Functional outcomes and complications of plate fixation for midshaft clavicle fractures by type and location: a systematic review and meta-analysis.

Background: Various plate types are used in the surgical treatment of displaced midshaft clavicle fractures. These plates can be positioned in different locations on the clavicle, although no studies to date have elucidated optimal plate type and location of fixation. This systematic review compares the functional outcomes and complications in the management of displaced midshaft clavicle fractures using plate fixation by stratifying by both plate type and location. Methods: A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted to identify all papers reporting functional outcomes, union rates, and/or complications using plates for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until March 2022. A meta-analysis was conducted for functional outcomes and type of complication, stratified by plate type (locking, compression, or reconstruction) and location (superior or anteroinferior). Pooled estimates of functional outcome scores and incidence of complications were calculated using a random effects model. Risk of bias and quality were assessed using the risk of bias version 2 and ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tools. The confidence in estimates were rated and described according to the recommendations of the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) working group. Results: Forty-five studies were included in the systematic review and 43 were included in the meta-analysis. Depending on plate type and location, pooled Constant-Murley Scores ranged from 89.23 to 93.48 at 12 months. Nonunion rates were 3% (95% confidence interval [CI] 1-6) for superior locking plates (GRADE Low). Rates of any complication (nonunion, hardware failure, hardware irritation, wound dehiscence, keloid, superficial infection, deep infection, delayed union, malunion, and/or persistent pain) by plate type and location ranged from 3% to 17% (GRADE Very Low to Moderate). Superior compression plates had the highest incidence of any complications (17% [95% CI 5-44], GRADE Very Low), while anterior inferior compression plates had the lowest incidence of any complication (3% [95% CI 0-15], GRADE Very Low). Hardware irritation was the most reported individual complication for superior locking plates and superior compression plates, 11% (95% CI 7-17, GRADE Low) and 11% (95% CI 3-33, GRADE Very Low), respectively. Conclusion: Although most studies were of low quality, studies reporting functional outcomes generally showed good functional results and similar incidence of any complication regardless of plate type and location. There is no evidence of a plate and location combination to optimize patient functional outcomes or complications. We were unable to reliably evaluate union rates or individual complications for most plate types stratified by location.

Fluoroscopic images of the sacroiliac joint alone are unable to identify simulated flexion or extension malreduction of the anterior pelvic ring in AO/OTA 61-B2.3 pelvic injuries.

PURPOSE: Reduction of AO/OTA 61-B2.3 (APC2) pelvic fractures is challenging in the setting of anterior ring comminution. The anterior ring is visually much simpler to evaluate for flexion or extension hemipelvis deformity than the posterior ring, except in the setting of comminution, necessitating some other visual reference to judge hemipelvis reduction. We sought to test whether pelvic inlet and outlet fluoroscopy of the contours of the sacroiliac joint could be used in isolation to judge hemipelvis flexion or extension. METHODS: Symphyseal and anterior SIJ ligaments were cut (6 cadaveric pelvis). The symphysis was held malreduced to produce one centimeter flexion and extension deformity: 1 cm was selected to mimic a maximum clinical scenario. The SIJ was assessed using inlet and outlet fluoroscopy. The scaled width of the SIJ was assessed at the joint apertures and midjoint on both inlet and outlet views. Joint widths in flexion and extension were compared against joint widths measured on the reduced SIJ using paired t-tests. RESULTS: There was no statistical difference in the superior (p = 0.227, 0.675), middle (p = 0.203, 0.693), and inferior (p = 0.232, 0.961) SIJ widths between hemipelvis flexion or extension models against reduced SIJ on outlet views. There was no statistical difference in the anterior (p = 0.731, 0.662), middle (p = 0.257, 0.655), and posterior (p = 0.657, 0.363) SIJ widths between flexion or extension models against reduced SIJ on inlet views. CONCLUSION: Inspection of SIJ width on inlet and outlet fluoroscopy cannot detect up to one centimeter of hemipelvis flexion or extension malreduction in the setting of AO/OTA 61-B2.3 (APC2) pelvic fractures with complex anterior injuries.

Identification of subtle residual sacroiliac joint flexion and extension malreductions in AO/OTA 61-C1.2 (APC3) pelvic injuries after provisional anterior ring reduction.

PURPOSE: Hemipelvis reduction in the setting of AO/OTA 61-C1.2 (APC3) pelvic injuries can be challenging. A common strategy is to provisionally reduce or fix the anterior ring prior to definitive fixation of the posterior ring. In this scenario, it is difficult to assess whether residual sacroiliac joint (SIJ) widening is due to hemipelvis flexion/extension or lateral displacement. This simulation sought to identify a radiographic marker for posterior ilium flexion or extension malreduction in the setting of a reduced anterior ring. METHODS: Symphyseal and both anterior and posterior SIJ ligaments were cut in 8 cadaveric pelvis. The symphysis was reduced and wired. One centimeter of posterior flexion or extension at the SIJ was created to mimic the clinical scenario of hemipelvis flexion or extension malreduction, and a lateral compressive force was applied. SIJ widening and the direction of anterior or posterior ileal displacement relative to the contralateral joint were assessed via inlet views. SIJ widening and the direction of cranial or caudal ileal displacement were assessed using outlet views. Comparisons between flexion and extension models used Fisher's exact test. RESULTS: On outlet views, all flexed hemipelvis demonstrated caudal ileal translation at the superior SIJ, in contrast to all extended hemipelvis demonstrated cranial translation (p < 0.0005); the scenarios were easily distinguishable. Conversely, inlet imaging was unable to identify the direction of malreduction. Flexion/extension scenarios resulted in similar amounts of SIJ widening. CONCLUSION: Residual flexion and extension hemipelvis malreductions in APC3 injuries after provisional anterior fixation can be differentiated by the direction of ileal displacement at the superior SIJ on the outlet view.

Core Decompression and Bone Marrow Aspiration Concentrate Grafting for Osteonecrosis of the Femoral Head.

BACKGROUND: Core decompression (CD) with bone marrow aspiration concentrate (BMAC) is a technique that may improve outcomes in osteonecrosis of the femoral head (ONFH). The primary aim of this study was to evaluate the radiographic progression free survival (PFS) of CD augmented with BMAC. Secondary aims were to determine the survivorship with conversion (CFS) to total hip arthroplasty (THA) as an endpoint, determine prognostic factors, and characterize the cellular quality of the BMAC. METHODS: A retrospective cohort study of 61 femoral heads (40 patients) was performed. Patient demographics, comorbidities, BMI, smoking status, etiology, location and extent of ONFH were recorded. The primary endpoint was radiographic progression of ONFH and secondarily, conversion to THA. Additional aims were to determine predictive factors for progression and report the cellular characteristics of the BMAC. Data obtained were compared to the results of a prior randomized controlled trial comparing CD alone versus CD with polymethylmethacrylate cement (PMMA) augmentation. RESULTS: Radiographic PFS of CD with BMAC at 2 and 5 years was 78.3% and 53.3%, respectively. The risk of progression was lower in the CD with BMAC group compared to CD alone (HR0.45, p = 0.03), however this difference no longer remained statistically significant on multivariate analysis. Conversion to total hip arthroplasty free survival (CFS) of CD with BMAC at both 2 and 5 years was 72.1% and 54.6%, respectively with no differences compared to the control groups (CD alone, CD and PMMA). The predictive factors for progression were obesity (BMI ≥ 30) and the extent of the disease as quantified by either percentage involvement, necrotic index or modified necrotic index. CONCLUSIONS: No differences in PFS or CFS between CD with BMAC compared to CD alone or CD with PMMA were identified. Independent statistically significant predictors of progression-free survival or conversion to THA are BMI ≥ 30 and the extent of ONFH. Further research with an adequately powered randomized controlled trial is needed. LEVEL OF EVIDENCE: 3.

Patellofemoral arthroplasty: expert opinion.

Isolated patellofemoral osteoarthritis (PFOA) is a common cause of anterior knee pain in patients over the age of 40 years. Patellofemoral arthroplasty (PFA) is an option to address PFAO when the non-operative or joint preserving management has failed.The goals of PFA are to reduce pain and increase function of the knee in a bone and ligament preserving fashion while maintaining or optimizing its kinematics. Over the last decades advances have been made in optimizing implants designs, addressing complications and improving functional and patient reported outcomes. Appropriate patient selection has proven to be imperative. Proper surgical technique and knowledge of pearls and pitfalls is essential.The indications and surgical technique for patellofemoral arthroplasty will be reviewed here.Level of evidence: Therapeutic Level V.

Levels of Urgency for Orthopaedic Procedures: Reliability and Adoption of a Consensus-driven Classification.

INTRODUCTION: The current COVID-19 disease pandemic has delayed nonurgent orthopaedic procedures to adequately care for those affected by the severe acute respiratory syndrome coronavirus 2, resulting in a backlog in orthopaedic surgical care. As the capacity for orthopaedic surgeries expands or contracts, allocation of limited resources in a manner that adequately reflects medical necessity and urgency is paramount. An orthopaedic surgery-specific prioritization schema with proven reliability is lacking. The primary aim of this study was to assess the reliability of a newly developed prioritization list used for the phased reinstatement of orthopaedic surgical procedures during the COVID-19 pandemic and afterward. The secondary aim was to report its implementation. METHODS: A consensus-based, orthopaedic surgery-specific, tiered prioritization list reflecting various levels of urgency was created by a committee of orthopaedic surgeons covering all subspecialties and representing academic, multispecialty, and private community practices. Reliability was tested for 63 randomized cases representing all orthopaedic subspecialties. Four raters evaluated the cases independently at two separate time points, at least one week apart. Fleiss kappa was used to assess intrarater and interrater agreement. Implementation were assessed by surveying both surgeons and the surgery scheduling administrative personnel at each surgical facility within a large health system for any adoption issues. RESULTS: Case distributions within tiers 1, 2, 3, and 4 were 35%, 14%, 27%, and 24%, respectively. Interrater agreement ranged from 0.63 (95% confidence interval [CI] 0.57 to 0.69) to 0.72 (95% CI 0.66 to 0.78) for the ratings. Intrarater reliability ranged from 0.62 to 1.0. The highest levels of agreement were in tiers 1, 4, and the subspecialties oncology and foot/ankle. The time from development to full scale adoption and implementation by all orthopaedic surgeons was rapid. DISCUSSION: This tiered prioritization list for orthopaedic procedures is both adoptable and reliable during the phased reinstatement of procedures during the COVID-19 pandemic and afterward. Further refinements may enhance utility. LEVELS OF EVIDENCE: Reliability study: Level I (Evid Based Spine Care J 2014 October;5(2):166. doi: 10.1055/s-0034-1394106).

Influence of radiographic projection and patient positioning on shortening of the fractured clavicle.

BACKGROUND: Radiographic measurements of shortening and vertical displacement in the fractured clavicle are subject to a variety of factors such as patient positioning and projection. The aims of this study were (1) to quantify differences in shortening and vertical displacement in varying patient positions and X-ray projections, (2) to identify the view and patient positioning indicating the largest amount of shortening and vertical displacement, and (3) to identify and quantify the inter- and intraobserver agreement. METHODS: A prospective clinical measurement study of 22 acute Robinson type 2B1 clavicle fractures was performed. Each patient underwent 8 consecutive standardized and calibrated X-rays in 1 setting. RESULTS: In the upright patient position, the difference of absolute shortening was 4.5 mm (95% confidence interval [CI]: 3.0-5.9, P < .0001) larger than in the supine patient position. For vertical displacement, the odds of being scored a category higher in the upright patient position were 4.7 (95% CI: 2.2-9.8) times as large as the odds of being scored a category higher in supine position. The odds of being scored a category higher on the caudocranial projection were 5.9 (95% CI: 2.8-12.6) times as large as the odds of being scored a category higher on the craniocaudal projection. CONCLUSION: Absolute shortening, relative shortening, and vertical displacement were found to be the greatest in the upright patient positioning with the arm protracted orientation on a 15° caudocranial projection. No statistically significant differences were found for a change in position of the arm between neutral and protracted.

Linked Double-Row Equivalent Arthroscopic Rotator Cuff Repair Leads to Significantly Improved Patient Outcomes.

BACKGROUND: Biomechanical studies have demonstrated that arthroscopic rotator cuff repair using a linked double-row equivalent construct results in significantly higher load to failure compared with conventional transosseous-equivalent constructs. PURPOSE: To determine the patient-reported outcomes (PROs), reoperation rates, and complication rates after linked double-row equivalent rotator cuff repair for full-thickness rotator cuff tears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Consecutive patients who underwent linked double-row equivalent arthroscopic rotator cuff repair with minimum 2-year follow-up were included. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score at final follow-up. Secondary outcomes included the Simple Shoulder Test (SST), shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, visual analog scale (VAS), reoperations, and complications. Clinical relevance was defined by the minimally clinically important difference (MCID). Comparisons on an individual level that exceeded MCID (individual-level scores) were deemed clinically relevant. Comparisons between preoperative and postoperative scores were completed using the Student t test. All P values were reported with significance set at P < .05. RESULTS: A total of 42 shoulders in 41 consecutive patients were included in this study (21 male patients [51.2%]; mean age, 64.5 ± 11.9 years; mean follow-up, 29.7 ± 4.5 months). All patients (100%) completed the minimum 2-year follow-up. The rotator cuff tear measured on average 15.2 ± 8.9 mm in the coronal plane and 14.6 ± 9.8 mm in the sagittal plane. The ASES score improved significantly from 35.5 ± 18.2 preoperatively to 93.4 ± 10.6 postoperatively (P < .001). The QuickDASH (P < .001), SST (P < .001), and VAS (P < .001) scores also significantly improved after surgery. All patients (42/42 shoulders; 100%) achieved clinically relevant improvement (met or exceeded MCID) on ASES and SST scores postoperatively. There were no postoperative complications (0.0%) or reoperations (0.0%) at final follow-up. CONCLUSION: Arthroscopic repair of full-thickness rotator cuff tears with the linked double-row equivalent construct results in statistically significant and clinically relevant improvements in PRO scores with low complication rates (0.0%) and reoperation rates (0.0%) at short-term follow-up.

Measurement of midshaft clavicle vertical displacement is not influenced by radiographic projection.

BACKGROUND: Measured shortening of midshaft clavicle fracture fragments is known to be influenced by multiple factors. The influence of radiographic projection on vertical displacement is unclear. The aims of this study were (1) to quantify the difference in measurements of vertical displacement in an absolute, relative, and categorical manner between 5 different projections; (2) to quantify the differences in interobserver and intraobserver agreement using a standardized method for measuring vertical displacement; and (3) to assess the association between categorical and continuous descriptions of vertical displacement. MATERIALS AND METHODS: A clinical measurement study was conducted on 31 sets of digitally reconstructed radiographs in 5 different projections (15° and 30° caudocranial, anteroposterior, and 15° and 30° craniocaudal views). Categorical data on vertical displacement in quartiles from 0%-200% were obtained followed by measurements using a standardized method by 3 observers at 2 points in time. Interobserver and intraobserver agreement for each of the 5 views was calculated. RESULTS: The absolute and relative vertical displacement showed no statistically significant difference between any of the caudocranial, anteroposterior, and craniocaudal views. Intraclass correlation coefficients for intraobserver and interobserver agreement were good to excellent. The correlation between categorical outcomes and both absolute and relative vertical displacement was very strong. CONCLUSION: Unlike shortening, absolute and relative vertical displacement of the midshaft clavicle fracture is not significantly influenced by radiographic projection. Standardized measurements of vertical displacement may not be necessary for clinical use because the correlation between categorical and continuous measurements was found to be very strong.

Functional outcomes, union rate, and complications of the Anser Clavicle Pin at 1 year: a novel intramedullary device in managing midshaft clavicle fractures.

BACKGROUND: Surgical management of displaced midshaft clavicle fractures in adults leads to better union rates, improved early functional outcomes, and increased patient satisfaction compared with nonoperative treatment. However, both intramedullary fixation and plate osteosynthesis are subject to a specific array of disadvantages and complications. The Anser Clavicle Pin is a novel intramedullary device designed to address these disadvantages and complications. The aim of this study was to evaluate the union rate, functional outcomes, and complications of the Anser Clavicle Pin at 1-year follow-up. METHODS: A prospective explorative case series including 20 patients with displaced midshaft clavicle fractures was performed in 2 hospitals. The primary outcomes were union rate, functional outcomes (Constant-Murley score and Disabilities of the Arm, Shoulder and Hand score), and complications. The secondary outcomes were closed reduction rate, operative time, image-intensifier time, hospital stay, incision length, time to radiologic union, postoperative pain reduction, reoperation rate, health-related quality-of-life score, and patient satisfaction. RESULTS: There was a 100% union rate. The Constant-Murley score at 1 year was 96.7 (standard deviation [SD], 5). The Disabilities of the Arm, Shoulder and Hand score was 5.1 (SD, 10). There were no infections, neuropathy of the supraclavicular nerve, or hardware irritation requiring removal of hardware. Three device-related complications (15%) occurred, including plastic deformation, protrusion, and hardware failure. The satisfaction score was 8.9 (SD, 1) on the visual analog scale at the 1-year follow-up. CONCLUSION: Managing displaced midshaft clavicle fractures with the Anser Clavicle Pin results in a 100% union rate and excellent functional outcomes and patient satisfaction. It has a low non-device-related complication rate, and the device-related complications that occurred in this series may be prevented in the future.

Functional outcomes and complications of intramedullary fixation devices for Midshaft clavicle fractures: a systematic review and meta-analysis.

BACKGROUND: An alternative to the current gold standard in operative treatment of displaced midshaft clavicle fractures (DMCF) using plate osteosynthesis, is internal fixation by means of intramedullary fixation devices. These devices differ considerably in their specifications and characteristics and an evaluation of their clinical results is warranted. The aim of this systematic review is to generate an overview of functional outcomes and complications in the management of DMCF per available intramedullary device. METHODS: A systematic review was conducted to identify all papers reporting functional outcomes, union rates and/or complications using an intramedullary fixation device for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until February 2020. Meta-analysis was conducted based on functional outcomes and type of complication per type of intramedullary fixation device. Pooled estimates of functional outcomes scores and incidence of complications were calculated using a random effects model. Risk of bias and quality was assessed using the Cochrane risk of bias and ROBINS-I tools. The confidence in estimates were rated and described according to the recommendations of the GRADE working group. RESULTS: Sixty-seven studies were included in this systematic review. The majority of studies report on the use of Titanium Elastic Nails (TEN). At 12 months follow up the Titanium Elastic Nail and Sonoma CRx report an average Constant-Murley score of 94.4 (95%CI 93-95) and 94.0 (95%CI 92-95) respectively (GRADE High). The most common reported complications after intramedullary fixation are implant-related and implant-specific. For the TEN, hardware irritation and protrusion, telescoping or migration, with a reported pooled incidence 20% (95%CI 14-26) and 12% (95%CI 8-18), are most common (GRADE Moderate). For the Rockwood/Hagie Pin, hardware irritation is identified as the most common complication with 22% (95%CI 13-35) (GRADE Low). The most common complication for the Sonoma CRx was cosmetic dissatisfaction in 6% (95%CI 2-17) of cases (GRADE Very low). CONCLUSION: Although most studies were of low quality, good functional results and union rates irrespective of the type of device are found. However, there are clear device-related and device-specific complications for each. The results of this systematic review and meta-analysis can help guide surgeons in choosing the appropriate operative strategy, implant and informing their patient. LEVEL OF EVIDENCE: IV.

A Biomechanical Comparison of Fiberglass Casts and 3-Dimensional-Printed, Open-Latticed, Ventilated Casts.

Background: The aim of this study was to quantify the stabilizing properties of a 3-dimensional (3D)-printed short-arm cast and compare those properties with traditional fiberglass casts in a cadaveric subacute distal radius fracture model. Methods: A cadaveric subacute fracture model was created in 8 pairs of forearms. The specimens were equally allocated to a fiberglass cast or 3D-printed cast group. All specimens were subjected to 3 biomechanical testing modalities simulating daily life use: flexion and extension of digits, pronation and supination of the hand, and 3-point bending. Between each loading modality, radiological evaluation of the specimens was performed to evaluate possible interval displacement. Interfragmentary motion was quantified using a 3D motion-tracking system. Results: Radiographic assessment did not reveal statistically significant differences in radiographic parameters between the 2 groups before and after biomechanical testing. A statistically significant difference in interfragmentary motion was calculated with the 3-point bending test, with a mean difference of 0.44 (±0.48) mm of motion. Conclusions: A statistically significant difference in interfragmentary motion between the 2 casting groups was only identified in 3-point bending. However, the clinical relevance of this motion remains unclear as the absolute motion is less than 1 mm. The results of this study show noninferiority of the 3D-printed casts compared with the traditional fiberglass casts in immobilizing a subacute distal radius fracture model. These results support the execution of a prospective randomized clinical trial comparing both casting techniques.

Use of standard musculoskeletal ultrasound to determine the need for fasciotomy in an elevated muscle compartment pressure cadaver leg model.

INTRODUCTION: Acute compartment syndrome (ACS) is a limb-threatening condition often associated with leg injury. The only treatment of ACS is fasciotomy with the purpose of reducing muscle compartment pressures (MCP). Patient discomfort and low reliability of invasive MCP measurements, has led to the search for alternative methods. Our goal was to test the feasibility of using ultrasound to diagnose elevated MCP. METHODS: A cadaver model of elevated MCPs was used in 6 cadaver legs. An ultrasound transducer was combined with a pressure sensing transducer to obtain a B-mode image of the anterior compartment, while controlling the amount of pressure applied to the skin. MCP was increased from 0 to 75 mmHg. The width of the anterior compartment (CW) and the pressure needed to flatten the bulging superficial compartment fascia (CFFP) were measured. RESULTS: Both the CW and CFFP showed high correlations to MCP in the individual cadavers. Average CW and CFFP significantly increased between baseline and the first elevated MCP states. Both Inter-observer and intra-observer agreements for the ultrasound measurements were good to excellent. DISCUSSION: Ultrasound indexes showed excellent correlations in compartment pressures, suggesting that there is a potential for the clinical use of this modality in the future.

In Vivo CT Analysis of Physiological Fibular Motion at the Level of the Ankle Syndesmosis During Plantigrade Weightbearing.

Background. It is clear that motion at the syndesmosis occurs due to ranging of the ankle joint, but the influence of weightbearing with the foot in the plantigrade position is unclear. In vivo computed tomographic (CT) evaluation of the syndesmosis has not been previously described. The purpose of this study is to quantify physiological fibular motion at the level of the ankle syndesmosis in both weightbearing and nonweightbearing conditions with the foot in the plantigrade position. Methods. CT images were obtained from 9 normal healthy subjects using a weightbearing CT imaging system. The subjects were positioned in a nonweightbearing and weightbearing state with their foot in the plantigrade position. Fibular translation and rotation were measured from the axial CT images using previously validated techniques. Results. Both the average lateral and anteroposterior translation of the fibula between weightbearing and nonweightbearing states was minimal (0.3 mm and 0.2 mm, respectively). The largest difference in translation observed in either direction was 0.9 mm. An average of 0.5° was found for rotational differences of the fibula between weightbearing and nonweightbearing. Neither of the translational and rotational parameters reached statistical significance. Conclusion. In vivo CT analysis of the distal tibiofibular joint with an intact syndesmosis did not reveal statistically significant physiological motion between weightbearing and nonweightbearing conditions with the foot in plantigrade position. Our findings suggest that weightbearing accounts for little motion at the syndesmosis and supports further investigation into the role of early protected weightbearing after syndesmosis fixation. Levels of Evidence: Level III: Case-control study.

Does altering projection of the fractured clavicle change treatment strategy?

BACKGROUND: Shortening of the fractured clavicle is proposed and debated as an indicator for surgical intervention. There is no standardized or uniform method for imaging and measuring shortening. Different methods and techniques can lead to different measured outcomes. However, the question remains whether a difference in measured shortening using a different technique has any short-term clinical relevance in terms of treatment strategy. The aim of this study was to investigate whether a different projection of the same midshaft clavicular fracture would lead to a different choice in treatment strategy. METHODS: Thirty-six AO-OTA (Arbeitsgemeinschaft für Osteosynthesefragen-Orthopaedic Trauma Association) 15A.1-15A.3 midshaft clavicular fractures were digitally reconstructed into radiographs using both 15° caudocranial and 15° craniocaudal projections. The 72 projections were rated in random order by 23 orthopedic trauma or upper-extremity surgeons on the need for either conservative or operative treatment. RESULTS: On average, the raters altered their treatment strategy with a different projection of the same midshaft clavicular fracture 12.2 times among the 36 cases (33.9%), ranging from 5 times (13.9%) to 19 times (52.8%). A statistically significant increase in choice for surgical treatment was identified when using the 15° caudocranial projection (P = .01). CONCLUSION: This study reveals the influence the projection of the midshaft clavicular fracture has on the surgeon's decision of treatment strategy. The decision changes from operative to nonoperative or vice versa in 33.9% of the cases.

Increased litigation burden among tibia, pelvis, and spine fractures: An analysis of 756 fracture-related malpractice cases.

OBJECTIVES: To analyze a series of claims from a large national malpractice insurer associated with fracture care to understand what parameters are associated with claims, defense costs, and paid indemnity. DESIGN: Review of claims in fracture care settings from a national database; case series. SETTING: Database draws from insured pool of 400,000 medical malpractice cases from 400 healthcare entities across the country, representing 165,000 physicians; both academic and private. PATIENTS/PARTICIPANTS: Fracture care patients bringing legal suit. MAIN OUTCOME MEASUREMENTS: Cost of legal proceedings and indemnity, ICD-9 codes, and contributing causes toward claims. RESULTS: A total of 756 fracture claims were asserted between 2005 and 2014 regarding fracture care within the database; 70% were brought for inaccurate, missed, or delayed diagnosis, while 22% addressed medical treatment and 8% were for surgical management. Orthopaedics was the primary service in 22%. Total cost (expenses and indemnity) to orthopaedic providers totaled $13.1MM (million). The most common claim against orthopaedics was for fractures of the tibia and fibula (11.4%). Impact factor (IF) analysis (as described by Matsen) of indemnity in these cases reveals 3 fracture regions of highest indemnity burden: fractures of the tibia and fibula (IF: 1.86, 11.4%), pelvis (IF: 1.77, 6.6%), and spine (IF 1.33, 6.6%). Analysis of contributing factors identifies the category of clinical judgement as the most common category (62%). Other common factors include patient noncompliance (31%), communication (28%), technical skill (17%), clinical systems (11%), and documentation (10%). The single most common specific cause of a claim in orthopaedic fracture care was misinterpretation of diagnostic imaging (25%). CONCLUSION: This study is the first of its kind to identify fractures of the tibia and fibula as high risk for litigation against orthopaedic providers and provides general counseling of legal pitfalls in fracture care. Finally, we are able to identify the act of patient assessment as a key issue in over half of all fracture-related claims against orthopaedic providers. Providers in general and specialty settings can use this information to help guide their treatment and care ownership decisions in the care of patients with fractures. LEVEL OF EVIDENCE: Economic - Level III.

Trauma care systems in India and China: A grim past and an evolving future.

Neither India nor China has a formalized trauma system in place. There are many similarities between the 2 countries in terms of size, rapid economic growth, increasing number of motor vehicles, and high rates of road traffic accident (RTA) fatalities. This paper describes the current development of elements of the trauma system in China and the strategies and efforts made to improve the trauma system in India. In China, though not organized and formalized, different phases of the trauma system are present at varying levels of maturity. In India, efforts are made to implement a trauma system by mainly focusing on preventive measures and the creation of trauma designated facilities. Although progress has been made, the concept of "adequate trauma care for all" continues to remain an aspiration in many Asian countries, including India and China. Continued and concerted effort across many levels will be required to achieve this goal.

Current Status of Musculoskeletal Trauma Care Systems Worldwide.

BACKGROUND AND RATIONALE: Although general trauma care systems and their effects on mortality reduction have been studied, little is known of the current state of musculoskeletal trauma delivery globally, particularly in low-income (LI) and low middle-income (LMI) countries. The goal of this study is to assess and describe the development and availability of musculoskeletal trauma care delivery worldwide. MATERIALS & METHODS: A questionnaire was developed to evaluate different characteristics of general and musculoskeletal trauma care systems, including general aspects of systems, education, access to care and pre- and posthospital care. Surgical leaders involved with musculoskeletal trauma care were contacted to participate in the survey. RESULTS: Of the 170 surveys sent, 95 were returned for use for the study. Nearly 30 percent of surgeons reported a formalized and coordinated trauma system in their countries. Estimates for the number of surgeons providing musculoskeletal trauma per one million inhabitants varied from 2.6 in LI countries to 58.8 in high-income countries. Worldwide, 15% of those caring for musculoskeletal trauma are fellowship trained. The survey results indicate a lack of implemented musculoskeletal trauma care guidelines across countries, with even high-income countries reporting less than 50% availability in most categories. Seventy-nine percent of the populations from LI countries were estimated to have no form of health care insurance. Formalized emergency medical services were reportedly available in only 33% and 50% of LI and LMI countries, respectively. Surgeons from LI and LMI countries responded that improvements in the availability of equipment (100%), number and locations of trauma-designated hospitals (90%), and physician training programs (88%) were necessary in their countries. The survey also revealed a general lack of resources for postoperative and rehabilitation care, irrespective of the country's income level. CONCLUSION: This study addresses the current state of musculoskeletal trauma care delivery worldwide. These results indicate a greater need for trauma system development and support, from prehospital through posthospital care. Optimization of these systems can lead to better outcomes for patients after trauma. This study represents a critical first step toward better understanding the state of musculoskeletal trauma care in countries with different levels of resources, developing strategies to address deficiencies, and forming regional and international collaborations to develop musculoskeletal trauma care guidelines.

Midshaft clavicle fractures: Current concepts.

Clavicle fractures are common fractures and the optimal treatment strategy remains debatable. The present paper reviews the available literature and current concepts in the management of displaced and/or shortened midshaft clavicle fractures.Operative treatment leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment also seems to be advantageous.However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar.The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model. Cite this article: EFORT Open Rev 2018;3:374-380. DOI: 10.1302/2058-5241.3.170033.

Influence of x-ray direction on measuring shortening of the fractured clavicle.

BACKGROUND: Midshaft clavicle fractures are often associated with a certain degree of shortening. There is great variety in the imaging techniques and methods to quantify this shortening. This study aims to quantify the difference in measurements of shortening and length of fracture elements between 5 views of the fractured clavicle. Furthermore, the interobserver and intraobserver agreement between these views using a standardized method is evaluated. MATERIALS AND METHODS: Digitally reconstructed radiographs were created for 40 computed tomography datasets in the anteroposterior (AP), 15° and 30° craniocaudal, and 15° and 30° caudocranial views. A standardized method for measuring the length of fracture elements and the amount of shortening was used. Interobserver and intraobserver agreement for each of the 5 views was calculated. RESULTS: The interobserver and intraobserver agreement was excellent for all 5 views, with all intraclass correlation coefficient values greater than 0.75. The measured differences in relative and absolute shortening between views were statistically significant between the 30° caudocranial view and all other views. The increase in median shortening measured between the commonly used 30° caudocranial view (2.7 mm) and the AP view (8.5 mm) was 5.8 mm (P < .001). The relative median shortening between these views increased by 3.5% (P < .001). CONCLUSION: The length of fracture elements and the amount of shortening in the fractured clavicle can be reliably measured using a standardized method. The increase in absolute and relative shortening when comparing the caudocranial measurements with the AP and craniocaudal measurements may indicate that the AP and craniocaudal views provide a more accurate representation of the degree of shortening.