Novel Technical Factors Affecting Proximal Humerus Fixation Stability.

OBJECTIVES: Intra-articular screw cut-out is a common complication after proximal humerus fracture (PHF) fixation using a locking plate. This study investigates novel technical factors associated with mechanical failures and complications in PHF fixation. DESIGN: A retrospective radiological study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Clinical and radiological data from consecutive PHF patients treated between January 2007 and December 2013 were reviewed. INTERVENTION: Open reduction and internal fixation with the Synthes Philos locking plate. MAIN OUTCOME MEASUREMENTS: Postoperative radiographs were assessed for quality of initial reduction, humeral head offset, screw length, number and position, restoration of medial calcar support or the presence of calcar screws, and intra-articular screw perforations. Using SliceOMatic software, we validated a method to accurately identify screws of 45 mm or longer on AP radiographs. Follow-up radiographs were reviewed for complications. RESULTS: Among 110 patients included [mean age 60 years, 78 women (71%), follow-up 2.5 years] and the following factors were associated with a worse outcome. (1) Screws >45 mm in proximal rows [Odds Ratio (OR) = 5.3 for screw cut-out); (2) lateral translation of the humeral diaphysis over 6 mm (OR = 2.7 for loss of reduction); (3) lack in medial support by bone contact (OR = 4.9 for screw cut-out); (4) varus reduction increased the risk of complications (OR = 4.3). CONCLUSION: The importance of reduction and calcar support in PHF fixation is critical. This study highlights some technical factors to which the surgeon must pay attention: avoid varus reduction, maximize medial support, avoid screws longer than 45 mm in the proximal rows, and restore the humeral offset within 6 mm or less. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Greater trochanteric pain after primary total hip replacement, comparing the anterior and posterior approach: A secondary analysis of a randomized trial.

BACKGROUND: Greater trochanteric pain (GTP) after total hip replacement is a common cause of residual lateral hip pain, regardless of the approach used. The goal of our study was to evaluate GTP after a direct anterior approach (DAA) compared to a posterior approach (PA) as well as the clinical outcomes of both approaches and answer the following: 1) What is the incidence of trochanteric pain after primary THA with two different surgical approaches? 2) What is the functional outcome of patients with GTP? 3) What proportion of patients with GTP resort to peritrochanteric injections? HYPOTHESIS: Our hypothesis is that GTP is present with both approaches but satisfaction is lower with the PA. PATIENTS AND METHODS: A secondary analysis of a previously published clinical trial with 55 total hip arthroplasty patients randomized in one of two surgical approaches: 27 patients underwent the anterior modified Hueter approach, while the other group of 28 patients were operated using the posterior approach. Study outcomes were Modified Harris Hip Score (MHHS), satisfaction score, pain when lying on the affected side, and requiring an injection. Hip offset, femur lateralization and leg lengthening were measured before and after surgery. RESULTS: Forty-five patients were available for complete follow-up at a mean of 62 months (range: 48-74). The incidence of GTP was higher in the posterior approach [PA: 6/21 (29%) vs DAA 4/24 (17%)) (p=0.3). Patients operated through a PA experienced more pain [5/21 (24%) of patients; VAS=mean 5.3] when lying on their operated side, compared to DAA patients [2/24 (8%) of patients; VAS=mean 2) (p=0.2)]. However, MHHS, patient satisfaction with surgery, radiological assessment for hip offset, femur lateralization or leg lengthening, and injections required were similar for both approaches. Overall, satisfaction and functional outcome with surgery was significantly lower in GTP patients, regardless of the approach. CONCLUSIONS: GTP impacts patient satisfaction and functional outcome in total hip arthroplasty patients. PA patients reported more trochanteric pain than DAA patients, which affected their clinical outcome. LEVEL OF EVIDENCE: III.

Direct anterior versus posterior approach for total hip arthroplasty: a multicentre, prospective, randomized clinical trial.

BACKGROUND: The ideal approach for a total hip arthroplasty (THA) would be kind to soft tissues, have the lowest complication rates and be easily reproducible. Although there have been several attempts to find the best approach for THA in the last decade, a definitive answer has not been found. We performed a prospective study to compare the direct anterior and posterior approaches for THA in terms of hospital length of stay, functional outcome, pain, implant position, complications and surgical time. METHODS: A prospective, randomized, multicentre clinical study was conducted between February 2011 and July 2013, with an average follow-up of 55 months. Patients undergoing the direct anterior or posterior approach for THA were enrolled. Hospital length of stay, surgical time and complications were documented. The Harris Hip Score and visual analogue scale were used to monitor functional outcome and pain until 5 years postoperatively. Radiologic analysis was used to assess implant position. RESULTS: Fifty-five patients (28 undergoing the direct anterior approach, 27 undergoing the posterior approach) were enrolled in this study. Length of stay, functional outcome, pain, implant position and complications were similar for the 2 approaches. There was a trend toward a better functional outcome for patients who underwent the direct anterior approach in the first 3 months postoperatively, with a peak at 4 weeks (Harris Hip Score 76.7 v. 68.7; p = 0.08). Average surgical time for the direct anterior approach was significantly longer (69.9 v. 45.7 min; p = 0.002). CONCLUSION: The direct anterior approach for THA appears to be a safe and effective option. However, there is no significant difference in hospital length of stay or postoperative recovery between the 2 approaches. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, no. NCT03673514.

CONTEXTE: L'approche idéale pour l'arthroplastie totale de la hanche (ATH) serait douce pour les tissus mous, aurait le taux de complications le plus bas et serait facilement reproductible. Dans les 10 dernières années, on a tenté à de nombreuses reprises de déterminer quelle est la meilleure approche, sans obtenir de réponse concluante. Nous avons mené une étude prospective visant à comparer la durée du séjour à l'hôpital, les résultats fonctionnels, la douleur, la position de l'implant, les complications et le temps de chirurgie associés aux approches antérieure directe et postérieure pour l'ATH. MÉTHODES: Un essai clinique randomisé prospectif multicentrique a été mené auprès de patients ayant subi une ATH par voie antérieure directe ou postérieure entre février 2011 et juillet 2013; le suivi moyen était de 55 mois. La durée du séjour à l'hôpital, le temps de chirurgie et les complications ont été notés. Le score de Harris pour la hanche et l'échelle analogique visuelle ont servi au suivi des résultats fonctionnels et de la douleur dans les 5 ans suivant l'opération. Des clichés radiologiques ont été analysés pour évaluer la position de l'implant. RÉSULTATS: Au total, 55 patients ont été recrutés (28 ayant subi une ATH par voie antérieure directe, et 27, une ATH par voie postérieure). La durée du séjour, les résultats fonctionnels, la douleur, la position de l'implant et les complications étaient sensiblement les mêmes, quelle que soit l'approche utilisée. Dans les 3 premiers mois suivant l'opération, les patients ayant subi une ATH par voie antérieure directe avaient tendance à présenter de meilleurs résultats fonctionnels que les autres, en particulier à la quatrième semaine postopératoire (score de Harris pour la hanche : 76,7 c. 68,7; p = 0,08). Le temps de chirurgie moyen pour l'approche antérieure directe était significativement plus long (69,9 c. 45,7 min; p = 0,002). CONCLUSION: La voie antérieure directe semble être une approche efficace et sûre. Aucune différence significative n'a toutefois été observée entre les 2 approches quant à la durée du séjour à l'hôpital ou au rétablissement postopératoire. ENREGISTREMENT DE L'ESSAI: ClinicalTrials.gov, no NCT03673514.

Deltopectoral vs. deltoid split approach for proximal HUmerus fracture fixation with locking plate: a prospective RAndomized study (HURA).

BACKGROUND: This study aimed to compare the functional and clinical outcomes between the deltoid split (DS) approach and the classic deltopectoral (DP) approach for locking plate fixation of proximal humerus fractures (PHF) in a prospective randomized multicenter study. METHODS: From 2007 to 2015, all patients with a PHF Neer II/III were invited to participate. Exclusion criteria were pre-existing pathology to the limb, patient refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty), and axillary nerve impairment. After consent, patients were randomized to one of the 2 treatments using the dark envelope method. Functional outcome was evaluated by validated questionnaires (12-Item Short Form Health Survey: version 2, Quick-DASH) with a minimum follow-up of 12 months. Complications were noted. RESULTS: A total of 85 patients (44 DS, 41 DP) were randomized (mean age of 62). Groups were equivalent in terms of age, gender, body mass index, severity of fracture, and preinjury scores. The mean follow-up was 26 months. All clinical outcome measures were in favor of the deltopectoral approach. Specifically, the Q-DASH and SF-12v2 were better in the DP group (12 vs. 26, P = .003 and 56 vs. 51, P = .049, respectively). There were more complications in DS patients, but they did not reach statistical significance. CONCLUSIONS: The primary hypothesis on the superiority of the deltoid split incision was rebutted. On the basis of our study, the DP approach seems to offer better function compared with the DS approach for fixation of Neer 2 and 3 PHF fractures fixed with a locking plate.

Quantitative localization of the entry point of the lateral ascending branch of the anterior circumflex humeral artery: a high definition CT-scan radiological study.

PURPOSE: To define the localization of the entry point of the lateral ascending branch of the anterior circumflex humeral artery (LACHA) for better surgical management and prevention of injury to this important vessel. The hypothesis is that the insertion point of the artery will be constant in subjects. METHODS: A retrospective study of 27 tomographic images was conducted to generate a three-dimensional (3D) model and localize the entry point of the LACHA. Using a coordinate system consisting of three axes: the proximal-distal axis (PDA), the anterior-posterior axis (APA) and the medial-lateral axis (MLA), the position of a foramen located in the superior portion of the bicipital groove and representing the entry point of LACHA was measured on each reconstructed model. RESULTS: On average, the foramen was located 10.0 mm distal along the PDA from the most proximal point of the greater tuberosity (GT). Along the MLA and with respect to the most medial portion of the GT, the foramen was located 3.4 mm medially, on average. No significant differences between men and women or between sides for foramen position measurements were found. CONCLUSION: Unnecessary procedures to the proximal biceps, aiming to prevent chronic pain, should be avoided in fracture fixation as they would affect a significant source of blood supply to the humeral head. These findings could help surgeons protect the only vascular supply they can during the fixation of proximal humeral fractures, when using the anterior or antero-lateral approaches.

Factors affecting outcome of partial radial head fractures: A Retrospective Cohort Study.

BACKGROUND: The purpose of this study is to evaluate which factors will affect range of motion (ROM) and function in partial radial head fractures. The hypothesis is that conservative treatment yields better outcomes. MATERIALS AND METHODS: This retrospective comparative cohort study included 43 adult volunteers with partial radial head fracture, a minimum 1-year follow up, separated into a surgical and non-surgical group. Risk factors were: associated injury, heterotopic ossification, worker's compensation, and proximal radio ulnar joint (PRUJ) implication. Outcomes included radiographic ROM measurement, demographic data, and quality of life questionnaires (PREE, Q-DASH, MEPS). RESULTS: Mean follow up was 3.5 years (1-7 years). Thirty patients (70%) had associated injuries with decreased elbow extension (-11°, p=0.004) and total ROM (-14°, p=0.002) compared to the other group. Heterotopic ossification was associated with decreased elbow flexion (-9.00°, p=0.001) and fractures involved the PRUJ in 88% of patients. Only worker's compensation was associated with worse scores. There was no difference in terms of function and outcome between patients treated non-surgically or surgically. DISCUSSION: We found that associated injuries, worker's compensation and the presence of heterotopic ossification were the only factors correlated with a worse prognosis in this cohort of patients. Given these results, the authors reiterate the importance of being vigilant to associated injuries. LEVEL OF EVIDENCE: IV, Retrospective study.

Involvement of the proximal radial ulnar joint in partial radial head fractures: a novel three-dimensional computed tomography scan evaluation method.

BACKGROUND: Partial radial head fractures (PRHF) can involve the proximal radioulnar joint (PRUJ) or be restricted to the 'safe zone' (SZ) during forearm rotation. The objective of the present study was to develop an assessment method for PRUJ involvement in radial head fractures using axial computed tomography (CT) scans. METHODS: The area of the radial head in contact with the PRUJ zone was identified, and defined on 18 cadaveric elbows CT scans; the quantitative relationship between PRUJ zone and radial tuberosity was established. Then, four evaluators validated it on PRHF CT scan axial views, classifying the fractures as involving the PRUJ or not. RESULTS: Using the radial tuberosity as the 0° of a 360° circle, the SZ was within 108° to 212° clockwise for a right elbow and counter clockwise for the left elbow. Fifty-five consecutive (30 men, 25 women, mean age of 49 years) partial radial head fracture CT scans were classified: four in the SZ only, three in the PRUJ zone and 48 in both the PRUJ and SZ. The kappa for the inter- and intra-observer agreement was 0.517 and 0.881, respectively. CONCLUSIONS: Ninety-three percent of partial radial head fractures will involve the PRUJ and the geometric model developed allows their classification, potentially helping surgeons decide on optimal treatment. LEVEL OF EVIDENCE: Retrospective basic science study. Level III: anatomic study, imaging.

Feasibility of a Hybrid Web-Based and In-Person Self-management Intervention Aimed at Preventing Acute to Chronic Pain Transition After Major Lower Extremity Trauma (iPACT-E-Trauma): A Pilot Randomized Controlled Trial.

Objective 1) To assess the feasibility of research methods to test a self-management intervention aimed at preventing acute to chronic pain transition in patients with major lower extremity trauma (iPACT-E-Trauma) and 2) to evaluate its potential effects at three and six months postinjury. Design A pilot randomized controlled trial (RCT) with two parallel groups. Setting A supraregional level 1 trauma center. Methods Fifty-six adult patients were randomized. Participants received the intervention or an educational pamphlet. Several parameters were evaluated to determine the feasibility of the research methods. The potential efficacy of iPACT-E-Trauma was evaluated with measures of pain intensity and pain interference with activities. Results More than 80% of eligible patients agreed to participate, and an attrition rate of ≤18% was found. Less than 40% of screened patients were eligible, and obtaining baseline data took 48 hours postadmission on average. Mean scores of mild pain intensity and pain interference with daily activities (<4/10) on average were obtained in both groups at three and six months postinjury. Between 20% and 30% of participants reported moderate to high mean scores (≥4/10) on these outcomes at the two follow-up time measures. The experimental group perceived greater considerable improvement in pain (60% in the experimental group vs 46% in the control group) at three months postinjury. Low mean scores of pain catastrophizing (Pain Catastrophizing Scale score < 30) and anxiety and depression (Hospital Anxiety and Depression Scale scores ≤ 10) were obtained through the end of the study. Conclusions Some challenges that need to be addressed in a future RCT include the small proportion of screened patients who were eligible and the selection of appropriate tools to measure the development of chronic pain. Studies will need to be conducted with patients presenting more serious injuries and psychological vulnerability or using a stepped screening approach.

Rationale, study design, and descriptive data of the Lucky Bone™ Fracture Liaison Service.

The study design of a multidisciplinary Fracture Liaison Service (2-year follow-up) aiming to optimize fragility fracture management in an outpatient setting is presented. Patient characteristics, investigation, and treatment initiation data at baseline were recorded. Results corroborate the care gap in osteoporosis management, reinforcing the need for secondary fracture prevention programs. PURPOSE: This paper describes the study design, implementation, and baseline characteristics of a multidisciplinary Fracture Liaison Service (FLS) in Quebec (Canada). METHODS: A FLS was implemented as a prospective cohort study. After identification, fracture risk was assessed and patients were started on treatment or referred, according to guidelines and risk assessment. Thereafter, patients were systematically followed over 2 years. Clinical data (fractures, bone density, blood testing (bone turnover markers), quality of life, physical disability) as well as administrative data (pharmacological, health services, hospitalization) was collected. Baseline descriptive data was analyzed and presented. RESULTS: Of 542 recruited participants, 532 underwent baseline assessment (85.7% female, mean age 63.4 years). Overall, 29.7% of participants either withdrew from the study or were lost to follow-up. Almost 27% were referred to a specialist, while > 70% received anti-osteoporosis medication prescriptions through the FLS at baseline. Mean femoral T-score was - 1.6 ± 1.0 and vertebral T-score was - 1.7 ± 1.4. Nearly 19% of subjects reported being under anti-osteoporosis medication at the time of incident fracture. Thirty-three percent of participants reported a prior fracture history, of which 29.7% reported being given anti-osteoporosis therapy. Most fracture sites were to the wrist and ankle, while < 19% were hip/femur or vertebral fractures. CONCLUSIONS: These results highlight the important care gap in fragility fracture management and reinforce the need for secondary fracture prevention programs. This prospective study will allow the evaluation of key performance indicators for outpatient clinic-based FLS, such as medication usage, by combining prospective clinical and administrative data.

Intraoperative Torque Test to Assess Syndesmosis Instability.

BACKGROUND:: In this cadaveric study, a new "torque test" (TT) stressing the fibula posterolaterally under direct visualization was compared with the classical external rotation stress test (ERT) and lateral stress test (LST). METHODS:: The anteroinferior tibiofibular ligament (AiTFL), the interosseous membrane (IOM), and the posteroinferior tibiofibular ligament (PiTFL) were sectioned sequentially on 10 fresh-frozen human ankles. At each stage of dissection, instability was assessed using the LST, ERT, and TT under direct visualization. Anatomical tibiofibular diastasis measurements were taken directly on cadavers and compared using the Wilcoxon signed rank test. RESULTS:: All 3 tests showed statistically significant motion in the syndesmosis when at least 2 ligaments were sectioned. The mean increase across diastasis with a 2-ligament section was 3.0 mm ( P = .005), 3.2 mm ( P = .005), and 4.8 mm ( P = .005) for the LST, ERT, and TT, respectively. The largest mean increase in diastasis was obtained with a complete injury using the TT and was 6.2 mm ( P = .008). With the TT, a 3.5-mm tibiofibular diastasis was 90% sensitive and 100% specific when 2 or more syndesmotic ligaments were sectioned. CONCLUSION:: The TT was a more sensitive and specific tool for detecting syndesmosis instability than classic LST and ERT. CLINICAL RELEVANCE:: Stressing the fibula in a posterolateral direction created a larger distal tibiofibular diastasis, which would be easier to detect in the intraoperative setting. The TT was more sensitive and specific to detecting a 2-ligament syndesmotic injury than the classic test and required less force to perform.

Total Hip Arthroplasty for Bilateral Femoral Neck Stress Fracture: A Case Report and Review of the Literature.

Femoral neck stress fractures (FNSFs) can be treated conservatively or surgically, depending on initial displacement and patient condition. Surgical treatment options include internal fixation, with or without valgus osteotomy or hip arthroplasty, either hemi or total. The latter is mainly considered when initial treatment fails. A review of the literature shows that total hip arthroplasty (THA) is only considered as primary treatment in displaced fractures (type 3) in low-demand patients. We present a case of successive bilateral FNSF in a young active patient, where a THA was performed on one side, after failed internal fixation, and where it was chosen as primary treatment on the other side after failed conservative treatment.

Incidence of symptomatic venous thromboembolism in 2372 knee and hip replacement patients after discharge: data from a thromboprophylaxis registry in Montreal, Canada.

BACKGROUND: Low-molecular-weight heparin (LMWH) is a recommended anticoagulant for thromboprophylaxis after major orthopedic surgery. Dabigatran etexilate is an oral anticoagulant recognized as noninferior to LMWH. We aimed to assess the incidence of symptomatic venous thromboembolic events (VTEs) after discharge in patients who underwent joint replacement, using a hospital registry. PATIENTS AND METHODS: Patients who underwent total knee and hip arthroplasty between September 2011 and March 2015 were selected. Subcutaneous enoxaparin (30 mg twice daily) was given during hospitalization. At discharge, patients received either enoxaparin 30 mg twice daily/40 mg once daily or dabigatran 220 mg/150 mg once daily. Patients were seen or called at 2, 6, and 12 weeks after surgery. Outcomes were the number of VTEs, including deep venous thrombosis, pulmonary embolism, and the number of major/minor bleeding events after discharge. RESULTS: After discharge, 1468 patients were prescribed enoxaparin and 904 dabigatran (1396 total knee arthroplasty and 976 total hip arthroplasty patients). Mean age was 66±10 years, and 60% were female. The cumulative incidence of VTEs during the 12-week follow-up was 0.7%. One patient sustained a VTE during the switch window. Seven patients sustained a pulmonary embolism (0.3%). There was no statistical difference between the total knee arthroplasty and total hip arthroplasty groups. The incidence of major and minor bleeding events during follow-up was 0.3% and 30.3%, respectively. These events had a higher incidence in the dabigatran group compared to the enoxaparin group after discharge (p<0.05), but not between knee and hip replacement groups for major bleeding events. CONCLUSION: A pharmaceutical prophylaxis protocol using LMWH and dabigatran during the post-discharge period resulted in low incidences of VTE and equivalence between treatments. However, the increased number of major and minor bleeding events in patients taking dabigatran is of concern regarding the safety and needs to be evaluated using analyses adjusted for risk factors.

Direct visualization of the syndesmosis for evaluation of syndesmotic disruption: A cadaveric study.

OBJECTIVES: Radiologic criteria for syndesmosis instability evaluation remain controversial and direct visualization (DV) of the distal tibiofibular articulation is an alternative diagnostic method worthy of further investigation. We speculate that DV is a more accurate way to evaluate syndesmosis instability than fluoroscopy. The purpose of this study is to determine whether syndesmosis instability can accurately be recognized through DV and if this new intraoperative diagnostic method is more sensitive than fluoroscopy in detecting syndesmosis instability. METHODS: Ten cadaveric ankles were tested using a sequential iatrogenic syndesmosis injury model. Specimens were tested incrementally with the lateral stress test (LST) and the external rotation stress test (ERT). The resulting instability was measured directly and fluoroscopically with a true mortise view by using medial clear space (MCS) and tibiofibular clear space (TFCS). RESULTS: DV detected a 2-ligaments injury at a mean diastasis of 3.02 mm (P = 0.0077) and 3.19 mm (P = 0.0077) with the LST and ERT, respectively. Fluoroscopically, TFCS showed a significant diastasis only with a complete syndesmosis rupture while MCS did not show any significant differences. CONCLUSIONS: DV of the syndesmosis in a cadaver injury model appears to be more sensitive than fluoroscopy in identifying injury, especially incomplete syndesmotic disruption.

A Hybrid Web-Based and In-Person Self-Management Intervention Aimed at Preventing Acute to Chronic Pain Transition After Major Lower Extremity Trauma: Feasibility and Acceptability of iPACT-E-Trauma.

BACKGROUND: A transition from acute to chronic pain frequently occurs after major lower extremity trauma. While the risk factors for developing chronic pain in this population have been extensively studied, research findings on interventions aiming to prevent chronic pain in the trauma context are scarce. Therefore, we developed a hybrid, Web-based and in-person, self-management intervention to prevent acute to chronic pain transition after major lower extremity trauma (iPACT-E-Trauma). OBJECTIVE: This study aimed to assess the feasibility and acceptability of iPACT-E-Trauma. METHODS: Using a descriptive design, the intervention was initiated at a supra-regional level-1 trauma center. Twenty-eight patients ≥18 years old with major lower extremity trauma, presenting with moderate to high pain intensity 24 hours post-injury were recruited. Feasibility assessment was two-fold: 1) whether the intervention components could be provided as planned to ≥80% of participants and 2) whether ≥80% of participants could complete the intervention. The rates for both these variables were calculated. The E-Health Acceptability Questionnaire and the Treatment Acceptability and Preference Questionnaire were used to assess acceptability. Mean scores were computed to determine the intervention's acceptability. RESULTS: More than 80% of participants received the session components relevant to their condition. However, the Web pages for session 2, on the analgesics prescribed, were accessed by 71% of participants. Most sessions were delivered according to the established timeline for ≥80% of participants. Session 3 and in-person coaching meetings had to be provider earlier for ≥35% of participants. Session duration was 30 minutes or less on average, as initially planned. More than 80% of participants attended sessions and <20% did not apply self-management behaviors relevant to their condition, with the exception of deep breathing relaxation exercises which was not applied by 40% of them. Web and in-person sessions were assessed as very acceptable (mean scores ≥3 on a 0 to 4 descriptive scale) across nearly all acceptability attributes. CONCLUSIONS: Findings showed that the iPACT-E-Trauma intervention is feasible and was perceived as highly acceptable by participants. Further tailoring iPACT-E-Trauma to patient needs, providing more training time for relaxation techniques, and modifying the Web platform to improve its convenience could enhance the feasibility and acceptability of the intervention. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 91987302; http://www.controlled-trials.com/ISRCTN91987302 (Archived by WebCite at http://www.webcitation.org/6ynibjPHa).

Preexisting Carpal and Carpometacarpal Osteoarthritis Has No Impact on Function after Distal Radius Fractures.

Background Functional outcomes of distal radius fractures vary widely regardless of treatment methods. Purpose This study aims to verify whether preexisting carpal and carpometacarpal (CMC) osteoarthritis (OA) will negatively impact wrist functional outcome in patients with distal radius fractures. Patients and Methods A retrospective case-control study was done using a prospective trauma database. Patients were matched 1:1 in two groups based on the presence of wrist or carpal arthritis (OA). The groups were matched for sex, follow-up, and treatment type. Patients were followed up for a minimum of 1 year and functional outcomes were assessed using validated scores. Results A total of 61 patients were included. Mean age was 63 years (range: 20-85) and average follow-up was 26 months. There were 31 patients in the OA+ group and 30 in the OA- group. Forty-one patients were treated surgically and 20 nonoperatively. None of the patients in the OA- developed OA during follow-up. Both groups were comparable for sex, residual deformity, and follow-up. There was no significant difference for the visual analog scale, Short Form-12, Quick Disability Arm Shoulder Hand, and Patient-rated Wrist Evaluation, or for radiographic outcomes. Conclusion Preexisting OA in the wrist or CMC does not seem to impact outcomes of distal radius fractures, regardless of treatment, age, or sex. Although this is a negative study, the results are important to help counsel patients with distal radius fractures. Further work must be done to identify other potential causes for negative outcomes. Level of Evidence Level III, prognostic study.

Effects of concomitant mild traumatic brain injury on resuming work after suffering from an isolated limb fracture: A cohort study.

BACKGROUND: The objective is to explore the effects of concomitant mild traumatic brain injury (mTBI) on return to work (RTW), among patients suffering from an isolated limb fracture. This follow-up study included a total of 170 working age subjects with an isolated limb fracture, and was conducted in a phone interview approximately 1-year post trauma. 41 had experienced an mTBI and 129 did not. METHODS: Data were obtained through a phone interview conducted on average 20.7 months (SD = 9.6 months) post-accident. The main outcome measure was the number of days taken to RTW after the injury. Demographic information was also gathered during the phone interview. Workers' compensation status was obtained through the hospitals' orthopaedic clinic data. RESULTS: The mTBI group took on average 329.7 days (SD = 298.0) to RTW after the injury, as opposed to 150.3 days (SD = 171.3) for the control group (p < 0.001). After excluding patients who received workers' compensation, the mTBI group still missed significantly more days of work (M = 299.4 days; SD = 333.0) than the control group (M = 105.2 days; SD = 121.6) (p < 0.0001). CONCLUSION: This study shows that mTBI increases work disability by preventing working-age individuals from rapidly returning to work.

Tourniquet and closed-suction drains in total knee arthroplasty. No beneficial effects on bleeding management and knee function at a higher cost.

BACKGROUND: Blood loss is a major concern in total knee arthroplasty (TKA) along with postoperative knee function. The present study explores the impact of tourniquet (T) and closed-suction drains (D) on these parameters in TKA. MATERIALS AND METHODS: A prospective study was conducted on 111 patients admitted for TKA. Subjects were divided into three groups: 36 in group T+D+, 42 in T-D+ and 33 in T-D- (where T+: prolonged tourniquet use, T-: cementation-only tourniquet, D+: closed-suction drain use, and D-: no drain). RESULTS: No statistically significant differences were observed among the three groups(T+D+, T-D+ and T-D-) for total blood loss, hemoglobin levels over the first six postoperative weeks and blood transfusion rate. Intraoperative bleeding was significantly reduced in T+ subjects compared to T- subjects (100±88mL vs. 279±235mL respectively, P<0.001), yet length of surgery was unaffected. Hidden blood loss was lower in D+ subjects compared to D- subjects (1161±554mL vs. 1667±554mL respectively, P<0.001), but was offset by the blood loss in the drains. Early postoperative range of motion (ROM) was superior in group T-D- compared to group T+D+. Nevertheless, postoperative week 6 ROM was similar between the 3 groups as was patient-reported postoperative pain. A patient with a drain represents 35min of extra nursing time and a total cost of $31.87 CAD. CONCLUSIONS: Whole-course tourniquet and closed-suction drain use in TKA do not yield beneficial results while increasing costs. Their use is therefore deemed unnecessary. LEVEL OF EVIDENCE: III (case control prospective study).

Modification of Distal Tibiofibular Relationship After a Mild Syndesmotic Injury.

BACKGROUND: The hypothesis of this study is that a sprain or tear of 1 or more of the 3 syndesmotic ligaments will result in a significant change in the osseous anatomy relationship when comparing injured to uninjured syndesmosis. Our secondary objective was to determine whether injuries to the syndesmosis as diagnosed on magnetic resonance imaging (MRI) could be found using static imaging. METHODS: This is a descriptive radiological study of ankle MRI reports over a 12-year period, from 2 different institutions, and divided in two groups: normal and injured syndesmotic ligaments. A series of 6 lengths and 2 angles were measured on MRI axial views that describe the rotation, lateral, and anteroposterior translational relation between the distal tibia and fibula. Parameters from injured and uninjured ankles were compared using Student's t-test. RESULTS: Fifty uninjured syndesmosis were compared to 64 injured syndesmoses. The majority of syndesmosis injuries concerned either an anterior inferior tibiofibular ligament sprain or tear. There was a significant difference in the anatomic position of the tibia and the fibula between injured and uninjured syndesmosis. CONCLUSIONS: The anterior inferior tibiofibular ligament is the most commonly injured ligament in the syndesmosis in sports injury and results in subtle variations in the syndesmotic anatomy, which plain radiographs cannot assess. Because of the previously validated computed tomography scan measurement, this study demonstrates a potential to identify syndesmotic injury on other more accessible imaging modalities, such as computed tomography scan, by using a well-defined measurement system. LEVELS OF EVIDENCE: Diagnostic, Level III : Retrospective, Radiologic Study.

MRI Quantification of the Impact of Ankle Position on Syndesmosis Anatomy.

BACKGROUND: Despite the common occurrence of syndesmotic injuries in ankle trauma, the distal tibiofibular relationship remains poorly understood. The aim of this study was to evaluate the anatomical impact of ankle sagittal positioning on the tibiofibular relationship in intact ankles by using a validated magnetic resonance imaging (MRI)-based measurement system. METHODS: In this radiologic study, 34 healthy volunteers underwent a series of ankle MRIs with the ankle stabilized in 3 positions: neutral position (NP), dorsiflexion (DF), and plantarflexion (PF). Using a previously validated measurement system, 6 fixed translational measurements and 2 fixed angles were recorded on each MRI and compared using paired t tests. RESULTS: When comparing PF to DF, the anterior distance between the tibial incisura and the fibula varied from 2.5 mm to 3.9 mm ( P < .001), respectively. The middle distance between the tibial incisura and the fibula varied from 1.5 mm to 2.6 mm ( P < .001). Fibular angle varied from 8.7 degrees to 7.8 degrees of internal rotation ( P = .046), respectively. When comparing NP to DF, only the anterior distance was found to be significantly different, varying 0.4 mm ( P < .002). CONCLUSIONS: Ankle dorsiflexion leads to an increase in external rotation and lateral translation of the fibula. These changes could be measured on MRI using a validated measurement system. Ankle motion did have an impact on the distal tibiofibular relationship and should be considered in studies pertaining to syndesmosis imaging. CLINICAL RELEVANCE: This is the first in vivo study demonstrating the impact of sagittal ankle position on the distal tibiofibular relationship in an uninjured ankle. Our findings also support the practice of placing the ankle in dorsiflexion when fixing a disrupted syndesmosis. LEVEL OF EVIDENCE: Level III, comparative study.

Fractures of the greater tuberosity of the humerus: a study of associated rotator cuff injury and atrophy.

BACKGROUND: This is a retrospective prognostic study on soft tissue injury following isolated greater tuberosity (GT) fractures of the proximal humerus with respect to the relationship between rotator cuff tears and GT displacement. METHODS: Forty-three patients with isolated GT fractures were recruited and evaluated with a standardized interview and physical examination, quality of life and shoulder function questionnaires (Western Ontario Rotator Cuff Index, SF-12 Version 2, Constant, Quick-Disabilities of the Arm, Shoulder and Hand, Visual Analogue Scale), standard shoulder radiographs and an ultrasound. The main outcome measurements were: incidence of rotator cuff tears and atrophy, biceps pathology and sub-acromial impingement; superior displacement of the GT fragment; and questionnaire scores. RESULTS: Mean age was 57 years (31 years to 90 years) with a follow-up of 2.4 years (0.8 years to 6.8 years). In total, 16% had a full rotator cuff tear and 57% showed subacromial impingement on ultrasound. Full rotator cuff tears and supraspinatus fatty atrophy significantly correlated with decreased function and abduction strength. Significant atrophy (>50%) of the supraspinatus and infraspinatus, without a rotator cuff tear, was correlated with the worst function in the presence of a residual displacement of the greater tuberosity at the last-follow-up (7 mm). CONCLUSIONS: Residual displacement, full rotator cuff tear and muscle atrophy are associated with the worst outcomes. Soft tissue imaging could benefit patients with an unfavourable outcome after a GT fracture to treat soft tissue injury.