A review of outcomes after operative fixation of clavicular fractures over a 10-year period-a single tertiary trauma unit experience.

BACKGROUND: Early definitive fixation of clavicular fractures is rising in popularity when compared with conservative management. Despite this, the relative risk of subsequent hardware removal or revision surgery is relatively undocumented in the literature. The aim of this study was to review all clavicle fractures treated operatively in a single tertiary referral trauma unit and determine the true incidence of hardware removal and revision rates among this cohort. METHODS: A retrospective electronic review was performed in a single tertiary trauma unit for all open reduction internal fixation of clavicle fractures over 10 years (2010-2019 inclusive). All patients were cross referenced for hardware removal during the same period. Patients identified as having undergone ORIF clavicle were reviewed via the National Integrated Medical Imaging System to identify the fracture pattern, fixation method, radiographic nonunion, or radiographic malunion. Age, gender, time from injury to fixation, and time from insertion to removal of hardware where relevant were also collected. RESULTS: Over the 10-year period from 2010 to 2019, 352 patients underwent ORIF of clavicular fractures. After application of inclusion and exclusion criteria, 346 patients (76% male and 24% female) were analyzed with a mean age of 34.46 years old (95% confidence interval [33.02-35.91]). In total, 54 (15.6%) patients underwent removal of hardware. When fracture type and fixation method were accounted for, only 11% of plate fixations for mid-shaft fractures (n = 29) were removed, whereas 76% of clavicular hook plates for distal fractures (n = 25) underwent removal (P < .001). No distal clavicle fractures treated with locking plates underwent removal (n = 23). Women were almost 3 times more likely to undergo removal of hardware than men (28.6% vs. 11.5%, P < .001). Seven patients (2%) underwent revision ORIF in the 10-year period for nonunion (n = 3), malunion (n = 2), and failure of fixation (n = 2). The mean follow-up time was 1 year (366 days) for those who underwent subsequent surgery and 5.7 years (2087 days) for those who did not. CONCLUSION: Clavicular fracture fixation using either locking or hook plates is a safe method of treatment with a very low reoperation rate for either hardware removal or revision. Women are more likely to request plate removal. Distal locking plates are a safe alternative to hook plates for distal one-third clavicle fractures with lower reoperation rates. Newer techniques are emerging for the management of distal fractures such as tight rope fixation and locking plates which also appear to be successful.

Hand dominance and experience improve bimanual performance on arthroscopic simulator task.

PURPOSE: The aim of this study was to identify if experience in arthroscopy confers ambidexterity to the operator and the role of baseline characteristics in arthroscopic simulator performance. METHODS: A prospective comparative study was carried out across four regional Orthopaedic training centres. Participants were divided into novice, intermediate or experienced groups based on arthroscopic experience. Baseline demographics including age, sex, handedness, and gaming history were also collected. Following familiarisation with the procedure, participants were asked to complete a simulated task requiring bimanual control consisting of visualisation with camera control and manipulation of highlighted objects using a grasping instrument. One attempt using camera control and grasping accuracy per hand was performed by each participant, with scores for each hand collected for analysis. Performance scores for camera alignment, camera path length, grasper path length and grasping efficiency were collected. Time taken to completion was also noted for each attempt. RESULTS: Fifty-six participants were recruited to the study. A significant difference in grasping efficiency between groups in the dominant hand was demonstrated (p = 0.013). Novices demonstrated laterality with superior performance in grasping efficiency in the dominant hand (p = 0.001). No significant difference was noted between dominant and non-dominant hand performance in the experienced group. CONCLUSION: Arthroscopic simulation-based training is a valuable learning tool for orthopaedic training. This study demonstrated that experienced orthopaedic surgeons have a greater degree of ambidexterity than intermediate or novice groups, hypothesised by authors to be conferred through conventional orthopaedic training. Dedicated bimanual control tasks to reduce laterality in trainees should be incorporated in simulated surgical curricula. LEVEL OF EVIDENCE: III.

Management of "torus" or "buckle" fractures of the distal radius: a systematic review.

BACKGROUND: Torus fractures, also known as buckle fractures, of the distal radius are a very common reason for presentation to emergency departments. Traditional approaches to their management involved immobilisation in a circumferential cast but the evidence now supports the use of removable splints with or without radiological and clinical follow-up. Unfortunately current practice conflicts with the evidence base and there is no guideline which highlights all the evidence as one clear, concise management protocol. METHODS: An online review of Pubmed, EMBASE, Biomed, and the Cochrane library using keyword searches combining "radius", "torus", "buckle" and "fracture" was performed. All prospective, retrospective or randomised trials involving the management of distal radius torus fractures in patients aged 0-18 years were included. Our outcomes focused on 5 aspects of patient care: immobilisation method and duration, clinical follow-up, radiological follow-up and the use of diagnostic ultrasound. RESULTS: The initial search identified 143 papers which following application of the inclusion and exclusion criteria 21 articles were deemed eligible. A Cochrane review and 8 systematic reviews were also identified and manually searched for missed articles and this yielded a further 3 articles. CONCLUSIONS: Current research indicates that torus fractures should be managed with a removable splint supplied in A&E and worn for 3 weeks. There is no need for fracture clinic follow-up or repeat radiological imaging once patients are given adequate information at the time of diagnosis. This would represent both an economical and resource saving for patients, parents and the health service.

Determining the accurate placement of a posterior portal in shoulder arthroscopy with the use of computerized tomography images.

Background: Portal placement is an important factor in performing a successful shoulder arthroscopy. Recent cadaveric studies have found variance in the anatomy of the glenohumeral joint. Our aim was to determine if computerized tomography (CT) images could be used to map the trajectory of the posterior portal objectively and then measure the distance between this trajectory and palpable landmarks to apply this knowledge to clinical practice. Methods: Two-dimensional multiplanar reformatted CT images were generated using OsiriX (Pixmeo, Switzerland) from CT images performed in a tertiary hospital over a 1-month period. The center of the glenoid was identified and a trajectory through it radiologically mapped. Horizontal and lateral measurements were taken from this trajectory to both the posterolateral edge of the acromion and tip of the coracoid. Results: Following application of inclusion and exclusion criteria, 226 shoulders were analyzed. Fifty scans were selected at random and re-reviewed by the primary examiner to assess intra-rater reliability which showed strong correlation and no significant differences between first and second measurements (P < .01, r > 0.6). The mean distance from acromion to portal trajectory was 1.39 cm inferiorly (95% confidence interval [CI] 1.31-1.48, standard deviation [SD] 0.65 cm) and 1.44 cm medially (95% CI 1.35-1.53, SD 0.71 cm). The mean distance from the coracoid to the trajectory was 1.71 cm inferiorly (95% CI 1.64-1.78, SD 0.55 cm) and 1.26 cm medially (95% CI 1-2-1.31, SD 0.45 cm). Paired t-test analysis between right and left shoulders within the same subject, where these data were available (n = 81), showed no significant difference (P > .05) between sides. Subset analysis was also performed between males and females, but only showed a significant difference between the vertical distance from the coracoid process to the center of the glenohumeral joint. This distance was shorter in females compared to males (1.56 cm in females compared to 1.84 cm in males, P < .001). Conclusions: Knowledge of shoulder anatomy is vital to the placement of arthroscopic portals, yet research on this topic has been based primarily on surface anatomy, small sample sized cadaveric studies or expert opinion alone. Our study shows that posterior portal placement in shoulder arthroscopy can be measured objectively using CT scanning.

What Happened after the Poly Implant Prothèse Recall? A Prospective Cohort Study of 808 Implants into the Predictive Value of Implant Rupture on Postexchange Complications.

BACKGROUND: Problems with a variety of breast implants have emerged with consequences for patients' health and safety. The authors' goal was to follow up on their Poly Implant Prothèse patients after their implant exchange. METHODS: This single-center, single-surgeon, prospective cohort study lasted from 2012 until 2017. Implant size, implantation interval, surgical details, and complications were registered. The Clavien-Dindo classification was used to grade postoperative complications. Logistic regression was used to investigate whether rupture, interval between implantation and explantation, and new implant size were predictors of postexchange complications. RESULTS: The authors explanted 808 implants in 404 patients. The rupture rate was 30.9 percent per patient and 20.2 percent per implant. The capsular contracture rate at the time of exchange was low, with 1.86 percent of implants and 2.7 percent of patients; 97.8 percent of patients elected implant exchange and only 2.2 percent just wanted their implants removed. The mean follow-up after implant exchange was 5.2 years, with the last mandatory outpatient appointment usually being scheduled 6 to 12 months after implant exchange. The authors found that 74 patients (18.3 percent) and 124 implants (15.3 percent) had postexchange complications, the majority of them minor (83 percent Clavien-Dindo grade I). Patients with a ruptured implant at the time of exchange were significantly more likely to develop postexchange complications than were patients without rupture. CONCLUSIONS: This is the first study providing such a complete long-term postexchange follow-up of a single surgeon's Poly Implant Prothèse implant cohort. Implant rupture at the time of exchange had a high predictive value for postexchange complications in the authors' series of 808 implants and 404 Poly Implant Prothèse recall patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Intracranial Involvement in Multiple Myeloma Presenting as a Cranial Nerve Palsy.

Multiple myeloma (MM) is characterized by the neoplastic proliferation of plasma cells producing a monoclonal immunoglobulin. Neurological complications in MM most frequently occur due to spinal cord compression by bony lesions, paraprotein-related neuropathy, hypercalcemia, hyperviscosity, or amyloidosis. Intracranial involvement is a rare complication of MM occurring in only 1% of patients. It can manifest as a solitary cerebral lesion, intra-parenchymal infiltration, or diffuse leptomeningeal disease. We present a case of a leptomeningeal myeloma in a 71-year-old woman with known relapsed MM presenting with a right sixth nerve palsy. Our patient was receiving spinal irradiation for a paraspinal plasmacytoma when she complained of double vision. Clinical exam revealed a right sixth nerve palsy. MRI revealed diffuse abnormal leptomeningeal thickening and enhancement typical for diffuse leptomeningeal infiltration. She was treated with whole brain irradiation and intrathecal methotrexate combined with a lenalidomide and dexamethasone chemotherapeutic regimen but unfortunately she passed away 5 weeks after onset of visual symptoms. MM involving the central nervous system (CNS) is a rare complication of MM and carries a poor prognosis with an average survival of 3 months. Due to its rarity, treatment of CNS MM is very heterogeneous. Thus case reporting is important to accumulate data on this rare presentation.

Frail older adults' perceptions of an in-hospital structured exercise intervention.

BACKGROUND: Exercise interventions need to be assessed qualitatively to establish how people participate in and perceive the intervention and how interventions should be delivered for maximal effect. OBJECTIVES: To explore how frail older inpatients perceived the effects of a pilot augmented prescribed exercise programme (APEP). DESIGN: An interpretive phenomenological design using open-ended semi-structured interviews. Data were analysed using thematic content analysis. SETTING: An acute teaching hospital. PARTICIPANTS: Thirteen of the frail older adults who participated in the APEP. RESULTS: The participants' perceived relationship with the interventionist was highly influential, affecting participation rates, perceived value of the APEP, and outcome expectations. Pre-existing positive outcome expectations increased the likelihood of fully engaging in the programme and valuing the outcomes. Barriers to the intervention included negative or no outcome expectations and fatalism. Recent exercise history affected their views of the APEP. Perceived positive outcomes included increased intention to exercise postdischarge, improved self-efficacy and perceived improvements in physical status. CONCLUSION: Exercise interventions targeting frail older adults in the acute setting may benefit from taking a multifaceted approach to implementation. Education tailored to the participants, and setting restorative goals, may improve outcome expectations and future intention to exercise. The relationship between the participants and those implementing an intervention appears critical to their participation and whether they value the programme.

Website malfunction: a case report highlighting the danger of using electrical insulating tape for buddy strapping.

A case of injury to the third web space of the right hand of a rugby player, as a result of buddy strapping with electrical insulating tape of the little and ring finger, is presented. A deep laceration of the web space and distal palmar fascia resulted, necessitating wound exploration and repair. This case highlights the danger of using electrical insulating tape as a means to buddy strap fingers.