The role of post-operative radiographs in predicting risk of flexor pollicis longus tendon rupture after volar plate fixation of distal radius fractures – A case control study

Background and aimVolar plating of distal radius fractures is one of the common procedures performed in trauma surgery. Flexor pollicis longus (FPL) rupture has been described as complication following volar plating of distal radius fractures.The aim of our study was to investigate the possible relation between parameters measured on post-operative radiographs and the occurrence of FPL ruptures.Materials and methodsThis was a case control study. The post-operative radiographs of 11 FPL rupture, and 22 non-FPL rupture patients were reviewed with respect to fracture reduction and plate position and the various parameters were calculated by five independent people.Logistic regression was used to examine the importance of the variables.ResultsWe identified two significant factors to predict FPL rupture after volar plating of distal radial fractures. These were radial tilt and plate distance from the joint line. The odds ratio of ruptures was 0.74 (95% CI 0.57–0.95) for every degree of radial tilt <25° and 0.50 (95% CI 0.28–0.88) for every millimetre that the distal end of the plate was away from the volar lip of the distal radius at the wrist joint.ConclusionPost-operative radiographs could help us predict FPL rupture after distal radius volar plating. The findings also highlight the need for good fracture reduction and thoughtful placement of the volar plate intraoperatively to minimise the risk of FPL tendon rupture.     

Ulnar styloid process nonunion and outcome in patients with a distal radius fracture: A meta-analysis of comparative clinical trials

PurposeThere is no consensus on the relation between ulnar styloid process nonunion and outcome in patients with distal radius fractures. The aim of this study was to analyze whether patient-reported outcome is influenced by the nonunion of the accompanying ulnar styloid fracture in distal radius fracture patients.MethodsA meta-analysis of published studies comparing outcomes after distal radius fractures with a united versus a non-united ulnar styloid process was performed. In addition, if provided by the authors, the raw data of these studies were pooled and analysed as one study. The outcome measures of the analyses included patient-reported outcome, functional outcome, grip-strength, pain, and distal radioulnar joint (DRUJ) instability.ResultsData from six comparative studies were included, concerning 365 patients with a distal radius fracture. One hundred and thirty-five patients with an ulnar styloid union were compared with 230 patients with a nonunion of the ulnar styloid. No significant differences were found between groups regarding any outcome measure.ConclusionBased on this meta-analysis, there is no relation between the nonunion of the ulnar styloid process and function in patients with a distal radius fracture.     

Plate selection for fixation of extra-articular distal humerus fractures: A biomechanical comparison of three different implants

Operative fixation of extra-articular distal humerus using a single posterolateral column plate has been described but the biomechanical properties or limits of this technique is undefined. The purpose of this study was to evaluate the mechanical properties of distal humerus fracture fixation using three standard fixation constructs.Two equal groups were created from forty sawbones humeri. Osteotomies were created at 80 mm or 50 mm from the tip of the trochlea. In the proximal osteotomy group, sawbones were fixed with an 8-hole 3.5 mm LCP or with a 6-hole posterolateral plate. In the distal group, sawbones were fixed with 9-hole medial and lateral 3.5 mm distal humerus plates and ten sawbones were fixed with a 6-hole posterolateral plate. Biomechanical testing was performed using a servohydraulic testing machine. Testing in extension as well as internal and external rotation was performed. Destructive testing was also performed with failure being defined as hardware pullout, sawbone failure or cortical contact at the osteotomy.In the proximal osteotomy group, the average bending stiffness and torsional stiffness was significantly greater with the posterolateral plate than with the 3.5 mm LCP. In the distal osteotomy group, the average bending stiffness and torsional stiffness was significantly greater with the posterolateral plate than the 3.5 mm LCP. In extension testing, the yield strength was significantly greater with the posterolateral plate in the proximal osteotomy specimens, and the dual plating construct in the distal osteotomy specimens. The yield strength of specimens in axial torsion was significantly greater with the posterolateral plate in the proximal osteotomy specimens, and the dual plating construct in the distal osteotomy specimens.Limited biomechanical data to support the use of a pre-contoured posterolateral distal humerus LCP for fixation of extra-articular distal humerus exists. We have found that this implant provided significantly greater bending stiffness, torsional stiffness, and yield strength than a single 3.5 mm LCP plate for osteotomies created 80 mm from the trochlea. At the more distal osteotomy, dual plating was biomechanically superior. Our results suggest that single posterolateral column fixation of extra-articular humerus fractures is appropriate for more proximal fractures but that dual plate fixation is superior for more distal fractures.     

Outcomes following the conservative management of patients with non-radicular peripheral neuropathic pain

Study designProspective cohort.IntroductionThere is limited evidence for conservative management of patients with non-radicular peripheral neuropathic pain (PNP).PurposeTo investigate the effectiveness of a comprehensive treatment approach on pain and disability in patients with non–radicular PNP and to determine if improvements are maintained following the discontinuation of therapy.MethodsPatients received a multi-modal therapeutic intervention. Outcome measures were the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QDASH), Numeric Pain Rating Scale (NPRS), and grip strength. Follow-up data were collected 5 ± 2 months post-discharge.ResultsThere was a significant improvement in the QDASH and mean pain (p < .001). There was no significant change in grip strength (p > .13). Follow-up data suggest that pain and disability scores are maintained (p < .001).ConclusionA comprehensive, conservative treatment program has a positive and lasting effect on pain and disability scores in patients with non-radicular PNP.Level of evidenceIIIa     

Divergent elbow dislocation with radial shaft fracture,distal ulnar deformation,and distal radioulnar joint instability: an unclassifiable Monteggia variant

Originally described by Monteggia and later classified by Bado, elbow dislocations with concurrent radial and ulnar shaft fractures with distal radioulnar joint (DRUJ) disruption are considered operative cases with high-energy injurious etiologies. Here, we present an unclassifiable Monteggia variant fracture suffered through a high axial load mechanism in a 47-year-old female. The fracture pattern initially exhibited included a divergent elbow dislocation, a radial shaft fracture, plastic deformation of the distal ulna, and DRUJ instability. Here we describe the pattern in detail, along with definitive treatment and clinical outcome at 1 year follow-up.     

Correction osteotomy of distal radius malunion stabilised with dorsal locking plates without grafting

The purpose of this study was to evaluate the results of our correction osteotomies of distal radial malunions without a bone graft. Eleven consecutive patients (mean age 52 years, range 18–71) were treated. A dorsal approach was utilised to perform an opening-wedge osteotomy which then was stabilised with two dorsal columnar plates without filling the osteotomy gap. All patients went on to radiographic union with a filling of the osteotomy gap within a mean period of 3 months (range 2–6 months). All patients had satisfactory results in terms of function and pain. Correction osteotomy and stabilisation with bicolumnar locked plate fixation without a bone graft provides sufficient stability to allow the highly vascularised metaphysis to heal. In patients without risk factors predisposing to non-union, this procedure is safe and feasible.     

Efficacy of ultrasound-guided oblique subcostal transversus abdominis plane block after laparoscopic sleeve gastrectomy: A double blind,randomized, placebo controlled study

IntroductionPain control in the morbidly obese can be especially challenging because of increased sensitivity to opioid-induced respiratory depression. The subcostal transversus abdominis plane block is associated with a large area of spread (T7-L1). The aim of the study was to test the hypothesis that US-guided TAP blocks can reduce opioid consumption during the first 24 h after of laparoscopic sleeve gastrectomy in comparison with port site local anesthetic infiltration and systemic analgesia.MethodSixty-three ASA II/III adult patients listed for elective laparoscopic sleeve gastrectomy were randomly allocated in one of three groups: Group I (OSTAP) received bilateral OSTAP block. Group II (Local) received local anesthetic infiltration at trocar port sites. Group III (Control) placebo group received TAP block and port site infiltration by same volumes of sterile normal saline. Twenty-four hours postopetrative morphine consumption, the dose of fentanyl (μg) required during surgery, equivalent morphine dose in the recovery unit (PACU) and first morphine dose were recorded. The quality of analgesia is assessed by Visual Analogue Scale for 24 h at rest and movement.ResultsThe mean opioid consumptions in PACU showed significant difference between the three groups, P = 0.02. The mean 24 h morphine consumption showed statistically significant difference between groups (P value < 0.001). Significant differences were found between both OSTAP and Local groups with control group (P < 0.001) and also between OSTAP and Local groups (P = 0.02). Pain score of OSTAP group was significantly lower than local infiltration group at 6 and 4 h at rest and movement respectively. OSTAP group had faster extubation time than other groups. Postoperative nausea and vomiting were not significant between groups. No signs or symptoms of local anesthetic systemic toxicity or complications were detected.ConclusionOblique subcostal TAP block is a good alternative for providing analgesia during the postoperative period. The block is easily performed using ultrasound guidance. It is safe, provides effective analgesia with significant morphine-sparing effect with reduced side-effects of opioids.     

Are locking plates better than non-locking plates for treating distal tibial fractures?

BackgroundLocking and non-locking plates has been used for distal tibia fracture osteosynthesis. Sufficient evidence to favor one implant over the other is lacking in the current literature. Our aim is to compare them in terms of fracture healing, alignment, functional outcome, complications.MethodsSixty-eight patients operated on using a percutaneous plate were retrospectively reviewed. They were divided into two groups: in group 1 (28 patients) a 4.5 mm narrow conventional dynamic compression plate (DCP) was used. In group 2 (40 patients) a titanium locked compression plate (LCP) was used.ResultsMean time to union was 16.2 and 15.4 weeks for group 1 and 2, respectively (p = 0.618). 11 patients (39.3%) in group 1 and 4 patients (10%) in group 2 showed malalignment (p = 0.016). AOFAS scores at follow up were 89 and 88 in groups 1 and 2, respectively. Implant removal was necessary in 9 cases (32.1%) and 4 cases (10%) in group 1 and group 2, respectively (p = 0.042). Three patients (10.7%) in group 1 and three patients (7.5%) in group 2 had an infection.ConclusionsBoth plating systems have similar results in terms of time to union, infection, and AOFAS scores. The LCP seems superior with respect to alignment and the need for implant removal.     

Five-year results of laparoscopic sleeve gastrectomy

BackgroundLaparoscopic sleeve gastrectomy (LSG) is gaining popularity, but studies reporting long-term results are still rare. The objective of this study was to present the 5-year outcome concerning weight loss, modification of co-morbidities, and late complications.MethodsThis is a retrospective analysis of a prospective cohort with a minimal follow-up of 5 years. A total of 68 patients underwent LSG either as primary bariatric procedure (n = 41) or as redo operation after failed laparoscopic gastric banding (n = 27) between August 2004 and December 2007. At the time of LSG, the mean body mass index (BMI) was 43.0±8.0 kg/m², the mean age 43.1±10.1 years, and 78% were female. The follow-up rate was 100% at 1 year postoperatively, 97% after 2 years, and 91% after 5 years; the mean follow-up time was 5.9±0.8 years.ResultsThe average excessive BMI loss was 61.5%±23.4% after 1 year, 61.1%±23.4% after 2 years, and 57.4%±24.7% after 5 years. Co-morbidities improved considerably; a remission of type 2 diabetes could be reached at 85%. The following complications were observed: 1 leak (1.5%), 2 incisional hernias (2.9%), and new-onset gastroesophageal reflux in 11 patients (16.2%). Reoperation due to insufficient weight loss was necessary in 8 patients (11.8%).ConclusionsLSG was effective 5.9 years postoperatively with an excessive BMI loss of almost 60% and a considerable improvement or even remission of co-morbidities.