Volar Locking Plating of Extra-articular Distal Radius Fracture: A Retrospective Clinical Study Comparing Locking Screws versus Smooth Locking Pegs.

Background Open reduction and internal fixation of distal radius fractures is one of the most common procedures performed in wrist surgery. The use of volar locking plate has gained increasing interest in the past decade. Epiphyseal fixation can be done either with locking screws or smooth locking pegs, with no evidence supporting the use of one rather than the other. Purpose The aim of this study is to compare the stability of distal radius fixation by volar locking plate using locking screws or smooth locking pegs. Methods Adult patients with A2-A3 AO fractures treated with a volar plate with locking screws only or smooth locking pegs only were retrospectively included. Radiographic assessment was performed to evaluate extra-articular parameters in the intraoperative postreduction and fixation period and after bony healing. Forty-seven distal radius fractures were included. Results Twenty-four fractures had fixation with locking screws and 23 had fixation with smooth locking pegs. For both groups, all radiographic parameters measured showed a statistically significant difference between the intraoperative postreduction and fixation period and the remote postoperative period after union of the fracture ( p < 0.05) attesting a slight loss of reduction. Nevertheless, there were no significant differences between the groups in radiographic extra-articular parameters. Conclusion This clinical study shows that there is no difference in stability fixation between locking screws or smooth locking pegs in A2-A3 distal radius fractures. Clinical Relevance The use of smooth locking pegs only for epiphyseal fixation appears to be safe in volar plating of A2-A3 distal radius fractures in adult patients and could be an alternative to locking screws. More clinical data are needed to confirm these results. Level of Evidence Level III; retrospective comparative study.

A novel pulsed electromagnetic field device as an adjunct therapy to surgical treatment of distal radius fractures: a prospective, double-blind, sham-controlled, randomized pilot study.

INTRODUCTION: The purpose of this study is to evaluate whether using a Fracture Healing Patch (FHP) device that generates pulsed electromagnetic fields (PEMF), applied at the fracture site immediately after open reduction and internal fixation surgery, can accelerate healing of acute distal radius fractures. METHODS: In a prospective, double-blind, randomized, and sham-controlled study, thirty-two patients with DRFs treated with ORIF were included. Patients were allocated to a PEMF (active) group (n = 15) or a control (sham) group (n = 17). All patients were assessed with regard to functional Patient-Rated Wrist Evaluation (PRWE), SF12, and radiological union outcomes (X-rays and computed tomography (CT) scans) at 2, 4, 6, and 12 weeks postoperatively. RESULTS: Patients treated with the FHP demonstrated significantly bone bridging at 4 weeks as assessed by CT (70% vs 54%, p = 0.05). Mean grip strength in the active group was significantly higher as compared to control (16 ± 9 kg vs 7 ± 3.5 kg, respectively, p = 0. 02). The function subscale of the PRWE was significantly better in PEMF-treated group at 6 weeks after surgery (27.2 VS 35.5, p = 0.04). No statistically significant differences were found in SF12. CONCLUSION: PEMF application after ORIF of DRFs is safe, may accelerate bone healing which could lead to an earlier return to daily life activities and work. LEVEL OF EVIDENCE: I.

The Effects of Novel Pulsed Electromagnetic Field Therapy Device on Acute Distal Radius Fractures: A Prospective, Double-Blind, Sham-Controlled, Randomized Pilot Study.

BACKGROUND: this pilot study aimed at determining whether the application of a novel new method of generating pulsed electromagnetic field (PEMF), the Fracture Healing Patch (FHP), accelerates the healing of acute distal radius fractures (DRF) when compared to a sham treatment. METHODS: 41 patients with DRFs treated with cast immobilization were included. Patients were allocated to a PEMF group (n = 20) or a control (sham) group (n = 21). All patients were assessed with regard to functional and radiological outcomes (X-rays and CT scans) at 2, 4, 6 and 12 weeks. RESULTS: fractures treated with active PEMF demonstrated significantly higher extent of union at 4 weeks as assessed by CT (76% vs. 58%, p = 0.02). SF12 mean physical score was significantly higher in PEMF treated group (47 vs. 36, p = 0.005). Time to cast removal was significantly shorter in PEMF treated patients, 33 ± 5.9 days in PEMF vs. 39.8 ± 7.4 days in sham group (p = 0.002). CONCLUSION: early addition of PEMF treatment may accelerate bone healing which could lead to a shorter cast immobilization, thus allowing an earlier return to daily life activities and work. There were no complications related to the PEMF device (FHP).

Rethinking Conservative Treatment of Humeral Diaphyseal Fractures in Elderly Patients With Dementia.

OBJECTIVES: To assess outcomes and complications of conservatively managed humeral diaphyseal fractures in elderly patients, with an emphasis on the subgroup diagnosed with dementia. DESIGN: Retrospective. SETTING: Upper extremity surgery unit at an academic Level I trauma center. PATIENTS/PARTICIPANTS: Consecutive patients 65 years of age and older who were managed conservatively for humeral diaphyseal fractures between 2007 and 2015. INTERVENTION: Conservatively managed humeral diaphyseal fractures. MAIN OUTCOME MEASUREMENTS: Complications and radiographic outcomes. RESULTS: One-hundred twenty-four patients who were conservatively managed for humeral diaphyseal fractures were identified. Their mean age was 77 (65-92) years, 36 (30%) of them were male and 88 (70%) were female. Fifty-seven (46%) patients experienced complications associated with their treatment, and 33 (27%) patients were eventually treated surgically. Seventeen (14%) patients were diagnosed with dementia. This subgroup had 64% fracture-related complications, and all of them were operated (P-value <0.01 compared with age-matched patients among the other 107 participants in the study). CONCLUSION: Conservative management of humeral diaphyseal fractures seems to be associated with greater morbidity in elderly patients, especially in those diagnosed with dementia. Therefore, early surgical treatment should be considered. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Peri-Implant Olecranon Tip Fracture: Complication of Olecranon Osteotomy Plating.

Several anatomic plates for fixation of the olecranon after a fracture or an osteotomy are commercially available. They serve as an alternative for tension band wiring, which is associated with a relatively high complication rate. Plating of the olecranon reportedly might result in nonunion or malunion and eventually may require revision surgery or plate removal because of skin irritation. The authors describe a proximal periprosthetic avulsion fracture of the tip of the olecranon as a unique complication associated with the use of an anatomic plate for fixation of an olecranon osteotomy. This retrospective case series included 35 patients with comminuted distal humerus fractures treated by open reduction and internal fixation through an olecranon osteotomy with an anatomic olecranon plate. Of the 35 patients, 6 (17.1%) had postoperative olecranon tip fracture, just proximal to the osteotomy site. In all cases, the fracture line coursed through the proximal cluster of screws situated on the proximal part of the plate. Avulsion fractures of the tip of the olecranon after plating of the olecranon osteotomy could have occurred as a result of biomechanical factors. The short design of the proximal part of the plate and the high screw density in the proximal part of the olecranon could lead to increased mechanical stress during contraction of the triceps. This complication should prompt further biomechanical evaluation of the plate design. [Orthopedics. 2021;44(4):e583-e587.].

Radial head excision and Achilles allograft interposition arthroplasty for the treatment of chronic pediatric radiocapitellar pathologies: A report of four cases.

BACKGROUND: Severe radiocapitellar pathologies represent a unique problem in the pediatric population, as radial head excision can lead to substantial long-term complications. We present a case series of four pediatric patients treated by a novel technique-radial head excision followed by Achilles allograft interposition arthroplasty. METHODS: Four children (ages 12-15 years) are described. Their clinical and radiographic outcomes were assessed by a visual analog scale, the Mayo Elbow Performance Score, the Disabilities of the Arm, Shoulder and Hand questionnaire, grip strength, and range of motion. RESULTS: At a mean follow-up of two years, the average flexion-extension arc of motion improved from 107° to 131°, and the rotation arc improved from 100° to 154°. The average visual analog scale, Mayo Elbow Performance Score, and Disabilities of the Arm, Shoulder and Hand scores were 2, 92.5, and 11.5, respectively. Two patients required subsequent additional procedures-manipulation under anesthesia and ulnar shortening osteotomy. Proximal migration of the radius was observed in three out of the four patients. DISCUSSION: Combined radial head excision and Achilles allograft interposition arthroplasty represents a viable option for the treatment of chronic pediatric radiocapitellar pathologies, with good results in terms of clinical and functional outcomes as well as patient satisfaction in the short-medium term.

Manipulation under anesthesia for the postsurgical stiff elbow: a case series and review of literature.

INTRODUCTION: Elbow joint stiffness is a common complication following elbow trauma or surgery. Current practices include first-line treatment with physiotherapy and various types of splints. In cases where early postoperative loss of elbow motion interferes with activities of daily living, manipulation under anesthesia (MUA) is considered a viable treatment option, but there is currently only limited data on the results of this procedure and its complications. MATERIALS AND METHODS: This retrospective study was comprised of 12 consecutive patients who underwent MUA for the treatment of postsurgical elbow stiffness in one institution between 2010 and 2017. Their pre- and post-manipulation range of motion and their functional scores were assessed. RESULTS: MUA was performed at a mean of 52 days (range 39-91 days) following the last surgical intervention, and the patients were followed for a mean of 3 years (range 0.75-7 years). The average flexion-extension arc of motion improved by 53.8°, and the average rotation arc improved by 57°. The average Mayo Elbow Performance Score was 73 (range 0-100) at the latest follow-up. Two patients eventually underwent an open elbow contracture release due to poor post-manipulation results. There were no post-MUA complications. CONCLUSIONS: MUA of a postoperative stiff elbow can improve both flexion-extension and rotatory arc of motion in cases of early evolving postoperative stiffness and should be part of the armamentarium for the treatment of this often debilitating condition.

Repeated closed reduction attempts of distal radius fractures in the emergency department.

INTRODUCTION: Repeated attempts of closed reduction of distal radius fractures (DRF) are performed in the emergency department setting to optimize fracture alignment and avoid surgery. The additional manipulation of the fracture may, however, increase dorsal comminution and lead to loss of reduction in the cast. This retrospective cohort study has investigated the effect of second reduction attempt on fracture alignment and comminution. MATERIALS AND METHODS: Six-hundred-eighteen patients with DRF were treated in the medical center in 2007-2010. Seventy-six (12.3%) DRF who underwent two reductions were included in the study. Radiographs taken after the first and second reduction attempts were reviewed for changes in fracture alignment parameters (radial height, radial inclination, volar tilt) and dorsal comminution length. Patients were also followed retrospectively to determine the rates of secondary displacement in a cast. RESULTS: A second closed reduction attempt improved mean radial height by 1.43 mm, mean radial inclination by 1.62° and mean volar tilt by 8.75°. Mean dorsal comminution length increased by 1.6 mm. Of the 19 (25%) patients with acceptable alignments after two reduction attempts, follow-up radiographs were available for 12, which showed successful reduction in four cases (33.3 or 5.2% of total 76 patients). CONCLUSIONS: A second closed reduction attempt improved immediate fracture alignment, but also worsened dorsal comminution. Only 5.2% of patients who underwent two reduction attempts had an acceptable final alignment and did not require surgery. Increased dorsal comminution may further compromise fracture stability, complicate surgery and have negative effect on the postoperative course.

Hairline fractures following volar plating of the distal radius: a recently recognized hardware-related complication.

OBJECTIVES: Intraoperative hairline longitudinal fractures were recently reported in association with distal radius volar plating. Our aim was to further analyze this newly described complication. METHODS: A retrospective radiographic and chart review was performed on 225 patients who underwent distal radius plating between June 2013 and June 2015. The Acu-Loc/Acu-Loc2© plating system (Acumed, Hillsboro, OR, USA) was used in 208 cases, and the VariAx© plating system (Stryker, Kalamazoo, MI, USA) was used in 17 cases. Three independent reviewers performed a blind evaluation of all relevant radiographs for the occurrence of longitudinal fractures around the plate, and validity was considered only when there was agreement among all three of them. RESULTS: Hairline longitudinal fractures were identified in 57 cases (25%), 55 with the Acu-Loc/Acu-Loc2© system and 2 with the VariAx© system. All fractures occurred with volar plating. Fracture occurrence was associated with age over 59 years, female gender, extra-articular fractures, and the use of Hexalobe screws (Acu-Loc/Acu-Loc2© system). CONCLUSIONS: We believe that the source of fracture occurrence lies within the screw design and that better screw design and possibly tapping in patients at risk may reduce the occurrence of intraoperative hairline longitudinal fractures. Further clinical and biomechanical research is needed to better understand this newly reported complication.

Adult Closed Distal Radius Fracture Reduction: Does Fluoroscopy Improve Alignment and Reduce Indications for Surgery?

BACKGROUND: This study compared the radiological outcomes of adult closed distal radius fractures (DRFs) reduction with and without fluoroscopy. We hypothesized that fluoroscopy-assisted reduction would not improve radiographic alignment or decrease the need for surgery. METHODS: Hospital medical records and radiographic images of all patients who presented with DRFs between April to June 2009 and April to June 2013 were reviewed. All patients underwent closed reduction and immobilization with or without fluoroscopic assistance. Reduction attempts were noted and pre- and postreduction posteroanterior and lateral radiographs were reviewed for fracture stability. RESULTS: Eighty-four patients underwent reduction without fluoroscopy (group 1), and 90 patients underwent reduction with the aid of fluoroscopy (group 2). According to accepted radiographic guidelines, nonsurgical treatment was indicated for 62% of patients in group 1 and 56% of patients in group 2 ( P = .44). In addition, no significant difference between the groups was observed in any postreduction radiographic parameters ( P > .53) or postreduction alignment of unstable fractures ( P = .47). CONCLUSIONS: Reduction without the use of fluoroscopy demonstrated noninferiority when compared with fluoroscopy-assisted reduction in the emergency department for closed adult DRFs.

In support of early surgery for hip fractures sustained by elderly patients taking clopidogrel: a retrospective study.

BACKGROUND: Early surgical treatment is indicated to reduce mortality and morbidity associated with immobilization due to hip fracture. The judiciousness of postponing surgery to allow withdrawal of clopidogrel and return of normal platelet function (5-10 days) in elderly patients being chronically treated with this antiplatelet medication is a matter of ongoing controversy. OBJECTIVE: The purpose of this study was to compare the morbidity and mortality rates in elderly patients receiving long-term treatment with clopidogrel who were operated on with or without delay (due to withdrawal of clopidogrel) following a hip fracture. METHODS: We compared relevant demographic and medical/surgical parameters in patients receiving long-term treatment with clopidogrel who sustained a hip fracture and underwent either early (n = 30, mean ± SD age 81.6 ± 8.7 years, 17 males [57%]) or delayed (n = 30, mean ± SD age 83.3 ± 7.1 years, 13 males [43%]) surgical intervention between May 2007 and February 2010. RESULTS: Both groups were similar with regard to sex, age, co-morbidities and fracture type. The mortality rate was similar in both groups. Patients in the delayed treatment group had more complications associated with prolonged immobilization (pulmonary embolism, pulmonary oedema, decubitus ulcer). Time from admission to surgery and hospitalization stay were significantly longer in the delayed treatment group than in the early treatment group (mean ± SD 7 days and 12 hours ± 2 days and 17 hours compared with 1 day and 16 hours ± 1 day [p < 0.0001] and 17 days and 17 hours ± 7 days and 5 hours versus 11 days and 2 hours ± 4 days and 19 hours [p = 0.0002], respectively). CONCLUSIONS: Early surgical intervention for hip fracture in patients receiving long-term treatment with clopidogrel appears to be safe in terms of bleeding complications. It has the potential to enable earlier mobilization and shorter hospitalization and may reduce mortality and complications associated with immobilization.

[Isolated fractures of the scaphoid: classification, treatment and outcome].

Scaphoid fracture is the most common fracture in carpal bone of the wrist and represents 11% of all upper extremity fractures. In most cases, the mechanism of injury is a fall with an outstretched hand. Scaphoid fracture detection can be made by clinical examination and standard radiography. Computed tomography (CT), bone scan and MRI improve the sensitivity of the diagnosis. Non-displaced fractures of the scaphoid are treated with cast immobilization in most cases. Operative treatment should be considered in displaced fractures or non-displaced fractures in young active patients by using internal fixation with cannulated screw for definitive anatomic and stable fixation. The main goals of operative treatment are attempts to reduce immobilization time and enable earlier return to work and activity. Displaced fractures of scaphoid, should be treated operatively, as they carry a greater risk for nonunion and malunion, which are associated with the development of radiocarpal arthritis, stiffness and wrist instability. Computed tomography is more useful as an assessment tool in pre-operative planning to determine the fracture location and fragment displacement. Early detection and appropriate treatment of scaphoid fractures is the key to favorable outcome in the treatment of scaphoid fractures.

Delayed Effect of Acupuncture Treatment in OA of the Knee: A Blinded, Randomized, Controlled Trial.

To assess the efficacy in providing improved function and pain relief by administering 8 weeks of acupuncture as adjunctive therapy to standard care in elderly patients with OA of the knee. This randomized, controlled, blinded trial was conducted on 55 patients with OA of the knee. Forty-one patients completed the study (26 females, 15 males, mean age ± SD 71.7 ± 8.6 years). Patients were randomly divided into an intervention group that received biweekly acupuncture treatment (n = 28) and a control group that received sham acupuncture (n = 27), both in addition to standard therapy, for example, NSAIDS, cyclooxygenase-2 inhibitors, acetaminophen, intra-articular hyaluronic acid and steroid injections. Primary outcomes measures were changes in the Knee Society Score (KSS) knee score and in KSS function and pain ratings at therapy onset, at 8 weeks (closure of study) and at 12 weeks (1 month after last treatment). Secondary outcomes were patient satisfaction and validity of sham acupuncture. There was significant improvement in all three scores in both groups after 8 and 12 weeks compared with baseline (P < .05). Significant differences between the intervention and control groups in the KSS knee score (P = .036) was apparent only after 12 weeks. Patient satisfaction was higher in the intervention group. Adjunctive acupuncture treatment seems to provide added improvement to standard care in elderly patients with OA of the knee. Future research should determine the optimal duration of acupuncture treatment in the context of OA.

Phosphodiesterase inhibitors in vascular ischemia: A case report and review of their use in ischemic conditions.

The treatment of digital ischemia remains difficult. Sildenafil (Viagra, Pfizer UK), a selective phosphodiesterase inhibitor, increases blood flow and is currently marketed for the treatment of erectile dysfunction. A case of a 57-year-old man with progressive episodic ischemia and pain of the fingertips resulting in finger tip ulceration is presented. After failure of medical and surgical management, a trial of oral sildenafil resulted in marked symptomatic improvement of his bilateral digital ischemia. Review of the literature shows that, particularly in patients with an underlying disease such as sclero-derma with a vasospastic component, a marked improvement in digital blood flow may be observed with sildenafil use. Overall, based on a number of case reports and preliminary animal studies in the literature, sildenafil appears to have a growing significance in the treatment of hand ischemia. Similarly, there is evidence that phosphodiesterase 5 inhibitors may be used as an adjunct to improving skin flap survival.

Management of clinically suspected scaphoid fractures: a survey of current practice in Israel.

BACKGROUND: Fracture of the scaphoid is the most common fracture of a carpal bone. Nevertheless, the diagnosis of SF might be challenging. Plain X-rays that fail to demonstrate a fracture line while clinical findings suggest the existence of such a fracture is not uncommon. Currently there is no consensus in the literature as to how a clinically suspected SF should be diagnosed, immobilized and treated. OBJECTIVES: To assess the current status of diagnosis and treatment of clinically suspected scaphoid fractures in Israeli emergency departments. METHODS: We conducted a telephonic survey among orthopedic surgeons working in Israeli EDs as to their approach to the diagnosis and treatment of occult SF. RESULTS: A total of 42 orthopedic surgeons in 6 hospital EDs participated in the survey. They reported performing a mean of 2.45 +/- 0.85 clinical tests, with tenderness over the snuffbox area being the sign most commonly used. A mean of 4.38 +/- 0.76 X-ray views were ordered for patients with a clinically suspected SF. The most common combination included posterior-anterior, lateral, semipronated and semisupinated oblique views. All participating surgeons reported immobilizing the wrists of patients with occult fractures in a thumb spica cast based on their clinical findings. Upon discharge from the ED patients were advised to have another diagnostic examination as follows: 29 (69%) repeated X-rays series, 18 (43%) were referred to bone scintigraphy and 2 (5%) to computed tomography; none were referred to magnetic resonance imaging. CONCLUSIONS: No consensus was found among Israeli orthopedic surgeons working in EDs regarding the right algorithm for assessment of clinically suspected SF. There is a need for better guidelines to uniformly dictate the order and set of tests to be used in the assessment of occult fractures.

Current recommendations for the treatment of radial head fractures.

Radial head fractures are the most common type of elbow fractures. Although a consensus has emerged that favors the nonsurgical treatment of undisplaced fractures, controversy surrounds the treatment of displaced radial head fractures. Further research is necessary to provide a better scientific rationale for making treatment recommendations. Options for the treatment of displaced fractures include nonoperative management, fragment excision, whole head excision, open reduction and internal fixation, and radial head arthroplasty. The purpose of this article is to review the mechanisms that result in radial head fracture, to describe important physical findings that assist in identifying injuries associated with radial head fractures, and to define the role of the various interventions described for the treatment of radial head fractures.

Intramedullary fixation of tibial shaft fractures using an expandable nail.

Interlocking intramedullary nails are the gold standard for treating tibial fractures. We compared the clinical and economic factors associated with tibial fracture fixation using either interlocking intramedullary or expandable nails. From 2000 to 2002, 53 patients with 53 diaphyseal tibial fractures of similar characteristics (AO/OTA 42A1-B3) were randomly and prospectively treated with either interlocking (n = 26) or expandable nails (n = 27). Patients were followed for a minimum of 2 years. The mean surgical duration was 104 minutes with interlocking nails and 52.9 minutes with expandable nails. Rehospitalizations were required in 12 patients (46%) and reoperations were required in nine patients (35%) with interlocking nails. Only one patient (3%) with an expandable nail required rehospitalization and reoperation. Union was achieved after 17 weeks (mean) with interlocking nails and 11.5 weeks with expandable nails. The beneficial economic ramifications of using expandable nails were a 39% reduction in overall surgical and hospital expenses. Expandable nails showed important clinical advantages for tibial fracture fixation, and complications related to lengthy operations, reoperations, and rehospitalizations were substantially reduced. Overall treatment cost was substantially lower with expandable nails. Based on these advantages, simplicity in use, and short surgical time, we recommend an expandable nail for treating tibial (AO Type A, B) shaft fractures.

[Carpal tunnel syndrome].

Carpal tunnel syndrome is the most common peripheral nerve compression syndrome. Compression of the median nerve in the carpal tunnel, disrupts the blood-nerve barrier causing edema, inflammation and fibrosis of its surrounding connective tissues. In the next stage of the syndrome there is a disruption of the myelin coverage of the nerve followed by damage to the axons. Most carpal tunnel syndromes are idiopathic. Other causes include intrinsic factors (which cause pressure within the tunnel), extrinsic factors (which cause pressure from outside the tunnel) and overuse/exertional factors. Patients usually report numbness and pain of the palmar aspect of their 1st, 2nd, 3rd and radial half of their 4th finger, night pain and gradual worsening of their symptoms. At a later stage, weakness and atrophy of the thenar muscles appears. The physical examination may show a decrease in sensibility, positive provocative tests and a decrease in thenar strength. The typical finding in the nerve conduction tests is a prolonged latency period. The conservative treatment for carpal tunnel syndrome includes ergonomic modifications, anti inflammatory medications and splintage and less frequently, special exercise and therapeutic ultrasound. The indications for operative treatment are failure of conservative treatment or severe carpal tunnel syndrome. The purpose of the operation is to relieve the pressure in the carpal tunnel by dissecting the transverse ligament. The operation can be done in an open approach, endoscopic approach or limited invasive approach.

A miniature and mobile intermittent pneumatic compression device for the prevention of deep-vein thrombosis after joint replacement.

The WizAir-DVT is a miniature, lightweight (690 g), battery-operated and mobile intermittent pneumatic compression device (ICD), which enables continuous intraoperative use and immediate patient mobilization postoperatively. We compared its efficacy with a commonly used ICD, the Kendall SCD. Peak femoral vein flow velocity was measured in 20 apparently healthy volunteers at rest and with each device: we found no significant differences between them. A second prospective, randomized, clinical trial was used to compare the efficiency of the device in preventing deep venous thrombosis (DVT) after joint replacement in 50 patients (n=25/group). None developed DVT. Doppler ultrasonography revealed no significant differences. The WizAir-DVT antithrombotic compression device is as safe and effective as the Kendall SCD.