To compare 24-month patient-reported outcomes after surgical treatment or casting in patients age 60 years of age or older with unstable distal radius fractures (DRF's).

The Wrist and Radius Injury Surgical Trial (WRIST), is the largest randomized, multicenter trial in Hand Surgery, which enrolled 304 adults with isolated, unstable DRF's at 24 institutions. WRIST participants were followed for 24 months- longest follow-up among prospective studies comparing four treatment methods. Patients who agreed to surgical treatment (n=187) were randomized to internal fixation with volar plate (VLPS), external fixation, or percutaneous pinning; patients who preferred conservative management (n=117) received casting. The primary outcome was 24-month Michigan Hand Outcomes Questionnaire (MHQ) Summary score. Secondary outcomes were MHQ Domain scores.

At 24-month assessment, participants' mean MHQ Summary score was 86 (95% CI: 83,88), representing good hand function. Participants reported good return of their Activities of Daily Living (ADLs) with a mean MHQ ADL score of 88 (95% CI: 85,91). Finally, participants were satisfied, with a mean MHQ Satisfaction score of 84 (95% CI: 80,88). There were no significant differences in score by treatment group in any MHQ domain at 24 months. Six weeks after surgery, VLPS participants scored significantly higher than the other three groups on (ADLs) and Satisfaction (both p<0.0001), whereas participants who received external fixation scored significantly lower than the casting and VLPS groups on the same domains. By the 3-month assessment, the gap between VLPS and casting had disappeared but external fixation participants continued to report significantly worse scores. External fixation participants did not report comparable ADL scores to the other three groups until 12 months after surgery.

Participants reported good outcomes 24 months after DRF regardless of treatment. Casting and VLPS are both acceptable treatments for older adults. The decision between the two treatments should be made considering patient goals regarding recovery speed and desire to avoid surgical risks. External fixation should be avoided because of worse outcomes in the year after surgery and the risk of pin site infections.

Buechel and Pappas invented a modified version of LCS RP system (Co-Cr) with light material (Titanium), axial rotation limiting bar and improved conformity. The purpose of this prospective randomized study was to compare the minimum 3-year clinical outcomes including lightness, preference, and instability between the Co-Cr implant system and the Titanium implant system in bilateral total knee arthroplasty.

We prospectively enrolled 108 patients and 20 patients were lost to follow-up. Therefore, 88 patients (176 knees; mean age, 69.9±6.0years) were included in the study. The range of motion and clinical scores such as Knee Society score (KSS), Hospital for Special Surgery score (HSS) and Western Ontario and McMaster University (WOMAC) scores were measured preoperatively and postoperatively. At each follow-up, patients also complete a Likert scale questionnaire regarding subjective pain, lightness, left-right side preference (naturalness and satisfaction) and subjective instability.

There were no significant differences in all preoperative variables between two groups (p>.05). Mean follow-up period was 46.3±8.8 (36 to 72) months. The mean weight of Titanium implants was three times lighter than that of Co-Cr implants (133.9g versus 390.1g, p<.01). At the minimum of 3-year follow-up, there were no significant differences in pain, range of motion (ROM), clinical scores including KSS, HSS, and WOMAC between both groups. Also, the study showed no significant differences with subjective pain, lightness, preference (convenience, naturalness, and satisfaction), and subjective instability between the Co-Cr protheses and the Titanium protheses (p>.05).

No differences in clinical outcomes as well as subjective side-to-side differences between the Co-Cr prostheses and the Titanium prostheses were observed in the minimum 3-year follow-up. This implies that patients do not feel differently with two different weighted implants in mid-term follow-up.

Purpose: Treatment of knee dislocations remains challenging and controversial. Several strategies for the management of multiple ligament knee injuries have been described and there are multiple unresolved questions. These include the indications for surgery, repair versus reconstruction, surgical timing and graft selection. The aim of this survey was to identify areas of agreement and controversy, to define the current standard of care and help generate research questions.

Method: Using the standard techniques for survey development we presented six clinical scenarios of acute knee dislocations (at least three ligaments) to all orthopaedic surgeons affiliated with Canadian medical schools. The scenarios were designed to cover the common combinations of knee dislocations in both a 25 year old active individual and a 50 year old sedentary individual. The responses were divided into three groups. Group A consisted of those with fellowship training, or practices focused on, sports knee. Group B was comprised of surgeons with trauma fellowship or a sub-specialty trauma practice. Group C were the remaining surgeons without these subspecialty foci. We report on the responses of groups A and B.

Results: An average of ten different treatment algorithms were reported for each scenario but there was agreement on the need for early surgical management in the young active individual with a knee dislocation and all dislocations involving a lateral sided injury. Conversely, there was a lack of consensus regarding the need for surgical treatment of the 50 year old individual with bi-cruciate injury and medial collateral ligament. The most common combinations of reconstruction and repair are reported for each clinical scenario. Surgeons strongly favor early surgical intervention, within three weeks of injury, except for the 50 year old sedentary individual with a bi-cruciate plus medial sided injury. Allograft was the most popular choice to reconstruct the PCL and lateral ligament. For the ACL graft there was a near equal distribution between hamstrings, patellar tendon and the use allograft tissue.

Conclusion: In the absence of higher level evidence, the information from this survey helps define the standard of care in Canada and identifies areas of controversy which would be a priority for a multi-centre prospective trial.