Variation in Treatment for Trapeziometacarpal Arthrosis

Background: Treatment recommendations for trapeziometacarpal (TMC) arthrosis are highly variable from surgeon to surgeon. This study addressed the influence of viewing radiographs on a decision to offer surgery for TMC arthrosis. Methods: In an online survey, 92 hand surgeons viewed clinical scenarios and were asked if they would offer surgery to 30 patients with TMC arthrosis. Forty-two observers were randomly assigned to review clinical information alone and 50 to review clinical information as well as radiographs. The degree of limitation of daily activities, time since diagnosis, prior treatment, pain with grind, crepitation with grind, and metacarpal adduction with metacarpophalangeal hyperextension were randomized for each patient scenario to determine the influence of these factors on offers of surgery. A cross-classified binary logistic multilevel regression analysis identified factors associated with surgeon offer of surgery. Results: Surgeons were more likely to offer surgery when they viewed radiographs (42% vs. 32%, P = 0.01). Other factors associated variation in offer of surgery included greater limitation of daily activities, symptoms for a year, prior splint or injection, deformity of the metacarpophalangeal joint. Factors not associated included limb dominance, prominence of the TMC joint, crepitation with the grind test, and pinch and grip strength. Conclusion: Surgeons that view radiographs are more likely to offer surgery to people with TMC arthrosis. Surgeons are also more likely to offer surgery when people do not adapt with time and nonoperative treatment. Given the notable influence of surgeon bias, and the potential for surgeon and patient impatience with the adaptation process, methods for increasing patient participation in the decision-making process merit additional attention and study

Is there evidence-based guidance for timing of soft tissue coverage of grade III B tibia fractures?

The treatment of soft tissue damage associated with severe complicated tibia fractures is a clinical challenge. A recent study of grade III B/C open tibia fractures treated by delayed soft tissue coverage resulted in 20% of patients having osteomyelitis, with a mean follow-up of only 10 months. This study prompted us to review the literature on the association of timing of soft tissue closure in complicated grade III B tibia fractures and the incidence of infections and bone union. A Medline literature search was performed focusing on evidence-based medicine with regard to the timing of soft tissue closure and patients developing bony union and complications such as osteomyelitis. It was difficult to analyze publications with rigor. It appears that the time of surgery has little influence on free-flap failure but that early aggressive debridement followed by soft tissue cover within 3 to 5 days reduces osteomyelitis and delayed bone union. A need for better designed studies is also indicate

Metaphyseal locking compression plate as an external fixator for the distal tibia

Recently we coined the term supercutaneous plating using a locking compression plate (LCP) as an external fixator. The use of this technique in peri-articular areas is facilitated by the development of anatomical plates with various screw sizes. The purpose of this report is to describe our results using the metaphyseal locking plate (LCP) as an external fixator in the treatment of infected post-traumatic problems of the distal tibia. Between August 2008 and January 2012 a total of seven patients underwent external plating ("supercutaneous plating") of the distal tibia using a metaphyseal locking plate. Average age was 43 years (range 20-79). Six out of seven patients had a documented infection at the time of external plate application. All patients in this cohort were followed prospectively at regular intervals by the senior author (PK). The plate was in situ for an average of 17.5 weeks (range 6-60). There were no clinically significant pin site infections. In four patients the plate was kept in place until there was complete consolidation. In three patients the external plate was exchanged for formal internal fixation once the infection had subsided. At the latest follow-up (average 12.8 months, range 4-31), all patients were fully weight bearing with a fully healed tibia. All patients were infection-free with well-healed wounds. Infection of the distal tibia after treatment of traumatic and post-traumatic problems is a challenging problem. It is common practice that after initial debridement and hardware removal, temporary bony stabilisation is provided by external fixation. Most external frames for the lower leg are bulky and cumbersome, causing significant problems for the patient. To circumvent these issues, we have successfully used an anatomically-contoured metaphyseal locking compression plate as external fixator in a series of seven patients for acute or post-traumatic problems of the tibi