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In 1999, Harris and Nanchahal (15) published their experience with CCI for the treatment of hand infections. There were
six cases of pyogenic flexor tenosynovitis. The authors’ techniqueconsi sted of twofenestrated tubes within the flexor
sheath; one was for instillation of irrigation and the other for
drainage. There werefour excellent (normal total active motionTAM), one good ( R 75% of contralateral TAM), and one fair
( R 50% of contralateral TAM) outcome.
This author and colleagues (11) retrospectively reviewed 47
cases of pyogenic flexor tenosynovitis to determine whether a
difference in outcomes existed between OD versus CCI. OD was
used in 32 patients and CCI was used in 15 patients. Complications appeared to be morecommon in the OD group ( N Z 9)
compared with the CCI group ( N Z 3), but this difference was
not significant. This study supported the use of CCI as the
preferred treatment for pyogenic flexor tenosynovitis because it
provides thorough mechanical tendonsheath irrigationand
causes smaller wounds with less scarring.
&
SUMMARY
Optimal management of pyogenic flexor tenosynovitis includes
early diagnosis, elevation and splinting the affected wrist and
hand in the safe position, appropriate antibiotics directed at the
suspected path ogens, andfrequentclinical re-examination.
When the early stage of tenosynovitis has passed (duration of
symptoms greaterthan 24 to 48 hour)orwhenmedical
treatment failstoshowimprovement,surgicaldrainageis
indicated. IntermittentCCI of theflexor tendon sheath
through small incisionsisaseffective as OD of thesheath
through long volar or lateral midaxial incisionswhere the
entire sheath is exposed. The limited incisions of CCI minimize
trauma to the softtissue of the finger,decrease the risk of
surgical complications, and allow for faster soft tissue healing.
As such, CCI decreases the time from surgery to therapistdirected range of motion exercises which optimizes long-term
function of the hand.
In the future, there may be arolefor minimally invasive
CCI of pyogenic flexor tenosynovitis in the OR, followed by
outpatient antibiotic treatment which has the potential benefit
of limiting the socioeconomic burden associated with hospitalization (19).
&
SUMMATION POINTS
Indications
&
Acute stage Isuppurative flexor tenosynovitis
Contraindications
&
Stage III infections
&
Chronic infections
&
Infections caused by atypical mycobacteria
Outcomes
&
Successful eradication of infection
&
90% regain full digital motion
Complications
&
Dislodging or kinking of the catheter
&
“Mini-compartment syndrome” of the digit
FIGURE 4 Clini calphotograph of aclosedcath eter irrigation of
pyogenic flexor tenosynovitis.
Angiocatheter
Flexor tendon sheath
Penrose drain
A1
A2
A3
A4
MC
P1
P2
P3
FIGURE 3 Diagram of the flexor tendon sheath
andpulley system of afinger.One centimeter
proximal to the skin incision over the A1 pulley,
an 18G angiocatheter is percutaneously inserted
for 2.5 to 3.0 cm into the flexor tendon sheath. A
midaxial counter incision (on the radial side for the
small finger and thumb, and the ulnar side for the
index, middle, and ring fingers) is made to vent the
sheath distal to the A4 pulley with aPenrose drain.
Abbreviations:MC, metacarpal bone; P1, proximal
phalanx;P2, middle phalanx; P3, distal phalanx.
Source:Courtesy of Virak Tan, MD.
324
&
Gutowski
&
REFERENCES
1. Kanavel AB. Infections of the Hand. 7th ed. Philadelphia,PA: Lea
&Febiger,1943.
2. Krieger LE, Schnall SB, Holtom PD ,Costigan W. Acute gonococcal
flexor tenosynovitis. Orthopedics 1997; 20:649–50.
3. Townsend DJ, Singer DI, Doyle JR. Candida tenosynovitisinan
AIDS patient: acase report. JHand Surg [Am] 1994; 19:293–4.
4. Dickson-Wright A. Te ndon sheath infection. Proc RSoc Med
1943–1944; 37:504.
5. Carter SJ, Burman S, Mersheimer WL .Treatment of digital tenosynovitis by irrigation with peroxide and oxytetracycline. Ann Surg
1966; 163:645–50.
6. Neviaser RJ. Closed tendon sheath irrigation for pyogenic flexor
tenosynovitis. JHand Surg 1978; 3:462–6.
7. Nemoto K, Ya nagida M, Nemoto T. Closed continuous irrigation as
atreatment for infection in the hand. JHand Surg 1993; 18(B):783–9.
8. Gosain AK, Markison RE. Catheter irrigation for treatment of
pyogenic closed space infections of the hand. Br JPlast Surg
1991; 44:270–3.
9. Schnall SB, Vu-Rose T, Holton PD ,etal. Tissue pressures in
pyogenic flexor tenosynovitis of the finger.JBone Joint Surg Br
1996; 78-B:793–5.
10. Besser MI. Digital flexor tendon irrigation. Hand 1976; 8:72.
11.Gutowski KA, Ochoa O, Adams WP,Jr. Closed catheter irrigation is
as effective as open drainage for treatment of pyogenic flexor
tenosynovitis. Ann Plastic Surg 2002; 49:350–4.
12. NeviaserRJ. Infections. In: Green DP,ed. Operative Hand
Surgery,3rd ed., Vol. 1. New York: Churchill Livingstone,
1993:1021–38.
13. Michon J. Phlegmon of the tendon sheaths. Ann Chir 1974;
28(4):277–80.
14. Moran GJ, Tala DA. Hand infections. Emerg Med Clin North Am
1993; 11:601–19.
15. Harris PA ,NanchahalJ.Closed continuous irrigation in the
treatment of hand infections. JHand Surg [Br] 1999; 24(3):328–33.
16. LoudonJB, MinieroJD, Scott JC. Infections of the hand. JBone Joint
Surg1948; 30B:409–29.
17. Pollen AG. Acute infections of the tendon sheaths. Hand 1974;
6:21–5.
18. Glass KD. Factors related to the resolution of treated hand
infections. JHand Surg1982; 7:388–94.
19. Bauman JT,Millon SJ, Tanner SL. The outpatienttreatment
of pyogenic flexor tenosynovitis. JSurg Orthop Adv 2005;
14(2):92–5.
Treatment of Pyogenic Flexor Tenosynovitis Using Closed Catheter Irrigation
&
325
43
Dupuytren’s Contracture
Lawrence C. Hurst and MarieA.Badalamente
Department of Orthopedics, State University of New York, Stony Brook, New York, U.S.A.
&
INTRODUCTION
Dupuytren’s disease (DD) is afixed flexion contracture deform-
ity of thefingersthatcan causeprogressive loss of hand
function. It was first described by Felix Plater of Basel in 1614
(1). Henry Cline, from London, in 1777 was the first to recognize
the role of the palmar fascia. However,inthese early times
confusion still existed as to whether the flexor tendons, their
sheaths, or the palmar fascia were responsible for the finger
contractures. Baron Guillaume Dupuytren, in France, in 1831 (2)
correctlydescribed thepathologicanatomy andperformed
surgery to correct the condition. Thus, the disorder now bears
his name.
It wasnot until the1940sand 1950s that investigators
recognized the fibrosis of the palmar fascia and changes in
cell density as time progressed (3,4). Luck divided the disease
into stages based on microscopic cell density.The classification
is still in use today.The first two stages, the proliferative and
involutional, are characterized by increasing cell densities with
collagen fibrosis. By the last residual stage, cell density markedly decreases with severe collagen fibrosis establishing the
well known cords of the disease. By the early 1970s, Gabbiani
and Majno’s work (5) firmly established that the pathognomic
cell in the palmar fascia was atype he termed as myofibroblast.
This cell had characteristics of afibroblast and smooth muscle
cell, since it contained adense array of intracellular contractile
filaments. The question remained for along period was how a
supposedlycontractilecelltypemight transmit contractile
forcestothe extracellular collagen, thus producing the contractures. In alandmarkstudy,Tomasek and Haaksma(6)
establishedthatthe intracellulargenerationofcontractile
forcesbymyofibroblasts was transmitted to the surrounding
collagen through astructure they termed the fibronexus. This is
atransmembraneadhesion complex from intracellular actin
filaments via fibronectin to surrounding collagen fibrils.
Since then, much literature has reported on the nature of
thecollagenous and extracellular matrix (7–11),aswellas
substances which may influence the contractility of myofibroblasts. The rationale was that if the cell biology of the disease
could be specifically detailed, then inhibitors of myofibroblast
proliferationand/or thecontractilepropertiescould be
developed. Among the cell substances studied were:
&
Prostaglandins E
2
and F
2 a
(12)
&
Platelet derived growth factor (13)
&
Lysophosphatic acid (14)
&
Interferon gamma 2 b (15,16)
&
Androgen receptors (17)
&
Beta-catenin oncogene (18)
&
Nerve growth factor (19)
&
Interleukin 1 a (20)
&
Alpha 5-beta 1integrin (21)
&
Z9f transcription factor (22)
Among the substances studied for their ability to induce
myofibroblast proliferation weretransforming growth factor b
1
and b2(23–25)and fibroblastgrowthfactor(23).Itisstill
unknown what cellular signals induce apoptosis (cell death)
of myofibroblasts in the last, residual stage of the disease.
The treatment goal for DD is restoration of hand function
by correcting the flexion contracture. At the present time, there
is no perfect operation or standardaccepted approach to
achieve this goal. Numerous surgical techniques are employed,
ranging from simple fasciotomy(divisionofthe contracted
cords) to limited or radical fasciectomy.Inaddition, there are
just as many different options for management of the skin. The
rate of complications from surgicalrelease of Dupuytren’s
contracture of the hand is relatively high and can be categorized
into intraoperative, early and late postoperative. Intraoperative
complications include nerve and arterial injuries. Early postoperativecomplications (beforewound healing) include
hematoma, wound infection, complex regional pain syndrome,
and skin slough. Late postoperative complications include scar
contraction and recurrence.
In an effort to minimize complications from Dupuytren’s
surgeries, many non- and minimally invasive techniques have
been investigated. In recent years many nonoperative therapies
targeting myofibroblasts have been studied. Hyperbaric oxygen
for the treatment of early stage DD has been described in a
case report on onepatient (26).Triamcinoloneinjections of
early disease nodules have been reportedtohave merit (27).
Similarly,depomedrone,invitro, wasshown to downregulate expression of transforming growth factor b (28). Also,
in vitro, tamoxifen has been shown to decrease the ability of
myofibroblasts to contract (29).The immunosuppressant
5-fluorouracilwas showninvitro to inhibitmyofibroblast
proliferation and differentiation (30). However,when used in
patients as atopical treatment, there was no beneficial clinical
effect (31,32).
French rheumatologists haverecently popularized
fasciotomy usingapercutaneousneedle technique. In this
technique, the bevel of the needle is used as acutting blade.
The surgical approach of this percutaneous technique is blind,
which is an obvious disadvantage. Foucher et al. (33) reviewed
the charts of 211patients in which 261 hands and 311fingers
weretreatedbypercutaneous needle aponeurotomy.The first
100 patients wereevaluated with amean follow-up of 3.2 years.
Only one digital nerve was found to be injured. However,the
recurrence rate was unacceptably high at 59%. These 59 patients
needed further hand surgery.
The use of thecontinuous elongationtechniqueor
technicadi extrensiona continua (TEC) device was developed
first in the 1960s and theninthe early1990s by Messina
et al. (34). This device provides continuous elongation of the
Dupuytren’scontracturebefore doinganopenfasciectomy.
TheMessina TECdevice provided skeletaltractionofthe
pathologic cordofDD(35,36). The traction (distraction) was
applied at arate of 2mmper day over an average period of
twoweeks. Othershave appliedthe skeletal tractionusing
the TEC device for as long as four weeks. Significant reduction
of thecontracture is usuallyachieved, butstretchingout
of the finger must be quickly followed by limited fasciectomy
or thecontracture will recurrapidly.The complications
followingTEC can be significant, suchasrapid recurrence,
infection, stiffness in extension, pain, and reflex sympathetic
dystrophy.
Another surgical method which was purported to be less
invasive is segmental aponeurectomy.This procedure was first
proposed by Vilain in 1982 in apresentation at aconference of
the Belgian Hand Group. Moermans (37,38) performed prospective studies of this technique. He postulated that if apermanent
discontinuity could be createdwithout wide dissection of the
diseased fascia, then the contracture might disappear.Small
pieces of diseased fascia about 1cmlong wereexcised, beginning from proximal to distal through C-shaped incisions. While
intraoperative correction of the joint contractures was achieved,
the mean recurrence rate at 2.6 years in Moerman’s series (37) of
213 patients was 35.7%. Andrew and Kay (39) also investigated
the use of segmental aponeurectomy in 40 hands. They reported
good results in correction of metacarpophalangeal (MP) joint
contracturesat12months follow-up, but only half the patients
with proximal interphalangeal (PIP)joint contractures had
agoodresult. In this study, themeanresidual PIP joint
contracture was 228 at both 1and 12 months postoperatively.
Segmentalaponeurectomy is notafavored techniquein
use today.
In the mid 1990s, the authors of this chapter began to
developanother nonoperativetherapy usingawell-known
enzyme, collagenase, for the purpose of lysing the Dupuytren’s
cord and inducing cord rupture. The concept of enzymatic
fasciotomy had been investigated before by Hueston (40), who
combined both trypsin and hyaluronidase intraoperatively.This
method provided clinical benefit initially,but reportedly had a
high recurrence rate (41).
We developed purified collagenase (Auxillian Inc.) as a
stand-alone injection therapyand notasanintraoperative
adjunct (42,43). The results of Phase 2clinical trials indicate
that collagenase injection into Dupuytren’s cords has merit as a
minimally invasivetreatmentofthisdisorder(44,45).Our
experience with this technique is presented below.
&
INDICATIONS
At thepresent time,collagenase injectionintoDupuytren’s
cords can only be done as part of the U.S. Food and Drug
Administration (FDA) investigational new drug. Indications are
evolving as more experience is gained from the clinical trials.
The authors have employed this technique on patients with the
clinical diagnosisofDDwho have 208 or greater flexion
contractures of the metacarpophalangeal (MCP) and/or PIP
joints. Patients with recurrence of contracturesafter asurgical
release are also candidates for the injection. These criteria are
similar to those for open release, where it is generally accepted
that progressive MP contracturesof30 8 or greater or any
progressive PIP contracture of greater than 158 is an indication
for surgery.
There arerelatively fewcontraindications forthis
procedure. Patients who are unable to tolerate aneedle puncture in the palm andthose whomay be allergic to the
collagenase should not undergo the procedure.
&
CONSIDERATIONS FOR PRE-PROCEDURE
PLANNING
Pre-procedureexamination shouldconfirm that DD is the
primary cause of the finger flexion deformity.Patients with
secondary PIP capsular/volar plate contracturemay require
operative procedureatthe PIP to restore extension. Imaging
and other studies are not usually needed.
&
TECHNIQUE
The procedure is done in the office setting. The skin over the
contracted cord is prepped and 10,000 units (0.58 mg AA4500)
collagenase (in asodium/calcium diluent) is delivered into the
cordatthe pointofmaximumbowstringingofthe finger
contracture using an insulin syringe and a27-gauge needle
(Fig. 1). Avolume of 0.25 mL for the MCP joints and 0.20 mL for
thePIP joints is used. In thecaseofpatientswith MCP
contractures of adjacentfingers, with pretendinous and
natatoryY-shapedcords (Fig. 2), placement of the injection
should be at the point of the Yinattempt to affect both digits.
Patients are seen the following day for passive manipulation/extension of the affected digit(s) to manually rupture the
cords.Local anestheticcan be usedwhenattemptingcord
rupture but is not required. If cordrupture does not occur
with the manipulation, thepatients are instructed to apply
extension forcesathomeunder theirown control. Home
extensionexercises areencouraged. Patients arealsofitted
with anight extension splint that is worn for four months.
Daily vitamin Emassage for four months is recommended to
keep the treatment area soft and pliable.
Formultiple joints or digits involvement that didnot
response adequatelytothe first injection, thecollagenase
injection technique is staged at four to six weeks later.The
rationale for allowing time between injections was to allow
potential adverse events to resolve. Atotal of three injections
can be done directed at the cord of one finger joint contracture.
The maximum number of injections perpatient,involving
several fingers and/or bilateral disease is still under investigation in clinical trials.
&
Illustrative Case Example
A70-year-oldright handdominantmalepresented with
bilateral DD of the hands. His contractures involved the right
FIGURE 1 The technique of collagenase injection involves direct cord
injection, as shown in this photo of an metacarpophalangeal joint.
328
&
Hurst and Badalamente
little MP and PIP joints (208 and 508 ,respectively) and the right
ring MP and PIP joints (508 and 358 ,respectively). Left hand
diseaseconsisted of 308 long andringfingercontractures.
Figures3and 4show this patient’s pretreatment contractures.
The first collagenase injection was directed at the right ring
MP/PIP contractures. The MP joint is always injected first as
this is thepoint of maximal bowstringing.Itisnot to be
expected that both MP and PIP joint contractures will resolve
with one injection. This is morelikely if there is acentral cord.
At dayone,the cord ruptured and thefinger wasfully
straightened. As the right little MP contracturehad anatatory
cord, this contracture also fully corrected to 0 8 by one week post
injection. The right little PIP joint contracture was injected with
collagenase six weeks later.Byone month after collagenase
injection, the PIP joint contracture was fully corrected to 0 8 .
Attention was then turned to the left hand contractures. At
five weeks post the second injection, the left ring MP contracturewas injected and the cord ruptured the next day with full
correction to 0 8 .Five weeks later,this patient received afinal
collagenase injection for the remaining left hand, long finger
MP contracture. Thiscontracture alsorespondedwithcord
rupture and full correctionto08 at one day after the injection.
This patient remains free of recurrence was no loss of flexion or
grip strength at the last follow-up visit, 12 months post the last
injection (Figs. 5and 6).
&
COMPLICATIONS AND THEIR MANAGEMENT
Side effects of the collagenase injection include finger/hand
edema, tenderness and ecchymosis of the injected finger.In
patients whose PIP joint cords wereinjected, some experienced
tenderness of the lymph nodes at the elbow and/or axilla. These
adverse events resolved within 7to14days of injection (44,45).
Skin tears can occur during manipulation and cordrupture
in patients with long-standing, severe contractures. The tears
can be treated with local wound care and will heal within
several weeks.
&
OUTCOMES
The outcome of collagenase correction of Dupuytren’s contractureisbased on FDA regulated Phase 2clinical trials (45). The
first part of the study was aplacebo-controlled, random, doubleblind investigation. Thirty-six patients with MP contractures and
13 patients with PIP contracturesonly were enrolled. Eighteen
MP patients were assigned to drug treatment and 18 to placebo.
FIGURE 2 Cord injection. When apatient has aY-shaped cord, created
by acombination of the central and natatory cords, the point of the Y
should be injected with collagenase.Injection of this site may result in
simultaneous correction of adjacentfinger metacarpophalangealjoint
contractures.
FIGURE 3 A70-year-old male patient with right hand ring and little
finger metacarpophalangeal andproximalinterphalangeal joint
contractures.
FIGURE 4 Same patient as in Figure 3, left hand long and ring finger
metacarpophalangeal joint contractures.
FIGURE 5 Same patient as in Figures3and4,after successful
collagenase injection treatments.
Dupuytren’sContracture&329
Fourteen of the 18 MP patients (77%) fully corrected after one
0.58 mg unit collagenase injection. The remaining four patients
fully corrected to 0 8 extension after asecond open label, 0.58 mg
unit collagenase injection. Tw oplacebopatientswithMP
contracturealsofully corrected,but it wassubsequently
determined that there was an error by the pharmacist. In fact,
these two placebo patients had been given 0.58 mg collagenase.
Five of seven patients (71%) with PIP joint contractureswho were
in the0.58mgcollagenase groupcorrectedfully afterone
injection and one patient corrected fully after asecond collagenaseinjection.Six of sixopenlabel placebopatientsdid not
respond. Upon re-treatment of placebo patients with 0.58 mg
collagenase, four of the six patients (66%) corrected to normal
extension. In this study,atotal of six patients were injected who
had prior surgical fasciectomy with recurrent contractures. All
had PIP joint (only) contractures. Three PIP joints werecorrected
to normal extension and three werenot. The recurrence rate, after
collagenase injection(s), in this study was 8% for MP joints and
25% for PIP joints, at five years.
Because the results of the 0.58 mg versus placebo study
indicated that collagenase injections had substantial merit, after
FDA consultation, it was decided that asecond random, doubleblind, placebo-controlled, dose responsestudy shouldbe
performed. This was to determine if 0.58 mg collagenase was
indeed the minimum, safe and effective dose. This trial was
multicenter with two test sites with 80 patients entered the study
(45). Fifty-five patients had MP joint contracturesand 25 patients
had PIP joint contractures. Patients wererandomized to placebo
cordinjections,
1
⁄
4
dose,
1
⁄
2
dose, or 0.58 mg collagenase. The
0.58 mg treatment group clearly showed the best clinical benefit
in inducing cord ruptures (Figs. 3and 4). By one month after
0.58 mg collagenase injection, 14 of the 18 patients (77%) with MP
contractures achievedfullextension.The remainingfour
patients with MP contractures who did not respond to the first
injection had asubsequent 0.58 mg injection. All four MP joints
correctedtonormal extension by one month.
PIP joint contractures also responded in asimilar manner.
Five of seven patients (71%) with PIP joint contractures who
weretreatedwith the 0.58 mg dose corrected to full extension
after one month.
Statistical testing, using Fisher ’s exact test, indicated that
the “clinical success rate” for return to normal extension at the
0.58 mg dose was 90% for MP joint contractures and 70% for PIP
joint contractures. The authors speculate that the lower success
rate in PIP joints may be due to resistantabductor digiti minimi
cords and that division of the volar plate check veins is not
possible with collagenase injections. The recurrence rate, after
collagenase injection(s), in this study was 10% for MP joints and
20% for PIP joints at five years.
&
SUMMARY
Collagenase injection into the Dupuytren’s cordisasafe and
effective minimally invasive method to treat MCP and/or PIP
flexion contractures. Patients regain finger extension and thus
have improved rangeoffinger motion.Flexion andgrip
strength werenot adversely affected by collagenase injection.
Arandom, placebo-controlled, dose-response study in clinical
trial IIB showed that 0.58 mg of collagenase is the minimum safe
and effective dose for cord injection. Adverse effects of collagenase injection are limited to local tissue reaction consisting of
pain,edema,ecchymosis,and an occasionalelbow and/or
axillarylymphadenopathy. These side effectsresolve in the
short term and have no long-term sequela. To date, clinical
trials show relativelylow recurrencerates.Weexpectthat
recurrences of disease can be treated with repeat collagenase
injections. Those that fail the maximum number of injections
can still be treated with an open surgical procedure.
At the time of this writing, collagenase injection for DD of
the hand is not yet commercially available. Multi-center,Phase 3
clinical trials areongoing to provide data to the FDAfor
approval. In the future, this minimally-invasive technique of
cord rupture may prove revolutionary as astand-alone treatment of DD.
&
SUMMATION POINTS
Indications
&
Can only be used as FDA investigational new drug
&
Similar to those for open release
&
RecurrenceofDupuytren’scontractures aftersurgical
release
Contraindications
&
Allergy to collagenase
Outcomes
&
90% of MP joint contractures regain full extension
&
70% of PIP joint contracturesregain full extension
&
Recurrence rate of 10% for MP joints and 20% for PIP joints
at five years
Complications/Adverse Effects
&
Finger/hand edema
&
Tenderness and ecchymosis of the injected finger
&
Transient lymphadenopathy at elbow and/or axilla
&
Skin tears
&
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FIGURE 6 Same patient as in Figures 3– 5showing normal flexion after
collagenase treatments.
330
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Hurst and Badalamente
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Dupuytren’sContracture
&
331
Index
Acute fractures, non-bridging external fixation of distal
radius, 144–145
Acute left thumb UCL injury,surgical technique, 8
Acutrak cannulated screw (Acumed), 30
Adaptive proximal schapoid implant, placement, 126
Agee technique, carpal tunnel release, 305–309
Anatomic basis for hand and wrist MIS, 1–2
Anchor
flanged, 7
threaded, 8
toggle, 7
AO/ASIF classification, distal radius fractures, 176, 183
AO/ASIF screw,30
ARC traction tower,225
Arthritis associated with scapholunate and scaphoid
nonunion, minimally invasive treatment, 247–255
See also Distal scaphoid excision, Proximal row carpectomy,
Radial styloidectomy.
Arthrodesis
external fixation of metacarpals and phalanges, 74–75
interphalangeal joint, 23
Arthroscopic portals, 2
Arthroscopic treatment. See Basal joint arthritis arthroscopy;
Chow technique; MP joint arthroscopy; Metacarpophalangeal joint fractures in the hand; Thumb
CMC arthroscopy; Wrist and hand arthroscopy;
Wrist ganglion cysts;
Articular fracture–phalangeal base, 49–50, 52
ASIF compression plate, in distal radius fractures, 154
Augmented external fixation, distal radius fractures, 133–142
aftercare, 139
complications, 139–140
goal of treatment, 133–135
indications, 133
Kirschner wires, 137
neutral alignment of wrist, 135, 136
operative technique, 135–138
outcomes, 140–142
physical exam, 133
preoperative planning, 133
surgical technique, 133–138
Awl, prefabricated, 1
Baby Bennett’s fracture, 38, 41
Balloon reduction and grafting, distal radius fractures,
175–179
complications, 177
indications, 175
outcomes, 178
postoperative management, 176–177
preoperative planning, 175
supplemental fixation, 177
surgical technique, 175–176
Basal joint arthritis, arthroscopy/debridement, 263–266
1R portal, 264
1U portal, 264
[Basal joint arthritis, arthroscopy/debridement]
anatomy,264
complications, 265
equipment, 264
indications, 263
nonoperative treatment, 264
outcomes, 265
pathogenesis, 263
preoperative imaging, 263–264
preoperativeplanning, 263
surgical technique, 264
Basal joint arthritis, soft-tissue interposition, 267–273
1R portal, 271
1U portal, 271, 272
complications, 270
indications, 267
operative setup, 268
outcomes, 270–271
portal sites, 269
preoperative planning, 267
subcutaneous landmarks, 268
surgical technique, 267–270
Bennett’s fracture
displaced, 47
mini screw fixation, 46–47
outcome, 52
percutaneous pinning, 38–39
Bent wire fixator,66–68, 69, 70
Bioabsorable implants, 19–26
animal investigations, 20
evolution of, 19–20
experimental studies, 20–21
human investigation, 21
indications for use, 21
processing and sterilization, 19–20
properties of, 19
Bioabsorbable suture anchors, 5–6
Biocompression screw (Arthrex Corp.), 24
BioSymMetRic PIP fixator (Biomet), 64–65
“perfect circle” technique, 66
Bone apatite, and calcium phosphate cement, 12
Bone bridge, use of, 5
Bone graft substitutes, 11–16
Bone lesions, bone graft substitutes and, 15–16
Bone tunnels, 5
Boxer ’s fracture, 38
Button, use in sutures, 5
C-arm image intensifier,1,2
Calcium phosphate cement, 11–12
hardening of, 12
injectable form, 12
ionic combinations, 11
Calcium sulfate cement, 12
Calcium sulfate resporption, 12