Ligament Sparing Elbow Hemiarthroplasty: A Novel Technique for the Management of Distal Humeral Fractures.

Intra-articular distal humerus fractures present various challenges with a wide array of treatment options. Open reduction internal fixation remains the treatment of choice. In older patient populations with poor bone quality and short-end segment fractures with articular comminution, open reduction internal fixation, however, may bring on unsurmountable technical challenges. Total elbow arthroplasty and elbow hemiarthroplasty (EHA) may offer superior functional outcomes in these cases. During EHA for fractures, the medial and lateral columns are reconstructed with the collateral ligaments to restore elbow stability. We hypothesize that in coronal sheer fracture patterns where the columns are intact, maintaining the native collateral ligaments and columns will provide both an anatomic and stable elbow joint. We introduce the ligament sparing EHA technique for unreconstructible coronal shear fractures. We describe this novel technique and compare our postoperative outcomes in 2 patients who underwent this surgery to those described in the literature. The postoperative Disabilities of the Arm, Shoulder, and Hand scores for the 2 patients were 13.8 and 10.3, respectively. The Mayo Elbow Performance Score for the 2 patients were 80 and 85, respectively. The operative arm presented a grip strength of 82% and 89% when compared with the contralateral arm, for the patients respectively. The range of motion varied between 78% and 100% of the contralateral arm for both patients. Although our results are promising and the ligament sparing EHA technique may be a more anatomic option in certain fracture patterns, further research with larger cohorts and multiple surgeons is needed to reinforce our results.

The Slip and Fall Index: Assessing the risk of slipping and falling on ice.

OBJECTIVES: Canadians are at an increased risk of outdoor slip and fall accidents during periods of ice and snow. The aim of this study was to create an index to alert the public of slippery outdoor conditions and promote pedestrian safety. METHODS: Emergency department (ED) presentations from the four adult hospitals in Calgary, Alberta, Canada, over an 11-year period (January 2008‒December 2018) were extracted and filtered using the ICD-10 code W00 (fall due to ice and snow). Multivariable dispersion-corrected Poisson regression models were used to determine the variables most predictive of these presentations. Month of year, the presence of ice, snow on ground (per 10 cm), and interactions between ice and snow, all up to 3 days prior, were used to create the Slip and Fall Index (SFI). RESULTS: The dataset included 14,977 slip and fall on ice/snow ED presentations. Females (57.36%, n = 8591) accounted for more presentations than males (42.64%, n = 6386). All months had a significant effect, either being predictive or protective of slip and falls on ice/snow. Current-day ice, snow on ground, and ice up to 3 days prior were predictive of increased presentations. Month and measurements of ice and snow can be input into the SFI, which generates the level of daily risk. CONCLUSION: The SFI is the first Canadian index with the purpose of measuring the risk of having a slip and fall accident on ice/snow.

RéSUMé: OBJECTIFS: Les Canadiennes et les Canadiens courent un risque accru de glissades et de chutes accidentelles à l'extérieur en période de glace et de neige. Notre étude visait à créer un indice pour avertir le public des conditions glissantes à l'extérieur et promouvoir la sécurité des piétons. MéTHODE: Les visites aux services des urgences (SU) des quatre hôpitaux pour adultes de Calgary (Alberta), au Canada, sur une période de 11 ans (janvier 2008‒décembre 2018) ont été extraites et filtrées à l'aide du code W00 (chute due à la glace et à la neige) de la CIM-10. Nous avons utilisé des modèles de régression de Poisson multivariés avec correction de la surdispersion pour déterminer les variables les plus susceptibles de prédire ces visites. Le mois de l'année, la présence de glace ou de neige au sol (par tranche de 10 cm) et les interactions entre la glace et la neige, tout cela au cours des trois jours précédents, ont servi à créer notre « indice des glissades et des chutes ¼ (IGC). RéSULTATS: Le jeu de données comprenait 14 977 visites aux SU en raison de glissades et de chutes sur la glace ou la neige. Les femmes (57,36%, n = 8 591) ont effectué plus de visites que les hommes (42,64%, n = 6 386). Tous les mois avaient un effet significatif, que ce soit comme variable prédictive ou préventive des glissades et des chutes sur la glace ou la neige. La présence de glace ou de neige au sol le jour même, et la présence de glace jusqu'à trois jours avant, ont permis de prédire les hausses des visites. Le mois et la hauteur de la glace et de la neige peuvent être saisis dans l'IGC, ce qui génère le niveau de risque quotidien. CONCLUSION: L'IGC est le premier indice canadien qui mesure le risque de glissades et de chutes accidentelles sur la glace ou la neige.

Risk Factors for the Development of Persistent Scaphoid Non-Union After Surgery for an Established Non-Union.

BACKGROUND: Between 2014 and 2020, candidates for scaphoid non-union (SNU) surgery were enrolled in a prospective randomized trial (Scaphoid Nonunion and Low Intensity Pulsed Ultrasound [SNAPU] trial) evaluating the effect of low-intensity pulsed ultrasound on postoperative scaphoid healing. At trial completion, 114/134 (85%) of these patients went on to union, and 20/134 (15%) went on to persistent SNU (PSNU). The purpose of this study was to use this prospectively gathered data to identify patient-, fracture-, and surgery-specific risk factors that may be predictive of PSNU in patients who undergo surgery for SNU. METHODS: Data were extracted from the SNAPU trial database. The inclusion and exclusion criteria of this study were the same as that of the SNAPU trial. Nineteen patient-, fracture-, and surgery-specific risk factors were determined a priori. A stepwise multivariable logistic regression model was used to identify independent risk factors for PSNU. RESULTS: Three risk factors were found to be independently significant predictors of PSNU: age at the time of surgery, dominant hand injury, and previous surgery on the affected scaphoid. With every decade of a patient's life, dominant hand injury, and previous scaphoid surgery, the odds of union are reduced by 1.72 times, 7.35 times, and 4.24 times, respectively. CONCLUSION: We identified three independent risk factors for PSNU: age at SNU surgery, dominant hand injury, and previous surgery on the affected scaphoid. The findings of this study are significant and may contribute to shared decision-making and prognostication between the patient, surgeon, and affiliated members of their care team.

FROST 2.0: Factors Predicting Orthopaedic Trauma Volumes - A Validation Study.

The anecdotal relationship between weather, season, and orthopaedic trauma volumes is understood by patients and healthcare providers: when the winter ground is icy, people fall. Previous research established that winter and summer months as well as ice and snow were significant predictors of orthopaedic trauma and surges in volumes. The current study validates the previously established predictive model in one Canadian city; the original methods were repeated using a new, yet geographically similar dataset. The effect of month and ice were consistent, which suggests the proposed model has sufficient external validity to guide resource allocation and primary prevention strategies.

Trends in implementation of evidence-based hip fracture management in a major Canadian city.

Aims: The importance of hip fracture care has resulted in an abundance of hip fracture management literature. The degree this evidence is incorporated into clinical practice is unknown. We examined 5 trends in hip fracture management: arthroplasty versus fixation, total hip arthroplasty (THA) versus hemiarthroplasty (HA), cemented versus uncemented femoral stem fixation, short versus long cephalomedullary nail (CMN) fixation, and time from admission to surgery. Our primary aim was to understand and assess hip fracture management trends in relation to pertinent literature. Methods: Data were collected from acute hip fractures in patients aged 50 years or older who presented from 2008 to 2018. ICD-10 diagnostic codes were assigned using preoperative radiographs. Surgical management was confirmed using intraoperative and postoperative radiographs and split into 6 categories: (1) short CMN, (2) long CMN, (3) cannulated screws, (4) dynamic hip screw, (5) HA, and (6) THA. Appropriate statistical tests were used to analyze trends. Results: In 4 assessed trends, hip fracture management aligned with high-level evidence. This was the case for a trend toward arthroplasty for displaced femoral neck fractures, increased use of THA relative to HA, increased use of short relative to long CMNs, and consistent decrease in surgical wait times. Despite the literature highlighting the disadvantages of uncemented femoral stems, our data demonstrated increased use of uncemented femoral stems. Conclusion: Evidence to guide orthopaedic practice is constantly emerging but may not be effectively used by clinicians. Our findings demonstrate the successes and failures of integrating evidence into hip fracture management and highlight that orthopaedic surgeons have an ongoing responsibility to strive for evidence-based practice.

Orthopaedic trauma on the weekend: Longer surgical wait times, and increased after-hours surgery.

INTRODUCTION: Orthopaedic trauma does not present in a linear fashion. Fluctuations in trauma volumes, after-hours surgery and surgical wait times impact orthopaedic surgeons and patients. There is little research focussing on how surgical trauma volumes change throughout the week. This study investigated the relationship between day of the week and surgical orthopaedic trauma volumes, after-hours surgery, and wait times for orthopaedic trauma patients. METHODS: All unscheduled surgical orthopaedic trauma cases presenting to one level I and three level IV urban adult trauma centers between 2008 and 2018 were retrospectively reviewed. Fluctuations in orthopaedic trauma volumes and amount of after-hours surgeries completed were investigated using Multivariable Poisson regression. Fluctuations in patient wait times were investigated using linear regression. RESULTS: Weekends were associated with increased surgical wait times (8.9%, p<0.001) despite decreased surgical trauma volumes (9.1%, p<0.001). Surgical orthopaedic trauma volumes were elevated on weekdays and decreased on weekends. More after-hours surgeries were performed from Thursday to Saturday with most performed on Friday night (26.6%, p<0.001). Surgical wait times increased midweek and remained high until Saturday. CONCLUSION: With a lack of dedicated trauma resources on the weekend, a significant increase in after-hours surgery and surgical wait times was identified following surgical volumes peaking on Thursday and Friday. We suggest adapting resource allocation to reflect surgical volumes. Dedicated weekend orthopaedic trauma resources or an adaptable schedule during increased orthopaedic trauma have the potential to ease this bottleneck, improve patient care, and decrease hospital costs.

COVID-19 orthopaedic trauma volumes: a Canadian experience during lockdown and staged reopening.

OBJECTIVES: The aim of this study is to report the impact of public health measures (PHM), including their relaxation, on surgical orthopaedic trauma volumes. We hypothesize an initial reduction in orthopaedic trauma volumes during lockdown followed by a surge as Stages 1 and 2 of reopening progressed in Summer 2020. METHODS: All unscheduled surgical orthopaedic trauma cases from March through August were retrospectively reviewed in Calgary, Alberta, Canada, from 2008 to 2020. Trauma volumes from 2008 to 2019 were used to model expected 2020 volumes, and multivariable Poisson regression was used to determine the effect of PHM on orthopaedic trauma volumes. RESULTS: A total of 22,331 trauma orthopaedic surgeries were included. During lockdown, there was a significant decrease in trauma volume compared with expected (-14.2%, -25.7 to -10.5%, P < .001) and there were significantly fewer ankle fractures (-17.8%, -30.9 to -2.2%, P = .027). During reopening Stage 2, there was a significant increase in trauma volume (+8.9%, +2.2 to +16.1%, P = .009). There was no change in the incidence of polytrauma, hip fracture, or wrist fracture during the pandemic. CONCLUSIONS: This study provides the first report of a surge in trauma volumes as PHM are relaxed during the COVID-19 pandemic. The ability to predict decreases in trauma volumes with strict PHM and subsequent surges with reopening can help inform operating room time management and staffing in future waves of COVID-19 or infectious disease pandemics. LEVEL OF EVIDENCE: Prognostic - Level III.

Management of patients with hip fracture receiving anticoagulation: What are we doing in Canada?

BACKGROUND: Direct oral anticoagulants (DOACs) are rapidly replacing warfarin for therapeutic anticoagulation; however, many DOACs are irreversible and may complicate bleeding in emergent situations such as hip fracture. In this setting, there is a lack of clear guidelines for the timing of surgery. The purpose of this study was to evaluate the current practices of Canadian orthopedic surgeons who manage patients with hip fracture receiving anticoagulation. METHODS: In January-March 2018, we administered a purpose-specific cross-sectional survey to all currently practising orthopedic surgeons in Canada who had performed hip fracture surgery in 2017. The survey evaluated approaches to decision-making and timing of surgery in patients with hip fracture receiving anticoagulation. RESULTS: A total of 280 surgeons representing a mix of academic and community practice, seniority and fellowship training responded. Nearly one-quarter of respondents (66 [23.4%]) were members of the Canadian Orthopaedic Trauma Society (COTS). Almost three-quarters (206 [73.6%]) felt that adequate clinical guidelines for patients with hip fracture receiving anticoagulation did not exist, and 177 (61.9%) indicated that anesthesiology or internal medicine had a greater influence on the timing of surgery than the attending surgeon. A total of 117/273 respondents (42.9%) indicated that patients taking warfarin should have immediate surgery (with or without reversal), compared to 63/270 (23.3%) for patients taking a DOAC (p < 0.001). Members of COTS were more likely than nonmembers to advocate for immediate surgery in all patients (p < 0.05). CONCLUSION: There is wide variability in Canada in the management of patients with hip fracture receiving anticoagulation. Improved multidisciplinary communication, prospectively evaluated treatment guidelines and focus on knowledge translation may add clarity to this issue. LEVEL OF EVIDENCE: IV.

FROST: Factors Predicting Orthopaedic Trauma Volumes.

INTRODUCTION: Orthopaedic surgeons often speculate weather and season impact the nature and volume of surgical trauma. Little evidence exists to support this. We aimed to identify the relationship between weather conditions, time of year, surgical orthopaedic trauma volumes, after-hours surgery, and surgical wait times. METHODS: Unscheduled surgical orthopaedic cases were retrospectively reviewed at major adult hospitals in Calgary, Alberta, Canada, over an eleven-year period (2008-2018). Weather variables were gathered and a predictive model for ice was generated. Multivariable Poisson regression was used to determine the effect of weather and time of year on orthopaedic trauma volumes and after-hours surgery. Linear regression was used to investigate surgical wait times. RESULTS: 41,421 unscheduled orthopaedic trauma surgeries were analyzed against daily weather patterns. 49% of all surgery performed was for hip (26.4%) or ankle fractures (22.6%). Same day snow (p=0.002) and ice for two days prior (p=0.031; p=0.003) were significantly associated with increased overall trauma volumes. Same day snow (p<0.001) and ice (p=0.002), as well as ice two days prior (p=0.001), predicted a significant increase in ankle fracture volumes. There was no correlation between weather patterns and hip fracture volumes. Independent of weather, time of year was highly predictive of large swings in orthopaedic trauma volumes and increased wait times. Generally, when patient volumes increased so did after-hours surgery. CONCLUSION: Winter and summer months as well as ice and daily snow contributed to the most significant increases in overall orthopaedic trauma volumes. On a snowy day in February with ice present for three consecutive days, trauma volumes increased as much as 71%. Despite this, resources dedicated to orthopaedic trauma are consistent throughout the year, which highlights the need to allocate resources for orthopaedic trauma surgery based on seasonal demands. We suggest our predictive model be used to guide the amount of operating room time reserved for orthopaedic trauma to better reflect expected volumes. This contrasts the current system which relies on after-hours surgeries and increased patient wait-times to compensate for increased orthopaedic trauma volumes. Since orthopaedic trauma can be predicted by weather patterns, interventions should aim to decrease weather-related orthopaedic trauma and reduce the burden prolonged wait times have on our system.

PrEvention of Posttraumatic contractuRes with Ketotifen 1 (PERK 1): A Randomized Clinical Trial.

OBJECTIVE: To assess the use of ketotifen fumarate (KF) to reduce posttraumatic contractures after elbow fractures and/or dislocations. DESIGN: Randomized clinical trial. SETTING: Three hospitals in Calgary, Canada, including one Level 1 trauma center. PARTICIPANTS: Adults (n = 151) sustaining operative or nonoperatively managed isolated distal humerus or proximal radius ± ulna fractures or elbow dislocations within 7 days of injury. INTERVENTIONS: KF 5 mg (n = 74) or lactose placebo (PL, n = 77) orally twice daily for 6 weeks. MAIN OUTCOMES: Primary outcome elbow flexion-extension arc range of motion (ROM) at 12 weeks postrandomization. Safety measures including serious adverse events and radiographic fracture line disappearance from 2 to 52 weeks postrandomization. RESULTS: The elbow ROM (mean, confidence interval) was not significantly different between KF (122 degrees, 118-127 degrees) and PL (124 degrees, 119-130 degrees) groups (P = 0.56). There was a significant difference in elbow ROM at 12 weeks postrandomization comparing operative (117 degrees, 112-122 degrees) versus nonoperative groups (128 degrees, 124-133 degrees) irrespective of intervention (P = 0.0011). There were 11 serious adverse events (KF = 6, PL = 5) that were those expected in an elbow fracture population potentially taking KF. There was no statistically significant difference in the rates of these events between the groups. The disappearance of fracture lines over the course of time was similar between groups. There was one nonunion in each group. CONCLUSIONS: In a population of operative and nonoperatively managed elbow fractures and/or dislocations KF did not reduce posttraumatic contractures. The administration of KF in this population was not found to result in a significantly higher number of major adverse events when compared with placebo. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

PrEvention of posttraumatic contractuRes with Ketotifen 2 (PERK 2) - protocol for a multicenter randomized clinical trial.

BACKGROUND: Injuries and resulting stiffness around joints, especially the elbow, have huge psychological effects by reducing quality of life through interference with normal daily activities such as feeding, dressing, grooming, and reaching for objects. Over the last several years and through numerous research results, the myofibroblast-mast cell-neuropeptide axis of fibrosis had been implicated in post-traumatic joint contractures. Pre-clinical models and a pilot randomized clinical trial (RCT) demonstrated the feasibility and safety of using Ketotifen Fumarate (KF), a mast cell stabilizer to prevent elbow joint contractures. This study aims to evaluate the efficacy of KF in reducing joint contracture severity in adult participants with operately treated elbow fractures and/or dislocations. METHODS/DESIGN: A Phase III randomized, controlled, double-blinded multicentre trial with 3 parallel groups (KF 2 mg or 5 mg or lactose placebo twice daily orally for 6 weeks). The study population consist of adults who are at least 18 years old and within 7 days of injury. The types of injuries are distal humerus (AO/OTA type 13) and/or proximal ulna and/or proximal radius fractures (AO/OTA type 2 U1 and/or 2R1) and/or elbow dislocations (open fractures with or without nerve injury may be included). A stratified randomization scheme by hospital site will be used to assign eligible participants to the groups in a 1:1:1 ratio. The primary outcome is change in elbow flexion-extension range of motion (ROM) arc from baseline to 12 weeks post-randomization. The secondary outcomes are changes in ROM from baseline to 6, 24 & 52 weeks, PROMs at 2, 6, 12, 24 & 52 weeks and impact of KF on safety including serious adverse events and fracture healing. Descriptive analysis for all outcomes will be reported and ANCOVA be used to evaluate the efficacy KF over lactose placebo with respect to the improvement in ROM. DISCUSSION: The results of this study will provide evidence for the use of KF in reducing post-traumatic joint contractures and improving quality of life after joint injuries. TRIAL REGISTRATION: This study was prospectively registered (July 10, 2018) with ClinicalTrials.gov reference: NCT03582176.

Scapholunate Ligament Injury and the Effect of Scaphoid Lengthening.

Objective We hypothesized that lengthening the scaphoid in a model of scapholunate ligament injury (SLI) will result in correction of radiographic markers of dorsal intercalated segment instability (DISI) deformity. Materials and Methods An SLI with DISI deformity was created by sectioning the SL ligament, the palmar radiocarpal ligaments, and scapho-trapezio-trapezoid ligaments of a cadaveric upper extremity ( n = 5). The wrist was radiographed in both anteroposterior and lateral planes to confirm creation of SLI and DISI. The scaphoid was then osteotomized at its waist. A series of grafts (1-8 mm) were then placed at the osteotomy site. Radiographs were completed at each length. The main outcome measures were scapholunate interval (SL, mm), scapholunate angle (SLA, degrees), and radiolunate angle (RLA, degrees). These values, measured following the insertion of varying graft lengths, were compared with baseline measurements taken "post-injury" status. Results The ability to create an SLI with DISI was confirmed in the postinjury group with a statistically significant change in RLA, SLA, and SL compared with preinjury. With osteotomy and progressive insertion of spacers, the values improved into the accepted normal ranges for RLA (6 mm) and SLA (4 mm) with scaphoid lengthening. Conclusions In this cadaveric model of SL injury, radiographic markers of DISI were returned to within normal ranges with scaphoid osteotomy and lengthening. Clinical Relevance The results of this study add insight into wrist kinematics in our injury model and may represent a potential future direction for surgical treatment of SLI.

Surgical outcomes of chronic isolated scapholunate interosseous ligament injuries: a systematic review of 805 wrists

Background: Management of chronic isolated scapholunate interosseous ligament (SLIL) injuries has generated a substantial volume of low-quality literature with descriptions of multiple new surgical techniques, and the impact of instability pattern and the optimal surgical technique remain unclear. The primary goal of this review was to compare clinical, radiographic and patient-rated outcomes between current surgical techniques. Methods: We performed a systematic literature search using multiple databases. We analyzed clinical, radiographic and patient-reported outcomes. We used a fixed-effects model weighted by sample size with combined outcomes estimated via least squares means with 95% confidence intervals. We also performed a subgroup analysis of static versus dynamic instability. Results: We assessed 805 procedures from 37 study groups, with 429 procedures used in subgroup analysis. There were no statistically significant differences in outcomes between surgical techniques or in subgroup analysis. Overall, postoperative wrist flexion and pain scores decreased, and grip strength and patient-rated outcomes improved. Conclusion: Compared to overall preoperative values, modest improvements in pain score, grip strength and functional outcome scores were obtained from a range of reconstructive procedures performed for chronic isolated SLIL injuries. No significant differences could be ascertained between surgical techniques, potentially owing to the low quality of evidence and procedure heterogeneity. This study provides accurate preoperative reference values for future studies, highlights the controversial clinical impact of instability classification, and the need for higher-quality multicentre or collaborative trials to improve our understanding and management of this common injury.

Contexte: La prise en charge des blessures chroniques du ligament interosseux scapho-lunaire (LISL) a généré un volume substantiel d'articles de faible qualité où sont décrites plusieurs nouvelles techniques chirurgicales, mais l'impact du modèle d'instabilité et la technique chirurgicale optimale restent à clarifier. Le principal objectif de cette revue était de comparer les résultats cliniques, radiographiques et autodéclarés par les patients entre les diverses techniques chirurgicales actuelles. Méthodes: Nous avons procédé à une interrogation systématique de la littérature dans plusieurs bases de données. Nous avons analysé les résultats cliniques, radiographiques et autodéclarés par les patients. Nous avons utilisé un modèle à effets fixes pondéré par la taille de l'échantillon, avec paramètres mixtes estimés par les moyennes des moindres carrés et des intervalles de confiance à 95 %. Nous avons aussi effectué une analyse de sous-groupes (instabilité radiographique dynamique c. statique). Résultats: Nous avons évalué 805 interventions dans 37 groupes étudiés, et 429 interventions ont été utilisées dans les analyses de sous-groupes. On n'a noté aucune différence statistiquement significative pour ce qui est des résultats entre les techniques chirurgicales ni dans les analyses de sous-groupes. Globalement, la flexion du poignet et la douleur ont diminué, et la force préhensile et autres paramètres autodéclarés par les patients se sont améliorés. Conclusion: Comparativement aux valeurs préopératoires globales, de modestes améliorations du score de douleur, de la force préhensile et des paramètres fonctionnels ont été obtenues au moyen de diverses interventions de reconstruction effectuées pour des blessures chroniques isolées du LISL. Aucune différence significative n'a pu être confirmée entre les techniques chirurgicales, probablement en raison de la faible qualité des données et de l'hétérogénéité des interventions. Cette étude fournit des valeurs de référence préopératoires précises pour de futures études et souligne l'impact clinique controversé de la classification de l'instabilité, ainsi que la nécessité de procéder à des essais multicentriques ou collaboratifs de meilleure qualité pour mieux comprendre et prendre en charge ce type fréquent de blessure.

Injuries of the Scapholunate Interosseous Ligament: An Update.

The scapholunate ligament is both a key ligament in the stability of the carpus and one of the most frequently injured. Thorough understanding of the anatomy, biomechanics, and pathophysiology of the wrist is important in treating injuries to the scapholunate ligament. The presentation of scapholunate instability often includes a vague injury history and pain with grip, wrist extension, and sport or labor. Identified injuries are classified based on dynamic and static radiographic findings, chronicity, and the presence or absence of arthrosis. Surgical options for the treatment of low- and high-grade injuries include both open and arthroscopic procedures and can be broadly classified into four categories: limited arthroscopic procedures, primary ligament repair, reconstructive procedures, and salvage procedures. No strong evidence currently supports any one treatment. Decision making is largely based on expert opinion and surgeon experience. Prognosis is often guarded, and patient expectations should be tempered.

Erratum: The Management of Kienböck Disease: A Survey of the ASSH Membership.

[This corrects the article DOI: 10.1055/s-0035-1544225.].

Volar plate capsulodesis for metacarpophalangeal hyperextension with basal joint arthritis.

Basal joint arthritis leads to thumb metacarpophalangeal (MCP) hyperextension that may prevent physiologic pinch. Various techniques have been used to address this hyperextension, but most are technically challenging, time-consuming, and not supported by long-term follow-up results. Furthermore, few groups have reported subjective, patient-based outcomes after such procedures. In a retrospective study, we evaluated a cohort of 14 patients who underwent a novel technique of thumb MCP capsulodesis in conjunction with basal joint arthroplasty. A mean of 4.74 years after surgery, subjective outcome measures (Disabilities of the Arm, Shoulder, and Hand questionnaire; visual analog scale for pain; patient satisfaction) and objective outcome measures (range of motion, grip and pinch strengths) all reflected excellent function. The described technique for MCP capsulodesis is an attractive adjunct to basal joint arthroplasty, but further prospective studies are needed to establish specific operative indications.

A retrospective cohort study of displaced segmental radial head fractures: is 2 mm of articular displacement an indication for surgery?

HYPOTHESIS: Many investigators agree that 2 mm of articular displacement is a reasonable indication for open reduction and internal fixation of Mason type II fractures of the radial head. However, there is no evidence to support that this degree of articular displacement is predictive of poor outcomes in conservatively treated fractures. We hypothesized there would be no difference between conservatively treated radial head fractures with greater 2 mm of displacement and those with less than 2 mm of displacement in terms of patient-reported or clinical outcomes. MATERIALS AND METHODS: We reviewed databases of all radial head fractures in our region. The primary outcomes were the Patient-Rated Elbow Evaluation and Disabilities of the Arm, Shoulder and Hand questionnaires. Secondary outcomes included radiologic radiocapitellar arthritis and range of motion (ROM) at follow-up. Postinjury treatment protocols, as well as patient factors, were examined for their effects on outcome. RESULTS: The results showed no significant difference in any outcome for conservatively treated radial head fractures with 2 mm (P = .8) or even 3 mm (P = .6) of articular displacement over a mean follow-up of 4.4 years. Early ROM and physiotherapy showed no significant differences in any outcome measure. Dominant hand injury showed no significant difference in patient-reported outcomes; however, ROM was significantly decreased on examination. CONCLUSIONS: This retrospective review suggests that fracture displacement of 2 to 3 mm is not necessarily an indication for surgical fixation in isolated fractures of the radial head. In addition, it appears that postinjury ROM/physiotherapy does not play a large role in improving patient outcome.

Locked plate fixation of the comminuted distal fibula: a biomechanical study.

BACKGROUND: The purpose of this study was to compare the biomechanical properties of locked versus nonlocked lateral fibular bridge plating of comminuted, unstable ankle fractures in a mode of catastrophic failure. METHODS: We created comminuted Weber C fractures in 8 paired limbs from fresh cadavers. Fractures were plated with either standard or locked one-third tubular bridge plating techniques. Specimens were biomechanically evaluated by external rotation to failure while subjected to a compressive load approximating body weight. We measured the angle to failure, torque to failure, energy to failure and construct stiffness. RESULTS: There was no significant difference in construct stiffness or other biomechanical properties between locked and standard one-third tubular plating techniques. CONCLUSION: We found no difference in biomechanical properties between locked and standard bridge plating of a comminuted Weber C fibular fracture in a model of catastrophic failure. It is likely that augmentation of fixation with K-wires or transtibial screws provides a construct superior to locked bridge plating alone. Further biomechanical and clinical analysis is required to improve understanding of the role of locked plating in ankle fractures and in osteoporotic bone.

Percutaneous reduction and fixation of displaced phalangeal neck fractures in children.

BACKGROUND: Several methods have been reported for fixation of displaced phalangeal neck fractures in children. The purpose of this study is to present a technique for the closed reduction and percutaneous fixation of displaced phalangeal neck fractures and the clinical results of 4 patients treated by this method. METHODS: Four consecutive patients with displaced phalangeal neck fractures were treated with closed reduction and single intramedullary Kirschner wire placed percutaneously with a novel technique. RESULTS: The average age at injury was 5 years 9 months (range, 23 mo to 10 y). Three patients were male and 1 was female. Two patients had fractures of the proximal phalangeal neck, whereas the other 2 had fractures of the middle phalangeal neck. After an average follow-up of 18 weeks, all patients had nearly full pain-free flexion and extension of the affected digit. CONCLUSIONS: The described technique is a simple, reproducible and effective treatment for displaced phalangeal neck fractures in children. LEVEL OF EVIDENCE: Level IV. Therapeutic study, case series.