Is Immobilization Necessary for Early Return to Work Following Distal Biceps Repair Using a Cortical Button Technique?: A Randomized Controlled Trial.

BACKGROUND: Improvements in surgical fixation to repair distal biceps tendon ruptures have not fully translated to earlier postoperative mobilization; it is unknown whether earlier mobilization affords earlier functional return to work. This parallel-arm randomized controlled trial compared the impact of early mobilization versus 6 weeks of postoperative immobilization following distal biceps tendon repair. METHODS: One hundred and one male participants with a distal biceps tendon rupture that was amenable to a primary repair with use of a cortical button were randomized to early mobilization (self-weaning from sling and performance of active range of motion as tolerated during first 6 weeks) (n = 49) or 6 weeks of immobilization (splinting for 6 weeks with no active range of motion) (n = 52). Follow-up assessments were performed by a blinded assessor at 2 and 6 weeks and at 3, 6, and 12 months. At 12 months, distal biceps tendon integrity was verified with ultrasound. The primary outcome was return to work. Secondary outcomes were pain, range of motion, strength, shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) score, and tendon integrity. Intention-to-treat analysis was performed. A linear mixed model for repeated measures was used to compare pain, range of motion, strength, and QuickDASH between the groups over time; return to work was assessed with use of independent t tests. RESULTS: The groups were similar preoperatively (p ≥ 0.16). The average age (and standard deviation) was 44.7 ± 8.6 years. Eighty-three participants (82%) were followed to 12 months. There were no differences between the groups in terms of return to work (p ≥ 0.83). Participants in the early mobilization group had significantly more passive forearm supination (p = 0.04), with passive forearm pronation (p = 0.06) and active extension and supination (p = 0.09) trending toward significantly greater range of motion in the early mobilization group relative to the immobilization group. Participants in the early mobilization group had significantly better QuickDASH scores over time than those in the immobilization group (p = 0.02). There were no differences between the groups in terms of pain (p ≥ 0.45), active range of motion (p ≥ 0.09), or strength (p ≥ 0.70). Two participants (2.0%, 1 in each group) had full-thickness tears on ultrasound at 12 months (p = 0.61). Compliance was not significantly different between the groups (p = 0.16). CONCLUSIONS: Early motion after distal biceps tendon repair with cortical button fixation is well tolerated and does not appear to be associated with adverse outcomes. No clinically important group differences were seen. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Utilizing the physician assistant role: case study in an upper-extremity orthopedic surgical program.

BACKGROUND: Shortages with resources and inefficiencies with orthopedic services in Canada create opportunities for alternative staffing models and ways to use existing resources. Physician assistants (PAs) are a common provider used in specialty orthopedic services in the United States; however, Canada has limited experience with PAs. As part of a larger demonstration project, Alberta Health Services (AHS) implemented 1 PA position in an upper-extremity surgical program in Alberta, Canada, to demonstrate the role in 4 areas: preoperative, operative, postoperative and follow-up care. METHODS: A mixed-methods evaluation was conducted using semi-structured interviews (n = 38), health care provider (n = 28) and patient surveys (n = 47), and 2 years of clinic data on new patients. Data from a double operating room experiment detailed expected versus actual times for 3 phases of surgery (pre, during, post). RESULTS: Preoperatively, the PA prioritizes patient referrals for surgery and redirects patients to alternative care. In the second year with the PA in place, there was an increase in total new patients seen (113%). Postoperatively, the PA attended rounds on 5 surgeons' patients and handled follow-up care activities. Health care providers and patients reported that the PA provided excellent care. Findings from the operating room showed that the preparation time was greater than expected (38.6%), whereas the surgeon time (20.6%) and postsurgery time (37.2%) was less than expected. CONCLUSION: After 24 months the PA has become a valuable member of the health care team and works across the continuum of orthopedic care. The PA delivers quality care and improves system efficiencies.

CONTEXTE: Le manque de ressources et les inefficacités des services d'orthopédie au Canada créent des possibilités pour de nouveaux modèles de dotation et de mise à contribution des ressources existantes. Aux États-Unis, les adjoints au médecin sont des fournisseurs de soins courants dans les services spécialisés d'orthopédie comparativement au Canada qui en fait une utilisation limitée. Dans le cadre d'un grand projet de démonstration, Alberta Health Services (AHS) a créé un poste d'adjoint au médecin dans un programme de chirurgie des membres supérieurs en Alberta, au Canada, afin de démontrer le rôle de l'adjoint au médecin à 4 étapes des soins : préopératoire, opératoire, postopératoire et suivi. MÉTHODES: Une évaluation avec méthodes mixtes a été effectuée au moyen d'entrevues semi-structurées (n = 38), de sondages auprès de fournisseurs de soins (n = 28) et de patients (n = 47), et de données des nouveaux patients de la clinique sur 2 ans. Les données d'une expérience en salle d'opération double indiquaient le temps prévu et le temps réel de 3 étapes des chirurgies (pré, per et postopératoire). RÉSULTATS: À l'étape préopératoire, l'adjoint au médecin a établi la priorité des patients référés en chirurgie et redirigé les patients vers d'autres soins. Lors de la deuxième année de l'adjoint au médecin, nous avons observé une augmentation du nombre de nouveaux patients accueillis (113 %). À l'étape postopératoire, l'adjoint au médecin a participé aux tournées auprès des patients de 5 chirurgiens et s'est occupé des activités liées aux soins de suivi. Les fournisseurs de soins et les patients ont signalé l'excellence des soins de l'adjoint au médecin. Les résultats de la salle d'opération ont révélé un temps de préparation plus élevé que prévu (38,6 %), alors que le temps de chirurgie (20,6 %) et le temps postchirurgical (37,2 %) étaient inférieurs aux prévisions. CONCLUSION: Après 24 mois, l'adjoint au médecin est devenu un membre valorisé de l'équipe de soins qui travaille à toutes les étapes du continuum des soins orthopédiques. L'adjoint au médecin fournit des soins de qualité et améliore l'efficacité du système.

Primary Wound Closure After Open Fracture: A Prospective Cohort Study Examining Nonunion and Deep Infection.

OBJECTIVES: Determine the proportion of subjects developing deep infection or nonunion after primary wound closure of open fractures (humerus, radius/ulna, femur, and tibia/fibula). Secondarily, a matched-series analysis compared outcomes with subjects who underwent delayed wound closure. DESIGN: Prospective cohort between 2009 and 2013 of subjects undergoing primary closure. SETTING: Trauma center. PARTICIPANTS: Eighty-three (84 fractures) subjects were enrolled. Eighty-two (99%) subjects (83 fractures) provided follow-up data. Matching (age, sec, fracture location, and grade) was performed using study data of delayed wound closure undertaken at the same center between 2001 and 2009 (n = 68 matched subjects). INTERVENTION: Primary wound closure occurred when the fracture grade was Gustilo grade 3A or lower and the wound deemed clean at initial surgery. Standardized evaluations occurred until the fracture(s) healed; phone interviews and chart reviews were also undertaken at 1 year. MAIN OUTCOME MEASUREMENTS: Deep infection is defined as infection requiring unplanned surgical debridement and/or sustained antibiotic therapy after wound closure; nonunion is defined as unplanned surgical intervention after definitive wound closure or incomplete radiographic healing 1-year after fracture. RESULTS: Three (4%) subjects had deep infections, whereas 10 (12%) subjects developed nonunion in the primary closure cohort. In the matched analyses [n = 68 pairs; (136 subjects)], the primary closure cohort had fewer deep infections [n = 3 (4%) vs. n = 6 (9%)] and nonunions [n = 9 (13%) vs. n = 19 (29%)] than the delayed closure cohort (P < 0.001). CONCLUSIONS: Primary wound closure after an open fracture appears acceptable in appropriately selected patients and may reduce the risk of deep infection and nonunion compared with delayed closure; a definitive randomized trial is needed. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Factors Associated With Development of Nonunion or Delayed Healing After an Open Long Bone Fracture: A Prospective Cohort Study of 736 Subjects.

OBJECTIVES: To determine factors associated with developing nonunion or delayed healing after open fracture. DESIGN: Prospective cohort between 2001 and 2009. SETTING: Three level 1 Canadian trauma centers. PARTICIPANTS: Seven hundred thirty-six (791 fractures) subjects were enrolled. Six hundred eighty-nine (94%) subjects (739 fractures) provided adequate outcome data. INTERVENTION: Subjects were followed until fracture(s) healed; phone interviews and chart reviews were conducted 1 year after fracture. Patient, fracture, and injury information, and time to surgery and antibiotics were recorded during hospitalization. MAIN OUTCOME MEASUREMENTS: Nonunion defined as unplanned surgical intervention after definitive wound closure or incomplete radiographic healing at 1 year and delayed healing defined as 2 consecutive clinical assessments showing no radiographic progression or incomplete radiographic healing between 6 months and 1 year. RESULTS: There were 413 (52%) tibia/fibular, 285 (36%) upper extremity, and 93 (13%) femoral fractures. Nonunion developed in 124 (17%) and delayed healing in 63 (8%) fractures. The median time to surgery was not different for fractures that developed nonunion compared with those who did not (P = 0.36). Deep infection [Odd ratio (OR) 12.75; 95% confidence interval (CI) 6.07-26.8], grade 3A fractures (OR 2.49; 95% CI, 1.30-4.78), and smoking (OR 1.73; 95% CI, 1.09-2.76) were significantly associated with developing a nonunion. Delayed healing was also significantly associated with deep infection (OR 4.34; 95% CI, 1.22-15.48) and grade 3B/C fractures (OR 3.69; 95% CI, 1.44-9.44). Multivariate regression found no association between nonunion and time to surgery (P = 0.15) or antibiotics (P = 0.70). CONCLUSIONS: Deep infection and higher Gustilo grade fractures were associated with nonunion and delayed healing. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Scaphoid excision and 4-corner fusion using retrograde headless compression screws.

Scapholunate advanced collapse is a predictable form of wrist arthritis resulting from longstanding scapholunate instability. Four-corner fusion and scaphoid excision is a reliable procedure used to treat scapholunate advanced collapse wrist that improves pain and preserves range of motion. Multiple methods of achieving fixation have been described for the procedure including K-wires, staples, and headless compression screws. In previously described techniques, the compression screws are inserted in an antegrade manner, breaching the articular surface of the lunate. Even small areas of chondral damage may undermine the long-term durability of the radiocarpal joint. Given the 4-corner fusion relies on the integrity of the radiolunate articulation for success, it would seem advantageous to preserve the articular cartilage of the lunate. The technique described here involves retrograde insertion of headless compression screws to achieve a 4-corner fusion. Although it is still early, we anticipate that this procedure will result in similar fusion rates to other forms of fixation.