Brandon E. Earp

Functional Outcomes for Unstable Distal Radial Fractures Treated with Open Reduction and Internal Fixation or Closed Reduction and Percutaneous Fixation: A Prospective Randomized Trial

BACKGROUND Despite the recent trend toward internal fixation of distal radial fractures, few randomized trials have examined whether volar plate fixation is superior to other stabilization techniques. The purpose of the present study was to compare (1) open reduction and internal fixation with use of a volar plate and early mobilization with (2) percutaneous fixation and casting or external fixation for the treatment of dorsally displaced unstable extra-articular and simple intra-articular fractures of the distal part of the radius, with a specific emphasis on early functional recovery. METHODS A prospective randomized study was performed at two institutions. Forty-five consecutive patients with a displaced, unstable fracture of the distal part of the radius were randomized to closed reduction and pin fixation (n = 22) or open reduction and internal fixation with a volar plate (n = 23). Clinical and radiographic assessments were conducted at six, nine, and twelve weeks after surgery and at one year. Outcome was measured on the basis of range of motion; grip and pinch strength; and Disabilities of the Arm, Shoulder and Hand scores. A questionnaire was used to determine patient satisfaction, and a detailed analysis of complications was performed. RESULTS Patients in the open reduction and internal fixation group had superior Disabilities of the Arm, Shoulder and Hand scores at six, nine, and twelve weeks. At six weeks, the average Disabilities of the Arm, Shoulder and Hand score was 27 in the open reduction and internal fixation group as compared with 53 in the closed reduction and pin fixation group (p < 0.01). At nine and twelve weeks, patients in the open reduction and internal fixation group continued to have lower scores (17 compared with 39 [p < 0.01] and 11 compared with 26 [p = 0.01], respectively). At one year, there was no significant difference between the two groups in terms of the Disabilities of the Arm, Shoulder and Hand scores. Patients in the open reduction and internal fixation group had greater range of motion and strength than patients in the closed reduction and pin fixation group at six and nine weeks, and more patients in the open reduction and internal fixation group were very satisfied with the overall wrist function and motion. Eight complications occurred, two in the open reduction and internal fixation group and six in the closed reduction and pin fixation group. CONCLUSIONS Both closed reduction with percutaneous pin fixation and open reduction with internal fixation with use of a volar plate are effective methods for the treatment of dorsally displaced, unstable, extra-articular or simple intra-articular fractures of the distal part of the radius. Better functional results can be expected in the early postoperative period in association with open reduction and internal fixation, and this form of treatment should be considered for patients requiring a faster return to function after the injury.

Volar Locking Plate Implant Prominence and Flexor Tendon Rupture

BACKGROUND Flexor tendon injury is a recognized complication of volar plate fixation of distal radial fractures. A suspected contributing factor is implant prominence at the watershed line, where the flexor tendons lie closest to the plate. METHODS Two parallel series of patients who underwent volar locked plating of distal radial fractures from 2005 to 2008 and with at least six months of follow-up were retrospectively reviewed. Group 1 included seventy-three distal radial fractures that were treated by three orthopaedic hand surgeons with use of a single plate design at one institution, and Group 2 included ninety-five distal radial fractures that were treated by four orthopaedic hand surgeons with use of a different plate design at another institution. On the postoperative lateral radiographs, a line was drawn tangential to the most volar extent of the volar rim, parallel to the volar cortical bone of the radial shaft. Plates that did not extend volar to this line were recorded as Grade 0. Plates volar to the line, but proximal to the volar rim, were recorded as Grade 1. Plates directly on or distal to the volar rim were recorded as Grade 2. RESULTS In Group 1, the average duration of follow-up was thirteen months (range, six to forty-nine months). Three cases of flexor tendon rupture were identified among seventy-three plated radii (prevalence, 4%). Grade-2 plate prominence was found in two of the three cases with rupture and in forty-six cases (63%) overall. In Group 2, the average duration of follow-up was fifteen months (range, six to fifty-six months). There were no cases of flexor tendon rupture and no plates with Grade-2 prominence among ninety-five plated radii. CONCLUSIONS Flexor tendon rupture after volar plating of the distal part of the radius is an infrequent but serious complication. The plate used in Group 1 is prominent at the watershed line of the distal part of the radius, which may increase the risk of tendon injury. We found no ruptures in Group 2, perhaps as a result of the lower profile of the plate. Further studies are needed before recommending one plate over another. Regardless of plate selection, surgeons should avoid implant prominence in this area.

Premenopausal women with a distal radial fracture have deteriorated trabecular bone density and morphology compared with controls without a fracture.

BACKGROUND Measurement of bone mineral density by dual x-ray absorptiometry combined with clinical risk factors is currently the gold standard in diagnosing osteoporosis. Advanced imaging has shown that older patients with fragility fractures have poor bone microarchitecture, often independent of low bone mineral density. We hypothesized that premenopausal women with a fracture of the distal end of the radius have similar bone mineral density but altered bone microarchitecture compared with control subjects without a fracture. METHODS Forty premenopausal women with a recent distal radial fracture were prospectively recruited and matched with eighty control subjects without a fracture. Primary outcome variables included trabecular and cortical microarchitecture at the distal end of the radius and tibia by high-resolution peripheral quantitative computed tomography. Bone mineral density at the wrist, hip, and lumbar spine was also measured by dual x-ray absorptiometry. RESULTS The fracture and control groups did not differ with regard to age, race, or body mass index. Bone mineral density was similar at the femoral neck, lumbar spine, and distal one-third of the radius, but tended to be lower in the fracture group at the hip and ultradistal part of the radius (p = 0.06). Trabecular microarchitecture was deteriorated in the fracture group compared with the control group at both the distal end of the radius and distal end of the tibia. At the distal end of the radius, the fracture group had lower total density and lower trabecular density, number, and thickness compared with the control group (-6% to -14%; p < 0.05 for all). At the distal end of the tibia, total density, trabecular density, trabecular thickness, and cortical thickness were lower in the fracture group than in the control group (-7% to -14%; p < 0.01). Conditional logistic regression showed that trabecular density, thickness, separation, and distribution of trabecular separation remained significantly associated with fracture after adjustment for age and ultradistal radial bone mineral density (adjusted odds ratios [OR]: 2.01 to 2.98; p < 0.05). At the tibia, total density, trabecular density, thickness, cortical area, and cortical thickness remained significantly associated with fracture after adjustment for age and femoral neck bone mineral density (adjusted OR:1.62 to 2.40; p < 0.05). CONCLUSIONS Despite similar bone mineral density values by dual x-ray absorptiometry, premenopausal women with a distal radial fracture have significantly poorer bone microarchitecture at the distal end of the radius and tibia compared with control subjects without a fracture. Early identification of women with poor bone health offers opportunities for interventions aimed at preventing further deterioration and reducing fracture risk.

Correlation of Radiographic Muscle Cross-Sectional Area with Glenohumeral Deformity in Children with Brachial Plexus Birth Palsy

BACKGROUND Muscle imbalance about the shoulder in children with persistent brachial plexus birth palsy is thought to contribute to glenohumeral joint deformity. We quantified cross-sectional areas of the internal and external rotator muscles in the shoulder by magnetic resonance imaging in patients with chronic brachial plexopathy and the correlation between these muscle cross-sectional area ratios and glenohumeral deformity. The purposes of this investigation were to evaluate differences in the ratios between affected and unaffected shoulders in the same individual and to assess whether an increased internal to external rotator muscle cross-sectional area correlated with greater glenohumeral deformity. METHODS This cohort study consisted of magnetic resonance imaging of seventy-four patients with chronic neuropathic changes about the shoulder from brachial plexus birth palsy. There were at least nine patients with scans available for each of the five classified subtypes of glenohumeral deformity: type I (fifteen patients), type II (seventeen), type III (seventeen), type IV (sixteen), and type V (nine). Cross-sectional areas of the pectoralis major, teres minor-infraspinatus (external rotators), and subscapularis muscles were measured. The supraspinatus muscle cross-sectional area could not be reliably measured. The ratio of subscapularis to external rotators, the ratio of pectoralis major to external rotators, and the compound ratio of subscapularis and pectoralis major to external rotators were compared with the severity of the glenohumeral deformity. Passive range of motion, Mallet and Toronto clinical scores, and Narakas type were also compared with the severity of the glenohumeral deformity and the muscle cross-sectional area measurements. RESULTS Muscle cross-sectional area ratios were significantly correlated with glenohumeral deformity type. The mean ratio of pectoralis major to external rotators for affected shoulders over all deformity types compared with that for unaffected shoulders was significantly increased by 30% (p < 0.001); the mean ratio for subscapularis and pectoralis major to external rotators, by 19% (p = 0.015), and the mean ratio for subscapularis to external rotators, by 10% (p = 0.008). There was a significant increase in the ratio of pectoralis major to external rotators in affected shoulders within each type of deformity. Analysis of variance indicated higher ratios of pectoralis major to external rotator muscle cross-sectional areas in more severe deformity types (p < 0.001). There were significant differences in external rotation measurements with the shoulder at 90 degrees of abduction only among glenohumeral deformity types I, II, and III (p < 0.05). CONCLUSIONS The degree of muscle imbalance between internal and external rotators about the shoulder is measurable by magnetic resonance imaging in children with persistent brachial plexopathy, and the imbalance correlates with the degree of glenohumeral deformity. Our results may provide useful information to guide the timing and the choice of operative intervention in these children.

Outcomes of open carpal tunnel release at a minimum of ten years.

BACKGROUND There is little research on the long-term outcomes of open carpal tunnel release. The purpose of this retrospective study was to determine the functional and symptomatic outcomes of patients at a minimum of ten years postoperatively. METHODS Two hundred and eleven patients underwent open carpal tunnel release from 1996 to 2000 performed by the same hand fellowship-trained surgeon. Follow-up with validated self-administered questionnaire instruments was conducted an average of thirteen years after surgery. The principal outcomes included the Levine-Katz symptom and function scores, ranging from 1 point (best) to 5 points (worst), and satisfaction with the results of surgery. The patients self-reported current comorbidities. RESULTS After a mean follow-up of thirteen years (range, eleven to seventeen years), 92% (194) of 211 patients were located. They included 140 who were still living and fifty-four who had died. Seventy-two percent (113) of the 157 located, surviving patients responded to the questionnaire. The mean Levine-Katz symptom score (and standard deviation) was 1.3 ± 0.5 points, and 13% of patients had a poor symptom score (≥2 points). The mean Levine-Katz function score was 1.6 ± 0.8 points, and 26% had a poor function score (≥2 points). The most common symptom-related complaint was weakness in the hand, followed by diurnal pain, numbness, and tingling. The least common symptoms were nocturnal pain and tenderness at the incision. Eighty-eight percent of the patients were either completely satisfied or very satisfied with the surgery. Seventy-four percent reported their symptoms to be completely resolved. Thirty-three percent of men were classified as having poor function compared with 23% of women. Two (1.8%) of 113 patients underwent repeat surgery. CONCLUSIONS At an average of thirteen years after open carpal tunnel release, the majority of patients are satisfied and free of symptoms of carpal tunnel syndrome.

Incidence of Extensor Pollicis Longus Tendon Rupture After Nondisplaced Distal Radius Fractures

PURPOSE The incidence of extensor pollicis longus (EPL) tendon rupture in the setting of nondisplaced distal radius fractures is unknown. Extensor pollicis longus rupture is a known complication after distal radius fractures and is believed to occur more frequently after minimally displaced and nondisplaced distal radius fractures. Our study sought to define the incidence of EPL tendon rupture after nondisplaced distal radius fractures presenting to a level 1 trauma center. METHODS Using our billing database, we identified distal radius fractures presenting to our institution between 2006 and 2009. We reviewed injury radiographs to identify fractures in which radiographic measurements were within predefined radiographic norms. Two fellowship-trained orthopedic hand surgeons, 1 fellowship-trained musculoskeletal radiologist, and 1 senior orthopedic surgery resident then reviewed these fractures. Only those fractures thought by all 4 reviewers to be nondisplaced were classified as nondisplaced for the purposes of this study. We then reviewed charts of these nondisplaced fractures to identify patients who subsequently sustained an EPL tendon rupture. RESULTS We identified 3 EPL ruptures out of 61 nondisplaced fractures (5%). These occurred at an average of 6.6 weeks after distal radius fractures. CONCLUSIONS The incidence of EPL rupture is higher than previously reported in the literature. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Arthroscopic Treatment of Partial Scapholunate Ligament Tears in Children with Chronic Wrist Pain

BACKGROUND Scapholunate ligament injury is rare in the adolescent and pediatric population, and the results of treatment have not been well described. The purpose of the present study was to review the outcomes of arthroscopic management of patients with persistent wrist pain and scapholunate ligament injury as documented on arthroscopic examination who had had a failure of at least six months of nonoperative management. METHODS The medical records of thirty-two pediatric and adolescent patients who underwent arthroscopic treatment of scapholunate ligament injuries were retrospectively reviewed to obtain preoperative and postoperative modified Mayo wrist scores, radiographic data, and intraoperative findings, including the classifications of interosseous ligament injury, chondral injury, and other abnormalities. Patients were contacted after a minimum of two years of follow-up for reevaluation of the Mayo wrist scores. RESULTS Arthroscopic evaluation revealed thirty Geissler type-II tears and two Geissler type-III tears. In addition to these scapholunate ligament injuries, seven of the thirty-two patients had partial tears of the short radiolunate ligament that appeared to be at the site of impaction from carpal subluxation, twelve had a triangular fibrocartilage complex injury, and twenty-seven had a chondral injury. The modified Mayo wrist scores showed improvement following arthroscopic débridement of partial-thickness tears and associated chondral injuries. The average wrist score was 66.3 preoperatively and 91.6 at an average of forty-three months of follow-up. Eight patients required subsequent surgery because of deterioration in their clinical status. After a mean duration of follow-up of 30.8 months, the average wrist score was 87.1. CONCLUSIONS The majority of pediatric and adolescent patients with wrist pain who have a failure of nonoperative management and who have a Geissler type-II scapholunate ligament tear on arthroscopic examination can have substantial long-term improvement following arthroscopic débridement of the tear combined with treatment of other associated injuries.

Surgical findings in the treatment of Dupuytren’s disease after initial treatment with clostridial collagenase (Xiaflex)

We investigated the difficulty of surgical fasciectomy after previous treatment with clostridial collagenase injection. The 35 clinicians who had participated in the initial trials of this injection were contacted via email. Twenty-eight responded, nine of whom reported on 15 patients. Most (seven of nine) felt there was no significant distortion of anatomy and rated the level of technical difficulty as equivalent to a primary Dupuytren’s fasciectomy at the observed degree of contracture (nine of 15 cases). One respondent (four of 15 cases) reported significantly more difficulty and grossly distorted anatomy. One surgical complication, a wound dehiscence, was reported.

The Impact of Collagenase Clostridium histolyticum Introduction on Dupuytren Treatment Patterns in the United States

PURPOSE The U.S. Food and Drug Administration approved the use of collagenase Clostridium histolyticum (CCH) in the United States in February 2010. This study addresses the impact of that approval on the number of Dupuytren contracture (DC) encounters and treatment patterns in the United States. METHODS Using the Intercontinental Marketing Services Health Office-Based Medical Claims database, we identified the monthly number of DC encounters and DC procedures between January 2007 and December 2013. Collagenase Clostridium histolyticum usage data from March 2010 to December 2013 was derived from the U.S. CCH manufacturers data warehouse. Using the combined data, the yearly increasing trends in DC encounters and treatment volume were compared before and after the introduction of CCH. Time trends in the relative procedure frequencies were then examined. Finally, the presence of seasonal variation was tested for in each treatment type. RESULTS Dupuytren contracture encounters increased on average by 19,015 per year between 2007 and 2009, whereas between 2011 and 2013, DC encounters increased on average by 34,940 per year. In terms of absolute procedure counts, the surgery trend line began decreasing in 2010 with the release of CCH. Meanwhile, CCH continuously increased between 2010 and 2013, and needle aponeurotomy (NA) remained relatively stable. By the year 2013, minimally invasive techniques (NA and CCH) comprised 39% of all treatment, compared with only 14% in 2007. Lastly, there was a statistically significant seasonal increase in the number of surgical procedures during the wintertime but no seasonal variation in NA or CCH. CONCLUSIONS After the introduction of CCH, the number of Dupuytren encounters increased at a greater annual rate. The introduction and growth of CCH coincided with a decrease in surgery. The number of NA procedures remained steady throughout the study period. The number of open surgery cases followed a predictable seasonal variation with more procedures during the winter months, but this seasonal variation was not seen with less invasive techniques. TYPE OF STUDY/LEVEL OF EVIDENCE Economic/Decision Analysis II.

Prognostic Indicators for Recurrent Symptoms After a Single Corticosteroid Injection for Carpal Tunnel Syndrome

BACKGROUND Corticosteroid injections are commonly used in the treatment of carpal tunnel syndrome in adults. This study sought to determine success rates early on and at one year postoperatively of a single corticosteroid injection while identifying prognostic indicators for symptom recurrence and repeat intervention. METHODS Fifty-four consecutive wrists in forty-nine patients with carpal tunnel syndrome treated with a single corticosteroid injection were prospectively enrolled. Demographic data and information on comorbidities were identified with a study-specific questionnaire. The Boston Carpal Tunnel Questionnaire was administered prior to injection. Patients returned to clinic at six weeks and were contacted at three, six, nine, and twelve months post-injection to determine symptom and intervention status. Kaplan-Meier analysis and Cox regression modeling were used to estimate recurrence rates and to identify predictors of symptom recurrence and repeat intervention. RESULTS Fifty-four symptomatic wrists in forty-nine patients with a mean age of fifty-three years were included. Two patients (two wrists) were lost to follow-up. Patients reported symptom recurrence in thirty-one wrists at a median duration of 155 days post-injection. Nineteen wrists underwent carpal tunnel release at a median time of 181 days after the injection. No patient underwent a repeat injection. In our study, diabetic patients were at a 2.6-fold greater risk of reporting recurring symptoms within a one-year follow-up period. Survivorship free from symptom recurrence was 53% at six months and 31% at twelve months; survivorship from repeat intervention was 81% at six months and 66% at twelve months. CONCLUSIONS A single injection achieved symptom relief in 79% of patients at six weeks; these results were maintained in 31% of patients at twelve months. Diabetic patients were at higher risk of symptom recurrence.