Ligament Reconstruction and Interposition Arthroplasty of the Acromioclavicular Joint.

Distal clavicle excision (DCE) for acromioclavicular (AC) joint primary osteoarthritis and post-traumatic arthritis has been shown to have good to excellent outcomes. However, there are studies that report significant rates of residual AC joint pain and distal clavicle instability after open and arthroscopic techniques. We describe a surgical technique for management of AC joint primary osteoarthritis, post-traumatic arthritis, and revision DCE that involves DCE with ligament reconstruction and tendon interposition arthroplasty. It provides distal clavicle stability and can theoretically reduce residual AC joint pain secondary to acromial abutment after DCE.

The effect of single-dose, preoperative intravenous tranexamic acid on early postoperative pain scores after rotator cuff repair: a double-blind, randomized controlled trial.

BACKGROUND: Tranexamic acid (TXA) is commonly used in upper and lower limb arthroplasty to limit blood loss and postoperative hematoma formation. The role of TXA in rotator cuff repair (RCR) surgery is less defined. This trial assessed the effect of preoperative TXA on early postoperative pain scores. METHODS: A randomized double-blind trail was conducted in 89 patients undergoing RCR. Patients were randomized to either 2 g of intravenous TXA or placebo at induction. The primary outcome was visual analog scale (VAS)-pain score at day 3 postoperation, with secondary outcomes including VAS-pain, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Constant scores at 2, 8, 24, and 52 weeks. RESULTS: There was no significant difference in VAS-pain scores between groups at day 3 postoperation. Pain scores were significantly better in the TXA group at 8 weeks. There was no difference between groups at any time point in the ASES or Constant score. The TXA group had improved motion at 6 months with a reduced rate of secondary adhesive capsulitis. CONCLUSION: TXA did not improve postoperative pain scores after RCR, however, patients who received the intervention demonstrated greater range of motion at 6 months with lower rates of secondary adhesive capsulitis.

Distal humerus hemiarthroplasty for trauma: a systematic review of the outcomes and complications.

BACKGROUND: In patients with distal humerus fractures that are unreconstructible, total elbow arthroplasty is an established alternative to open reduction-internal fixation. Distal humerus hemiarthroplasty is a further alternative to avoid the significant lifestyle limitations associated with total elbow arthroplasty. Distal humerus hemiarthroplasty is an increasingly popular treatment option for unreconstructible distal humeral fractures not amenable to reconstruction. The aim of this systematic review was to assess the literature regarding the functional outcomes and complications of the use of distal humerus hemiarthroplasty for acute trauma. METHODS: A systematic review of the PubMed, Embase, and Scopus databases was performed. The search terms included "distal humerus fracture" OR "elbow fracture" AND "hemiarthroplasty" OR "arthroplasty" OR "replacement." Studies were limited to those published in the English language with reported functional outcome measures and complications. Patient demographic characteristics, implant systems, clinical outcomes (range of motion and functional outcome scores), and complications were extracted. RESULTS: Thirteen studies with a total of 207 patients met the inclusion criteria. The average age ranged from 44 to 79 years, with the mean length of follow-up ranging from 11 to 82 months postoperatively. A mean range-of-motion arc ≥ 93° was achieved in all studies, with 11 of 13 studies achieving mean functional range of motion ≥ 100°. All studies reported good to excellent mean outcome scores. Heterotopic ossification, ulnar cartilage wear, stiffness, and ulnar neuropathy were the most commonly encountered complications. The reoperation rate and revision rate were 17% and 3%, respectively. CONCLUSIONS: Distal humerus hemiarthroplasty is a viable option in the treatment of unreconstructible distal humerus fractures, with good to excellent outcomes expected. Long-term outcome data and the use of distal humerus hemiarthroplasty in younger patients are yet to be fully defined.

A Prospective Review of a Novel Electronic Journal Club Format in an Orthopedic Residency Unit.

INTRODUCTION: Journal clubs are useful for teaching critical appraisal skills and maintaining contemporary knowledge in orthopedics. The didactic format is most common; however, work commitments can pose difficulty in full attendance. Also with the current legislative working time restrictions for residents in Europe and North America, work and training time require separation with times that may not suit all attendees. Online forums such as "Twitter" have recently been used to accommodate various journal clubs. We aimed to establish a journal club using smartphone messaging application "WhatsApp" to discuss key orthopedic papers and teach critical appraisal skills to residents. DESIGN: A prospective cohort study including all residents and attendings in the department. A research practice questionnaire, the "Evidence-based Practice Questionnaire" and a 28-question MCQ on research methods from the American Academy of Orthopedic Surgeons resident question database was completed by all participants prior to the study. A paper was uploaded each Friday, and discussed the following Tuesday through Friday for 6 consecutive weeks. The original questionnaire and MCQs were again completed after the 6-week study period. SETTING: A Trauma & Orthopedic residency unit. PARTICIPANTS: All orthopedic residents, from PGY1-4 and attendings. RESULTS: An average of 22 questions were asked (min 13, max 28), and 55 responses per week (min 30, max 88). In the EBPQ questionnaire, an example question of "how often you critically appraised a paper you have discovered" improved from an average score of 2.45 to 5.4. Self-rating of research skills improved from a score of 3.27 to 5.9. MCQ scores improved from an average of 48.2% among the group to 69%. CONCLUSIONS: Residents' critical appraisal skills were improved while providing adequate time and flexibility to reflect on questions. Subspecialty topic discussions led by attendings, stimulated discussion of clinical pearls of interest to all participants. The simplicity of this method, and its widespread availability potentiates the implementation by any specialty looking to educate its residents.

Displaced Salter-Harris I fracture of the distal ulna physis.

A 10-year-old girl presented to the emergency department having sustained a fall onto an outstretched left hand while playing soccer. Clinical and radiographical assessment identified a Salter-Harris I distal ulna fracture, as well as a buckle fracture of the distal radius. The injury was closed, and she had no neurovascular deficits on examination. She was brought to the operating theatre the following morning for closed reduction under general anaesthesia. Image intensification was used to confirm anatomical reduction, and an above-elbow moulded plaster-of-paris cast was applied. Follow-up clinical assessment at 6 weeks confirmed healing of the fracture, and she proceeded to make a full recovery. This case describes the anatomy and physiology of such rare injuries and outlines treatment principles and potential pitfalls based on best available evidence.

Periprosthetic hip fractures: A review of the economic burden based on length of stay.

INTRODUCTION: With the increasing rates of total hip replacements being performed worldwide, there is an increasing incidence of periprosthetic fractures. As our patients' demographics change to include older patients with multiple medical co-morbidities, there is a concurrent increase in morbidity and mortality rates. This leads to longer hospital stays and increasing hospital costs. In the current economic climate, the cost of treating periprosthetic fractures must be addressed and appropriate resource and funding allocation for future provision of services should be planned. MATERIALS AND METHODS: All periprosthetic hip fractures that were admitted to a single trauma unit over a three-year period were reviewed. Independent chart review, haematological and radiological review was undertaken. All patients with a periprosthetic fracture associated with a total hip arthroplasty or hemiarthroplasty were included. Follow up data including complications were collated. Data from the hospital inpatient database and finance department was utilized for cost analysis. All statistical analysis was preformed using Minitab version 17. RESULTS: 48 patients were identified who met the inclusion criteria for review. The majority of participants were female with a mean age of 73.5 years. The mean time to fracture was 4.5 years (9 months-18.5 years). Periprosthetic fracture was associated with total hip arthroplasty in 24 cases and a Vancouver B2 classification was most common at n = 20. The majority of patients had revision arthroplasty, with a mean length of stay of 24 days for the whole cohort (9-42). Vancouver B3 fractures had the longest inpatient stay at a mean of 26 days. The mean cost of for a full revision of stem with additional plate and cable fixation was over €27000 compared to €14,600 for ORIF and cable fixation based on length of hospital stay. CONCLUSION: The prolonged length of stay associated with Vancouver B2 and B3 fractures leads to increased costs to the healthcare service. Accurately calculating the costs of total treatment for periprosthetic fractures is difficult due to a lack of transparency around implant and staffing costs. However, as we can expect increasing incidence of periprosthetic fractures presenting in the coming years it is paramount that we make financial provisions within healthcare budgets to ensure we can treat these patients appropriately.

Spinal Metastatic Disease: A Review of the Role of the Multidisciplinary Team.

Historically, a simple approach centered on palliation was applicable to the majority of patients with metastatic spinal disease. With advances in diagnosis and treatment, a more complicated algorithm has devolved requiring a multidisciplinary approach with institutional commitment and support. We performed a database review including pertinent articles exploring the multidisciplinary management of spinal metastatic disease. The wide variation in clinical presentation and tumor response to treatment necessitates a multidisciplinary approach that integrates the diagnosis and treatment of the cancer, symptom management, and rehabilitation for optimal care of patients with spinal metastases. Advances in the field of radiology have led to earlier and more focused diagnosis of spinal metastasis and acts to guide therapy. Advances in surgical techniques, neurophysiologic monitoring, and anesthetic expertise have allowed surgeons to perform more extensive procedures leading to improved outcomes and reduced morbidity. Radiation oncology input that is essential as external beam radiation therapy can provide significant pain relief. Non-operative measures may include bisphosphonate infusions, management of complications (e.g. hypercalcemia of malignancy), monoclonal antibody infusions, and chemotherapy if indicated in the treatment of the primary malignancy. Input from psychology services is necessary to address the biopsychosocial ramifications of spinal metastasis. Allied health professionals in the form of physiotherapists, social workers, and dieticians also contribute in maximizing patients' quality of life and well-being.

Heterotopic Ossification following acetabular fixation: Incidence and risk factors: 10-year experience of a tertiary centre.

BACKGROUND: Heterotopic Ossification (HO) is a well-recognized complication following acetabular fracture fixation and its presence is prognostic for suboptimal clinical outcome. There are many controversies pertaining to its aetiology, including surgical approach, associated injuries and the use of HO prophylaxis. Long term data from high volume centres is necessary to address these issues. AIM: To determine the incidence of HO post open reduction and internal fixation (ORIF) of acetabular fractures and to examine the associated risk and prognostic factors. METHOD: We studied a cohort of 369 consecutive acetabular fractures that underwent ORIF at our institution over a 10 year period. Data was analyzed using univariate and multivariate logistic regression. RESULTS: The existence of HO was evident in 65 patients (17.62%), of these 39 (60.0%) were Class I, 16 (24.6%) were Class II, 8 (12.3%) were Class III, and 2 (3.1%) were Class IV according to Brooker Classification. We found a significant association between admission to an Intensive Care Unit (ICU) (P-value=0.039), chest injury (P-value=0.013), multiple fractures (P-value=0.005), and the time lapse between injury and operation (P-value=0.025), and some statistical significance with surgical approach, ipsilateral fractures, open fractures, tibial and patellar fractures. Age over 30 years as the only prognostic factor for severe HO. Prophylaxis with Indomethacin did not appear to confer any benefit in our patient group. CONCLUSION: The risk factors for developing HO following acetabular fracture fixation are multifactorial and include admission to ICU, associated chest injuries, multiple fractures and delay between injury and surgery. Surgical approach, ipsilateral fractures and tibia and patellar fractures may also play a role. Age over thirty years was the only prognostic factor for developing severe HO.