Bridge plating in the setting of radiocarpal instability: Does distal fixation to the second or third metacarpal matter? A cadaveric study

BACKGROUND

Radiocarpal dislocations are rare but potentially devastating injuries. Poorer outcomes are associated with inadequate or lost reduction, such as ulnar translocation, but no consensus exists on the ideal fixation technique. Dorsal bridge plate fixation has been described for various settings in the treatment of complex distal radius fractures and can be fixed distally to the second or third metacarpal, but its application for radiocarpal dislocations has not been established.

AIM

To determine whether distal fixation to the second or third metacarpal matters.

METHODS

Using a cadaveric radiocarpal dislocation model, the effect of distal fixation was studied in two stages: (1) A pilot study that investigated the effect of distal fixation alone; and (2) a more refined study that investigated the effect of described techniques for distal and proximal fixation. Radiographs were measured in various parameters to determine the quality of the reduction achieved.

RESULTS

The pilot study found that focusing on distal fixation alone without changing proximal fixation results in ulnar translocation and volar subluxation when fixing distally to the second metacarpal compared with the third. The second iteration demonstrated that anatomic alignment in coronal and sagittal planes could be achieved with each technique.

CONCLUSION

In a cadaveric radiocarpal dislocation model, anatomic alignment can be maintained with bridge plate fixation to the second metacarpal or the third metacarpal if the described technique is followed. When considering dorsal bridge plate fixation for radiocarpal dislocations, the surgeon is encouraged to understand the nuances of different fixation techniques and how implant design features may influence proximal placement.

Providing Orthopaedic Care to Vulnerably Underserved Patients: AOA Critical Issues

Implementation of the Affordable Care Act has increased the number of Americans with health insurance. However, a substantial portion of the population is still considered underserved, including those who are uninsured, underinsured, and those who are enrolled in Medicaid. The patients frequently face substantial access-to-care issues. Many underlying social determinants of health impact this vulnerable, underserved population, and surgeons must understand the nuances of caring for the underserved. There are numerous opportunities to engage with this population, and providing care to the indigent can be rewarding for both the vulnerably underserved patient and their surgeon.

Providing Hand Surgery Care to Vulnerably Uninsured Patients

Economically vulnerable US patients are at risk for undertreatment of hand-related conditions as well as poorer outcomes. The cost of indigent care can be substantial to both the patients and their communities. Caring for these patients in a system that depends on inconsistent coverage requires a network of safety-net hospitals. To ensure that patients have access to care, the protection of safety-net hospitals should be prioritized when discussing federal and state funding allocation. On an individual scale, surgeons can also make changes in their practices to help find sustainable ways to care for indigent patients.

Bridge Plating for Distal Radius Fractures in Low-Demand Patients With Assist Devices

Bridge plate fixation has traditionally been described for the treatment of high-energy distal radius fractures with extensive comminution, associated instability, and polytrauma with the need for immediate upper extremity assisted weight bearing. Certain patient populations who may similarly benefit from such effective and expedient stabilization include patients with multiple comorbidities who may have lower-energy fractures, poor bone quality, and a baseline reliance on ambulatory assist devices. This article reviews treatment considerations for distal radius fractures in low-demand patients and explores the rationale and technique of bridge plate fixation in this population.

Bedside Procedures in Hand Surgery

Many conditions presenting to the hand surgeon are amenable to a bedside procedure rather than a formal operating room setting. With proper patient, room, and surgeon preparation, bedside procedures can provide an efficient and effective treatment for infection, trauma, and foreign bodies. Key differences from the operating room environment include patient expectations, analgesia, room setup, instrumentation, and surgical technique. This article provides a detailed primer for performing bedside procedures in the emergency department, outpatient clinic, and inpatient hospital room.

Surgical Techniques for Correction of Traumatic Hyperextension Instability of the Proximal Interphalangeal Joint: A Biomechanical Study

PURPOSE

To compare the biomechanical strengths of 5 surgical techniques for treatment of traumatic hyperextension instability of the proximal interphalangeal (PIP) joint.

METHODS

Thirty-six cadaveric fingers were randomly assigned to 6 groups: normal control, volar plate repair, flexor digitorum superficialis tenodesis (FDST), single lateral band transfer (SLBT), double lateral band transfer, and dual split lateral band transfer. For each experimental specimen, the volar plate and accessory collateral ligaments were transected, the PIP joint was hyperextended to 90°, and a PIP joint stabilizing procedure was completed. The ultimate strength of each procedure was ascertained by loading to failure, and the fingers were dissected to determine the pathoanatomy of failure. Force-displacement curves were used to estimate the stiffness of each group, and multiple pairwise statistical comparisons were performed.

RESULTS

The mean PIP joint stiffness in the control group was significantly greater than the mean PIP joint stiffness in the FDST and SLBT groups, but not significantly different from the mean PIP joint stiffness in the other 3 groups. There were no significant differences in the mean PIP joint stiffness between the 5 joint stabilizing techniques. The SLBT, double lateral band transfer, and dual split lateral band transfer repairs all failed by massive disruption of the flexor tendon sheath, whereas the volar plate repairs and FDST repairs failed by either suture anchor pullout or suture breakage.

CONCLUSIONS

The stiffness of 5 surgical techniques to stabilize a traumatic hyperextensible PIP joint did not vary significantly.

CLINICAL RELEVANCE

The 5 described techniques to stabilize a posttraumatic PIP joint hyperextension deformity may provide for equal restraint to PIP joint hyperextension instability in the early postoperative period. The choice of procedure should take into consideration other factors not studied, including the potential for PIP joint flexion contracture and long-term durability.

Understanding readmission after primary total hip and knee arthroplasty: who's at risk?

Readmission has been cited as an important quality measure in the Patient Protection and Affordable Care Act. We queried an electronic database for all patients who underwent Total Hip Arthroplasty or Total Knee Arthroplasty at our institution from 2006 to 2010 and identified those readmitted within 90 days of surgery, reviewed their demographic and clinical data, and performed a multivariable logistic regression analysis to determine significant risk factors. The overall 90-day readmission rate was 7.8%. The most common readmission diagnoses were related to infection and procedure-related complications. An increased likelihood of readmission was found with coronary artery disease, diabetes, increased LOS, underweight status, obese status, age (over 80 or under 50), and Medicare. Procedure-related complications and wound complications accounted for more readmissions than any single medical complication.

Reproductive effects and geographical distributions of two Wolbachia strains infecting the Neotropical beetle, Chelymorpha alternans Boh. (Chrysomelidae, Cassidinae)

Wolbachia are maternally inherited endocellular bacteria known to alter insect host reproduction to facilitate their own transmission. Multiple Wolbachia infections are more common in tropical than temperate insects but few studies have investigated their dynamics in field populations. The beetle, Chelymorpha alternans, found throughout the Isthmus of Panama, is infected with two strains of Wolbachia, wCalt1 (99.2% of beetles) and wCalt2 (53%). Populations infected solely by the wCalt1 strain were limited to western Pacific Panama, whereas populations outside this region were either polymorphic for single (wCalt1) and double infections (wCalt1 + wCalt2) or consisted entirely of double infections. The wCalt2 strain was not found as a single infection in the wild. Both strains caused cytoplasmic incompatibility (CI). The wCalt1 strain caused weak CI (approximately 20%) and the double infection induced moderate CI (approximately 70-90%) in crosses with uninfected beetles. The wCalt1 strain rescued about 75% of eggs fertilized by sperm from wCalt2 males. Based on the relationships of beetle mtDNA and infection status, maternal transmission, and repeated population sampling we determined that the double infection invaded C. alternans populations about 100,000 years ago and that the wCalt2 strain appears to be declining in some populations, possibly due to environmental factors. This may be the first study to demonstrate an association between widespread strain loss and environmental factors in the field.