Purpose

Management of compound fractures, which have a higher infection risk than closed fractures, currently depends on surgeon training and past practice rather than evidence based practice. Some centres use delayed closure involving a second surgery with repeat debridement and wound closure 48 hours after initial debridement and fixation. Other centres use primary closure in the absence of gross contamination or major soft tissue deficits, where debridement, fixation and wound closure occur during the initial surgery. Delayed closure was used at our centre until January 2009 when the standard of care evolved to primary closure where appropriate. Primary closure allows more efficient OR utilization due to fewer OR visits, but it is unknown if primary closure increases the risk of infection, which can, in turn, lead to fracture non-union. The purpose of this pilot study was to complete a safety analysis of infection rates in the first 40 patients undergoing primary closure of a compound fracture; enrolment is ongoing and updated results will be presented.

Purpose: Clinical gait analysis is considered the “gold standard” for evaluating individual walking patterns. However, in conditions where an individual may exhibit transient voluntary control of gait (such as idiopathic toe walking), their walking pattern in a gait lab may not accurately reflect their gait during daily activities. An accurate assessment of such patients’ functional gait is essential in determining appropriate management options and response to treatment. Therefore, a battery-powered, wireless data acquisition system (WDAS) was developed to record daily functional walking patterns. The goal of the present study was to compare the tilt angle and load data obtained from the WDAS with those measured by gait lab equipment in a sample of healthy adult volunteers.

Method: Seven members of the research team participated in our validation study. Following informed consent, the WDAS was attached to the dorsum (laces) of each subject’s right shoe. Two thin film load sensors were wired to the device and placed under the sole of the foot, inside the shoe. Three spherical markers were placed on the same foot (head of first metatarsal, head of fifth metatarsal, calcaneous). Data were simultaneously recorded by the WDAS (30 Hz) and gait lab (60 Hz). To calibrate the device, each subject performed three static standing tasks (normal standing, weight bearing on toes, weight bearing on heels). Each subject then performed five normal walking trials and five toe-walking trials over a ten-metre, level course.

Results: From the WDAS and gait lab, the average percentage of time spent on the toes (load values under first toe greater than zero) during the stance phase of normal gait was 50.2% and 67.4%, respectively. During toe walking, this increased to 98.9% and 99.8%, respectively. This indicates that the WDAS and gait lab are similar in their ability to discern between normal and toe-walking gait. For the inclination angle, within-subject correlation values of r = 0.76 and r = 0.92 were observed during normal walking and toe walking, respectively. This indicates acceptable levels of agreement between the inclination measures of the WDAS and gait lab.

Conclusion: The validity of angle data from the WDAS was confirmed, when compared to data retrieved from a formal, gait analysis lab. Furthermore, the WDAS was able to clearly differentiate between a normal and a toe walking pattern. The WDAS may assist clinicians in the diagnosis and treatment of gait abnormalities, based on information retrieved during daily activities.

Purpose: The Instability Severity Index Score (ISIS) is a 6-item questionnaire that has been reported to predict failure of arthroscopic Bankart repair among patients treated for recurrent anterior glenohumeral instability. Two of the ISIS items pertain to radiographic features (presence of a Hill-Sachs lesion, loss of glenoid contour). These, however have yet to be validated. The goal of this study was to examine the inter – and intra-rater agreement and corresponding reliability of the radiographic aspects of the ISIS.

Method: Fifty-two plain, randomly selected, true antero-posterior radiographs in 45° gleno-humeral external rotation were evaluated by five assessors (three upper extremity orthopaedic surgeons, one senior orthopaedic resident and one musculoskeletal radiologist). Radiographs were retrieved for patients with documented recurrent shoulder instability requiring surgical stabilization and placed in a blinded Microsoft Powerpoint presentation for evaluation. Assessors were asked to determine the presence/absence of a Hill-Sachs lesion and if a loss of glenoid contour was present. Radiographs were evaluated in random order on two occasions, separated by a one-week time interval. Intra – and inter-rater reliability was assessed using percentage of agreement and kappa statistics.

Results: For session one, the number of Hill-Sachs lesions observed among raters ranged from 11 to 32. This resulted in inter-rater agreement ranging from 48% to 78% (k = 0.07 to 0.42), indicating poor to fair reliability. Cases with loss of glenoid contour ranged from seven to 14 with inter-rater agreement of 66% and 90% (k = 0.01 to 0.61), suggesting poor to moderate reliability. Session two led to modest increases in inter-rater agreement. The number of Hill-Sachs lesions observed ranged from four to 30 (agreement of 48% to 84%; k = 0.11 to 0.60) indicating fair to moderate reliability and the number of cases with loss of glenoid contour ranged from three to 14 (agreement of 66% to 94%; k = – 0.04 to 0.69), ranging from poor to moderate reliability. With respect to intra-rater reliability, agreement ranged from 71% to 94% (k = 0.41 to 0.86) for Hill-Sachs lesions, indicating fair to good reliability and 76% to 94% (k= 0.20 to 0.74) for loss of glenoid contour, ranging from fair to good reliability. Intra-rater agreement and corresponding kappa values were highest among the upper extremity surgeons and the musculoskeletal radiologist, particularly for loss of glenoid contour (85% to 94%; k = 0.56 to 0.74) suggesting there is moderate to good reliability in this measurement.

Conclusion: Our results indicate that the intra-rater reliability of the ISIS radiographic features was highest among upper extremity specialists and the musculoskeletal radiologist, suggesting that the ISIS may have utility in an experienced clinician’s individual practice. As the inter-rater reliability appears low, particularly for Hill-Sachs lesions, its wide-spread use across surgeons should be examined in further research.