AO Distal Radius Fracture Classification: Global Perspective on Observer Agreement

Background The primary objective of this study was to test interobserver reliability when classifying fractures by consensus by AO types and groups among a large international group of surgeons. Secondarily, we assessed the difference in inter- and intraobserver agreement of the AO classification in relation to geographical location, level of training, and subspecialty. Methods A randomized set of radiographic and computed tomographic images from a consecutive series of 96 distal radius fractures (DRFs), treated between October 2010 and April 2013, was classified using an electronic web-based portal by an invited group of participants on two occasions. Results Interobserver reliability was substantial when classifying AO type A fractures but fair and moderate for type B and C fractures, respectively. No difference was observed by location, except for an apparent difference between participants from India and Australia classifying type B fractures. No statistically significant associations were observed comparing interobserver agreement by level of training and no differences were shown comparing subspecialties. Intra-rater reproducibility was "substantial" for fracture types and "fair" for fracture groups with no difference accounting for location, training level, or specialty. Conclusion Improved definition of reliability and reproducibility of this classification may be achieved using large international groups of raters, empowering decision making on which system to utilize. Level of Evidence Level III.

The Zeitgeist of Challenging the Evidence. A Perspective on the International Consensus Meeting on Periprosthetic Joint Infection

BACKGROUND

The economic burden of the treatment of periprosthetic joint infection (PJI) is high and the treatment of PJI has a high degree of international controversy. Several papers have declared the International Consensus Meeting on Periprosthetic Joint Infection (ICMPJI) to be the "flawless pledge of international academics" to overcome the challenges of musculoskeletal infections. The purpose of this paper is to highlight for the first time some essential insights into the key dilemmas that are associated with this international consensus process.

METHODS

The proceedings of the ICMPJI was reviewed, and the critical consensus agreements that were reached were communicated via e-mail to 48 leading orthopaedic surgeons, microbiologists and statisticians around the world. Of these, 30 responded, 8 did not, and 10 of respondents were not aware of the ICMPJI.

RESULTS

A thorough review of the ICMPJI proceedings identified a clear need to resolve some of the dilemmas that we highlight in this paper. The Delphi procedure has been described as a survey technique that enables a group dynamic-based practice. Although there have been several published reports on this procedure, its scientific merit is still being debated. Several challenges and questions have been raised regarding the application of the Delphi technique, but there is no doubt that it is a vital approach for achieving consensus on subjects where none currently exists.

CONCLUSION

Performing prospective clinical studies in this area is currently the best and only option to overcome this challenge. In the long term, this approach will not only incorporate the standard of clinical evidence but also adopt regional mores for treating infection, which include patient values, cultural differences and local financial resources.

Ulnar-Sided Wrist Pain due to Long Ulnar Styloid: A Case Report

Ulnar styloid impaction syndrome involves repetitive friction between an excessively long ulnar styloid and the carpus, resulting in chondromalacia, synovitis, and pain. The arthroscopic diagnosis, evaluation, and management of this syndrome are not well characterized. We present a patient with chronic wrist pain of unknown origin, culminating with arthroscopic findings demonstrating substantial loss of articular cartilage on both the lunate and triquetrum. The patient successfully underwent operative ulnar styloid excision, ultimately resolving chronic wrist pain symptomology.

Head-locking durability of fixed and variable angle locking screws under repetitive loading

Polyaxial locking screws are increasingly applied in fracture fixation. To investigate the durability of the head-locking mechanism, the removal torque of variable angle (VA) and fixed angle (FA) stainless steel and titanium locking screws was investigated without and after a cyclic loading test. Stainless steel (St) and titanium (Ti) 2.4 mm orthogonally inserted FA screws and 2.4 mm VA screws inserted in different inclinations (0°-15°) (n = 6 per group) were locked at 0.8 Nm. Removal torque was determined without (W) and after (A) cyclic loading (sinusoidal load, 5 Hz, constant amplitude of 25 N, up to 10'000 cycles, or failure). Significant differences in-between the groups were detected by Student's t-test (p < 0.05). Except VA Ti in 0deg and FA, all groups exhibited a drop in removal torque below the insertion torque without and after cyclic testing. The removal torque was (St: FA W:0.81 Nm ± 0.04 A:0.72Nm ± 0.04; VA0deg W:0.73 Nm ± 0.04 A:0.65 Nm ± 0.05; VA15deg W:0.51 Nm ± 0.05 A:0.50 Nm ± 0.08; Ti: FA W:0.82 Nm ± 0.03 A:0.70 Nm ± 0.04; VA0deg W:0.80 Nm ± 0.02 A:0.72 Nm ± 0.05; VA15deg W:0.55 Nm ± 0.03 A:0.54 Nm ± 0.06). In all groups, the removal torque after cyclic testing did not drop below 16% of the removal torque without cyclic testing. No head loosening was observed after cyclic testing. Stainless steel and titanium 2.4 mm fixed and variable angle locking screws provide a stable and lasting head-locking mechanism. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:949-952, 2016.

Intralesional Versus Wide Resection of Low-Grade Chondrosarcomas of the Hand

PURPOSE

To report our experience with intralesional curettage (resection with positive margins) and amputation (resection with negative margins) of low-grade chondrosarcomas (LCS) of the hand.

MATERIALS AND METHODS

Skeletally mature patients treated surgically for LCS of the hand at our institutions were reviewed. Demographics and oncological history were collected. Results of the entire cohort and by treatment modality were analyzed radiographically, functionally (strength, Disabilities of the Arm, Shoulder, and Hand measure), cosmetically, and oncologically (recurrence, Musculoskeletal Tumor Society score, metastasis, and mortality rates).

RESULTS

Seventeen cases in 16 patients were identified. Nine patients were women. Average age at surgery was 43 years (range, 20-80 years). Mean follow-up was 18 years (range, 9-23 years). Six of the 17 lesions treated at different institutions with intralesional procedures presented as recurrent disease. We treated 3 with a repeat intralesional procedure and the remaining with wide resection. Recurrence incidence was the same in both groups. The remaining 11 new-onset cases were treated with intralesional procedures (6) or wide resections (5). One of the 6 tumors treated with an intralesional procedure recurred. None treated with wide resection recurred. Recurrence incidence combining new- onset and recurrent disease after intralesional procedures was 22% versus 13% for wide resections. Average grip strength was 37 kg (range, 21-55 kg), and pinch strength was 7.6 kg (range, 4.5-12.5 kg). Mean Disabilities of the Arm, Shoulder, and Hand score was 2 (range, 0-10). There were no wound complications, and appearance was satisfactory in most cases (visual analog scale score, > 8). Average Musculoskeletal Tumor Society score was 29 points (range, 21-30 points). No patients presented with metastatic disease or died because of LCS.

CONCLUSIONS

Intralesional resections aiming to preserve function are safe, recognizing that more than 1 procedure may be required. Amputation also plays a role with excellent functional outcome in cases in which severe joint deformity or involvement of soft tissues and neurovascular structures interferes with function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A Unified Approach to Outcomes Assessment for Distal Radius Fractures

Distal radius fractures are one of the most common upper extremity injuries. Currently, outcome assessment after treatment of these injuries varies widely with respect to the measures that are used, timing of assessment, and the end points that are considered. A more consistent approach to outcomes assessment would provide a standard by which to assess treatment options and best practices. In this summary, we review the consensus regarding outcomes assessment after distal radius fractures and propose a systematic approach that integrates performance, patient-reported outcomes, pain, complications, and radiographs.

Corrective Osteotomy for Intra-Articular Distal Humerus Malunion

BACKGROUND

An intra-articular distal humerus malunion can be disabling. To improve function, reduce pain and/or prevent further secondary osteoarthritis an intra-articular corrective osteotomy can be considered. Herein we present the indications, practical guidelines for pre- operative planning and surgical technique. Subsequently, we provide long-term results in a small series.

METHODS

We included six consecutive patients operated for intra-articular distal humerus malunion. Mean follow-up was 88 months. At lastest follow up elbow function was assessed according to standardized questionnaires and classification systems.

RESULTS

All six patients healed their osteotomies. Three patients had a postoperative complication which were treated succesfully. Range of motion improved significantly and all patients were satisfied with the outcome. The elbow performance scores were good to excellent in all. Correlation analyses showed that age and level of osteoarthritis are very strong predictors for the long-term elbow function and quality of life.

CONCLUSION

An intra-articular corrective osteotomy for a malunited distal humerus fracture is a worthwhile procedure. Based on our results it should particularly be considered in young patients with minimal osteoarthritis and moderate to severe functional disability and/or pain.

Distal Radius Volar Rim Fracture Fixation Using DePuy-Synthes Volar Rim Plate

Background To assess the results of distal radius fractures with the involvement of the volar rim fixed with the DePuy-Synthes Volar Rim Plate. Case Description We searched for the patients with volar rim fracture and/or volar rim fractures as part of a complex fracture fixed with a volar rim plate. Ten patients met the inclusion criteria: three patients with type 23B3, six patients with type 23C, and one patient with very distal type 23A. The mean follow-up was 14 months (range: 2-26). Fractures healed in all patients. Of the three patients with isolated volar rim fractures (type 23B3), two patients had no detectable deficits in motion. These patients had an average Gartland and Werley score of 9 (range: 2-14). Of the other seven patients (six with type 23C and one with type 23A fracture), three patients healed with full range of motion and four had some deficits in range of motion. Two patients had excellent results, three had good results, and two had fair results using the Gartland and Werley categorical rating. One patient healed with a shortened radius and ulnar impingement requiring a second surgery for ulnar head resection arthroplasty. Literature Review Results after nonoperative treatment of volar rim fractures are not satisfactory and often require subsequent corrective osteotomy. Satisfactory outcomes are achieved when the fragments are well reduced and secured regardless of the device type. Clinical Relevance Volar rim plates give an adequate buttress of the volar radius distal to volar projection of the lunate facet and do not interfere with wrist mobility. Furthermore, the dorsal fragments can be fixed securely through the volar approach eliminating the need for a secondary posterior incision. However, patients should be informed of the potential problems and the need to remove the plate if symptoms develop.

Stabilisation of distal radius fractures: Lessons learned and future directions

Our understanding of the diagnosis and management of distal radius fractures has been a long developed over centuries. There has been a shift in treatment of these very common injuries from closed reduction and casting to internal fixation. The answer to the best method of treatment has yet to be found. Today, we have a multitude of treatment options available with varying degrees of evidence to support their use. This review helps to illustrate the lessons we have learned and future directions for treatment.

Patient Satisfaction and its Relation to Perceived Visit Duration With a Hand Surgeon

PURPOSE

To determine whether patient perception of time spent with a hand surgeon relates to patient satisfaction after a single new-patient office visit.

METHODS

Prior to each visit, 112 consecutive new patients predicted how much time they expected to spend with the surgeon. Following the visit, patients were asked to estimate the time spent with the surgeon, indicate whether the surgeon appeared rushed, and rate their overall satisfaction with the surgeon. Wait time and actual visit duration were measured. Patients also completed a sociodemographic survey, the Consultation and Relational Empathy Measure, the Newest Vital Sign Health Literacy test, and 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Upper Extremity Function, Pain Interference, and Depression. Multivariable logistic and linear regression models were used to determine predictors of patient satisfaction, patient-perceived surgeon rush, and high previsit expectations of visit duration.

RESULTS

Patient satisfaction was not associated with perceived visit duration but did correlate strongly with patient-rated surgeon empathy and symptoms of depression. Neither visit duration nor previsit expectations of visit length were determinants of patient-perceived surgeon rush. Only surgeon empathy was associated. Less-educated patients anticipated needing more time with the surgeon.

CONCLUSIONS

Patient satisfaction with the surgeon and with the time spent during the office visit was primarily linked to surgeon empathy rather than to visit duration or previsit expectation of visit length. Efforts to make hand surgery office visits more patient-centered should focus on improving dialogue quality, and not necessarily on making visits longer.

Diagnosis and treatment of acute extremity compartment syndrome

Acute compartment syndrome of the extremities is well known, but diagnosis can be challenging. Ineffective treatment can have devastating consequences, such as permanent dysaesthesia, ischaemic contractures, muscle dysfunction, loss of limb, and even loss of life. Despite many studies, there is no consensus about the way in which acute extremity compartment syndromes should be diagnosed. Many surgeons suggest continuous monitoring of intracompartmental pressure for all patients who have high-risk extremity injuries, whereas others suggest aggressive surgical intervention if acute compartment syndrome is even suspected. Although surgical fasciotomy might reduce intracompartmental pressure, this procedure also carries the risk of long-term complications. In this paper in The Lancet Series about emergency surgery we summarise the available data on acute extremity compartment syndrome of the upper and lower extremities in adults and children, discuss the underlying pathophysiology, and propose a clinical guideline based on the available data.

Physician Empathy as a Driver of Hand Surgery Patient Satisfaction

PURPOSE

To examine the relationship between patient-rated physician empathy and patient satisfaction after a single new hand surgery office visit.

METHODS

Directly after the office visit, 112 consecutive new patients rated their overall satisfaction with the provider and completed the Consultation and Relational Empathy Measure, the Newest Vital Sign health literacy test, a sociodemographic survey, and 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Pain Interference, Upper-Extremity Function, and Depression. We also measured the waiting time in the office to see the physician, the duration of the visit, and the time from booking until appointment. Multivariable logistic and linear regression models were used to identify factors independently associated with patient satisfaction.

RESULTS

Patient-rated physician empathy correlated strongly with the degree of overall satisfaction with the provider. After controlling for confounding effects, greater empathy was independently associated with patient satisfaction, and it alone accounted for 65% of the variation in satisfaction scores. Older patient age was also associated with satisfaction. There were no differences between satisfied and dissatisfied patients with regard to waiting time in the office, duration of the appointment, time from booking until appointment, and health literacy.

CONCLUSIONS

Physician empathy was the strongest driver of patient satisfaction in the hand surgery office setting. As patient satisfaction plays a growing role in reimbursement, targeted educational programs to enhance empathic communication skills in hand surgeons merit consideration.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Early history of scapular fractures

The first to use the term Scapula was Vesalius (1514-1564) and thus it has remained ever since. Probably the oldest injured scapula, from 250 million years ago, was described by Chinese authors of a skeletal examination of a fossilised remains of a dinosaur Yangchuanosaurus hepingensis. In humans, the oldest known scapular fractures date back to the prehistoric and early historic times. In ancient times, a fracture of acromion was described in the treatises of Hippocrates. Early modern history of the treatment of scapular fractures is closely interlinked with the history of the French surgery. The first to point out the existence of these fractures were Petit, Du Verney and Desault in the 18th century. The first study devoted solely to scapular fractures was published by Traugott Karl August Vogt in 1799. Thomas Callaway published in 1849 an extensive dissertation on injuries to the shoulder girdle, in which he discussed a number of cases known at that time. The first radiograph of a scapular fracture was published by Petty in 1907. Mayo Robson (1884), Lambotte (1913) and Lane (1914) were pioneers in the surgical treatment of these fractures, followed in 1923 by the French surgeons Lenormat, Dujarrier and Basset. The first internal fixation of the glenoid fossa, including a radiograph, was published by Fischer in 1939.

Concept of variable angle locking--evolution and mechanical evaluation of a recent technology

Applications for fracture-adapted screw positioning offered by variable angle locking screws are increasing. The locking strength of the variable angle locking mechanism at different insertion angles was compared to conventional fixed angle locking screws. Stainless steel (S) and titanium (Ti) variable and fixed angle 2.4 mm locking screws, inserted at different inclinations (0°-15°), and locked at 0.8 Nm were subjected to a load-to-failure test. Ultimate failure moment at the screw-head interface and failure mode of the screws were determined. Significant differences were detected by one-way ANOVA (p < 0.05). Stainless steel and titanium variable angle locking screws inserted at 2°-10° inclination exhibited a failure moment comparable to the 0° position (S 1.67± 0.04 Nm; Ti 1.67 ± 0.14 Nm) and failed predominantly at the screw neck, with the head remaining fixed to the plate. Inserted at 15° inclination, screws revealed a lower failure moment (S 1.33 ± 0.06 Nm, Ti 1.58 ± 0.05Nm), and failed predominantly by breakout of the head thread. Fixed angle locking screws inserted at an inclination >2° did not lock properly in the plate hole, providing insufficient locking strength. Variable angle locking screws offer a stable head-locking mechanism at different inclinations, comparable to the locking strength of orthogonal inserted fixed angle locking screws. Marginal inclinations >15° should be used with care.

Radial Head Prosthesis Removal: a Retrospective Case Series of 14 Patients

BACKGROUND

The purpose of this study was to report the preoperative complaints and postoperative outcome of patients after removal of the radial head prosthesis.

METHODS

This is a retrospective review of 14 adult patients (6 females and 8 males) from 2007 to 2011, who underwent radial head prosthesis removal by three surgeons. The average time between implantation and removal was 23 months (range from 2 weeks to 12 years, median 12 months).

RESULTS

The leading reported complaints before removal were restricted mobility of the elbow (active range of motion of less than 100 degrees) in 6, pain in 3, and pain together with restricted mobility in 4 patients. The objective findings before removal were restricted mobility of the elbow in 10 (71%), capitellar cartilage wear, loose implants, and heterotopic ossification each in 8 (57%), subluxation of the radio-capitellar joint or malpositioning of the stem in 5 (36%), and chronic infection in 2 (14%) patients. All patients with pain had wear of the capitellar cartilage on radiographs. The ulnar nerve was decompressed in four patients at the time of removal. Four patients underwent a subsequent operation for postoperative ulnar nerve symptoms 5 to 21 months after removal. Four patients were still complaining about persistent pain at the last follow-up visit. Except two patients, the total range of motion improved with a mean of 34 degrees (range 5 to 70) after a mean follow-up of 11 months.

CONCLUSIONS

Removal of radial head prosthesis improved function and lessened pain in our case series. The reoperation rate was yet nearly 30% due to ulnar neuritis. Selective ulnar nerve decompression at the time of removal must be evaluated, especially in patients with expected large gain in range of motion after removal.

Treatment of distal humerus fractures in adults: a historical perspective

Nonsurgical treatment was the mainstay of management of distal humerus fractures for centuries and nonunions and malunions were common. The 19th century featured the recognition of distinct injury patterns. With advances in radiology, anesthesia, antisepsis, and hardware technology, surgical treatment is now generally preferred, yet loss of elbow joint mobility can still be a vexing problem.

Instability of the distal radioulnar joint

The distal radioulnar joint is a complex structure necessary for forearm motion and force transmission across the wrist. Anatomic and biomechanical advances have revealed broad contributions to distal radioulnar joint stability and refined our understanding of the forces acting across it. Instability often co-occurs with other modes of pathology, such as arthrosis or malunion; and appropriate diagnosis and treatment require a comprehensive understanding of all contributing factors. Distal radioulnar joint instability can be broadly categorized as primary, post-traumatic or post-surgical. Treatment strategies include percutaneous, arthroscopic, soft-tissue, osteotomy and arthroplasty techniques. The purpose of this article is to review distal radioulnar joint instability and its management.

Outcome Assessment after Aptis Distal Radioulnar Joint (DRUJ) Implant Arthroplasty

BACKGROUND

Conventional treatments after complicated injuries of the distal radioulnar joint (DRUJ) such as Darrach and Kapandji-Sauvé procedures have many drawbacks, which may eventually lead to a painful unstable distal ulna. The development of DRUJ prosthesis has significantly evolved over the past years. In this study, we assessed the outcome results of patients after DRUJ implant arthroplasty using the Aptis (Scheker) prosthesis.

METHODS

We identified 13 patients with 14 prosthesis during the past 10 years. Patients underwent DRUJ arthroplasty due to persistent symptoms of instability, chronic pain, and stiffness. Records and follow-up visits were reviewed to find the final post-operative symptoms, pain, range of motion, and grip strength with a mean follow-up of 12 months (range: 2-25 months). Also, patients were contacted prospectively by phone in order to administer the disabilities of the arm shoulder and hand (DASH), patient rated wrist evaluation (PRWE), and visual analogue scale (VAS), and to interview regarding satisfaction and progress in daily activities. Eleven patients out of 13 could be reached with a median follow-up time of 60 months (range: 2 to 102 months).

RESULTS

No patient required removal of the prosthesis. Only two patients underwent secondary surgeries in which both required debridement of the screw tip over the radius. The median DASH score, PRWE score, VAS, and satisfaction were 1.3, 2.5, 0, and 10, respectively. The mean range of flexion, extension, supination, and pronation was 62, 54, 51, and 64, respectively.

CONCLUSIONS

Distal radioulnar joint injuries are disabling and patients usually undergo one or more salvage surgeries prior to receiving an arthroplasty. The Scheker prosthesis has shown satisfactory results with 100% survival rate in all reports. The constrained design of this prosthesis gives enough stability to prevent painful subluxation.

Risk factors for return with a second trigger digit

The purpose of this study was to determine predictors of return to the same practice with a second idiopathic trigger digit. A total of 2234 patients with Quinnell grade 2 or greater (objective triggering) of one or more digits were retrospectively analysed. A total of 490 of 2234 (22%) patients returned to the same practice with a second trigger digit, with an average follow-up time of 2.1 years (range, 7 days to 10 years). Predictors of return with a second trigger digit included carpal tunnel syndrome, Type 1 diabetes mellitus and duration of follow-up in years. Patients diagnosed with idiopathic trigger digit can be advised that about one in five will return to the same practice with another trigger digit, with approximately double the risk in patients that have carpal tunnel syndrome or Type 1 diabetes.

Nonacute Treatment of Elbow Fracture with Persistent Ulnohumeral Dislocation or Subluxation

➤ There are patterns of traumatic elbow instability that help a surgeon to anticipate which structures are injured.➤ Patients treated for persistent subluxation or dislocation of the elbow more than two weeks after injury regain less motion and experience more adverse events.➤ The primary goal of treatment is stable reduction of the ulnohumeral joint and functional elbow motion.➤ Motion and pain are affected by contracture and scarring of the soft tissues, malalignment of the joint, fracture malunion, damage to the articular surface, and ulnar neuropathy.➤ Biomechanical and clinical studies support treatment with radial head arthroplasty and/or coronoid reconstruction for patients who have osseous insufficiency.

Complications of hinged external fixation compared with cross-pinning of the elbow for acute and subacute instability

BACKGROUND

Elbows that are unstable after injury or reconstructive surgery often are stabilized using external fixation or cross-pinning of the joint supplemented by cast immobilization. The superiority of one approach or the other remains a matter of debate.

QUESTIONS/PURPOSES

We compared patients treated with external fixation or cross-pinning in terms of (1) adverse events, (2) Broberg and Morrey scores, and (3) ROM.

METHODS

Between 1998 and 2010, 19 patients (19 elbows) had hinged external fixation and 10 patients (11 elbows) cross-pinning and casting for subacute or acute posttraumatic elbow instability. Our general indications for both techniques were persistent elbow instability after usual treatment. Initially, we used external fixation for delayed treatment of fracture-dislocations and cross-pinning for simple elbow dislocations in patients who could not tolerate surgery, but more recently we have used cross-pinning for both indications. Adverse events, elbow scores, and ROM were retrospectively evaluated by chart review, with the latter two end points being calculated at a mean of 31 months (range, 5-83 months) and 10 months (range, 5-21 months) after index procedure for the patients treated with external fixation and cross-pinning, respectively.

RESULTS

Seven of 19 patients treated with external fixation experienced nine device-related adverse events: three pin tract infections, two nerve problems, one broken pin, one residual subluxation, one suture abscess, and one pin tract fracture of the ulna resulting in a nonunion. Of the 10 patients (11 elbows) treated with cross-pinning, one patient had pin tract inflammation that resolved with pin removal. Mean Broberg and Morrey score was 90 (95% CI, 84-95) after external fixation and 90 (95% CI, 84-96) after cross-pinning (p = 0.88). There were no differences between the external fixation and cross-pinning groups in mean flexion (123° versus 128°, p = 0.49), extension (29° versus 29°, p = 0.97), forearm pronation (68° versus 74°, p = 0.56), and forearm supination (47° versus 68°, p = 0.15).

CONCLUSIONS

When the elbow remains unstable after reduction and usual treatment for fractures and dislocations or has been out of place for more than 2 weeks, both cross-pinning and external fixation can help maintain elbow alignment while structures heal. Hinged external fixation is associated with more adverse events related to the device, but Broberg and Morrey score and ROM are similar between techniques.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.