Editorial Commentary: Clinical Trial Subgroup Analyses and Investigation of Secondary Outcome Measures Should Be Limited in Number to Avoid False Findings.

Large randomized clinical trials are our highest quality evidence. Performing subgroup analyses and analysis of secondary outcome measures can and should be done to increase the scientific yield of these expensive and difficult studies. However, caution must be maintained when dramatic or unexpected outcomes are achieved. If we perform a large number of subgroup analyses and these are independent of each other, the risk of false-positive findings increases.

Editorial Commentary: Regression Modeling and Nomograms in Biomedical Research Are Valuable Decision-Making Tools When Externally Validated and Well Maintained.

The mathematical formulas underpinning biostatistical modeling in medical research can be complicated. Nomograms are pictoral tools showing a graphical solution of a formula in which all variables in the formula can be read off the diagram. Nomograms can be used to simplify the calculation of risk of recurrence of injuries or disease. Although nomograms can be valuable, external validation is required (of all models) to ensure accuracy outside of the original population, because variation in patient populations, activities, and risk behaviors outside of the patient data used in the original analysis may deteriorate model performance (external validity). A model also needs to be maintained over time to ensure continued accuracy as populations and activities change. A model that fails to keep up will eventually have its accuracy and clinical utility fade. An externally validated, well-maintained model can be a valuable tool for patient counseling and decision-making.

The influence of posterior acromial morphology on outcomes and return to pushups in young patients undergoing arthroscopic posterior capsulolabral repair.

Background: Prior evidence has identified specific posterior acromial morphology as significantly associated with unidirectional posterior shoulder instability. The purpose of this study is to determine the influence of posterior acromial morphology on the outcomes of arthroscopic posterior capsulolabral repair (APCLR) for unidirectional posterior shoulder instability. Additionally, we sought to determine the influence of posterior acromial morphology on the rate and time to return to pushups following APCLR. Methods: We performed a retrospective review of prospectively collected data. The study included consecutive patients undergoing APCLR. Data collected included demographics, radiographic measurements including posterior acromial height (PAH) and posterior acromial tilt on preoperative scapular-Y radiographs, and patient-reported outcome measures at the preoperative and postoperative visits. In addition, starting at 6 months postoperative, patients were asked if they could perform pushups defined as at least 10 repetitions. At the final follow-up, we collected the number of pushups patients were able to perform. Results: Thirty-two consecutive patients underwent APCLR with a mean follow-up of 26 months (range, 12-41). Significant improvement from preoperative to 2 years postoperative was demonstrated in Subjective Shoulder Value (50-85), VAS (6-2.5), American Shoulder and Elbow Surgeons (48 to 83), and Western Ontario Shoulder Instability (WOSI) (1437-777), P = .001. The recurrent instability rate was 3/32 (9%). Patients with PAH > 23 (N = 17) had a recurrent instability rate of 18% (3/17) versus PAH ≤ 23 (N = 15) 0% (0/15), worse WOSI scores (P = .41), and a lower number of pushups (P = .48). The percentage of patients reporting the ability to perform pushups was (6 months/1 year/2 years) (50%/78%/95%). The mean number of pushups reported at the final follow-up was 33 (range, 1-60). Discussion: Following APCLR, approximately 50% of patients resume pushups at 6 months postoperatively, and 80% return at 1 year. Patients reported performing a mean of 33 pushups following APCLR at the final follow-up. Patients with a PAH greater than 23 on preoperative scapular-Y radiographs had a higher rate of recurrent posterior instability, worse WOSI scores, and lower return to pushups; however, the results did not meet statistical significance. Therefore, future larger studies are needed to determine if posterior acromial morphology is independently associated with worse outcomes and increased recurrent instability rates following APCLR.

A High Rate of Return to Running Is Seen After Both Arthroscopic and Open Shoulder Surgery.

Purpose: To determine the percentage of patients who report the ability to run 1 mile at various time points after arthroscopic and open shoulder surgery. Methods: We performed a retrospective review of prospectively collected data for all active-duty military patients aged 18 to 45 years who underwent shoulder surgery at a single institution over a 2-year period. The rehabilitation protocol discouraged running before 3 months, but all patients were able to return to unrestricted running at 3 months postoperatively. Patients were excluded if they lacked 1-year follow-up data. Parameters collected included demographic information and validated patient-reported outcome measures at the preoperative and short-term postoperative visits, as well as patients' ability to run at least 1 mile postoperatively. Results: A total of 126 patients were identified who underwent shoulder surgery with return-to-running data. Compared with baseline, significant improvements in patient-reported outcomes were shown at 1 and 2 years postoperatively (P = .001). The percentage of patients reporting the ability to run 1 mile postoperatively was 59% at 3 months, 74% at 4.5 months, 79% at 6 months, 83% at 12 months, and 91% at 24 months. There was no significant difference in patients undergoing shoulder surgery for instability versus non-instability diagnoses or in patients undergoing open versus arthroscopic anterior stabilization. All 11 patients unable to return to running at final follow-up had chronic lower-extremity diagnoses limiting their running ability. Conclusions: Young military athletes undergoing arthroscopic and open shoulder surgery have a high rate of early return to running. Approximately 60% of patients report the ability to run 1 mile at 3 months postoperatively, and three-quarters of patients do so at 4.5 months. Age, sex, military occupation, underlying diagnosis or type of surgery did not influence the rate of return to running after shoulder surgery. Level of Evidence: Level IV, therapeutic case series.

Editorial Commentary: Adoption of New Medical Technology Requires Replication of Consistent Results Across Multiple Studies: Biologic Injections for Knee Osteoarthritis.

Determining when to adopt new treatment methods in a clinical practice is a challenging undertaking. Uncertain outcomes of emerging technology can undermine the impartial assessment of risk and benefit. "Optimism bias" can lead to premature adoption of technology. An additional risk is that influential colleagues often persuade clinicians to innovate. "Replicability" or obtaining consistent results across studies aimed at answering the same scientific question must be a goal prior to adoption of innovative devices and treatments. The ability to replicate the results by a separate research group in a similar population with different input data is critical to gaining acceptance from providers without a personal stake in the development of technology.

Rate and time to return to shooting following arthroscopic and open shoulder surgery.

Background: There is limited information on return to shooting following shoulder surgery. The purpose of this study is to determine the rate and timing for resuming shooting a rifle following shoulder surgery. Methods: We performed a retrospective review of prospectively collected data. The study included patients undergoing arthroscopic and open shoulder stabilization for unidirectional shoulder instability, and arthroscopic surgery for rotator cuff tears, SLAP lesions, biceps tendinopathy, and acromioclavicular pathology. Data collected included the laterality of surgery, shooting dominance, and patient-reported outcome measures at the preoperative and postoperative visits. Starting at the 4.5-month clinic visit, patients were asked if they could shoot a military rifle. Results: One hundred patients were identified with arthroscopic and open shoulder surgery with a mean age of 30 years (range, 18-45) and a mean follow-up of 24 months (range, 12-32). The cohort consisted of patients undergoing arthroscopic Bankart repair (n = 23), arthroscopic posterior labral repair (n = 18), open Latarjet (n = 16), mini-open subpectoral biceps tenodesis (OBT) (n = 25), OBT with open distal clavicle resection (DCR) (n = 10), open DCR (n = 4), and arthroscopic rotator cuff repair with concomitant OBT (n = 4). Significant improvement in SSV, VAS, ASES, and WOSI was shown at 1-year postoperative, SSV 85, VAS 2, ASES 85, WOSI 239, P = .001. The percentage of patients reporting the ability to shoot a military rifle postoperatively were 47%, 63%, 85%, and 94% at 4.5 months, 6 months, 1 year, and 2 years, respectively. At 4.5 months postoperatively, patients who underwent surgery ipsilateral to their shooting dominance (n = 59) had a rate of return to shooting (33%) versus shoulder surgery on the contralateral side of shooting dominance (n = 41) (60%), P = .04. However, there was no significant difference in the groups at 6 months and 1 year. Additionally, there was a significant difference in the rate of return to shooting at 6 months in patients undergoing arthroscopic posterior labral repair versus the remainder of the cohort (posterior instability (33%) vs. (69%), P = .016), and a significant difference between posterior shoulder stabilization and anterior shoulder stabilization (70%), P = .03. Conclusion: Patients undergoing arthroscopic and open shoulder surgery have a high rate of return to shooting. Approximately 60% of patients resume shooting at 6 months postoperatively and 85% return at 1 year. Patients undergoing shoulder surgery on the contralateral side of their shooting dominance return to shooting significantly faster than those with shoulder surgery ipsilateral to their shooting dominance. Additionally, those undergoing arthroscopic posterior shoulder stabilization return to shooting at a slower rate than anterior stabilization surgery.

High Incidence of Anterior Shoulder Pain in Young Athletes Undergoing Arthroscopic Posterior Labral Repair for Posterior Shoulder Instability.

PURPOSE: The purposes of this study were to determine the incidence of anterior shoulder pain in young athletes undergoing arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability and in patients with preoperative anterior shoulder pain treated without biceps tenodesis at the time of arthroscopic posterior labral repair who underwent a revision biceps tenodesis procedure at short-term follow up. METHODS: A retrospective review was performed at a single institution over a 24-month period. The study included young patients who underwent an arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability. The electronic medical record, magnetic resonance arthrograms, and arthroscopic images were reviewed to exclude patients with posterior labral tears with anterior labral tear or SLAP (superior labrum anterior-to-posterior) tear extension on advanced imaging and arthroscopic examination. Data collected included the presence of preoperative tenderness to palpation of the biceps tendon in the groove, the results of a preoperative Speed test, postoperative Subjective Shoulder Value, the presence of postoperative anterior shoulder pain, and the need for a secondary biceps tenodesis. RESULTS: We identified 65 patients who underwent arthroscopic labral repair for posterior shoulder instability. From this cohort, 26 patients with symptomatic unidirectional posterior shoulder instability underwent an arthroscopic posterior labral repair. The incidence of preoperative anterior shoulder pain with Zone 2 biceps groove tenderness and a positive Speed test was identified in 20 of 26 patients (76.9%). Of 26 patients, 5 (19%) had concomitant biceps tenodesis. The median postoperative Subjective Shoulder Value was 80 (interquartile range, 60-90) at median follow-up of 2.1 years. Of the 20 patients with preoperative anterior shoulder pain, 8 of 20 (40%) reported persistent anterior pain. One patient (4.7%) underwent a secondary biceps tenodesis. CONCLUSIONS: There is a high incidence of anterior shoulder pain and Zone 2 biceps groove tenderness in patients undergoing isolated arthroscopic posterior labral repair for unidirectional posterior shoulder instability. At short-term follow-up, few patients required a secondary biceps tenodesis procedure; however, 30% of patients had persistent anterior shoulder pain. LEVEL OF EVIDENCE: Level IV, retrospective diagnostic case series.

Editorial Commentary: Radiographic Measurements of Knee Joint Space Are Inadequate for Demonstrating Chondral Restoration.

Orthopaedic advancements into the 21st century will increasingly focus on chondral restoration to either halt or reverse degenerative processes. Researchers and clinicians will need tools beyond patient-reported outcomes to measure the effectiveness of these treatment efforts. The use of joint space width (JSW) as a surrogate for chondral restoration is inadequate. At a minimum, such observations must standardize load transmission across the joint to be useful. Simple, readily available, standardized, and clinically useful measures of knee chondral restoration would facilitate and accelerate advances in the field. For now, it may be that improvement in JSW after chondral restoration could be attributable to changes in mechanical alignment of the knee and not the chondral restoration. JSW is an inadequate surrogate for chondral restoration, and anyone doing a stress radiograph of a unicompartmental degenerative knee recognizes this point.

Ultrasound-Guided Biceps Tendon Sheath Injections Frequently Extravasate Into the Glenohumeral Joint.

PURPOSE: To evaluate the frequency of glenohumeral joint extravasation of ultrasound (US)-guided biceps tendon sheath injections. METHODS: Fifty shoulders with a clinical diagnosis of bicipital tenosynovitis pain received a US-guided biceps sheath injection with anesthetic, steroid, and contrast (5.0 mL mixture) followed immediately by orthogonal radiographs to localize the anatomic distribution of the injection. Radiographic evaluation of contrast localization was determined and interobserver reliability calculated. RESULTS: All 50 postinjection radiographs (100%) demonstrated contrast within the biceps tendon sheath. In addition, 30 of 50 (60%) radiographs also revealed contrast in the glenohumeral joint. Interobserver reliability for determination of intraarticular contrast was good (kappa value 0.87). CONCLUSIONS: US-guided bicipital sheath injections reproducibly result in intrasheath placement of injection fluid. Bicipital sheath injections performed with 5 mL of volume result in partial extravasation into the joint 60% of the time. These data may be useful for surgeons who use the results of diagnostic biceps injections for diagnosis and surgical decision-making. LEVEL OF EVIDENCE: III, prospective cohort study, diagnosis.

Intraoperative Identification of Clavicle Fracture Patterns: Do Clavicles Fail in a Predictable Pattern?

OBJECTIVES: To characterize the fracture pattern and pattern of fragmentation for displaced, midshaft clavicle fractures undergoing operative management. DESIGN: Prospective observational study. SETTING: Two institutions. Level 1 and Level 2 Trauma Centers. PATIENTS/PARTICIPANTS: Fifty-three patients who underwent operative repair of midshaft clavicle fracture. INTERVENTION: All clavicles were treated by operative open reduction internal fixation. MAIN OUTCOME MEASUREMENTS: All clavicles were categorized by the Robinson classification based on injury plain film bilateral upright clavicle radiographs. In addition, intraoperative fracture characteristics of fragment length and location were measured and recorded to evaluate the fracture pattern. All fractures were analyzed to determine the frequency of segmental comminution versus length-stable patterns, analyze characteristics of butterfly fragment size, number and location as well as the location of the cortical read for those length-stable fractures. RESULTS: Analysis revealed 55% were Robinson 2B2 based on preoperative radiographs. Length-stable, anatomic reduction was achievable in 83%. For those in which an anatomic cortical read was achievable, 97.7% had a read present in the posterior-superior aspect of the clavicle. CONCLUSIONS: Midshaft clavicle fractures that meet conventional criteria for operative repair occur in a predictable manner with butterfly fragments generated from anterior-inferior compression and simple fracture line generated from tension along the posterior-superior aspect of the clavicle. Understanding this pattern can assist in the in surgical planning.

Editorial Commentary: Anatomy of the Anterolateral Ligament of the Knee-The Science of Looking for Bigfoot.

The anterolateral ligament of the knee continues to create a spirited debate within orthopaedics. This can be traced as far back as 1879, when Segond initially described a "pearly, resistant, fibrous band" of the anterolateral aspect of the knee. More recently, much orthopaedic research has been aimed at not only the clinical significance-but defining its very existence. At times, it seems akin to a modern-day search for Bigfoot-some see it, some do not. The authors of this commentary are becoming less skeptical of the anterolateral ligament's existence but remain in search of its surgical significance.

Stress radiographs for evaluating acromioclavicular joint separations in an active-duty patient population: What have we learned?

INTRODUCTION: Acromioclavicular (AC) joint separation is a common entity in athletic patient populations. The surgical treatment of these injuries varies based upon extent of injury, with numerous imaging modalities recommended to differentiate injury severity and treatment options. The use of weighted stress radiographs is controversial in the diagnostic evaluation of AC separation with previous consensus recommending against their use. No study to date has investigated the clinical utilization of diagnostic studies in the evaluation of AC joint separations in a military surgeon population. METHODS: Thirty-eight shoulder or sports medicine sub-specialty certified orthopaedic surgeons on active service in the Army, Air Force, and Navy were surveyed on their evaluation and treatment protocols for AC joint injuries. Specifically analyzed were imaging choice including the use of weighted stress radiographs as well as treatment recommendations based upon Rockwood grade. Responses were recorded in addition to surgeon descriptive data. Responses were analyzed with descriptive statistics. RESULTS: Thirty-seven of the identified thirty eight surgeons responded to the survey, for a 97% response rate. Of the group, 70% of surgeons were within 10 years of completing fellowship with an estimated average of 15 AC joint separations treated annually. Plain radiographic examination was relied upon by 48% of surgeons for treatment of AC joint separation with 13% using weighted stress radiographs. Overall, 10% of surgeon stated that their treatment plan would vary based upon results from a weighted stress view. 51% of surgeons included magnetic resonance imaging in their diagnostic approach of these injuries. Treatment recommendation varied according to injury severity with 78% preferring nonoperative treatment for acute Grade III injuries with 86% waiting a minimum of 3 months before proceeding with operative treatment. For Grade V injuries, 81% of surgeon preferred operative treatment, with 59% incorporating a soft-tissue graft in their repair or reconstructive procedure. DISCUSSION: This study identified substantial practice variation amongst military surgeons treating a relatively homogenous population with AC joint separations, reflective of a lack of definitive evidence to guide diagnosis and treatment. Overall, nonoperative management is the preferred initial approach for Type III injuries and operative treatment is the preferred initial approach for Type V injuries. The diagnostic evaluation varied across the surgeon cohort, but 87% elected against the use of weighted stress radiographs for the evaluation of AC joint separations, with only 10% relying upon them to dictate their recommended treatment. Future research identifying optimal diagnosis and treatment of AC joint separations is needed.

Editorial Commentary: Understanding Anterior Cruciate Ligament Failure: New Questions Emerge as Existing Ones Are Answered.

Cartilage injuries are prevalent in patients undergoing knee anterior cruciate ligament revision surgery.

Arthroscopic treatment of posterior shoulder instability in patients with and without glenoid dysplasia: a comparative outcomes analysis.

BACKGROUND: The purpose of this study was to evaluate the influence of glenoid dysplasia on outcomes after isolated arthroscopic posterior labral repair in a young military population. METHODS: Thirty-seven male patients who underwent arthroscopic posterior labral repair for symptomatic posterior shoulder instability were evaluated at a mean duration of 3.1 years. A comparative analysis was performed for those with glenoid dysplasia and without dysplasia. Additional factors analyzed included military occupational specialty (MOS), preoperative mental health clinical encounters and mental health medication use, and radiographic characteristics (version, posterior humeral head subluxation, and posterior capsular area) on a preoperative standard shoulder magnetic resonance arthrogram. The groups were analyzed with regard to shoulder outcome scores (subjective shoulder value [SSV], American Shoulder and Elbow Surgeons [ASES] rating scale, Western Ontario Shoulder Instability Index [WOSI]), need for revision surgery, and medical separation from the military. RESULTS: Of 37 patients, 3 (8.1%) underwent revision surgery and 6 (16%) underwent medical separation. Overall outcome assessment demonstrated a mean SSV of 67.9 (range, 25-100) ± 22.1, mean ASES of 65.6 (range, 15-100) ± 22, and mean WOSI of 822.6 (range, 5-1854) ± 538. There were no significant differences in clinical outcome scores between the glenoid dysplasia and no dysplasia groups (SSV, P = .55; ASES, P = .57; WOSI, P = .56). MOS (P = .02) and a history of mental health encounters (P = .04) were significantly associated with diminished outcomes. CONCLUSIONS: The presence or absence of glenoid dysplasia did not influence the outcome after arthroscopic posterior labral repair in a young military population. However, a history of mental health clinical encounters and an infantry MOS were significantly associated with poorer clinical outcomes.

Refuting the lipstick sign.

BACKGROUND: Arthroscopic examination of the tendon has been described as the "gold standard" for diagnosis of tendinitis of the long head of the biceps (LHB). An arthroscopic finding of an inflamed and hyperemic LHB within the bicipital groove has been described as the "lipstick sign." Studies evaluating direct visualization in diagnosis of LHB tendinitis are lacking. METHODS: During a 1-year period, 363 arthroscopic shoulder procedures were performed, with 16 and 39 patients prospectively selected as positive cases and negative controls, respectively. All positive controls had groove tenderness, positive Speed maneuver, and diagnostic ultrasound-guided bicipital injection. Negative controls had none of these findings. Six surgeons reviewed randomized deidentified arthroscopic pictures of enrolled patients The surgeons were asked whether the images demonstrated LHB tendinitis and if the lipstick sign was present. RESULTS: Overall sensitivity and specificity were 49% and 66%, respectively, for detecting LHB tendinitis and 64% and 31%, respectively, for erythema. The nonweighted κ score for interobserver reliability ranged from 0.042 to 0.419 (mean, 0.215 ± 0.116) for tendinitis and from 0.486 to 0.835 (mean, 0.680 ± 0.102) for erythema. The nonweighted κ score for intraobserver reliability ranged from 0.264 to 0.854 (mean, 0.615) for tendinitis and from 0.641 to 0.951 (mean, 0.783) for erythema. CONCLUSIONS: The presence of the lipstick sign performed only moderately well in a rigorously designed level III study to evaluate its sensitivity and specificity. There is only fair agreement among participating surgeons in diagnosing LHB tendinitis arthroscopically. Consequently, LHB tendinitis requiring tenodesis remains a clinical diagnosis that should be made before arthroscopic examination.

Accuracy of Ultrasound-Guided Intra-articular Hip Injections Performed in the Orthopedic Clinic.

Intra-articular hip injections have proven clinical value for both diagnostic and therapeutic purposes. Historically, these injections have been performed by radiologists using fluoroscopic guidance. This necessitates a radiology referral, delays the injection, and represents lost productivity for the orthopedist. Ultrasound-guided intra-articular hip injections have been described in the radiology literature with excellent accuracy. These injections were performed by radiologists. The purpose of this study was to determine the accuracy of ultrasound-guided hip injections performed in the orthopedic clinic by orthopedic surgeons and orthopedic physician assistants. Fifty ultrasound-guided hip injections were performed using a standard technique. Contrast was included, and an anteroposterior pelvis radiograph was obtained immediately following injection. Diagnosis, body mass index, procedure time, and visual analog scale scores were recorded. Radiographs were reviewed independently by a musculoskeletal radiologist and an orthopedic surgeon to determine intra-articular placement of the injection. A total of 50 hips were injected. There was no identifiable contrast in 2 patients, leaving 48 hips for analysis. Of these, contrast was injected intra-articularly in 46 hips for an accuracy of 96%. Average procedural time was 2.6 minutes, and the average visual analog scale score was 1.9 during the procedure. Revenue value units ranged from 1.72-2.55 for ultrasound-guided hip injections. These findings indicate ultrasound-guided intra-articular hip injections performed in the orthopedic clinic by surgeons or physician assistants are accurate, efficient, and patient-friendly. Additionally, they preserve patient continuity and maintain productivity within the orthopedic clinic. [Orthopedics. 2017; 40(2):96-100.].

Return to Duty Rates Following Meniscal Repair Surgery in an Active Duty Military Population.

Meniscal injury is a common knee injury in a young athletic population. Maintaining the integrity of the meniscus is critical to reducing contact pressures on the tibiofemoral articulation. The purpose of this study is to analyze the outcomes of meniscal repair in a young military population. We conducted a retrospective review of all meniscal repairs performed on active duty Army personnel at a Military Medical Center from January 2002 to December 2012. One hundred seventy-eight active duty patients, mean age 28 (19-48) years underwent 178 meniscal repairs. Postoperatively, 33 (18.5%) patients were medically separated from the military at an average time of 29 months. Fifty (28%) patients required a permanent duty restricting profile. Ninety-five (53.5%) patients required no profile after meniscal repair at an average follow-up of 5 (1.5-12.3) years. Meniscal repair in this young military population allowed 81.5% of patients to return to duty; however, 34% of those required a permanent duty restricting profile. Approximately 20% of patients required medical separation from the military after meniscal repair. Older age was significantly associated with the ability to remain on active duty (p = 0.01).

Glenoid Dysplasia: Pathophysiology, Diagnosis, and Management.

➤Subtle forms of glenoid dysplasia may be more common than previously thought and likely predispose some patients to symptomatic posterior shoulder instability. Severe glenoid dysplasia is a rare condition with characteristic radiographic findings involving the posteroinferior aspect of the glenoid that often remains asymptomatic.➤Instability symptoms related to glenoid dysplasia may develop over time with increased activities or trauma. Physical therapy focusing on rotator cuff strengthening and proprioceptive control should be the initial management.➤Magnetic resonance imaging and computed tomographic arthrograms are useful for detecting subtle glenoid dysplasia by revealing the presence of an abnormally thickened or hypertrophic posterior part of the labrum, increased capsular volume, glenoid retroversion, and posteroinferior glenoid deficiency.➤Open and arthroscopic labral repair and capsulorrhaphy procedures have been described for symptomatic posterior shoulder instability. Glenoid retroversion of >10° may be a risk factor for failure following soft-tissue-only procedures for symptomatic glenoid dysplasia.➤Osseous procedures are categorized as either glenoid reorientation (osteotomy) or glenoid augmentation (bone graft), and no predictable results have been demonstrated for any surgical strategy. Glenoid osteotomies have been described for increased retroversion, with successful results, although others have noted substantial complications and poor outcomes.➤In severe glenoid dysplasia, the combination of bone deficiency and retroversion makes glenoid osteotomy extremely challenging. Bone grafts placed in a lateralized position to create a blocking effect may increase the risk of the development of arthritis, while newer techniques that place the graft in a congruent position may decrease this risk.

Intramedullary Fixation of Clavicle Fractures: Anatomy, Indications, Advantages, and Disadvantages.

Historically, management of displaced midshaft clavicle fractures has consisted of nonsurgical treatment. However, recent literature has supported surgical repair of displaced and shortened clavicle fractures. Several options exist for surgical fixation, including plate and intramedullary (IM) fixation. IM fixation has the potential advantages of a smaller incision and decreased dissection and soft-tissue exposure. For the last two decades, the use of Rockwood and Hagie pins represented the most popular form of IM fixation, but concerns exist regarding stability and complications. The use of alternative IM implants, such as Kirschner wires, titanium elastic nails, and cannulated screws, also has been described in limited case series. However, concerns persist regarding the complications associated with the use of these implants, including implant failure, migration, skin complications, and construct stability. Second-generation IM implants have been developed to reduce the limitations of earlier IM devices. Although anatomic and clinical studies have supported IM fixation of midshaft clavicle fractures, further research is necessary to determine the optimal fixation method.

Infection Rate of Intramedullary Nailing in Closed Fractures of the Femoral Diaphysis After Temporizing External Fixation in an Austere Environment.

OBJECTIVES: To determine the infection rate of intramedullary (IM) nailing of closed diaphyseal femur fractures after temporary stabilization with external fixation in an austere combat environment. DESIGN: Retrospective case series. SETTING: Iraq and Afghanistan Theater and Military Medical Treatment Centers in the United States and Landstuhl, Germany. PATIENTS: Military personnel who underwent temporizing external fixation of a closed diaphyseal femur fracture (OTA 32) with later conversion to an IM nail between 2003 and 2012. INTERVENTION: Patients were identified from the Joint Theater Trauma Registry and Department of Defense electronic medical record, and a retrospective review was performed. MAIN OUTCOME MEASUREMENTS: Variables measured included age, gender, mechanism of injury, Injury Severity Score, associated injuries (to include thoracic and abdominal injuries), base deficit, history of massive transfusion, date of injury, date and place of external and IM fixations, time to conversion procedure, report of superficial or deep infection, report of fracture union, and date of last follow-up. RESULTS: One hundred twenty-two patients, mean age 25 (18-43) years, sustained 125 closed femoral diaphyseal fractures from May 2003 to July 2012. External fixation was performed at a mean of 0.2 days (median of the day of injury) and a range of 0-3 days. Mean time to IM nail conversion procedure was 6.9 (1-20) days. Infection rate was 2.5%, with a P of 0.188. Average follow-up was 41.4 (12-119) months. CONCLUSIONS: Acceptable low infection rates can be achieved after IM nailing of closed diaphyseal femur fractures treated with initial external fixation in an austere combat environment. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.