Is pronator quadratus muscle repair required after anterior plate fixation for distal radial fractures? A prospective randomized comparative study.

In this prospective, randomized comparative study in patients with distal radial fractures, we aimed to determine whether surgical repair of the superficial head after anterior locking plate fixation of the radius improves clinical or functional outcomes or both, and distal radioulnar joint stability. One hundred patients were randomized to undergo distal radial fixation with or without repair of the superficial head. Twenty-one patients were lost to follow-up, leaving a final sample of 79 patients. No differences were observed between the groups in functional scores or complication after operation. Surgical repair of the superficial head of the pronator quadratus muscle after osteosynthesis with an anterior locking plate for distal radial fractures does not appear to substantially contribute to preserving distal radioulnar joint stability or improving the consolidation process.Level of evidence: II.

Anatomic and Biomechanical Study of the Forearm Interosseous Membrane, Distal Oblique Bundle, and Triangular Fibrocartilage Complex: Role in Galeazzi Fracture Dislocation.

Purpose: The purpose of this study was to measure distal radioulnar joint (DRUJ) dislocation and radioulnar displacement associated with sequential sectioning of the different bands of the interosseous membrane and triangular fibrocartilage complex in the simulation of a Galeazzi fracture dislocation. Methods: Twelve fresh-frozen cadaver forearms were dissected. We examined the anatomy and function of the forearm interosseous membrane. Each forearm was then mounted onto a biomechanical wrist and forearm device. In the control group, radial osteotomy was performed and the degree of DRUJ displacement with progressive loads was measured. In addition to radial osteotomy, in group 1, the central band (CB) was sectioned; in group 2, the CB, distal membranous portion of the interosseous membrane, and distal oblique bundle were sectioned; and in group 3, the CB, distal membranous portion of the interosseous membrane, distal oblique bundle, and triangular fibrocartilage complex were sectioned. Results: The radioulnar displacement (mm) at 25 N, 50 N, and 75 N was recorded. In group 1, applying progressive loads resulted in an average DRUJ displacement of 4.3, 5.9, and 7.9 mm, respectively. In group 2, the displacement was 5.2, 5.7, and 6.9 mm, respectively. In group 3, the displacement was 6.2, 8.1, and 9.9 mm, respectively. Our study showed a correlation between increase in the load applied to the same injury and the degree of displacement (P = .001). In group 3, the degree of DRUJ displacement was statistically increased compared to the other groups (P = .04). Conclusions: Migration of the radius under loads implies disruption of both the CB and triangular fibrocartilage complex. The distal oblique bundle by itself does not seem to have a relevant role in radioulnar displacement at the DRUJ. Clinical relevance: This study provides insights into the interosseous membrane and stability of the DRUJ, which can contribute to a better understanding of Galeazzi fracture-dislocations.

Is ultrasound superior to fluoroscopy in distal radius volar fixation?

OBJECTIVES: In volar distal radius fixation, conventional and additional fluoroscopic views could not be sufficient to assess dorsal screw penetration. Ultrasound (US) has been suggested as a technique to improve this assessment. The objective was to determine the agreement between these two explorations in a clinical study. Quantify time-consuming of intraoperative US was the secondary objective. MATERIAL AND METHODS: A prospective descriptive study was performed. Thirty patients with a surgical distal radius fracture were treated with volar fixation by five consultant surgeons in a level I Trauma Centre. Final intraoperative fluoroscopic views: AP, lateral, 20º tilted lateral and Dorsal Tangential views (DTV) were performed assessing for dorsal screw protrusion. Then, ultrasound was performed to reassess dorsal cortex integrity. Those protruding screws were registered and changed. RESULTS: A total of 153 screws were examined. Four protruding screws were observed with no multiple protruding screws in the same fixation. Intraoperative ultrasound detected a dorsal screw protrusion in one fixation, assessed as correct by radiological projections. Almost perfect agreement was found between DTV and US examination k = 0.83 (p < 0.001). The mean surgical time was 63 ± 20.3 min while the addition of the ultrasound, supposed an average of 4 ± 1 min more. CONCLUSION: Ultrasound did not show a clinically significant improvement in the assessment dorsal screw penetration in distal radius fixation. A high agreement was observed between US and the described fluoroscopic views. The addition of intraoperative US was a non-significant time-consuming procedure.

Population Pharmacokinetics of Intra-articular and Intravenous Administration of Tranexamic Acid in Patients Undergoing Total Knee Replacement.

BACKGROUND: Tranexamic acid (TXA), an antifibrinolytic drug, is usually administered intravenously; however, intra-articular administration has recently been proven to be as effective as intravenous administration. Limited information regarding the pharmacokinetics (PK) of TXA after intra-articular administration has been reported. AIMS: The aim of this study was to develop a population PK model of TXA administered as a single intra-articular dose and as two intravenous doses, and to study the sources of interindividual variability (IIV) in the PK processes of TXA. The developed model was used to simulate PK profiles of TXA at different dosage regimens and in patients with renal impairment. METHODS: Patients who underwent primary unilateral total knee replacement (TKR) received 1 g/10 mL (concentration of 100 mg/mL) of TXA applied directly to the surgical field before wound closure, or 2 g (two doses of 1 g) of intravenous TXA. A population PK model was developed using a nonlinear mixed-effects approach and sources of IIV, such as sex, age, body weight, height, body mass index (BMI), preoperative haemoglobin, preoperative haematocrit, and creatinine clearance. RESULTS: Twenty-four patients were included, 12 in each group. Twenty patients were female, mean age (standard deviation) was 73.7 years (5.6). The disposition of TXA was best described as a two-compartment model with clearance dependent on creatinine clearance. Bootstrap results indicated that the model was stable and robust. The estimated bioavailability for intra-articular administration was 81%. Simulations indicated that 100% of patients would have plasma concentrations associated with partial fibrinolysis at 8 h post-administration with the dosages and routes of administration used in the present study. Intra-articular administration would produce complete inhibition of fibrinolysis in only 12% of patients compared with 72.5% with intravenous administration. No adverse events were reported. CONCLUSIONS: This population PK model demonstrated that a single dose of high-concentration, low-volume intra-articular TXA can achieve antifibrinolytic plasma concentrations of the drug for 8 h, providing both local and systemic effects in patients undergoing TKR. TXA administration to the surgical field could be an alternative to the intravenous; route for patients undergoing TKR; however, clinical studies are needed to assess the toxic local effects of TXA. TRIAL REGISTRATION: Spanish Clinical Studies Registry Number: 2017-004059-22. Date of registration: 12 April 2018.

Coronal shear fractures of the capitellum and trochlea: interobserver variability in classifying the fracture and the need for a computed tomography scan for the correct surgical planning.

BACKGROUND: To determine interobserver agreement in the classification by X-rays and by computed tomography (CT) scan of the coronal shear fractures of the capitellum and trochlea as well as the agreement between these two tests. METHODS: Patients with coronal shear fractures of the capitellum who were managed at our center between January 2008 and December 2017 were included. This retrospective cohort study was carried out with the approval of the ethics committee of our institution (Nº: IIBSP-Cod-2019-02, Ref. 19/070). Clinical, radiographic, and elbow-specific outcomes, including the Mayo Elbow Performance Index, were evaluated. Three observers analyzed the preoperative X-rays from all the cases. Each one of them independently classified the fractures according to the Bryan and Morrey classification (with the modification of McKee et al). The interobserver agreement was calculated by Cohen kappa coefficient. The same methodology was used to analyze the CT scan. Thereafter, one single value was determined for each X-ray and CT scan, from the good interobserver agreements. Finally, the agreement between the global X-ray classification and the global CT scan classification was calculated using the agreement percentage and the Cohen kappa coefficient. RESULTS: There were 3 males and 6 females, with a mean age of 47 years (range, 18-83). The mean follow-up period was 18 months (12-40). The average Mayo Elbow Performance Index score was 85 (range, 65-100) points. The complications were nonunion in one patient (11 %), degenerative arthritis in 7 (78 %), joint step-off in 5 (55%), and heterotopic ossification in 7 (78%). The agreement analysis between the global X-ray classification and the global CT scan classification showed a 57.1% agreement, with a kappa coefficient of -0.167. These values imply the absence of agreement. CONCLUSION: Our results demostrated that simple X-rays do not allow for the adequate interpretation of distal humeral coronal plane fractures. Although an acceptable interobserver agreement was found, there is no agreement when the same fractures were analyzed by CT scan. The authors routinely recommend CT scan to assess the extent of the fracture and perform surgical planning.

Hook Plate as a Treatment for Flexor Digitorum Profundus Avulsion Types II and III.

Avulsion fracture types II and III of flexor digitorum profundus (FPD), also called Jersey Finger, in flexor zone 1 are an uncommon pathology requiring surgical treatment. The aim of this study was to assess whether hook miniplates were an accessible and reliable option to repair FDP avulsion types II and III. Between July and August 2018, we treated 2 consecutive patients' zone 1 Leddy-Packer type II and III FDP injuries with hook plates and 1.2 × 7 mm screws included in Medartis Aptus Hand fixation system set. Patients were aged 37 and 39 years, a man and a woman, respectively. At the end of the follow-up, we evaluated the Visual Analog Scale, range of motion, grip strength, and Quick Disabilities of the Arm, Shoulder, and Hand. Both patients completed 12 months of follow-up with excellent functional and radiological results. Neither presented complications or residual disability. This injury has been treated with a wide range of surgical techniques, including anchor suture, pullout button sutures, screws, and plates. However, due to the difficulty in surgical fixation of fragments around finger joints, limited access to ligaments and tendons, and the lack of cases, none of the techniques have turned out as a clear option above others. Hook plates placed in distal phalanx emerge as surgical treatment for FDP avulsion types II and III in flexor zone 1, with excellent clinical outcomes.

Association Between Myocardial Injury and Cardiovascular Outcomes of Orthopaedic Surgery: A Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Substudy.

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) is common and of prognostic importance. Little is known about MINS in orthopaedic surgery. The diagnostic criterion for MINS was a level of ≥0.03 ng/mL on a non-high-sensitivity troponin T (TnT) assay due to myocardial ischemia. METHODS: We undertook an international, prospective study of 15,103 patients ≥45 years of age who had inpatient noncardiac surgery; 3,092 underwent orthopaedic surgery. Non-high-sensitivity TnT assays were performed on postoperative days 0, 1, 2, and 3. Among orthopaedic patients, we determined (1) the prognostic relevance of the MINS diagnostic criteria, (2) the 30-day mortality rate for those with and without MINS, and (3) the probable proportion of MINS cases that would go undetected without troponin monitoring because of a lack of an ischemic symptom. RESULTS: Three hundred and sixty-seven orthopaedic patients (11.9%) had MINS. MINS was associated independently with 30-day mortality including among those who had had orthopaedic surgery. Orthopaedic patients without and with MINS had a 30-day mortality rate of 1.0% and 9.8%, respectively (odds ratio [OR], 11.28; 95% confidence interval [CI], 6.72 to 18.92). The 30-day mortality rate was increased for patients with MINS who had an ischemic feature (i.e., symptoms, or evidence of ischemia on electrocardiography or imaging) (OR, 18.25; 95% CI, 10.06 to 33.10) and for those who did not have an ischemic feature (OR, 7.35; 95% CI, 3.37 to 16.01). The proportion of orthopaedic patients with MINS who were asymptomatic and in whom the myocardial injury would have probably gone undetected without TnT monitoring was 81.3% (95% CI, 76.3% to 85.4%). CONCLUSIONS: One in 8 orthopaedic patients in our study had MINS, and MINS was associated with a higher mortality rate regardless of symptoms. Troponin levels should be measured after surgery in at-risk patients because most MINS cases (>80%) are asymptomatic and would go undetected without routine measurements. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Low-concentration distal nerve blocks with 0.125% levobupivacaine versus systemic analgesia for ambulatory trapeziectomy performed under axillary block: a randomized controlled trial.

BACKGROUND: Trapeziectomy is one of the most painful procedures in ambulatory surgery. This prospective randomized trial aimed to compare postoperative pain control using distal peripheral nerve blocks (dPNB) with a low concentration of a long-acting local anesthetic versus conventional systemic analgesia. METHODS: Fifty-two patients undergoing trapeziectomy were randomized to receive levobupivacaine 0.125% 5 mL on radial and median nerves at the elbow (dNB group), or not to receive these blocks (control group). In both groups, surgery was performed under axillary block (mepivacaine 1% 20 mL) and the same analgesic regimen was prescribed at discharge. The primary outcome was postoperative pain at 24 and 48 hours after surgery and maximum pain score on the first and second postoperative day. Secondary outcomes were duration of dPNB, rescue analgesia requirements, opioid-related side effects, consumption and effectiveness of antiemetic therapy, and upper limb motor block. RESULTS: Fifty patients were analyzed. Maximum pain intensity was moderate to severe (dPNB vs. control) in 33.3% vs. 92.3% (P=0.002) on the first day after surgery and 20.8% vs. 80.8% (P<0.001) on the second day. The average duration of analgesia after dPNB was 10 hours and no patient reported motor block. dPNB reduced rescue analgesia requirements and the incidence of postoperative nausea and vomiting (PONV). CONCLUSIONS: dPNB on target nerves provided better analgesia than systemic analgesia after trapeziectomy performed under axillary block. Opioid consumption and the incidence of PONV were lower in the dPNB group.

Radial nerve injury following elbow external fixator: report of three cases and literature review.

INTRODUCTION: Radial nerve palsy is a rare but serious complication following elbow external fixation. Only 11 cases have been reported in the literature to date, but the incidence may be underreported. We present three new cases of this complication. MATERIALS AND METHODS: We analyzed the three cases of radial palsy seen in our center following the application of an external fixator as treatment for complex elbow injuries. RESULTS: Mean patient age at surgery was 50 years. Two patients were female and one was male. In the three cases, the initial lesion was a posterior elbow dislocation, associated with a fracture of the radial shaft in one and a radial head fracture and coronoid fracture, respectively, in the other two. Due to persistent elbow instability, an external fixator was applied in all three cases. The fixator pins were introduced percutaneously in two cases and under direct vision in an open manner in the third case. Radial palsy was noted immediately postoperatively in all cases. It was permanent in two cases and temporary in the third. CONCLUSION: Radial nerve palsy after placement of an external elbow fixator was resolved in only 1 of our 3 cases and in 6 of the 11 cases in the literature to date. Although the event is rare, these alarming results highlight the need for recommendations to avoid this complication.

Delayed rupture of all finger flexor tendons (excluding thumb) following nonoperative treatment of Colles' fracture: A case report and literature review.

AIMS: We report a case of delayed all digital flexor tendon ruptures after nonoperative management of distal radius fracture. METHODS: An 84-year-old woman, noted loss of flexion of your fingers. She had a history of Colles' fracture 40 years before, which had been left untreated. Darrach procedure were carried and a tendon transfers for the flexor tendon ruptures. RESULTS: Despite attempts of early active mobilisation, a poor operative outcome was observed. CONCLUSION: Tendon rupture can occur several months or years after the injury, and prompt recognition and treatment can minimize disability.

Silicone proximal interphalangeal joint arthroplasty for primary osteoarthritis using a volar approach.

PURPOSE: To evaluate the short-term clinical and radiographic outcome of a silicone proximal interphalangeal (PIP) joint implant using a volar approach in patients with primary osteoarthritis. METHODS: We retrospectively reviewed 36 proximal PIP joints that were replaced with Avanta silicone implants in 26 patients. Inclusion criteria were diagnosis of primary osteoarthrtitis of the PIP joint and failure to respond to conservative treatment. Clinical asessment included range of motion, patient satisfaction, and pain scores. The Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire was administered at final follow-up. Radiographs were reviewed for alignment and implant fracture. Complications were also recorded. RESULTS: After an average follow-up of 18 months (range, 12-60 mo), pain relief was markedly reduced in all patients, decreasing from a mean score of 7.2 preoperatively to 0.4 postoperatively. The arc of active motion of the PIP joint improved from 33° to 72°. Satisfaction averaged 4.8 on a 5-point Likert scale, and all patients stated they would repeat the surgery. The median final average Quick-Disabilities of the Arm, Shoulder, and Hand score was 7 (range, 4-12). Radiograph review showed 2 implant fractures at 1 and 2 years after surgery, respectively, but without clinical changes. The average deformity in the coronal plane changed from 12° (range, 8° to 18°) preoperatively to 4° (range, 3° to 8°) postoperatively, whereas the average flexion contracture changed from 18° (range, 10° to 30°) to 0° (all patients achieved full active extension). No other complications were observed. No revision surgery has been needed to date. CONCLUSIONS: The volar approach to PIP joint silicone arthroplasty offers the advantages of maintaining the integrity of the extensor mechanism, providing pain relief, and improving postoperative range of motion with minimal complications. However, further research is needed to determine the long-term efficacy of this implant. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Treatment of little finger carpometacarpal posttraumatic arthritis with a silicone implant.

PURPOSE: To evaluate the short-term clinical and radiographic outcome of a flexible silicone proximal interphalangeal joint implant between the hamate and the metacarpal, to treat posttraumatic little finger carpometacarpal (CMC) osteoarthritis. METHODS: We treated 3 men with a mean age of 30 years by means of a proximal interphalangeal silicone implant arthroplasty for CMC osteoarthritis of the little finger. Indications were disabling pain on the ulnar side of the hand, grip weakness, loss of CMC joint mobility, and disability for work and daily activities. RESULTS: All patients were free of pain at a mean follow-up of 20 months. Transverse metacarpal arch mobility and grip strength were restored. The appearance was acceptable, without misalignment, malrotation, or shortening of the little finger ray. Radiographic evaluation showed no fractures or dislocations of the implant and no signs of foreign body reaction to silicone particles. CONCLUSIONS: This technique offers the advantages of eliminating pain, maintaining length, and restoring mobility of the transverse metacarpal arch, and results in acceptable function and grip strength.

Comminuted radial head fractures treated with pyrocarbon prosthetic replacement.

PURPOSE: We had evaluated our experience in the treatment of displaced and comminuted radial head fractures with pyrocarbon radial head prosthesis. METHODS: From May 2003 to July 2008, radial head prostheses were performed in 47 patients. There were 29 female and 18 male with mean age 51 (34-70 years). The follow-up was a mean of 48 (12-60 months). Fractures of the radial head have been classified by Hotchkiss. The indications for a radial head replacement were type III fractures in 27 cases, type IV fractures in ten cases, comminuted radial fracture associated with disruption of the medial collateral ligament in three cases, Monteggia variant in five cases, and Essex-Lopresti in two cases. Functional outcomes were assessed by visual analog scales (VAS) of pain, joint motion and stability, and using the Mayo Elbow Performance Index. RESULTS: The mean VAS score for elbow pain was 1 (0.5-2.1). Patients showed an average arc of motion from 6° to 140°, with 75° of pronation and 67° of supination. By using the Mayo Elbow Performance Index, 42 patients had good/excellent results, with three fair and two poor outcomes. Complications were two implant dislocations, one elbow stiffness, one dissociation of the implant, one stem rupture, and two posterior interosseous nerve palsy that recovered from 5 to 8 weeks. We had not seen persistent instability, infection, synostosis, severe degenerative changes, or impingement. CONCLUSIONS: The treatment of comminuted radial head fracture with pyrocarbon implant usually gives an optimal result depending on the severity of the initial injury and the presence of associated lesions. The size of the prosthesis is often overestimated, causing restriction in motion due to impingement, overstuffing, or dislocations.

Intraosseous vascularity of the distal radius: anatomy and clinical implications in distal radius fractures.

This study aimed to describe the intraosseous blood supply of the distal radius and its clinical implications in distal radius fractures. Twelve adult wrists from fresh cadavers (six males, six females, 50-90 years of age, mean 68 years) were injected through the brachial artery with latex. Dissections were performed using magnifying loupes and hands were processed using the Spalteholz technique. The distal radius was supplied by three main vascular systems: epiphyseal, metaphyseal, and diaphyseal. The palmar epiphyseal vessels branched from the radial artery, palmar carpal arch, and anterior branch of the anterior interosseous artery. These vessels entered the bone through the radial styloid process at level of the Lister's tubercle but palmar and sigmoid notch. The dorsal contribution to Lister's tubercle is to the dorsal epiphyseal vessels. The intraosseous point of entry to the dorsal epiphyseal vessels was from the fourth and fifth extensor compartment arteries. In the metaphyseal area, we found numerous periosteal and cortical branches originating deep in the pronator quadratus and the anterior interosseous artery. These branches provided the main supply to the distal radius. Vessels perforated the bone and formed an anastomotic network. In the diaphyseal area, only the nutrient vessel provided intraosseous vascularity in the distal radius. Numerous metaphyseal-epiphyseal branches arise within the pronator quadratus and the anterior interosseous artery and course towards the distal radius. These branches may be fundamental to the healing of the distal radius fractures and make nonunion a rare complication.