Complications of operatively treated distal radial fractures

Distal radial fractures represent the most common fractures of the upper extremity. Operative treatment is performed for approximately one-third of distal radial fractures in the adult population. Complications following operative treatment of distal radial fractures vary depending on the treatment modality and can be stratified into preoperative and postoperative complications. Complications can occur in the near, intermediate and long term. The most common complications seen are tendon irritation and rupture, chronic regional pain syndrome (CRPS), carpal tunnel syndrome, ulnar or radial neuropathy, compartment syndrome, malunion, inadequate fixation or loss of fixation, symptomatic hardware, post-traumatic arthritis, stiffness and infection. Careful planning, treatment and patient selection can help to mitigate these complications.Level of evidence: V.

Flexor Pollicis Tendon Reconstruction With Allograft Tendon After Rupture: Technique and Case Series

Division or rupture of the flexor pollicis longus (FPL) tendon can occur secondary to direct injury, laceration, or attritional rupture. Attritional rupture is particularly common in the setting volar plate fixation of a distal radius fracture. FPL tendon discontinuity can be restored through either primary repair or reconstruction. Primary repair can be challenging if not done within the first few days after injury secondary to contraction of the FPL muscle with retraction of the proximal tendon. Repair in this environment can lead to tension across the repair site as well as necessary flexion of the interphalangeal joint to accommodate primary repair. In the setting of attritional rupture, the proximal and distal ends are typically not viable for direct repair. We present our preferred technique for restoration of the FPL tendon, which is reconstruction with an allograft tendon.

Management of giant cell tumors of the distal radius

Background

The distal radius is the most common location for giant cell tumors (GCT) in the upper extremity. Treatment should balance the goals of maximizing function and minimizing recurrence and other complications. Given the complexity in surgical treatment, various techniques have been described without clear standards of treatment.

Objectives

The purpose of this review is to provide an overview of evaluation of patients presenting with GCT of the distal radius, discuss management, and provide an updated summary on outcomes of treatment options.

Conclusion

Surgical treatment should consider tumor Grade, involvement of the articular surface, and patient-specific factors. Options include intralesional curettage and en bloc resection with reconstruction. Within reconstruction techniques, radiocarpal joint preserving and sparing procedures can be considered. Campanacci Grade 1 tumors can be successfully treated with joint preserving procedures, whereas for Campanacci Grade 3 tumors consideration should be given to joint resection to prevent recurrence. Treatment of Campanacci Grade 2 tumors is debated in the literature. Intralesional curettage and adjuvants can successfully treat cases where the articular surface can be preserved, while en-bloc resection should be used in cases where the articular surface cannot undergo aggressive curettage. A variety of reconstructive techniques are used for cases needing resection, with no clear gold standard. Joint sparing procedures preserve motion at the wrist joint, whereas joint sacrificing procedures preserve grip strength. Choice of reconstructive procedure should be made based on patient-specific factors, considering relative functional outcomes, complications, and recurrence rates.

Shoulder Periprosthetic Joint Infection and All-Cause Mortality: A Worrisome Association

Background

Periprosthetic joint infection (PJI) can be a devastating complication following shoulder arthroplasty. PJI following hip and knee arthroplasties has been found to increase mortality. However, anatomical and bacteriologic differences could potentially result in a different trend after shoulder arthroplasties. Thus, the purpose of the present study was to determine whether there is an association between shoulder PJI and all-cause mortality.

Methods

Our institutional Total Joint Registry Database was queried to identify patients who underwent revision shoulder arthroplasty procedures between 2000 and 2018. A total of 1,160 procedures were then classified as either septic (21.8%) or aseptic (78.2%). Septic revisions were further subdivided into (1) debridement, antibiotics, irrigation, and implant retention (9.1%); (2) 2-stage reimplantation for deep infection (61.3%); (3) implant resection without reimplantation (3.6%); and (4) unexpected positive cultures at revision surgery (26.1%). The most common bacterium isolated was Cutibacterium acnes (64.4%). All-cause patient mortality was determined with use of our registry and confirmed with use of a nationwide mortality database. All-cause crude and adjusted mortality rates were then compared between groups.

Results

The 1-year crude mortality rate was 1.8% (95% confidence interval [CI], 0.9% to 2.6%) for the aseptic group and 2.8% (95% CI, 0.7% to 4.8%) for the septic group (p = 0.31). Multivariate Cox regression analysis demonstrated an elevated but statistically similar adjusted hazard ratio for 1-year all-cause mortality of 1.9 (95% CI, 0.8 to 4.6) when comparing the septic to the aseptic group (p = 0.17). The risk of 2-year all-cause mortality was significantly higher in the septic group, with a hazard ratio of 2.2 (95% CI, 1.1 to 4.5; p = 0.029). In univariate analyses, increased 5-year mortality in the septic revision group was associated with age, Charlson Comorbidity Index, and methicillin-resistant Staphylococcus aureus infection, whereas C. acnes infection was associated with lower mortality.

Conclusions

Shoulder PJI is associated with an adjusted 2-year all-cause mortality rate that is double that of aseptic patients. The results of the present study should be utilized to appropriately counsel patients who are considered to be at risk for infection following shoulder arthroplasty.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Abstract 2994: Acute Ischemia in Broca's Area is Associated with Apraxia of Speech and Phonological Short-Term Memory Deficit

Background: Apraxia of speech (AOS) is commonly thought of as a motor programming deficit, but could be due to impaired ability to maintain the sequence of phonemes (speech sounds) in short-term memory (STM) while articulating the word. We hypothesized that AOS and impaired digit span are associated with acute ischemia (infarct and/or hypoperfusion) of pars opercularis of Broca’s area (Brodmann's area 44), and that severity of AOS and digit span would be strongly correlated.

Methods: We tested 87 patients on the first day of admission for left hemisphere acute ischemic stroke (mean age= 60.0±15.9; mean education 13.6±3.7 years) with Apraxia Battery for Adults-II and digit span tests and MRI, including Diffusion and Perfusion Weighted Imaging (DWI, PWI). We defined Apraxia of Speech (AOS) as 3 or 4 abnormal scores on the subtests of ABA-II: Words of Increasing Length A and B (which scores an increase in articulatory errors with increased word length for short and longer words/phrases, respectively), Repeated Trials (which scores variability in errors in repetition of the same polysyllabic words), and Inventory of Articulation (which scores characteristics of AOS). We defined impaired phonological STM as forward digit span < 5 or backward digit span < 3. The first author and 1 other technician, masked to the AOS results, examined MRI DWI and PWI scans for the presence or absence of ischemia (bright on DWI and/or hypoperfused on PWI) in each of 12 regions of interest: Brodmann’s area (BA) 4, 6, 10, 11, 19, 20, 21, 22, 37, 38, 39, 40, 44, 45, anterior and posterior insula. Hypoperfusion was defined as > 4 sec delay in TTP compared to opposite hemisphere. We evaluated association between the ischemia in each Brodmann area (BA) and (1) presence of AOS and (2) impaired STM using chi square tests.

Results: AOS was significantly associated only with BA 6 (premotor cortex; chi square= 7.07; df1; p<.003) and BA 44 (pars opercularis of Broca’s area; chi square= 5.3; df1; p<.02), but not BA 45 (pars triangularis) or other ROIs. Impaired STM measured by forward digit span <5 was associated with BA 6 (chi square= 20.2; df1; p<.000001) and BA 44 (chi square= 15.2; df1; p=.00009), and BA 45 (chi square= 19.2; df1; p=.0001). There was strong correlation between digits forward span and Repeated Trials score (r=.35; p=.003), either because both speech articulation and STM rely on Broca’s area, or because orchestration of speech articulation demands holding phoneme sequences in phonological STM.

Conclusions: Acute ischemia of the pars opercularis of Broca’s area (Brodmann’s Area 44) is associated with AOS and STM deficits. The severity of AOS and digit span deficits were highly correlated. The relationship between AOS and phonological STM begs further investigation.