Surgical Results of Chronic Distal Biceps Ruptures: A Systematic Review.

BACKGROUND: Distal biceps tendon tears can cause weakness and fatigue with activities requiring elbow flexion and supination. Surgical management of chronic tears (>21 days) is not well described in the literature. PURPOSE: To determine the clinical outcomes of chronic distal biceps repairs and reconstructions. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: We performed a search of Medline (PubMed and Ovid), EMBASE, CINAHL physical therapy, Cochrane Database of Systematic Reviews and Central Register of Controlled Trials, and PubMed Central from inception until September 29, 2020, to identify articles on chronic distal biceps ruptures. The inclusion criteria were studies with at least 1 outcome measure and 10 patients with chronic distal biceps ruptures treated surgically. The quality of the included studies was assessed with the methodological index for nonrandomized studies (MINORS) score. Functional outcomes and complications were reviewed. RESULTS: A total of 12 studies were included after systematic database screenings. The MINORS scores ranged from 5 to 19. There were a total of 1704 distal biceps ruptures, of which 1270 were acute and 434 were chronic. Average follow-up time was 12 months to 5.1 years. Single-incision (n = 3), 2-incision (n = 2), or both (n = 6) surgical techniques were used in these studies. Four studies described the use of autografts, and 4 articles used allografts in the chronic repair. Range of motion, function, and strength outcomes were similar when compared with the contralateral arm. Pain was reduced to minimal levels. Main postoperative complications were of paresthesia (specifically to the lateral antebrachial cutaneous nerve), which were temporary in 69.1% of cases. CONCLUSION: The results of this review indicate that surgical management of chronic distal biceps ruptures demonstrates improvement in outcomes including pain reduction and functional ability. Although there may be a slightly higher immediate complication rate, the functional outcomes remain comparable with those seen in the patient population with acute distal biceps.

Arthroscopic Versus Mini-open Rotator Cuff Repair: A Randomized Trial and Meta-analysis.

BACKGROUND: Patients with complete rotator cuff tears who fail a course of nonoperative therapy can benefit from surgical repair. PURPOSE: This randomized trial compared mini-open (MO) versus all-arthroscopic (AA) rotator cuff repair. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients with rotator cuff tears were randomized to undergo MO or AA repair at 9 centers by 23 surgeons. The primary outcome (Western Ontario Rotator Cuff Index [WORC]) and secondary outcomes (American Shoulder and Elbow Surgeons [ASES] score, Shoulder Pain and Disability Index [SPADI] pain subscale, 12-Item Short Form Health Survey [SF-12], reported medication use, adverse events), as well as measurements of range of motion and strength, were collected at 1 month before surgery; at 2 and 6 weeks postoperatively; and at 3, 6, 12, 18, and 24 months postoperatively. A blinded radiologist evaluated rotator cuff integrity on magnetic resonance imaging (MRI) at baseline and 1 year. Intention-to-treat analysis of covariance with the preoperative WORC score, age, and tear size as covariates assessed continuous outcomes. Sex differences were assessed. A meta-analysis synthesized the primary outcome between MO and AA repair with previous trials. RESULTS: From 954 patients screened, 411 were ineligible (276 because of recovery with physical therapy), 449 were screened at surgery (175 ineligible), and 274 completed follow-up (138 MO and 136 AA). The AA and MO groups were similar before surgery. WORC scores improved from 40 preoperatively to 89 (AA) and 93 (MO) at 2 years, for an adjusted mean difference of 3.4 (95% CI, -0.4 to 7.2). There were no statistically significant differences between the AA and MO groups at any time point. All secondary patient-reported outcomes were not significantly different between the MO and AA groups, except the 2-year SPADI pain score (8 vs 12, respectively; P = .02). A similar recovery in range of motion and strength occurred in both groups over time. MRI indicated minimal improvement in muscle relative to fat (AA: n = 3; MO: n = 2), with most worsening (AA: n = 25; MO: n = 24) or remaining unchanged (AA: n = 70; MO: n = 70). Opioid use was significantly reduced after surgery (from 21% to 5%). The meta-analysis indicated no significant standardized mean difference between groups in the primary outcome across all pooled studies (standardized mean difference, -0.06 [95% CI, -0.34 to 0.22]). CONCLUSION: Both AA and MO rotator cuff repair provide large clinical benefits, with few adverse events. There is strong evidence of equivalent clinical improvements. TRIAL REGISTRATION: NCT00128076.

Reoperation following open reduction and plate fixation of displaced mid-shaft clavicle fractures.

BACKGROUND: Operative fixation of displaced, mid-shaft clavicle fractures has become an increasingly common practice. With this emerging trend, data describing patient outcomes with longer follow-up are necessary. PATIENTS AND METHODS: We retrospectively reviewed the medical records of subjects treated with plate fixation for displaced mid-shaft clavicle fractures from 2003 to 2009 at a Level I trauma hospital. All subjects were greater than 12 months post-index surgery. Treatment involved ORIF with either a low-contact dynamic compression plate (LCDC) or a contoured plate (pre-contoured or pelvic reconstruction plate). Our primary outcome was reoperation for any indication. RESULTS: 143 subjects were included. The mean age was 36 ± 14 years and the mean time to reoperation or chart review was 33 months. Contoured plates were used in 64% of cases and LCDC plates were used in the remaining subjects. Twenty-nine subjects (20%) underwent reoperation: 23.5% of subjects treated with LCDC plates and 18.5% of subjects treated with contoured plates (p=0.52). Indications for reoperation included implant irritation (n=25), implant failure (n=2), and non-union (n=2). There was near statistically significant association with reoperation and female gender (p=0.05) but no association between reoperation and age (p=0.14), fracture class (p=0.53), plate type (p=0.49), or plate location (p=0.93). The mean QuickDASH score for the population surveyed was 8.8 (5.5-12.1; 95% CI) with near statistically significant and clinically relevant difference between those considering reoperation and those not 22.3 (8.6-36.0; 95% CI) versus 6.7 (3.6-9.8; 95% CI). CONCLUSIONS: This study represents a large series of displaced clavicle fractures treated with open reduction and plate fixation. Reoperation following plate fixation is relatively common, but primarily due to implant irritation. No difference in reoperation rates between plate types or location could be detected in our current sample size. Also, excellent functional outcomes continue to be observed several years after clavicle fracture fixation.

Attempting primary closure for all open fractures: the effectiveness of an institutional protocol.

BACKGROUND: Immediate primary closure of open fractures has been historically believed to increase the risk of wound infection and fracture nonunion. Recent literature has challenged this belief, but uncertainty remains as to whether primary closure can be used as routine practice. This study evaluates the impact of an institutional protocol mandating primary closure for all open fractures. METHODS: We retrospectively reviewed all open fractures treated in a single level 1 trauma centre in a 5-year period. Prior to the study, a protocol was adopted standardizing management of open fractures and advocating primary closure of all wounds as a necessary goal of operative treatment. Patient and fracture characteristics, type of wound closure and development of infectious and bone healing complications were evaluated from time of injury to completion of outpatient follow-up. RESULTS: A total of 297 open fractures were treated, 255 (85.8%) of them with immediate primary closure. Type III open injuries accounted for 24% of all injuries. Wounds that were immediately closed had a superficial infection rate of 11% and a deep infection rate of 4.7%. Both proportions are equivalent to or lower than historical controls for delayed closure. Fracture classification, velocity of trauma and time to wound closure did not correlate significantly with infection, delayed union or nonunion. CONCLUSION: Attempting primary closure for all open fractures is a safe and efficient practice that does not increase the postoperative risk of infection and delayed union or nonunion.

CONTEXTE: On a de tout temps cru que la fermeture primaire immédiate des fractures ouvertes accroissait le risque d'infection de la plaie et de non soudure osseuse. La littérature récente remet cette position en question, mais on ignore encore si la fermeture primaire peut être utilisée de routine. Cette étude évalue l'impact d'un protocole d'établissement imposant la fermeture primaire de toutes les fractures ouvertes. MÉTHODES: Nous avons passé en revue de manière rétrospective toutes les fractures ouvertes traitées dans un seul centre de traumatologie de Niveau 1 au cours d'une période de 5 ans. Avant l'étude, un protocole a été adopté pour standardiser la prise en charge des fractures ouvertes et promouvoir la fermeture primaire de toutes les plaies comme objectif imposé du traitement opératoire. Les caractéristiques des patients et des fractures, les types de fermeture de plaie et les complications infectieuses ou liées à la guérison osseuse ont été évalués à partir du moment de la blessure et jusqu'à la fin du suivi en clinique externe. RÉSULTATS: En tout, 297 fractures ouvertes ont été traitées, 255 d'entre elles (85,8 %), au moyen d'une fermeture primaire immédiate. Les traumatismes ouverts de Type III comptaient pour 24 % de toutes les blessures. Les plaies qui ont été refermées immédiatement ont présenté un taux d'infection superficielle de 11 % et un taux d'infection profonde de 4,7 %. Ces 2 proportions sont équivalentes ou inférieures à ce qui a été observé chez les témoins historiques chez qui la fermeture de plaie a été reportée. La classification des fractures, la vitesse de l'impact à l'origine des traumatismes et le temps écoulé avant la fermeture des plaies n'ont pas été en corrélation significative avec l'infection et le retard de soudure osseuse ou la non soudure osseuse. CONCLUSION: Tenter d'appliquer une fermeture primaire à toutes les fractures ouvertes est une pratique sécuritaire et efficace qui n'accroît pas le risque d'infection postopératoire, de retard de soudure osseuse ou de non soudure osseuse.