Persistent post-surgical pain and associated disability are common after a traumatic fracture repair. Preliminary evidence suggests that patients' beliefs and perceptions may influence their prognosis. We sought to explore this association. We used data from the Fluid Lavage of Open Wounds trial to determine, in 1560 open fracture patients undergoing surgical repair, the association between Somatic PreOccupation and Coping (captured by the SPOC questionnaire) and recovery at 1 year. Of the 1218 open fracture patients with complete data available for analysis, 813 (66.7%) reported moderate to extreme pain at 1 yr. The addition of SPOC scores to an adjusted regression model to predict persistent pain improved the concordance statistic from 0.66 to 0.74, and found the greatest risk was associated with high SPOC scores [odds ratio: 5.63, 99% confidence interval (CI): 3.59–8.84, absolute risk increase 40.6%, 99% CI: 30.8%, 48.6%]. Thirty-eight per cent (484 of 1277) reported moderate to extreme pain interference at 1 yr. The addition of SPOC scores to an adjusted regression model to predict pain interference improved the concordance statistic from 0.66 to 0.75, and the greatest risk was associated with high SPOC scores (odds ratio: 6.06, 99% CI: 3.97–9.25, absolute risk increase: 18.3%, 95% CI: 11.7%, 26.7%). In our adjusted multivariable regression models, SPOC scores at 6 weeks post-surgery accounted for 10% of the variation in short form-12 physical component summary scores and 14% of short form-12 mental component summary scores at 1 yr. Amongst patients undergoing surgical repair of open extremity fractures, high SPOC questionnaire scores at 6 weeks post-surgery were predictive of persistent pain, reduced quality of life, and pain interference at 1 yr

Negative pressure wound therapy (NPWT) is commonly used to manage severe open fracture wounds. The recently completed X randomized controlled trial (RCT) evaluated the effect of NPWT versus standard wound management on 12-month disability and rate of deep infection among patients with severe open fractures of the lower limb and reported no differences. Using data from the Y trial of open fracture patients, we aimed to evaluate the impact of NPWT on the odds of having deep infections and health-related quality of life (HRQL). Our analyses included participants from the Y trial who had Gustilo II and III lower extremity fractures. To adjust for the influence of injury characteristics on type of dressing received, a propensity score was developed from the dataset. A one-to-one matching algorithm was then used to pair patients with a similar propensity for NPWT. Mixed effects logistic regression was used to evaluate the association between type of wound dressing and development of a deep infection requiring operative management (dependent variable) in the matched cohort. Gustilo type, irrigation solution, fracture location, mechanism of injury, and degree of contamination were included as adjustment variables. To determine any differences in HRQL between the NPWT and standard wound dressing groups, we conducted two multi-level models with three levels (centre, patient, and time) and included Short Form-12 (SF-12) Physical Health Component (PCS) and SF-12 Mental Health Component (MCS) as dependent variables. Gustilo type, irrigation solution, fracture location, mechanism of injury, degree of contamination, and pre-injury SF-12 scores were included as adjustment variables. All tests were 2-tailed with alpha=0.05. After applying propensity score-matching to adjust for the influence of injury characteristics on type of dressing used, there were 270 matched pairs of patients available for comparison. The odds of developing a deep infection requiring operative management within 12 months of initial surgery was 4.22 times higher in patients who received NPWT compared to those who did not receive NPWT (Odds Ratio (OR) 4.22, 95% Confidence Interval (CI) 2.26–7.87. 1,329 participants were included in our HRQL analysis and those treated with NPWT had significantly lower SF-12 PCS at all follow-up visits (6w, 3m, 6m, 12m) post fracture (p=0.01). Participants treated with NPWT had significantly lower SF-12 MCS at 6-weeks post-fracture (p=0.03). Unlike the X trial, our analysis found that patients treated with NPWT had higher odds of developing a deep infection requiring operative management and that being treated with NPWT was associated with lower physical quality of life in the 12 months post-fracture. While there may have been other potential adjustment variables not controlled for in this analysis, our results suggest that the use of this treatment should be re-evaluated

Reverse shoulder arthroplasty (RSA) has an increasing effective use in the treatment of patients with a variety of diagnoses, including rotator cuff deficiency, inflammatory arthritis, or failed shoulder prostheses. Glenoid bone loss is not uncommonly encountered in these cases due to the significant wear. Severe bone loss can compromise glenoid baseplate positioning and fixation, consequently increasing the risk for early component loosening, instability, and scapular notching. To manage severe glenoid bone deficiencies, bone grafts are commonly used. Although, many studies report outcome of bone grafting in revision RSA, the literature on humeral head autograft for glenoid bone loss in primary RSA is less robust. The purpose of this study is to evaluate the clinical and radiographic outcomes of primary RSA with humeral head autograft for glenoid bone loss at our institution. Institutional review board approval was obtained to retrospectively review the records of 22 consecutive primary RTSA surgeries in 21 patients with humeral head autograft for glenoid bone loss between January 2008 and December 2016. Five patients died during follow-up, three were unable to be contacted and one refused to participate, leaving a final study cohort of 12 patients with 13 shoulders that underwent RSA. All patients had a clinical evaluation including detailed ROM and clinical evaluation using the American Shoulder and Elbow Surgeons (ASES) Score, Constant Score, Western Ontario Osteoarthritis of the Shoulder Index (WOOS), and Short Form-12 (SF-12) questionnaires. Preoperative and postoperative plain radiographs and CT scans were assessed for component position, loosening, scapular notching, as well as graft incorporation, resorption, or collapse. There were 6 males and 6 females, with an average age of 74 ± 6.8 years. The average BMI was 31.7 ± 5.3, and the median ASA score was 3. Average follow-up was 3.4 ± 1.1 years. The average postoperative range of motion measurements for the operative arm are: flexion = 120 ± 37, abduction = 106 ± 23, external rotation = 14 ± 12, internal rotation at 90 degrees of abduction = 49 ± 7, external rotation at 90 degrees of abduction = 50 ± 28. Average functional scores are: ASES: 76.9 ± 19.2, WOOS: 456 ± 347, SF12 physical: 34.2 ± 8.2, SF12 mental: 54.1 ± 10.2, Constant Score: 64.6 ± 14. No evidence of hardware loosening or evidence of bone graft resorption were encountered. On CT, the average of pre operative B-angle was 79.3 ± 9.3 while the pre operative reverse shoulder angle was 101.4 ± 28. Glenoid retroversion average on CT was 13.3 ± 16.6. Post operative baseplate inclination average was 82 ± 7.4 while the baseplate version 7.8 ±10. The operative technique was able to achieve up to 30 degrees of inclination correction and up to 50 degrees of version correction. In conclusion, primary reverse shoulder arthroplasty with humeral head autograft for glenoid bone loss provides excellent ROM and functional outcomes at mid-term follow-up. This technique has a high rate of bone incorporation and small risk of bone resorption at mid term follow up

Purpose. Identifying optimal treatment strategies for inpatients with traumatic foot and ankle injuries has been hampered by a wide variety of outcome measures with unproven reliability and validity. It remains plausible that the choice of functional outcome measures may influence measurement of treatment effects. This prospective observational study aims to measure the correlation and agreement across six functional outcome measures in patients with traumatic foot and ankle injuries. Methods. Patients 18 years of age or older with a traumatic foot or ankle injury completed the Short Form-12 (SF-12), Short Musculoskeletal Functional Assessment (SMFA), Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM), American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Questionnaire and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale at a single follow-up visit. Raw scores were calculated and transformed to a functional level of excellent, very good, good, fair or poor. Pearson correlation co-efficients providing measures of correlation and agreement between functional levels were assessed. Results. Fifty-two patients were enrolled at a mean follow-up of 15.5 months. Moderate to strong correlations were found for most pair-wise comparisons of raw scores and functional levels (?=0.43-0.92, p< 0.002). The strongest correlations were found between the SMFA, FFI, FAAM and AAOS Foot and Ankle Questionnaire. Despite significant correlation between scores, considerable disagreement between functional levels was observed. None of the 52 subjects attained the same functional level on all 6 outcome measures. Conclusion. High correlations between scores and functional level suggest it is unnecessary to use more than one outcome measure when examining functional outcome in patients with foot and ankle trauma. However, inconsistencies between functional levels attained with the different instruments suggest a need for further validation and scrutiny

Background:. Custom cutting guides (CCG) in total knee arthroplasty (TKA) use preoperative 3-dimensional imaging to fabricate cutting blocks specific to a patient's native anatomy. To date, small cohorts and short follow-up have limited reports studying clinical and functional outcomes of CCGs versus standard intramedullary and extramedullary alignment instrumentation. The purpose of this study was to determine if CCGs improve clinical outcomes versus standard alignment guides following TKA at a mean of 2 years postoperatively. Methods:. This was a prospective cohort study of a consecutive series of patients undergoing primary TKA using the same cruciate-retaining, cemented system between January 2009 and April 2012. Exclusion criteria were patients with prior open knee surgery, a flexion contracture of greater than 20 degrees, a distal femoral or proximal tibial defect requiring a metal or allograft augment, the use of either femoral or tibial stem extensions, or a contraindication to obtaining a magnetic resonance imaging (MRI) scan. All patients were offered the option of receiving a preoperative MRI and TKA with CCGs, and each patient self-selected for either the CCG or standard cohort. The first 95 patients that selected CCGs were compared with the first 95 that were performed with standard instrumentation. The alignment goal for all TKAs was a hip-knee-ankle (HKA) angle of 0 degrees with the femoral and tibial components aligned perpendicular to the mechanical axis. University of California at Los Angeles (UCLA), Short Form-12 (SF-12), and Oxford Knee scores were collected preoperatively. These scores, along with the Forgotten Joint score and a questionnaire assessing patient satisfaction and residual symptoms, were administered at most recent follow-up. Postoperative, rotationally controlled coronal scout CT scans were used to measure the overall hip-knee-ankle (HKA) alignment. Perioperative complications occurring within 6 months of the index procedure were reviewed. Independent samples t-tests and Chi-square tests were used, with a p-value <0.05 considered significant. Results:. 95 patients in the standard (mean follow-up 2.5 ± 1.1 years) and 95 patients in the CCG (mean follow-up 2.2 ± 1.0 years) cohorts were analyzed. There was no difference in mean age (p=0.48), BMI (p=0.19), mean tourniquet time (59.1 ± 13.2 minutes in CCG v 59.7 ± 14.7 minutes in standard; p=0.75) or percentage of outliers for HKA alignment (23% in standard versus 31% in CCG with HKA outside of 0 ± 3 degrees; p=0.2) between the two cohorts. However, CCG patients did have increased UCLA (p=0.03), SF-12 physical (p=0.001) and Oxford knee scores (p=0.001) preoperatively. At the most recent follow-up, no differences were present for range of motion, UCLA, SF-12, Oxford Knee, or Forgotten Joint scores between the two cohorts (p=0.09 v 0.76). In addition, no differences were present for the incremental improvement in these scores from preoperatively to postoperatively (p=0.1 v 0.9). Patient satisfaction and the presence of residual symptoms were similar (p=0.1 v 0.8), with only 66.3% of standard patients and 67.6% of CCG patients noting their knee to feel “normal” or comparable to their nonoperative knee (p=0.7). After excluding 5 superficial wound complications in the standard cohort caused by use of a subcutaneous braided suture, no differences in overall or knee related complications were appreciated between the two cohorts (p=0.5 v 0.65). Conclusions:. At a mean follow-up of greater than 2 years, CCGs fail to demonstrate any advantages in clinical outcomes versus the use of standard instrumentation in TKA. The clinical benefit of CCGs must be proven prior to continued implementation of this technology

Introduction:. While indications for total knee (TKA) and hip arthroplasty (THA) have expanded over the last 35 years, implant labeling has largely remained stagnant, with conditions including obesity, developmental dysplasia, and many others (Table 1) still considered as contraindications. Implant labeling has not co-evolved with surgical indications, as most orthopaedic implants are cleared through the 510(k) process, which conserves the labeling of the predicate device. While surgeons can legally use devices for off-label indications, the scrutiny regarding off-label use of orthopaedic implants has intensified. The objective of this study was to determine the incidence of off-label use at our institution, define the risk in terms of revision rate associated with off-label use, and to compare activity level, functional outcomes, and general health outcomes for on- and off-label TKA and THA patients. Methods:. Patients who underwent primary TKA or THA at a large academic tertiary referral center between January 1, 2010 and June 30, 2010 were considered for the study (n = 705). Of this cohort, a convenience sample of 283 patients were selected for the study based on the presence of baseline outcomes data. Patients were contacted via mail and/or phone to collect details regarding potential revision surgeries, UCLA activity scores, short form-12 (SF-12), Knee Injury and Osteoarthritis Outcome Score (KOOS) or Hip Disability and Osteoarthritis Outcome Score (HOOS). Using labeled contraindications from the product inserts from multiple orthopaedic implant manufacturers, procedures were categorized as on-label or off-label. Outcomes including revision rate, activity score, and SF-12, KOOS, and HOOS scores were adjusted for age, gender, and BMI by fitting a logistic model and analyzed using the Wald chi-square test (SPSS, Chicago, IL). Results:. 225 patients responded to the survey (79.5% follow-up), with an average follow-up of 2.4 years (± 0.24). Demographics, including age (p = 0.07) and gender (p = 0.31), were not significantly different between the 2 groups. Since obesity was a contraindication, the off-label group was significantly heavier (mean BMI = 34.0) than the on-label group (mean BMI = 26.0; p < 0.001). The overall rate of cases defined as off-label was 68.4% (154/225), the majority of which were due to obesity (118/154; 76.6%), followed by patients who used steroids, immunosuppressive drugs, or diabetes medication (37/154; 24.0%). Adjusting for age, gender, and BMI, the revision rate for on-label (4/71; 5.6%) compared with off-label (11/154; 7.1%) was not significantly different (p = 0.62). Adjusted UCLA activity scores were not significantly different between on-label (5.9 ± 2.0) and off-label (5.7 ± 2.0) patients (p = 0.56). When comparing the adjusted improvements (i.e. difference between preoperative and postoperative) in SF-12, KOOS, and HOOS scores, only the SF-12 role physical subscore was statistically lower for off-label patients (Table 2; p = 0.03). Discussion:. These pilot data suggest that on- and off-label use of THA and TKA implants result in similar short-term revision rates, activity levels, and functional and general health outcomes. In addition, the improvements realized by off-label patients, as reflected by SF-12 composite scores and KOOS/HOOS quality of life, support the use of these devices in previously contraindicated conditions, with no discernible increased risk of revision