A Biomechanical Comparison of Locked Unicortical with Non-Locking Bicortical Screws for Metacarpal Shaft Fractures in a Randomized Human Cadaveric Model.

Background: Locking plate fixation is widely used in large long bone fixation and is now available for small "long" bones in the hand. Potential advantages of unicortical locked fixation are reduced risk of over-drilling and therefore reduced risk of damage to surrounding structures and reduced risk of irritation from proud screws. Furthermore, unicortical fixation may be used where bicortical fixation is technically impossible. Our aim was to compare fixation strength of unicortical locked plate fixation with bicortical non-locked fixation in a human cadaveric model, by assessing strength under cyclical loading conditions and load to failure (LTF). Methods: 16 matched pairs of embalmed and refrigerated human cadaveric metacarpals were randomly allocated to either unicortical locked or bicortical non-locked plate and screw fixation. A transverse osteotomy was made. Fractures were stabilized with 2.0 mm self-tapping locking or cortical screws. Each metacarpal was then loaded with a 3-point cantilever testing using a 100 N cell on an Instron materials testing device, cyclically loading them at 1,000 repetitions of 30 N and 50 N. If there was no visible failure of the fixation from cyclical loading they were then loaded to failure with a 1 kN cell. Results: There was a significant difference of average LTF between the bicortical non-locking and unicortical locking of 38.07-59.95 N (p < 0.01). However, both groups showed no statistically significant difference when comparing their performance under cyclical loading. Conclusions: The authors regard unicortical locked fixation as a useful adjunct to standard plating technique.

Short Term Outcomes Following Open Reduction Internal Fixation Surgery for a Distal Radius Fracture: 2 Week Versus 4 Week Immobilization. A Retrospective Analysis.

STUDY DESIGN: The study was a retrospective cohort analysis for a 41 month period; from January 2013 to May 2016. INTRODUCTION: It is suggested that patients following a distal radius fracture (DRF) achieve a comparable outcome at 3 and 6 months post surgery regardless of the time they begin mobilization. In previous studies there has been limited analysis of outcomes within the initial 3 months: functional return, time taken from work and use of therapy resources are key outcomes which have not formally been investigated in previous studies. PURPOSE OF THE STUDY: To analyze short term outcomes of patients following open reduction internal fixation (ORIF) for a DRF. METHODS: A retrospective cohort analysis was conducted to determine primarily if there is a difference in time from work, number of therapy appointments, cost of therapy materials, time to discharge from therapy and secondarily range of motion (ROM) and grip strength (GS); when measured in patients who begin mobilization prior to 2 weeks compared to those who begin mobilization at 4 or greater weeks post surgery. RESULTS: Patients mobilized early were discharged from hand therapy significantly quicker (p = 0.033) and returned to work significantly faster (p = 0.019) than those mobilized later. Patients who began mobilization at 2 weeks or earlier post surgery had significantly greater wrist extension/flexion arc at 4 weeks (p < 0.001) and 6 weeks (p < 0.001) and rotation at 4 weeks (p < 0.001). CONCLUSIONS: Patients who begin mobilization at 2 weeks or earlier following ORIF for a DRF will lose less time from work and will be discharged sooner from hand therapy. They will additionally have increased ROM in the early post surgery phase.

Costo-osteochondral graft (rib graft) reconstruction of the irreparable proximal scaphoid.

We present our series of 21 cases in which proximal scaphoid nonunions with fragmentation were treated with costo-osteochondral graft reconstruction (rib graft). The median follow-up was 29 months. Union was achieved in all 21 patients. There were significant improvements in subjective and objective outcome measurements and carpal alignment was well maintained in all patients, as shown by normal postoperative capitolunate angle measurements. No donor site complications were encountered. Rib graft reconstruction offers a reliable and straightforward option for the difficult problem of the irreparable proximal pole of the scaphoid.Level of evidence: IV.

Evolving Threat of Community Acquired Methicillin Resistant Staphylococcus aureus Upper Extremity Infections in the South Pacific: 2011-2015.

Background: Community Acquired Methicillin Resistant Staphylococcus aureus (CA-MRSA) rates have been increasing worldwide and contribute to a growing "global health security threat" as reported by the WHO. Our group previously reported an overall rate of 7% in CA-MRSA upper extremity infections between 2004-2009 at the Auckland Regional Hand Unit. This fell below the Center for Disease Control (CDC) recommendation for empiric antimicrobial cover once local rates exceed 10-15%. We examined prevalence and characteristics of CA-MRSA upper extremity infections in our region over a subsequent 5-year period. Methods: One thousand two hundred and fifty-two patients with upper extremity infections requiring operative management between 2011 and 2015 inclusive were included in this study. Associated clinical characteristics were recorded including ethnicity, cultured organisms, antibiotic sensitivities, infection rate, and treatment practice. Results: One hundred and fifty (12%) of patients had culture positive CA-MRSA upper extremity infections. There was an increasing annual trend. Of note, rates of CA-MRSA in the Maori and Pacific Island ethnic subpopulations exceeded 15% in 2014 and 2015. Susceptibilities, associated factors and patient demographics are reported. Conclusions: Our unit enjoys significantly lower rates of CA-MRSA upper extremity infections than has been reported internationally. However, trends are increasing relative to our prior 6-year report, and the threshold for empiric treatment has been met within the Maori and Pacific Island ethnic subpopulations. This evolving threat is also highlighted by increasing cases of multi-drug resistant CA-MRSA. Evolving regional guidelines for empiric coverage of CA-MRSA among high-risk ethnic subpopulations identified by this study are underway.

Factors Associated With Disability and Sick Leave in Early Complex Regional Pain Syndrome Type-1.

OBJECTIVE: Factors influencing disability and work absence in complex regional pain syndrome type-1 (CRPS)-1 have not been thoroughly described in the literature. We sought to determine whether demographic variables, work-related factors, CRPS clinical severity ratings, pain scores, or psychological variables were associated with disability and sick leave in early CRPS-1. METHODS: A total of 66 CRPS-1 patients were recruited within 12 weeks of CRPS onset. Patients completed measures of pain, depression, anxiety, stress, pain catastrophizing, and pain-related fear. A physical examination was conducted to assess signs and symptoms of CRPS and to calculate a CRPS severity score. Demographic details, clinical details, treatments, work type, and work status were recorded. RESULTS: In multivariate analyses, the following factors were associated with greater disability: higher pain scores, more restricted ankle or wrist extension, and higher levels of depression. Among the 49 who were either working or studying before developing CRPS, 28 had stopped work or study at the time of assessment. Multivariate analyses showed that sick leave was more likely among those whose CRPS was triggered by more severe injuries, whose work was more physically demanding, among those with higher disability scores, and there was also a significant effect of depression on sick leave, which was mediated by disability. DISCUSSION: Although the study was cross-sectional and so cannot differentiate cause from effect, results suggest that even in the early stages of CRPS, a cycle of pain, disability, depression, and work absence can emerge. Treatments aimed to prevent this cycle may help prevent adverse long-term outcomes.

Do psychological factors influence recovery from complex regional pain syndrome type 1? A prospective study.

Previous studies have shown that the outcomes of complex regional pain syndrome (CRPS) vary significantly between patients, but few studies have identified prognostic indicators. The aim of this study was to determine whether psychological factors are associated with recovery from recently onset CRPS amongst patients followed prospectively for 1 year. Sixty-six patients with CRPS (type 1) were recruited within 12 weeks of symptom onset and assessed immediately and at 6 and 12 months, during which time they received treatment as usual. At each assessment, the following were measured: signs and symptoms of CRPS, pain, disability, depression, anxiety, stress, pain-related fear, pain catastrophising, laterality task performance, body perception disturbance, and perceived ownership of the limb. Mixed-effects models for repeated measures were conducted to identify baseline variables associated with CRPS severity, pain, and disability over the 12 months. Results showed that scores for all 3 outcome variables improved over the study period. Males and those with lower levels of baseline pain and disability experienced the lowest CRPS severity scores over 12 months. Those with lower baseline anxiety and disability had the lowest pain intensity over the study period, and those with lower baseline pain and pain-related fear experienced the least disability over the 12 months. This suggests that anxiety, pain-related fear, and disability are associated with poorer outcomes in CRPS and could be considered as target variables for early treatment. The findings support the theory that CRPS represents an aberrant protective response to perceived threat of tissue injury.

Comparison of plain x-rays and computed tomography for assessing distal radioulnar joint inclination.

PURPOSE: To compare the inclination of the distal radioulnar joint (DRUJ) on computed tomography (CT) and plain radiography (XR) in order to assess the effect of narrowing the range of inclination used in the original Tolat classification system to identify potentially problematic reverse oblique DRUJs. METHODS: Two independent investigators compared the angle of inclination and Tolat type on matched wrist XRs in the coronal plane and CTs of the same patients with normal DRUJs. The degree of agreement between XR and CT was determined. Inter- and intra-observer reliabilities were calculated. The prevalence of the 3 inclination types of the DRUJs using Tolat's definition was recorded. Their original quantitative definition of the parallel Tolat type 1 DRUJ included all DRUJs with a measured inclination of ±10°. We noted and compared the resultant changes in prevalence of the different DRUJ types after narrowing the inclination range to ±5° and ±3°. RESULTS: Highly significant correlation between CT and XR measurements were found for both observers. Despite this, the limits of agreement between CT and XR in determining the sigmoid notch inclination was -9° to 11° (±2° standard deviations from the mean difference). When measured from the CTs and using Tolat's original algorithm, the prevalence of Tolat type 1 DRUJ was 47% (N = 34), type 2 was 51% (N = 37), and type 3 was 1% (N = 1). These percentages changed to 7% (N = 5) for type 1, 78% (N = 56) for type 2, and 15% (N = 11) for type 3 when applying narrower ranges of inclination. CONCLUSIONS: Narrowing the range of sigmoid notch inclination that defines type 1 (parallel) DRUJs when using CT provided a more accurate representation of the morphological types. It revealed an increased number of potentially problematic type 3 DRUJs. However, the statistical limits of agreement between CT and XR suggested that high-resolution 3-dimensional imaging is required to apply the new algorithm. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Community acquired methicillin resistant Staphylococcus aureus hand infections: a South Pacific perspective - characteristics and implications for antibiotic coverage.

PURPOSE: Community acquired methicillin resistant Staphylococcus aureus (CA-MRSA) infections are reported to be increasing worldwide. In the United States when rates exceed 15% empiric treatment is suggested. The aim of our study was to determine local rates and treatment of CA-MRSA within our region. METHODS: Nine hundred and forty-two patients were admitted to our service during a six-year period with culture-positive hand infections identified from operative cultures at the time of surgery. RESULTS: Sixty-six (7.0%) patients had CA-MRSA positive cultures identified. Thirty-two (48.5%) patients were noted to have remained on antibiotic treatment that did not reflect their MRSA positive status after cultures returned. Despite this, re-admission and re-operation rates were low and comparable to our non-MRSA control group. CONCLUSIONS: Within our CA-MRSA group, current rates do not support automatic empiric treatment for CA-MRSA. Based on sensitivity data, co-trimoxazole and intravenous vancomycin are appropriate and effective antibiotic treatment within our region. Our data supports the importance of drainage of pyogenic infections in helping to resolve complicated hand infections.