Treatment of Distal Radius Fractures in Women Older than 80 Years: A Preliminary Report of Functional and Radiographic Outcomes after Open Reduction and Internal Fixation.

Background Distal radius fractures are one of the most common fractures seen in the elderly. The management of distal radius fractures in the elderly, especially patients older than 80 years, has not been well defined. The purpose of this study was to evaluate operative treatment of distal radius fractures in patients older than 80 years to determine functional outcomes and complication rates. Materials and Methods A retrospective review was performed to identify patients 80 years or older who were treated for a distal radius fracture with open reduction and internal fixation (ORIF). Medical records were reviewed for demographics, medical history, functional outcomes including quick Disabilities of the Arm, Shoulder, and Hand (qDASH), radiographs, and postoperative complications. Results There were 40 patients included for review. Average age was 84 years. The preoperative qDASH score was 69. At 6 months follow-up, the postoperative qDASH score was 13 ( p < 0.001). There were five (12.5%) complications reported postoperatively. All fractures healed with adequate radiographic alignment and there were no hardware failures. Conclusion Distal radius fractures in patients older than 80 years treated with ORIF have good functional outcomes and low complication rates. Increased functionality and independence of the elderly, as well as updated implant design can lead to the effective surgical management of these patients. When indicated from a clinical perspective, operative fixation of distal radius fractures should be considered in patients older than 80 years.

Lunatocapitate and Triquetrohamate Arthrodeses for Degenerative Arthritis of the Wrist: A Midterm Follow-Up.

BACKGROUND: Degenerative arthritis of the wrist is a common condition often treated with 4 corner arthrodesis (FCA) or a partial wrist fusion. A number of limited intercarpal arthrodeses have been proposed for treatment of this condition. One technique, described by Wang and Bednar in 2012, involves fusion of the lunatocapitate and triquetrohamate joints. This study presents midterm follow-up of outcomes following this 2 column arthrodesis. METHODS: From 2000 to present, patients who underwent lunatocapitate and triquetrohamate arthrodesis were evaluated. The original cohort from the 2012 study was reviewed, as well as any additional patients who since underwent this procedure. Only patients who had greater than 5 years of follow-up data were included. Outcomes included demographics, wrist range of motion, grip strength, complications, and radiographic evidence of union. RESULTS: Twenty-one cases were included in the final analysis. Mean follow-up was 8.75 years. Wrist extension and flexion were 58% and 90% of the unaffected side, respectively. Grip strength was 92% of the unaffected side. Osseous union was achieved in 95.2% of cases. Two cases underwent revision surgery, one for nonunion and one following a fall. CONCLUSIONS: Lunatocapitate and triquetrohamate arthrodesis offers a treatment for wrist arthritis that yields good clinical outcomes, low nonunion rates, and no conversions to total wrist arthrodesis, as shown by 5-year follow-up data. Limited intercarpal arthrodesis is an alternative to FCA, with the advantage of a smaller surgical footprint and simpler technique, while still providing excellent mid- to long-term outcomes.

The Impact of Intraoperative Nursing Care on Perioperative Complications During Wide-Awake Local Anesthesia Hand Surgery.

Purpose: The wide-awake local anesthesia technique in hand surgery is widely used, but there are currently no guidelines or protocols for the number of operating room personnel required to optimize patient safety intraoperatively. This study aimed to evaluate perioperative complication rates of wide-awake local anesthesia hand surgeries performed at surgery centers that used different numbers of operating room nurses. Methods: We conducted a retrospective review of patients who underwent wide-awake local anesthesia hand surgery at 4 surgical centers over a 30-month consecutive period. Two surgical centers used 3 operating room nurses, and 2 centers used 2 operating room nurses. The complications reported included intraoperative case abortion because of critical change in patient vitals, intraoperative medication delivery, intraoperative intravenous placement for medication delivery, intraoperative conversion to sedation, intraoperative medical complications, and postoperative transfer to the emergency department or a hospital. Results: A total of 1,771 wide-awake local anesthesia surgical procedures were identified, with 925 performed at a facility that used 2 operating room nurses and 846 performed at a facility that used 3 operating room nurses. There were no perioperative complications in either group during the study period. Conclusions: There was no difference in perioperative complications between the surgery centers that used 3 versus 2 intraoperative nurses during wide-awake local anesthesia hand surgery. This study supports that limiting the nursing personnel for wide-awake local anesthesia hand surgeries could be an efficient way to cut procedural costs without compromising patient safety. Type of study/level of evidence: Therapeutic IV.

Incidence of Operating Room Fires During Hand Surgical Procedures.

Background: The purpose of the present study is to report the incidence of operating room fires during hand surgical procedures. Methods: The clinic and OR electronic medical records of seven fellowship-trained orthopedic hand surgeons at a single, large practice were retrospectively reviewed. All upper extremity procedures performed between June 2014 to June 2019 in both hospital and surgery center settings were included in the review. Demographic data was collected. The incidence of operating room fires was determined. Results: A total of 18,819 hand and upper extremity surgical procedures were included. There were 16,767 (89.1%) cases performed in a surgery center, while 2,052 (10.9%) of cases were performed in a hospital. There were 12,691 (67.4%) soft tissue procedures and 6,127 (32.6%) bony procedures performed. Chlorhexidine gluconate preparation solution was used in 9607 cases (51%). Chloraprep solution was used in 6280 cases (33.4%). Betadine was used in 2,932 cases (15.6%). One surgeon has monopolar electrocautery only available during cases. Five surgeons have bipolar available, and one has both mono and bipolar electrocautery available. There were no fires (0%) identified during the study period. Conclusion: The incidence of operating room fires during hand surgical procedures is extremely low. While hand surgeons can be reassured that the likelihood of an operating room fire is minimal, surgeons should not become complacent and should maintain a high level of vigilance to prevent these potentially devastating occurences.

Evaluation of the Incidence and Etiology of Unplanned Return to Operating Room Following Open Reduction Internal Fixation of Distal Radius Fractures.

BACKGROUND: Distal radius fractures (DRF) are the most common upper extremity fractures in adults. The purpose of this study was to determine the incidence, causes, and independent predictors for unplanned return to the operating room (URTO) in a single institution within 90 days following distal radius open reduction internal fixation (ORIF). METHODS: A retrospective study of 2933 consecutive patients from January 2015 to December 2019 who underwent distal radius ORIF was undertaken. Patients who returned to the operating room within 90 days of the index procedure were identified. Patients with planned return to the operating room for staged procedures were excluded, yielding a patient cohort of those with URTO. Demographic data, causes for reoperation, and final Quick Disabilities of the Arm, Shoulder and Hand DASH (QuickDASH) scores were collected. RESULTS: Overall, 45 patients had URTO (1.5%) occurring a mean of 44 (6-89) days from the index procedure. Reasons for reoperation included nerve complications (n = 14), loss of fixation (n = 11), hardware complications (n = 9), wound complications (n = 7), and tendon complications (n = 4). Neurologic reasons for return included carpal tunnel release (n = 13) and ulnar nerve decompression (n = 1). QuickDASH scores were higher for URTO compared with control cohort at the final follow-up (33 [range: 0-91] vs 14 [range: 0-100], P < .01). CONCLUSIONS: Mechanical hardware failure and neurologic symptoms were the most common reasons for URTO after distal fracture ORIF.

The Incidence of Psychologic Stress following a Fall and Surgical Treatment of Distal Radius Fractures.

Background and Purpose Experiencing a fall and a subsequent distal radius fracture can have a major impact not only on patients' physical function, but also on their emotional state. The purpose of this project was to describe the prevalence of fear of falling (FoF) and posttraumatic stress disorder (PTSD) following surgically managed distal radius fractures due to a fall. Methods Patients who underwent surgery for a distal radius fracture due to a fall were identified by a database query. Patients were divided into three groups based on time from surgery: 0 to 2 weeks (acute), 3 to 6 months (mid-term), and 12 to 15 months (long-term). FoF was measured using the Falls Efficacy Scale-International (FES-I) questionnaire. PTSD was measured using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (DSM) Text Revision-5 (PCL-5) questionnaire. A total of 239 patients who met inclusion criteria were consented via phone and completed the emailed surveys. Results FES-I scores were significantly higher in the acute group versus the long-term group ( p = 0.04). High concern for FoF was observed in 63% (19/30) of patients in the acute group, in 35% (14/40) in the mid-term group ( p = 0.019 vs. acute), and in 19% (8/42) in the long-term group ( p < 0.001 vs. acute). Probable PTSD was observed in 2.3% (1/44) of patients in the acute group, in 4.8% (2/42) in the mid-term group, and in 7.3% (3/41) in the long-term group. Conclusion Patients who undergo surgical fixation of a distal radius fracture due to a fall are subject to FoF and PTSD symptoms. To maximize postoperative outcomes, it is important for surgeons to be aware of these psychological effects and know how to screen for them. Level of Evidence This is a Level III study.

Unplanned Return to the Operating Room in Upper-Extremity Surgery: Incidence and Reason for Return.

PURPOSE: Complications after upper-extremity surgery are generally infrequent. The purpose of this study was to assess the rate of early unplanned return to the operating room (URTO) within 3 months after surgery) in upper-extremity surgical procedures. Our hypotheses were that the rate of URTO in upper-extremity surgery would be low and that surgically treated fractures would be at greatest risk for complications. METHODS: We performed a retrospective review of all upper-extremity surgical procedures performed at a large academic practice of fellowship-trained hand surgeons over a 5-year period. A chart review was conducted of all patients who underwent a second surgery within 3 months of the initial surgery. The surgical billing database was queried to determine the incidence of URTO per Current Procedural Terminology code. RESULTS: There were 422 Current Procedural Terminology codes with URTO out of a total of 62,608, for an incidence of 0.6%. The most frequently performed procedures were carpal tunnel release (10,674; 0.1% URTO), trigger finger release (4,549; 0.5% URTO), and open reduction internal fixation (ORIF) for distal radius fracture (2,728; 1.2% URTO). Procedures with the highest incidences of URTO were open reduction and internal fixation of the ulna (4.9%) and excision of the olecranon bursa (4.1%). Traumatic injuries were more commonly associated with URTO compared with elective procedures. Bony trauma and soft tissue trauma had URTO incidences of 1.4% and 1.1%, respectively, whereas bony elective and soft tissue elective cases were 0.6% and 0.4%, respectively. CONCLUSIONS: The 90-day URTO rate after upper-extremity surgery was low but higher than previously reported 30-day reoperation rates. Elbow procedures were most likely to result in URTO, as were procedures relating to bony and soft tissue trauma. Based on these results, we are able to counsel patients that the most common procedures we perform have low URTO rates, but surgically treated fractures are at greatest risk. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Plate Fixation of Distal Radius Fractures: What Type of Plate to Use and When?

There are several options for plate fixation of distal radius fractures. Volar plating has broad applicability and consistent outcomes, and thus is the most commonly used plate type. Dorsal plates are advantageous for specific fracture patterns, and can provide direct fracture reduction and buttressing, but may be prominent and can cause tendon irritation. Bridge plates offer an alternative to external fixation while avoiding the complications with prominent hardware, because they span highly comminuted fractures and can be used for immediate weight bearing; however, they require plate removal. Choice of plate fixation should depend on fracture type, patient factors, and surgeon experience.

Early loss of fixation after surgical treatment of distal radius fractures: Does the number of screws matter?

Fixation methods in distal radius fractures has been studied biomechanically, but studies evaluating clinical correlation of that data are lacking. We hypothesize that the use of unthreaded pegs and decreased screw number would correlate with an early failure of fixation. There were 50 operatively treated distal radius fractures with initial post-operative radiographs that demonstrated loss of fixation. An age, BMI, and fracture-type matched cohort of 50 non-failed distal radius fractures was used for comparison. The average number of distal screws in the failed fixation group was 5.3 compared to 4.8 in the group with no loss of fixation (p = 0.07). The average number of proximal shaft screws used in the failed fixation group was 3.2 compared to 3.2 in the control group (p = 0.60). There was no difference between the use of pegs in either group. There was a significant difference between distal screw number between constructs that failed from distal screw pullout as compared to the control group, 5.6 vs. 4.8 (p = 0.0001). In conclusion, there was no difference in the number of proximal screws used in distal radius fractures that demonstrated loss of early fixation. Additionally, having more than five screws in the distal fragment had a higher rate of failure from distal screw pullout, however this was likely confounded by the more severe intra-articular fractures that had additional fixation applied in an attempt to increase stability. Finally, using smooth pegs or screws in the distal fragment made no difference in loss of fixation.

Comparison of Surgical Techniques for Fixation of Terrible Triad Injuries of the Elbow: A Meta-Analysis.

Treatment of the terrible triad injury of the elbow remains a difficult problem. There are several ways to treat the radial head and coronoid fractures; controversy still exists regarding the best way to treat each. The purpose of this meta-analysis was to compare the clinical outcomes of radial head and coronoid fractures treated using current protocols. No differences in functional outcomes were found between the different surgical techniques. There is no superior current protocol for treating these injuries. Surgical treatment should be dictated by fracture type and surgeon experience. [Orthopedics. 2020;43(6):328-332.].

A Metaphyseal Corner Fracture that Wasn't: A Case Report of Osteitis from Congenital Syphilis.

CASE: Congenital syphilis (CS) is an infrequently seen condition in the United States; however, rates of CS have been on the rise. We present a case of an infant with a lesion of the radius that was initially diagnosed as a metaphyseal corner fracture and treated as such until maternal syphilis testing was noted to be positive. Ultimately, the child was diagnosed with CS. She is now undergoing treatment with penicillin and recovering well. CONCLUSION: Although CS is rare, the incidence is on the rise and should remain on the differential of lytic lesions of bone in young children.

Total Elbow Arthroplasty Versus Open Reduction and Internal Fixation for the Management of Distal Humerus Fractures in the Elderly.

Distal humerus fractures, which are challenging injuries seen in geriatric patients, are often repaired using open reduction and internal fixation or total elbow arthroplasty. This updated meta-analysis, which includes more recent open reduction and internal fixation techniques, examined outcomes following distal humerus fractures repaired using open reduction and internal fixation vs total elbow arthroplasty. Although distal humerus fractures treated with total elbow arthroplasty achieved statistically higher functional scores relative to those treated with open reduction and internal fixation, this difference was not clinically significant. Furthermore, the authors found no early difference in the use of either open reduction and internal fixation or total elbow arthroplasty in the management of distal humerus fractures. Choice of treatment should be based on patients' long-term demands and anticipated need for implant longevity. [Orthopedics. 2019; 42(1):22-27.].

Fecal transplant for recurrent Clostridium difficile infection in children with and without inflammatory bowel disease.

Ten children at our institution received single-infusion fecal microbiome transplant (FMT) using healthy, related screened donor stool to treat recurrent Clostridium difficile infection (RCDI) via nasogastric tube (2 patients) or colonoscopic delivery. Nine of the 10 (90%) children had resolution of their symptoms after a single-infusion FMT with follow-up of 1 month to 4 years. No concerning related adverse events were recognized during short- or long-term follow-up. Three of these children had concomitant inflammatory bowel disease and 2 of these 3 (66%) patients cleared RCDI with no clinical change in their underlying inflammatory bowel disease clinical activity as assessed by Physician's Global Assessment. All of the patients who had clinical improvement of gastrointestinal symptoms of RCDI while treated with antibiotics had lasting return of baseline health after FMT.