Aims

We aimed to compare reoperations following distal radial fractures (DRFs) managed with early fixation versus delayed fixation following initial closed reduction (CR).

This study aimed to determine if multiple failed closed reductions (CRs) prior to fixation of distal radius fracture is associated with the odds of complication-related reoperation up to two years post fracture.

We identified all distal radius fracture patients aged 18 or older between the years of 2003-2016 in Ontario, Canada from linked administrative databases. We used procedural and fee codes to identify patients who underwent primary outpatient surgical fixation between 8 and 14 days post fracture, and grouped patients by the number of CRs they underwent prior to definitive fixation. We excluded patients who underwent fixation within 7 days of their fracture to exclude more complex fracture types and/or patients who required more immediate surgery. We grouped patients according to the number of CRs they underwent prior to definitive fixation. We used intervention and diagnostic codes to identify reoperations within two years of fixation. We used multi-level multivariable logistic regression to compare the association between the number of CRs and reoperation while accounting for clustering at the surgeon level and adjusting for other relevant covariables. We performed an age-stratified analysis to determine if the association between the number of CRs and reoperation differed by patient age.

We identified 5,464 patients with distal radius fractures managed with outpatient fixation between 8 and 14 days of their fracture. A total of 1,422 patients (26.0%) underwent primary surgical fixation (mean time to fixation 10.6±2.0 days), while 3,573 (65.4%) underwent secondary fixation following one failed CR (mean time to fixation 10.1±2.2 days, time to CR 0.3±1.2 days), and 469 (8.6%) underwent fixation following two failed CRs (mean time to fixation 10.8±2.2 days, time to first CR 0.0±0.1 days, time to second CR 4.7±3.0 days). The CR groups had higher proportions of female patients compared to the primary group, and patients who underwent two failed CRs were more likely to be fixed with a plate (vs. wires or pins). The unadjusted proportion of reoperations was significantly higher in the group who underwent two failed CRs (7.5%) compared to those who underwent primary fixation (4.4%), and fixation following one failed CR (4.9%). Following covariable adjustment, patients who underwent two failed CRs had a significantly higher odds of reoperation (odds ratio [OR] 1.72 [1.12-2.65]) compared to those who underwent primary fixation. This association appeared to worsen for patients over the age of 60 (OR 3.93 [1.76-8.77]). We found no significant difference between the odds of reoperation between patients who underwent primary fixation vs. secondary fixation following one failed CR.

We found that patients with distal radius fractures who undergo multiple CRs prior to definitive fixation have a significantly higher odds of reoperation compared to those who undergo primary fixation, or fixation following a single CR. This suggests that surgeons should offer fixation if indicated following a single failed CR rather than attempt multiple closed reductions. Prospective studies are required to confirm these findings.

Rotator cuff repair (RCR) can be performed open or arthroscopically, with a recent dramatic increase in the latter. Despite controversy about the preferred technique, there has been an increase in the number of repairs performed arthroscopically. The purpose of this study was, therefore, to compare revision rates following open and arthroscopic RCR repair.

Adult patients undergoing first-time, primary rotator cuff repair in Ontario, Canada (April 2003-March 2014) were identified using physician billing and hospital databases. Patients were followed for a minimum of two and up to 13 years for the primary outcome, revision rotator cuff repair, and secondary outcome, surgical site infection. The intervention considered was open versus arthroscopic technique. Patient factors (age, gender, residence, socioeconomic status, medical comorbidities) and provider factors (surgical volume, hospital setting, worked night before, year of surgery) were recorded. Standardized mean differences were used for covariate comparison. A Cox Proportional Hazards model was used to compare RCR survivorship between the two groups after adjustment for patient and provider factors, generating hazard ratios with 95% confidence intervals (HR, 95% CIs). Censoring occurred on the first of the primary outcome, death, shoulder arthroplasty or arthrodesis, or the end of the follow-up period (March 2016).

A total of 37,255 patients were included. The overall revision RCR rate was 2.9% (1,096 patients) with a median time to revision of 23 months (IQR 12–52). Revision repair was more common in the arthroscopic group in comparison to the open group (3.2% vs 2.6%, NNT 166.7, p=0.004), with an adjusted HR of 0.72 (0.63–0.83 95% CI, p < 0 .0001). The surgical site infection rate was significantly higher in the open group compared with the arthroscopic group (0.5% vs 0.2%, NNT 333.3, p < 0 .001). Patient and provider covariates had no statistically significant effect on revision rates, aside from increasing age (per 10 year increase, HR 0.85, 0.81–0.90 95% CI, p < 0 .0001).

Revision rotator cuff repair is approximately 30% more common in patients undergoing arthroscopic repair, in comparison to open repair, after adjustment. Surgical site infection is uncommon regardless of surgical technique, however, it is slightly more common following open repair. In the setting of an economic healthcare crisis, trends of increasing arthroscopic RCR may demand scrutiny, as the technique is associated with higher revision rates and higher costs.

Acute metatarsal fractures are a common extremity injury. While surgery may be recommended to reduce the risk of nonunion or symptomatic malunion, most fractures are treated with nonoperative management. However, there is significant variability between practitioners with no consensus among clinicians on the most effective nonoperative protocol, despite how common the form of treatment. This systematic review identified published conservative treatment modalities for acute metatarsal fractures and compares their non-union rate, chronic pain, and length of recovery, with the objective of identifying a best-practices algorithm.

Searches of CINAHL, EMBASE, MEDLINE, and CENTRAL identified clinical studies, level IV or greater in LOE, addressing non-operative management strategies for metatarsal fractures. Two reviewers independently screened the titles, abstracts, and full texts, extracting data from eligible studies. Reported outcome measures and complications were descriptively analyzed. Studies were excluded if a rehabilitation program outlining length of immobilization, weight-bearing and/or strengthening approaches was not reported.

A total of 12 studies (8 RCTs and 4 PCs), from the 2411 studies that were eligible for title screening, satisfied inclusion criteria. They comprised a total of 610 patients with acute metatarsal fractures, with a mean age of 40.2 years (range, 15 – 82). There were 6 studies that investigated avulsion fractures, 2 studies on true Jones fractures, and 4 studies with mixed fracture types. Studies assessed a variety of treatment modalities including: WB and NWB casts, elasticated support bandages, hard-sole shoes, plaster slippers, metatarsal shoe casts, and air cast boots. Most studies investigated the outcomes of NWB casts and elasticated support bandages.

The NWB short leg cast had no reported non-unions, delayed-unions, or refractures for avulsion fractures. In true Jones fractures, there was an average non-union rate of 23.6% (range, 5.6 – 27.8%), delayed-union rate of 11.8% (range, 5.6 – 18.8%), and refracture rate of 3% (range, 0 – 5.6%). Overall, the average AOFAS score was 87.2 (range, 84 – 91.7) and the average VAS score was 83.7 (range, 75 – 93).

The elasticated support bandage had an average non-union rate of 3.4% (range, 0 – 12%), and delayed-union rate of 3.8% for acute avulsion fractures, with no reported refractures. No included study arm investigated outcomes of elasticated support bandages for the true Jones fracture. The average AOFAS score for elasticated support bandages was 93.5 (range, 90 – 100). The average VAS score was 88.9 (range, 90 – 100).

Most acute metatarsal fractures heal well, with good-to-excellent functional outcomes and moderate-to-high patient satisfaction. Conservative strategies for avulsion fractures are highly successful and based on this data the authors recommend patients undergo a schedule that involves 3 – 4 weeks in an elasticated support bandage, short leg cast, or equivalent, and WB thereafter as tolerated, with return-to-activity after clinical union. Despite poorer conservative outcomes for true Jones fractures, patients should undergo 8 weeks in a NWB short leg cast, followed by a walking cast or hard-sole shoe for an additional 4 – 6 weeks, or until clinical union. However, surgical consultation is recommended.

Rotator cuff injuries represent a significant burden to the health care system, affecting more than 30% of the population over the age of sixty. Despite the advanced surgical techniques that are available, poor results are sometimes seen in a subset of patients receiving surgical treatment for their rotator cuff disease. The reasons for this failure of treatment remain unclear, particularly if the surgery was ‘technically’ successful. An increasing body of evidence has demonstrated a strong correlation between pre-operative psychological factors and functional outcome following several orthopaedic procedures. This association, however, has not been fully demonstrated or effectively investigated in the context of rotator cuff treatment. The main objective for this study was to conduct a systematic review to determine the impact of psychosocial factors on the outcome of treatment in patients with rotator cuff disease.

A systematic search was conducted of Medline, CINAHL, and PsychInfo databases for articles published from database inception until September 2018. The titles and abstracts were screened for all of the studies obtained from the initial search. Inclusion and exclusion criteria were applied, and a full text review was conducted on those studies meeting the eligibility criteria.

A total of 1252 studies were identified. Following removal of duplicates and application of the inclusion and exclusion criteria, 46 studies underwent a full-text review. Ten studies were included in the final analysis. A total of 1,206 patients, with a mean follow-up of 13 months, were included. Three studies examined patient expectations prior to treatment. All three found that higher expectations prior to treatment led to a significantly improved outcome following both operative and non-operative treatment.

Three studies assessed the association between pre-operative general psychological measures and post-operative pain and function. All three studies found patients with worse pre-operative general psychological scores demonstrated increased post-operative pain. Two of the studies also found a negative association with post-operative function, while one of the studies found no association with post-operative function. Three studies assessed the impact of pre-operative anxiety and depression on outcomes following surgical treatment of rotator cuff disease. Only one of the studies found a negative association with post-operative pain and function. The remaining two studies found no association between anxiety or depression and any outcomes following surgery. Finally, one study examined the impact of general distress on outcomes following the surgical treatment of rotator cuff disease and found no association with post-operative levels of pain or function.

The results of this systematic review indicate that there is somewhat conflicting and contradictory evidence within the literature. Overall, however, there does appear to be an association between pre-operative psychological factors and post-operative function and pain, in that higher levels of pre-operative psychological dysfunction are predictive of poorer function and increased pain following the treatment of rotator cuff disease.

Aims

The purpose of this study was to compare the effectiveness of surgical repair to conservative treatment and subacromial decompression for the treatment of chronic/degenerative tears of the rotator cuff.

Anatomic studies have demonstrated that bipolar glenoid and humeral bone loss have a cumulative impact on shoulder instability, and that these defects may engage in functional positions depending on their size, location, and orientation, potentially resulting in failure of stabilisation procedures. Determining which lesions pose a risk for engagement remains a challenge, with Itoi's 3DCT based glenoid track method and arthroscopic assessment being the accepted approaches at this time. The purpose of this study was to investigate the interaction of humeral and glenoid bone defects on shoulder engagement in a cadaveric model. Two alternative approaches to predicting engagement were evaluated; 1) CT scanning the shoulder in abduction and external rotation 2) measurement of Bankart lesion width and a novel parameter, the intact anterior articular angle (IAAA), on conventional 2D multi-plane reformats.

Hill-Sachs and Bony Bankart defects of varying size were created in 12 cadaveric upper limbs, producing 45 bipolar defect combinations. The shoulders were assessed for engagement using cone beam CT in various positions of function, from 30 to 90 degrees of both abduction and external rotation. The humeral and glenoid defects were characterised by measurement of their size, location, and orientation. The abduction external rotation scan and 2D IAAA approaches were compared to the glenoid track method for predicting engagement.

Engagement was predicted by Itoi's glenoid track method in 24 of 45 specimens (53%). The abduction external rotation CT scan performed at 60 degrees of glenohumeral abduction (corresponding to 90 degrees of abduction relative to the trunk) and 90 degrees of external rotation predicted engagement accurately in 43 of 45 specimens (96%), with sensitivity and specificity of 92% and 100% respectively. A logistic model based on Bankart width and IAAA provided a prediction accuracy of 89% with sensitivity and specificity of 91% and 87%. Inter-rater agreement was excellent (Kappa = 1) for classification of engagement on the abduction external rotation CT, and good (intraclass correlation = 0.73) for measurement of IAAA.

Bipolar lesions at risk for engagement can be identified using an abduction external rotation CT scan at 60 degrees of glenohumeral abduction and 90 degrees of external rotation, or by performing 2D measurements of Bankart width and IAAA on conventional CT multi-plane reformats. This information will be useful for peri-operative decision making around surgical techniques for shoulder stabilisation in the setting of bipolar bone defects.

The purpose of this study was to validate a dry model for the assessment of performance of arthroscopic rotator cuff repair (RCR) and labral repair (LR). We hypothesised that the combination of a checklist and a previously validated global rating scale (GRS) would be a valid and reliable means of assessing RCR and LR when performed by residents in a dry model.

An arthroscopic RCR and LR was performed on a dry model by residents, fellows, and sports medicine staff. Any prior RCR and LR exposure was noted. Participants were given a detailed surgical manuscript and technique video before the study began. Evaluation of residents was performed by staff surgeons with task-specific checklists created using a modified Delphi procedure, and the Arthroscopic Surgical Skill Evaluation Tool (ASSET). The hand movements and arthroscopic view of the procedures were recorded. Both videos were scored by a fellow blinded to the year of training of each participant.

A total of 35 residents, six fellows and five staff surgeons performed both arthroscopic RCR and LR on a dry model model (48 total). The internal reliability (Cronbach's Alpha) of the test using the total ASSET score was high (>0.8)). One-way analysis of variance for the total ASSET score and the total checklist score demonstrated a difference between participants based upon year of training (p<0.05). Post hoc analysis also demonstrated a significant difference in global ratings and checklist scores between junior residents (PGY1–3) and senior residents (PGY4&5), senior residents and fellows, and fellows and staff. A good correlation was seen between the total ASSET score and prior exposure to RCR and LR. The inter-rater reliability (ICC) between the examiner ratings and the blinded assessor ratings for the total ASSET score was good (0.8).

The results of this study provide evidence that the performance of a RCR and LR in a dry model is a valid and reliable method of assessing a resident's ability to perform these procedures, prior to performance in the operating room.

Summary

Analysis of existing data of patients who had undergone debridement procedure for osteoarthritis (OA) of glenohumeral joint showed improvement in disability at a minimum of one year following surgery. Injured workers were significantly younger and had a poorer outcome.

Introduction and Aims: Fibrin-sealant has been recommended as a tissue glue for autologous chondrocyte implantation. It is known that the active compound of fibrin-sealant is thrombin, but its effect on chondrocytes is still unclear. The aims of this study are to examine if fibrin-sealant stimulates proliferation and survival of human chondrocytes.

Method: To determine if human chondrocytes express thrombin receptors, we have conducted immunoconfocal analyses and RT-PCR for the detection of PAR type I, II, III and IV. To examine if thrombin activates intracellular signalling of chondrocytes, we have examined the intracellular calcium signalling by thrombin. Proliferation of chondrocytes was also tested with various concentrations of thrombin. The migration of chondrocytes was monitored by co-culturing of the cells with fibrin-sealant for up to 15 days.

Results: Primary human chondrocytes express thrombin receptor PAR types I, II, II and IV as evidenced by immunohistochemistry and RT-PCR. Induction of intracellular calcium signals was evidenced in majority of chondrocytes at 100 seconds after addition of thrombin. To confirm if evaluation of calcium signal activation is by a specific PAR receptor, we have examined the effect of specific peptides, which mimic the receptor activation on calcium signalling. The result showed that expression of PAR I and II receptor in chondrocytes is responsible for the activation of intracellular calcium. When human chondrocytes were co-cultured with thrombin at a dose between 1u/mL to 10u/mL, there was no effect on cellular proliferation at 24 hours. However at 48 hours, thrombin stimulated proliferation and survival of chondrocytes in a dose-dependent manner. A maximum of threefolds induction was evidenced at a dose of 10u/mL (p< 0001). Co-culture of chondrocytes with fibrin-sealant showed that after 12 hours only a few cells had migrated from the membrane to the fibrin-sealant, but after 36 hours many cells had formed a layer on the surface of the fibrin-sealant. By 15 days of co-culture, it was evidenced that the majority of chondrocytes were migrating into the fibrin-sealant.

Conclusion: The results of this study show that human chondrocytes express thrombin receptor and fibrin-sealant is capable of inducing chondrocyte proliferation and migration.

Introduction Fibrin-sealant has been widely used clinically for the protection of haemorrhage, wounds and tissue fluid leakage. Recently fibrin-sealant has been recommended as a tissue glue for autologous chondrocyte implantation. It is known that the active compound of fibrin-sealant is thrombin but its effect on chondro-cyte is still unclear. The aims of this study are to examine if fibrin-sealant stimulates proliferation and survival of human chondrocytes.

Methods Primary human chondrocytes derived from articular cartilage were used for the detection of thrombin receptors RAR type I, II, III and IV by immunohistochemistry and RT-PCR. To examine the effect of thrombin on chondrocytes, the changes in free intra-cellular calcium were monitored after the addition of thrombin. Proliferation of chondrocytes were also tested with various concentrations of thrombin. The survival of chondrocytes was monitored by co-culturing of the cells with fibrin-sealant for up to 15 days. Primary human chondrocytes express thrombin receptor RAR types I, II, III and IV as evidenced by immunohistochemistry and RT-PCR. However, the level of expression appears to be varied between cells. This has been reflected by the measurement of intracellular calcium signal in chondrocytes.

Results Induction of intracellular calcium signals was evidenced in the majority of chondrocytes at 100 seconds after addition of thrombin. When human chondrocytes were co-cultured with thrombin at a dose between 1u/ml to 10u/ml, there was no effect on cellular proliferation at 24 hours. However, at 48 hours thrombin stimulated proliferation and survival of chondrocytes in a dose dependent manner. A maximum of three folds induction was evidenced at a dose of 10u/ml (p< 0001). Co-culture of chondrocytes with fibrin-sealant showed that after 12 hours only a few cells had migrated from the membrane to the fibrin-sealant, but after 36 hours many cells had formed a layer on the surface of fibrin-sealant. By 15 days of co-culture, it was evidenced that majority of chondrocytes were migrating into the fibrin-sealant. Immunohistology study showed that these cells express type II collagen, suggesting that they maintain the phenotype of chondrocytes.

Conclusions The results of this study show that human chondrocytes express thrombin receptor and fibrin-sealant is capable of inducing chondrocyte proliferation and maintain the survival of chondrocytes.

In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source.