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Trapeziometacarpal dislocation is a rare traumatic lesion, especially in the pediatric population. Various treatments have been described for acute cases. We report the case of a 15-year-old boy who was admitted in the emergency department with chronic post-traumatic trapeziometacarpal dislocation due to an untreated first metacarpal base fracture (Bennett), with complete articular destruction. The patient was treated by open reduction, interposition of a costal cartilage graft, and intermetacarpal K-wire fixation. Follow-up at 2 years after the surgery showed excellent clinical and radiological results. This surgical technique had not been described previously in the pediatric population.

The goal of wrist denervation is to decrease pain at the wrist, whether caused by an intra- or extra-articular problem or even when the reason for the pain is unknown. It is an alternative to partial or total arthrodesis and proximal row carpectomy. Our hypothesis was that wrist denervation with a two-incision technique was a reliable and efficient way to treat painful degenerative wrists. Thirty-three patients, 48 years old on average, were included in this study. Indications were scapholunate advanced collapse (SLAC) in 18 cases, scaphoid nonunion advanced collapse (SNAC) in 10, distal radius fracture sequelae with advanced radiocarpal osteoarthritis in 4, and post-traumatic ulnocarpal impingement in 1 case. At 41 months’ follow-up (12–161), there was a 75% reduction in pain levels, decreasing from 7.1 to 1.8 on a visual analog scale (VAS). There were no modifications related to wrist range of motion or grip strength. The QuickDASH averaged 23 points (5 to 70). Radiographic evaluation showed progression of intracarpal degeneration in 6 patients. All but 2 patients returned to their previous work. Persistent dysesthesia was observed in 7 patients; it resolved in 3 cases and persisted in 4. One patient developed complex regional pain syndrome (CRPS). A midcarpal arthrodesis with scaphoidectomy was performed in one patient because of disabling pain 5 months after surgery. Wrist denervation with a two-incision technique for post-traumatic osteoarthritis led to satisfactory results in 75% of cases with reduction in pain, preservation of range of motion and grip strength. However, this technique does not stop the progression of osteoarthritis. It can be discussed as a therapeutic alternative to proximal row carpectomy or intracarpal arthrodesis to treat degenerative painful wrists. Type of study/level of evidence Therapeutic IV.

Objectives: In a series of 9 cases with radio-carpal arthritis from trauma that benefitted from a radioscapholunate arthrodesis with excision of the distal scaphoid pole, we desired to measure the perioperative range of motion to see if mobility was preserved after the operation. We also sought to describe our graft technique with a bone cover coming from the cortical distal radius. Methods: We retrospectively collected data from nine patients that benefitted from this surgical technique and we documented the clinical and radiological information. Results: With a mean follow-up of three years, we had the following perioperative results: flexion 44°, extension 41°, ulnar deviation 24° and radial deviation 17°. This range of motion was depressed at postoperative follow-up. We did not observe any pseudoarthrosis. We did find a high complication rate with three cases of mediocarpal arthritis, one tendon rupture and one radiotriquetral conflict. During the postoperative period, the pain was 0/10. Conclusions: Radioscapholunate arthrodesis in the case of radiocarpal arthritis with the use of a bone graft coming from the distal radius demonstrated robust results in terms of pain. The perioperative benefit on mobility was not found during postoperative period. A bone graft using a cortical cover from the distal radius yielded favorable results with regards to bone healing. [Hand Microsurg 2017; 6(2.000): 62-67]

ObjectiveThe optimal duration of postsurgical antibiotic therapy for adult native joint bacterial arthritis remains unknown.MethodsWe conducted a prospective, unblinded, randomised, non-inferiority study comparing either 2 or 4 weeks of antibiotic therapy after surgical drainage of native joint bacterial arthritis in adults. Excluded were implant-related infections, episodes without surgical lavage and episodes with a follow-up of less than 2 months.ResultsWe enrolled 154 cases: 77 in the 4-week arm and 77 in the 2-week arm. Median length of intravenous antibiotic treatment was 1 and 2 days, respectively. The median number of surgical lavages was 1 in both arms. Recurrence of infection was noted in three patients (2%): 1 in the 2-week arm (99% cure rate) and 2 in the 4-week arm (97% cure rate). There was no difference in the number of adverse events or sequelae between the study arms. Of the overall 154 arthritis cases, 99 concerned the hand and wrist, for which an additional subgroup analysis was performed. In this per-protocol subanalysis, we noted three recurrences: one in the 2-week arm (97 % cure); two in the 4-week arm (96 % cure) and witnessed sequelae in 50% in the 2-week arm versus 55% in the 4-week arm, of which five (13%) and six (13%) needed further interventions.ConclusionsAfter initial surgical lavage for septic arthritis, 2 weeks of targeted antibiotic therapy is not inferior to 4 weeks regarding cure rate, adverse events or sequelae and leads to a significantly shorter hospital stay, at least for hand and wrist arthritis.Trial registration numberNCT03615781.

Necrotizing fasciitis is a rare condition. Due to the agressivity of the infection and the amputation rate, it is very important to be aware of this diagnostic and do a proper surgical debridement. We describe a clinical case of a patient with a necrotizing fasciitis that needed two fingers amputation. After the antibiotic treatment and a second surgical debridement we performed a skin graft. The follow up at 6 months show a good function of the hand.

Hand aneurysms are a rare entity only described as case reports in the literature. The aim of our study was to describe a series of four cases and the surgical technique using an arterial bypass. We also wanted to define an algorithm for the imaging of this pathology. We have operated on four patients with hand aneurysms in the past decade or so. One patient had an aneurysm in the thumb proper palmar digital artery, one in the superficial palmar arch and the two others in the ulnar artery. All patients had an excision surgery with direct arterial bypass; no patient had a venous graft. All patients were seen a few years after the surgery and underwent an ultrasonography to check the anastomosis permeability. All anastomoses were permeable 2 to 8 years after surgery. Through a review of the literature we discuss the best algorithm for imaging a hand aneurysm. Direct arterial suture by proximal and distal mobilization allows for long-term permeability. If a graft is necessary, a graft of arterial origin should be preferred. The additional first-line examination is ultrasonography, followed by arteriography if acute ischemia is present; otherwise, CT angiography or MR angiography is performed.

Whether patients with asymptomatic bacteriuria should be investigated and treated before elective hip and knee replacement is controversial, although it is a widespread practice. We conducted a prospective observational cohort study with urine analyses before surgery and three days post-operatively. Patients with symptomatic urinary infections or an indwelling catheter were excluded. Post-discharge surveillance included questionnaires to patients and general practitioners at three months. Among 510 patients (309 women and 201 men), with a median age of 69 years (16 to 97) undergoing lower limb joint replacements (290 hips and 220 knees), 182 (36%) had pre-operative asymptomatic bacteriuria, mostly due to Escherichia coli, and 181 (35%) had white cells in the urine. Most patients (95%) received a single intravenous peri-operative dose (1.5 g) of cefuroxime as prophylaxis. On the third post-operative day urinary analysis identified white cells in 99 samples (19%) and bacteriuria in 208 (41%). Pathogens in the cultures on the third post-operative day were different from those in the pre-operative samples in 260 patients (51%). Only 25 patients (5%) developed a symptomatic urinary infection during their stay or in a subsequent three-month follow-up period, and two thirds of organisms identified were unrelated to those found during the admission. All symptomatic infections were successfully treated with oral antibiotics with no perceived effect on the joint replacement.We conclude that testing and treating asymptomatic urinary tract colonisation before joint replacement is unnecessary.Cite this article: Bone Joint J 2014;96-B:390–4.

The optimal duration of postsurgical antibiotic therapy for native hand and finger joint septic arthritis is unknown. We conducted a three-year (May 2015–May 2018), prospective, unblended, single-center, interventional study of adult patients agreeing to a randomization (1–1) to either 2 or 4 weeks of systemic and targeted antibiotic therapy after surgical drainage for native joint infection of the hand or wrist. It was a non-inferiority trial with a lower margin of 10% and two major outcomes—cure of infection and persistent (mechanical) sequelae at the last control visit. We excluded patients with implant-related infections while the implant was still in place, patients without surgical lavage, and patients with short follow-ups (

L’hemi-arthroplastie du radius distal est une alternative chirurgicale encore peu repandue dans le cadre de la prise en charge des fractures comminutive du radius distal du sujet âge. Dans ce contexte, l’osteosynthese est a risque de complications et de deplacement secondaire notamment de par la mauvaise qualite osseuse. Le but de cette etude etait de rapporter les resultats a court et moyen terme des hemi-arthroplasties du radius distal dans le traitement des fractures type C3 selon l’AO du sujet âge. De juillet 2016 a novembre 2018, 12 patients âges en moyenne de 79 ans (68–89) ont beneficie de la mise en place d’une hemi-arthroplastie radiale cimentee. Tous les patients ont ete evalues sur le plan clinique, fonctionnel et radiographique. Les complications per- et postoperatoires ont ete recherchees. Dans 11 cas, il s’agissait de la prothese REMOTION (SBI) et dans un cas de la prothese SOPHIATM (Biotech). Une resection de la tete ulnaire de type DARRACH a ete realisee conjointement chez 9 patients. Le recul moyen etait de 8 mois (3–24). Les mobilites moyennes etaient de 33° (20–60) en flexion et 48° (30–70) en extension. L’arc de mobilite en prono-supination etait en moyenne de 160° (140–180). La force de serrage moyenne etait de 11 kgf (5–20) au Jamar. Huit patients etaient strictement indolores au dernier recul. Trois reprises chirurgicales ont eu lieu durant le suivi. Un cas d’infection precoce (2 semaines) a necessite un lavage avec conservation de l’implant et antibiotherapie durant 3 mois. Un patient a ete repris pour une arthropathie radio-ulnaire distale avec realisation d’un DARRACH. Enfin, une instabilite radio-carpienne est survenue a 6 semaines postoperatoire avec luxation radio-carpienne anterieure pour laquelle une reprise chirurgicale a ete realisee. Les radiographies au dernier recul n’ont pas mis en evidence de descellement de l’implant ni de translation ulnaire du carpe. L’hemi-arthroplastie du radius distal permet de restaurer rapidement une mobilite et une autonomie satisfaisante chez les sujets âges. Malgre un taux de reprise a 25 %, cette option therapeutique nous parait preferable a une osteosynthese chez les sujets âges, autonomes, presentant des fractures type C3 selon l’AO du radius distal. Un suivi a long terme voire une etude comparative apparait indispensable afin de pouvoir valider de facon consensuelle cette prise en charge.

Summary Background Staphylococcus aureus is the most common cause of soft tissue infections. It is unknown, however, if a patient who has had such an infection is at greater risk for future soft tissue infections with S. aureus . Methods We conducted an epidemiological survey of adult patients hospitalized in the only public hospital in Geneva for treatment (usually combined surgical and medical) of a soft tissue infection caused by S. aureus . By reviewing nursing and medical records from the emergency department and hospital wards, we assessed whether or not they developed any other soft tissue infections (excluding a recurrence) after or before the index one. Results Among 1023 index episodes of soft tissue infections, 670 (65%) were caused by S. aureus, of which 47 were caused by methicillin-resistant strains (30 healthcare-associated and 17 community-acquired). The patients' median age was 51 years and 334 (34%) were immune-compromised. The median time span between the patient's first and last consultation (for any reason) in our hospital was 21.4 years (interquartile range, 10-30 years). In addition to their index infection, 124 patients (12%) developed a new nosocomial or community-acquired soft tissue infection. Among the index cases with an S. aureus infection, 92 (14%) had another soft tissue infection, compared to 32 (9%) who had a non-staphylococcal index infection (Pearson-χ 2 -test; p =0.03). Similarly, patients with an index S. aureus infection, compared to those with a non- S. aureus infection, had a higher rate of another soft tissue infection caused by S. aureus (χ 2 -test; p 0.01). In multivariate analysis, an index infection due to S. aureus shows a high association to further S. aureus soft tissue infections (logistic regression; odds ratio 2.5, 95% confidence interval 1.4-4.6). Conclusion Among adult patients hospitalised for a soft tissue infection, those infected with S. aureus (compared with other pathogens) may be at higher risk of a subsequent soft tissue infection, particularly with S. aureus .

A 30-year-old male smoker presented to the emergency department with anterior ST-segment elevation myocardial infarction. Primary percutaneous coronary intervention performed via the right radial artery showed an ostial thrombotic subocclusion of the left anterior descending artery ([Figure 1A][1

Trapezometacarpal dislocation is an uncommon traumatic lesion, especially in pediatric population, accounting for less than 1% of hand traumas. The lesion is usually due to an axial force, transmitted on a partially flexed thumb, causing the metacarpal bone to dislocate dorsally. When acute, various treatments have been described — closed reduction and cast, open or closed reduction with temporary K-Wire fixation, dorsal capsule and ligament reconstruction. In this abstract, we report a case of a 15-year-old boy who was admitted in the emergency department with a chronic post-traumatic trapeziometacarpal dislocation. The history reveals that he suffered from an thumb traumatism, by falling of a motorcycle seven months before, left untreated. By the time of the admission, he was suffering from thumb pain following a minor trauma that happened one week before. The X-rays and the preoperative CT scan showed a trapeziometacarpal dislocation, due to an untreated first metacarpal base fracture, with complete articular destruction. He underwent surgery, which consisted of an open reduction, a interposition graft of costal cartilage (9th rib) and ligament reconstruction (intermetacarpal, anterior oblique, posterior capsule). A temporary K-wire between first and second metacarpal was made followed by a cast immobilization for one month. The follow-up of the surgery showed a complete recuperation of the articular mobility and an absence of pain. Finally the X-rays revealed a reduction of the luxation.

Les revisions chirurgicales apres neurolyses ouvertes ou endoscopiques primaires du nerf median au niveau du tunnel carpien sont necessaires en cas de recidive ou persistance des symptomes. Soltani et al. (2013) demontrent par une meta-analyse que les revisions chirurgicales avec interposition d’un lambeau vascularise ont un taux de succes superieur (86 %) aux revisions chirurgicales sans lambeau (75 %). Nous presentons les resultats cliniques d’une etude retrospective incluant 20 revisions chirurgicales par neurolyse a ciel ouvert du nerf median et lambeau synovial selon Wulle au niveau du tunnel carpien effectuees entre janvier 2012 et decembre 2016. Un total de 20 interventions dont 17 patients (moyenne d’âge ± EC : 53,9 ± 14,8) ont beneficie d’une neurolyse a ciel ouvert associee a un lambeau synovial comme traitement chirurgical en cas de recidive du syndrome de tunnel carpien. Seuls les cas avec recidive du tunnel carpien presentant une cicatrisation du retinaculum des flechisseurs ou presentant un nerf median avec une fibrose peri-neurale a l’imagerie par resonances magnetique, a l’ultrason et ou par constatation directe peroperatoire ont ete inclus dans l’analyse. Les resultats de la chirurgie ont ete repartis en 4 categories en fonction du dernier suivi postoperatoire. Un resultat excellent est defini comme la disparition complete des plaintes, un bon resultat comme une diminution notable des symptomes, un resultat nul definit une faible amelioration ou l’absence d’amelioration et un mauvais resultat etant une aggravation des symptomes. Les analyses descriptives demontrent que 75 % des patients presentent une evolution favorable, dont 20 % un resultat excellent et 55 % un bon resultat, alors que 10 % presentent une evolution nulle et 15 % une evolution defavorable. Le recul est situe entre 46 jours et 1280 jours postoperatoires avec un recul median de 348 jours (recul moyen ± EC : 371j ± 367). Les resultats de notre etude demontrent que 75 % des patients presentent une evolution favorable apres revision du canal carpien par neurolyse a ciel ouvert et lambeau synovial de recouvrement. Cette option chirurgicale peu invasive est interessante et devrait faire partie de l’arsenal therapeutique des syndromes de tunnel carpiens recidivants.

Les TCG sont des tumeurs rares dans la main. Lorsque l’atteinte est osseuse, il faut, pour eviter les recidives, realiser une resection large. Cela implique une perte de substance osseuse qu’il faut par la suite reconstruire. Nous decrivons 2 cas de reconstruction osseuse dans ce contexte tumoral avec la technique de la membrane induite selon Masquelet (un premier metacarpien et une phalange). Description des cas Cas 1 : il s’agit d’une jeune patiente de 24 ans qui presente une TCG de l’interphalangienne distale du 3e doigt de la main droite. Le bilan par imagerie montre un envahissement articulaire et dans ce contexte une resection de l’articulation et de la partie distale de P2 est planifiee. La patiente beneficie d’un premier temps de Masquelet avec resection tumorale, mise en place de ciment et stabilisation par une broche. Deux mois plus tard, elle beneficie du deuxieme temps de Masquelet avec greffe osseuse spongieuse prise au depend du radius distal et stabilisation avec une vis de compression. Le suivi radiologique montre une consolidation. Cas 2 : il s’agit d’une patiente de 67 ans qui presente une TCG du premier metacarpien avec extension dans la base de P1. Le bilan par imagerie confirme l’atteinte articulaire. Une chirurgie est planifiee pour resection de la tumeur et arthrodese metacarpo-phalangienne. Un premier temps de Masquelet est realise avec stabilisation par plaque. Deux mois plus tard, la patiente beneficie du deuxieme temps de Masquelet avec prise de greffe cortico-spongieuse prise au depend de la crete iliaque. Le suivi radiologique montre une consolidation acquise a 2 mois post deuxieme temps de Masquelet. La technique de la membrane induite, grâce a ses facteurs d’osteoinductions, permet de reconstruire des pertes de substance osseuse dans les resections larges necessaires a la chirurgie des TCG. Le delai entre les 2 chirurgies nous permet d’avoir les resultats de la pathologie et de s’assurer des marges saines de resection. Le suivi de nos 2 cas montre une consolidation et une absence de recidive. Un suivi au long cours est necessaire.

There is controversy as to whether or not diabetic foot infections (DFIs) caused by methicillin-resistant Staphylococcus aureus (MRSA) are associated with worse outcomes than DFIs caused by other pathogens. To address this issue we performed a nonsystematic literature search of published articles in English language journals seeking studies reporting on the outcomes of DFIs related to their microbiology. We retrieved 48 articles published from 1999 to 2013 that described a total of 7771 cases of DFI. The overall proportion of DFIs with an isolate of S aureus was about 30%; just over one third of these (11% of all cases) were MRSA strains. Among the DFI cases caused by MRSA 1543 were episodes of soft tissue infections and 113 of osteomyelitis, while non-MRSA organisms caused 5761 soft tissue infections and 354 cases of osteomyelitis. Only 5 of the included articles attempted a comparison between DFI caused by MRSA and those caused by other pathogens, with no clear differences noted. The median total duration of antibiotic therapy for DFI caused by MRSA was 26 days, of which a median of 10 days was given intravenously. Only a few articles reported the proportion of patients with a recurrence, but they often did not differentiate between MRSA and non-MRSA cases. Four publications reported a worse functional or microbiological outcome in MRSA, compared to non-MRSA, cases, but the findings were variable and differences did not seem to be significant. Many trials failed to adjust for case-mix or to definitively demonstrate a relationship between microbiology and outcomes. Few of the articles specifically commented on whether the MRSA isolates were health care- or community-acquired strains. Notwithstanding the substantial limitations of the available literature, there does not appear to be a need for any special treatment for DFI caused by MRSA. The current guidelines for treating according to established international recommendations seem appropriate.

The search for asymptomatic bacterial urinary tract colonization (UTC) and its eradication before elective hip and knee arthroplasty surgery is controversial, but reflects widespread practice. The influence of perioperative antibiotic prophylaxis on the dynamics of UTC is unknown.

Summary QUESTIONS UNDER STUDY/PRINCIPLES: Prosthetic joint infections (PJI) may be a potential sentinel event for an unknown neoplastic or infectious source in elderly patients. However, the value and cost-effectiveness of investigations to determine the origin of these infections is unknown. METHODS: Retrospective study at Geneva University Hospitals, evaluating associated medical examinations performed in search of the origin of all presumed surgical site and haematogenous arthroplasty infections. RESULTS: A total of 182 PJI were found in 182 patients (median age 75 years). Seventy PJI (38%) were classified as probably haematogenous, occurring more than 2 years post-implantation, with 27 (15%) due to Gram-negative pathogens. Overall, the origin of PJI was found solely by admission history in 28 cases (15%). Among the remaining 154 cases, no remote origin could be detected despite 17 echocardiograms, 17 other sonograms, 49 chest x-rays, 23 computed tomograms, 107 urinary cultures, 11 endoscopies, 9 scintigraphies and 31 medical specialist consultations. The average cost of these exams was 675 Swiss francs (845 US$) per PJI. At long-term follow-up six patients were found to have developed a neoplasm, of which only one (hepatocellular carcinoma after PJI due to Streptococcus bovis) could eventually be attributed to prior infection. CONCLUSIONS: From an epidemiologic point of view, patient history is the best way to predict the origin of PJI. Blind additional radiographic or endoscopic exams are costly, inconclusive and do not contribute to the management of these cases.

Introduction Les anevrismes de la main sont une pathologie rare faiblement decrite dans la litterature. Nous rapportons une serie de 5 cas pris en charge dans notre centre. Methode Nous avons revu 5 cas de facon retrospective operes durant les 10 dernieres annees. On retrouve 4 hommes et 1 femme, la moyenne d’âge etait de 49 ans. Les patients presentaient cliniquement une masse pulsatile a la face palmaire de la main. Un patient presentait simultanement une endocardite, et une patiente avait presente dans l’enfance une endocardite. Un patient presentait un anevrisme sur une artere digitale, 2 patients sur l’arcade palmaire superficielle et 2 patients sur l’artere ulnaire. Tous les patients ont eu un complement d’imagerie avec echographie puis angio-IRM. Chaque patient a beneficie d’une prise en charge chirurgicale avec excision de l’anevrisme. Resultats Tous les anevrismes ont ete reseques, les analyses pathologiques ont confirme 3 anevrismes d’origine mycotique. Un anevrisme etait d’origine traumatique sur le territoire de l’artere ulnaire dans un contexte de syndrome du marteau hypothenarien, un anevrisme etait d’origine idiopathique. La technique chirurgicale etait chez 4 patients une excision avec mobilisation des arteres de part et d’autre pour permettre une suture microchirurgicale directe termino-terminale. Cette technique a pu etre utilisee sur le territoire de l’artere ulnaire a 2 reprises, sur l’artere digitale et sur une arcade palmaire superficielle. Chez un patient du fait du defect arteriel trop important sur l’arcade palmaire superficielle (> 2 cm) nous avons realise un pontage veineux provenant de l’avant-bras. Discussion La prise en charge des anevrismes a la main reste exceptionnelle et seuls quelques cas sont decrits dans la litterature. Notre serie represente bien le panel retrouve dans la litterature avec certains cas d’origine infectieuse, un cas d’origine traumatique. Dans tous les cas il faut privilegier la mobilisation arterielle pour realiser une suture directe, si la perte de substance est trop importante (> 2 cm) il faut envisager un pontage. Les resultats de la litterature sur l’utilisation de greffons veineux au long terme presentent un taux de thrombose entre 20 et 50 %. Cela ne peut que nous encourager a suivre au long cours notre serie afin de suivre la permeabilite des sutures directes entre arteres et le suivi du pontage veineux a l’aide d’echo-Doppler.