Hand & Wrist

“Fingers, toes, ears, and nose are places where epinephrine never goes,” Thomas Ehlers, DPM, wrote in Podiatry Today. “That is an adage I heard during podiatry school, my clerkships, and from various attendings throughout my training.”

But as Dr. Ehlers added, epinephrine gets a bad rap. The catchy admonition “has been proven a myth time and time again.”

So why do many clinicians believe the combination of epinephrine and lidocaine to be off-limits in surgical interventions involving the digits and other regions with low blood flow? Although medical trainees across multiple disciplines are taught to fear the practice, citing the potential for gangrene, its reputation for harm is not supported by the evidence.
 

Lack of Feeling Doesn’t Care About Your Facts

The debate surfaced anew in response to a recent column by Kenny Lin, MD, MPH, family physician and associate director of the Lancaster General Hospital Family Medicine Residency, in Lancaster, Pennsylvania, about the rather pedestrian topic of why he no longer performs surgery to correct ingrown toenails. Dr. Lin’s admission that he used to do the procedure with a combination of epinephrine and lidocaine turned into a major focus of the comments — many of them harshly critical of the practice:

“Epinephrine is not an appropriate drug to use for podiatry or use in any peripheral area. Gangrene?” one commenter posted.

“Leave epi out of lidocaine to fingers, toes, nose, and ear lobes,” another wrote.

“No lido with epi, whether or not it is contraindicated, because: If there’s any adverse outcome, a lawyer will find plenty of references saying it was contraindicated,” a reader chimed in.

Other commenters disagreed, with one saying, “Please, folks, don’t show that you trained 50 years ago and haven’t changed practice since…”

For Dr. Lin, the response was surprising given what he believes to be the lack of evidence supporting the purported dangers.

“When I think about this, it’s something that was taught to me during residency — that they should not be used on certain areas,” Dr. Lin said. “But since then, studies have been published looking at thousands of cases of people using epinephrine with lidocaine and haven’t found any cases of necrosis.”

Many doctors, like Dr. Lin, say they were cautioned against this in their training. Others don’t remember exactly where they’ve heard it but recognize the idea has a nebulous hold on practice.

Combining epinephrine with lidocaine helps make the numbing last longer, stops bleeding, and reduces the use of lidocaine required, all of which improve the chances of an effective and comfortable intervention for the patient, Dr. Lin said. The approach also reduces the use of tourniquets, which come with their own risks including nerve injury.

However, in areas with limited circulation, this vasoconstrictive effect may be more pronounced, potentially leading to complications for patients with complicating factors.

Clinicians who regularly use the combination of epinephrine and lidocaine for surgery do concede that it can pose certain hazards and considerations in areas without robust blood flow.

But the literature largely points to its safety.

In 2001, California-based plastic and reconstructive surgeon Keith Denkler, MD, published a deep dive on the topic starting in the 19th century, including a review of Index Medicus from 1880 to 1966, a computer review of the National Library of Medicine database from 1966 to 2000, and major textbooks from 1900 to 2000.

He found a total of 48 cases of digital gangrene — but most involved the use of cocaine or procaine. Of the 48 cases, 21 involved the use of epinephrine, and 17 used an unknown concentration based on manual dilution.

“Multiple other concurrent conditions (hot soaks, tight tourniquets, and infection) existed in these case reports, making it difficult to determine the exact cause of the tissue insult,” Dr. Denkler wrote.

In a 2010 retrospective review in the Journal of the American Society of Plastic Surgeons, authors examined 1111 cases involving digital and hand surgery. Of the 611 patients who received injections of 1% lidocaine with epinephrine, none experienced digital necrosis.

Another review from 2003 touted the combination’s safety, in hopes to “help dispel the myth that epinephrine has no place in podiatric anesthesia.” But authors noted limitations of use, including “known sensitivity, thyrotoxicosis, and use of either tricyclic antidepressants or monoamine oxidase inhibitors.”

James Christina, DPM, executive director and CEO of the American Podiatric Medical Association, echoed that sentiment. He said he regularly used the combination to correct bunions, hammer toes, and ingrown toenails over his 20 years of practicing but acknowledged the technique is not appropriate for all such patients.

“There’s always been caution when using epinephrine with local anesthetic,” Dr. Christina told this news organization. “You need a healthy patient with normal circulation and no other complications; someone without vascular compromise.”

Marie Hanna, MD, MEHP, chief of regional anesthesia and acute pain management at Johns Hopkins University, Baltimore, counts herself among the cautious. Citing Principles of Office Anesthesia: Part I. Infiltrative Anesthesia, Dr. Hanna said epinephrine should never be used in digital and penile blocks or in skin flaps with marginal viability.

“It is perfectly fine in certain areas, like the wrist or the arm,” Dr. Hanna said. “But specifically for use in end organs like nose, fingers, ears, toes — all of these with tenuous blood supply — it is not good practice.”

The divide among doctors comes down to theoretical concern, rather than empirical basis, said Rebecca Johnson, MD, chair of the American Society of Anesthesiologists committee on Regional Anesthesia and Acute Pain Medicine and a faculty member at Mayo Clinic, in Rochester, Minnesota.

“It’s just one of those myths we have in practice,” she said.

And legally, Dr. Johnson noted, the mere existence of a myth can be enough of a deterrent for medical practitioners: “Like anything, when you’re trying to do the right thing, if a complication would occur for another reason, you’d want to make sure a jury of your peers didn’t bring up that myth.”

The sources in this story reported no relevant financial conflicts of interest.
 

A version of this article appeared on Medscape.com.

“Fingers, toes, ears, and nose are places where epinephrine never goes,” Thomas Ehlers, DPM, wrote in Podiatry Today. “That is an adage I heard during podiatry school, my clerkships, and from various attendings throughout my training.”

But as Dr. Ehlers added, epinephrine gets a bad rap. The catchy admonition “has been proven a myth time and time again.”

So why do many clinicians believe the combination of epinephrine and lidocaine to be off-limits in surgical interventions involving the digits and other regions with low blood flow? Although medical trainees across multiple disciplines are taught to fear the practice, citing the potential for gangrene, its reputation for harm is not supported by the evidence.
 

Lack of Feeling Doesn’t Care About Your Facts

The debate surfaced anew in response to a recent column by Kenny Lin, MD, MPH, family physician and associate director of the Lancaster General Hospital Family Medicine Residency, in Lancaster, Pennsylvania, about the rather pedestrian topic of why he no longer performs surgery to correct ingrown toenails. Dr. Lin’s admission that he used to do the procedure with a combination of epinephrine and lidocaine turned into a major focus of the comments — many of them harshly critical of the practice:

“Epinephrine is not an appropriate drug to use for podiatry or use in any peripheral area. Gangrene?” one commenter posted.

“Leave epi out of lidocaine to fingers, toes, nose, and ear lobes,” another wrote.

“No lido with epi, whether or not it is contraindicated, because: If there’s any adverse outcome, a lawyer will find plenty of references saying it was contraindicated,” a reader chimed in.

Other commenters disagreed, with one saying, “Please, folks, don’t show that you trained 50 years ago and haven’t changed practice since…”

For Dr. Lin, the response was surprising given what he believes to be the lack of evidence supporting the purported dangers.

“When I think about this, it’s something that was taught to me during residency — that they should not be used on certain areas,” Dr. Lin said. “But since then, studies have been published looking at thousands of cases of people using epinephrine with lidocaine and haven’t found any cases of necrosis.”

Many doctors, like Dr. Lin, say they were cautioned against this in their training. Others don’t remember exactly where they’ve heard it but recognize the idea has a nebulous hold on practice.

Combining epinephrine with lidocaine helps make the numbing last longer, stops bleeding, and reduces the use of lidocaine required, all of which improve the chances of an effective and comfortable intervention for the patient, Dr. Lin said. The approach also reduces the use of tourniquets, which come with their own risks including nerve injury.

However, in areas with limited circulation, this vasoconstrictive effect may be more pronounced, potentially leading to complications for patients with complicating factors.

Clinicians who regularly use the combination of epinephrine and lidocaine for surgery do concede that it can pose certain hazards and considerations in areas without robust blood flow.

But the literature largely points to its safety.

In 2001, California-based plastic and reconstructive surgeon Keith Denkler, MD, published a deep dive on the topic starting in the 19th century, including a review of Index Medicus from 1880 to 1966, a computer review of the National Library of Medicine database from 1966 to 2000, and major textbooks from 1900 to 2000.

He found a total of 48 cases of digital gangrene — but most involved the use of cocaine or procaine. Of the 48 cases, 21 involved the use of epinephrine, and 17 used an unknown concentration based on manual dilution.

“Multiple other concurrent conditions (hot soaks, tight tourniquets, and infection) existed in these case reports, making it difficult to determine the exact cause of the tissue insult,” Dr. Denkler wrote.

In a 2010 retrospective review in the Journal of the American Society of Plastic Surgeons, authors examined 1111 cases involving digital and hand surgery. Of the 611 patients who received injections of 1% lidocaine with epinephrine, none experienced digital necrosis.

Another review from 2003 touted the combination’s safety, in hopes to “help dispel the myth that epinephrine has no place in podiatric anesthesia.” But authors noted limitations of use, including “known sensitivity, thyrotoxicosis, and use of either tricyclic antidepressants or monoamine oxidase inhibitors.”

James Christina, DPM, executive director and CEO of the American Podiatric Medical Association, echoed that sentiment. He said he regularly used the combination to correct bunions, hammer toes, and ingrown toenails over his 20 years of practicing but acknowledged the technique is not appropriate for all such patients.

“There’s always been caution when using epinephrine with local anesthetic,” Dr. Christina told this news organization. “You need a healthy patient with normal circulation and no other complications; someone without vascular compromise.”

Marie Hanna, MD, MEHP, chief of regional anesthesia and acute pain management at Johns Hopkins University, Baltimore, counts herself among the cautious. Citing Principles of Office Anesthesia: Part I. Infiltrative Anesthesia, Dr. Hanna said epinephrine should never be used in digital and penile blocks or in skin flaps with marginal viability.

“It is perfectly fine in certain areas, like the wrist or the arm,” Dr. Hanna said. “But specifically for use in end organs like nose, fingers, ears, toes — all of these with tenuous blood supply — it is not good practice.”

The divide among doctors comes down to theoretical concern, rather than empirical basis, said Rebecca Johnson, MD, chair of the American Society of Anesthesiologists committee on Regional Anesthesia and Acute Pain Medicine and a faculty member at Mayo Clinic, in Rochester, Minnesota.

“It’s just one of those myths we have in practice,” she said.

And legally, Dr. Johnson noted, the mere existence of a myth can be enough of a deterrent for medical practitioners: “Like anything, when you’re trying to do the right thing, if a complication would occur for another reason, you’d want to make sure a jury of your peers didn’t bring up that myth.”

The sources in this story reported no relevant financial conflicts of interest.
 

A version of this article appeared on Medscape.com.

“Fingers, toes, ears, and nose are places where epinephrine never goes,” Thomas Ehlers, DPM, wrote in Podiatry Today. “That is an adage I heard during podiatry school, my clerkships, and from various attendings throughout my training.”

But as Dr. Ehlers added, epinephrine gets a bad rap. The catchy admonition “has been proven a myth time and time again.”

So why do many clinicians believe the combination of epinephrine and lidocaine to be off-limits in surgical interventions involving the digits and other regions with low blood flow? Although medical trainees across multiple disciplines are taught to fear the practice, citing the potential for gangrene, its reputation for harm is not supported by the evidence.
 

Lack of Feeling Doesn’t Care About Your Facts

The debate surfaced anew in response to a recent column by Kenny Lin, MD, MPH, family physician and associate director of the Lancaster General Hospital Family Medicine Residency, in Lancaster, Pennsylvania, about the rather pedestrian topic of why he no longer performs surgery to correct ingrown toenails. Dr. Lin’s admission that he used to do the procedure with a combination of epinephrine and lidocaine turned into a major focus of the comments — many of them harshly critical of the practice:

“Epinephrine is not an appropriate drug to use for podiatry or use in any peripheral area. Gangrene?” one commenter posted.

“Leave epi out of lidocaine to fingers, toes, nose, and ear lobes,” another wrote.

“No lido with epi, whether or not it is contraindicated, because: If there’s any adverse outcome, a lawyer will find plenty of references saying it was contraindicated,” a reader chimed in.

Other commenters disagreed, with one saying, “Please, folks, don’t show that you trained 50 years ago and haven’t changed practice since…”

For Dr. Lin, the response was surprising given what he believes to be the lack of evidence supporting the purported dangers.

“When I think about this, it’s something that was taught to me during residency — that they should not be used on certain areas,” Dr. Lin said. “But since then, studies have been published looking at thousands of cases of people using epinephrine with lidocaine and haven’t found any cases of necrosis.”

Many doctors, like Dr. Lin, say they were cautioned against this in their training. Others don’t remember exactly where they’ve heard it but recognize the idea has a nebulous hold on practice.

Combining epinephrine with lidocaine helps make the numbing last longer, stops bleeding, and reduces the use of lidocaine required, all of which improve the chances of an effective and comfortable intervention for the patient, Dr. Lin said. The approach also reduces the use of tourniquets, which come with their own risks including nerve injury.

However, in areas with limited circulation, this vasoconstrictive effect may be more pronounced, potentially leading to complications for patients with complicating factors.

Clinicians who regularly use the combination of epinephrine and lidocaine for surgery do concede that it can pose certain hazards and considerations in areas without robust blood flow.

But the literature largely points to its safety.

In 2001, California-based plastic and reconstructive surgeon Keith Denkler, MD, published a deep dive on the topic starting in the 19th century, including a review of Index Medicus from 1880 to 1966, a computer review of the National Library of Medicine database from 1966 to 2000, and major textbooks from 1900 to 2000.

He found a total of 48 cases of digital gangrene — but most involved the use of cocaine or procaine. Of the 48 cases, 21 involved the use of epinephrine, and 17 used an unknown concentration based on manual dilution.

“Multiple other concurrent conditions (hot soaks, tight tourniquets, and infection) existed in these case reports, making it difficult to determine the exact cause of the tissue insult,” Dr. Denkler wrote.

In a 2010 retrospective review in the Journal of the American Society of Plastic Surgeons, authors examined 1111 cases involving digital and hand surgery. Of the 611 patients who received injections of 1% lidocaine with epinephrine, none experienced digital necrosis.

Another review from 2003 touted the combination’s safety, in hopes to “help dispel the myth that epinephrine has no place in podiatric anesthesia.” But authors noted limitations of use, including “known sensitivity, thyrotoxicosis, and use of either tricyclic antidepressants or monoamine oxidase inhibitors.”

James Christina, DPM, executive director and CEO of the American Podiatric Medical Association, echoed that sentiment. He said he regularly used the combination to correct bunions, hammer toes, and ingrown toenails over his 20 years of practicing but acknowledged the technique is not appropriate for all such patients.

“There’s always been caution when using epinephrine with local anesthetic,” Dr. Christina told this news organization. “You need a healthy patient with normal circulation and no other complications; someone without vascular compromise.”

Marie Hanna, MD, MEHP, chief of regional anesthesia and acute pain management at Johns Hopkins University, Baltimore, counts herself among the cautious. Citing Principles of Office Anesthesia: Part I. Infiltrative Anesthesia, Dr. Hanna said epinephrine should never be used in digital and penile blocks or in skin flaps with marginal viability.

“It is perfectly fine in certain areas, like the wrist or the arm,” Dr. Hanna said. “But specifically for use in end organs like nose, fingers, ears, toes — all of these with tenuous blood supply — it is not good practice.”

The divide among doctors comes down to theoretical concern, rather than empirical basis, said Rebecca Johnson, MD, chair of the American Society of Anesthesiologists committee on Regional Anesthesia and Acute Pain Medicine and a faculty member at Mayo Clinic, in Rochester, Minnesota.

“It’s just one of those myths we have in practice,” she said.

And legally, Dr. Johnson noted, the mere existence of a myth can be enough of a deterrent for medical practitioners: “Like anything, when you’re trying to do the right thing, if a complication would occur for another reason, you’d want to make sure a jury of your peers didn’t bring up that myth.”

The sources in this story reported no relevant financial conflicts of interest.
 

A version of this article appeared on Medscape.com.

Dupuytren contracture can be treated with three invasive methods, but new data from a randomized controlled trial show better 2-year success rates for surgery than for needle fasciotomy and collagenase injection, despite retreatments.

The common hereditary disorder affects the palmar fascia in middle-aged and older people, more often men. The disease typically affects the ring and little fingers and they may curl toward the palm. The disease can’t be cured, but can be eased.

Findings of the study, led by Mikko Petteri Räisänen, MD, with the Department of Orthopedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, and Tampere University, Tampere, both in Finland, were published online in Annals of Internal Medicine.
 

Initially, Outcomes Similar

Initially, in the multisite, randomized controlled, outcome assessor–blinded, superiority trial, the outcomes were similar among the treatments, the authors write, but at 2 years only the surgery group maintained the success rate.

The primary outcome was more than 50% contracture release and patients reaching the patient-acceptable symptom state. Secondary outcomes included hand function, pain, patient satisfaction, quality of life, finger flexion, residual contracture angle, risk for retreatment, and serious adverse events.

A total of 292 (97%) and 284 (94%) patients completed the 3-month and 2-year follow ups, respectively.

Success rates at 3 months were similar: 71% (95% CI, 62%-80%) for surgery; 73% (95% CI, 64%-82%) for needle fasciotomy; and 73% (95% CI, 64%-82%) for collagenase injection.

At 2 Years, Surgery Superior

At 2 years, however, surgery had superior success rates. Surgery success rates vs needle fasciotomy were 78% vs 50% (adjusted risk difference, 0.30; 95% CI, 0.17-0.43).

Surgery success rates vs collagenase injection were 78% vs 65% (aRD, 0.13; 95% CI, 0.01-0.26).

“Secondary analyses paralleled with the primary analysis,” the authors write.

Patients may choose surgery despite initial morbidity which includes potential time off work and higher costs than the other options if the long-term outcome is better, the authors write.

“Collagenase is likely a viable alternative to needle fasciotomy only if its costs are substantially reduced,” the authors write.

A strength of the study is its generalizability, as researchers recruited patients in a setting with universal healthcare where few people seek care outside public hospitals.

Another strength of the trial is that the blinded outcome assessors measured the contracture angles with the participant’s hand covered by a rubber glove and patients were instructed not to reveal their treatment group to the assessor.

Some Physicians Offer Noninvasive Treatments First

Family physician Shannon Scott, DO, medical director of the Midwestern University Multispecialty Clinic in Scottsdale, Arizona, treats many patients with the contracture.

In her practice, patients come to her seeking noninvasive options first. But if they are not satisfied with their hand function after noninvasive treatments such as osteopathic manipulative treatment, physical therapy, and a home exercise program, the next steps are the choices compared in the study. The findings of this randomized controlled trial, she says, will help her in counseling patients choosing among those options.

“What’s important for me as a family physician to understand is more about the path that led to this decision” to seek more invasive treatment and whether the patients in the study had first completed a course of noninvasive care, Dr. Scott says.

The condition, especially in the population most affected — older adults — can greatly affect activities of daily living, she noted. Patients may also often have other conditions contributing to the symptoms of Dupuytren contracture in the neck, arm, or shoulder, for instance, that limit range of motion or cause pain. Addressing those symptoms noninvasively may help relieve the contracture, she says.

Asking patients about their goals is essential, Dr. Scott says. “What patients are looking for is function and the definition for one patient may be different than the level of function for another. Many patients get to a desired level of function with nonsurgical options first.”

A First for the Comparison

Dawn LaPorte, MD, a hand surgeon at Johns Hopkins Medicine in Baltimore, Maryland, who also was not part of the study, says although surgery was thought to have better long-term success rates, this is the first time the data have been able to show that at 2 years.

She added that the results are particularly striking because the endpoint was a 50% release when surgeons hope for a complete release. Even with the 50% release outcome at 2 years, surgery had better success.

She noted that the authors plan to look at outcomes at 5 and 10 years, but, she says, “the fact that surgery is already significantly better at 2 years really says a lot.”

Treatments Have Tradeoffs

She says the conclusions may change the discussions physicians have with patients.

Collagenase injections are an office procedure, and there’s no anesthesia. “There’s usually no lost time from work, and they can use their hand pretty normally the following day,” Dr. LaPorte says. One downside, compared with surgery, is that there may be a more frequent recurrence rate. Patients may have a skin tear that usually heals over a couple of weeks, she added.

Additionally, “the collagenase drug is very expensive,” she notes, so preapproval is important so that the patient doesn’t have to pay out of pocket.

Needle fasciotomy can also be done in the office without anesthesia. There’s less time off work than with surgery.

“With both that and the injection, they should see release of the contracture right away,” Dr. LaPorte says, but the concern is a quicker recurrence rate.

While surgery isn’t a cure, she says, and there is a lower recurrence rate, it typically means time off work, anesthesia, and an incision to heal, and may mean postoperative therapy.

The study was funded by the Research Council of Finland. Disclosures are available with the full text.

Dr. LaPorte and Dr. Scott report no relevant financial relationships.

Dupuytren contracture can be treated with three invasive methods, but new data from a randomized controlled trial show better 2-year success rates for surgery than for needle fasciotomy and collagenase injection, despite retreatments.

The common hereditary disorder affects the palmar fascia in middle-aged and older people, more often men. The disease typically affects the ring and little fingers and they may curl toward the palm. The disease can’t be cured, but can be eased.

Findings of the study, led by Mikko Petteri Räisänen, MD, with the Department of Orthopedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, and Tampere University, Tampere, both in Finland, were published online in Annals of Internal Medicine.
 

Initially, Outcomes Similar

Initially, in the multisite, randomized controlled, outcome assessor–blinded, superiority trial, the outcomes were similar among the treatments, the authors write, but at 2 years only the surgery group maintained the success rate.

The primary outcome was more than 50% contracture release and patients reaching the patient-acceptable symptom state. Secondary outcomes included hand function, pain, patient satisfaction, quality of life, finger flexion, residual contracture angle, risk for retreatment, and serious adverse events.

A total of 292 (97%) and 284 (94%) patients completed the 3-month and 2-year follow ups, respectively.

Success rates at 3 months were similar: 71% (95% CI, 62%-80%) for surgery; 73% (95% CI, 64%-82%) for needle fasciotomy; and 73% (95% CI, 64%-82%) for collagenase injection.

At 2 Years, Surgery Superior

At 2 years, however, surgery had superior success rates. Surgery success rates vs needle fasciotomy were 78% vs 50% (adjusted risk difference, 0.30; 95% CI, 0.17-0.43).

Surgery success rates vs collagenase injection were 78% vs 65% (aRD, 0.13; 95% CI, 0.01-0.26).

“Secondary analyses paralleled with the primary analysis,” the authors write.

Patients may choose surgery despite initial morbidity which includes potential time off work and higher costs than the other options if the long-term outcome is better, the authors write.

“Collagenase is likely a viable alternative to needle fasciotomy only if its costs are substantially reduced,” the authors write.

A strength of the study is its generalizability, as researchers recruited patients in a setting with universal healthcare where few people seek care outside public hospitals.

Another strength of the trial is that the blinded outcome assessors measured the contracture angles with the participant’s hand covered by a rubber glove and patients were instructed not to reveal their treatment group to the assessor.

Some Physicians Offer Noninvasive Treatments First

Family physician Shannon Scott, DO, medical director of the Midwestern University Multispecialty Clinic in Scottsdale, Arizona, treats many patients with the contracture.

In her practice, patients come to her seeking noninvasive options first. But if they are not satisfied with their hand function after noninvasive treatments such as osteopathic manipulative treatment, physical therapy, and a home exercise program, the next steps are the choices compared in the study. The findings of this randomized controlled trial, she says, will help her in counseling patients choosing among those options.

“What’s important for me as a family physician to understand is more about the path that led to this decision” to seek more invasive treatment and whether the patients in the study had first completed a course of noninvasive care, Dr. Scott says.

The condition, especially in the population most affected — older adults — can greatly affect activities of daily living, she noted. Patients may also often have other conditions contributing to the symptoms of Dupuytren contracture in the neck, arm, or shoulder, for instance, that limit range of motion or cause pain. Addressing those symptoms noninvasively may help relieve the contracture, she says.

Asking patients about their goals is essential, Dr. Scott says. “What patients are looking for is function and the definition for one patient may be different than the level of function for another. Many patients get to a desired level of function with nonsurgical options first.”

A First for the Comparison

Dawn LaPorte, MD, a hand surgeon at Johns Hopkins Medicine in Baltimore, Maryland, who also was not part of the study, says although surgery was thought to have better long-term success rates, this is the first time the data have been able to show that at 2 years.

She added that the results are particularly striking because the endpoint was a 50% release when surgeons hope for a complete release. Even with the 50% release outcome at 2 years, surgery had better success.

She noted that the authors plan to look at outcomes at 5 and 10 years, but, she says, “the fact that surgery is already significantly better at 2 years really says a lot.”

Treatments Have Tradeoffs

She says the conclusions may change the discussions physicians have with patients.

Collagenase injections are an office procedure, and there’s no anesthesia. “There’s usually no lost time from work, and they can use their hand pretty normally the following day,” Dr. LaPorte says. One downside, compared with surgery, is that there may be a more frequent recurrence rate. Patients may have a skin tear that usually heals over a couple of weeks, she added.

Additionally, “the collagenase drug is very expensive,” she notes, so preapproval is important so that the patient doesn’t have to pay out of pocket.

Needle fasciotomy can also be done in the office without anesthesia. There’s less time off work than with surgery.

“With both that and the injection, they should see release of the contracture right away,” Dr. LaPorte says, but the concern is a quicker recurrence rate.

While surgery isn’t a cure, she says, and there is a lower recurrence rate, it typically means time off work, anesthesia, and an incision to heal, and may mean postoperative therapy.

The study was funded by the Research Council of Finland. Disclosures are available with the full text.

Dr. LaPorte and Dr. Scott report no relevant financial relationships.

Dupuytren contracture can be treated with three invasive methods, but new data from a randomized controlled trial show better 2-year success rates for surgery than for needle fasciotomy and collagenase injection, despite retreatments.

The common hereditary disorder affects the palmar fascia in middle-aged and older people, more often men. The disease typically affects the ring and little fingers and they may curl toward the palm. The disease can’t be cured, but can be eased.

Findings of the study, led by Mikko Petteri Räisänen, MD, with the Department of Orthopedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio, and Tampere University, Tampere, both in Finland, were published online in Annals of Internal Medicine.
 

Initially, Outcomes Similar

Initially, in the multisite, randomized controlled, outcome assessor–blinded, superiority trial, the outcomes were similar among the treatments, the authors write, but at 2 years only the surgery group maintained the success rate.

The primary outcome was more than 50% contracture release and patients reaching the patient-acceptable symptom state. Secondary outcomes included hand function, pain, patient satisfaction, quality of life, finger flexion, residual contracture angle, risk for retreatment, and serious adverse events.

A total of 292 (97%) and 284 (94%) patients completed the 3-month and 2-year follow ups, respectively.

Success rates at 3 months were similar: 71% (95% CI, 62%-80%) for surgery; 73% (95% CI, 64%-82%) for needle fasciotomy; and 73% (95% CI, 64%-82%) for collagenase injection.

At 2 Years, Surgery Superior

At 2 years, however, surgery had superior success rates. Surgery success rates vs needle fasciotomy were 78% vs 50% (adjusted risk difference, 0.30; 95% CI, 0.17-0.43).

Surgery success rates vs collagenase injection were 78% vs 65% (aRD, 0.13; 95% CI, 0.01-0.26).

“Secondary analyses paralleled with the primary analysis,” the authors write.

Patients may choose surgery despite initial morbidity which includes potential time off work and higher costs than the other options if the long-term outcome is better, the authors write.

“Collagenase is likely a viable alternative to needle fasciotomy only if its costs are substantially reduced,” the authors write.

A strength of the study is its generalizability, as researchers recruited patients in a setting with universal healthcare where few people seek care outside public hospitals.

Another strength of the trial is that the blinded outcome assessors measured the contracture angles with the participant’s hand covered by a rubber glove and patients were instructed not to reveal their treatment group to the assessor.

Some Physicians Offer Noninvasive Treatments First

Family physician Shannon Scott, DO, medical director of the Midwestern University Multispecialty Clinic in Scottsdale, Arizona, treats many patients with the contracture.

In her practice, patients come to her seeking noninvasive options first. But if they are not satisfied with their hand function after noninvasive treatments such as osteopathic manipulative treatment, physical therapy, and a home exercise program, the next steps are the choices compared in the study. The findings of this randomized controlled trial, she says, will help her in counseling patients choosing among those options.

“What’s important for me as a family physician to understand is more about the path that led to this decision” to seek more invasive treatment and whether the patients in the study had first completed a course of noninvasive care, Dr. Scott says.

The condition, especially in the population most affected — older adults — can greatly affect activities of daily living, she noted. Patients may also often have other conditions contributing to the symptoms of Dupuytren contracture in the neck, arm, or shoulder, for instance, that limit range of motion or cause pain. Addressing those symptoms noninvasively may help relieve the contracture, she says.

Asking patients about their goals is essential, Dr. Scott says. “What patients are looking for is function and the definition for one patient may be different than the level of function for another. Many patients get to a desired level of function with nonsurgical options first.”

A First for the Comparison

Dawn LaPorte, MD, a hand surgeon at Johns Hopkins Medicine in Baltimore, Maryland, who also was not part of the study, says although surgery was thought to have better long-term success rates, this is the first time the data have been able to show that at 2 years.

She added that the results are particularly striking because the endpoint was a 50% release when surgeons hope for a complete release. Even with the 50% release outcome at 2 years, surgery had better success.

She noted that the authors plan to look at outcomes at 5 and 10 years, but, she says, “the fact that surgery is already significantly better at 2 years really says a lot.”

Treatments Have Tradeoffs

She says the conclusions may change the discussions physicians have with patients.

Collagenase injections are an office procedure, and there’s no anesthesia. “There’s usually no lost time from work, and they can use their hand pretty normally the following day,” Dr. LaPorte says. One downside, compared with surgery, is that there may be a more frequent recurrence rate. Patients may have a skin tear that usually heals over a couple of weeks, she added.

Additionally, “the collagenase drug is very expensive,” she notes, so preapproval is important so that the patient doesn’t have to pay out of pocket.

Needle fasciotomy can also be done in the office without anesthesia. There’s less time off work than with surgery.

“With both that and the injection, they should see release of the contracture right away,” Dr. LaPorte says, but the concern is a quicker recurrence rate.

While surgery isn’t a cure, she says, and there is a lower recurrence rate, it typically means time off work, anesthesia, and an incision to heal, and may mean postoperative therapy.

The study was funded by the Research Council of Finland. Disclosures are available with the full text.

Dr. LaPorte and Dr. Scott report no relevant financial relationships.

The European Society of Cardiology guidelines on cardiovascular assessment and management of patients undergoing noncardiac surgery have seen extensive revision since the 2014 version.

They still have the same aim – to prevent surgery-related bleeding complications, perioperative myocardial infarction/injury (PMI), stent thrombosis, acute heart failure, arrhythmias, pulmonary embolism, ischemic stroke, and cardiovascular (CV) death.

Surgeons_Operating_Theater_web.jpg

Cochairpersons Sigrun Halvorsen, MD, PhD, and Julinda Mehilli, MD, presented highlights from the guidelines at the annual congress of the European Society of Cardiology and the document was simultaneously published online in the European Heart Journal.

The document classifies noncardiac surgery into three levels of 30-day risk of CV death, MI, or stroke. Low (< 1%) risk includes eye or thyroid surgery; intermediate (1%-5%) risk includes knee or hip replacement or renal transplant; and high (> 5%) risk includes aortic aneurysm, lung transplant, or pancreatic or bladder cancer surgery (see more examples below).

It classifies patients as low risk if they are younger than 65 without CV disease or CV risk factors (smoking, hypertension, diabetes, dyslipidemia, family history); intermediate risk if they are 65 or older or have CV risk factors; and high risk if they have CVD.  

In an interview, Dr. Halvorsen, professor in cardiology, University of Oslo, zeroed in on three important revisions:

First, recommendations for preoperative ECG and biomarkers are more specific, he noted.

The guidelines advise that before intermediate- or high-risk noncardiac surgery, in patients who have known CVD, CV risk factors (including age 65 or older), or symptoms suggestive of CVD:

• It is recommended to obtain a preoperative 12-lead ECG (class I).
• It is recommended to measure high-sensitivity cardiac troponin T (hs-cTn T) or high-sensitivity cardiac troponin I (hs-cTn I). It is also recommended to measure these biomarkers at 24 hours and 48 hours post surgery (class I).
• It should be considered to measure B-type natriuretic peptide or N-terminal of the prohormone BNP (NT-proBNP).

However, for low-risk patients undergoing low- and intermediate-risk noncardiac surgery, it is not recommended to routinely obtain preoperative ECG, hs-cTn T/I, or BNP/NT-proBNP concentrations (class III).

Troponins have a stronger class I recommendation, compared with the IIA recommendation for BNP, because they are useful for preoperative risk stratification and for diagnosis of PMI, Dr. Halvorsen explained. “Patients receive painkillers after surgery and may have no pain,” she noted, but they may have PMI, which has a bad prognosis.

Second, the guidelines recommend that “all patients should stop smoking 4 weeks before noncardiac surgery [class I],” she noted. Clinicians should also “measure hemoglobin, and if the patient is anemic, treat the anemia.”

Third, the sections on antithrombotic treatment have been significantly revised. “Bridging – stopping an oral antithrombotic drug and switching to a subcutaneous or IV drug – has been common,” Dr. Halvorsen said, “but recently we have new evidence that in most cases that increases the risk of bleeding.”

“We are [now] much more restrictive with respect to bridging” with unfractionated heparin or low-molecular-weight heparin, she said. “We recommend against bridging in patients with low to moderate thrombotic risk,” and bridging should only be considered in patients with mechanical prosthetic heart valves or with very high thrombotic risk.
 

More preoperative recommendations

In the guideline overview session at the congress, Dr. Halverson highlighted some of the new recommendations for preoperative risk assessment.  

If time allows, it is recommended to optimize guideline-recommended treatment of CVD and control of CV risk factors including blood pressure, dyslipidemia, and diabetes, before noncardiac surgery (class I).

Patients commonly have “murmurs, chest pain, dyspnea, and edema that may suggest severe CVD, but may also be caused by noncardiac disease,” she noted. The guidelines state that “for patients with a newly detected murmur and symptoms or signs of CVD, transthoracic echocardiography is recommended before noncardiac surgery (class I).

“Many studies have been performed to try to find out if initiation of specific drugs before surgery could reduce the risk of complications,” Dr. Halvorsen noted. However, few have shown any benefit and “the question of presurgery initiation of beta-blockers has been greatly debated,” she said. “We have again reviewed the literature and concluded ‘Routine initiation of beta-blockers perioperatively is not recommended (class IIIA).’ “

“We adhere to the guidelines on acute and chronic coronary syndrome recommending 6-12 months of dual antiplatelet treatment as a standard before elective surgery,” she said. “However, in case of time-sensitive surgery, the duration of that treatment can be shortened down to a minimum of 1 month after elective PCI and a minimum of 3 months after PCI and ACS.”
 

Patients with specific types of CVD

Dr. Mehilli, a professor at Landshut-Achdorf (Germany) Hospital, highlighted some new guideline recommendations for patients who have specific types of cardiovascular disease.

Coronary artery disease (CAD). “For chronic coronary syndrome, a cardiac workup is recommended only for patients undergoing intermediate risk or high-risk noncardiac surgery.”

“Stress imaging should be considered before any high risk, noncardiac surgery in asymptomatic patients with poor functional capacity and prior PCI or coronary artery bypass graft (new recommendation, class IIa).”

Mitral valve regurgitation. For patients undergoing scheduled noncardiac surgery, who remain symptomatic despite guideline-directed medical treatment for mitral valve regurgitation (including resynchronization and myocardial revascularization), consider a valve intervention – either transcatheter or surgical – before noncardiac surgery in eligible patients with acceptable procedural risk (new recommendation).

Cardiac implantable electronic devices (CIED). For high-risk patients with CIEDs undergoing noncardiac surgery with high probability of electromagnetic interference, a CIED checkup and necessary reprogramming immediately before the procedure should be considered (new recommendation).

Arrhythmias. “I want only to stress,” Dr. Mehilli said, “in patients with atrial fibrillation with acute or worsening hemodynamic instability undergoing noncardiac surgery, an emergency electrical cardioversion is recommended (class I).”

Peripheral artery disease (PAD) and abdominal aortic aneurysm. For these patients “we do not recommend a routine referral for a cardiac workup. But we recommend it for patients with poor functional capacity or with significant risk factors or symptoms (new recommendations).”

Chronic arterial hypertension. “We have modified the recommendation, recommending avoidance of large perioperative fluctuations in blood pressure, and we do not recommend deferring noncardiac surgery in patients with stage 1 or 2 hypertension,” she said.
 

Postoperative cardiovascular complications

The most frequent postoperative cardiovascular complication is PMI, Dr. Mehilli noted.

“In the BASEL-PMI registry, the incidence of this complication around intermediate or high-risk noncardiac surgery was up to 15% among patients older than 65 years or with a history of CAD or PAD, which makes this kind of complication really important to prevent, to assess, and to know how to treat.”

“It is recommended to have a high awareness for perioperative cardiovascular complications, combined with surveillance for PMI in patients undergoing intermediate- or high-risk noncardiac surgery” based on serial measurements of high-sensitivity cardiac troponin.

The guidelines define PMI as “an increase in the delta of high-sensitivity troponin more than the upper level of normal,” Dr. Mehilli said. “It’s different from the one used in a rule-in algorithm for non-STEMI acute coronary syndrome.”

Postoperative atrial fibrillation (AFib) is observed in 2%-30% of noncardiac surgery patients in different registries, particularly in patients undergoing intermediate or high-risk noncardiac surgery, she noted.

“We propose an algorithm on how to prevent and treat this complication. I want to highlight that in patients with hemodynamic unstable postoperative AF[ib], an emergency cardioversion is indicated. For the others, a rate control with the target heart rate of less than 110 beats per minute is indicated.”

In patients with postoperative AFib, long-term oral anticoagulation therapy should be considered in all patients at risk for stroke, considering the anticipated net clinical benefit of oral anticoagulation therapy as well as informed patient preference (new recommendations).

Routine use of beta-blockers to prevent postoperative AFib in patients undergoing noncardiac surgery is not recommended.

The document also covers the management of patients with kidney disease, diabetes, cancer, obesity, and COVID-19. In general, elective noncardiac surgery should be postponed after a patient has COVID-19, until he or she recovers completely, and coexisting conditions are optimized.

The guidelines are available from the ESC website in several formats: pocket guidelines, pocket guidelines smartphone app, guidelines slide set, essential messages, and the European Heart Journal article.
 

Noncardiac surgery risk categories

The guideline includes a table that classifies noncardiac surgeries into three groups, based on the associated 30-day risk of death, MI, or stroke:

• Low (< 1%): breast, dental, eye, thyroid, and minor gynecologic, orthopedic, and urologic surgery.
• Intermediate (1%-5%): carotid surgery, endovascular aortic aneurysm repair, gallbladder surgery, head or neck surgery, hernia repair, peripheral arterial angioplasty, renal transplant, major gynecologic, orthopedic, or neurologic (hip or spine) surgery, or urologic surgery
• High (> 5%): aortic and major vascular surgery (including aortic aneurysm), bladder removal (usually as a result of cancer), limb amputation, lung or liver transplant, pancreatic surgery, or perforated bowel repair.

The guidelines were endorsed by the European Society of Anaesthesiology and Intensive Care. The guideline authors reported numerous disclosures.

A version of this article first appeared on Medscape.com.

The European Society of Cardiology guidelines on cardiovascular assessment and management of patients undergoing noncardiac surgery have seen extensive revision since the 2014 version.

They still have the same aim – to prevent surgery-related bleeding complications, perioperative myocardial infarction/injury (PMI), stent thrombosis, acute heart failure, arrhythmias, pulmonary embolism, ischemic stroke, and cardiovascular (CV) death.

Surgeons_Operating_Theater_web.jpg

Cochairpersons Sigrun Halvorsen, MD, PhD, and Julinda Mehilli, MD, presented highlights from the guidelines at the annual congress of the European Society of Cardiology and the document was simultaneously published online in the European Heart Journal.

The document classifies noncardiac surgery into three levels of 30-day risk of CV death, MI, or stroke. Low (< 1%) risk includes eye or thyroid surgery; intermediate (1%-5%) risk includes knee or hip replacement or renal transplant; and high (> 5%) risk includes aortic aneurysm, lung transplant, or pancreatic or bladder cancer surgery (see more examples below).

It classifies patients as low risk if they are younger than 65 without CV disease or CV risk factors (smoking, hypertension, diabetes, dyslipidemia, family history); intermediate risk if they are 65 or older or have CV risk factors; and high risk if they have CVD.  

In an interview, Dr. Halvorsen, professor in cardiology, University of Oslo, zeroed in on three important revisions:

First, recommendations for preoperative ECG and biomarkers are more specific, he noted.

The guidelines advise that before intermediate- or high-risk noncardiac surgery, in patients who have known CVD, CV risk factors (including age 65 or older), or symptoms suggestive of CVD:

• It is recommended to obtain a preoperative 12-lead ECG (class I).
• It is recommended to measure high-sensitivity cardiac troponin T (hs-cTn T) or high-sensitivity cardiac troponin I (hs-cTn I). It is also recommended to measure these biomarkers at 24 hours and 48 hours post surgery (class I).
• It should be considered to measure B-type natriuretic peptide or N-terminal of the prohormone BNP (NT-proBNP).

However, for low-risk patients undergoing low- and intermediate-risk noncardiac surgery, it is not recommended to routinely obtain preoperative ECG, hs-cTn T/I, or BNP/NT-proBNP concentrations (class III).

Troponins have a stronger class I recommendation, compared with the IIA recommendation for BNP, because they are useful for preoperative risk stratification and for diagnosis of PMI, Dr. Halvorsen explained. “Patients receive painkillers after surgery and may have no pain,” she noted, but they may have PMI, which has a bad prognosis.

Second, the guidelines recommend that “all patients should stop smoking 4 weeks before noncardiac surgery [class I],” she noted. Clinicians should also “measure hemoglobin, and if the patient is anemic, treat the anemia.”

Third, the sections on antithrombotic treatment have been significantly revised. “Bridging – stopping an oral antithrombotic drug and switching to a subcutaneous or IV drug – has been common,” Dr. Halvorsen said, “but recently we have new evidence that in most cases that increases the risk of bleeding.”

“We are [now] much more restrictive with respect to bridging” with unfractionated heparin or low-molecular-weight heparin, she said. “We recommend against bridging in patients with low to moderate thrombotic risk,” and bridging should only be considered in patients with mechanical prosthetic heart valves or with very high thrombotic risk.
 

More preoperative recommendations

In the guideline overview session at the congress, Dr. Halverson highlighted some of the new recommendations for preoperative risk assessment.  

If time allows, it is recommended to optimize guideline-recommended treatment of CVD and control of CV risk factors including blood pressure, dyslipidemia, and diabetes, before noncardiac surgery (class I).

Patients commonly have “murmurs, chest pain, dyspnea, and edema that may suggest severe CVD, but may also be caused by noncardiac disease,” she noted. The guidelines state that “for patients with a newly detected murmur and symptoms or signs of CVD, transthoracic echocardiography is recommended before noncardiac surgery (class I).

“Many studies have been performed to try to find out if initiation of specific drugs before surgery could reduce the risk of complications,” Dr. Halvorsen noted. However, few have shown any benefit and “the question of presurgery initiation of beta-blockers has been greatly debated,” she said. “We have again reviewed the literature and concluded ‘Routine initiation of beta-blockers perioperatively is not recommended (class IIIA).’ “

“We adhere to the guidelines on acute and chronic coronary syndrome recommending 6-12 months of dual antiplatelet treatment as a standard before elective surgery,” she said. “However, in case of time-sensitive surgery, the duration of that treatment can be shortened down to a minimum of 1 month after elective PCI and a minimum of 3 months after PCI and ACS.”
 

Patients with specific types of CVD

Dr. Mehilli, a professor at Landshut-Achdorf (Germany) Hospital, highlighted some new guideline recommendations for patients who have specific types of cardiovascular disease.

Coronary artery disease (CAD). “For chronic coronary syndrome, a cardiac workup is recommended only for patients undergoing intermediate risk or high-risk noncardiac surgery.”

“Stress imaging should be considered before any high risk, noncardiac surgery in asymptomatic patients with poor functional capacity and prior PCI or coronary artery bypass graft (new recommendation, class IIa).”

Mitral valve regurgitation. For patients undergoing scheduled noncardiac surgery, who remain symptomatic despite guideline-directed medical treatment for mitral valve regurgitation (including resynchronization and myocardial revascularization), consider a valve intervention – either transcatheter or surgical – before noncardiac surgery in eligible patients with acceptable procedural risk (new recommendation).

Cardiac implantable electronic devices (CIED). For high-risk patients with CIEDs undergoing noncardiac surgery with high probability of electromagnetic interference, a CIED checkup and necessary reprogramming immediately before the procedure should be considered (new recommendation).

Arrhythmias. “I want only to stress,” Dr. Mehilli said, “in patients with atrial fibrillation with acute or worsening hemodynamic instability undergoing noncardiac surgery, an emergency electrical cardioversion is recommended (class I).”

Peripheral artery disease (PAD) and abdominal aortic aneurysm. For these patients “we do not recommend a routine referral for a cardiac workup. But we recommend it for patients with poor functional capacity or with significant risk factors or symptoms (new recommendations).”

Chronic arterial hypertension. “We have modified the recommendation, recommending avoidance of large perioperative fluctuations in blood pressure, and we do not recommend deferring noncardiac surgery in patients with stage 1 or 2 hypertension,” she said.
 

Postoperative cardiovascular complications

The most frequent postoperative cardiovascular complication is PMI, Dr. Mehilli noted.

“In the BASEL-PMI registry, the incidence of this complication around intermediate or high-risk noncardiac surgery was up to 15% among patients older than 65 years or with a history of CAD or PAD, which makes this kind of complication really important to prevent, to assess, and to know how to treat.”

“It is recommended to have a high awareness for perioperative cardiovascular complications, combined with surveillance for PMI in patients undergoing intermediate- or high-risk noncardiac surgery” based on serial measurements of high-sensitivity cardiac troponin.

The guidelines define PMI as “an increase in the delta of high-sensitivity troponin more than the upper level of normal,” Dr. Mehilli said. “It’s different from the one used in a rule-in algorithm for non-STEMI acute coronary syndrome.”

Postoperative atrial fibrillation (AFib) is observed in 2%-30% of noncardiac surgery patients in different registries, particularly in patients undergoing intermediate or high-risk noncardiac surgery, she noted.

“We propose an algorithm on how to prevent and treat this complication. I want to highlight that in patients with hemodynamic unstable postoperative AF[ib], an emergency cardioversion is indicated. For the others, a rate control with the target heart rate of less than 110 beats per minute is indicated.”

In patients with postoperative AFib, long-term oral anticoagulation therapy should be considered in all patients at risk for stroke, considering the anticipated net clinical benefit of oral anticoagulation therapy as well as informed patient preference (new recommendations).

Routine use of beta-blockers to prevent postoperative AFib in patients undergoing noncardiac surgery is not recommended.

The document also covers the management of patients with kidney disease, diabetes, cancer, obesity, and COVID-19. In general, elective noncardiac surgery should be postponed after a patient has COVID-19, until he or she recovers completely, and coexisting conditions are optimized.

The guidelines are available from the ESC website in several formats: pocket guidelines, pocket guidelines smartphone app, guidelines slide set, essential messages, and the European Heart Journal article.
 

Noncardiac surgery risk categories

The guideline includes a table that classifies noncardiac surgeries into three groups, based on the associated 30-day risk of death, MI, or stroke:

• Low (< 1%): breast, dental, eye, thyroid, and minor gynecologic, orthopedic, and urologic surgery.
• Intermediate (1%-5%): carotid surgery, endovascular aortic aneurysm repair, gallbladder surgery, head or neck surgery, hernia repair, peripheral arterial angioplasty, renal transplant, major gynecologic, orthopedic, or neurologic (hip or spine) surgery, or urologic surgery
• High (> 5%): aortic and major vascular surgery (including aortic aneurysm), bladder removal (usually as a result of cancer), limb amputation, lung or liver transplant, pancreatic surgery, or perforated bowel repair.

The guidelines were endorsed by the European Society of Anaesthesiology and Intensive Care. The guideline authors reported numerous disclosures.

A version of this article first appeared on Medscape.com.

The European Society of Cardiology guidelines on cardiovascular assessment and management of patients undergoing noncardiac surgery have seen extensive revision since the 2014 version.

They still have the same aim – to prevent surgery-related bleeding complications, perioperative myocardial infarction/injury (PMI), stent thrombosis, acute heart failure, arrhythmias, pulmonary embolism, ischemic stroke, and cardiovascular (CV) death.

Surgeons_Operating_Theater_web.jpg

Cochairpersons Sigrun Halvorsen, MD, PhD, and Julinda Mehilli, MD, presented highlights from the guidelines at the annual congress of the European Society of Cardiology and the document was simultaneously published online in the European Heart Journal.

The document classifies noncardiac surgery into three levels of 30-day risk of CV death, MI, or stroke. Low (< 1%) risk includes eye or thyroid surgery; intermediate (1%-5%) risk includes knee or hip replacement or renal transplant; and high (> 5%) risk includes aortic aneurysm, lung transplant, or pancreatic or bladder cancer surgery (see more examples below).

It classifies patients as low risk if they are younger than 65 without CV disease or CV risk factors (smoking, hypertension, diabetes, dyslipidemia, family history); intermediate risk if they are 65 or older or have CV risk factors; and high risk if they have CVD.  

In an interview, Dr. Halvorsen, professor in cardiology, University of Oslo, zeroed in on three important revisions:

First, recommendations for preoperative ECG and biomarkers are more specific, he noted.

The guidelines advise that before intermediate- or high-risk noncardiac surgery, in patients who have known CVD, CV risk factors (including age 65 or older), or symptoms suggestive of CVD:

• It is recommended to obtain a preoperative 12-lead ECG (class I).
• It is recommended to measure high-sensitivity cardiac troponin T (hs-cTn T) or high-sensitivity cardiac troponin I (hs-cTn I). It is also recommended to measure these biomarkers at 24 hours and 48 hours post surgery (class I).
• It should be considered to measure B-type natriuretic peptide or N-terminal of the prohormone BNP (NT-proBNP).

However, for low-risk patients undergoing low- and intermediate-risk noncardiac surgery, it is not recommended to routinely obtain preoperative ECG, hs-cTn T/I, or BNP/NT-proBNP concentrations (class III).

Troponins have a stronger class I recommendation, compared with the IIA recommendation for BNP, because they are useful for preoperative risk stratification and for diagnosis of PMI, Dr. Halvorsen explained. “Patients receive painkillers after surgery and may have no pain,” she noted, but they may have PMI, which has a bad prognosis.

Second, the guidelines recommend that “all patients should stop smoking 4 weeks before noncardiac surgery [class I],” she noted. Clinicians should also “measure hemoglobin, and if the patient is anemic, treat the anemia.”

Third, the sections on antithrombotic treatment have been significantly revised. “Bridging – stopping an oral antithrombotic drug and switching to a subcutaneous or IV drug – has been common,” Dr. Halvorsen said, “but recently we have new evidence that in most cases that increases the risk of bleeding.”

“We are [now] much more restrictive with respect to bridging” with unfractionated heparin or low-molecular-weight heparin, she said. “We recommend against bridging in patients with low to moderate thrombotic risk,” and bridging should only be considered in patients with mechanical prosthetic heart valves or with very high thrombotic risk.
 

More preoperative recommendations

In the guideline overview session at the congress, Dr. Halverson highlighted some of the new recommendations for preoperative risk assessment.  

If time allows, it is recommended to optimize guideline-recommended treatment of CVD and control of CV risk factors including blood pressure, dyslipidemia, and diabetes, before noncardiac surgery (class I).

Patients commonly have “murmurs, chest pain, dyspnea, and edema that may suggest severe CVD, but may also be caused by noncardiac disease,” she noted. The guidelines state that “for patients with a newly detected murmur and symptoms or signs of CVD, transthoracic echocardiography is recommended before noncardiac surgery (class I).

“Many studies have been performed to try to find out if initiation of specific drugs before surgery could reduce the risk of complications,” Dr. Halvorsen noted. However, few have shown any benefit and “the question of presurgery initiation of beta-blockers has been greatly debated,” she said. “We have again reviewed the literature and concluded ‘Routine initiation of beta-blockers perioperatively is not recommended (class IIIA).’ “

“We adhere to the guidelines on acute and chronic coronary syndrome recommending 6-12 months of dual antiplatelet treatment as a standard before elective surgery,” she said. “However, in case of time-sensitive surgery, the duration of that treatment can be shortened down to a minimum of 1 month after elective PCI and a minimum of 3 months after PCI and ACS.”
 

Patients with specific types of CVD

Dr. Mehilli, a professor at Landshut-Achdorf (Germany) Hospital, highlighted some new guideline recommendations for patients who have specific types of cardiovascular disease.

Coronary artery disease (CAD). “For chronic coronary syndrome, a cardiac workup is recommended only for patients undergoing intermediate risk or high-risk noncardiac surgery.”

“Stress imaging should be considered before any high risk, noncardiac surgery in asymptomatic patients with poor functional capacity and prior PCI or coronary artery bypass graft (new recommendation, class IIa).”

Mitral valve regurgitation. For patients undergoing scheduled noncardiac surgery, who remain symptomatic despite guideline-directed medical treatment for mitral valve regurgitation (including resynchronization and myocardial revascularization), consider a valve intervention – either transcatheter or surgical – before noncardiac surgery in eligible patients with acceptable procedural risk (new recommendation).

Cardiac implantable electronic devices (CIED). For high-risk patients with CIEDs undergoing noncardiac surgery with high probability of electromagnetic interference, a CIED checkup and necessary reprogramming immediately before the procedure should be considered (new recommendation).

Arrhythmias. “I want only to stress,” Dr. Mehilli said, “in patients with atrial fibrillation with acute or worsening hemodynamic instability undergoing noncardiac surgery, an emergency electrical cardioversion is recommended (class I).”

Peripheral artery disease (PAD) and abdominal aortic aneurysm. For these patients “we do not recommend a routine referral for a cardiac workup. But we recommend it for patients with poor functional capacity or with significant risk factors or symptoms (new recommendations).”

Chronic arterial hypertension. “We have modified the recommendation, recommending avoidance of large perioperative fluctuations in blood pressure, and we do not recommend deferring noncardiac surgery in patients with stage 1 or 2 hypertension,” she said.
 

Postoperative cardiovascular complications

The most frequent postoperative cardiovascular complication is PMI, Dr. Mehilli noted.

“In the BASEL-PMI registry, the incidence of this complication around intermediate or high-risk noncardiac surgery was up to 15% among patients older than 65 years or with a history of CAD or PAD, which makes this kind of complication really important to prevent, to assess, and to know how to treat.”

“It is recommended to have a high awareness for perioperative cardiovascular complications, combined with surveillance for PMI in patients undergoing intermediate- or high-risk noncardiac surgery” based on serial measurements of high-sensitivity cardiac troponin.

The guidelines define PMI as “an increase in the delta of high-sensitivity troponin more than the upper level of normal,” Dr. Mehilli said. “It’s different from the one used in a rule-in algorithm for non-STEMI acute coronary syndrome.”

Postoperative atrial fibrillation (AFib) is observed in 2%-30% of noncardiac surgery patients in different registries, particularly in patients undergoing intermediate or high-risk noncardiac surgery, she noted.

“We propose an algorithm on how to prevent and treat this complication. I want to highlight that in patients with hemodynamic unstable postoperative AF[ib], an emergency cardioversion is indicated. For the others, a rate control with the target heart rate of less than 110 beats per minute is indicated.”

In patients with postoperative AFib, long-term oral anticoagulation therapy should be considered in all patients at risk for stroke, considering the anticipated net clinical benefit of oral anticoagulation therapy as well as informed patient preference (new recommendations).

Routine use of beta-blockers to prevent postoperative AFib in patients undergoing noncardiac surgery is not recommended.

The document also covers the management of patients with kidney disease, diabetes, cancer, obesity, and COVID-19. In general, elective noncardiac surgery should be postponed after a patient has COVID-19, until he or she recovers completely, and coexisting conditions are optimized.

The guidelines are available from the ESC website in several formats: pocket guidelines, pocket guidelines smartphone app, guidelines slide set, essential messages, and the European Heart Journal article.
 

Noncardiac surgery risk categories

The guideline includes a table that classifies noncardiac surgeries into three groups, based on the associated 30-day risk of death, MI, or stroke:

• Low (< 1%): breast, dental, eye, thyroid, and minor gynecologic, orthopedic, and urologic surgery.
• Intermediate (1%-5%): carotid surgery, endovascular aortic aneurysm repair, gallbladder surgery, head or neck surgery, hernia repair, peripheral arterial angioplasty, renal transplant, major gynecologic, orthopedic, or neurologic (hip or spine) surgery, or urologic surgery
• High (> 5%): aortic and major vascular surgery (including aortic aneurysm), bladder removal (usually as a result of cancer), limb amputation, lung or liver transplant, pancreatic surgery, or perforated bowel repair.

The guidelines were endorsed by the European Society of Anaesthesiology and Intensive Care. The guideline authors reported numerous disclosures.

A version of this article first appeared on Medscape.com.

Practice has gone back and forth on whether atrial fibrillation (AFib) should be considered in the preoperative cardiovascular risk (CV) evaluation of patients slated for noncardiac surgery, and the Revised Cardiac Risk Index (RCRI), currently widely used as an assessment tool, doesn’t include the arrhythmia.

But consideration of preexisting AFib along with the RCRI predicted 30-day mortality more sharply than the RCRI alone in an analysis of data covering several million patients slated for such procedures.

ECG_Electrocardiogram_web.jpg

• 1.31 (95% CI, 1.30-1.33) for heart failure
• 1.40 (95% CI, 1.37-1.43) for stroke
• 1.59 (95% CI, 1.43-1.75) for systemic embolism
• 1.14 (95% CI, 1.13-1.16) for major bleeding  
• 0.81 (95% CI, 0.79-0.82) for MI

Those with preexisting AFib also had longer hospitalizations at a median 5 days, compared with 4 days for those without such AFib (P < .001).

The study has the limitations of most any retrospective cohort analysis. Other limitations, the report notes, include lack of information on any antiarrhythmic meds given during hospitalization or type of AFib.

For example, AFib that is permanent – compared with paroxysmal or persistent – may be associated with more atrial fibrosis, greater atrial dilatation, “and probably higher pressures inside the heart,” Dr. Mentias observed.

“That’s not always the case, but that’s the notion. So presumably people with persistent or permanent atrial fib would have more advanced heart disease, and that could imply more risk. But we did not have that kind of data.”

Dr. Mentias and Dr. Prasada report no relevant financial relationships; disclosures for the other authors are in the report. Dr. Curtis discloses serving on advisory boards for Abbott, Janssen Pharmaceuticals, Sanofi, and Milestone Pharmaceuticals; receiving honoraria for speaking from Medtronic and Zoll; and serving on a data-monitoring board for Medtronic. Dr. Korada reports he has no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Practice has gone back and forth on whether atrial fibrillation (AFib) should be considered in the preoperative cardiovascular risk (CV) evaluation of patients slated for noncardiac surgery, and the Revised Cardiac Risk Index (RCRI), currently widely used as an assessment tool, doesn’t include the arrhythmia.

But consideration of preexisting AFib along with the RCRI predicted 30-day mortality more sharply than the RCRI alone in an analysis of data covering several million patients slated for such procedures.

ECG_Electrocardiogram_web.jpg

• 1.31 (95% CI, 1.30-1.33) for heart failure
• 1.40 (95% CI, 1.37-1.43) for stroke
• 1.59 (95% CI, 1.43-1.75) for systemic embolism
• 1.14 (95% CI, 1.13-1.16) for major bleeding  
• 0.81 (95% CI, 0.79-0.82) for MI

Those with preexisting AFib also had longer hospitalizations at a median 5 days, compared with 4 days for those without such AFib (P < .001).

The study has the limitations of most any retrospective cohort analysis. Other limitations, the report notes, include lack of information on any antiarrhythmic meds given during hospitalization or type of AFib.

For example, AFib that is permanent – compared with paroxysmal or persistent – may be associated with more atrial fibrosis, greater atrial dilatation, “and probably higher pressures inside the heart,” Dr. Mentias observed.

“That’s not always the case, but that’s the notion. So presumably people with persistent or permanent atrial fib would have more advanced heart disease, and that could imply more risk. But we did not have that kind of data.”

Dr. Mentias and Dr. Prasada report no relevant financial relationships; disclosures for the other authors are in the report. Dr. Curtis discloses serving on advisory boards for Abbott, Janssen Pharmaceuticals, Sanofi, and Milestone Pharmaceuticals; receiving honoraria for speaking from Medtronic and Zoll; and serving on a data-monitoring board for Medtronic. Dr. Korada reports he has no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Practice has gone back and forth on whether atrial fibrillation (AFib) should be considered in the preoperative cardiovascular risk (CV) evaluation of patients slated for noncardiac surgery, and the Revised Cardiac Risk Index (RCRI), currently widely used as an assessment tool, doesn’t include the arrhythmia.

But consideration of preexisting AFib along with the RCRI predicted 30-day mortality more sharply than the RCRI alone in an analysis of data covering several million patients slated for such procedures.

ECG_Electrocardiogram_web.jpg

• 1.31 (95% CI, 1.30-1.33) for heart failure
• 1.40 (95% CI, 1.37-1.43) for stroke
• 1.59 (95% CI, 1.43-1.75) for systemic embolism
• 1.14 (95% CI, 1.13-1.16) for major bleeding  
• 0.81 (95% CI, 0.79-0.82) for MI

Those with preexisting AFib also had longer hospitalizations at a median 5 days, compared with 4 days for those without such AFib (P < .001).

The study has the limitations of most any retrospective cohort analysis. Other limitations, the report notes, include lack of information on any antiarrhythmic meds given during hospitalization or type of AFib.

For example, AFib that is permanent – compared with paroxysmal or persistent – may be associated with more atrial fibrosis, greater atrial dilatation, “and probably higher pressures inside the heart,” Dr. Mentias observed.

“That’s not always the case, but that’s the notion. So presumably people with persistent or permanent atrial fib would have more advanced heart disease, and that could imply more risk. But we did not have that kind of data.”

Dr. Mentias and Dr. Prasada report no relevant financial relationships; disclosures for the other authors are in the report. Dr. Curtis discloses serving on advisory boards for Abbott, Janssen Pharmaceuticals, Sanofi, and Milestone Pharmaceuticals; receiving honoraria for speaking from Medtronic and Zoll; and serving on a data-monitoring board for Medtronic. Dr. Korada reports he has no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In a multicenter, randomized trial in the United Kingdom, fixing wrist fracture with Kirschner wires (K-wires) did not improve patient outcomes at 1 year when compared with well-molded casting without surgery.

There are around 100,000 adult distal radius fractures in the United Kingdom each year. Current National Health Service guidelines in the United Kingdom recommend using K-wires to stabilize wrist fractures when closed reduction is possible or there is no involvement of the articular surface. This is in contrast to fractures that require open reduction and internal fixation with a plate and screws to align the joint articular surface.

As a result, the use of K-wires for surgical fixation has been increasing since 2010 with a comparable decrease of the use of plates and screws.

Even though fixation with wires can provide reliable functional outcomes for patients after reduction of a displaced wrist fracture, surgery still carries risks for the patient and adds an additional expense. A well-molded plaster cast is a safer and cheaper intervention, but it is unclear if it could provide the same functional outcome as pinning.

Therefore, researchers in the United Kingdom conducted a multicenter, randomized trial among 36 hospitals within the NHS as part of the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2). Investigators randomly assigned 500 patients aged 16 years and older with dorsally displaced distal radius fractures to manipulation followed by a molded cast or manipulation followed by surgical fixation with K-wires plus a cast.

The study was published online in BMJ.

At 1 year, there were no significant differences between the groups in Patient-Rated Wrist Evaluation (PRWE) scores centered on pain and function.

In an interview, Matthew Costa, PhD, professor of orthopaedic trauma at the University of Oxford (England) and the study’s lead author, said, “If a closed reduction of the fracture can be achieved, clinicians may consider the application of a molded plaster cast as a safe and cost-effective alternative to surgical fixation.”

However, in referencing the data his group published, he did find one thing surprising: “One in eight patients treated with a molded cast required later surgery for loss of fracture position in the first 6 weeks after their injury.”

Dr. Costa added, “This was indeed the key bit of information that patients need when making their decision about surgery. Initial feedback from our patient and public involvement group is that they would be happy to take this chance given that seven out of eight patients didn’t need any form of surgical fixation.”

Philip Blazar, MD, chief of the hand and upper extremity service, Brigham and Women’s Faulkner Hospital in Boston, commended the U.K. authors on completing a challenging randomized controlled trial.

Speaking to this news organization, Dr. Blazer observed a critical difference between U.K. and U.S. guidelines. “It is important to remember that a sizable number of these patients had surgery,” said Dr. Blazar, who was not involved with the study. “They had pins inserted under an anesthetic, and would not have [had] surgery compared to current practice as recommended by many authorities, including the American Academy of Orthopedic Surgeon’s Clinical Practice Guidelines on Distal Radius Fractures.”

Like Dr. Costa, Dr. Blazar expressed concerns about the secondary surgeries in the study group: “27% of patients had a second surgery: 13% in the first 6 weeks after manipulation for loss of reduction, and the remaining 14% had carpal tunnel releases, tendon transfers, tenolysis, and/or capsulectomy for limited range of motion.”

In addition, Dr. Blazar is worried that, although recovery is generally considered to be only 12 months for these type of injuries – the duration of follow-up time in the DRAFFT2 study – “the probable outcome is that in the second 12 months after the injury, there will continue to be more of these types of surgeries.”

Dr. Costa agreed that close follow-up is warranted, “It does suggest that patients treated in a molded cast do need to be followed up carefully to spot those that do need later surgery.”

Still, for Dr. Blazar, the largest takeaway of the study is that, “At 12 months, disability scores between these two groups are not different, but the group treated nonsurgically had 10 times the number of secondary surgeries (27% vs. 2%-3%).”

Moving forward, Dr. Blazar would like to see more specific indications for who would benefit from pinning. He told this news organization, “The greatest limitation is that this study provides no information on which patients with distal radius fractures where reduction is indicated would benefit from surgery. Looking at the details of this study, all patients with displaced fractures from age 16 to the elderly were treated as one indication. My impression is that most surgeons operate on patients taking into account radiographic and patient factors such as age, hand dominance, occupation, overall medical health, and activity level.”

The DRAFFT2 study was funded by the U.K. National Institute for Health Research Health Technology Assessment Programme and was supported by NIHR Oxford Biomedical Research Centre. Dr. Blazar and Dr. Costa have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In a multicenter, randomized trial in the United Kingdom, fixing wrist fracture with Kirschner wires (K-wires) did not improve patient outcomes at 1 year when compared with well-molded casting without surgery.

There are around 100,000 adult distal radius fractures in the United Kingdom each year. Current National Health Service guidelines in the United Kingdom recommend using K-wires to stabilize wrist fractures when closed reduction is possible or there is no involvement of the articular surface. This is in contrast to fractures that require open reduction and internal fixation with a plate and screws to align the joint articular surface.

As a result, the use of K-wires for surgical fixation has been increasing since 2010 with a comparable decrease of the use of plates and screws.

Even though fixation with wires can provide reliable functional outcomes for patients after reduction of a displaced wrist fracture, surgery still carries risks for the patient and adds an additional expense. A well-molded plaster cast is a safer and cheaper intervention, but it is unclear if it could provide the same functional outcome as pinning.

Therefore, researchers in the United Kingdom conducted a multicenter, randomized trial among 36 hospitals within the NHS as part of the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2). Investigators randomly assigned 500 patients aged 16 years and older with dorsally displaced distal radius fractures to manipulation followed by a molded cast or manipulation followed by surgical fixation with K-wires plus a cast.

The study was published online in BMJ.

At 1 year, there were no significant differences between the groups in Patient-Rated Wrist Evaluation (PRWE) scores centered on pain and function.

In an interview, Matthew Costa, PhD, professor of orthopaedic trauma at the University of Oxford (England) and the study’s lead author, said, “If a closed reduction of the fracture can be achieved, clinicians may consider the application of a molded plaster cast as a safe and cost-effective alternative to surgical fixation.”

However, in referencing the data his group published, he did find one thing surprising: “One in eight patients treated with a molded cast required later surgery for loss of fracture position in the first 6 weeks after their injury.”

Dr. Costa added, “This was indeed the key bit of information that patients need when making their decision about surgery. Initial feedback from our patient and public involvement group is that they would be happy to take this chance given that seven out of eight patients didn’t need any form of surgical fixation.”

Philip Blazar, MD, chief of the hand and upper extremity service, Brigham and Women’s Faulkner Hospital in Boston, commended the U.K. authors on completing a challenging randomized controlled trial.

Speaking to this news organization, Dr. Blazer observed a critical difference between U.K. and U.S. guidelines. “It is important to remember that a sizable number of these patients had surgery,” said Dr. Blazar, who was not involved with the study. “They had pins inserted under an anesthetic, and would not have [had] surgery compared to current practice as recommended by many authorities, including the American Academy of Orthopedic Surgeon’s Clinical Practice Guidelines on Distal Radius Fractures.”

Like Dr. Costa, Dr. Blazar expressed concerns about the secondary surgeries in the study group: “27% of patients had a second surgery: 13% in the first 6 weeks after manipulation for loss of reduction, and the remaining 14% had carpal tunnel releases, tendon transfers, tenolysis, and/or capsulectomy for limited range of motion.”

In addition, Dr. Blazar is worried that, although recovery is generally considered to be only 12 months for these type of injuries – the duration of follow-up time in the DRAFFT2 study – “the probable outcome is that in the second 12 months after the injury, there will continue to be more of these types of surgeries.”

Dr. Costa agreed that close follow-up is warranted, “It does suggest that patients treated in a molded cast do need to be followed up carefully to spot those that do need later surgery.”

Still, for Dr. Blazar, the largest takeaway of the study is that, “At 12 months, disability scores between these two groups are not different, but the group treated nonsurgically had 10 times the number of secondary surgeries (27% vs. 2%-3%).”

Moving forward, Dr. Blazar would like to see more specific indications for who would benefit from pinning. He told this news organization, “The greatest limitation is that this study provides no information on which patients with distal radius fractures where reduction is indicated would benefit from surgery. Looking at the details of this study, all patients with displaced fractures from age 16 to the elderly were treated as one indication. My impression is that most surgeons operate on patients taking into account radiographic and patient factors such as age, hand dominance, occupation, overall medical health, and activity level.”

The DRAFFT2 study was funded by the U.K. National Institute for Health Research Health Technology Assessment Programme and was supported by NIHR Oxford Biomedical Research Centre. Dr. Blazar and Dr. Costa have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In a multicenter, randomized trial in the United Kingdom, fixing wrist fracture with Kirschner wires (K-wires) did not improve patient outcomes at 1 year when compared with well-molded casting without surgery.

There are around 100,000 adult distal radius fractures in the United Kingdom each year. Current National Health Service guidelines in the United Kingdom recommend using K-wires to stabilize wrist fractures when closed reduction is possible or there is no involvement of the articular surface. This is in contrast to fractures that require open reduction and internal fixation with a plate and screws to align the joint articular surface.

As a result, the use of K-wires for surgical fixation has been increasing since 2010 with a comparable decrease of the use of plates and screws.

Even though fixation with wires can provide reliable functional outcomes for patients after reduction of a displaced wrist fracture, surgery still carries risks for the patient and adds an additional expense. A well-molded plaster cast is a safer and cheaper intervention, but it is unclear if it could provide the same functional outcome as pinning.

Therefore, researchers in the United Kingdom conducted a multicenter, randomized trial among 36 hospitals within the NHS as part of the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2). Investigators randomly assigned 500 patients aged 16 years and older with dorsally displaced distal radius fractures to manipulation followed by a molded cast or manipulation followed by surgical fixation with K-wires plus a cast.

The study was published online in BMJ.

At 1 year, there were no significant differences between the groups in Patient-Rated Wrist Evaluation (PRWE) scores centered on pain and function.

In an interview, Matthew Costa, PhD, professor of orthopaedic trauma at the University of Oxford (England) and the study’s lead author, said, “If a closed reduction of the fracture can be achieved, clinicians may consider the application of a molded plaster cast as a safe and cost-effective alternative to surgical fixation.”

However, in referencing the data his group published, he did find one thing surprising: “One in eight patients treated with a molded cast required later surgery for loss of fracture position in the first 6 weeks after their injury.”

Dr. Costa added, “This was indeed the key bit of information that patients need when making their decision about surgery. Initial feedback from our patient and public involvement group is that they would be happy to take this chance given that seven out of eight patients didn’t need any form of surgical fixation.”

Philip Blazar, MD, chief of the hand and upper extremity service, Brigham and Women’s Faulkner Hospital in Boston, commended the U.K. authors on completing a challenging randomized controlled trial.

Speaking to this news organization, Dr. Blazer observed a critical difference between U.K. and U.S. guidelines. “It is important to remember that a sizable number of these patients had surgery,” said Dr. Blazar, who was not involved with the study. “They had pins inserted under an anesthetic, and would not have [had] surgery compared to current practice as recommended by many authorities, including the American Academy of Orthopedic Surgeon’s Clinical Practice Guidelines on Distal Radius Fractures.”

Like Dr. Costa, Dr. Blazar expressed concerns about the secondary surgeries in the study group: “27% of patients had a second surgery: 13% in the first 6 weeks after manipulation for loss of reduction, and the remaining 14% had carpal tunnel releases, tendon transfers, tenolysis, and/or capsulectomy for limited range of motion.”

In addition, Dr. Blazar is worried that, although recovery is generally considered to be only 12 months for these type of injuries – the duration of follow-up time in the DRAFFT2 study – “the probable outcome is that in the second 12 months after the injury, there will continue to be more of these types of surgeries.”

Dr. Costa agreed that close follow-up is warranted, “It does suggest that patients treated in a molded cast do need to be followed up carefully to spot those that do need later surgery.”

Still, for Dr. Blazar, the largest takeaway of the study is that, “At 12 months, disability scores between these two groups are not different, but the group treated nonsurgically had 10 times the number of secondary surgeries (27% vs. 2%-3%).”

Moving forward, Dr. Blazar would like to see more specific indications for who would benefit from pinning. He told this news organization, “The greatest limitation is that this study provides no information on which patients with distal radius fractures where reduction is indicated would benefit from surgery. Looking at the details of this study, all patients with displaced fractures from age 16 to the elderly were treated as one indication. My impression is that most surgeons operate on patients taking into account radiographic and patient factors such as age, hand dominance, occupation, overall medical health, and activity level.”

The DRAFFT2 study was funded by the U.K. National Institute for Health Research Health Technology Assessment Programme and was supported by NIHR Oxford Biomedical Research Centre. Dr. Blazar and Dr. Costa have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A simple tool to guide choice of antithrombotic therapy following total joint arthroplasty led to a reduction in pulmonary embolism (PE) after being introduced systemwide, according to a prospectively tracked evaluation of a large patient cohort. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.

“We developed a simplified scoring system for evaluating risk of thromboembolism and guiding prophylaxis that led to a significant reduction in events across a large integrated health care system,” reported James Wylie, MD, associate medical director for hip and knee preservation and orthopedic research at Intermountain Healthcare, Salt Lake City, Utah.

The goal of the methodology was to create a uniform and evidence-based approach to risk assessment in order to guide selection of appropriate venous thromboembolism (VTE) prophylaxis. The tool takes into account the need to individualize antithrombotic drugs for risk of both VTE and for bleeding.

“VTE is a major threat following total joint replacement, but not all patients require anticoagulants. Recent evidence supports a shift to aspirin for low-risk patients,” explained Dr. Wylie in an interview.

The risk tool assigns points for such factors as history of VTE, older age, history of coronary artery disease, history of cancer, and increased body mass index. There are two possible ratings to guide strategies. Those with standard risk are candidates for 81 mg of aspirin twice daily. Those with high risk are candidates for 2.5 mg of apixaban, also administered twice daily. Custom dosing of warfarin is an alternative for the latter group. Regardless of strategy, prophylaxis is administered for 30 days following arthroplasty

“The risk score is calculated automatically, because you have to click a box in the electronic medical record for all of those factors as part of admission orders,” Dr. Wylie said.

The protocol was introduced in July 2017 and adoption was tracked prospectively over 18 months. In an evaluable cohort of 20,284 patients, PE rates in the 71% of patients adherent to the protocol were compared with the 29% who were not.

Over the observation period, the rates of PE were 0.34% and 0.62% (P = .004) for those adherent and nonadherent, respectively. The rate of unplanned readmissions and death, which were secondary outcomes, were both numerically lower in the group treated by adherent surgeons, but the differences did not reach statistical significance.

Adoption of the protocol by surgeons did increase over the course of the observation period, and this correlated with a decrease in unplanned readmissions. Bleeding-related readmission was a rare event in this analysis and did not significantly increase over time, according to Dr. Wylie.

The risk assessment tool, developed by a multispecialty team at Intermountain Healthcare, was based on a review of hundreds of published papers and guidelines, according to Nathan Momberger, MD, who is the associate medical director of total joint replacement at Intermountain and was a coauthor on this study. A member of the team that developed the risk assessment tool, Dr. Momberger noted that new risk score was developed at a time when clinicians have been moving quickly away from warfarin to direct oral anticoagulants.

“None of our surgeons were using the same VTE prophylaxis when we started this project,” Dr. Momberger said. This was a motivation for developing a systemwide approach. In the 22 participating hospitals, there were 50 surgeons performing total knee arthroplasty and 40 surgeons were performing total hip surgery at the time the new protocol was introduced.

Further analyses will provide a more detailed analysis of the effect of the protocol on other thrombotic events, including deep vein thrombosis, and on cost. Since these data were analyzed, protocol adoption has increased and now exceeds 80%, according to Dr. Wylie.

Although a standardized approach to VTE prophylaxis following total joint arthroplasty is attractive, the ideal strategy remains controversial, according to Sunny Parikh, MD, an orthopedic surgeon affiliated with Colchester (England) General Hospital.

As a coauthor of a recent study that quantified symptomatic VTE rates at his and a neighboring hospital over a 3-year period (BMC Musculoskelet Disord. 2020;21:95), Dr. Parikh reported that VTE rates did not reach zero even with a prolonged course of the low-molecular-weight heparin enoxaparin.

At 90 days, the symptomatic VTE rate was only 0.3% for total knee arthroplasty but reached 1.2% for total hip arthroplasty.

“At the time of this study we were using enoxaparin for 28 days following total hip replacements and for 14 days following total knee replacements,” Dr. Parikh reported. Since this study, his institution has switched to a regimen recommended by the U.K.’s National Institute for Health and Clinical Excellence (NICE).

Under the NICE guidelines, VTE prophylaxis for total hip arthroplasty is 40 mg enoxaparin once daily for 14 days followed by 75 mg aspirin for another 14 days, according to Dr. Parikh. For total knee arthroplasty, the standard regimen is 75 mg aspirin for 14 days.

For those who might not be best managed with the standard approach, “there is no clear guideline.” Rather, in patients with renal or liver impairment, “we discuss the case with the hematology team to adjust the doses,” Dr. Parikh reported.

The advantage of a standardized approach applied to all or most patients is that is eliminates disparities, but Dr. Parikh agreed that risk-adjusted prophylaxis might be warranted for optimal outcomes.

Dr. Wylie reported a financial relationship with Arthrex.
 

A simple tool to guide choice of antithrombotic therapy following total joint arthroplasty led to a reduction in pulmonary embolism (PE) after being introduced systemwide, according to a prospectively tracked evaluation of a large patient cohort. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.

“We developed a simplified scoring system for evaluating risk of thromboembolism and guiding prophylaxis that led to a significant reduction in events across a large integrated health care system,” reported James Wylie, MD, associate medical director for hip and knee preservation and orthopedic research at Intermountain Healthcare, Salt Lake City, Utah.

The goal of the methodology was to create a uniform and evidence-based approach to risk assessment in order to guide selection of appropriate venous thromboembolism (VTE) prophylaxis. The tool takes into account the need to individualize antithrombotic drugs for risk of both VTE and for bleeding.

“VTE is a major threat following total joint replacement, but not all patients require anticoagulants. Recent evidence supports a shift to aspirin for low-risk patients,” explained Dr. Wylie in an interview.

The risk tool assigns points for such factors as history of VTE, older age, history of coronary artery disease, history of cancer, and increased body mass index. There are two possible ratings to guide strategies. Those with standard risk are candidates for 81 mg of aspirin twice daily. Those with high risk are candidates for 2.5 mg of apixaban, also administered twice daily. Custom dosing of warfarin is an alternative for the latter group. Regardless of strategy, prophylaxis is administered for 30 days following arthroplasty

“The risk score is calculated automatically, because you have to click a box in the electronic medical record for all of those factors as part of admission orders,” Dr. Wylie said.

The protocol was introduced in July 2017 and adoption was tracked prospectively over 18 months. In an evaluable cohort of 20,284 patients, PE rates in the 71% of patients adherent to the protocol were compared with the 29% who were not.

Over the observation period, the rates of PE were 0.34% and 0.62% (P = .004) for those adherent and nonadherent, respectively. The rate of unplanned readmissions and death, which were secondary outcomes, were both numerically lower in the group treated by adherent surgeons, but the differences did not reach statistical significance.

Adoption of the protocol by surgeons did increase over the course of the observation period, and this correlated with a decrease in unplanned readmissions. Bleeding-related readmission was a rare event in this analysis and did not significantly increase over time, according to Dr. Wylie.

The risk assessment tool, developed by a multispecialty team at Intermountain Healthcare, was based on a review of hundreds of published papers and guidelines, according to Nathan Momberger, MD, who is the associate medical director of total joint replacement at Intermountain and was a coauthor on this study. A member of the team that developed the risk assessment tool, Dr. Momberger noted that new risk score was developed at a time when clinicians have been moving quickly away from warfarin to direct oral anticoagulants.

“None of our surgeons were using the same VTE prophylaxis when we started this project,” Dr. Momberger said. This was a motivation for developing a systemwide approach. In the 22 participating hospitals, there were 50 surgeons performing total knee arthroplasty and 40 surgeons were performing total hip surgery at the time the new protocol was introduced.

Further analyses will provide a more detailed analysis of the effect of the protocol on other thrombotic events, including deep vein thrombosis, and on cost. Since these data were analyzed, protocol adoption has increased and now exceeds 80%, according to Dr. Wylie.

Although a standardized approach to VTE prophylaxis following total joint arthroplasty is attractive, the ideal strategy remains controversial, according to Sunny Parikh, MD, an orthopedic surgeon affiliated with Colchester (England) General Hospital.

As a coauthor of a recent study that quantified symptomatic VTE rates at his and a neighboring hospital over a 3-year period (BMC Musculoskelet Disord. 2020;21:95), Dr. Parikh reported that VTE rates did not reach zero even with a prolonged course of the low-molecular-weight heparin enoxaparin.

At 90 days, the symptomatic VTE rate was only 0.3% for total knee arthroplasty but reached 1.2% for total hip arthroplasty.

“At the time of this study we were using enoxaparin for 28 days following total hip replacements and for 14 days following total knee replacements,” Dr. Parikh reported. Since this study, his institution has switched to a regimen recommended by the U.K.’s National Institute for Health and Clinical Excellence (NICE).

Under the NICE guidelines, VTE prophylaxis for total hip arthroplasty is 40 mg enoxaparin once daily for 14 days followed by 75 mg aspirin for another 14 days, according to Dr. Parikh. For total knee arthroplasty, the standard regimen is 75 mg aspirin for 14 days.

For those who might not be best managed with the standard approach, “there is no clear guideline.” Rather, in patients with renal or liver impairment, “we discuss the case with the hematology team to adjust the doses,” Dr. Parikh reported.

The advantage of a standardized approach applied to all or most patients is that is eliminates disparities, but Dr. Parikh agreed that risk-adjusted prophylaxis might be warranted for optimal outcomes.

Dr. Wylie reported a financial relationship with Arthrex.
 

A simple tool to guide choice of antithrombotic therapy following total joint arthroplasty led to a reduction in pulmonary embolism (PE) after being introduced systemwide, according to a prospectively tracked evaluation of a large patient cohort. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.

“We developed a simplified scoring system for evaluating risk of thromboembolism and guiding prophylaxis that led to a significant reduction in events across a large integrated health care system,” reported James Wylie, MD, associate medical director for hip and knee preservation and orthopedic research at Intermountain Healthcare, Salt Lake City, Utah.

The goal of the methodology was to create a uniform and evidence-based approach to risk assessment in order to guide selection of appropriate venous thromboembolism (VTE) prophylaxis. The tool takes into account the need to individualize antithrombotic drugs for risk of both VTE and for bleeding.

“VTE is a major threat following total joint replacement, but not all patients require anticoagulants. Recent evidence supports a shift to aspirin for low-risk patients,” explained Dr. Wylie in an interview.

The risk tool assigns points for such factors as history of VTE, older age, history of coronary artery disease, history of cancer, and increased body mass index. There are two possible ratings to guide strategies. Those with standard risk are candidates for 81 mg of aspirin twice daily. Those with high risk are candidates for 2.5 mg of apixaban, also administered twice daily. Custom dosing of warfarin is an alternative for the latter group. Regardless of strategy, prophylaxis is administered for 30 days following arthroplasty

“The risk score is calculated automatically, because you have to click a box in the electronic medical record for all of those factors as part of admission orders,” Dr. Wylie said.

The protocol was introduced in July 2017 and adoption was tracked prospectively over 18 months. In an evaluable cohort of 20,284 patients, PE rates in the 71% of patients adherent to the protocol were compared with the 29% who were not.

Over the observation period, the rates of PE were 0.34% and 0.62% (P = .004) for those adherent and nonadherent, respectively. The rate of unplanned readmissions and death, which were secondary outcomes, were both numerically lower in the group treated by adherent surgeons, but the differences did not reach statistical significance.

Adoption of the protocol by surgeons did increase over the course of the observation period, and this correlated with a decrease in unplanned readmissions. Bleeding-related readmission was a rare event in this analysis and did not significantly increase over time, according to Dr. Wylie.

The risk assessment tool, developed by a multispecialty team at Intermountain Healthcare, was based on a review of hundreds of published papers and guidelines, according to Nathan Momberger, MD, who is the associate medical director of total joint replacement at Intermountain and was a coauthor on this study. A member of the team that developed the risk assessment tool, Dr. Momberger noted that new risk score was developed at a time when clinicians have been moving quickly away from warfarin to direct oral anticoagulants.

“None of our surgeons were using the same VTE prophylaxis when we started this project,” Dr. Momberger said. This was a motivation for developing a systemwide approach. In the 22 participating hospitals, there were 50 surgeons performing total knee arthroplasty and 40 surgeons were performing total hip surgery at the time the new protocol was introduced.

Further analyses will provide a more detailed analysis of the effect of the protocol on other thrombotic events, including deep vein thrombosis, and on cost. Since these data were analyzed, protocol adoption has increased and now exceeds 80%, according to Dr. Wylie.

Although a standardized approach to VTE prophylaxis following total joint arthroplasty is attractive, the ideal strategy remains controversial, according to Sunny Parikh, MD, an orthopedic surgeon affiliated with Colchester (England) General Hospital.

As a coauthor of a recent study that quantified symptomatic VTE rates at his and a neighboring hospital over a 3-year period (BMC Musculoskelet Disord. 2020;21:95), Dr. Parikh reported that VTE rates did not reach zero even with a prolonged course of the low-molecular-weight heparin enoxaparin.

At 90 days, the symptomatic VTE rate was only 0.3% for total knee arthroplasty but reached 1.2% for total hip arthroplasty.

“At the time of this study we were using enoxaparin for 28 days following total hip replacements and for 14 days following total knee replacements,” Dr. Parikh reported. Since this study, his institution has switched to a regimen recommended by the U.K.’s National Institute for Health and Clinical Excellence (NICE).

Under the NICE guidelines, VTE prophylaxis for total hip arthroplasty is 40 mg enoxaparin once daily for 14 days followed by 75 mg aspirin for another 14 days, according to Dr. Parikh. For total knee arthroplasty, the standard regimen is 75 mg aspirin for 14 days.

For those who might not be best managed with the standard approach, “there is no clear guideline.” Rather, in patients with renal or liver impairment, “we discuss the case with the hematology team to adjust the doses,” Dr. Parikh reported.

The advantage of a standardized approach applied to all or most patients is that is eliminates disparities, but Dr. Parikh agreed that risk-adjusted prophylaxis might be warranted for optimal outcomes.

Dr. Wylie reported a financial relationship with Arthrex.
 

ABSTRACT

Fragility fractures are estimated to affect 3 million people annually in the United States. As they are associated with a significant mortality rate, the prevention of these fractures should be a priority for orthopedists. At-risk patients include the elderly and those with thyroid disease, diabetes, hypertension, and heart disease. Osteoporosis is diagnosed by the presence of a fragility fracture or by dual-energy x-ray absorptiometry (DXA) in the absence of a fragility fracture. In 2011, the United States Preventive Services Task Force (USPSTF) recommended that all women ≥65 years should be screened for osteoporosis by DXA. Women <65 years with a 10-year fracture risk =/> than that of a 65-year-old white woman should also be screened for osteoporosis. Lifestyle changes, such as calcium and vitamin D supplementation, exercise, and smoking cessation, are non-pharmacologic treatment options. The National Osteoporosis Foundation recommends treating osteoporosis with pharmacotherapy in patients with a high risk for fracture (T score <–2.5) or history of fragility fracture. Understanding risk factors and eliminating medications known to cause decreased BMD are vital to prevention and will be necessary to limit these fractures and their associated expenses in the future.

Continue to: Fragility fractures are caused by...

Fragility fractures are caused by falls from standing height or repetitive physiological loads.¹ With the growing aging population in the United States, it is estimated that 3 million people will be affected by fragility fractures yearly.² In the setting of osseous insufficiency, fractures that are typically associated with high-energy trauma are encountered in patients who simply trip over a parking lot curb or fall off their bike. After surgery, the severe disruption of patients’ lives continues with a prolonged rehabilitation period.

ABSTRACT

Fragility fractures are estimated to affect 3 million people annually in the United States. As they are associated with a significant mortality rate, the prevention of these fractures should be a priority for orthopedists. At-risk patients include the elderly and those with thyroid disease, diabetes, hypertension, and heart disease. Osteoporosis is diagnosed by the presence of a fragility fracture or by dual-energy x-ray absorptiometry (DXA) in the absence of a fragility fracture. In 2011, the United States Preventive Services Task Force (USPSTF) recommended that all women ≥65 years should be screened for osteoporosis by DXA. Women <65 years with a 10-year fracture risk =/> than that of a 65-year-old white woman should also be screened for osteoporosis. Lifestyle changes, such as calcium and vitamin D supplementation, exercise, and smoking cessation, are non-pharmacologic treatment options. The National Osteoporosis Foundation recommends treating osteoporosis with pharmacotherapy in patients with a high risk for fracture (T score <–2.5) or history of fragility fracture. Understanding risk factors and eliminating medications known to cause decreased BMD are vital to prevention and will be necessary to limit these fractures and their associated expenses in the future.

Continue to: Fragility fractures are caused by...

Fragility fractures are caused by falls from standing height or repetitive physiological loads.¹ With the growing aging population in the United States, it is estimated that 3 million people will be affected by fragility fractures yearly.² In the setting of osseous insufficiency, fractures that are typically associated with high-energy trauma are encountered in patients who simply trip over a parking lot curb or fall off their bike. After surgery, the severe disruption of patients’ lives continues with a prolonged rehabilitation period.

ABSTRACT

Fragility fractures are estimated to affect 3 million people annually in the United States. As they are associated with a significant mortality rate, the prevention of these fractures should be a priority for orthopedists. At-risk patients include the elderly and those with thyroid disease, diabetes, hypertension, and heart disease. Osteoporosis is diagnosed by the presence of a fragility fracture or by dual-energy x-ray absorptiometry (DXA) in the absence of a fragility fracture. In 2011, the United States Preventive Services Task Force (USPSTF) recommended that all women ≥65 years should be screened for osteoporosis by DXA. Women <65 years with a 10-year fracture risk =/> than that of a 65-year-old white woman should also be screened for osteoporosis. Lifestyle changes, such as calcium and vitamin D supplementation, exercise, and smoking cessation, are non-pharmacologic treatment options. The National Osteoporosis Foundation recommends treating osteoporosis with pharmacotherapy in patients with a high risk for fracture (T score <–2.5) or history of fragility fracture. Understanding risk factors and eliminating medications known to cause decreased BMD are vital to prevention and will be necessary to limit these fractures and their associated expenses in the future.

Continue to: Fragility fractures are caused by...

Fragility fractures are caused by falls from standing height or repetitive physiological loads.¹ With the growing aging population in the United States, it is estimated that 3 million people will be affected by fragility fractures yearly.² In the setting of osseous insufficiency, fractures that are typically associated with high-energy trauma are encountered in patients who simply trip over a parking lot curb or fall off their bike. After surgery, the severe disruption of patients’ lives continues with a prolonged rehabilitation period.

ABSTRACT

Upper limb injuries in soccer represent only a marginal portion of injuries, however this is mainly true for outfield players. Goalkeepers are reported to have up to 5 times more upper extremity injuries, many of them requiring substantial time-loss for treatment and rehabilitation. The most common upper extremity injury locations are the shoulder/clavicle followed by the hand/finger/thumb, elbow, wrist, forearm, and upper arm. The mechanism of injury, presentation, physical examination, and imaging features all play a significant role in reaching the correct diagnosis. Taking to consideration the position the player plays and his demands will also enable tailoring the optimal treatment plan that allows timely and safe return to play. This article discusses common upper extremity injuries observed in soccer players, focusing on proper diagnosis and optimal management.

Continue to: Upper limb injuries in association with soccer...

Upper limb injuries in association with soccer have been reported to represent only 3% of all time-loss injuries in professional soccer players¹. However, they are considered an increasing problem in recent years^2-4 and have been reported in high proportions in children under the age of 15 years.⁵ Some of the reasons for the increase in upper extremity injuries may be explained by modern soccer tactics that have been characterized by high speed, pressing, and marking.² Furthermore, upper extremity injuries may still be underestimated in soccer, mainly because outfield players are sometimes able to train and play even when they suffer from an upper extremity injury.

ABSTRACT

Upper limb injuries in soccer represent only a marginal portion of injuries, however this is mainly true for outfield players. Goalkeepers are reported to have up to 5 times more upper extremity injuries, many of them requiring substantial time-loss for treatment and rehabilitation. The most common upper extremity injury locations are the shoulder/clavicle followed by the hand/finger/thumb, elbow, wrist, forearm, and upper arm. The mechanism of injury, presentation, physical examination, and imaging features all play a significant role in reaching the correct diagnosis. Taking to consideration the position the player plays and his demands will also enable tailoring the optimal treatment plan that allows timely and safe return to play. This article discusses common upper extremity injuries observed in soccer players, focusing on proper diagnosis and optimal management.

Continue to: Upper limb injuries in association with soccer...

Upper limb injuries in association with soccer have been reported to represent only 3% of all time-loss injuries in professional soccer players¹. However, they are considered an increasing problem in recent years^2-4 and have been reported in high proportions in children under the age of 15 years.⁵ Some of the reasons for the increase in upper extremity injuries may be explained by modern soccer tactics that have been characterized by high speed, pressing, and marking.² Furthermore, upper extremity injuries may still be underestimated in soccer, mainly because outfield players are sometimes able to train and play even when they suffer from an upper extremity injury.

ABSTRACT

Upper limb injuries in soccer represent only a marginal portion of injuries, however this is mainly true for outfield players. Goalkeepers are reported to have up to 5 times more upper extremity injuries, many of them requiring substantial time-loss for treatment and rehabilitation. The most common upper extremity injury locations are the shoulder/clavicle followed by the hand/finger/thumb, elbow, wrist, forearm, and upper arm. The mechanism of injury, presentation, physical examination, and imaging features all play a significant role in reaching the correct diagnosis. Taking to consideration the position the player plays and his demands will also enable tailoring the optimal treatment plan that allows timely and safe return to play. This article discusses common upper extremity injuries observed in soccer players, focusing on proper diagnosis and optimal management.

Continue to: Upper limb injuries in association with soccer...

Upper limb injuries in association with soccer have been reported to represent only 3% of all time-loss injuries in professional soccer players¹. However, they are considered an increasing problem in recent years^2-4 and have been reported in high proportions in children under the age of 15 years.⁵ Some of the reasons for the increase in upper extremity injuries may be explained by modern soccer tactics that have been characterized by high speed, pressing, and marking.² Furthermore, upper extremity injuries may still be underestimated in soccer, mainly because outfield players are sometimes able to train and play even when they suffer from an upper extremity injury.

ABSTRACT

Delayed unions and nonunions of the scaphoid are most often treated by open reduction and internal fixation with bone grafting. We sought to evaluate a large consecutive series of nondisplaced or minimally displaced scaphoid nonunions and delayed unions treated by a compression screw without bone grafting by 2 fellowship trained hand surgeons. A total of 23 patients (19 males, 4 females) were identified who had fractures located at the distal third (2), the waist (18), and the proximal third (3). Of the 23 patients, 19 had a complete follow-up (mean follow-up period, 5.2 months) with evidence of radiographic union. There were no radiographic signs of arthrosis, osteonecrosis of the scaphoid, hardware-related complications, or reported revision surgeries. In conclusion, nonunions and delayed unions in nondisplaced or minimally displaced scaphoids without carpal malalignment can be successfully treated using compression screw fixation without bone grafting.

Continued to: Scaphoid nonunions or delayed unions with displacement...

Scaphoid nonunions or delayed unions with displacement, humpback deformities, or dorsal intercalated segmental instability deformities require open exposure with reduction of the fracture and autogenous bone grafting (structural or nonstructural and vascularized or nonvascularized).^1,2 However, in the absence of displacement or deformity, compression and internal fixation without bone grafting may be sufficient to achieve union.

Several reports have described the use of internal fixation alone in the management of scaphoid nonunions with both minimal and extensive bone loss.^3-7 These studies have shown that screw fixation alone affords less morbidity to the patient while allowing high rates of union.

Previous reports of internal fixation alone included limited numbers of patients for review. Therefore, we aim to review a large consecutive series of scaphoid delayed unions and nonunions without osteonecrosis or deformity managed by only internal fixation. Our hypothesis is that drilling combined with compression and rigid stabilization would allow for bony union in these cases

MATERIALS AND METHODS

After Institutional Review Board approval was obtained, a retrospective review of prospectively collected data was performed on consecutive patients with a delayed union or nonunion of the scaphoid. All injuries had failed conservative treatment of casting for at least 12 weeks and ultrasound stimulation, and were subsequently treated by compression screw fixation by 1 of 2 fellowship trained hand surgeons. The database comprised the data of patients who presented to a single, Level 1 trauma center between 2000 and 2012.  

Delayed unions and nonunions were defined as a lack of radiographic trabecular bridging and pain on clinical examination at 3 and 6 months, respectively. All fractures were nondisplaced or minimally displaced (<2 mm), and patients with carpal malalignment or humpback deformity (based on scapholunate angle on plain radiographs) were excluded. Clinical outcome measures included evidence of radiographic union, revision surgery, pain, and reported complications.

Continue to: Inclusion criteria were all patients who sustained...

Inclusion criteria were all patients who sustained a minimally displaced scaphoid fracture and were treated conservatively with casting for at least 12 weeks and ultrasound stimulation, and progressed to delayed unions or nonunions.

Patients younger than age 18 years or with radiographic evidence of arthrosis or humpback deformity were excluded. Any fracture with >2 mm of gapping on original injury radiographs was not considered as minimally displaced and was also excluded. Furthermore, patients with a previous ipsilateral scaphoid injury or hand surgery were also excluded.

Compression screw placement was recorded as being either central or eccentric based on Trumble and colleagues’⁸ criteria. Posteroanterior (PA), lateral, and scaphoid view radiographs were reviewed by the first author (DS) and the treating hand surgeon (AS). Central screw placement was substantiated if the screw was in the middle third of the proximal pole in all 3 views.

The final set of postoperative radiographs was reviewed for unions. Union was defined as bridging trabeculation with near or complete obliteration of the fracture line on PA, lateral, and scaphoid radiographic views. Computerized tomography (CT) was performed at the discretion of the treating surgeon, and its use was not required if there was near obliteration of the fracture line on the 3-view radiographs and in the absence of patient-reported pain. Patients with bone loss or sclerosis were included as long as no deformity existed.

After surgical intervention, a short-arm cast was applied for 6 weeks, followed by a wrist splint for 4 to 8 weeks depending on patient comfort.

Continue to: SURGICAL TECHNIQUE...

SURGICAL TECHNIQUE

Either a 1-cm to 2-cm transverse incision distal to Lister’s tubercle or a longitudinal incision just ulnar was utilized. The extensor pollicis longus was identified and retracted. A longitudinal or an L-shaped capsulotomy was made to identify the proximal pole of the scaphoid. With the wrist flexed, a guide wire was inserted down the central axis of the scaphoid and confirmed by fluoroscopy. The measurement was made off the guidewire and 4 to 6 mm was subtracted. The scaphoid was then drilled, and the variable pitch compression screw (Acutrak Headless Compression Screw, Acumed) was inserted. Compression and position of the screw were confirmed by fluoroscopy before closure.

RESULTS

A total of 23 patients (19 males, 4 females) with acute scaphoid fractures who were treated conservatively with casting for at least 12 weeks and ultrasound stimulation, and progressed to delayed unions or nonunions were identified in this study. The ages of the patients ranged from 19 to 50 years. Of the 23 patients, 6 were smokers. The majority of patients sustained fractures in the scaphoid waist (18 patients) (Figure 1). Two patients had distal third fractures, and 3 had proximal third fractures.

The average time from the sustained injury to the surgical intervention was 8.2 months (range, 3.1-27.6 months). There were no patients with delayed diagnoses. Three fractures were identified as delayed unions with failure of union and pain after 3 months of conservative treatment, whereas the other 20 were identified as nonunions with at least 6 months of failed conservative treatment.

shah0818_f1_2.jpg

Of the 23 patients, 21 were found to have centrally placed variable compression screws based on Trumble and colleagues’⁸ criteria. Of the 23 patients, 19 had a complete follow-up course with radiographs at 6 months after surgery. All of these 19 patients had evidence of radiographic union defined as bridging trabeculation with near or complete obliteration of the fracture line on PA, lateral, and scaphoid radiographic views (Figure 2). Of the 6 smokers, 5 progressed to radiographic union and 1 patient had <6 months of postoperative return visits and could not be contacted. At the final clinic visit, all of the 19 patients denied wrist pain on direct palpation over the scaphoid tubercle, and no complications were reported. There were no repeat or revision surgical interventions.

Four patients had limited follow-up with <6 months of postoperative return visits. Their final set of radiographs did not demonstrate complete bridging trabeculation. One patient who moved away from the area was lost to follow-up but was contacted. The patient stated that he had a pain-free wrist with no further surgical interventions on his scaphoid. The other 3 patients could not be contacted.

shah0818_f2_2.jpg

DISCUSSION

The management of scaphoid nonunions and delayed unions has dramatically evolved over the past 20 years.^1,3-8 Historically, semi-rigid stabilization using Kirschner wires and casting afforded a 77% union rate in these cases.⁹ More recently, several authors have reported that stabilization without bone grafting can predictably unite scaphoid nonunions. Treating patients with uncomplicated scaphoid nonunions and delayed unions by internal fixation alone may be all that is required to achieve union.

The definitions of a scaphoid nonunion and delayed union are complex. The exact time when a scaphoid fracture heals varies between patients.^2,5,10 However, the majority of hand surgeons believe that failure to see clear signs of healing (in waist fractures) after 3 months from the injury would suggest a failure to heal and a “delayed” union, whereas failure after 6 months from the injury and without clear signs of healing indicate a nonunion.^5,6,10,11 Any resorption at the fracture site suggests that the fracture will not heal by continued immobilization alone and will require surgery.¹⁰

Continue to: Hand surgeons have several surgical options...

Hand surgeons have several surgical options when managing scaphoid injuries. Mahmoud and Koptan⁴ used a volar approach to percutaneously deliver a headless compression screw into 27 nonunions. Postoperative CT scans demonstrated fracture union in all 27 patients, and no patient underwent revision surgery. Interestingly, 14 of their patients had extensive preoperative resorption (but no deformity) of >5 mm.

Although volar percutaneous approaches for internal fixation have been cited to provide high rates of union and high patient satisfaction in acute scaphoid fracture fixation, this study utilized a dorsal approach. Both Wozasek and Moser¹² and Haddad and Goddard¹³ reported excellent results and high union rates using a volar approach in consecutive acute scaphoid fractures. Despite these results, there are concerns that using a volar approach may damage the scaphotrapezial joint and may be prone to eccentric placement of compression screws.^8,14

Slade and colleagues³ did utilize the dorsal approach with arthroscopic assistance to deliver a compression screw into scaphoid nonunions in 15 consecutive patients without any evidence of deformity, sclerosis, or resorption. Similar to our investigation, they treated patients with both delayed unions and nonunions. CT scans were used to confirm unions in all their patients. Using a dorsal approach, Yassaee and Yang¹⁵ treated 9 consecutive patients using a compression screw without bone grafting for both delayed and nonunion scaphoid injuries. Other authors have used both volar and dorsal approaches in 12 consecutive delayed and nonunion scaphoid injuries and found that 11 of the 12 injuries progressed to unions.⁶

Although these authors and several others advocate the use of CT scans to assess unions, our investigation used bridging trabeculation obliteration of the fracture line on 3 standard radiographic views to confirm unions in addition to the absence of pain clinically.^16,17 CT scans expose the patient to increased radiation that, in our experience, does not alter the postoperative clinical course.¹⁸ If there is clear evidence of bridged callus and no pain on physical examination, a CT scan performed to reconfirm the union affords little benefit to clinical management.¹⁹

Continue to: All these previous studies have demonstrated...

All these previous studies have demonstrated excellent union rates but using a limited series of patients. We reviewed a large number of consecutive patients with scaphoid delayed unions and nonunions treated by screw fixation without bone grafting. Our hospital is a safety net institution for a large urban catchment area and had complete radiographic and clinical data for 19 of our 23 patients. One patient was contacted by telephone and he reported no pain and no revision surgical interventions.

The limitations of this study include not only its retrospective design but also its limited secondary outcome measures. However, our primary outcomes of union, pain, and complications are of utmost importance to clinicians and patients alike. Similar to other authors, we used radiographs to confirm unions. Although bridging trabeculation in radiographs has been demonstrated as soon as 1 month after the injury, there may be problems with interobserver reliability.^{4,13,15,20,21}

Patients being lost to follow-up is not uncommon in the orthopedic trauma literature and can influence results.^22,23 It is speculative to infer that the 3 patients who did not complete a follow-up course did not return because their pain had mitigated.

CONCLUSION 

Like several fractures, the lack of stability and the absence of micro-motion are believed to contribute to fibrous nonunions in scaphoid fractures.¹³ This study provides a large consecutive cohort of patients with minimally displaced scaphoid delayed unions and nonunions that were successfully treated by rigid internal fixation without bone grafting. These results confirm previous reports that bone grafting is not required to provide predictable unions for the majority of scaphoid nonunions.

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

Delayed unions and nonunions of the scaphoid are most often treated by open reduction and internal fixation with bone grafting. We sought to evaluate a large consecutive series of nondisplaced or minimally displaced scaphoid nonunions and delayed unions treated by a compression screw without bone grafting by 2 fellowship trained hand surgeons. A total of 23 patients (19 males, 4 females) were identified who had fractures located at the distal third (2), the waist (18), and the proximal third (3). Of the 23 patients, 19 had a complete follow-up (mean follow-up period, 5.2 months) with evidence of radiographic union. There were no radiographic signs of arthrosis, osteonecrosis of the scaphoid, hardware-related complications, or reported revision surgeries. In conclusion, nonunions and delayed unions in nondisplaced or minimally displaced scaphoids without carpal malalignment can be successfully treated using compression screw fixation without bone grafting.

Continued to: Scaphoid nonunions or delayed unions with displacement...

Scaphoid nonunions or delayed unions with displacement, humpback deformities, or dorsal intercalated segmental instability deformities require open exposure with reduction of the fracture and autogenous bone grafting (structural or nonstructural and vascularized or nonvascularized).^1,2 However, in the absence of displacement or deformity, compression and internal fixation without bone grafting may be sufficient to achieve union.

Several reports have described the use of internal fixation alone in the management of scaphoid nonunions with both minimal and extensive bone loss.^3-7 These studies have shown that screw fixation alone affords less morbidity to the patient while allowing high rates of union.

Previous reports of internal fixation alone included limited numbers of patients for review. Therefore, we aim to review a large consecutive series of scaphoid delayed unions and nonunions without osteonecrosis or deformity managed by only internal fixation. Our hypothesis is that drilling combined with compression and rigid stabilization would allow for bony union in these cases

MATERIALS AND METHODS

After Institutional Review Board approval was obtained, a retrospective review of prospectively collected data was performed on consecutive patients with a delayed union or nonunion of the scaphoid. All injuries had failed conservative treatment of casting for at least 12 weeks and ultrasound stimulation, and were subsequently treated by compression screw fixation by 1 of 2 fellowship trained hand surgeons. The database comprised the data of patients who presented to a single, Level 1 trauma center between 2000 and 2012.  

Delayed unions and nonunions were defined as a lack of radiographic trabecular bridging and pain on clinical examination at 3 and 6 months, respectively. All fractures were nondisplaced or minimally displaced (<2 mm), and patients with carpal malalignment or humpback deformity (based on scapholunate angle on plain radiographs) were excluded. Clinical outcome measures included evidence of radiographic union, revision surgery, pain, and reported complications.

Continue to: Inclusion criteria were all patients who sustained...

Inclusion criteria were all patients who sustained a minimally displaced scaphoid fracture and were treated conservatively with casting for at least 12 weeks and ultrasound stimulation, and progressed to delayed unions or nonunions.

Patients younger than age 18 years or with radiographic evidence of arthrosis or humpback deformity were excluded. Any fracture with >2 mm of gapping on original injury radiographs was not considered as minimally displaced and was also excluded. Furthermore, patients with a previous ipsilateral scaphoid injury or hand surgery were also excluded.

Compression screw placement was recorded as being either central or eccentric based on Trumble and colleagues’⁸ criteria. Posteroanterior (PA), lateral, and scaphoid view radiographs were reviewed by the first author (DS) and the treating hand surgeon (AS). Central screw placement was substantiated if the screw was in the middle third of the proximal pole in all 3 views.

The final set of postoperative radiographs was reviewed for unions. Union was defined as bridging trabeculation with near or complete obliteration of the fracture line on PA, lateral, and scaphoid radiographic views. Computerized tomography (CT) was performed at the discretion of the treating surgeon, and its use was not required if there was near obliteration of the fracture line on the 3-view radiographs and in the absence of patient-reported pain. Patients with bone loss or sclerosis were included as long as no deformity existed.

After surgical intervention, a short-arm cast was applied for 6 weeks, followed by a wrist splint for 4 to 8 weeks depending on patient comfort.

Continue to: SURGICAL TECHNIQUE...

SURGICAL TECHNIQUE

Either a 1-cm to 2-cm transverse incision distal to Lister’s tubercle or a longitudinal incision just ulnar was utilized. The extensor pollicis longus was identified and retracted. A longitudinal or an L-shaped capsulotomy was made to identify the proximal pole of the scaphoid. With the wrist flexed, a guide wire was inserted down the central axis of the scaphoid and confirmed by fluoroscopy. The measurement was made off the guidewire and 4 to 6 mm was subtracted. The scaphoid was then drilled, and the variable pitch compression screw (Acutrak Headless Compression Screw, Acumed) was inserted. Compression and position of the screw were confirmed by fluoroscopy before closure.

RESULTS

A total of 23 patients (19 males, 4 females) with acute scaphoid fractures who were treated conservatively with casting for at least 12 weeks and ultrasound stimulation, and progressed to delayed unions or nonunions were identified in this study. The ages of the patients ranged from 19 to 50 years. Of the 23 patients, 6 were smokers. The majority of patients sustained fractures in the scaphoid waist (18 patients) (Figure 1). Two patients had distal third fractures, and 3 had proximal third fractures.

The average time from the sustained injury to the surgical intervention was 8.2 months (range, 3.1-27.6 months). There were no patients with delayed diagnoses. Three fractures were identified as delayed unions with failure of union and pain after 3 months of conservative treatment, whereas the other 20 were identified as nonunions with at least 6 months of failed conservative treatment.

shah0818_f1_2.jpg

Of the 23 patients, 21 were found to have centrally placed variable compression screws based on Trumble and colleagues’⁸ criteria. Of the 23 patients, 19 had a complete follow-up course with radiographs at 6 months after surgery. All of these 19 patients had evidence of radiographic union defined as bridging trabeculation with near or complete obliteration of the fracture line on PA, lateral, and scaphoid radiographic views (Figure 2). Of the 6 smokers, 5 progressed to radiographic union and 1 patient had <6 months of postoperative return visits and could not be contacted. At the final clinic visit, all of the 19 patients denied wrist pain on direct palpation over the scaphoid tubercle, and no complications were reported. There were no repeat or revision surgical interventions.

Four patients had limited follow-up with <6 months of postoperative return visits. Their final set of radiographs did not demonstrate complete bridging trabeculation. One patient who moved away from the area was lost to follow-up but was contacted. The patient stated that he had a pain-free wrist with no further surgical interventions on his scaphoid. The other 3 patients could not be contacted.

shah0818_f2_2.jpg

DISCUSSION

The management of scaphoid nonunions and delayed unions has dramatically evolved over the past 20 years.^1,3-8 Historically, semi-rigid stabilization using Kirschner wires and casting afforded a 77% union rate in these cases.⁹ More recently, several authors have reported that stabilization without bone grafting can predictably unite scaphoid nonunions. Treating patients with uncomplicated scaphoid nonunions and delayed unions by internal fixation alone may be all that is required to achieve union.

The definitions of a scaphoid nonunion and delayed union are complex. The exact time when a scaphoid fracture heals varies between patients.^2,5,10 However, the majority of hand surgeons believe that failure to see clear signs of healing (in waist fractures) after 3 months from the injury would suggest a failure to heal and a “delayed” union, whereas failure after 6 months from the injury and without clear signs of healing indicate a nonunion.^5,6,10,11 Any resorption at the fracture site suggests that the fracture will not heal by continued immobilization alone and will require surgery.¹⁰

Continue to: Hand surgeons have several surgical options...

Hand surgeons have several surgical options when managing scaphoid injuries. Mahmoud and Koptan⁴ used a volar approach to percutaneously deliver a headless compression screw into 27 nonunions. Postoperative CT scans demonstrated fracture union in all 27 patients, and no patient underwent revision surgery. Interestingly, 14 of their patients had extensive preoperative resorption (but no deformity) of >5 mm.

Although volar percutaneous approaches for internal fixation have been cited to provide high rates of union and high patient satisfaction in acute scaphoid fracture fixation, this study utilized a dorsal approach. Both Wozasek and Moser¹² and Haddad and Goddard¹³ reported excellent results and high union rates using a volar approach in consecutive acute scaphoid fractures. Despite these results, there are concerns that using a volar approach may damage the scaphotrapezial joint and may be prone to eccentric placement of compression screws.^8,14

Slade and colleagues³ did utilize the dorsal approach with arthroscopic assistance to deliver a compression screw into scaphoid nonunions in 15 consecutive patients without any evidence of deformity, sclerosis, or resorption. Similar to our investigation, they treated patients with both delayed unions and nonunions. CT scans were used to confirm unions in all their patients. Using a dorsal approach, Yassaee and Yang¹⁵ treated 9 consecutive patients using a compression screw without bone grafting for both delayed and nonunion scaphoid injuries. Other authors have used both volar and dorsal approaches in 12 consecutive delayed and nonunion scaphoid injuries and found that 11 of the 12 injuries progressed to unions.⁶

Although these authors and several others advocate the use of CT scans to assess unions, our investigation used bridging trabeculation obliteration of the fracture line on 3 standard radiographic views to confirm unions in addition to the absence of pain clinically.^16,17 CT scans expose the patient to increased radiation that, in our experience, does not alter the postoperative clinical course.¹⁸ If there is clear evidence of bridged callus and no pain on physical examination, a CT scan performed to reconfirm the union affords little benefit to clinical management.¹⁹

Continue to: All these previous studies have demonstrated...

All these previous studies have demonstrated excellent union rates but using a limited series of patients. We reviewed a large number of consecutive patients with scaphoid delayed unions and nonunions treated by screw fixation without bone grafting. Our hospital is a safety net institution for a large urban catchment area and had complete radiographic and clinical data for 19 of our 23 patients. One patient was contacted by telephone and he reported no pain and no revision surgical interventions.

The limitations of this study include not only its retrospective design but also its limited secondary outcome measures. However, our primary outcomes of union, pain, and complications are of utmost importance to clinicians and patients alike. Similar to other authors, we used radiographs to confirm unions. Although bridging trabeculation in radiographs has been demonstrated as soon as 1 month after the injury, there may be problems with interobserver reliability.^{4,13,15,20,21}

Patients being lost to follow-up is not uncommon in the orthopedic trauma literature and can influence results.^22,23 It is speculative to infer that the 3 patients who did not complete a follow-up course did not return because their pain had mitigated.

CONCLUSION 

Like several fractures, the lack of stability and the absence of micro-motion are believed to contribute to fibrous nonunions in scaphoid fractures.¹³ This study provides a large consecutive cohort of patients with minimally displaced scaphoid delayed unions and nonunions that were successfully treated by rigid internal fixation without bone grafting. These results confirm previous reports that bone grafting is not required to provide predictable unions for the majority of scaphoid nonunions.

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

Delayed unions and nonunions of the scaphoid are most often treated by open reduction and internal fixation with bone grafting. We sought to evaluate a large consecutive series of nondisplaced or minimally displaced scaphoid nonunions and delayed unions treated by a compression screw without bone grafting by 2 fellowship trained hand surgeons. A total of 23 patients (19 males, 4 females) were identified who had fractures located at the distal third (2), the waist (18), and the proximal third (3). Of the 23 patients, 19 had a complete follow-up (mean follow-up period, 5.2 months) with evidence of radiographic union. There were no radiographic signs of arthrosis, osteonecrosis of the scaphoid, hardware-related complications, or reported revision surgeries. In conclusion, nonunions and delayed unions in nondisplaced or minimally displaced scaphoids without carpal malalignment can be successfully treated using compression screw fixation without bone grafting.

Continued to: Scaphoid nonunions or delayed unions with displacement...

Scaphoid nonunions or delayed unions with displacement, humpback deformities, or dorsal intercalated segmental instability deformities require open exposure with reduction of the fracture and autogenous bone grafting (structural or nonstructural and vascularized or nonvascularized).^1,2 However, in the absence of displacement or deformity, compression and internal fixation without bone grafting may be sufficient to achieve union.

Several reports have described the use of internal fixation alone in the management of scaphoid nonunions with both minimal and extensive bone loss.^3-7 These studies have shown that screw fixation alone affords less morbidity to the patient while allowing high rates of union.

Previous reports of internal fixation alone included limited numbers of patients for review. Therefore, we aim to review a large consecutive series of scaphoid delayed unions and nonunions without osteonecrosis or deformity managed by only internal fixation. Our hypothesis is that drilling combined with compression and rigid stabilization would allow for bony union in these cases

MATERIALS AND METHODS

After Institutional Review Board approval was obtained, a retrospective review of prospectively collected data was performed on consecutive patients with a delayed union or nonunion of the scaphoid. All injuries had failed conservative treatment of casting for at least 12 weeks and ultrasound stimulation, and were subsequently treated by compression screw fixation by 1 of 2 fellowship trained hand surgeons. The database comprised the data of patients who presented to a single, Level 1 trauma center between 2000 and 2012.  

Delayed unions and nonunions were defined as a lack of radiographic trabecular bridging and pain on clinical examination at 3 and 6 months, respectively. All fractures were nondisplaced or minimally displaced (<2 mm), and patients with carpal malalignment or humpback deformity (based on scapholunate angle on plain radiographs) were excluded. Clinical outcome measures included evidence of radiographic union, revision surgery, pain, and reported complications.

Continue to: Inclusion criteria were all patients who sustained...

Inclusion criteria were all patients who sustained a minimally displaced scaphoid fracture and were treated conservatively with casting for at least 12 weeks and ultrasound stimulation, and progressed to delayed unions or nonunions.

Patients younger than age 18 years or with radiographic evidence of arthrosis or humpback deformity were excluded. Any fracture with >2 mm of gapping on original injury radiographs was not considered as minimally displaced and was also excluded. Furthermore, patients with a previous ipsilateral scaphoid injury or hand surgery were also excluded.

Compression screw placement was recorded as being either central or eccentric based on Trumble and colleagues’⁸ criteria. Posteroanterior (PA), lateral, and scaphoid view radiographs were reviewed by the first author (DS) and the treating hand surgeon (AS). Central screw placement was substantiated if the screw was in the middle third of the proximal pole in all 3 views.

The final set of postoperative radiographs was reviewed for unions. Union was defined as bridging trabeculation with near or complete obliteration of the fracture line on PA, lateral, and scaphoid radiographic views. Computerized tomography (CT) was performed at the discretion of the treating surgeon, and its use was not required if there was near obliteration of the fracture line on the 3-view radiographs and in the absence of patient-reported pain. Patients with bone loss or sclerosis were included as long as no deformity existed.

After surgical intervention, a short-arm cast was applied for 6 weeks, followed by a wrist splint for 4 to 8 weeks depending on patient comfort.

Continue to: SURGICAL TECHNIQUE...

SURGICAL TECHNIQUE

Either a 1-cm to 2-cm transverse incision distal to Lister’s tubercle or a longitudinal incision just ulnar was utilized. The extensor pollicis longus was identified and retracted. A longitudinal or an L-shaped capsulotomy was made to identify the proximal pole of the scaphoid. With the wrist flexed, a guide wire was inserted down the central axis of the scaphoid and confirmed by fluoroscopy. The measurement was made off the guidewire and 4 to 6 mm was subtracted. The scaphoid was then drilled, and the variable pitch compression screw (Acutrak Headless Compression Screw, Acumed) was inserted. Compression and position of the screw were confirmed by fluoroscopy before closure.

RESULTS

A total of 23 patients (19 males, 4 females) with acute scaphoid fractures who were treated conservatively with casting for at least 12 weeks and ultrasound stimulation, and progressed to delayed unions or nonunions were identified in this study. The ages of the patients ranged from 19 to 50 years. Of the 23 patients, 6 were smokers. The majority of patients sustained fractures in the scaphoid waist (18 patients) (Figure 1). Two patients had distal third fractures, and 3 had proximal third fractures.

The average time from the sustained injury to the surgical intervention was 8.2 months (range, 3.1-27.6 months). There were no patients with delayed diagnoses. Three fractures were identified as delayed unions with failure of union and pain after 3 months of conservative treatment, whereas the other 20 were identified as nonunions with at least 6 months of failed conservative treatment.

shah0818_f1_2.jpg

Of the 23 patients, 21 were found to have centrally placed variable compression screws based on Trumble and colleagues’⁸ criteria. Of the 23 patients, 19 had a complete follow-up course with radiographs at 6 months after surgery. All of these 19 patients had evidence of radiographic union defined as bridging trabeculation with near or complete obliteration of the fracture line on PA, lateral, and scaphoid radiographic views (Figure 2). Of the 6 smokers, 5 progressed to radiographic union and 1 patient had <6 months of postoperative return visits and could not be contacted. At the final clinic visit, all of the 19 patients denied wrist pain on direct palpation over the scaphoid tubercle, and no complications were reported. There were no repeat or revision surgical interventions.

Four patients had limited follow-up with <6 months of postoperative return visits. Their final set of radiographs did not demonstrate complete bridging trabeculation. One patient who moved away from the area was lost to follow-up but was contacted. The patient stated that he had a pain-free wrist with no further surgical interventions on his scaphoid. The other 3 patients could not be contacted.

shah0818_f2_2.jpg

DISCUSSION

The management of scaphoid nonunions and delayed unions has dramatically evolved over the past 20 years.^1,3-8 Historically, semi-rigid stabilization using Kirschner wires and casting afforded a 77% union rate in these cases.⁹ More recently, several authors have reported that stabilization without bone grafting can predictably unite scaphoid nonunions. Treating patients with uncomplicated scaphoid nonunions and delayed unions by internal fixation alone may be all that is required to achieve union.

The definitions of a scaphoid nonunion and delayed union are complex. The exact time when a scaphoid fracture heals varies between patients.^2,5,10 However, the majority of hand surgeons believe that failure to see clear signs of healing (in waist fractures) after 3 months from the injury would suggest a failure to heal and a “delayed” union, whereas failure after 6 months from the injury and without clear signs of healing indicate a nonunion.^5,6,10,11 Any resorption at the fracture site suggests that the fracture will not heal by continued immobilization alone and will require surgery.¹⁰

Continue to: Hand surgeons have several surgical options...

Hand surgeons have several surgical options when managing scaphoid injuries. Mahmoud and Koptan⁴ used a volar approach to percutaneously deliver a headless compression screw into 27 nonunions. Postoperative CT scans demonstrated fracture union in all 27 patients, and no patient underwent revision surgery. Interestingly, 14 of their patients had extensive preoperative resorption (but no deformity) of >5 mm.

Although volar percutaneous approaches for internal fixation have been cited to provide high rates of union and high patient satisfaction in acute scaphoid fracture fixation, this study utilized a dorsal approach. Both Wozasek and Moser¹² and Haddad and Goddard¹³ reported excellent results and high union rates using a volar approach in consecutive acute scaphoid fractures. Despite these results, there are concerns that using a volar approach may damage the scaphotrapezial joint and may be prone to eccentric placement of compression screws.^8,14

Slade and colleagues³ did utilize the dorsal approach with arthroscopic assistance to deliver a compression screw into scaphoid nonunions in 15 consecutive patients without any evidence of deformity, sclerosis, or resorption. Similar to our investigation, they treated patients with both delayed unions and nonunions. CT scans were used to confirm unions in all their patients. Using a dorsal approach, Yassaee and Yang¹⁵ treated 9 consecutive patients using a compression screw without bone grafting for both delayed and nonunion scaphoid injuries. Other authors have used both volar and dorsal approaches in 12 consecutive delayed and nonunion scaphoid injuries and found that 11 of the 12 injuries progressed to unions.⁶

Although these authors and several others advocate the use of CT scans to assess unions, our investigation used bridging trabeculation obliteration of the fracture line on 3 standard radiographic views to confirm unions in addition to the absence of pain clinically.^16,17 CT scans expose the patient to increased radiation that, in our experience, does not alter the postoperative clinical course.¹⁸ If there is clear evidence of bridged callus and no pain on physical examination, a CT scan performed to reconfirm the union affords little benefit to clinical management.¹⁹

Continue to: All these previous studies have demonstrated...

All these previous studies have demonstrated excellent union rates but using a limited series of patients. We reviewed a large number of consecutive patients with scaphoid delayed unions and nonunions treated by screw fixation without bone grafting. Our hospital is a safety net institution for a large urban catchment area and had complete radiographic and clinical data for 19 of our 23 patients. One patient was contacted by telephone and he reported no pain and no revision surgical interventions.

The limitations of this study include not only its retrospective design but also its limited secondary outcome measures. However, our primary outcomes of union, pain, and complications are of utmost importance to clinicians and patients alike. Similar to other authors, we used radiographs to confirm unions. Although bridging trabeculation in radiographs has been demonstrated as soon as 1 month after the injury, there may be problems with interobserver reliability.^{4,13,15,20,21}

Patients being lost to follow-up is not uncommon in the orthopedic trauma literature and can influence results.^22,23 It is speculative to infer that the 3 patients who did not complete a follow-up course did not return because their pain had mitigated.

CONCLUSION 

Like several fractures, the lack of stability and the absence of micro-motion are believed to contribute to fibrous nonunions in scaphoid fractures.¹³ This study provides a large consecutive cohort of patients with minimally displaced scaphoid delayed unions and nonunions that were successfully treated by rigid internal fixation without bone grafting. These results confirm previous reports that bone grafting is not required to provide predictable unions for the majority of scaphoid nonunions.

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

Fiberglass casts are frequently valved to accommodate swelling following injury or surgery. The use of cast spacers has been recommended to bridge this gap between pressure reduction and cast strength, but no studies have assessed their effect on cast pressure.

We applied 30 long-arm fiberglass casts to adult volunteers, divided between a univalve group and a bivalve group. A pediatric blood pressure bladder was applied under the cast to simulate soft tissue swelling. Valved casts were secured using an elastic wrap, 10-mm cast spacer, or 15-mm cast spacer. Measurements of cast pressure and circumference were performed at each stage and compared on the basis of type of valve and securement.

Our results indicated that cast univalving resulted in an approximately 60% reduction in cast pressures, with a 75% reduction seen in the bivalve group. The addition of cast spacers resulted in significant pressure reductions for both valving groups. The univalve group secured with a 10-mm cast spacer produced reductions in cast pressure similar to those of the elastic-wrapped bivalve cast, both with the cast padding intact and with it released.

The use of cast spacers results in significant cast pressure reductions, regardless of valving technique. A univalved cast secured with a cast spacer can produce decreases in cast pressures similar to those seen with an elastic-wrapped bivalved cast, and it is a viable option for reducing cast pressure without compromising cast structural integrity with a bivalve technique.

Continue to: Complications following closed reduction...

Complications following closed reduction and casting of pediatric forearm fractures are rare, but they do occur. Arguably the most devastating of these complications is the risk of developing compartment syndrome or Volkmann contracture secondary to injury-associated swelling under a circumferential cast.^1-4 The peak in swelling can develop from 4 to 24 hours following the initial cast application,⁵ and as such, medical providers may not be able to identify it early because most children are discharged following closed reductions. For this reason, many providers implement prophylactic measures to minimize pressure-related complications.

A popular method for reducing pressure accumulation within a cast is to valve, or cut, the cast. Previous investigations have shown that cast valving results in significant reductions in cast pressure.^2,6-9 Bivalving a circumferential cast results in significantly greater reductions in cast pressure when compared with univalve techniques;^6,7,9 however, bivalving has also been shown to result in significant impairment in the structural integrity of the cast.¹⁰ An additional method to facilitate cast pressure reduction without impairing the structural integrity of the cast that accompanies a bivalve is to incorporate a cast spacer with a univalve technique to hold the split cast open.¹¹ Although this method is commonly used in clinical practice, its ability to mitigate cast pressures has not previously been investigated.

The goal of this study is to investigate the influence of incorporating cast spacers with valved long-arm casts. We hypothesized that cast spacers would provide a greater pressure reduction for both univalved and bivalved casts when compared with the use of an elastic wrap. Additionally, we proposed that by incorporating a cast spacer with a univalved cast, we could attain pressure reduction equivalent to that of a bivalved cast secured with an elastic wrap.

MATERIALS AND METHODS

Upon receiving approval from the Institutional Review Board, experimental testing began with the application of 30 total casts performed on uninjured adult human volunteers. Pressure readings were provided with the use of a bladder from a pediatric blood pressure cuff (Welch Allyn Inc), as previously described.⁶ The bladder was placed on the volar aspect of the volunteer’s forearm, held in place with a 3-in diameter cotton stockinet (3M). Cotton cast padding (Webril-Kendall) was applied, 3 in wide and 2 layers thick, and a long-arm cast was applied, 2 layers thick with 3-in wide fiberglass casting material (Scotchcast Plus Casting Tape; 3M).

Once the cast was applied and allowed to set, the blood pressure bladder was inflated to 100 mm Hg. After inflation, forearm cast circumference was measured at 2 set points, assessed at points 2 cm distal to the elbow flexor crease and 10 cm distal to the previous point (Figure 1). Using these data, we calculated estimated cast volume using the volumetric equation for a frustum. Following this point, casts were split into 2 experimental groups, univalve or bivalve, with 15 casts comprising each group. The univalve group consisted of a single cut along the dorsum of the extremity, and the bivalve group incorporated a second cut to the volar extremity. Cast valving was performed using an oscillating cast saw (Cast Vac; Stryker Instruments), with care taken to ensure the continuity of the underlying cast padding.

shaw0818_f1.jpg

Continue to: Following valving, casts were secured via...

Following valving, casts were secured via 3 separate techniques: overwrap with a 3-in elastic wrap (Econo Wrap; Vitality Medical), application of two 10-mm and 15-mm cast spacers (CastWedge; DM Systems) (Figure 2). After securement, cast pressures were recorded, and circumference measurements were performed at the 2 previously identified points. The cast padding was then cut at the valve site and secured via the 3 listed techniques. Cast pressure and circumference measurements were performed at set time points (Figure 3). Changes in cast pressure were recorded in terms of the amount of change from the initial cast placement to account for differences in the size of volunteers’ forearms. Volumetric calculations were performed only for the spacer subgroups owing to the added material in the elastic wrap group. Estimated cast volume was calculated using the equation for volume of a frustum (Figure 4).

shaw0818_f2.jpg

shaw0818_f3.jpg

shaw0818_f4.jpg

We used a 2-cast type (univalve and bivalve) by 4 securement subgroups (initial, elastic wrap, 10-mm spacer, and 15-mm spacer) design, with cast type serving as a between-subject measure and securement serving as a within-subject variable. An a priori power analysis showed that a minimum sample size of 15 subjects per condition should provide sufficient power of .80 and alpha set at .05, for a total of 30 casts. Statistical analyses were performed using IBM SPSS Statistics software version 21 (IBM). Experimental groups were analyzed using mixed-design analysis of variance (ANOVA). Post hoc comparisons between valving groups and cast securement were performed using Scheffe’s test to control for type II errors. Change in cast volume between the initial cast and cast spacers groups was compared using paired Student’s t tests. Statistical significance was predetermined as P < .05.

RESULTS

A summary of collected data for cast pressure and volume is detailed in Table 1, subdividing the variables on the basis of cast type and type of securement. Recorded pressures of the different subgroups are depicted in Figures 5 and 6 according to type of securement (initial, elastic wrap, 10-mm spacer, or 15-mm spacer). Results of the mixed-design ANOVA demonstrated significant differences between the initial cast pressure and univalve and bivalve groups (P < .05). There was a main effect for bivalve having lower pressure overall (F [1, 1)] = 3321.51, P < .001). There was also a main effect indicating that pressure was different for each type of securement (elastic wrap, 10-mm spacer, 15-mm spacer) (F [1, 28] = 538.54, P <. 01). Post hoc testing confirmed pressure decreased significantly, in descending order from elastic wrap, to 10-mm spacers, to 15-mm spacers (P < .05).

Table 1. Cumulative Data for Two Casting groups at Each Timepoint

shaw0818_f5.jpg

shaw0818_f6.jpg

Continue to: Table 2...

The summary of volumetric changes is listed in Table 2. The decrease in pressure correlated with an associated increase in cast volume, as demonstrated in Figure 7. The degree of increase in cast volume was more pronounced in the bivalve group (P < .001). The volume increased in the 15-mm group compared with the 10-mm group for both groups (P < .001) and increased for each spacer group with the release of the underlying padding (P < .05).

Table 2. Volumetric Data

shaw0818_f7.jpg

Analysis of the planned comparisons demonstrated no significant difference between the bivalve with elastic wrap and univalve with 10-mm spacer subgroups (t [28] = 1.85, P = .075, d = .68). In comparing the bivalve with elastic wrap group with the univalve and 15-mm spacer subgroup, the univalve group showed significantly lower pressures [t [28] = 6.32, P < .001, d = .2.31).

DISCUSSION

Valving of circumferential casting is a well-established technique to minimize potential pressure-related complications. Previous studies have demonstrated that univalving techniques produce a 65% reduction in cast pressure, whereas bivalving produces an 80% decrease.^6,7,9 Our results showed comparable pressure reductions of 75% with bivalving and 60% with univalving. The type of cast padding has been shown to have a significant effect on the cast pressure, favoring lower pressures with cotton padding over synthetic and waterproof padding, which, when released, can provide an additional 10% pressure reduction.^6,7

Although bivalving techniques are superior in pressure reduction, the reduction comes at the cost of the cast’s structural integrity. Crickard and colleagues¹⁰ performed a biomechanical assessment of the structural integrity by 3-point bending of casts following univalve and bivalve compared with an intact cast. The authors found that valving resulted in a significant decrease in the casts’ bending stiffness and load to failure, with bivalved casts demonstrating a significantly lower load to failure than univalved casts. One technique that has been used to enhance the pressure reduction in univalved casting techniques is the application of a cast spacer. Rang and colleagues¹¹ recommended this technique as part of a graded cast-splitting approach for the treatment of children’s fractures. This technique was applied to fractures with only modest anticipated swelling, which accounted for approximately 95% of casts applied in their children’s hospital. Our results support the use of cast spacers, demonstrating significant reduction in cast pressure in both univalve and bivalve techniques. Additionally, we found that a univalved cast with a 10-mm cast spacer provided pressure reduction similar to that of a bivalved cast.

The theory behind the application of cast spacers is that a split fiberglass cast will not remain open unless held in position.¹¹ Holding the cast open is less of a restraint to pressure reduction in bivalving techniques, because the split cast no longer has the contralateral intact hinge point to resist cast opening, demonstrated in the compromise in structural integrity seen with this technique.¹⁰ By maintaining the split cast in an opened position, the effective volume of the cast is increased, which allows for the reduction in cast pressure. This is demonstrated in our results indicating an increase in estimated cast volume with an associated incremental reduction in cast pressure with the application of incrementally sized cast spacers. Although this technique does have the potential for skin irritation caused by cast expansion, as well as local swelling at the cast window location, it is a cost-effective treatment method compared with overwrapping a bivalved cast, $1.55 for 1 cast spacer vs an estimated $200 for a forearm cast application.

This study is not without its limitations. Our model does not account for the soft tissue injury associated with forearm fractures. However, by using human volunteers, we were able to include the viscoelastic properties that are omitted with nonliving models, and our results do align with those of previous investigations regarding pressure change following valving. We did not incorporate a 3-point molding technique commonly used with reduction and casting of acute forearm fractures, owing to the lack of a standardized method for applying the mold to healthy volunteers. Although molding is necessary for most fractures in which valving is considered, we believe our data still provide valuable information. Additionally, valving of circumferential casts has not been shown, prospectively, to result in a reduction of cast-related compartment syndrome, maintenance of reduction, or need for surgery.^12,13 However, these results are reflective of reliable patients who completed the requisite follow-up care necessary for inclusion in a randomized controlled trial and may be applicable to unreliable patients or patient situations, a setting in which the compromise in cast structural integrity may be unacceptable.

CONCLUSION

We demonstrated that incorporating cast spacers into valved long-arm casts provides pressure reduction comparable to that achieved with the use of an elastic wrap. The addition of a 10-mm cast spacer to a univalved long-arm cast provides pressure reduction equivalent to that of a bivalved cast secured with an elastic wrap. A univalved cast secured with a cast spacer is a viable option for treatment of displaced pediatric forearm fractures, without compromising the cast’s structural integrity as required with bivalved techniques.

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

Fiberglass casts are frequently valved to accommodate swelling following injury or surgery. The use of cast spacers has been recommended to bridge this gap between pressure reduction and cast strength, but no studies have assessed their effect on cast pressure.

We applied 30 long-arm fiberglass casts to adult volunteers, divided between a univalve group and a bivalve group. A pediatric blood pressure bladder was applied under the cast to simulate soft tissue swelling. Valved casts were secured using an elastic wrap, 10-mm cast spacer, or 15-mm cast spacer. Measurements of cast pressure and circumference were performed at each stage and compared on the basis of type of valve and securement.

Our results indicated that cast univalving resulted in an approximately 60% reduction in cast pressures, with a 75% reduction seen in the bivalve group. The addition of cast spacers resulted in significant pressure reductions for both valving groups. The univalve group secured with a 10-mm cast spacer produced reductions in cast pressure similar to those of the elastic-wrapped bivalve cast, both with the cast padding intact and with it released.

The use of cast spacers results in significant cast pressure reductions, regardless of valving technique. A univalved cast secured with a cast spacer can produce decreases in cast pressures similar to those seen with an elastic-wrapped bivalved cast, and it is a viable option for reducing cast pressure without compromising cast structural integrity with a bivalve technique.

Continue to: Complications following closed reduction...

Complications following closed reduction and casting of pediatric forearm fractures are rare, but they do occur. Arguably the most devastating of these complications is the risk of developing compartment syndrome or Volkmann contracture secondary to injury-associated swelling under a circumferential cast.^1-4 The peak in swelling can develop from 4 to 24 hours following the initial cast application,⁵ and as such, medical providers may not be able to identify it early because most children are discharged following closed reductions. For this reason, many providers implement prophylactic measures to minimize pressure-related complications.

A popular method for reducing pressure accumulation within a cast is to valve, or cut, the cast. Previous investigations have shown that cast valving results in significant reductions in cast pressure.^2,6-9 Bivalving a circumferential cast results in significantly greater reductions in cast pressure when compared with univalve techniques;^6,7,9 however, bivalving has also been shown to result in significant impairment in the structural integrity of the cast.¹⁰ An additional method to facilitate cast pressure reduction without impairing the structural integrity of the cast that accompanies a bivalve is to incorporate a cast spacer with a univalve technique to hold the split cast open.¹¹ Although this method is commonly used in clinical practice, its ability to mitigate cast pressures has not previously been investigated.

The goal of this study is to investigate the influence of incorporating cast spacers with valved long-arm casts. We hypothesized that cast spacers would provide a greater pressure reduction for both univalved and bivalved casts when compared with the use of an elastic wrap. Additionally, we proposed that by incorporating a cast spacer with a univalved cast, we could attain pressure reduction equivalent to that of a bivalved cast secured with an elastic wrap.

MATERIALS AND METHODS

Upon receiving approval from the Institutional Review Board, experimental testing began with the application of 30 total casts performed on uninjured adult human volunteers. Pressure readings were provided with the use of a bladder from a pediatric blood pressure cuff (Welch Allyn Inc), as previously described.⁶ The bladder was placed on the volar aspect of the volunteer’s forearm, held in place with a 3-in diameter cotton stockinet (3M). Cotton cast padding (Webril-Kendall) was applied, 3 in wide and 2 layers thick, and a long-arm cast was applied, 2 layers thick with 3-in wide fiberglass casting material (Scotchcast Plus Casting Tape; 3M).

Once the cast was applied and allowed to set, the blood pressure bladder was inflated to 100 mm Hg. After inflation, forearm cast circumference was measured at 2 set points, assessed at points 2 cm distal to the elbow flexor crease and 10 cm distal to the previous point (Figure 1). Using these data, we calculated estimated cast volume using the volumetric equation for a frustum. Following this point, casts were split into 2 experimental groups, univalve or bivalve, with 15 casts comprising each group. The univalve group consisted of a single cut along the dorsum of the extremity, and the bivalve group incorporated a second cut to the volar extremity. Cast valving was performed using an oscillating cast saw (Cast Vac; Stryker Instruments), with care taken to ensure the continuity of the underlying cast padding.

shaw0818_f1.jpg

Continue to: Following valving, casts were secured via...

Following valving, casts were secured via 3 separate techniques: overwrap with a 3-in elastic wrap (Econo Wrap; Vitality Medical), application of two 10-mm and 15-mm cast spacers (CastWedge; DM Systems) (Figure 2). After securement, cast pressures were recorded, and circumference measurements were performed at the 2 previously identified points. The cast padding was then cut at the valve site and secured via the 3 listed techniques. Cast pressure and circumference measurements were performed at set time points (Figure 3). Changes in cast pressure were recorded in terms of the amount of change from the initial cast placement to account for differences in the size of volunteers’ forearms. Volumetric calculations were performed only for the spacer subgroups owing to the added material in the elastic wrap group. Estimated cast volume was calculated using the equation for volume of a frustum (Figure 4).

shaw0818_f2.jpg

shaw0818_f3.jpg

shaw0818_f4.jpg

We used a 2-cast type (univalve and bivalve) by 4 securement subgroups (initial, elastic wrap, 10-mm spacer, and 15-mm spacer) design, with cast type serving as a between-subject measure and securement serving as a within-subject variable. An a priori power analysis showed that a minimum sample size of 15 subjects per condition should provide sufficient power of .80 and alpha set at .05, for a total of 30 casts. Statistical analyses were performed using IBM SPSS Statistics software version 21 (IBM). Experimental groups were analyzed using mixed-design analysis of variance (ANOVA). Post hoc comparisons between valving groups and cast securement were performed using Scheffe’s test to control for type II errors. Change in cast volume between the initial cast and cast spacers groups was compared using paired Student’s t tests. Statistical significance was predetermined as P < .05.

RESULTS

A summary of collected data for cast pressure and volume is detailed in Table 1, subdividing the variables on the basis of cast type and type of securement. Recorded pressures of the different subgroups are depicted in Figures 5 and 6 according to type of securement (initial, elastic wrap, 10-mm spacer, or 15-mm spacer). Results of the mixed-design ANOVA demonstrated significant differences between the initial cast pressure and univalve and bivalve groups (P < .05). There was a main effect for bivalve having lower pressure overall (F [1, 1)] = 3321.51, P < .001). There was also a main effect indicating that pressure was different for each type of securement (elastic wrap, 10-mm spacer, 15-mm spacer) (F [1, 28] = 538.54, P <. 01). Post hoc testing confirmed pressure decreased significantly, in descending order from elastic wrap, to 10-mm spacers, to 15-mm spacers (P < .05).

Table 1. Cumulative Data for Two Casting groups at Each Timepoint

shaw0818_f5.jpg

shaw0818_f6.jpg

Continue to: Table 2...

The summary of volumetric changes is listed in Table 2. The decrease in pressure correlated with an associated increase in cast volume, as demonstrated in Figure 7. The degree of increase in cast volume was more pronounced in the bivalve group (P < .001). The volume increased in the 15-mm group compared with the 10-mm group for both groups (P < .001) and increased for each spacer group with the release of the underlying padding (P < .05).

Table 2. Volumetric Data

shaw0818_f7.jpg

Analysis of the planned comparisons demonstrated no significant difference between the bivalve with elastic wrap and univalve with 10-mm spacer subgroups (t [28] = 1.85, P = .075, d = .68). In comparing the bivalve with elastic wrap group with the univalve and 15-mm spacer subgroup, the univalve group showed significantly lower pressures [t [28] = 6.32, P < .001, d = .2.31).

DISCUSSION

Valving of circumferential casting is a well-established technique to minimize potential pressure-related complications. Previous studies have demonstrated that univalving techniques produce a 65% reduction in cast pressure, whereas bivalving produces an 80% decrease.^6,7,9 Our results showed comparable pressure reductions of 75% with bivalving and 60% with univalving. The type of cast padding has been shown to have a significant effect on the cast pressure, favoring lower pressures with cotton padding over synthetic and waterproof padding, which, when released, can provide an additional 10% pressure reduction.^6,7

Although bivalving techniques are superior in pressure reduction, the reduction comes at the cost of the cast’s structural integrity. Crickard and colleagues¹⁰ performed a biomechanical assessment of the structural integrity by 3-point bending of casts following univalve and bivalve compared with an intact cast. The authors found that valving resulted in a significant decrease in the casts’ bending stiffness and load to failure, with bivalved casts demonstrating a significantly lower load to failure than univalved casts. One technique that has been used to enhance the pressure reduction in univalved casting techniques is the application of a cast spacer. Rang and colleagues¹¹ recommended this technique as part of a graded cast-splitting approach for the treatment of children’s fractures. This technique was applied to fractures with only modest anticipated swelling, which accounted for approximately 95% of casts applied in their children’s hospital. Our results support the use of cast spacers, demonstrating significant reduction in cast pressure in both univalve and bivalve techniques. Additionally, we found that a univalved cast with a 10-mm cast spacer provided pressure reduction similar to that of a bivalved cast.

The theory behind the application of cast spacers is that a split fiberglass cast will not remain open unless held in position.¹¹ Holding the cast open is less of a restraint to pressure reduction in bivalving techniques, because the split cast no longer has the contralateral intact hinge point to resist cast opening, demonstrated in the compromise in structural integrity seen with this technique.¹⁰ By maintaining the split cast in an opened position, the effective volume of the cast is increased, which allows for the reduction in cast pressure. This is demonstrated in our results indicating an increase in estimated cast volume with an associated incremental reduction in cast pressure with the application of incrementally sized cast spacers. Although this technique does have the potential for skin irritation caused by cast expansion, as well as local swelling at the cast window location, it is a cost-effective treatment method compared with overwrapping a bivalved cast, $1.55 for 1 cast spacer vs an estimated $200 for a forearm cast application.

This study is not without its limitations. Our model does not account for the soft tissue injury associated with forearm fractures. However, by using human volunteers, we were able to include the viscoelastic properties that are omitted with nonliving models, and our results do align with those of previous investigations regarding pressure change following valving. We did not incorporate a 3-point molding technique commonly used with reduction and casting of acute forearm fractures, owing to the lack of a standardized method for applying the mold to healthy volunteers. Although molding is necessary for most fractures in which valving is considered, we believe our data still provide valuable information. Additionally, valving of circumferential casts has not been shown, prospectively, to result in a reduction of cast-related compartment syndrome, maintenance of reduction, or need for surgery.^12,13 However, these results are reflective of reliable patients who completed the requisite follow-up care necessary for inclusion in a randomized controlled trial and may be applicable to unreliable patients or patient situations, a setting in which the compromise in cast structural integrity may be unacceptable.

CONCLUSION

We demonstrated that incorporating cast spacers into valved long-arm casts provides pressure reduction comparable to that achieved with the use of an elastic wrap. The addition of a 10-mm cast spacer to a univalved long-arm cast provides pressure reduction equivalent to that of a bivalved cast secured with an elastic wrap. A univalved cast secured with a cast spacer is a viable option for treatment of displaced pediatric forearm fractures, without compromising the cast’s structural integrity as required with bivalved techniques.

This paper will be judged for the Resident Writer’s Award.

ABSTRACT

Fiberglass casts are frequently valved to accommodate swelling following injury or surgery. The use of cast spacers has been recommended to bridge this gap between pressure reduction and cast strength, but no studies have assessed their effect on cast pressure.

We applied 30 long-arm fiberglass casts to adult volunteers, divided between a univalve group and a bivalve group. A pediatric blood pressure bladder was applied under the cast to simulate soft tissue swelling. Valved casts were secured using an elastic wrap, 10-mm cast spacer, or 15-mm cast spacer. Measurements of cast pressure and circumference were performed at each stage and compared on the basis of type of valve and securement.

Our results indicated that cast univalving resulted in an approximately 60% reduction in cast pressures, with a 75% reduction seen in the bivalve group. The addition of cast spacers resulted in significant pressure reductions for both valving groups. The univalve group secured with a 10-mm cast spacer produced reductions in cast pressure similar to those of the elastic-wrapped bivalve cast, both with the cast padding intact and with it released.

The use of cast spacers results in significant cast pressure reductions, regardless of valving technique. A univalved cast secured with a cast spacer can produce decreases in cast pressures similar to those seen with an elastic-wrapped bivalved cast, and it is a viable option for reducing cast pressure without compromising cast structural integrity with a bivalve technique.

Continue to: Complications following closed reduction...

Complications following closed reduction and casting of pediatric forearm fractures are rare, but they do occur. Arguably the most devastating of these complications is the risk of developing compartment syndrome or Volkmann contracture secondary to injury-associated swelling under a circumferential cast.^1-4 The peak in swelling can develop from 4 to 24 hours following the initial cast application,⁵ and as such, medical providers may not be able to identify it early because most children are discharged following closed reductions. For this reason, many providers implement prophylactic measures to minimize pressure-related complications.

A popular method for reducing pressure accumulation within a cast is to valve, or cut, the cast. Previous investigations have shown that cast valving results in significant reductions in cast pressure.^2,6-9 Bivalving a circumferential cast results in significantly greater reductions in cast pressure when compared with univalve techniques;^6,7,9 however, bivalving has also been shown to result in significant impairment in the structural integrity of the cast.¹⁰ An additional method to facilitate cast pressure reduction without impairing the structural integrity of the cast that accompanies a bivalve is to incorporate a cast spacer with a univalve technique to hold the split cast open.¹¹ Although this method is commonly used in clinical practice, its ability to mitigate cast pressures has not previously been investigated.

The goal of this study is to investigate the influence of incorporating cast spacers with valved long-arm casts. We hypothesized that cast spacers would provide a greater pressure reduction for both univalved and bivalved casts when compared with the use of an elastic wrap. Additionally, we proposed that by incorporating a cast spacer with a univalved cast, we could attain pressure reduction equivalent to that of a bivalved cast secured with an elastic wrap.

MATERIALS AND METHODS

Upon receiving approval from the Institutional Review Board, experimental testing began with the application of 30 total casts performed on uninjured adult human volunteers. Pressure readings were provided with the use of a bladder from a pediatric blood pressure cuff (Welch Allyn Inc), as previously described.⁶ The bladder was placed on the volar aspect of the volunteer’s forearm, held in place with a 3-in diameter cotton stockinet (3M). Cotton cast padding (Webril-Kendall) was applied, 3 in wide and 2 layers thick, and a long-arm cast was applied, 2 layers thick with 3-in wide fiberglass casting material (Scotchcast Plus Casting Tape; 3M).

Once the cast was applied and allowed to set, the blood pressure bladder was inflated to 100 mm Hg. After inflation, forearm cast circumference was measured at 2 set points, assessed at points 2 cm distal to the elbow flexor crease and 10 cm distal to the previous point (Figure 1). Using these data, we calculated estimated cast volume using the volumetric equation for a frustum. Following this point, casts were split into 2 experimental groups, univalve or bivalve, with 15 casts comprising each group. The univalve group consisted of a single cut along the dorsum of the extremity, and the bivalve group incorporated a second cut to the volar extremity. Cast valving was performed using an oscillating cast saw (Cast Vac; Stryker Instruments), with care taken to ensure the continuity of the underlying cast padding.

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Continue to: Following valving, casts were secured via...

Following valving, casts were secured via 3 separate techniques: overwrap with a 3-in elastic wrap (Econo Wrap; Vitality Medical), application of two 10-mm and 15-mm cast spacers (CastWedge; DM Systems) (Figure 2). After securement, cast pressures were recorded, and circumference measurements were performed at the 2 previously identified points. The cast padding was then cut at the valve site and secured via the 3 listed techniques. Cast pressure and circumference measurements were performed at set time points (Figure 3). Changes in cast pressure were recorded in terms of the amount of change from the initial cast placement to account for differences in the size of volunteers’ forearms. Volumetric calculations were performed only for the spacer subgroups owing to the added material in the elastic wrap group. Estimated cast volume was calculated using the equation for volume of a frustum (Figure 4).

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We used a 2-cast type (univalve and bivalve) by 4 securement subgroups (initial, elastic wrap, 10-mm spacer, and 15-mm spacer) design, with cast type serving as a between-subject measure and securement serving as a within-subject variable. An a priori power analysis showed that a minimum sample size of 15 subjects per condition should provide sufficient power of .80 and alpha set at .05, for a total of 30 casts. Statistical analyses were performed using IBM SPSS Statistics software version 21 (IBM). Experimental groups were analyzed using mixed-design analysis of variance (ANOVA). Post hoc comparisons between valving groups and cast securement were performed using Scheffe’s test to control for type II errors. Change in cast volume between the initial cast and cast spacers groups was compared using paired Student’s t tests. Statistical significance was predetermined as P < .05.

RESULTS

A summary of collected data for cast pressure and volume is detailed in Table 1, subdividing the variables on the basis of cast type and type of securement. Recorded pressures of the different subgroups are depicted in Figures 5 and 6 according to type of securement (initial, elastic wrap, 10-mm spacer, or 15-mm spacer). Results of the mixed-design ANOVA demonstrated significant differences between the initial cast pressure and univalve and bivalve groups (P < .05). There was a main effect for bivalve having lower pressure overall (F [1, 1)] = 3321.51, P < .001). There was also a main effect indicating that pressure was different for each type of securement (elastic wrap, 10-mm spacer, 15-mm spacer) (F [1, 28] = 538.54, P <. 01). Post hoc testing confirmed pressure decreased significantly, in descending order from elastic wrap, to 10-mm spacers, to 15-mm spacers (P < .05).

Table 1. Cumulative Data for Two Casting groups at Each Timepoint

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Continue to: Table 2...

The summary of volumetric changes is listed in Table 2. The decrease in pressure correlated with an associated increase in cast volume, as demonstrated in Figure 7. The degree of increase in cast volume was more pronounced in the bivalve group (P < .001). The volume increased in the 15-mm group compared with the 10-mm group for both groups (P < .001) and increased for each spacer group with the release of the underlying padding (P < .05).

Table 2. Volumetric Data

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Analysis of the planned comparisons demonstrated no significant difference between the bivalve with elastic wrap and univalve with 10-mm spacer subgroups (t [28] = 1.85, P = .075, d = .68). In comparing the bivalve with elastic wrap group with the univalve and 15-mm spacer subgroup, the univalve group showed significantly lower pressures [t [28] = 6.32, P < .001, d = .2.31).

DISCUSSION

Valving of circumferential casting is a well-established technique to minimize potential pressure-related complications. Previous studies have demonstrated that univalving techniques produce a 65% reduction in cast pressure, whereas bivalving produces an 80% decrease.^6,7,9 Our results showed comparable pressure reductions of 75% with bivalving and 60% with univalving. The type of cast padding has been shown to have a significant effect on the cast pressure, favoring lower pressures with cotton padding over synthetic and waterproof padding, which, when released, can provide an additional 10% pressure reduction.^6,7

Although bivalving techniques are superior in pressure reduction, the reduction comes at the cost of the cast’s structural integrity. Crickard and colleagues¹⁰ performed a biomechanical assessment of the structural integrity by 3-point bending of casts following univalve and bivalve compared with an intact cast. The authors found that valving resulted in a significant decrease in the casts’ bending stiffness and load to failure, with bivalved casts demonstrating a significantly lower load to failure than univalved casts. One technique that has been used to enhance the pressure reduction in univalved casting techniques is the application of a cast spacer. Rang and colleagues¹¹ recommended this technique as part of a graded cast-splitting approach for the treatment of children’s fractures. This technique was applied to fractures with only modest anticipated swelling, which accounted for approximately 95% of casts applied in their children’s hospital. Our results support the use of cast spacers, demonstrating significant reduction in cast pressure in both univalve and bivalve techniques. Additionally, we found that a univalved cast with a 10-mm cast spacer provided pressure reduction similar to that of a bivalved cast.

The theory behind the application of cast spacers is that a split fiberglass cast will not remain open unless held in position.¹¹ Holding the cast open is less of a restraint to pressure reduction in bivalving techniques, because the split cast no longer has the contralateral intact hinge point to resist cast opening, demonstrated in the compromise in structural integrity seen with this technique.¹⁰ By maintaining the split cast in an opened position, the effective volume of the cast is increased, which allows for the reduction in cast pressure. This is demonstrated in our results indicating an increase in estimated cast volume with an associated incremental reduction in cast pressure with the application of incrementally sized cast spacers. Although this technique does have the potential for skin irritation caused by cast expansion, as well as local swelling at the cast window location, it is a cost-effective treatment method compared with overwrapping a bivalved cast, $1.55 for 1 cast spacer vs an estimated $200 for a forearm cast application.

This study is not without its limitations. Our model does not account for the soft tissue injury associated with forearm fractures. However, by using human volunteers, we were able to include the viscoelastic properties that are omitted with nonliving models, and our results do align with those of previous investigations regarding pressure change following valving. We did not incorporate a 3-point molding technique commonly used with reduction and casting of acute forearm fractures, owing to the lack of a standardized method for applying the mold to healthy volunteers. Although molding is necessary for most fractures in which valving is considered, we believe our data still provide valuable information. Additionally, valving of circumferential casts has not been shown, prospectively, to result in a reduction of cast-related compartment syndrome, maintenance of reduction, or need for surgery.^12,13 However, these results are reflective of reliable patients who completed the requisite follow-up care necessary for inclusion in a randomized controlled trial and may be applicable to unreliable patients or patient situations, a setting in which the compromise in cast structural integrity may be unacceptable.

CONCLUSION

We demonstrated that incorporating cast spacers into valved long-arm casts provides pressure reduction comparable to that achieved with the use of an elastic wrap. The addition of a 10-mm cast spacer to a univalved long-arm cast provides pressure reduction equivalent to that of a bivalved cast secured with an elastic wrap. A univalved cast secured with a cast spacer is a viable option for treatment of displaced pediatric forearm fractures, without compromising the cast’s structural integrity as required with bivalved techniques.

This paper will be judged for the Resident Writer’s Award.