Proximal humerus open reduction internal fixation with and without biceps tenodesis: assessment of early clinical outcomes.

Background: The role of biceps tenodesis (BT) during open reduction internal fixation (ORIF) of proximal humerus fractures (PHFs) remains unclear. A subset of patients undergoing ORIF have persistent pain with unclear etiology. The purpose of our study was to compare outcomes of ORIF of PHFs with and without concomitant BT. We hypothesize patients undergoing BT at the time of ORIF will have improved patient-reported outcome scores with fewer secondary procedures related to treatment of the biceps. Methods: In this retrospective cohort study, all patients undergoing ORIF for a PHF at a single level one trauma center from January 2019 to June 2022 were reviewed. Patients under the age of 18 were excluded. Primary outcomes were patient-reported outcomes measurement information system physical function, depression, and pain interference scores at 5 time points up to final follow-up. Secondary outcomes included total operative time, complications, subsequent procedures, steroid injections, and range of motion. Chi-square tests were performed for categorical values and paired t-tests for continuous variables. Results: 71 patients met inclusion criteria: 41 undergoing ORIF without BT and 30 undergoing ORIF with BT. Average follow-up was 11 months. There were no statistically significant differences in patient demographics between groups. There were no differences in patient-reported outcomes measurement information system scores at any time point postoperatively. At final follow-up patients in the ORIF with BT group had higher forward flexion than those who did not undergo BT (142 vs. 123 degrees, respectively, P < .02). There were no differences in surgical time, revision rates, postsurgical complications, or postoperative injections between groups. Conclusion: BT performed during ORIF of PHFs did not result in significantly different functional or patient-reported outcomes between groups, except for greater forward flexion at final follow-up. Although BT was done more commonly in severe PHFs, patients in both groups had similar rates of subsequent biceps-related procedures and revision surgery.

Optimizing the Entry Point for Medullary Hip Screws.

INTRODUCTION: Medullary hip screws (MHSs) are the most common treatment of intertrochanteric hip fractures because they can be used for varied fracture patterns and resist shortening. Identifying the appropriate MHS entry point can be intellectually and technically challenging. We aimed to quantify the variability in the ideal entry point (IEP) for MHSs. METHODS: Standing alignment radiographs of 50 patients were evaluated using TraumaCad (Brainlab). The femoral neck shaft angle and the offset from the tip of the greater trochanter (GT) to the femur's longitudinal axis ('greater trochanter offset') were measured. Five MHS system templates were superimposed on the femur's longitudinal axis, and the distance from the GT tip to MHS's top center was measured. Five independent reviewers each templated 20 images such that all images were measured at least twice. A random sample of five images was selected for all five raters to measure and to calculate an intraclass coefficient Mean IEPs were compared with an independent sample Student t -test. RESULTS: The mean GT offset was 13.5 ± 5.6 mm (range 12.9 to 26.7 mm). The mean neck shaft angle was 129.5 ± 4.0 (range 120 to 139). The mean IEP for nail systems ranged from 5.7 to 7.1 mm medial to the GT tip; there was no notable difference in pairwise comparison of nail systems or in aggregate. Intraclass coefficient for all ratings, measurements, and nail types ranged from moderate to good. Both intra-rater and inter-rater reliability were excellent. DISCUSSION AND CONCLUSION: In a sample with broad variation in femoral anatomy, there is a specific, roughly 1.5 mm wide interval that is 6.4 mm medial to the GT tip that serves as the IEP for the most common MHS systems. No notable difference seems to exist in the IEP among these MHS systems.

Biomechanical Properties of Knee Medial Collateral Ligament Compared to Palmaris Longus for Ulnar Collateral Ligament Reconstruction.

Ulnar collateral ligament reconstruction (UCLR) is frequently performed among injured overhead-throwing athletes. One of the most common graft choices when performing a UCLR is the ipsilateral palmaris longus tendon (PL). The purpose of this study was to investigate the material properties of aseptically processed cadaveric knee collateral ligaments (kMCL) as a potential graft source for UCLR and compare them to the gold standard PL autograft. Each PL and kMCL cadaveric sample was subjected to cyclic preconditioning, stress relaxation, and load-to-failure testing, and the mechanical properties were recorded. PL samples exhibited a greater average decrease in stress compared to the kMCL samples during the stress-relaxation test (p < 0.0001). PL samples also demonstrated a greater average Young's modulus in the linear region of the stress-strain curve compared to the kMCL samples (p < 0.01). The average yield strain and maximum strain of kMCL samples were significantly greater than the PL, p = 0.03 and 0.02, respectively. Both graft materials had comparable maximum toughness and demonstrated a similar ability to deform plastically without rupture. The clinical significance of our result is that prepared knee medial collateral ligament allografts may provide a viable graft material for use in the reconstruction of elbow ligaments.

Clinical Characteristics and Treatment Patterns of Open Hand Fractures in the Pediatric Population.

BACKGROUND: Open hand fractures are one of the most common injuries in the pediatric population. These injuries are at higher risk of infection, especially in cases of frank contamination. Several studies on adult hand fractures are available in the literature; however, pediatric open hand fractures have yet to be extensively studied. This study aimed to define pediatric open hand fracture's demographics, clinical characteristics, and treatment patterns. METHODS: Using the Protected Health Information database, pediatric patients (<18 y old) with the diagnosis of open hand fracture from June 2016 to June 2018 were extracted. Demographic, treatment, and follow-up data were collected. Clinical outcomes included readmission and postoperative infection rates. RESULTS: There were a total of 4516 patients who met the inclusion criteria; the median age was 7 years (interquartile range: 3 to 11); 60% males; 60% white. Displaced fractures occurred in 74% of patients, with the right hand (52%) and middle finger (27%) predominance. The most common mechanism of injury was a crushing injury in-between objects (56%). Associated nerve injury occurred in 78 patients (4%) and vascular injury in 43 patients (2%). Open reduction and internal fixation were performed in 30% of patients. Cephalosporins were the most commonly prescribed antibiotics (73%), followed by aminopenicillins (7%). Nine patients had complications related to surgical intervention (0.2%), and postoperative infection occurred in 44 patients (1%). CONCLUSIONS: Pediatric open hand fractures most often occur during childhood and more frequently in males. These fractures tend to be more distal and displaced; reduction and fixation are required in one-third of the cases. Despite the absence of treatment guidelines and variability, this injury exhibits low complication rates. LEVEL OF EVIDENCE: Level III, retrospective study.

Characterizing Single-star Negative Online Reviews of Orthopaedic Trauma Association Members.

INTRODUCTION: The purpose of this study was to characterize factors that contribute to 1-star negative reviews regarding orthopaedic trauma surgeons. METHODS: A search was done for Orthopaedic Trauma Association members on Yelp.com , Healthgrade.com , and Vitals.com in New York, Boston, San Francisco, Los Angeles, Dallas, Phoenix, Seattle, Baltimore, Denver, Houston, Philadelphia, and Washington, DC. All single-star reviews (out of a possible 5 stars) were included in this study. Reviews were categorized as either clinical or nonclinical and then further subcategorized. Categorical variables were analyzed using a chi-square test. The rate ratio (the ratio of the rate for nonsurgical divided by surgical reviews) was determined for each category. RESULTS: Two hundred eighty-eight single-star reviews were included in the study, comprising 655 total complaints. Of all complaints, 274 (41.8%) were clinically related and 381 (58.2%) were nonclinical. Of the 288 single-star reviews, 96 (33.3%) were from surgically treated patients and 192 (66.7%) were from nonsurgical patients. Most complaints were in reference to nonclinical aspects of care such as physician bedside manner (173 reviews, 60%), not enough time spent with provider (58 reviews, 20%), and wait time (42 complaints, 15%). The most common clinical complaints were for complication (61 reviews, 21%), disagree with decision/plan (49 reviews, 17%), and uncontrolled pain (45 reviews, 16%). Surgical patients had a significantly higher rate of clinical complaints than nonsurgical patients (1.57 vs. 0.64 clinical complaints per review, P < 0.001). Nonsurgical patients had a significantly higher rate of nonclinical complaints than surgical patients (1.43 vs. 1.10 nonclinical complaints per review, P < 0.001). DISCUSSION: Most 1-star reviews referenced a nonclinical aspect of care with a physician's bedside manner being the most common complaint. Surgical patients were markedly more likely to reference a clinical aspect of care, such as complications or misdiagnosis compared with nonsurgical patients, who more commonly referenced nonclinical aspects of care.

A Comprehensive Review of Over the Counter Treatment for Chronic Low Back Pain.

PURPOSE OF THE REVIEW: Chronic low back pain (CLBP) is a major contributor to societal disease burden and years lived with disability. Nonspecific low back pain (LBP) is attributed to physical and psychosocial factors, including lifestyle factors, obesity, and depression. Mechanical low back pain occurs related to repeated trauma to or overuse of the spine, intervertebral disks, and surrounding tissues. This causes disc herniation, vertebral compression fractures, lumbar spondylosis, spondylolisthesis, and lumbosacral muscle strain. RECENT FINDINGS: A systematic review of relevant literature was conducted. CENTRAL, MEDLINE, EMBASE, PubMed, and two clinical trials registry databases up to 24 June 2015 were included in this review. Search terms included: low back pain, over the counter, non-steroidal anti-inflammatory (NSAID), CLBP, ibuprofen, naproxen, acetaminophen, disk herniation, lumbar spondylosis, vertebral compression fractures, spondylolisthesis, and lumbosacral muscle strain. Over-the-counter analgesics are the most frequently used first-line medication for LBP, and current guidelines indicate that over-the-counter medications should be the first prescribed treatment for non-specific LBP. Current literature suggests that NSAIDs and acetaminophen as well as antidepressants, muscle relaxants, and opioids are effective treatments for CLBP. Recent randomized controlled trials also evaluate the benefit of buprenorphine, tramadol, and strong opioids such as oxycodone. This systematic review discusses current evidence pertaining to non-prescription treatment options for chronic low back pain.

Current Concepts of Minimally Invasive Treatment Options for Plantar Fasciitis: a Comprehensive Review.

PURPOSE OF REVIEW: Chronic foot pain constitutes a large portion of the chronic pain burden in the overall population. Plantar fasciitis is one of the most common and most easily identifiable causes of chronic foot pain. The syndrome has been estimated to cause 11 to 15% of foot pain visits, requiring professional care. Moreover, studies have suggested that 1 in 10 people will develop plantar fasciitis at some point in their life. Conservative management has been shown to be effective and considered first-line treatment. Minimally invasive treatment options are typically reserved for those who fail conservative management. With the advent of new techniques and improvements in current therapeutic options, there has been an expansion of available minimally invasive treatment options. The purpose of this review is to provide a comprehensive update on the current understanding of minimally invasive treatments of plantar fasciitis. RECENT FINDINGS: This review shows that conservative management continues to be the first-line therapy, whereas other treatment options were those who failed conservative management using modern techniques that have shown improving effectiveness, with successful restoration of patient functionality, recovery, and satisfaction. However, a multitude of these minimally invasive treatment options are evolving. CONCLUSION: While conservative management continues to be the mainstay of treatment for plantar fasciitis, multiple minimally invasive treatment options are emerging with potential effectiveness in reducing pain and improving the function.

Minimally Invasive Treatment of Chronic Ankle Instability: a Comprehensive Review.

PURPOSE OF REVIEW: Chronic ankle pain is a prevalent and significant cause of chronic pain. While the definition of chronic ankle pain is heterogeneous and poorly defined in the literature, systematic reviews and meta-analyses have estimated this condition to be a prevalent and debilitating source of chronic pain. The most identifiable and prominent cause of chronic ankle pain is chronic ankle instability (CAI), a condition defined by instability of the ankle-joint complex. It is a common consequence of lateral ankle sprains or ligamentous injuries and can be described as a failure of the lateral ankle joint complex after an acute, or recurring, ankle injury. The objective of this manuscript is to provide a comprehensive review of CAI diagnosis and our current understanding of minimally invasive treatment options. RECENT FINDINGS: First-line treatment is conservative management, some of which includes neuromuscular rehabilitation, balance training, nonsteroidal anti-inflammatory drugs (NSAIDs), manual mobilization, ice therapy, and compression. While conservative management is effective, additional treatments for those who fail conservative management, or who seek alternative options also have been explored. Recent advances and modern techniques have expanded available treatment options, many of which are becoming less invasive, and have shown improving functionality, recovery, and patient satisfaction. Minimally invasive treatments highlighted in this review include: arthroscopic surgery, steroid injections, plasma-rich plasma injections, hyaluronic acid (HA) injections, medicinal signaling cell injections, radiofrequency therapies, and shockwave therapies. This review will discuss some of these current treatments for minimally invasive treatment of CAI, as well as suggest novel treatments for clinical trials and further investigation.

An Evidence Based Review of Epidurolysis for the Management of Epidural Adhesions.

Purpose of Review: This review presents epidurolysis as a procedure to alleviate pain and disability from epidural adhesions. It reviews novel and groundbreaking evidence, describing the background, indications, benefits and adverse events from this procedure in an effort to provide healthcare experts with the data required to decide on an intervention for their patients. Recent Findings: Epidural adhesions (EA) or epidural fibrosis (EF) is defined as non-physiologic scar formation secondary to a local inflammatory reaction provoked by tissue trauma in the epidural space. Often, it is a sequelae of surgical spine intervention or instrumentation. The cost associated with chronic post-operative back pain has been reported to be up to nearly $12,500 dollars per year; this, coupled with the increasing prevalence of chronic lower back pain and the subsequent increase in surgical management of back pain, renders EF a significant cost and morbidity in the U.S. Though risk factors leading to the development of EA are not well established, epidural fibrosis has been reported to be the culprit in up to 46% of cases of Failed Back Surgery Syndrome (FBSS), a chronic pain condition found in up to 20-54% of patients who receive back surgery. Moreover, EF has also been associated with lumbar radiculopathy after lumbar disc surgery. Epidurolysis is defined as the mechanical dissolution of epidural fibrotic scar tissue for persistent axial spine or radicular pain due to epidural fibrosis that is refractory to conservative therapy Endoscopic lysis of adhesions is a procedural technique which has been shown to improve chronic back pain in one-third to one-half of patients with clinically symptomatic fibrous adhesions. Here we review some of the novel evidence that supports this procedure in EA and FBSS. Summary: The literature concerning epidurolysis in the management of epidural adhesions is insufficient. Prospective studies, including randomized controlled trials and observational studies, have suggested epidurolysis to be effective in terms of pain reduction, functional improvement, and patient satisfaction scores. Observational studies report epidurolysis as a well-tolerated, safe procedure. Current evidence suggests that epidurolysis may be used as an effective treatment modality for epidural adhesions. Nonetheless, further high quality randomized controlled studies assessing the safety and efficacy of epidurolysis in the management of epidural adhesions is needed.

Management of primary anterior shoulder dislocations: a narrative review.

The recurrence rate following acute anterior shoulder dislocations is high, particularly in young, active individuals. The purpose of this paper is to provide a narrative overview of the best available evidence and results with regards to diagnostic considerations, comorbidities, position of immobilization, surgical versus conservative management, and time to return to play for the management of primary anterior shoulder dislocations. Three independent reviewers performed literature searches using PubMed, MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Randomized controlled trials and systematic reviews meeting inclusion criteria from 1930 to April 2019 were appraised and discussed with the intent to consolidate the best available evidence with regards to lowering recurrence rates. A majority of studies support early surgical intervention for individuals between 21 and 30 years of age following primary shoulder dislocations, as this group is particularly susceptible to recurrence. Conservative treatment plans favor 1-3 weeks of immobilization in internal rotation, followed by rehabilitation. Surgical methods are associated with longer time to return to play, but lower recurrence rates. Return to play time is best determined on an individualized basis, when subjective and objective function of both shoulders is determined to be symmetric. This paper broadly summarizes the best available evidence for the management of primary anterior shoulder dislocations. There remains a need for randomized studies to determine ideal long-term treatment following conservative or surgical management, as general timelines for returning to play following injury remain vague. LEVEL OF EVIDENCE: IV, Narrative Review.