Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial.

BACKGROUND: Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. The use of immediate surgical fixation to manage this type of fracture has increased, despite insufficient evidence of improved outcomes over non-surgical management. The SWIFFT trial compared the clinical effectiveness of surgical fixation with cast immobilisation and early fixation of fractures that fail to unite in adults with scaphoid waist fractures displaced by 2 mm or less. METHODS: This pragmatic, parallel-group, multicentre, open-label, two-arm, randomised superiority trial included adults (aged 16 years or older) who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear bicortical fracture of the scaphoid waist on radiographs. An independent remote randomisation service used a computer-generated allocation sequence with randomly varying block sizes to randomly assign participants (1:1) to receive either early surgical fixation (surgery group) or below-elbow cast immobilisation followed by immediate fixation if non-union of the fracture was confirmed (cast immobilisation group). Randomisation was stratified by whether or not there was displacement of either a step or a gap of 1-2 mm inclusive on any radiographic view. The primary outcome was the total patient-rated wrist evaluation (PRWE) score at 52 weeks after randomisation, and it was analysed on an available case intention-to-treat basis. This trial is registered with the ISRCTN registry, ISRCTN67901257, and is no longer recruiting, but long-term follow-up is ongoing. FINDINGS: Between July 23, 2013, and July 26, 2016, 439 (42%) of 1047 assessed patients (mean age 33 years; 363 [83%] men) were randomly assigned to the surgery group (n=219) or to the cast immobilisation group (n=220). Of these, 408 (93%) participants were included in the primary analysis (203 participants in the surgery group and 205 participants in the cast immobilisation group). 16 participants in the surgery group and 15 participants in the cast immobilisation group were excluded because of either withdrawal, no response, or no follow-up data at 6, 12, 26, or 52 weeks. There was no significant difference in mean PRWE scores at 52 weeks between the surgery group (adjusted mean 11·9 [95% CI 9·2-14·5]) and the cast immobilisation group (14·0 [11·3 to 16·6]; adjusted mean difference -2·1 [95% CI -5·8 to 1·6], p=0·27). More participants in the surgery group (31 [14%] of 219 participants) had a potentially serious complication from surgery than in the cast immobilisation group (three [1%] of 220 participants), but fewer participants in the surgery group (five [2%]) had cast-related complications than in the cast immobilisation group (40 [18%]). The number of participants who had a medical complication was similar between the two groups (four [2%] in the surgery group and five [2%] in the cast immobilisation group). INTERPRETATION: Adult patients with scaphoid waist fractures displaced by 2 mm or less should have initial cast immobilisation, and any suspected non-unions should be confirmed and immediately fixed with surgery. This treatment strategy will help to avoid the risks of surgery and mostly limit the use of surgery to fixing fractures that fail to unite. FUNDING: National Institute for Health Research Health Technology Assessment Programme.

Acromioclavicular joint reconstruction implants have differing ability to restore horizontal and vertical plane stability.

PURPOSE: Persistent acromioclavicular joint (ACJ) instability following high grade injuries causes significant symptoms. The importance of horizontal plane stability is increasingly recognised. There is little evidence of the ability of current implant methods to restore native ACJ stability in the vertical and horizontal planes. The purpose of this work was to measure the ability of three implant reconstructions to restore native ACJ stability. METHODS: Three groups of nine fresh-frozen shoulders each were mounted into a robotic testing system. The scapula was stationary and the robot displaced the clavicle to measure native anterior, posterior, superior and inferior (A, P, S, I) stability at 50 N force. The ACJ capsule, conoid and trapezoid ligaments were transected and the ACJ was reconstructed using one of three commercially available systems. Two systems (tape loop + screw and tape loop + button) wrapped a tape around the clavicle and coracoid, the third system (sutures + buttons) passed directly through tunnels in the clavicle and coracoid. The stabilities were remeasured. The data for A, P, S, I stability and ranges of A-P and S-I stability were analyzed by ANOVA and repeated-measures Student t tests with Bonferroni correction, to contrast each reconstruction stability versus the native ACJ data for that set of nine specimens, and examined contrasts among the reconstructions. RESULTS: All three reconstructions restored the range of A-P stability to that of the native ACJ. However, the coracoid loop devices shifted the clavicle anteriorly. For S-I stability, only the sutures + buttons reconstruction did not differ significantly from native ligament restraint. CONCLUSIONS: Only the sutures + buttons reconstruction, that passed directly through tunnels in the clavicle and coracoid, restored all stability measures (A, P, S, I) to the native values, while the tape implants wrapped around the bones anteriorised the clavicle. These findings show differing abilities among reconstructions to restore native stability in horizontal and vertical planes. (300 words).

Ligamentous and capsular restraints to anterior-posterior and superior-inferior laxity of the acromioclavicular joint: a biomechanical study.

BACKGROUND: Approximately 9% of shoulder girdle injuries involve the acromioclavicular joint (ACJ). There is no clear gold standard or consensus on surgical management of these injuries, in part perpetuated by our incomplete understanding of native ACJ biomechanics. We have therefore conducted a biomechanical study to assess the stabilizing structures of the ACJ in superior-inferior (SI) translation and anterior-posterior (AP) translation. METHODS: Twenty fresh frozen cadaveric specimens were prepared and mounted onto a robotic arm. The intact native joint was tested in SI translation and AP translation under a 50-N displacing force. Each specimen was retested after sectioning of its stabilizing structures in the following order: investing fascia, ACJ capsular ligaments, trapezoid ligament, and conoid ligament. Their contributions to resisting ACJ displacements were calculated. RESULTS: In the intact native ACJ, mean anterior displacement of the clavicle was 7.9 ± 4.3 mm, mean posterior displacement was 7.2 ± 2.6 mm, mean superior displacement was 5.8 ± 3.0 mm, and mean inferior displacement was 3.6 ± 2.6 mm. The conoid ligament was the primary stabilizer of superior displacement (45.6%). The ACJ capsular ligament was the primary stabilizer of inferior displacement (33.8%). The capsular ligament and conoid ligament contributed equally to anterior stability, with rates of 23% and 25.2%, respectively. The capsular ligament was the primary contributor to posterior stability (38.4%). CONCLUSION: The conoid ligament is the primary stabilizer of superior displacement of the clavicle at the ACJ and contributes significantly to AP stability. Consideration should be given to reconstruction of the ACJ capsular ligament for complete AP stability in high-grade and horizontally unstable ACJ injuries.

Surgical versus conservative management of ankle fractures in adults: A systematic review and meta-analysis.

AIMS: This study compared outcomes of surgical versus conservative management of ankle fractures in adults through a systematic review and meta-analysis. METHODS: We searched CINAHL, EMBASE, MEDLINE and CENTRAL databases (1946-June 2019) for randomised and quasi-randomised controlled trials comparing surgical versus conservative management of closed adult ankle fractures of any type. Estimates of effect were pooled using random effects meta-analysis. RESULTS: 1153 patients from 7 trials were included. Our primary outcome, ankle function score, was not statistically significantly different at 6-months (pooled mean difference (surgical minus conservative) = 1.0; 95% CI: -2.3 to 4.3; p = 0.55) or 12-months or more (pooled mean difference = 4.6; 95% CI: -1.0 to 10.2; p = 0.11) between surgical and conservative groups in three trials assessing displaced or unstable fractures, and two trials using non-validated questionnaires. One trial assessing AO-type-B1 fractures without talar shift had a statistically significant difference favouring conservative management, which was not clinically meaningful. Surgery had lower rates of early treatment failure and malunion/non-union, but higher rates of further surgery and infection. CONCLUSIONS: Surgical and conservative management of displaced or unstable ankle fractures produce similar short-term functional outcomes. The higher risk of early treatment failure and malunion/non-union in the conservative group versus higher rates of further surgery and infection in the surgical group should be considered. Trials are needed to assess longer-term results and inform management of select patient groups.

Comparison of plain x-rays and computed tomography for assessing distal radioulnar joint inclination.

PURPOSE: To compare the inclination of the distal radioulnar joint (DRUJ) on computed tomography (CT) and plain radiography (XR) in order to assess the effect of narrowing the range of inclination used in the original Tolat classification system to identify potentially problematic reverse oblique DRUJs. METHODS: Two independent investigators compared the angle of inclination and Tolat type on matched wrist XRs in the coronal plane and CTs of the same patients with normal DRUJs. The degree of agreement between XR and CT was determined. Inter- and intra-observer reliabilities were calculated. The prevalence of the 3 inclination types of the DRUJs using Tolat's definition was recorded. Their original quantitative definition of the parallel Tolat type 1 DRUJ included all DRUJs with a measured inclination of ±10°. We noted and compared the resultant changes in prevalence of the different DRUJ types after narrowing the inclination range to ±5° and ±3°. RESULTS: Highly significant correlation between CT and XR measurements were found for both observers. Despite this, the limits of agreement between CT and XR in determining the sigmoid notch inclination was -9° to 11° (±2° standard deviations from the mean difference). When measured from the CTs and using Tolat's original algorithm, the prevalence of Tolat type 1 DRUJ was 47% (N = 34), type 2 was 51% (N = 37), and type 3 was 1% (N = 1). These percentages changed to 7% (N = 5) for type 1, 78% (N = 56) for type 2, and 15% (N = 11) for type 3 when applying narrower ranges of inclination. CONCLUSIONS: Narrowing the range of sigmoid notch inclination that defines type 1 (parallel) DRUJs when using CT provided a more accurate representation of the morphological types. It revealed an increased number of potentially problematic type 3 DRUJs. However, the statistical limits of agreement between CT and XR suggested that high-resolution 3-dimensional imaging is required to apply the new algorithm. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

The Adhesive Capsulitis Corticosteroid and Dilation (ACCorD) randomized controlled trial.

Aims: Is it feasible to conduct a definitive multicentre trial in community settings of corticosteroid injections (CSI) and hydrodilation (HD) compared to CSI for patients with frozen shoulder? An adequately powered definitive randomized controlled trial (RCT) delivered in primary care will inform clinicians and the public whether hydrodilation is a clinically and cost-effective intervention. In this study, prior to a full RCT, we propose a feasibility trial to evaluate recruitment and retention by patient and clinician willingness of randomization; rates of withdrawal, crossover and attrition; and feasibility of outcome data collection from routine primary and secondary care data. Methods: In the UK, the National Institute for Health and Care Excellence (NICE) advises that prompt early management of frozen shoulder is initiated in primary care settings with analgesia, physiotherapy, and joint injections; most people can be managed without an operation. Currently, there is variation in the type of joint injection: 1) CSI, thought to reduce the inflammation of the capsule reducing pain; and 2) HD, where a small volume of fluid is injected into the shoulder joint along with the steroid, aiming to stretch the capsule of the shoulder to improve pain, but also allowing greater movement. The creation of musculoskeletal hubs nationwide provides infrastructure for the early and effective management of frozen shoulder. This potentially reduces costs to individuals and the wider NHS perhaps negating the need for a secondary care referral. Results: We will conduct a multicentre RCT comparing CSI and HD in combination with CSI alone. Patients aged 18 years and over with a clinical diagnosis of frozen shoulder will be randomized and blinded to receive either CSI and HD in combination, or CSI alone. Feasibility outcomes include the rate of randomization as a proportion of eligible patients and the ability to use routinely collected data for outcome evaluation. This study has involved patients and the public in the trial design, dissemination methods, and how to include groups who are underserved by research. Conclusion: We will disseminate findings among musculoskeletal clinicians via the British Orthopaedic Association, the Chartered Society of Physiotherapy, the Royal College of Radiologists, and the Royal College of General Practitioners. To ensure wide reach we will communicate findings through our established network of charities and organizations, in addition to preparing dissemination findings in Bangla and Urdu (commonly spoken languages in northeast London). If a full trial is shown to be feasible, we will seek additional National Institute for Health and Care Research funding for a definitive RCT. This definitive study will inform NICE guidelines for the management of frozen shoulder.

Transcatheter arterial embolisation for the relief of shoulder and elbow chronic joint pain refractory to conventional treatment: Systematic review.

Angiogenesis and accompanying nerve fibres might cause unsettling joint pain. Studies have suggested that transcatheter arterial embolisation (TAE) of these abnormal neovessels could relieve pain and symptoms in patients with upper limb joint pain refractory to conventional treatment. This study aims to investigate the efficacy and safety of TAE in treating chronic pain of shoulder and elbow joints that have been resistant to other treatments. Using six databases, a systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The primary outcome involved changes in the visual analogue scale (VAS) after TAE; while secondary outcomes involved comparing other parameters where relevant. Average VAS decreased from baseline, then at 1 day, 1 week, 1 month, 3 months, 4 months, 6 months, 1 year, 2 years and 44 months (7.5 at baseline vs. 4.7, 4.3, 3.4, 2.1, 2.5, 1.2, 0.7, 1.1 and 0.1, respectively). Average Quick-DASH scores decreased from baseline, then at 1, 3 and 6 months (61.3 at baseline vs. 30.6, 19.3 and 6.9, respectively). Minor adverse events were reported in 27/143 (18.9%) patients, where they resolved spontaneously or with oral analgesia. TAE is a possible treatment option for refractory shoulder and elbow joint pain; however, randomised controlled trials are still required.

A model of osteoblast-osteocyte kinetics in the development of secondary osteons in rabbits.

The kinetics of osteogenic cells within secondary osteons have been examined within a 2-D model. The linear osteoblast density of the osteons and the osteocyte lacunae density were compared with other endosteal lamellar systems of different geometries. The cell density was significantly greater in the endosteal appositional zone and was always flatter than the central osteonal canals. Fully structured osteons compared with early structuring (cutting cones) did not show any significant differences in density. The osteoblast density may remain constant because some of them leave the row and become embedded within matrix. The overall shape of the Haversian system represented a geometrical restraint and it was thought to be related to osteoblast-osteocyte transformation. To test this hypothesis of an early differentiation and recruitment of the osteoblast pool which completes the lamellar structure of the osteon, the number and density of osteoblasts and osteocyte lacunae were evaluated. In the central canal area, the mean osteoblast linear density and the osteocyte lacunae planar density were not significantly different among sub-classes (with the exclusion of the osteocyte lacunae of the 300-1000 µm(2) sub-class). The mean number of osteoblasts compared with osteocyte lacunae resulted in significantly higher numbers in the two sub-classes, no significant difference was seen in the two middle sub-classes with the larger canals, and there were significantly lower levels in the smallest central canal sub-class. The TUNEL technique was used to identify the morphological features of apoptosis within osteoblasts. It was found that apoptosis occurred during the late phase of osteon formation but not in osteocytes. This suggests a regulatory role of apoptosis in balancing the osteoblast-osteocyte equilibrium within secondary osteon development. The position of the osteocytic lacunae did not correlate with the lamellar pattern and the lacunae density in osteonal radial sectors was not significantly different. These findings support the hypothesis of an early differentiation of the osteoblast pool and the independence of the fibrillar lamellation from osteoblast-osteocyte transformation.

Barista's fracture: a new occupational hazard.

Stress fracture of the clavicle is a rare injury usually occurring in high-level athletes. It is typically a result of repetitive sporting activity or unusual strain. We present the first case of an occupational clavicle stress fracture in a young female barista. The patient initially presented with insidious onset clavicular pain. There was no history of trauma, and an undisplaced fracture was present on the plain radiograph but overlooked by the emergency physicians. Two weeks later, the patient presented again with worsening symptoms, and a displaced fracture of the clavicle was diagnosed on plain radiograph. A thorough occupational history revealed the cause of her pain, which was the mechanical activity of coffee tamping and the fracture went on to unite with no further complications. No other cause was found on investigations including magnetic resonance imaging. The fracture healed with cessation of coffee tamping. This case highlights a previously unrecognised occupational hazard of coffee tamping as a potential cause of stress fracture of clavicle.

Open reduction of developmental hip dysplasia using a medial approach: a review of 24 hips.

The results of the Ferguson medial approach for reduction of developmental hip dysplasia were reviewed for 24 hips. The mean age at surgery was 4.8 months and the mean length of clinical follow-up was 59 months. Clinically all hips were normal in follow-up and radiologically the acetabular index was within normal limits. There was the need for further surgery in two cases with loss of concentric reduction. There were two cases showing evidence of vascular insult post operatively according to the classification of Kalmachi and MacEwan. We conclude that the Ferguson medial approach is a safe and effective form of treatment for open reduction of developmental hip dysplasia in cases where closed reduction either has failed or is inappropriate. The age of the child or the presence of the upper femoral ossific nucleus does not appear to affect outcome. The procedure can safely be performed before six months of age.

AO Distal Radius Fracture Classification: Global Perspective on Observer Agreement.

Background The primary objective of this study was to test interobserver reliability when classifying fractures by consensus by AO types and groups among a large international group of surgeons. Secondarily, we assessed the difference in inter- and intraobserver agreement of the AO classification in relation to geographical location, level of training, and subspecialty. Methods A randomized set of radiographic and computed tomographic images from a consecutive series of 96 distal radius fractures (DRFs), treated between October 2010 and April 2013, was classified using an electronic web-based portal by an invited group of participants on two occasions. Results Interobserver reliability was substantial when classifying AO type A fractures but fair and moderate for type B and C fractures, respectively. No difference was observed by location, except for an apparent difference between participants from India and Australia classifying type B fractures. No statistically significant associations were observed comparing interobserver agreement by level of training and no differences were shown comparing subspecialties. Intra-rater reproducibility was "substantial" for fracture types and "fair" for fracture groups with no difference accounting for location, training level, or specialty. Conclusion Improved definition of reliability and reproducibility of this classification may be achieved using large international groups of raters, empowering decision making on which system to utilize. Level of Evidence Level III.

Are standard antero-posterior and 20° caudal radiographs a true assessment of mid-shaft clavicular fracture displacement?

AIMS: Decision-making in management of clavicle fractures is often based on the degree of displacement and shortening present on plain radiographs. We aimed to evaluate whether plain radiographs provide an accurate representation of the true displacement present, which can be difficult to image in orthogonal planes. METHODS: Consecutive high-energy trauma patients with midshaft clavicular fractures requiring further CT imaging of the thorax/abdomen for other associated injuries between 2009 and 2012 were evaluated. The plain radiographs and CT scan were both performed at initial presentation. Displacement and shortening of the clavicle fracture were assessed on the standard clavicle views and then compared with the axial images obtained from CT scans. RESULTS: 26 patients admitted following a high-energy trauma that necessitated CT scan of chest/abdomen/pelvis were included. All patients also underwent standard clavicle view radiographs at the same initial assessment. Displacement varied from 0 to 233%. Shortening was measured as between 0 and 29 mm. The displacement measured on the CT scan was a mean of 19% greater than the AP view and 11% greater than the 20° caudal. This difference was found to be statistically significant (p = 0.019) between the AP view and the axial view on CT. The difference between 20° caudal views did not extend to statistical significance (p = 0.211). There were no significant differences found between the two modalities on assessment of shortening. CONCLUSIONS: Plain radiographs give an accurate representation of the shortening present in midshaft clavicle fractures. Displacement may be underestimated if the standard AP and 20° caudal views alone are relied upon.

Defining residual radial translation of distal radius fractures: a potential cause of distal radioulnar joint instability.

BACKGROUND: Instability of the distal radioulnar joint (DRUJ) is a complication that can occur following distal radius fracture or malunion. We have observed that residual radial translation of the distal radius, relative to the radial shaft, may be a causal factor of DRUJ instability, even once the traditional radiographic parameters (volar tilt, radial inclination, and ulnar variance) have been restored. Residual radial translation of the distal fragment may cause detensioning of the distal interosseous membrane (IOM) and pronator quadratus with poor apposition between the ulnar head and sigmoid notch. This may potentially lead to persistent instability of the ulnar head following internal fixation. Residual radial translation deformity is at risk of being overlooked by the wrist surgeon as there is no existing radiographic parameter that accurately measures this deformity. PATIENTS AND METHODS: In this study, 100 normal wrist radiographs were reviewed by three fellowship-trained orthopedic surgeons to develop a simple and reproducible technique to measure radial translation. RESULTS: Utilizing the method described, the point of intersection between the ulnar cortex of the shaft of the radius and the lunate left a mean average of 45.48% (range 25­73.68%) of the lunate remaining on the radial side. In the majority of cases more of the lunate resided ulnar to this line. High levels of agreement with inter-rater (intraclass coefficients = 0.967) and intra-rater (intraclass coefficients = 0.79) reliability was observed. CONCLUSIONS: The results of this study can be used to define a normal standard against which residual radial translation can be measured to assess the reduction of distal radius fractures. This new parameter aids in the development of surgical techniques to correct residual radial translation deformity. In addition, awareness and correction of this potential malreduction at the time of surgery may decrease the need for other procedures on the ulnar side of the wrist to improve DRUJ stability, such as ulnar styloid fixation, TFCC repair, or ligamentous grafting [corrected].

Herpes zoster virus: an unusual but potentially treatable cause of sciatica and foot drop.

The herpes zoster virus is a rare but potential cause of acute motor weakness. This article describes 2 patients with drop foot secondary to an infection of varicella zoster who were incorrectly referred to an orthopedic clinic from their general practitioners. The first patient was a 74-year-old man who presented with weakness in the right foot and a vesicular rash. The pattern of disease supported the clinical diagnosis of shingles affecting the L5 motor and sensory division. No investigation was required, and the patient was treated with a foot drop splint. The second patient was a 71-year-old man who presented with right leg and foot weakness and a vesicular rash affecting his right buttock and posterior right thigh. Lumbar magnetic resonance excluded a stenotic lesion; electrophysiological studies supported the diagnosis of a lower motor neuron lesion. The patient was treated with a 1-week course of acyclovir and a foot drop splint. The correct diagnosis will aid in correct referral and will prompt management, which will potentially provide a faster and better outcome for the patient.

The value of preoperative and intraoperative electromyography in the management of obstetric brachial plexus injury.

The treatment of obstetric brachial plexus palsy (OBPP) with neuroma-in-continuity is controversial. The recent literature advocates excision of neuroma-in-continuity in OBPP and repair with nerve graft irrespective of its neurophysiological conductivity. This approach risks sacrificing the regenerating axons, and the result has not yet been proven to be superior to neurolysis alone. In this case report, the authors aim to outline their strategy of using the combination of preoperative and intraoperative clinical and neurophysiological findings to aid their decision making. The lack of upper trunk recovery and the unfavorable preoperative neurophysiological findings in a child with Narakas Group 4 OBPP at 5 months of age prompted an urgent exploration with the intention of performing neurotization. This procedure was abandoned and neurolysis was performed due to the favorable intraoperative neurophysiological findings. At 4 years of age, the child scored 12 of 15 on Mallet classification and has an excellent range of movement. No secondary operation was needed. The authors hope to highlight the idea that the surgical option for neurolysis alone should be kept open and that intraoperative electromyography can be a valuable tool to add to the surgeon's armamentarium.

Cervical Prevertebral Soft Tissue Swelling in the Traumatized Patient: What is Normality in the Intubated Patient?

Interpretation of prevertebral soft tissue swelling is generally thought to be invalid in the presence of an endotracheal tube (ETT). There is however little scientific data to support this.We evaluate the prevertebral soft tissue swelling of 43 traumatized patients that have had an endotracheal tube (ETT) placed in the acute setting. A control group of 92 patients were also evaluated which had been subjected to acute trauma and no ETT. There was a significant increase in soft tissue swelling (p < 0.0001) found in the ETT group at the C2 level compared to the non-tube group. There was no significant difference between the two groups at the C4 and C6 levels.We feel that interpretation of prevertebral swelling in the traumatized patient at the C2 level is invalid in the presence of an ETT, and indeed is significantly increased after intubation despite no injury at this level. However, the interpretation of soft tissue swelling at and below C4 remains a useful tool in the evaluation of an occult cervical injury.