Tak-Chuen Wong

Casting versus percutaneous pinning for extra-articular fractures of the distal radius in an elderly chinese population: a prospective randomised controlled trial

We carried out a prospective randomised controlled clinical trial to compare the functional and radiological outcomes of casting with percutaneous pinning in treating extra-articular distal radial fracture in an elderly Chinese population. Sixty patients were randomly allocated by sealed envelopes to either a ‘Cast’ group (n = 30) or a ‘K-wire’ group (n = 30). All patients were available for final follow-up assessment. The radiological outcomes in terms of dorsal angulation, radial inclination and radial length were statistically significantly better in the K-wire group, whereas the Mayo wrist score and quality of life, healing rate, healing time, and complications were similar. The functional outcomes and quality of life were not affected by the treatments. Both treatments had a very low rate of complication and high healing rates.

Squamous cell carcinoma of the nail bed: three case reports.

Squamous cell carcinoma of the nail bed is rare, and the disease is often misdiagnosed as a benign condition. Digital amputation is often performed because of the delay in diagnosis and the involvement of the distal phalanx. Between March 1999 and March 2002, 3 patients presented to the Pamela Youde Nethersole Eastern Hospital, Hong Kong, with squamous cell carcinoma of the nail bed. Two of the patients underwent a digit-salvaging procedure—namely, wide local excision and flap coverage—and their functional outcome was satisfactory. The remaining patient received partial amputation of the thumb without significant functional loss. A high degree of suspicion is thus needed to detect squamous cell carcinoma of the nail bed; a biopsy of chronic recurrent nail bed lesions should be performed.

Bone–Periosteum–Bone Graft Reconstruction for Chronic Ulnar Instability of the Metacarpophalangeal Joint of the Thumb—Minimum 5-Year Follow-Up Evaluation

PURPOSE The present study evaluated prospectively the functional and radiological results of a consecutive series of 7 patients who had bone-periosteum-bone (BPB) grafts harvested from the iliac crest for treatment of chronic ulnar instability of the metacarpophalangeal (MCP) joint of the thumb after a minimum of 60 months. METHODS Seven thumbs from 7 patients were entered into a prospective study for surgical treatment of chronic finger joint instability. Treatment consisted of reconstruction of the ulnar collateral ligament of the MCP joint of the thumb by a BPB graft harvested from the iliac crest. Stability, range of motion, pinch grip, and radiographs were evaluated at least 60 months after surgery. RESULTS All 7 patients had full active range of motion of the treated thumb at the final follow-up evaluation (average, 75 months after surgery). All patients had equal stability and normal pinch grip when comparing with the untreated thumb. The mean time off work was 3 months for 6 patients who were injured at work. At final follow-up evaluation, radiographs showed all grafts incorporated without implant complications, no osteoarthritis changes were noted, and stress radiographs showed that all patients had normal stability in the treated thumb when compared with the untreated thumb. CONCLUSIONS Chronic ulnar instability of the MCP joint of the thumb reconstructed with BPB graft harvested from the iliac crest is an effective and safe method to allow restoration and maintenance of a stable, pain-free thumb. The results of the current study support the long-term durability of this method. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

A double-blind, prospective, randomised, controlled clinical trial of minimally invasive dynamic hip screw fixation of intertrochanteric fractures

OBJECTIVE To compare minimally invasive dynamic hip screw (MIDHS) fixation with conventional dynamic hip screw (CDHS) fixation for treatment of intertrochanteric femoral fracture. METHODS Of the 66 participants in this double-blind study, 35 were randomised to MIDHS and 31 to CDHS fixation. Main outcome measurements were wound size, haemoglobin decrease, blood transfusion rate, pain score, analgesic consumption, Elderly Mobility Scale score, hip screw position, tip-apex distance, union rate, time to healing and complication rate. RESULTS The groups had similar preoperative clinical data. Postoperatively the MIDHS group had significantly smaller wound size, less blood loss, lower blood transfusion rates, pain scores and rates of analgesic consumption, and higher early Elderly Mobility Scale scores. There were no significant differences in fracture alignment, hip screw position, tip-apex distance, union rate, time to healing or complication rate. CONCLUSION MIDHS fixation of intertrochanteric fractures is effective and safe and significantly reduces blood loss, pain and rehabilitation period, without sacrificing reduction alignment, screw position, fixation stability or bone healing.

Minimally invasive management of trans-scaphoid perilunate fracture-dislocations.

This retrospective study evaluates the functional and radiological results of a series of acute trans-scaphoid dorsal perilunate fracture-dislocations treated operatively by minimally invasive technique. Twenty-one patients had surgery performed by one of three surgeons between 1994 and 2006, and all cases involved: (1) closed reduction of the carpus; (2) closed reduction and percutaneous screw fixation of the scaphoid fracture; and (3) closed reduction and multiple Kirschner wire stabilisation of the carpal dissociation. Seventeen males and four females with an average age of 29 years were evaluated. Ninety five per cent of internally fixed scaphoid healed at a mean time of 16 weeks. Radiographic alignment of the carpus was satisfactory in 17 cases. The average Mayo wrist score was 80 with three excellent and two poor results. There was one patient with asymptomatic DISI deformity. Two patients had radiographic evidence of mid-carpal arthritis. One patient with a scaphoid nonunion required surgical repair with bone grafting. The results of this study suggest that a minimally invasive technique for treating acute trans-scaphoid perilunate fracture-dislocations can be considered as an alternative to open approaches.

Palmar fixation of dorsally displaced distal radius fractures using locking plates with SmartLock locking screws

We performed a prospective cohort study on a consecutive series of 35 unstable, dorsally displaced distal radius fractures, which were treated with palmar locking plates and SmartLock locking screws. There were 17 men and 18 women with a mean age of 44 years who were reviewed at a mean follow-up of 10 months. All the fractures healed at a mean time of 7 weeks. Radiographs did not show any change in alignment from the initial postoperative period until fracture union. The average Mayo wrist score was 90 after fracture union. One patient had an early loss of fracture reduction and one patient developed complex regional pain syndrome. There was no difference in the quality of life before and after surgery. Palmar plate fixation using SmartLock locking screws is effective and safe in stabilising unstable dorsally displaced distal radius fracture and produces good radiological and functional outcomes.

Haemodynamic Instability Secondary to Minimally Displaced Pubic Rami Fractures: A Report of Two Cases

We report 2 patients with haemodynamic instability secondary to minimally displaced pubic rami fractures following a fall. Both complained of pain and swelling in the abdomen and groin, and had abdominal distension and bruising in the abdomen, groin, and perineum. All these may be early signs of severe vascular injury and should be treated promptly. Both patients were treated with embolisation of the injured vessels using emergency angiography.

The effectiveness of capsular decompression for internal fixation of intracapsular hip fractures

Purpose. To compare the results of screw fixation plus capsular decompression versus screw fixation alone for managing intracapsular hip fractures. Methods. Of 201 patients with intracapsular hip fractures, 99 underwent screw fixation with capsular decompression (capsular decompression group) and 102 underwent screw fixation alone (control group). The incidence and time to development of avascular necrosis of the femoral head, union rate, time to union, and other clinical parameters were compared. Results. In patients with displaced fractures, the incidence of avascular necrosis was significantly higher in the control than capsular decompression group, whereas the time to development of this complication was significantly shorter. Conclusion. Capsular decompression did not improve the union rate and time to union in undisplaced intracapsular hip fractures, but in displaced fractures it appeared to reduce the incidence and delay the onset of avascular necrosis.

Palmar corticocancellous grafting and Acutrak screw fixation for nonunion of the scaphoid.

Dear Sir, Non-vascularized bone grafts have been used to treat scaphoid nonunion stabilized with different fixation methods (Chen et al., 1999; Daly et al., 1996). We retrospectively studied the radiological and functional outcomes of 44 nonunions of scaphoid fractures in 44 patients treated between December 1994 and April 2004 with a volar tricorticocancellous graft from iliac crest and stabilized with an Acutrak screw (20 with a MiniAcutrak screw). Three were lost to follow-up. Patients were reviewed at a mean of 75 (range 60–96) months. There were 38 men and six women with a mean age of 28 (range 19–44) years at the time of surgery. The mean time from injury to surgery was 14 (range 8–20) months. The dominant side was involved in 24 patients. Twenty-nine fractures were located at the waist of scaphoid, five at the distal and ten at the proximal pole. We used curettes or a high speed burr to debride fibrous tissue from the nonunion site, taking care not to damage the outer cortical shell. The tourniquet was released after the debridement to note any punctate bleeding from the bone surfaces. After aggressive resection of the fibrous tissue and sclerotic bone the resulting big defect needed a large tricorticocancellous graft which was obtained from iliac crest. The graft was inserted with wrist placed in maximum dorsiflexion and ulnar deviation to hold the gap open. In one patient the graft shattered during drilling and another graft was obtained and secured using a smaller sized headless, cannulated compression Mini-Acutrak screw. At final follow-up, bone healing, assessed by trabeculae crossing the fracture site and absence of pain, was achieved in 40 of 44 cases. All patients were pain free. The mean arc of wrist motion was 130 compared to 150 on the opposite side. The mean postoperative grip strength was 28 kgf compared to 30 kgf on the opposite hand. Radiographs showed that four patients had slight decrease in joint space (grade one osteoarthritis) between the radial styloid and scaphoid. There were no wound infections or neurovascular complications. Two patients had complex regional pain syndrome which recovered spontaneously 6 months after the operation. The nonunion did not heal in four patients, all with proximal third nonunions. All were revised with a vascularized bone graft and healed 6 months later. The grafts did not dislodge and implant position was satisfactory. There was no donor site morbidity. The advantages of this method were: (1) the impaction of the tricorticocancellous graft gave some stability; (2) the shape and correct carpal alignment were restored correcting any humpback deformity; (3) the compression screw increased stability; and (4) the risk of the graft dislodging compared to that for cancellous bone chips was small. We feel that the good union rate in our patients was related to the aggressive resection of the fibrous tissue and sclerotic bone. Impaction of the graft into the scaphoid together with internal fixation gave increased stability.

A modified technique of interpositional arthroplasty in treating the Basal joint arthritis of the thumb in a Chinese population.

We performed a retrospective review of 22 thumbs in 22 Chinese patients attending for the basal joint arthritis of the thumb over the last 14 years. There were 16 women and six men with a mean age of 50 years old. All were treated surgically by partial trapeziectomy and volar oblique ligament reconstruction with flexor carpi radialis tendon and interpositional arthroplasty with a free palmaris longus tendon ball after failure of conservative treatment. The mean follow-up time was 48 months. Radiographs did not show any differences in the arthroplasty space index, arthroplasty space, trapezial space ratio and scaphoid-thumb metacarpal distance at the pre-operative evaluation and at the final follow-up evaluation. There was significant difference in the pain score, grip strength, Kapandji score and functional status before and after surgery at final follow-up period. One patient had complex regional pain syndrome which was resolved after receiving a course of anti-inflammatory drugs and physiotherapy. The authors suggest that the modified technique of partial trapeziectomy with tendon interpositional arthroplasty is a safe and effective method in treating basal joint arthritis of the thumb with good short term functional and radiological outcomes and minimal complication.