Neuromuscular Electrical Stimulation-Enhanced Physical Therapist Intervention for Functional Posterior Shoulder Instability (Type B1): A Multicenter Randomized Controlled Trial

OBJECTIVE

Functional posterior shoulder instability (FPSI) (type B1) is a severe type of instability, mainly in teenagers and young adults, that leads to loss of function, pain, and stigmatization among peers. An experimental nonsurgical treatment protocol based on neuromuscular electrical stimulation (NMES) showed very promising early results in the treatment of FPSI. The hypothesis of this study was that NMES-enhanced physical therapy leads to better outcomes than physical therapy alone as the current gold standard of treatment in patients with FPSI.

METHODS

In this multicenter randomized controlled trial, patients with FPSI were randomly allocated in a 1:1 ratio to either 6 weeks of physical therapy or 6 weeks of physical therapy with simultaneous motion-triggered NMES. Baseline scores as well as outcome scores at 6 weeks, 3 months, 6 months, and 12 months after the intervention were obtained. The predefined primary outcome of this trial was the Western Ontario Shoulder Instability Index (WOSI) at the 3-month time point.

RESULTS

Forty-nine patients were randomized and eligible for the trial. The group that received physical therapy with simultaneous motion-triggered NMES showed a significantly better main outcome measurement in terms of the 3-month WOSI score (64% [SD = 16%] vs 51% [SD = 24%]). Two-thirds of the patients from the physical therapist group crossed over to the group that received physical therapy with simultaneous motion-triggered NMES due to dissatisfaction after the 3-month follow-up and showed a significant increase in their WOSI score from 49% [SD = 8%] to 67% [SD = 24%]. The frequency of instability episodes showed a significant improvement in the group that received physical therapy with simultaneous motion-triggered NMES at the 3-month follow-up and beyond, while in the physical therapist group, no significant difference was observed.

CONCLUSION

The current study shows that NMES-enhanced physical therapy led to statistically significant and clinically relevant improvement in outcomes in the treatment of FPSI compared to conventional physical therapy alone-from which even patients with prior unsatisfactory results after conventional physical therapy can benefit.

IMPACT

Based on the results of this study, NMES-enhanced physical therapy is an effective new treatment option for FPSI, a severe type of shoulder instability. NMES-enhanced physical therapy should be preferred over conventional physical therapy for the treatment of patients with FPSI.

Factors Predicting the Outcome After Arthroscopically Assisted Stabilization of Acute High-Grade Acromioclavicular Joint Dislocations

BACKGROUND

Factors influencing the outcome after arthroscopically assisted stabilization of acute high-grade acromioclavicular (AC) joint dislocations remain poorly investigated.

PURPOSE

To identify determinants of the radiological outcome and investigate associations between radiological and clinical outcome parameters.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors performed a retrospective analysis of patients who underwent arthroscopically assisted stabilization for acute high-grade AC joint dislocations. The following potential determinants of the radiological outcome were examined using univariable and multivariable regression analyses: timing of surgery, initial AC joint reduction, isolated coracoclavicular (CC) versus combined CC and AC stabilization, ossification of the CC ligaments, age, and overweight status. In addition, associations between radiological (ie, CC difference, dynamic posterior translation [DPT]) and clinical outcome parameters (Subjective Shoulder Value, Taft score [TS] subjective subcategory, and Acromioclavicular Joint Instability Score [ACJI] pain subitem) were evaluated using univariable analysis.

RESULTS

One hundred four patients with a mean (±SD) age of 38.1 ± 11.5 years were included in this study. The mean postoperative follow-up was 2.2 ± 0.9 years. Compared with patients with an overreduced AC joint after surgery, the CC difference was 4.3 mm (95% CI, 1.3-7.3; P = .006) higher in patients with incomplete reduction. Patients with anatomic reduction were 3.1 times (95% CI, 1.2-7.9; P = .017) more likely to develop DPT than those with an overreduced AC joint. An incompletely reduced AC joint was 5.3 times (95% CI, 2.1-13.4; P < .001) more likely to develop DPT versus an overreduced AC joint. Patients who underwent isolated CC stabilization were 4.8 times (95% CI, 1.1-21.0; P = .039) more likely to develop complete DPT than patients with additional AC stabilization. Significantly higher CC difference values were noted for patients who reported pain on the subjective TS (P = .025). Pain was encountered more commonly in patients with DPT (P_TS = .049; P_ACJI = .038).

CONCLUSION

Clinicians should consider overreduction of the AC joint because it may lead to favorable radiological results. Because of its association with superior radiographic outcomes, consideration should also be given to the use of additional AC cerclage.

Effectiveness of bracing in the treatment of nonosseous restriction of elbow mobility: a systematic review and meta-analysis of 13 studies

BACKGROUND

Restriction of elbow mobility is a very frequent complaint after trauma or surgery. The objective of this study was to assess and compare the effectiveness of dynamic, static, or static-progressive bracing in patients with elbow stiffness of traumatic or postoperative origin and without evidence of ossification. For the purpose of this study, effectiveness was measured as the increase in total range of motion, as well as extension and flexion.

MATERIALS AND METHODS

We performed a systematic search of the keywords "elbow AND (stiffness OR stiff) AND (brace OR splint OR conservative)" in the online databases PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Library. We included all clinical studies using dynamic or static bracing in patients with elbow stiffness. Eligible outcomes were changes in total range of motion, flexion, and extension; sustainability of results; and complications.

RESULTS

We included 13 eligible studies, providing data on 14 treated groups in 247 patients. The mean age of these patients was 34.5 ± 10.4 years, and female patients comprised 46% ± 12%. The mean duration from the incident to the start of brace treatment was 6.9 ± 5.1 months. The mean improvement in range of motion during the course of treatment was 38.4° ± 8.9° (95% confidence interval, 39.5°-41.8°).

CONCLUSIONS

The current evidence strongly supports the use of static-progressive stretching 3 times 30 minutes per day in each direction as a first line of treatment in patients with post-traumatic and postsurgical elbow stiffness. If this treatment fails or if reasons for stiffness other than soft-tissue incompliance are identified, further surgical interventions should be considered.

Combined orthopedic and vascular lower extremity injuries: sequence of care and outcomes

Combined vascular and orthopedic injuries requiring repair are rare. However, these injuries have a high amputation rate and significant morbidity. In a retrospective review of lower extremity injuries managed at a level I trauma center over 9 years, we identified 26 patients with combined vascular and orthopedic injuries. We evaluated their rates of amputation and revascularization procedures based on sequence of care and initial intervention. Patients were stratified into 3 groups based on the initial intervention given: definitive vascular repair (n = 17), orthopedic stabilization (n = 4), and temporary shunt (n = 5). Amputation rates were 29% (5/17) in the vascular group and 20% (1/5) in the shunt group; there were no amputations in the orthopedic group (0/4). Revascularization rates were 41% (7/17), 25% (1/4), and 20% (1/5) in the vascular, orthopedic, and shunt group, respectively. Mangled Extremity Severity Scores higher than 6 had an overall relative risk of 5.5 for amputation (P<.05). We conclude that temporary vascular shunting followed by orthopedic stabilization and then definitive vascular repair is the most reasonable sequence of care for minimizing rates of amputation and revascularization procedures in this cohort of patients.

Comparison of two different locking plates for two-, three- and four-part proximal humeral fractures--results of an international multicentre study

PURPOSE

The aim of this study was to compare the functional outcome, quality of restoration, and complication rate after open reduction and internal fixation (ORIF) of displaced or unstable 2-, 3- and 4-part humeral fractures using two different locking plates.

METHODS

The data used in this analysis was prospectively collected in two large multicentre studies in 15 European Level 1 trauma centres. A total of 318 patients with proximal humeral fractures were treated with ORIF using either the locking proximal humerus plate (LPHP) or proximal humeral internal locking system (PHILOS). Outcome measurements included Constant and Neer scores, evaluation of local pain at the fracture site and complications, and radiographic assessment at one year.

RESULTS

At one year, the mean Constant scores (relative to the contralateral shoulder) improved significantly for both groups and were above 80% for 2-, 3-, and 4-part fractures. A significantly shorter surgical time, less pain at the fracture site, and better functional outcome was achieved by PHILOS-treated patients with 2-part fractures throughout the one-year follow-up month and with 3-part fractures at three months (p < 0.05). There was no difference between the treatment outcomes for 4-part fractures, and no difference in the complication rates (p > 0.05).

CONCLUSIONS

PHILOS and LPHP can be considered as useful implants for ORIF of displaced and unstable proximal humeral fractures. There was a slight advantage of the PHILOS system with regard to operative time and functional outcome, especially for the treatment of 2- and 3-part fractures.

Dynamic vs static external fixation of distal radial fractures: A randomized study

OBJECTIVES

The present randomized study is conducted to compare the functional and anatomical outcomes of dynamic multiplanar external fixation against that of static external fixation in the management of displaced unstable comminuted fractures of the distal radius.

MATERIALS AND METHODS

Sixty adult patients with displaced unstable comminuted fractures of the distal radius were randomly allocated either to the dynamic (n=30) or static (n=30) fixator groups. Patients in the dynamic fixator group were managed with closed reduction and application of Penning-type articulated fixator (Orthofix, Srl, Italy); the injured wrist was partially dynamized at 3 weeks. Patients in the static group were managed with monoplanar static external fixator of Joshi's external stabilizing system (JESS) type fixator. In both groups, the fixator was maintained for 6-8 weeks. The patients were followed-up over 2 years. The primary outcome measures were the functional outcome as measured using the Gartland and Werley and DASH scores and anatomical outcome as measured using the Lindstrom score. The secondary objective was to correlate anatomical and functional outcomes and to look at overall local complications.

RESULTS

Palmar tilt was better restored in the Penning fixator group (P<0.0001). There was reduced loss of ulnar tilt (P=0.05) and radial height (P=0.04) in the Penning fixator group. Gartland and Werley score was better in the Penning fixator group at each time point of the follow-up. The DASH score was similar in the two groups at 2 years (P=0.14). There was poor correlation (0.19) between functional outcome and anatomical restoration at 2 years.

CONCLUSIONS

In the management of displaced unstable comminuted fracture of the distal radius, use of an articulated multiplanar external fixator, allowing partial dynamization of the injured wrist at 3 weeks, resulted in improved early functional and anatomical outcome as compared to static external fixation. However, there was no significant difference in functional outcome at 2 years.

Comparison of functional outcome after volar plate fixation with 2.4-mm titanium versus 3.5-mm stainless-steel plate for extra-articular fracture of distal radius

PURPOSE

Open reduction and locked volar plate and screw fixation is a popular treatment method for extra-articular distal radius fractures with dorsal metaphyseal comminution. In this study, we compared the use of a titanium 2.4-mm precontoured plate with that of a stainless-steel oblique 3.5-mm T-shaped plate to test the null hypothesis that there would be no difference in wrist function or upper extremity-specific health status in the internal fixation of AO-type A3.2 distal radius fractures.

METHODS

We retrospectively analyzed 24 patients treated with a 2.4-mm titanium plate and 38 patients treated with a 3.5-mm stainless-steel plate for an extra-articular and dorsally angulated distal radius fracture, from data gathered in a prospective cohort study of plate and screw fixation of distal radius fractures. The 2 cohorts were analyzed for differences in motion, grip strength, pain, Gartland and Werley score, Disabilities of the Arm, Shoulder, and Hand score, and Short Form-36 score at 6, 12, and 24 months of follow-up. Group differences and their change over time were determined using regression analysis and the likelihood ratio test.

RESULTS

There were no significant differences in wrist function and arm-specific health status between patients treated with a 2.4-mm plate and those treated with a 3.5-mm plate at 6, 12, or 24 months of follow-up. However, we observed a trend toward greater wrist flexion at 1 year (66 degrees vs 55 degrees ; p=.07) and greater flexion-extension arc (137 degrees vs 123 degrees ; p=.08) and pronation-supination arc (172 degrees vs 160 degrees ; p=.07) at 24 months after surgery in patients treated with a 2.4-mm plate.

CONCLUSIONS

Patients with a dorsally angulated extra-articular distal radius facture can expect similar results when treated with either a precontoured 2.4-mm titanium plate or a 3.5-mm stainless-steel T-shaped plate.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Comparison of AO Type-B and Type-C volar shearing fractures of the distal part of the radius

BACKGROUND

Fractures of the volar articular margin of the distal part of the radius with volar radiocarpal subluxation (volar shearing, or Barton, fractures) can be accompanied by a fracture of the dorsal metaphyseal cortex. We tested the null hypothesis that there is no difference in wrist function or health status after open reduction and plate-and-screw fixation between volar shearing fractures with a dorsal cortical fracture (complete articular, AO Type C) and those without a dorsal cortical fracture (partial articular, AO Type B).

METHODS

In a multicenter cohort study, fifty-seven patients with a volar marginal shearing fracture of the distal part of the radius and volar radiocarpal subluxation were followed for at least one year following plate-and-screw fixation. Thirty-seven patients who also had a dorsal metaphyseal cortical fracture (Type-C fracture) were compared with twenty patients who had a partial articular (Type-B) fracture. The two cohorts were analyzed for differences in wrist and forearm motion, grip strength, pain, and the Gartland and Werley, Disabilities of the Arm, Shoulder and Hand (DASH), and Short Form-36 (SF-36) scores at six, twelve, and twenty-four months postoperatively. Differences in mean values and their change over time were determined.

RESULTS

There were no significant differences between patients with a Type-B fracture and those with a Type-C fracture with respect to motion, grip strength, or the Gartland and Werley or DASH score at any time point. At six months after the surgery, the patients with a Type-B volar shearing fracture reported a mean score for pain in motion of 0.5 point on a 10-point visual analogue scale compared with 2.2 points for patients with a Type-C fracture (difference in means, 1.7 points [95% confidence interval, 0.7 to 2.6 points]; p < 0.001), but no significant difference was seen at twelve or twenty-four months.

CONCLUSIONS

Volar shearing fractures are usually complete articular, Type-C injuries. Patients with a Type-C volar shearing fracture experience more pain during early recovery, but ultimately their outcome is comparable with that for patients with a Type-B (partial articular) volar shearing fracture.

The need for education in evidence-based orthopedicsAn international survey of AO course participants

BACKGROUND

As evidence-based practitioners, surgeons need to understand study methodology to critically appraise and conduct research.

OBJECTIVE

To determine current understanding of study methodology and critical appraisal among participants at an international educational meeting.

METHODS

We surveyed participants attending the 76th and 77th AO Course (December 2002) in Davos, Switzerland. We obtained information regarding participant age, gender, clinical and research experience, subspecialty area and respondents' roles in the AO course. The survey questions were formatted into three areas: evidence-based orthopedics, randomization and blinding issues.

RESULTS

532 participants completed the questionnaire. They represented 78 countries, the majority of which (31%) were from German-speaking countries. A greater proportion of participants trusted randomized controlled trials (89%) and meta-analyses of randomized trials (81%) when compared with case series and case reports. 60 respondents (11%) had never heard of the term "randomization" as a study design method to limit bias, and 114 respondents (21%) had never heard of the term "blinding" as a method of reducing bias in surgical research. When those who had heard of blinding were asked to define the term "double-blind", 20 different definitions resulted. Having completed the survey, nine-tenths of the respondents endorsed the need for training of surgeons in research methodology.

Effect of an unrepaired fracture of the ulnar styloid base on outcome after plate-and-screw fixation of a distal radial fracture

BACKGROUND

The impact of an unrepaired fracture of the ulnar styloid base on recovery after internal fixation of a fracture of the distal part of the radius is uncertain. We evaluated a series of patients with an internally fixed fracture of the distal part of the radius to test the hypothesis that there is no difference in wrist motion or function scores between those with an untreated fracture of the ulnar styloid base and those with no ulnar fracture.

METHODS

Two cohorts of seventy-six matched patients, one with a fracture of the ulnar styloid base and the other with no ulnar fracture, were retrospectively analyzed by examining data gathered in a prospective study of plate-and-screw fixation of distal radial fractures. Patients were matched for age, sex, AO fracture type, and injury mechanism. The two cohorts were analyzed for differences in motion, grip strength, pain, the Gartland and Werley score, the DASH (Disabilities of the Arm, Shoulder and Hand) score, and the SF-36 (Short Form-36) score at six, twelve, and twenty-four months postoperatively. In a second analysis, sixty-four patients with <2 mm of displacement of a fracture of the ulnar styloid base were compared with forty-nine patients with greater displacement. Differences between cohorts and within cohorts over time were determined with use of regression analysis and the likelihood ratio test.

RESULTS

No significant differences were found between patients with an unrepaired fracture of the ulnar styloid base and those with no ulnar fracture at any of the follow-up intervals. However, a trend was observed toward less grip strength at six months (71% [of that on the contralateral side] compared with 79%; mean difference, -8% [95% confidence interval=-15.3% to -0.6%]; p=0.03) and less flexion (54 degrees compared with 59 degrees ; mean difference, -5 degrees [95% confidence interval=-11.7 degrees to -0.8 degrees ]; p=0.02) and ulnar deviation (32 degrees compared with 36 degrees ; mean difference, -4 degrees [95% confidence interval=-7 degrees to -0.1 degrees ]; p=0.05) at twenty-four months after surgery in patients with an untreated fracture of the ulnar styloid base. There were no significant differences with regard to any tested outcome measure between the patients with >or=2 mm of displacement of an unrepaired fracture of the ulnar styloid base and those with less displacement.

CONCLUSIONS

An unrepaired fracture of the base of the ulnar styloid does not appear to influence function or outcome after treatment of a distal radial fracture with plate-and-screw fixation, even when the ulnar fracture was initially displaced >or=2 mm.

Hierarchy of evidence: differences in results between non-randomized studies and randomized trials in patients with femoral neck fractures

INTRODUCTION

There have been a number of non-randomized studies comparing arthroplasty with internal fixation in patients with femoral neck fractures. However, there remains considerable debate about whether the results of non-randomized studies are consistent with the results of randomized, controlled trials. Given the economic burden of hip fractures, it remains essential to identify therapies to improve outcomes; however, whether data from non-randomized studies of an intervention should be used to guide patient care remains unclear. We aimed to determine whether the pooled results of mortality and revision surgery among non-randomized studies were similar to those of randomized trials in studies comparing arthroplasty with internal fixation in patients with femoral neck fractures.

MATERIALS AND METHODS

We conducted a Medline search from 1969 to June 2002, identifying both randomized and non-randomized studies comparing internal fixation with arthroplasty in patients with femoral neck fractures. Additional strategies to identify relevant articles included Cochrane database, SCISEARCH, textbooks, annual meeting programs, and content experts. We abstracted information on mortality and revision rates in each study and compared the pooled results between non-randomized and randomized studies. In addition, we explored potential reasons for dissimilar results between the two study designs.

RESULTS

We identified 140 citations that addressed the general topic of comparison of arthroplasty and internal fixation for hip fracture. Of these, 27 studies met the eligibility criteria, 13 of which were non-randomized studies and 14 of which were randomized trials. Mortality data was available in all 13 non-randomized studies ( n=3108 patients) and in 12 randomized studies ( n=1767 patients). Non-randomized studies overestimated the risk of mortality by 40% when compared with the results of randomized trials (relative risk 1.44 vs 1.04, respectively). Information on revision risk was available in 9 non-randomized studies ( n=2764 patients) and all 14 randomized studies ( n=1901 patients). Both estimates from non-randomized and randomized studies revealed a significant reduction in the risk of revision surgery with arthroplasty compared with internal fixation (relative risk 0.38 vs 0.23, respectively). The reduction in the risk of revision surgery with arthroplasty compared with internal fixation was 62% for non-randomized studies and 77% for randomized trials. Thus, non-randomized studies underestimated the relative benefit of arthroplasty by 19.5%. Non-randomized studies with point estimates of relative risk similar to the pooled estimate for randomized trials all controlled for patient age, gender, and fracture displacement in their comparisons of mortality. We were unable to identify reasons for differences in the revision rate results between the study designs.

CONCLUSIONS

Similar to other reports in medical subspecialties, non-randomized studies provided results dissimilar to randomized trials of arthroplasty vs internal fixation for mortality and revision rates in patients with femoral neck fractures. Investigators should be aware of these discrepancies when evaluating the merits of alternative surgical interventions, especially when both randomized trials and non-randomized comparative studies are available.

Operative treatment of extra-articular proximal tibial fractures

BACKGROUND

Extra-articular proximal tibial fractures are often the result of high-energy trauma with displacement and comminution. Most authors agree that operative management of these fractures is warranted to optimize patient outcomes. It is unclear, however, which surgical option (plate, nail, external fixator, or combination) is preferable. (1-17) OBJECTIVE: To evaluate the effect of alternative operative techniques in the management of extra-articular proximal third tibial fractures on rates of nonunion, malunion, infection, compartment syndrome, and implant failure.

HIGHEST AVAILABLE EVIDENCE

1. Intramedullary nail (level 3 prospective case series). 2. Plates (level 3 prospective case series). 3. External fixator (level 4 case series).

STUDY IDENTIFICATION

1. Cochrane Database: 0 articles. 2. PubMed Search: Proximal tibial fractures: 568 hits; And external fixation: 69 hits; And plate: 103 hits; And intramedullary nail: 77 hits. Clinical queries search: proximal tibial fracture (specificity/therapy): 1 hit; proximal tibial fracture (sensitivity): 24 hits. Systematic reviews: 3 hits (none relevant). 3. OTA website abstract database: 8 abstracts. Total number potentially relevant articles: 29 (following review of all study titles and abstracts). Total number included after review: 17 (1-17) .

Common statistical methods in orthopaedic clinical studies

We discuss the statistical representation and management of random error in orthopaedic clinical studies. Descriptive studies (such as case series) collect information about a sample that may be generalized to describe a population. Typically this description is in the form of summary statistics, such as means, proportions, or rates. Error in these variables may be represented by confidence intervals. Correlation and regression are techniques for investigation of the relationship between two or more variables. Descriptive statistics, comparisons of groups, especially hypothesis tests, and assessment of association including correlation and regression are important statistical concepts for clinicians involved in the conduct or appraisal of orthopaedic clinical research.