Complications of hand surgery

Hand surgery involves the surgical treatment of hand conditions and encompasses small bone fixation, arthroscopy, joint replacement and reconstruction of tendon and nerves. Complications following surgery to the hand may be due to patient factors, surgical decisions and the complex anatomy of the hand. Here we describe the complications associated with common surgical interventions for both elective and traumatic injuries to the hand. Following hand surgery, a balance between immobilisation and early range of motion is offset by the risk of wound complications, non-union of fractures and tendon re-rupture with stiffness and reduced range of motion of the digits. Superficial infection is relatively common following procedures to the hand, however long-term sequelae are rare. Implant failure, subsidence, instability and reduced range of motion are seen following arthroplasty procedures. Complex regional pain syndrome offers a significant challenge following injury to the hand and specifically after surgical procedures. Surgeons should consider the risk of particular surgical techniques, other perioperative factors and patient factors that may contribute to the development of complications following hand surgery. Patients should be adequately counselled in order to make an informed decision regarding the management of their condition.     

老年人股骨粗隆间骨折手术时机对预后影响的临床研究

目的：探讨老年股骨粗隆间骨折手术时机对临床预后结局的影响。方法整群选取2015年1月—2016年1月该院收治的老年股骨粗隆间骨折患者68例为研究对象。根据患者手术时间将其分为A组与B组, A组32例,B组36例,观察两组患者不同年龄术后30 d、1年的死亡情况。结果两组患者术后30d、1年死亡率比较差异无统计学意义,P>0.05；但A组、B组患者中超过80岁的患者术后1年死亡率明显低于80岁以下年龄患者,P<0.05,差异具有统计学意义。结论年龄超过80岁的老年股骨粗隆间骨折患者术后1年死亡率相对较高。     

Primary epidural lumbar Ewing sarcoma presenting as cauda equina syndrome in an adult patient who underwent surgical decompression: A case report

Ewing sarcoma (ES) is a rare primary neoplasm in the lumbar adult spine and may mimic a benign tumor. In this case, after a patient's three-month history of lower back pain and rapidly progressing leg numbness and weakness, magnetic resonance imaging (MRI) showed a mass in the third lumbar vertebra. At a two-month follow-up, imaging showed a fracture, compression and lesion enlargement. Decompression and fixation confirmed ES, and the patient began combined radiotherapy and chemotherapy. Two months postoperatively, residual ES was suspected on MRI. The patient underwent a second surgery, and histopathology confirmed necrosis. A six-month follow-up after the first surgery showed no tumor recurrence. This case supports the inclusion of ES in the differential diagnosis of pathologic spinal fracture. Early decompression and spinal fixation are critical for preserving neurologic and spinal functions in ES complicated by a compression fracture. Combined adjuvant radiotherapy and chemotherapy remain the standard therapeutic strategy.     

A systematic review of combined pelvic and acetabular injuries

PurposeInjuries of both pelvic ring and acetabulum as rare very few articles are available in literature. There are no set protocols in defining the injury let alone defining early and definitive management strategies. This article is an attempt to encompass all available data to give us guidelines in managing these injuries.MethodsAn extensive literature review was carried out on PubMed/Medline, google scholar and Embase databases was done with the eligibility criteria of 1) Case series with a minimum of 20 cases. 2) The patient’s outcome reported. 3) Full article available. 4) Article in English. 5) Minimum Jadad score of 3. As per PRISMA guidelines the search was done and gradually filtered down to relevant articles which were 8 in number.ResultsThe incidence of these injuries range from 5 to 16%. The transverse acetabular fracture pattern is the commonest followed by associated both column fractures. There is equal propensity of Anteroposterior compression and lateral compression injuries. The injury mechanism appears to transmitted lateral force from the greater trochanter inwards with an implosion injury causing acetabular and pelvic injury as a continuum. The initial management is similar to managing pelvic ring injuries with focus on patient resuscitation, hemodynamic stabilization and temporary stabilization. The injury severity score and the mortality rates are comparable to isolated unstable pelvic ring injuries. Definitive management focuses on fixing the posterior pelvic ring first followed by the acetabular fracture and then the anterior pelvic ring. The displacement rates and outcome is worse than isolated acetabular injuries or pelvic injuries.ConclusionCombined Pelvic and acetabular injuries are complex injuries which need to be managed initially as we manage pelvic injury and later as we fix as an acetabular fracture meticulously.     

Subdental synchondrosis and anatomy of the axis in aging: a histomorphometric study on 30 autopsy cases

During skeletal development the two ossification centers of the odontoid process are separated from the corpus of the axis by a subdental synchondrosis. This synchondrosis is thought to close and disappear spontaneously in adolescence although this has never been studied in detail. The basis of the dens is of clinical relevance as type II dens fractures are located here. To characterize the morphological architecture of the axis with particular attention to the subdental synchondrosis, the complete axis was harvested from thirty age-matched and gender-matched patients of the three different age groups at autopsy. The subdental synchondrosis and the bone structure of the dens, the basis of the dens and the body of C2 were analyzed by radiography, histology and quantitative histomorphometry. At the macroscopic level the persistency of the subdental synchondrosis in the adult cervical spine was detected in 87% (26 of 30) of the specimens. Histomorphometry revealed a residual disc blastema with an average size of 25.8% of the sagittal depth of the basis of the dens at this level. Bony integration of the synchondrosis was poor throughout all ages. Histologically a cartilaginous matrix composition of the subdental synchondrosis persisted throughout all groups. The trabecular microarchitecture demonstrated a significant reduction of bone volume and trabecular number as well as an increased trabecular separation within the basis of the dens as compared to the corpus or the dens of C2. This histomorphometric data regarding a poor integration of the synchondrosis into the trabecular network and the reduced bone mass within the basis of the dens might offer a previously underestimated explanation for the occurrence of type II dens fractures and their association with pseudoarthrosis, respectively.Matthias Gebauer and Christian Lohse contributed equally to this study and therefore share first authorship.     

难复性肱骨近端骨折脱位的手术治疗

目的探讨难复性肱骨近端骨折脱位的合理手术治疗,以提高疗效。方法回顾性总结27例难复性肱骨近端骨折脱位病例资料。按NEER分型,两部分骨折脱位16例行切开复位T形钢板或三叶草钢板内固定,三部分骨折脱位11例行切开复位克氏针张力带内固定,术中采用可吸收缝线修补撕裂的肩袖及关节囊,术后早期功能锻炼。结果27例均获随访,时间12~59个月,平均29个月。疗效评价标准参照Constant-Murley评定方法,优良率达85.2%。结论对于难复性肱骨近端骨折脱位,保护局部血运甚为重要,术中采用间接复位技术、合理选择简单有效的内固定、充分保护软组织及修复肩袖等原则的应用对于术后功能恢复及预防相关并发症十分重要。     

Salvage of a failed valgus osteotomy for non-union of an unstable pertrochanteric fracture

Salvage of a failed valgus osteotomy for nonunion of an unstable pertrochanteric fracture is reported. A valgus intertrochanteric osteotomy was performed for a failed sliding hip screw fixation of an unstable pertrochanteric fracture at another institution. Four months following osteotomy, the fracture was still un-united with two distal screws of the hip plate broken and a coxa vara deformity. Reconstruction was performed with a nine-hole 95° angle blade plate and cancellous bone graft, because the insufficient fixation of the distal fragment was considered to be the main reason for failure. The osteotomy was healed at six months post-surgery and the patient reported complete resolution of symptoms. Intertrochanteric valgus osteotomy is an effective procedure for mal-union and non-union of pertrochanteric fracture but stable fixation is required for a good result. The blade of the angle plate offers good purchase of the proximal fragment and secures it under rotational and bending stresses. We recommend that distal fragments should be fixed with at least seven cortices for this type of osteotomy.