Operative Versus Nonoperative Treatment of Acute Displaced Distal Clavicle Fractures: A Multicenter Randomized Controlled Trial.

OBJECTIVES: To evaluate the differences in patient outcomes after operative or nonoperative treatment of displaced, type II distal clavicle fractures. DESIGN: Multicenter, prospective, randomized controlled trial. SETTING: Level I trauma centers. PATIENTS/PARTICIPANTS: Patients with completely displaced type II distal clavicle fractures were included. Fifty-seven patients were randomized: 27 to the operative group and 30 to the nonoperative group. INTERVENTION: Patients randomized to nonoperative care received a standard shoulder sling, followed by pendulum or gentle range of motion shoulder exercises at any time as directed by the attending surgeon. Patients randomized to the operative group received plate fixation with a precontoured distal clavicular plate or a "hook" plate within 28 days from injury. MAIN OUTCOME MEASURE: Disabilities of the Arm, Shoulder and Hand scores at 1 year. RESULTS: There were no between-group differences in Disabilities of the Arm, Shoulder and Hand or Constant scores at 1 year. More patients in the operative group went on to union (95% vs. 64%, P = 0.02) within 1 year. Twelve patients in the operative group underwent a second operation for implant removal (12/27, 44%). In the nonoperative group, 6 patients (6/30, 20%) subsequently underwent 8 operative procedures. CONCLUSION: Although this study failed to demonstrate a difference in functional outcomes between operative and nonoperative treatment of Neer type II distal clavicle fractures, nonoperative management led to more complications including a moderate rate of nonunion, which often required secondary surgery to correct, a higher rate of early dissatisfaction with shoulder appearance, and a delayed return to activities in the first 6 months. Operative management provided a safe and reliable treatment option with few complications, but often required secondary implant removal, especially with hook plate fixation. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

An international, cross-sectional survey of the management of Vancouver type B1 periprosthetic femoral fractures around total hip arthroplasties.

INTRODUCTION: The incidence of periprosthetic femoral fractures around total hip arthroplasties is increasing. Fractures around a stable implant stem (Vancouver type B1) are among the most common of these fractures. Various fixation strategies for Vancouver type B1 periprosthetic fractures have been reported in the literature; however, little high-level evidence exists. This study was designed to determine the current management strategies and opinions among orthopaedic surgeons treating Vancouver type B1 periprosthetic femoral fractures, and to evaluate the need for a large prospective randomized controlled trial for the management of these injuries. METHODS: Orthopaedic surgeon members of the Orthopaedic Trauma Association (OTA), the Canadian Orthopaedic Association (COA), and the Hip Society were invited to participate in a 51-item web-based survey surrounding the management of periprosthetic femoral fractures around total hip replacements, as well as the perceived need for future research in this area. Responses were summarized using proportions, and further stratified by practice type, case volume, surgeon age, and fellowship training. RESULTS: For Vancouver type B1 fractures, open reduction and internal fixation (ORIF) with locked plating was favoured slightly over ORIF with cable plating ± cortical strut allograft (51.1% versus 45.5%). When compared to cable plating with cortical strut allograft, respondents believed that isolated locked plating resulted in lower nonunion and reoperation rates, but similar infection and malunion rates. Subgroup analyses revealed that practice type, surgeon age, case volume, and fellowship training influenced surgeons' management of periprosthetic femoral fractures and beliefs regarding complications. There is high demand for a large prospective randomized controlled trial for Vancouver type B1 fracture fixation. CONCLUSIONS: Consensus surrounding the management of Vancouver type B1 periprosthetic femoral fractures is lacking, and there is a perceived need among orthopaedic surgeons for a large prospective randomized controlled trial in order to define the optimal management of these injuries.

Orthopaedic surgeons' opinions surrounding the management of proximal humerus fractures: an international survey.

PURPOSE: The purpose of this study was to survey surgeons' preferences surrounding the management and evaluation of proximal humerus fractures internationally. METHODS: A questionnaire was developed using previous literature and input from practicing orthopaedic surgeon opinion leaders. Between November 13, 2014 and December 31, 2014, the questionnaire was posted on the membership section of three major orthopaedic and shoulder surgery association websites. Survey responses were anonymous. RESULTS: The survey was completed by 134 unique practicing orthopaedic surgeons. The majority of respondents (72%) practiced in North America while 28% practiced internationally. For displaced two-part fractures, a preference for open reduction and internal fixation (ORIF) with locking plates was identified (75%). No consensus was reached for preferred treatment of three- and four- part fractures: 37% chose ORIF with locking plates, 26% chose hemi-arthroplasty (HA), and 29% chose reverse shoulder arthroplasty (RSA). Preferred treatment types for three- and four-part fractures were marginally significantly different depending on place of practice (North America vs. international, p = 0.058). A significantly larger proportion of surgeons who had completed an upper extremity fellowship (35%) chose RSA for the treatment of three and four-part fractures, compared to those who had not (9%, p = 0.002). No consensus was observed regarding what outcome measure is best to assess function following proximal humerus fractures. CONCLUSIONS: The management of more complex, displaced proximal humerus fractures remains controversial. Additionally, there are conflicting opinions on what outcome measure is best to assess function following the treatment of proximal humerus fractures.

Prospective Randomized Clinical Trial Investigating the Effect of the Reamer-Irrigator-Aspirator on the Volume of Embolic Load and Respiratory Function During Intramedullary Nailing of Femoral Shaft Fractures.

OBJECTIVES: We sought to determine whether the use of the Reamer-Irrigator-Aspirator (RIA) device resulted in a decreased amount of fat emboli compared with standard reaming (SR) when performing intramedullary (IM) nailing of femoral shaft fractures. DESIGN: Prospective randomized clinical trial. SETTING: Multi-centered trial, level I trauma centers. PATIENTS/PARTICIPANTS: All eligible patients who presented to participating institutions with an isolated femoral shaft fracture amenable to fixation with antegrade IM nailing. Thirty-one patients were enrolled: nine were excluded because of technical difficulties with the transesophageal echocardiogram (TEE) recording. Therefore, the study comprised 22 patients: 11 patients randomized to the SR group and eleven patients randomized to the RIA group. INTERVENTION: Antegrade IM nailing of a femoral shaft fracture with standard reamers or the RIA device. All patients were monitored intraoperatively with a continuous TEE to assess embolic events in the right atrium. A radial arterial line was used to monitor blood gases and potential systemic effects of emboli. MAIN OUTCOME MEASURE: Duration, size, and severity of emboli as measured by TEE. The operative procedure was divided into 6 distinct stages: preoperative, reduction, guidewire passage, reaming, nail insertion, and postoperative. RESULTS: There was no significant difference in emboli between the RIA and SR groups preoperatively, during fracture reduction, guidewire insertion, or postoperatively. Measured with a standardized scoring system, there was a modest reduction in total emboli score in the RIA group during reaming (SR 5.30 [SD; 1.81] vs. RIA 4.05 [SD; 2.19], P = 0.005) and during nail insertion (SR 5.09 [SD; 1.74] vs. RIA 4.25 [SD; 1.89], P = 0.03). We were unable to correlate this reduction with any improvement in physiologic parameters (mean arterial pressure, end-tidal CO2, O2 saturation, pH, paO2, and paCO2). CONCLUSIONS: This study showed a modest reduction of embolic debris during the reaming and nail insertion segments of the operative procedure. We were unable to correlate this with any change in physiologic parameters. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Are patients willing to pay for total shoulder arthroplasty? Evidence from a discrete choice experiment.

BACKGROUND: Total shoulder arthroplasty (TSA) is a common treatment to decrease pain and improve shoulder function in patients with severe osteoarthritis (OA). In Canada, patients requiring this procedure often wait a year or more. Our objective was to determine patient preferences related to accessing TSA, specifically comparing out-of-pocket payments for treatment, travel time to hospital, the surgeon's level of experience and wait times. METHODS: We administered a discrete choice experiment among patients with endstage shoulder OA currently waiting for TSA. Respondents were presented with 14 different choice sets, each with 3 options, and they were asked to choose their preferred scenario. A conditional logit regression model was used to estimate the relative preference and willingness to pay for each attribute. RESULTS: Sixty-two respondents completed the questionnaire. Three of the 4 attributes significantly influenced treatment preferences. Respondents had a strong preference for an experienced surgeon (mean 0.89 ± standard error [SE] 0.11), while reductions in travel time (-0.07 ± 0.04) or wait time (-0.04 ± 0.01) were of less importance. Respondents were found to be strongly averse (-1.44 ± 0.18) to surgical treatment by a less experienced surgeon and to paying out-of-pocket for their surgical treatment (-0.56 ± 0.05). CONCLUSION: Our results suggest that patients waiting for TSA to treat severe shoulder OA have minimal willingness to pay for a reduction in wait time or travel time for surgery, yet will pay higher amounts for treatment by an experienced surgeon.

CONTEXTE: L'arthroplastie totale de l'épaule est un traitement courant visant à atténuer la douleur et à augmenter la fonction de l'épaule chez les patients atteints d'arthrose grave. Au Canada, l'attente est souvent d'un an ou plus pour cette intervention. Notre objectif était de cerner les préférences des patients concernant l'accès à l'arthroplastie, particulièrement en ce qui a trait aux déboursés personnels pour le traitement, à la durée du trajet vers l'hôpital, à l'expérience du chirurgien et au temps d'attente. MÉTHODES: Nous avons mené une expérience avec choix discrets auprès de patients atteints d'arthrose de l'épaule au stade terminal actuellement en attente d'une arthroplastie totale. Les répondants ont reçu 14 ensembles de choix différents, comportant chacun 3 options, et devaient choisir leur scénario préféré. Nous avons utilisé un modèle de régression logit conditionnelle pour estimer la préférence relative et la disposition à payer pour chaque caractéristique. RÉSULTATS: En tout, 62 répondants ont rempli le questionnaire. Trois des 4 caractéristiques ont significativement influencé les préférences de traitement. Les répondants avaient une forte préférence pour un chirurgien expérimenté (moyenne de 0,89 ± écart-type de 0,11), alors que la réduction de la durée du trajet (­0,07 ± 0,04) ou du temps d'attente (­0,04 ± 0,01) était moins importante. Les répondants se sont révélés très réfractaires (­1,44 ± 0,18) à se faire opérer par un chirurgien peu expérimenté et à payer de leur poche leur traitement chirurgical (­0,56 ± 0,05). CONCLUSION: Nos résultats semblent indiquer que les patients en attente d'une arthroplastie totale de l'épaule pour traiter une arthrose grave sont très peu disposés à payer pour réduire le temps d'attente ou la durée du trajet, mais qu'ils sont prêts à desserrer les cordons de leur bourse pour être opérés par un chirurgien chevronné.