Cesare Fusetti

Complications of plate fixation in metacarpal fractures

BACKGROUND The objective of this study is to assess the complications after open reduction and plate fixation of extra-articular metacarpal fractures. METHODS We retrospectively reviewed the clinical and radiologic records of 129 consecutive patients with 157 metacarpal fractures treated by open reduction and internal fixation with plates between 1993 and 1999. Intra-articular fractures and fractures of the thumb metacarpal were excluded. Eighty-one patients (64 men and 17 women) with 104 fractures were available for review, at an average follow-up of 13.6 months (range, 6-27 months). RESULTS Twenty-eight patients (35%) and 33 fractures (32%) had one or more complications, including difficulty with fracture healing (12 patients [15%]), stiffness (eight patients [10%]), plate loosening or breakage (seven patients [8%]), complex regional pain syndrome (two patients), and one patient who developed a deep infection. CONCLUSION Despite technical advances in implant material, design, and instrumentation, plate fixation of metacarpal fractures remains fraught with complications and unsatisfactory results.

Minimally Invasive Fixation versus Conservative Treatment of Undisplaced Scaphoid Fractures: A Cost-Effectiveness Study

This study compares the direct and indirect costs of conservative and minimally invasive treatment for undisplaced scaphoid fractures. Costs data concerning groups of non-operated and operated patients were analysed. Direct costs were higher in operated patients. Although highly variable, indirect costs were significantly smaller in operated patients and the total costs were higher in nonoperated patients. In conclusion, operative treatment of scaphoid fractures is initially more expensive than conservative treatment but markedly decreases the work compensation costs.

Trans-trapezium carpo-metacarpal dislocation of the thumb

We report a case of carpo-metacarpal dislocation associated with an isolated horizontal fracture of the trapezium. It is a rare lesion which is difficult to diagnose by standard radiography, and CT may be necessary for the diagnosis and correct treatment. In our case, stable osteosynthesis was achieved by internal screw fixation, and at follow-up there was an unrestricted, painless range of motion of the thumb.

Sexual quality-of-life after hip surgery

Abstract To study the effect of reconstructive hip surgery on the quality of sexual relations in women, we made a retrospective review of 224 women who underwent reconstructive hip surgery at a mean age of 44.5 years. Evaluation was with a standardized questionnaire regarding sexual activity and an orthopaedic examination. Consenting partners of these women completed a limited questionnaire. There was a marked decrease in hip pain and definite improvement in hip mobility. The quality of sex for many of the women and their partners was enhanced. Eighty percent of women and their partners felt the information received regarding sexual activities and pregnancy postoperatively was woefully inadequate. Physicians must not overlook the benefit that reconstructive hip surgery and, particularly, total hip arthroplasty conveys to the sexual life of the younger woman afflicted with hip disease. In addition, physicians must strive to provide better information to these women and their respective partners.

Analysis of the Inter- and Intra-Observer Agreement in Radiographic Evaluation of Wrist Fractures Using the Multimedia Messaging Service

BackgroundOrthopaedic surgeons are often asked to evaluate X-rays of patients admitted to the Accident and Emergency Department with the suspicion of a wrist fracture or, in the case of an evident fracture, to decide the correct treatment. The aim of this study was to evaluate the feasibility of a correct interpretation of the images of injured wrists on the screen of a last generation mobile phone, in order to evaluate if the specialist could make the right diagnosis and choose the correct treatment.MethodsFive orthopaedic and one hand surgeons have evaluate the X-rays of 67 patients who sustained an injury to their wrist. In the case of fracture, they were asked to classify it according to the AO and Mayo classification systems. The evaluation of the images was accomplished through the PACS and using a mobile phone, at a different time. In order to check the inter- and intra-observer reliability, the same pattern was followed after a few months.ResultsThe mobile phone showed basically the same agreement between the observers highlighting the worsening of the inter- and intra-observer reliability with the increment of the variables considered by a classification system.ConclusionsThe present paper confirms that a last generation mobile phone can already be used in the clinical practise of orthopaedic surgeons on call who could use it as a useful device in remote or poorly served areas for a rapid and economic consultationLevel of EvidenceThe level of evidence of this case is economic and decision analysis, level 2

Proximal row carpectomy in emergency

Proximal row carpectomy (PRC) is a well-accepted procedure for the treatment of early post-traumatic degenerative disease of the wrist. Much less frequently, PRC has been advocated as an emergency procedure for irreparable fracture-dislocation of the wrist. Our objective was to compare the results of PRC in patients having undergone this procedure in the two contexts. We conducted a retrospective analysis of the clinical and radiographic results of six patients treated by emergency PRC as compared to six patients who underwent elective PRC. The mean follow-up was 36 months. Both the patients satisfaction and the grasp of the wrist joint were significantly better in patients who underwent PRC emergency as compared to those having undergone elective PRC. Quick DASH score, radiographic results, and return to work were also more favourable in these patients, but the difference between the two groups was not significant. This study confirms that PRC is a valuable salvage technique indicated in early posttraumatic wrist collapse. Moreover, when performed in emergency, the procedure shows even better subjective and objective results, allowing a majority of patients to return to their previous job.

Bone-tendon ligamentoplasty for chronic ulnar instability of the thumb metacarpophalangeal joint: an anatomic reconstruction of the ulnar collateral ligament.

The metacarpophalangeal joint (MCP) of the thumb allows movement in two planes of motion: flexion/ extension and pronation/supination. In extension, the MCP joint is stabilized mainly by the palmar plate, from 15° onward by the collateral ligaments, with some degree of mediolateral shift with further flexion, until they are completely taut in full flexion. The ulnar collateral ligament (UCL) consists of two portions: the main portion of the UCL has its origin on the dorsal third of the metacarpal head and inserts distal and volar at the base of the proximal phalanx, whereas the smaller portion has its insertion in the palmar plate. The main portion of the UCL is taut in flexion, whereas the accessory portion is taut in extension. The UCL is essential to achieve a useful pinch grip. If the UCL is insufficient, contraction of the flexor pollicis longus muscle causes a lateral shift of the proximal phalanx instead of flexion. If one portion of the ligament is torn and the other is intact, flexion leads to thumb supination. In cases of chronic ulnar instability of the MCP joint, anatomic reconstruction of the UCL is the prerequisite for achieving stability while maintaining mobility. To gain these ends, we believe that both portions of the UCL should be reconstructed individually. HISTORICAL PERSPECTIVE

False aneurysm of the common digital artery. Is reconstruction with an arterial graft worth the efforts? A case report

False aneurysms in the hand are rare. A false aneurysm of the common digital artery in the palm for the second and third finger is reported, illustrating our experience with arterial graft reconstruction after excision as a valid alternative surgical therapy to a vein graft, when ligation or end‐to‐end anastomosis are not indicated or feasible. The superficial palmar branch of the radial artery was chosen as donor vessel based on the similarity in vessel diameter and wall thickness to the common digital arteries. Ease of harvesting and performing the microvascular anastomosis using an arterial graft allows for a viable reconstruction after false aneurysm excision in the palm.

False aneurysm of the interosseous artery and anterior interosseous syndrome - an unusual complication of penetrating injury of the forearm: a case report

BackgroundPalsies involving the anterior interosseous nerve (AIN) comprise less than 1% of all upper extremity nerve palsies.ObjectivesThis case highlights the potential vascular and neurological hazards of minimal penetrating injury of the proximal forearm and emphasizes the phenomenon of delayed presentation of vascular injuries following seemingly obscure penetrating wounds.Case ReportWe report a case of a 22-year-old male admitted for a minimal penetrating trauma of the proximal forearm that, some days later, developed an anterior interosseous syndrome. A Duplex study performed immediately after the trauma was normal. Further radiologic investigations i.e. a computer-tomographic-angiography (CTA) revealed a false aneurysm of the proximal portion of the interosseous artery (IA). Endovascular management was proposed but a spontaneous rupture dictated surgical revision with simple excision. Complete neurological recovery was documented at 4 months postoperatively.Conclusions/SummaryAfter every penetrating injury of the proximal forearm we propose routinely a detailed neurological and vascular status and a CTA if Duplex evaluation is negative.

Should aspirin be stopped before carpal tunnel surgery? A prospective study

AIM To determine whether patients taking aspirin during carpal tunnel release had an increase of complications. METHODS Between January 2008 and January 2010, 150 patients underwent standard open carpal tunnel release (CTR) under intravenous regional anaesthesia. They were divided into three groups: groups 1 and 2 were made of 50 patients each, on aspirin 100 mg/d for at least a year. In group 1 the aspirin was never stopped. In group 2 it was stopped at least 5 d before surgery and resumed 3 d after. Group 3 acted as a control, with 50 patients who did not take aspirin. The incidence of clinically significant per- or post-operative complications was recorded and divided into local and cardio-cerebro-vascular complications. Local complications were then divided into minor and major according to Page and Stern. Local haematomas were assessed at 2 d (before resuming aspirin in group 2) and 14 d (after resuming aspirin in group 2) postoperatively. Patients were reviewed at 2, 14 and 90 d after surgery. RESULTS There was no significant difference in the incidence of complications in the three groups. A total of 3 complications (2 major and 1 minor) and 27 visible haematomas were recorded. Two major complications were observed respectively in group 1 (non stop aspirin) and in group 3 (never antiaggregated). The minor complication, observed in one patient of group 2 (stop aspirin), consisted of a wound dehiscence, which only led to delayed healing. All haematomas were observed in the first 48 h, no haematoma lasted for more than 2 wk and all resolved spontaneously. A major haematoma (score > 20 cm(2)) was observed in 8 patients. A minor haematoma (score < 20 cm(2)) was recorded in 19 patients. All patients at 90 d after surgery were satisfied with the result in terms of relief of their preoperative symptoms. Major and minor haematomas did not impair hand function or require any specific therapy. CONCLUSION Our study demonstrates that continuation of aspirin did not increase the risk of complications. It is unnecessary to stop aspirin before CTR with good surgical techniques.