Are displaced distal clavicle fractures associated with inferior clinical outcomes following nonoperative management? A systematic review.

BACKGROUND: Management of displaced distal clavicle fractures remains a topic of discussion because of notoriously high nonunion rates, but there is little documented in the literature as to what effect this may have on patient-reported function. The aim of this systematic review was to look at nonoperative management following displaced distal clavicle fractures to determine union rates, complications, and patient-reported outcome measures. METHODS: A review of the online databases MEDLINE and Embase was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Clinical studies that included a cohort of nonoperatively managed displaced distal clavicle fractures and reported on union rate, complications, and patient-reported functional scores were included. RESULTS: Eleven studies were eligible for inclusion (2 randomized controlled trials, 1 prospective noncomparative cohort study, 5 retrospective comparative cohort studies, and 3 case series) with a total of 779 patients included in this review. Average union rate was 63.2% (22.2%-94.4%) in nonoperatively managed patients, compared with 96.3% (87.9%-100%) in operatively managed patients. The Constant-Murley score and Disabilities of the Arm, Shoulder, and Hand questionnaire were the most frequently used outcome measure tools. No study demonstrated any significant difference in any outcome measure when comparing nonoperative with operative treatment. Complication rate (including nonunion) in nonoperatively managed patients was 45.1%, with 11.1% requiring delayed surgery. Average complication rate in the operatively managed groups was 41.2%, with 40.1% requiring a second operation. CONCLUSION: Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates, but shoulder function remains excellent, and risk of complications and delayed surgery are low. Decision making must take into account patient factors and expectations to provide high-quality, individualized care.

Clinical Outcomes of the Modified Broström Technique in the Management of Chronic Ankle Instability After Early, Intermediate, and Delayed Presentation.

The modified Broström technique (MBT) is considered the reference standard for surgical management of ankle instability, with good short-term outcomes. However, limited evidence is available regarding outcomes for delayed presentations of instability. We report our outcomes for patients who underwent ligament repair using the MBT, from a single-surgeon retrospective study of consecutive patients. The minimum postoperative follow-up period was 6 months during a 5-year study period. The patients were retrospectively divided into 3 groups according to the delay in presentation: group 1, 6 months to 2 years; group 2, 2 to 4 years; and group 3, >4 years. We collected data on patient demographics, injury pattern, and intraoperative surgeon findings. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale (AHS) was used to evaluate patient outcomes and satisfaction with surgery. Twenty-six patients were treated with MBT. The mean follow-up period was 36.9 (range 6-42) months. Twenty-five (96.2%) patients had unilateral injuries, and 1 (3.85%) had bilateral repairs. Of the 26 patients, 21 (80.8%) completed the AOFAS-AHS, with a mean score of 87.4 (range 12 to 100). The mean interval from injury to surgery was 47.9 months. The results were excellent in 15 (71.4%), good in 3 (14.3%), fair in 1 (4.8%), and poor in 2 (9.5%) using the AOFAS-AHS. We found no significant difference in the overall AOFAS-AHS score or postoperative satisfaction among the groups (p > .05). All patients had a stable ankle joint at their final follow-up visit. In conclusion, patients with persistent or chronic ankle instability have good clinical outcomes and satisfaction after the MBT, irrespective of the time from injury to presentation.

A Comparison of Magnetic Resonance Imaging and SPECT-CT Imaging in Complex Spine Pathology: Does SPECT-CT Provide Additional Diagnostic Information Over Magnetic Resonance Imaging?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Magnetic Resonance Imaging (MRI) is often regarded as the gold standard for spinal pathology, as it provides good structural visualisation. SPECT-CT, however, provides combined structural and functional information. There is a paucity of literature comparing SPECT-CT with MRI in the spine. Our aim was to determine whether SPECT-CT provides additional information to MRI in individuals with complex spinal pathology, including deformity, which altered management. METHODS: We conducted a retrospective review of all individuals seen at our tertiary spinal unit that were investigated with both MRI and SPECT-CT of the spine between 2007-2020. We reviewed imaging reports, and collated diagnoses, surgical treatment and the relative contributions of MRI and SPECT-CT to management decisions. RESULTS: 104 individuals identified, with a mean age of 30 years (89 females and 15 males). Diagnostic categories were adolescent, adult, and congenital deformity, degenerative pathology, and miscellaneous pathology. MRI returned positive findings in 58 (55.8%), and SPECT-CT in 41 (39.4%) cases. SPECT-CT identified 10 cases of facet joint degeneration, 5 of increased uptake around metalwork suggestive of loosening, 1 pseudoarthrosis, 1 partial failure of fusion and 1 osteoid osteoma which were not reported on MRI, all in individuals who had previously undergone spinal instrumentation. Despite this, SPECT-CT only altered management for 6 individuals (5.8%). CONCLUSIONS: MRI is less useful in the setting of previous instrumentation due to metal artefact. Where MRI is inconclusive, particularly in individuals with previous spinal instrumentation, SPECT-CT may provide a diagnosis, but is not recommended as primary imaging.

Digital templating in hip hemiarthroplasty: Is it possible to accurately predict femoral head size from magnification alone?

Background: Templating is an integral part of pre-operative planning in elective hip arthroplasty to achieve favourable long-term outcomes, but its applications in trauma surgery remain limited. When templating from radiographs without a calibration marker, there is always an element of magnification which must be accounted for. Our aim was to establish our institute-specific magnification and to determine whether using this to predict femoral head size in hemiarthroplasty was more accurate than using set magnifications previously reported in the literature. Materials & methods: Fifty consecutive patients who underwent hip hemiarthroplasty were retrospectively identified, their pre-operative radiographs reviewed and femoral head measured with templating software. Intra- and inter-observer reliability analyses were performed. Using this value, and two set values of 15% and 21% magnification, we attempted to predict femoral head sizes of our original cohort. The results were compared using paired t-test to ascertain if there was any significant difference in accuracy. Results: We established our institute-specific magnification as 17%. Inter- and intra-observer reliability were excellent. However, using this magnification we were only able to correctly predict to within ± one femoral head size in 49% of patients. There was no significant difference in accuracy comparing our institute-specific magnification with other magnifications from the literature. Conclusion: We would not recommend using magnification factor in digital templating software as this could potentially lead to errors in predicting final femoral head size in hip hemiarthroplasty and adversely affect patient outcomes.