Methodology for Online Reliability Studies: A Primer for Orthopedic Surgeons.

In orthopedic surgery, there is an increasing number of papers about online studies on the reliability of classification systems. Useful classification systems need to be reliable and valid. Measurement of validity can be variable and is prone to observer bias. These online collaboratives derive adequate power to study reliability by having a large group of trained surgeons review a small number of cases instead of the "classic" reliability studies in which a small number of observers evaluate many cases. Large online interobserver studies have advantages (i.e., less than 15 minutes to complete the survey, the ability to randomize, and the ability to study factors associated with reliability, accuracy, or decision-making). This 'handbook' paper gives an overview of current methods for online reliability studies. We discuss the study design, sample size calculation, statistical analyses of results, pitfalls, and limitations of the study design.

Post-traumatic disturbance of the epiphysis of the humeral trochlea: a spectrum of pathology.

BACKGROUND: Hegemann disease and fishtail deformity are classified as growth disturbances in the physeal plate of the humeral trochlea. It is questionable if these 2 diseases should be considered as 2 distinct conditions. The aims of this study are to (1) point out similarities between both conditions, (2) discuss etiology, and (3) provide diagnostic tools. METHODS: In a multicenter prospective cohort study, 19 patients with growth disturbance of the humeral trochlea were included. Assessment consisted of a detailed history, physical examination, and standard radiographs in 2 directions. The radiographs were evaluated for skeletal age, carrying angles, and trochlear notch angles. Statistical analysis was performed using Stata. RESULTS: A total of 19 patients were included: 2 males (11%) and 17 females (89%). The mean age of the patients was 12.8 years. In 17 patients (89%), a traumatic injury of the elbow was reported, before presentation. Decreased trochlear notch angle (<104°) was seen in 16 patients (84%). Accelerated closure of the growth plate of the affected elbow was seen in all skeletally immature patients. CONCLUSIONS: The main risk factor for both Hegemann disease and fishtail deformity is an injury of the elbow with open growth plates. Imaging studies support the hypothesis that both diseases are likely to be a continuum of the same process. Therefore, we propose to use 1 nomenclature for this pathologic process: post-traumatic disturbance of the epiphysis of the humeral trochlea.

Early repolarisation among athletes.

OBJECTIVES: Traditionally, early repolarisation (ER) is considered a benign ECG variant, predominantly found in youths and athletes. However, a limited number of studies have reported an association between ER and the incidental occurrence of ventricular fibrillation or sudden cardiac death. Yet definite, direct comparisons of the incidence of ER in unselected, contemporary populations in athletes as compared with non-athletes and across different sports are lacking. This study therefore aimed to investigate whether ER is more common among athletes as compared with non-athletes, and if ER patterns differ between sport disciplines based on static and dynamic intensity. METHODS: To assess ER we retrospectively analysed ECGs of 2241 adult subjects (2090 athletes, 151 non-athletes), who had a sports medical screening between 2010 and 2014 in an outpatient clinic. The outcome was tested for confounders in a multivariable logistic regression analysis. RESULTS: ER was found in 502 athletes (24%). We found a 50% higher prevalence of ER in the athlete group compared with the control group (OR 1.5 (SE 0.34), adjusted 95% CI 1.0 to 2.4) in multivariable analysis. A 30% higher prevalence of ER in the inferior leads only (OR 1.3 (SE 0.38), adjusted 95% CI 0.74 to 2.3), a 120% higher prevalence of ER in the lateral leads only (OR 2.2 (SE 1.0), adjusted 95% CI 0.87 to 5.4), and a 20% higher prevalence of ER in the inferior and lateral leads (OR 1.2 (SE 0.49), adjusted 95% CI 0.55 to 2.7) was found in athletes. CONCLUSION: Athletes had a 50% higher prevalence of ER and a 30% higher prevalence of ER in the inferior leads specifically. There was no association between training duration or sports discipline and ER.

Follow-up radiographs in isolated Greater Tuberosity fractures lead to a change in treatment recommendation; an online survey study.

INTRODUCTION: It is common practice to obtain follow-up radiographs of non-operatively treated isolated greater tuberosity (GT) fractures 1 to 2 weeks after trauma. However, the majority of non-operatively treated GT fractures remain stable and do not require reconsideration of the initial treatment decision. Radiological follow-up therefore might be unnecessary. Our primary objective was to study whether radiological folow-up changes the initial treatment recommendation, hypothesizing no change. MATERIALS AND METHODS: Radiographs of 25 patients diagnosed with an isolated GT fracture were selected from our hospital database and presented on a web-based platform. Sixty-eight trauma- and orthopedic surgeons evaluated these radiographs. First the radiographs directly post-trauma and then, in random order, the radiographs 5-14 days post-trauma alongside the first radiographs. Each observer evaluated each set of radiographs once. The observers answered which treatment they would recommend (non-operative/operative), and how certain they were about their advice (absolutely certain, certain, some doubt, very uncertain). Recommendation-consistency and inter-observer agreement are presented as percentages and intra class correlation coefficients (ICC). RESULTS: Overall, 84% (95% CI 82.1-85.8) of treatment recommendations was unchanged after evaluation of the second radiograph. Agreement within each observer ranged from 60 to 98%. The mean proportion of patients about whom the observers were (absolutely) certain of their recommendation increased from 70% at the first evaluation to 83% at the second evaluation (12.8; 95% CI 9.8-15.9). Furthermore, the ICC between the surgeons improved from 0.37 (95% CI 0.26-0.54) for the first evaluation to 0.60 (95% CI 0.47-0.74) for the second. CONCLUSION: In 16% of the patients the treatment recommendation for an isolated GT fracture changed after the evaluation of radiographs 1 to 2 weeks post-trauma. In addition, surgeons were more certain about their recommendation and there was less inter-observer variation. Radiological follow-up of a non-operatively treated isolated GT fracture therefore seems justifiable. LEVEL OF EVIDENCE: III, diagnostic study.

Radiographic Predictors for Short-term Functional Outcome after Radial Head Arthroplasty in Patients with Persistent Symptoms after Treatment for Radial Head.

BACKGROUND: Evaluation of the accurate position after radial head arthroplasty remains a challenge for surgeons. Standard radiographs are used to evaluate the position of the implant, however, results regarding radiographic deficiencies on clinical outcome are not consistent. In this retrospective study our main aim was to determine if subtle radiographic deficiencies after radial head arthroplasty can predict functional outcomes measured with the Mayo Elbow Performance Score (MEPS). METHODS: A total of 24 patients, that had a press-fit bipolar radial head arthroplasty because of persistent symptoms after treatment of a radial head fracture, were included. The mean follow-up time was 27 months and the MEPS was assessed at the final follow-up. Three upper extremity orthopaedic surgeons evaluated 12 potential deficiencies on anteroposterior and lateral radiographs in consensus agreement. RESULTS: The median MEPS was 97.5 (Interquartile Range 82.5-100). No association was found between the presence of subtle radiographic deficiencies and MEPS. CONCLUSION: Functional outcome of the elbow after uncemented press-fit bipolar radial head arthroplasty is not associated with subtle radiographic deficiencies. Therefore, surgeons might accept small imperfections on postoperative radiographs.

Avascular Necrosis of the Scaphoid Preiser Disease.

No consensus regarding optimal treatment or etiology of Preiser disease exists. We described the epidemiology, classification and treatment characteristics of 18 patients with Preiser disease. Patients with changes related to previous trauma, and without radiographs were excluded. Based on the radiographs at diagnosis, we classified 13 scaphoids as Herbert Lanzetta stage II, four as stage III, and one as stage IV. In 12 patients nonspecific treatment was offered and only two patients received surgical treatment. We found that chosen treatment is not associated with the severity of Herbert Lanzetta stage and the outcome is not influenced by chosen treatment.

Unplanned Operations and Adverse Events after Surgery for Diaphyseal Fracture of the Clavicle.

BACKGROUND: We used a database of patients treated at three hospitals to study the primary null hypothesis that there are no factors associated with unplanned reoperations or adverse events after surgical repair for diaphyseal clavicle fracture. Additionally we addressed the following secondary study questions: 1. What is the prevalence of unplanned reoperations or adverse events after surgical repair for diaphyseal clavicle fracture? 2. Is early implant loosening or breakage after surgical repair for diaphyseal clavicle fracture related to fixation type? 3. Is the type of fixation associated with the prevalence of brachial plexus palsy after surgical repair of a diaphyseal clavicle fracture? METHODS: We retrospectively analyzed 249 adult patients who had surgery for a diaphyseal clavicle fracture to determine factors associated with unplanned reoperations or adverse events. Thirty-two patients (13%) had at least one unplanned reoperation or adverse event. Four of 249 patients (1.6%) developed early implant loosening or breakage. Patients that had local implant irritation, planned implant removal, or sensory symptoms thought to be due to nerve irritation were not included in the reported unplanned reoperations or adverse event rate. RESULTS: Only female sex was associated with unplanned reoperations or adverse events after surgery for diaphyseal clavicle fracture. No other patient, technical, or injury related factors tested in this study were associated with unplanned reoperations or adverse events. CONCLUSION: Patients that have surgery for diaphyseal clavicle fracture have an approximately 13% risk of an unplanned second surgery or an adverse event. Women can be counseled that they are three times as likely as men to have an unplanned reoperations or adverse event.

What Predicts Outstanding Orthopedic Residents among the Program?

BACKGROUND: An oversupply of qualified applicants leads to intense competition for the limited number of first year orthopedic residency positions. Therefore, program directors can be more selective in choosing their future residents. However, it is unclear if there are resident characteristics that correspond with trainee performance. METHODS: We asked (1) what resident characteristics are associated with subjective residency performance score? and (2) what resident characteristics are associated with Orthopedic In-Training Examination (OITE) score?A total of 119 orthopedic residents accepted at the Harvard Combined Orthopedic Residency Program from 1999 - 2009 were included in this study. The current program director together with two former program directors in the selected time period defined the subjective residency performance score based on the clinical skills of the residents during training. RESULTS: Former Olympic or varsity athlete (P=0.018) and Alpha Omega Alpha (AOA) status (P=0.014) were associated with a better subjective residency performance score. Higher USMLE step 1 score (P=0.0038), known person within faculty prior to the residency (did a research rotation, or local medical student) (P=0.041), and AOA (P=0.015) status were associated with a higher OITE score. CONCLUSION: AOA status of the applicant for orthopedic residency is associated with both a higher OITE score and a better subjective residency performance score.

Correction to: Tension band wiring for simple olecranon fractures: evaluation of surgical technique.

Unfortunately, after publication of this article [1], it was noticed that the author J. Carel Goslings was tagged incorrectly during the production process. This resulted in the PubMed display of the author name as 'J Carel Goslings'. The correct display is 'Goslings JC'. This correction contains the correct tagging.

Interobserver reliability of radiographic assessment after radial head arthroplasty.

BACKGROUND: Radiographs are part of routine clinical care after radial head arthroplasty (RHA). Therefore, the aim of this diagnostic study was to assess the interobserver reliability of radiographic assessment following RHA. METHODS: Anteroposterior (AP) and lateral radiographs of 24 consecutive patients who underwent press-fit bipolar RHA were evaluated with respect to 14 parameters by 14 orthopaedic surgeons specializing in the elbow: shaft loosening (AP, lateral), subcollar bone resorption, nonbridging heterotopic ossification, capitellar erosion, capitellar osteopenia, implant size, ulnohumeral joint gapping, ulnohumeral joint degeneration, proximal radio-ulnar joint congruency, stem size, stem positioning (AP, lateral) and component dissociation or polyethylene wear of the head with increased angulation. Observer agreement was evaluated using the multirater kappa (κ) measure. RESULTS: Nine of 14 parameters had poor interobserver agreement [κ = 0.0 to 0.20, confidence interval (CI) = 0.0 to 0.31). Four parameters had fair agreement: subcollar bone resorption (κ = 0.27, CI = 0.12 to 0.40), capitellar erosion (κ = 0.30, CI = 0.20 to 0.40), ulnohumeral joint degeneration (κ = 0.35, CI = 0.22 to 0.51) and stem positioning in AP view (κ = 0.24, CI = 0.14 to 0.36). One parameter had moderate agreement: nonbridging heterotopic ossification (κ = 0.47, CI = 0.31 to 0.64). CONCLUSIONS: The overall interobserver reliability of radiographic assessment following press-fit bipolar RHA was poor among experienced elbow surgeons. Therefore, radiographic evaluation after RHA should be interpreted with caution when making treatment decisions.

Ulnar Neck Fractures Associated with Distal Radius Fractures.

Background There is little published data to guide management of ulnar neck fractures associated with fractures of the distal radius. Purpose As unplanned surgery usually reflects adverse events and this injury combination is relatively uncommon, we used a large database to study the incidence of unplanned surgeries after surgical and nonsurgical treatment of distal metaphyseal ulna fractures associated with a distal radius fracture and identify factors associated with these unplanned surgeries. Patients and Methods We identified 277 patients with an ulnar neck fracture associated with a distal radius fracture. Fifty-six (20%) ulnar neck fractures were initially treated operatively and six of them (11%) had a second, unplanned surgery. Of the 221 initially nonoperatively treated fractures, only one (0.45%) had a subsequent unplanned surgery that seemed unrelated to the fracture (ulnar nerve neurolysis). Results Bivariate analysis showed that younger age, open fracture, multifragmentary fractures, and initial operative treatment of the ulnar neck fracture were significantly associated with unplanned surgery. A multivariable analysis was not feasible due to the small number of unplanned surgeries. Conclusion Eighty percent of ulnar neck fractures associated with a fracture of the distal radius was treated nonoperatively in our region, and subsequent surgery for problems was very uncommon. Operative treatment and fracture complexity were associated with unplanned surgery, which reflected some measure of injury severity, technical inadequacy, and inherent problems associated with surgery. Level of Evidence Level II, prognostic study.

The Effect of Priming With Questionnaire Content on Grip Strength in Patients With Hand and Upper Extremity Illness.

BACKGROUND: Grip strength is a performance-based measure of upper extremity function that might be influenced by priming (the influence of a response to a stimulus by exposure to another stimulus). This study addressed the influence of questionnaire content on performance measurements such as grip strength between patients who complete the standard Pain Catastrophizing Scale (PCS) compared with patients who complete a positively adjusted PCS. METHODS: Between June 2015 and August 2015, we enrolled 122 patients who presented to 3 hand surgeons at 3 outpatient offices. They were randomized to 2 groups: the control group, which completed the PCS, and the intervention group, which completed a positively phrased version of the PCS. Before and after completion of the questionnaire, we measured each patient's grip strength 3 times by alternating between hands. Two patients were excluded after participation. We calculated both the preintervention and postintervention mean and maximum grip strengths. RESULTS: There was no significant difference between groups on mean or maximum grip strength before completion of the questionnaires. There was a greater improvement in mean grip strength of both hands in the intervention group compared with the PCS group. This improvement was statistically significant in the affected hand. The maximum grip strength showed a statistically significant greater improvement in both hands in the positive PCS group compared with the control group. CONCLUSIONS: Positive priming through a questionnaire leads to an increase in mean and maximum grip strength when compared with the standard questionnaire that uses negative terms rather than positive.

Tension band wiring for simple olecranon fractures: evaluation of surgical technique.

BACKGROUND: In some settings, specific techniques for open reduction and internal fixation are preferred based on the eminence of a surgeon or professional organization. An emphasis on technical aspects of surgery that are not proved superior and vary substantially from surgeon to surgeon can be confusing for trainees. This study applied a numerical grading of the technical aspects of tension band wire (TBW) fixation for olecranon fracture; assessed the interobserver agreement of each criterion; and measured the correlation of the technical grading and objective and subjective long-term outcomes. MATERIALS AND METHODS: Forty observers were invited to rate the technical aspects of TBW fixation of the olecranon on 26 post-operative radiographs. The interobserver reliability of the rating was measured using the intra-class correlation coefficient. The correlation between the rating and motion, Mayo elbow performance index, and disabilities of the arm, shoulder and hand score was tested with the Spearman's rank correlation test. RESULTS: None of the figure-of-eight TBW constructs were considered perfect according to the numerical grading: the majority of observers found three deviations per fixation. The interobserver agreement was only fair for the total number of deviations and no correlation between the number of deviations and long-term objective and subjective outcome was found. CONCLUSIONS: A rating of the technical aspects of TBW for olecranon fractures was unreliable and did not correlate with subjective and objective outcomes. Emphasis on specific technical aspects of fixation might be confusing for trainees and could distract them from the principles of effective treatment. LEVEL OF EVIDENCE: Level IV diagnostic study.

The Influence of Psychological Factors on the Michigan Hand Questionnaire.

Background: Psychosocial factors help account for the gap between impairment and disability. This study examines the relationship between the Michigan Hand Questionnaire (MHQ) and commonly used psychological measures in patients with upper extremity illness. Methods: A cohort of 135 new or follow-up patients presenting to an urban academic hospital-based hand surgeon were invited to complete a web-based version of the MHQ, Abbreviated Pain Catastrophizing Scale (PCS), and two Patient-Reported Outcomes Measurement Information System (PROMIS)-based questionnaires: Pain Interference and Depression. Bivariate and multivariable analyses measured the correlation of these psychological measures with MHQ. Results: Accounting for potential confounding factors in multivariable regression, upper extremity disability as rated by the MHQ was independently associated with PROMIS Depression, PROMIS Pain Interference, visit type, and working status. The model accounted for 37% of the variability in MHQ scores, with PROMIS Pain Interference having the most influence. Conclusion: Among the non-pathophysiological factors that contribute to patient-to-patient variation in MHQ scores, the measure of less effective coping strategies and symptoms of depression were most influential. Our data add to the evidence of the pivotal role of emotional health in upper extremity symptoms and limitations and the importance of psychosocial considerations in the care of hand illness.

Diagnostic Wrist Arthroscopy for Nonspecific Wrist Pain.

Background: This study addresses the prevalence of discrete pathophysiology accounting for patients' symptoms during diagnostic wrist arthroscopy in individuals with wrist pain without a specific preoperative diagnosis. Secondarily, we determined the number and type of surgeries subsequent to diagnostic wrist arthroscopy. Methods: Between January 2000 and January 2015, 135 diagnostic wrist arthroscopies were performed by 12 surgeons in 3 urban academic hospitals. We recorded the diagnostic findings of diagnostic wrist arthroscopy and any subsequent surgeries. Results: One hundred and five patients had synovitis or a normal wrist (78%), 17 had likely age-appropriate changes (eg, central triangular fibrocartilage complex defects scapholunate changes) (13%), 8 (6%) were given uncommon diagnoses, and 5 (4%) had osteochondral defects. Sixteen patients (12%) had subsequent wrist surgery: 2 were for adverse events, 2 were carpal tunnel releases, and 12 were other surgeries. Conclusion: Diagnostic arthroscopy performed in the setting of an unclear preoperative diagnosis yielded limited diagnostic benefit.

Graft Site Morbidity in Elbow Ligament Reconstruction Procedures: A Systematic Review.

BACKGROUND: It is unclear which tendon harvest for ulnar or lateral collateral ligament reconstruction has the lowest graft site morbidity rate. PURPOSES: To obtain graft site morbidity rates after tendon harvest for ulnar and lateral collateral ligament reconstruction procedures. STUDY DESIGN: Systematic review/Meta-analysis. METHODS: Studies were eligible if (1) patients had undergone elbow ligament reconstruction procedures; (2) original data for at least 5 patients were available; (3) the article was written in English, German, or Dutch; (4) a full-text article was available; and (5) information about graft site morbidity was available. The review excluded studies about complicated elbow ligament reconstruction procedures due to initial fractures, revision procedures, or circumferential graft techniques; animal studies; (systematic) reviews; and expert opinions. Because the majority of studies were case reports, no selection form or overall scoring system to evaluate methodological quality was used. RESULTS: The review included 619 patients with an ulnar or lateral collateral ligament reconstruction procedure. The autograft types used included palmaris longus tendon (58%), gracilis tendon (24%), semitendinosus tendon (8%), triceps tendon (7%), toe extensor tendon (<2%), plantaris tendon (<2%), extensor carpi radialis longus tendon (<1%), and Achilles tendon (<1%). CONCLUSION: Graft site morbidity occurred in 1% of the patients after an ulnar or lateral collateral ligament reconstruction procedure. This study did not have enough samples of all the autograft types to conclude that autograft type and graft site morbidity are unrelated.

Portal placement in elbow arthroscopy by novice surgeons: cadaver study.

PURPOSE: In this anatomical cadaver study, the distance between major nerves and ligaments at risk for injury and portal sites created by trainees was measured. Trainees, inexperienced in elbow arthroscopy, have received a didactic lecture and cadaver instruction prior to portal placement. The incidence of iatrogenic injury from novice portal placement was also determined. METHODS: Anterolateral, direct lateral, and anteromedial arthroscopic portals were created in ten cadavers by ten inexperienced trainees in elbow arthroscopy. After creating each portal, the trajectory of the portal was marked with a guide pin. Subsequently, the cadavers were dissected and the distances between the guide pin in the anterolateral, direct lateral, and anteromedial portals and important ligaments and nerves were measured. RESULTS: The difference between the distance of the direct lateral portal and the posterior antebrachial cutaneous nerve (PABCN) (22 mm, p < 0.001), the lateral antebrachial cutaneous nerve (4.0 mm, p < 0.001), and the radial nerve (25 mm, p < 0.001) was different from the average reported distances in the literature. A difference was found between the distance of the anterolateral portal and the PABCN (32 mm, p < 0.001) compared to previous studies. Three major iatrogenic complications were observed, including: laceration of the posterior bundle of the medial ulnar collateral ligament, lateral ulnar collateral ligament midsubstance laceration, and median nerve partial laceration. CONCLUSION: Surgeons increasingly consider arthroscopic treatment as an option for elbow pathology. In the present study a surgical complication rate of 30 % was found with novice portal placement during elbow arthroscopy. Furthermore, as the results from this study have indicated, accurate, precise, and safe portal placement in elbow arthroscopy is not easily achieved by didactic lecture and cadaver instruction session alone. Level of evidence V.

Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis.

BACKGROUND: The ability of injection of corticosteroids into the subacromial space to relieve pain ascribed to rotator cuff tendinosis is debated. The number of patients who have an injection before one gets relief beyond what a placebo provides is uncertain. QUESTIONS/PURPOSES: We asked: (1) Do corticosteroid injections reduce pain in patients with rotator cuff tendinosis 3 months after injection, and if so, what is the number needed to treat (NNT)? (2) Are multiple injections better than one single injection with respect to pain reduction at 3 months? METHODS: We systematically searched seven electronic databases for randomized controlled trials of corticosteroid injection for rotator cuff tendinosis compared with a placebo injection. Eligible studies had at least 10 adults and used pain intensity as an outcome measure. The Hedges's g as adjusted pooled standardized mean difference (SMD) (which expresses the size of the intervention effect in each study relative to the total variability observed among pooled studies) and NNT were calculated at assessment points less than 1 month, 1-2 months, and 2-3 months. The protocol of this study was registered at the international prospective register of systematic reviews. Eleven studies of 726 patients satisfied our criteria for data pooling. Three studies containing 292 patients used repeat injections. A random effects model was used owing to substantial heterogeneity among studies. The funnel plot indicated the possibility of some missing studies, but Orwin's fail-safe N and Duval and Tweedie's trim and fill suggested that missing studies would not significantly affect the results. RESULTS: Corticosteroid injection did not reduce pain intensity in adult patients with rotator cuff tendinosis more than a placebo injection at the 3-month assessment. A small transient pain relief occurred at the assessment between 4 and 8 weeks with a SMD of 0.52 (range, 0.27-0.78) (p < 0.001). At least five patients must be treated for one patient's pain to be transiently reduced to no more than mild. Multiple injections were not found to be more effective than a single injection at any time. CONCLUSIONS: Corticosteroid injections provide-at best-minimal transient pain relief in a small number of patients with rotator cuff tendinosis and cannot modify the natural course of the disease. Given the discomfort, cost, and potential to accelerate tendon degeneration associated with corticosteroids, they have limited appeal. Their wide use may be attributable to habit, underappreciation of the placebo effect, incentive to satisfy rather than discuss a patient's drive toward physical intervention, or for remuneration, rather than their utility. LEVEL OF EVIDENCE: Level I, therapeutic study.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation.

PURPOSE: Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth. METHODS: A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure. RESULTS: The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups. CONCLUSIONS: When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

A Meta-Analysis of the Effect of Corticosteroid Injection for Enthesopathy of the Extensor Carpi Radialis Brevis Origin.

PURPOSE: The null hypothesis that there is no effect of corticosteroid injection on visual analog scale for pain in patients with enthesopathy of the extensor carpi radialis brevis (eECRB) origin 6 months after treatment was tested. Our secondary hypotheses were that there is no effect of corticosteroid injection on pain intensity at 1 and 3 months after treatment; that there is no effect of corticosteroid injection on grip strength at 1, 3, and 6 months after treatment; and that there is no effect of corticosteroid injection on Disabilities of the Arm, Shoulder, and Hand scores at 1, 3 and 6 months after treatment. METHODS: EMBASE, PubMed Publisher, MEDLINE, OvidSP, Web of Science, Google Scholar, and the Cochrane Central were searched for relevant studies. Studies were eligible if there was (1) a description of corticosteroid injection treatment for eECRB; (2) randomized placebo injection-controlled trials with at least 10 adults included with eECRB; (3) a full-text article available with data describing the mean differences between the corticosteroid and the control groups and the outcome measures used; and (4) follow-up of at least 1 month. In total, 7 randomized controlled trials comparing the effect of corticosteroid injection with a placebo injection on symptoms of eECRB were included in our meta-analysis. RESULTS: We found no difference in pain intensity 6 months after injection of corticosteroids or placebo. Pain intensity was slightly, but significantly, lower 1 month, but not 3 months, after steroid injection. There were no significant differences in grip strength or Disabilities of the Arm, Shoulder, and Hand score at any time point. CONCLUSIONS: This meta-analysis showed that there is no difference in pain intensity between corticosteroid injection and placebo 6 months after injection. We interpret the weight of evidence to date as suggesting that corticosteroid injections are neither meaningfully palliative nor disease modifying when used to treat eECRB. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.