure with reliable results. Failure of fixation is sometimes seen. The aim of the present study was to identify the reasons for failure. In total, 517 cases met the study inclusion criteria. Of them, 23 cases had failure of fixation (4.4%). Failure analysis generated qualitative data. Subsequent thematic analysis identified the primary mode of failure and contributing factors. Primary modes were identified as failure to support all key fracture fragments (n = 20), wrong choice of implant (n = 1), failure of union (n = 1) and poor bone quality (n = 1). Contributing factors were errors in plate positioning, fracture reduction, implant selection and screw configuration, as well as fracture pattern complexity and poor bone quality. Most failed fixations had a primary mode and two or three contributing factors. Overall anterior plating is reliable with a low rate of surgical failure. Knowledge of failure modes will aid operative planning and prevent failure.Level of evidence: V.

Reducing the incidence of pin site infection in hand surgery with the use of a protocol from Ilizarov.

Reported pin site infection rates in Kirschner wire fixation in the hand and wrist vary from 2% to 35%. In our unit we follow a strict pin site management protocol adapted from the Russian Ilizarov Scientific Centre. This study aims to identify if our current protocol reduces the incidence of pin site infection in hand and wrist surgery, and improves wire survival rates, to a level where exposed wires can be used safely. A retrospective review of 200 patients, treated with 369 percutaneous wires, in our hand surgery department over a 6-year period was carried out. Nine patients (4.5%) were diagnosed with a pin site infection with a wire survival rate of 99.5%.In our unit using our current protocol, results support the safe use of exposed wires with appropriate pin site care initiated in theatre. Adherence to this protocol allows wires to remain in-situ throughout treatment with minimal complications.Level of evidence: IV.

Incidence of tendon ruptures after locking plate fixation of distal radial fractures: are the cited rates still accurate?

With the introduction of the anterior locking plate in the early part of this century, there was a large change in how distal radial fractures were treated. Early articles about the techniques reported tendon ruptures occurring in as many as 10%, although studies from our unit reported rates closer to 2%. Subsequent refinements in surgical technique and improvements in plate design have been made with the aim of reducing the number of ruptures. Despite this, the original articles and their rates continue to be quoted. In this retrospective study of 798 cases treated with anterior locking plates, tendon ruptures have been significantly reduced and are now as low as 0.5%. Contributing factors leading to this improvement are identified and discussed.Level of evidence: III.

A Study Comparing the Outcomes of Transverse Ulnar Shortening Osteotomy Fixed with a DCP to Oblique Osteotomy Fixed with a Procedure Specific Plate.

Background: Ulnar shortening osteotomy (USO) is a well-established procedure for ulnar impaction syndrome. Various types of osteotomies have been described. Methods: A retrospective cohort study was conducted to compare the results of transverse osteotomy (TO) fixed with a small fragment dynamic compression plate (Synthes, Pennsylvania, USA), to oblique osteotomy (OO) fixed with a procedure specific plate and instrumentation system (Acumed LLC, Oregon, USA). A total of 39 patients underwent TO and 62 patients underwent OO between 2007 and 2016. The main outcomes compared were rate of union, duration of radiological healing, implant removal rate and other complications. Results: The two groups were comparable with regards to demographics, side operated and smoking status (p > 0.05). Amongst the TO group; 36 out of 39 patients (92.3%) achieved union, 3 patients (7.7%) developed non-union. Six out of the 36 healed TO (16.6%) required removal of hardware due to implant-related pain. No other complications were recorded amongst TO group needing surgical intervention. Amongst the OO group, 2 of the early cohort of 62 patients (3.2%) sustained acute failure of the metalwork due to technical error. One of the remaining 60 patients (1.6%) developed non-union giving an overall union rate of 95.2%. Two patients out of 59 healed OO (3.3%) required removal of hardware. Conclusions: Although there were 2 early failures, there was a trend towards improved union rate with OO, but this did not reach statistical significance (p > 0.05). There was a significantly higher hardware removal rate recorded in TO group (p = 0.023). The OO showed shorter duration for radiological healing than TO (p < 0.05). USO performed with an OO and fixed with procedure specific plate has lower implant removal rate, a shorter duration for radiological healing and comparable union rate to TO fixed with DCP, but needs careful attention to detail.

Complex regional pain syndrome in distal radius fractures: How to implement changes to reduce incidence and facilitate early management.

STUDY DESIGN: Implementation paper. INTRODUCTION: Complex regional pain syndrome (CRPS) is relatively a common condition in the distal radius fracture (DRF) population with the effects resulting in many sufferers experiencing persistent pain and impairment 2 to 6 years after onset. Prevention is desirable as there is no known proven cure. PURPOSE OF THE STUDY: This study demonstrates how knowledge about CRPS and its prevention generated through iterative studies can be translated into practice in the workplace and how an interdisciplinary community of practice with therapists at the core can effect change. METHODS: A series of practice changes were introduced including a patient information leaflet, a local gold standard for care of DRF, education for staff regarding risk factors and early warning signs of CRPS, and simple patient and staff visual aids. RESULTS: The incidence of CRPS was reduced from 25% to 1% in the DRF population at the study site, and collaborative care pathways were ingrained onto the working culture. DISCUSSION: The process of learning together fostered the development of an interdisciplinary team with therapists acting as CRPS champions. Interdisciplinary team reflective practice facilitated simple but effective interventions, which reduced the incidence of CRPS in DRF population locally. It is not yet known whether this is transferable. CONCLUSIONS: Simple interventions can have a significant impact on the incidence of CRPS in a community of practice where a culture of team reflection and shared learning occurs.

Rheumatoid hand surgery: is there a decline? A 22-year population-based study.

BACKGROUND: Rheumatoid arthritis (RA) is the most common idiopathic inflammatory arthritis affecting 0.8 % of the population. It can cause significant hand and wrist damage and dysfunction. Recent advances in anti-rheumatic treatments have the potential to decrease the prevalence of hand deformities in patients with RA. Our aim was to investigate whether there has been a decline over 22-years in the number of hand surgical procedures being undertaken for patients with RA and whether this correlates with the introduction of new anti-rheumatic therapies. METHODS: We performed a retrospective, population-based (Derbyshire) study of all patients with RA who underwent hand surgery at the Pulvertaft Hand Centre from 1990 to 2012. Index procedures included (1) teno-synovectomy and soft tissue procedures, (2) wrist arthrodesis/arthroplasty and (3) finger arthrodesis. RESULTS: A total of 297 procedures were performed in 153 Derbyshire patients with RA over the 22-year period, with mean age at surgery 59 years (range 24-88 years). The female to male ratio was 2.5:1. The overall trend showed a peak in 2004 and a subsequent decline thereafter. This coincides with an increasing tendency by local rheumatologists to introduce earlier and more intensive conventional disease-modifying drugs and biological therapies for more resistant disease. CONCLUSIONS: There has been a decline in the number of hand surgery procedures being performed on patients with RA during our 22-year population-based study. It indicates that medical treatments and strategies have been successful at preventing disease progression.

Functional Outcome and Complications at 2.5 Years Following Volar Locking Plate Fixation of Distal Radius Fractures.

Distal radius fractures are increasingly treated by internal fixation, but there have been relatively few studies relating to functional outcome at 12 months or more. The aim of this study was to ascertain the patient reported function of the wrist at a minimum of 12 months following fixation of a distal radius fracture, the time taken to return to work, and the complication rate. We conducted a retrospective review of 187 consecutive patients treated by a specialist hand and wrist trauma team at a tertiary referral unit over a 5 year period. Mean age was 57.3 years (range 16-93). Median time to surgery was 4 days (interquartile range 2-9). Median follow up was 31 months (interquartile range 23-41 months). The median PRWE score was 3; (range 0-83). There was no difference in outcome in patients who had surgery delayed by greater than 2 weeks (p > 0.05). The median time to return to work was 5 weeks (interquartile range 1-8 weeks). There were 15 complications (8 %) including 3 tendon injuries. We have demonstrated an early return to work in patients who were employed, a low complication rate, and highly favourable functional outcomes at a mean of 30 months postoperatively. We recommend the use of the DVR plate and involvement of a dedicated hand and wrist trauma team for treatment of unstable fractures of the distal radius.

The litigation cost of negligent scaphoid fracture management.

The aims of the study were to quantify the litigation cost of scaphoid mismanagement, identify the main reasons why patients sought compensation and hence provide suggestions for reducing litigation. Data were obtained from the National Health Service Litigation Authority. All orthopaedic-related litigation between 1995 and 2010 in the UK was reviewed. Litigation specifically against mismanagement of scaphoid fractures were identified and grouped according to the plaintiff's complaint. Exclusions were all unsettled claims. There were 85 closed cases of scaphoid fracture mismanagement over 15 years. Reasons for litigation were as follows: seven failures in interpreting radiographs, 57 missed fractures, four fractures not immobilized, nine discharged too early, five delayed operations and three inappropriate surgeries. The mean cost was &OV0556;41 680 per case (range &OV0556;0-&OV0556;206 789), and a cumulative cost of &OV0556;3 542 855. The majority of litigation may relate to a lack of follow-up and may demonstrate a failure of protocol-driven reassessment. Secondary surveys following major trauma are also highly relevant.

No drain, autologous transfusion drain or suction drain? A randomised prospective study in total hip replacement surgery of 168 patients.

We performed a prospective, randomised controlled trial to assess the differences in the use of a conventional suction drain, an Autologous Blood Transfusion (ABT) drain and no drain, in 168 patients. There was no significant difference between the drainage from ABT drains ( mean : 345 ml) and the suction drain (314 ml). Forty percent of patients receiving a suction drain had a haemoglobin level less than 10 g/dL at 24 hours, compared to 35% with no drain and 28% with an ABT drain. Patients that had no drains had wounds that were dry significantly sooner, mean 3.0 days compared to a mean of 3.9 days with an ABT drain and a mean of 4 days with a suction drain. Patients that did not have a drain inserted stayed in hospital a significantly shorter period of time, compared with drains. We feel the benefits of quicker drying wounds, shorter hospital stays and the economic savings justify the conclusion that no drain is required after hip replacement.

Functional results of isolated femoral revision of hip resurfacing arthroplasty.

BACKGROUND: Conversion of a failed femoral resurfacing component is reportedly a straightforward procedure; however, little has been published regarding the functional results following revision. Our primary aim was to compare the functional results for a group of patients who had had isolated femoral component revision after a failed hip resurfacing with those for a group of patients with a surviving hip resurfacing. Our secondary aim was to identify whether the mode of failure affects functional outcome. METHODS: Between 1997 and 2002, data were prospectively collected on 5000 Birmingham Hip Resurfacing procedures. One hundred and seventy-seven hips were revised, and, of those, seventy-six had an isolated femoral component revision. We reviewed the modes of failure and the post-revision clinical outcomes for this subgroup (the revised implant group) and compared the results with those for the patients who had a surviving hip resurfacing implant (the surviving implant group). RESULTS: The median Harris and Merle d'Aubigné hip scores were significantly better in the surviving implant group than in the revised implant group (median Harris score, 96 compared with 82 [p < 0.001]; median Merle d'Aubigné score, 17 compared with 14 [p < 0.001]). When we analyzed outcomes following revision, we found that the mode of failure affected outcome. Patient satisfaction and clinical outcomes were worse following revision because of femoral component loosening in comparison with revision because of femoral neck fracture or revision because of femoral head collapse or osteonecrosis. In these three subgroups, the median Harris hip scores were 66, 87, and 92, respectively, and the median Merle d'Aubigné scores were 10, 14, and 15, respectively. Six of fifteen patients in the femoral loosening group believed that they were worse or much worse after the revision than they had been before the primary procedure, compared with four of twenty-five patients in the femoral neck fracture group and two of twenty-two patients in the femoral head collapse or osteonecrosis group. Four patients (four hips) experienced complications as a consequence of revision surgery (three deep infections and one case of loosening of an uncemented femoral stem). CONCLUSIONS: The functional results for patients who had revision of the femoral component of a current-generation metal-on-metal resurfacing arthroplasty were worse than those for patients with a surviving hip resurfacing. Patients who had revision because of femoral component loosening had worse outcomes than those who had revision because of femoral neck fracture or femoral head collapse or osteonecrosis.

Replacement arthroplasty of the first metatarsophalangeal joint using a ceramic-coated endoprosthesis for the treatment of hallux rigidus.

We prospectively assessed 40 patients who underwent total first metatarsophalangeal joint replacement arthroplasty using a ceramic implant for the treatment of hallux rigidus. A total of 42 toes in 40 patients were included in the assessment. Preoperatively, the mean American Orthopaedic Foot and Ankle Society (AOFAS) hallux first metatarsal score was 36.00 +/- 10.79 points, and first metatarsophalangeal joint range of motion was 4.9 degrees +/- 5.52 degrees . The mean preoperative AOFAS score increased from 36.00 +/- 10.79 to 82.20 +/- 9.54 at 3 months (P < .001), to 87.00 +/- 10.62 at 12 months, and to 84.20 +/- 10.69 at 24 months. There was no statistically significant change in scores from 3 months onward. Range of motion increased to 70.80 degrees +/- 15.97 degrees in the operating room and reduced to 45.60 degrees +/- 12.28 degrees at 3 months postoperative, decreasing to 40.00 degrees +/- 12.72 degrees at 12 months and 33.30 degrees +/- 17.19 degrees at 24 months postop. We advocate total toe arthroplasty with this all-ceramic press-fit implant as an effective procedure for the treatment of moderate to severe hallux rigidus. This ceramic, total first metatarsophalangeal joint endoprosthesis yields good improvement in foot-related quality-of-life scores, reasonable range of motion, and a low early revision rate.