Immobilization in external rotation after primary shoulder dislocation reduces the risk of recurrence in young patients. A randomized controlled trial.

INTRODUCTION: Patients that sustain anterior shoulder dislocation frequently experience recurrence. Immobilisation in external rotation has been proposed as a treatment that could lower this risk. HYPOTHESIS: There is a difference in recurrence rates between immobilization in internal or external rotation following a first-time anterior shoulder dislocation. PATIENTS AND METHODS: Single-center randomized controlled trial. Fifty patients with a first episode of traumatic anterior dislocation were randomly assigned to immobilization in internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. Clinical follow-up: 24 months. Additionally, some patients underwent a magnetic resonance imaging with intra-articular contrast (MR arthrography) within seven days after trauma, and then at three months. PRIMARY OUTCOME: recurrence of dislocation. Secondary outcome: healing rate of labral lesions on MR arthrography. RESULTS: Follow-up rate in the IR and ER group was 92% and 96% respectively. Recurrence rate did not show a statistically significant difference overall (IR 47.8% vs. ER 29.2%; p=0.188), but showed a significant difference favouring ER in the 20-40 years subgroup (IR 50% vs. ER 6.4%; p=0.044). Labral lesions' healing rate was 46.2% vs. 60% (IR vs ER; p=0.680). The recurrence rate among those with healed vs. non-healed labrum (regardless of immobilization) was 11.1% vs. 77.7% (p=0.001). DISCUSSION: This study suggests that immobilization in ER compared to IR reduces the risk of recurrence after a first-time anterior shoulder dislocation in patients aged between 20 and 40 years. LEVEL OF EVIDENCE: II, low-powered prospective randomized trial.

Does Posterior Scoliosis Correction Improve Respiratory Function in Adolescent Idiopathic Scoliosis? A Systematic Review and Meta-analysis.

STUDY DESIGN: A systematic review and meta-analysis. OBJECTIVES: Pulmonary dysfunction is often advocated among the indications for surgical correction of adolescent idiopathic scoliosis (AIS). Previous studies have discussed the effect of scoliosis correction on respiratory function without reaching a definitive conclusion: Some showed that the respiratory function can improve after scoliosis surgery without defining the precise role of anterior, posterior, and combined approaches on this improvement; furthermore, the majority of these studies did not take normal growth into account. As a result, the role of surgery remains to be clarified. The object of the present study was to synthesize the current knowledge regarding changes in respiratory function after posterior corrective surgery for AIS. METHODS: A comprehensive systematic search was performed to identify all relevant studies in the following electronic databases: MEDLINE, EMBASE, CINAHL (EBSCO). We focused on the studies (1) that discussed posterior fusion surgery for AIS without thoracoplasty, (2) that discussed comparisons of pre- and postoperative percent-predicted values of forced vital capacity (%FVC) or forced expiratory volume (%FEV), and (3) with minimum 2-year follow-up. Forest plots were depicted and Z value was calculated as a test for overall effect. RESULTS: Ten studies (6 prospective and 4 retrospective studies) met our inclusion criteria. The overall effect showed that there was no significant difference in %FVC or %FEV between pre- and postoperative measurements (very low evidence). CONCLUSIONS: Posterior correction surgery for mild to moderate AIS patients showed no significant improvement of postoperative respiratory function measured by relative, percent-predicted values at minimum 2-year follow-up.

Does Surgical Intervention or Timing of Surgery Have an Effect on Neurological Recovery in the Setting of a Thoracolumbar Burst Fracture?

Traumatic thoracolumbar burst fractures are one of the most common forms of spinal trauma with the majority occurring at the junctional area where mechanical load is maximal (AOSpine Thoracolumbar Spine Injury Classification System Subtype A3 or A4). Burst fractures entail the involvement of the middle column, and therefore, they are typically associated with bone fragment in the spinal canal, which may cause compression of the spinal cord, conus medullaris, cauda equina, or a combination of these. Fortunately, approximately half of the patients with thoracolumbar burst fractures are neurologically intact due to the wide canal diameter. Recent evidences have revealed that functional outcomes in the long term may be equivalent between operative and nonoperative management for neurologically intact thoracolumbar burst fractures. Nevertheless, consensus has not been met regarding the optimal treatment strategy for those with neurological deficits. The present review article summarizes the contemporary evidences to discuss the role of nonoperative management in the presence of neurological deficits and the optimal timing of decompression surgery for neurological recovery. In summary, although operative management is generally recommended for thoracolumbar fracture with significant neurological deficits, the evidence is weak, and nonoperative management can also be an option for those with solitary radicular symptoms. With regards to timing of operative management, high-quality studies comparing early and delayed intervention are lacking. Extrapolating from the evidence in cervical spine injury leads to an assumption that early intervention would also be beneficial for neurological recovery, but further studies are warranted to answer these questions.

The Need for Clinical Practice Guidelines in Assessing and Managing Perioperative Neurologic Deficit: Results from a Survey of the AOSpine International Community.

OBJECTIVES: There is no standardized approach to assess and manage perioperative neurologic deficit (PND) in patients undergoing spinal surgery. This survey aimed to evaluate the awareness and usage of clinical practice guidelines (CPGs) as well as investigate how surgeons performing spine surgeries feel about and manage PND and how they perceive the value of developing CPGs for the management of PND. METHODS: An invitation to participate was sent to the AOSpine International community. Questions were related to the awareness, usage of CPGs, and demographics. Results from the entire sample and subgroups were analyzed. RESULTS: Of 770 respondents, 659 (85.6%) reported being aware of the existence of guideline(s), and among those, 578 (87.7%) acknowledged using guideline(s). Overall, 58.8% of surgeons reported not feeling comfortable managing a patient who wakes up quadriplegic after an uneventful multilevel posterior cervical decompression with instrumented fusion. Although 22.9% would consider an immediate return to the operating room, the other 77.1% favored conducting some kind of investigation/medical intervention first, such as performing magnetic resonance imaging (85.9%), administrating high-dose corticosteroids (50.2%), or increasing the mean arterial pressure (44.7%). Overall, 90.6% of surgeons believed that CPGs for the management of PND would be useful and 94.4% would be either likely or extremely likely to use these CPGs in their clinical practice. CONCLUSIONS: Most respondents are aware and routinely use CPGs in their practice. Most surgeons performing spine surgeries reported not feeling comfortable managing PND. However, they highly value the creation and are likely to use CPGs in its management.

Effects of Right Lower Limb Orthopedic Immobilization on Braking Function: An On-The-Road Experimental Study With Healthy Volunteers.

Little is known about how immobilization of the right lower limb might affect driving. The purpose of the present study was to evaluate the effect of 2 types of immobilization on the emergency braking time of healthy subjects during actual driving conditions. The emergency braking times of 14 healthy volunteers were assessed in a closed circuit under 3 conditions: wearing running shoes, wearing an Aircast Walker(®), or wearing a walking cast on their right lower limb. An instrumented car was used to measure the emergency braking times during braking tests with and without a distractor. The foot movement times were significantly increased with both immobilization devices compared with the running shoe (p < .01). The median total braking time with the running shoe during emergency braking without a distractor was 0.452 (interquartile range, 25th to 75th [IQR], 0.413 to 0.472) second. The results obtained with the Aircast Walker(®) or the walking cast were significantly longer (p < .01), at 0.480 (IQR, 0.431 to 0.537) second and 0.512 (IQR, 0.451 to 0.535) second, respectively. When a distractor was added, the total braking time with the running shoe, Aircast Walker(®), and walking cast was 0.489 (IQR, 0.429 to 0.575), 0.516 (IQR, 0.459 to 0.586), and 0.510 (IQR, 0.469 to 0.570) second, respectively, with no statistically significant differences among these 3 conditions. Wearing an immobilization device on the right lower limb minimally lengthens the emergency braking time in healthy drivers under actual driving conditions. Clinicians must nonetheless exercise caution when advising a driver wearing an orthopedic immobilization, because driving a motor vehicle is a complex psychomotor task that goes well beyond the emergency braking time.

Subacromial impingement syndrome caused by a voluminous subdeltoid lipoma.

Subacromial impingement syndrome is a clinical diagnosis encompassing a spectrum of possible etiologies, including subacromial bursitis, rotator cuff tendinopathy, and partial- to full-thickness rotator cuff tears. This report presents an unusual case of subdeltoid lipoma causing extrinsic compression and subacromial impingement syndrome. The patient, a 60-year-old man, presented to our institution with a few years' history of nontraumatic, posteriorly localized throbbing pain in his right shoulder. Despite a well-followed 6-months physiotherapy program, the patient was still suffering from his right shoulder. The MRI scan revealed a well-circumscribed 6 cm × 2 cm × 5 cm homogenous lesion compatible with a subdeltoid intermuscular lipoma. The mass was excised en bloc, and subsequent histopathologic examination confirmed a benign lipoma. At 6-months follow-up, the patient was asymptomatic with a complete return to his activities. Based on this case and a review of the literature, a subacromial lipoma has to be included in the differential diagnosis of a subacromial impingement syndrome refractory to nonoperative treatment. Complementary imaging modalities are required only after a failed conservative management to assess the exact etiology and successfully direct the surgical treatment.

Scientific overview: CSCI-CITAC annual general meeting and young investigator's forum 2010.

In 2010, the annual general meeting of the Clinical Investigator Trainee Association of Canada - Association des cliniciens-chercheurs en formation du Canada (CITAC-ACCFC) and the Canadian Society for Clinician Investigators (CSCI) was held between September 20 and 22 in Ottawa. Several globally-renowned scientists, including this year's CSCI/Royal College Henry Friesen Award recipient, Dr. Paul Kubes, Distinguished Scientist Award recipient, Dr. Gideon Koren and Joe Doupe Young Investigator Award recipient, Dr. Torsten Neil, discussed a variety of topics relating to the role of technology in medicine. The meeting was well attended by clinician scientists and trainees from across Canada and offered trainees mentorship and networking opportunities in addition to showcasing their research at the young investigator forum. The aim of this scientific overview is to highlight the research presented by trainees at both the oral plenary session as well as the poster presentation sessions of this meeting. Similar to last year's meeting [1], research questions being investigated by trainees covered the spectrum of medical disciplines, encompassing both basic science as well as clinical areas, and are summarized below.

Scientific overview of the CSCI-CITAC 2009 conference.

From September 21st-23rd 2009, the Clinical Investigator Trainee Association of Canada - Association des cliniciens-chercheurs en formation du Canada (CITAC-ACCFC) and the Canadian Society for Clinician Investigators (CSCI), held their annual conference in Ottawa. Participants included clinician investigators and trainees from across the country. The conference featured many excellent guest speakers including this year's recipient of the Henry G. Friesen International Prize in Health Research, Sir John Bell. There were several forums focusing on professional development, with topics such as "sustaining the clinician investigator in Canada", "succeeding as a clinician investigator", and "collaborating internationally with MD+ trainees", alongside networking opportunities to help establish relationships with potential mentors and collaborators. Further, the CSCI-CITAC annual conference featured some of the cutting edge research that MD+ trainees throughout Canada are engaged in. Trainees presented their research either at the Young Investigators Forum poster session or at the oral plenary. This scientific overview aims to highlight some of the research presented by trainees at the annual conference. The broad themes of scientific interest included topics from both basic science and clinical research. In this article, we summarize some of the major research questions that are being investigated by clinician-investigator trainees in the following areas: neurological sciences, cell biology, medicine, immunology, obstetrics, gynecology, neonatology, orthopedics, rheumatology, and public health.

Effects of orthopaedic immobilization of the right lower limb on driving performance: an experimental study during simulated driving by healthy volunteers.

BACKGROUND: The effects of immobilization of the right lower limb on driving performance are unknown. Therefore, clinicians and legislators cannot put forth recommendations for road safety for patients requiring such immobilization. The objective of the present study was to evaluate the effect of two orthopaedic immobilization devices on the braking performances of healthy volunteers under simulated driving conditions. METHODS: The braking performances of forty-eight healthy volunteers were evaluated under three conditions: wearing a running shoe, wearing a walking cast, and wearing an Aircast Walker on the right lower limb. A computerized driving simulator was used to measure the maximum force applied on the brake pedal during braking as well as the braking reaction time and the total braking time during emergency braking with and without a distractor. RESULTS: The mean braking forces applied with the shoe, the walking cast, and the Aircast Walker were 293.8, 275.4, and 287.2 lb (133.3, 124.9, and 130.3 kg), respectively. The value with the walking cast was significantly lower than that with the shoe or Aircast Walker (p < 0.0001); there was no difference between the shoe and the Aircast Walker. The adjusted mean braking reaction times during emergency braking without a distractor were 0.580 second (shoe), 0.609 second (cast), and 0.619 second (Aircast Walker). The value with the running shoe was significantly lower than that with either type of immobilization (p < or = 0.0001). With a distractor, the mean braking reaction time was shorter with the running shoe than it was with either form of immobilization (p < or = 0.0001); the mean time was also shorter with the walking cast than it was with the Aircast Walker (p = 0.003). During both emergency braking tasks (with and without a distractor), the mean total braking time was shorter with the shoe than it was with either type of immobilization (p < 0.0001). With a distractor, the adjusted mean total braking time was shorter with the walking cast than it was with the Aircast Walker (p = 0.035). CONCLUSIONS: Immobilization of the right lower limb affects the braking force as well as the braking reaction time and total braking time during emergency braking by healthy volunteers. While these changes are significant, their impact on the ability to drive safely during emergency braking situations is questionable. Future research into the impact of such immobilization on the emergency braking performances of patients is warranted to confirm these observations.