Should nails be locked dynamically or statically in atypical femoral fractures? - A radiological analysis of time to union and reoperations in 236 displaced fractures with 4 years average follow-up.

INTRODUCTION: Atypical femoral fractures (AFFs) are associated with delayed union and higher reoperation rates. Axial dynamization of intramedullary nails is hypothesized to reduce time-to-union (TTU) and fixation failure as compared to static locking. METHODS: Consecutive acutely displaced AFFs fixed with long intramedullary nails across five centres between 2006 and 2021 with a minimum postoperative follow-up of three months were retrospectively reviewed. The primary outcome was TTU, compared between AFFs treated with dynamically or statically locked intramedullary nails. Fracture union was defined as a modified Radiographic Union Score for Tibial fractures score of 13 or greater. Secondary outcomes involved revision surgery and treatment failure, defined as non-union beyond 18 months or revision internal fixation for mechanical reasons. RESULTS: A total of 236 AFFs (127 dynamically locked and 109 statically locked) were analysed with good interobserver reliability of fracture union assessment (intraclass correlation coefficient = 0.89; 95% CI = 0.82-0.98). AFFs treated with dynamized nails had significantly shorter median TTU (10.1 months; 95% CI = 9.24-10.96 vs 13.0 months; 95% CI = 10.60-15.40) (log-rank test, p = 0.019). Multivariate Cox regression revealed that dynamic locking was independently associated with greater likelihood of fracture union within 24 months (p = 0.009). Reoperations were less frequent in the dynamic locking group (18.9% vs 28.4%), although the difference was not statistically significant (p = 0.084). Static locking was an independent risk factor for reoperation (p = 0.049), as were varus reduction and lack of teriparatide use within three months of surgery. Static locking also demonstrated a higher frequency of treatment failure (39.4% vs 22.8%, p = 0.006) and was an independent predictor of treatment failure in logistic regression (p = 0.018). Other factors associated with treatment failure included varus reduction and open reduction. CONCLUSIONS: Dynamic locking of intramedullary nails in AFFs is associated with faster time to union, lower rate of non-union, and fewer treatment failures.

Tuition Costs of Master's of Health Professions Education Programs: A Cross-Sectional Analysis.

PURPOSE: The increasing professionalization of medical education during the past 2 decades has ushered in an era in which formal degrees, particularly master's of health professions education (MHPE), have become important for career advancement in medical education. Although tuition costs can pose a substantial barrier for many seeking advanced degrees in health professions education, data on tuition associated with these programs are lacking. This study examines the accessibility of pertinent cost-related information available to prospective students and the variability of costs among programs worldwide. METHOD: The authors conducted an Internet-based, cross-sectional study, augmented with emails and direct contact with educators, to extract tuition-related data for MHPE programs between March 29, 2022, and September 20, 2022. Costs were converted to an annual total within each jurisdiction's currency and converted to U.S. dollars on August 18, 2022. RESULTS: Of the 121 programs included in the final cost analysis, only 56 had publicly available cost information. Excluding programs free to local students, the mean (SD) total tuition cost was $19,169 ($16,649), and the median (interquartile range) cost was $13,784 ($9,401- $22,650) (n = 109). North America had the highest mean (SD) tuition for local students ($26,751 [$22,538]), followed by Australia and New Zealand ($19,778 [$10,514]) and Europe ($14,872 [$7,731]), whereas Africa had the lowest ($2,598 [$1,650]). The region with the highest mean (SD) tuition for international students was North America ($38,217 [$19,500]), followed by Australia and New Zealand ($36,891 [$10,397]) and Europe ($22,677 [$10,010]), whereas Africa had the lowest ($3,237 [$1,189]). CONCLUSIONS: There is substantial variability in the geographic distribution of MHPE programs and marked differences in tuition. Incomplete program websites and limited responsiveness from many programs contributed to a lack of transparency regarding potential financial implications. Greater efforts are necessary to ensure equitable access to health professions education.

Surgeon-designed patient-specific instrumentation improves glenoid component screw placement for reverse total shoulder arthroplasty in a population with small glenoid dimensions.

PURPOSE: Glenoid component loosening is a potential complication of reverse total shoulder arthroplasty (rTSA), occurring in part due to lack of adequate screw purchase in quality scapular bone stock. This study was to determine the efficacy of a surgeon-designed, 3D-printed patient-specific instrumentation (PSI) compared to conventional instrumentation (CI) in achieving longer superior and inferior screw lengths for glenoid component fixation. METHODS: A multi-centre retrospective analysis of patients who underwent rTSA between 2015 and 2020. Lengths of the superior and inferior locking screws inserted for fixation of the glenoid baseplate component were recorded and compared according to whether patients received PSI or CI. Secondary outcomes included operative duration and incidence of complications requiring revision surgery. RESULTS: Seventy-three patients (31 PSI vs. 42 CI) were analysed. Average glenoid diameter was 24.5 mm (SD: 3.1) and 81% of patients had smaller glenoid dimensions compared to the baseplate itself. PSI produced significantly longer superior (44.7 vs. 30.7 mm; P < 0.001) and inferior (43.0 vs. 31 mm; P < 0.001) mean screw lengths, as compared to CI. A greater proportion of maximal screw lengths for the given rTSA construct (48 mm) were observed in the PSI group (71.9% vs. 11.9% superior, 59.4% vs. 11.9% inferior). Operative duration was not statistically significantly different between the PSI and CI groups (150 min vs. 169 min, respectively; P = 0.229). No patients had radiographic loosening of the glenoid component with an average of 2-year follow-up. CONCLUSION: PSI facilitates longer superior and inferior screw placement in the fixation of the glenoid component for rTSA. With sufficient training, PSI can be designed and implemented by surgeons themselves.

Patient-specific 3D-printed helmet for post-craniectomy defect - a case report.

BACKGROUND: Patients who undergo decompressive craniectomy (DC) are often fitted with a helmet that protects the craniectomy site from injury during rehabilitation. However, conventional "one-size-fits-all" helmets may not be feasible for certain craniectomy defects. We describe the production and use of a custom 3D-printed helmet for a DC patient where a conventional helmet was not feasible due to the craniectomy defect configuration. CASE PRESENTATION: A 65-year-old male with ethmoid sinonasal carcinoma underwent cranionasal resection and DC with free vastus lateralis flap reconstruction to treat cerebrospinal fluid leakage. He required an external helmet to protect the craniectomy site, however, the rim of a conventional helmet compressed the craniectomy site, and the straps compressed the vascular pedicle of the muscle flap. Computed topography (CT) scans of the patient's cranium were imported into 3D modelling software and used to fabricate a patient-specific, strapless helmet using fused deposition modelling (FDM). The final helmet fit the patient perfectly and circumvented the compression issues, while also providing better cosmesis than the conventional helmet. Four months postoperatively, the helmet remains intact and in use. CONCLUSIONS: 3D printing can be used to produce low-volume, patient-specific external devices for rehabilitation where standardized adjuncts are not optimal. Once initial start-up costs and training are overcome, these devices can be produced by surgeons themselves to meet a wide range of clinical needs.

Topical administration of tranexamic acid in elderly patients undergoing short femoral nailing for intertrochanteric fracture: A randomised controlled trial.

INTRODUCTION: Topical application of tranexamic acid (TXA) has been proposed as an alternative to intravenous administration to reduce perioperative bleeding in orthopaedic surgery. The purpose of this randomised controlled trial was to evaluate the efficacy and safety of 1 g topically applied TXA in patients undergoing fixation of intertrochanteric hip fractures by short femoral nailing. METHODS: A total of 121 patients were enrolled between May 2018 and January 2020. Patients were randomly allocated (1:1) to receive either 10 mL (1 g) of TXA or 10 mL of normal saline (NS) injected through the subfascial drain following wound closure. Total blood loss, total drain output and blood transfusion requirements up to postoperative day 3 were recorded. Rates of thromboembolic complications and mortality up to 90 days postoperatively were also compared. RESULTS: There was no statistically significant difference in total blood loss, total drain output or proportion of patients requiring transfusions. Median total blood loss was 1.088 L (IQR: 0.760-1.795) in the TXA group and 1.078 L (IQR: 0.797-1.722) in the NS group (P = .703). Median total drain output was 60 mL (IQR: 40-140) in the TXA group and 70 mL (IQR: 30-168) in the NS group (P = .696). Blood transfusions were administered in 29 patients (47.5%) in the TXA group and 27 patients (45.0%) in the NS group (P = .782). There was also no difference in frequency of thrombotic complications or mortality within 90 days. There were five thrombotic events in the TXA group and four in the NS group (P = .751). The 90-day mortality rate was 6.6% (4 patients) in the TXA group and 3.3% (2 patients) in the NS group (P = .680). CONCLUSION: A 1 g dose of topically administered TXA did not produce any difference in blood loss, transfusion requirements, thromboembolic complications, or 90-day mortality. Future trials may consider the effect of larger doses in patients undergoing hip fracture fixation surgery.

Differences in soft tissue damage using a percutaneous versus open approach for antegrade straight humeral nailing: a quantitative and qualitative anatomical study.

BACKGROUND: Percutaneous insertion of third-generation straight humeral nails is a recent alternative to the conventional open method. Rather than splitting, retracting and subsequently repairing the supraspinatus fibers to visualize the humeral head entry site, the percutaneous approach utilizes a cannulated awl to enter the intramedullary canal through the supraspinatus fibers without visualizing internal shoulder structures. Despite recent evidence demonstrating satisfactory outcomes in the percutaneous method, the potential for iatrogenic injury to the rotator cuff and other shoulder structures is not fully understood. MATERIALS AND METHODS: We performed an anatomical study of 46 shoulders in 23 cadavers to compare damage caused to internal shoulder structures between the open and percutaneous techniques. Dimensions and morphologies of supraspinatus and humeral head perforations were recorded. RESULTS: The percutaneous technique produced greater latitudinal tearing (p = 0.002) and less longitudinal tearing (p < 0.001) of muscle fibers, however there was no difference in supraspinatus hole area (p = 0.748). The long head biceps tendon was within 3 mm of the bone entry hole in 13 (28%) shoulders, with one shoulder in the open group exhibiting full tendon transection. CONCLUSIONS: Percutaneous insertion of intramedullary nails using a cannulated awl appears to produce similar soft tissue and bone entry site morphology as compared to the conventional open technique. The percutaneous method was associated with slightly greater latitudinal tearing, however the effects of this remain to be clarified through clinical studies. External rotation should be avoided during instrumentation to reduce the risk of biceps tendon transection.

Three-Dimensional Printing and Computer Navigation for Correction of Multiple Deformities in Osteogenesis Imperfecta: A Case Report.

CASE: A 44-year-old man with osteogenesis imperfecta presented with multiple debilitating musculoskeletal deformities. Bi-level osteotomies, assisted by 3-dimensional (3D)-printed patient-specific cutting guides, were performed to correct extraarticular valgus and procurvatum tibial deformities. Concomitant computer-navigated total knee arthroplasty was performed to restore neutral mechanical alignment. Postoperative x-ray showed good correction of deformities, and 1 year postoperatively, the patient is able to walk unaided with significant resolution of knee pain. CONCLUSION: 3D-printed osteotomy guides and computer navigation can be instrumental in procedures requiring a high degree of precision. With sufficient training, modern orthopaedic technologies can be implemented by surgeons themselves and combined to facilitate precise and personalized management of challenging conditions.

A comparison of six outcome measures across the recovery period after distal radius fixation-Which to use and when?

PURPOSE: Many standardized outcome measures exist to measure recovery after surgical fixation of distal radius fractures, however, choosing the optimal instrument is difficult. We evaluated responsiveness, ceiling/floor effects, and criterion validity over multiple time intervals across a 2-year follow-up period for six commonly used instruments. METHODS: A total of 259 patients who received open reduction and internal fixation for distal radius fractures between 2012 and 2015 were recruited. Patients were administered the Patient-Rated Wrist Evaluation (PRWE), Shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), Green and O'Brien score (Cooney modification) (CGNO), Gartland and Werley score (Sarmiento modification) (SGNW), flexion-extension arc (FEArc), and grip fraction test (GripFrac) at 1.5, 3, 6, 12, and 24 months postoperatively. Responsiveness was evaluated by calculating standardized response means (SRM) and Cohen's d effect sizes (ES), and by correlating each instrument's change scores against those of QuickDASH and PRWE, which were also used as external comparators to assess criterion validity. Ceiling/floor effects were calculated for all measures at each time point. RESULTS: SRM (1.5-24 months) were 1.81, 1.77, 1.43, 1.16, 2.23, 2.45 and ES (1.5-24 months) were 1.81, 1.82, 1.95, 1.31, 1.99 and 2.90 for QuickDASH, PRWE, CGNO, SGNW, FEArc, and GripFrac respectively. Spearman correlation coefficients against QuickDASH at 24 months were: 0.809, 0.248, 0.563, 0.285, and 0.318 for PRWE, CGNO, SGNW, FEArc, and GripFrac respectively. Significant (>15% of patients reaching maximum score) ceiling effects were observed before 6 months for PRWE and SGNW. CONCLUSIONS: Our evidence supports the use of QuickDASH, PRWE, FEArc and GripFrac up to 6 months postsurgery, and QuickDASH and PRWE after 6 months. LEVEL OF EVIDENCE: Level II.

Patient expectations predict outcomes following distal radius fracture: a prospective cohort study using the TEFTOM questionnaire.

INTRODUCTION: The relationship between patient expectations and clinical outcomes has recently been of increasing interest in the field of orthopaedics. The objective of this study was to evaluate the relationships between (1) patient pre-treatment expectations and post-treatment clinical outcomes, and (2) fulfillment of expectations and patient satisfaction, following distal radius fracture. METHODS: This was a prospective multicenter cohort study conducted across three hospitals. A total of 133 patients admitted to hospital between 2016 and 2018 with a distal radius fracture were recruited. Patients were administered the Trauma Expectation Factor (TEF) at baseline to measure expectations of pain and functioning at one-year post-injury. Patients were followed up at 6 and 12 months post-injury and outcomes were measured using the Trauma Outcome Measure (TOM), Shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, and Short-Form 12-item (SF-12) health survey. Fulfillment of expectations was measured as TEF score minus TOM score at each time point. Patient satisfaction was also measured using the Patient Satisfaction Questionnaire Short Form (PSQ-18). Multivariate regression models were created to evaluate the effect of expectations on outcomes. RESULTS: Patient expectations correlated moderately with outcomes at 6 and 12 months post-injury. In the multivariate analysis, patient expectations were predictive of better outcomes at 6 and 12 months. Injury severity, age, mechanism of injury, and whether the injury occurred on duty also contributed significantly to one or more regression models. Patient satisfaction correlated weakly with fulfillment of expectations at 6 months, but moderately with all outcome scores. At 12 months, satisfaction did not correlate significantly with expectations fulfillment but correlated moderately to highly with all outcome scores. CONCLUSION: Patient expectations independently predicted outcomes at 6 and 12 months post-injury. Standardized assessment and management of patient expectations may be relevant to future clinical practice and research to best quantify and optimize patient outcomes.

Comparison of radiological and clinical outcomes, complications, and implant removals in anatomically pre-contoured clavicle plates versus reconstruction plates - a propensity score matched retrospective cohort study of 106 patients.

BACKGROUND: Plate fixation is frequently used to treat displaced midshaft clavicular fractures, however the ideal plate choice remains subject to discussion; reconstruction locking compression plates (RLCPs) are cheaper and can be easily contoured, whereas anatomically pre-contoured locking compression plates (ALCPs) are thought to provide better stability and therefore lower rates of mechanical failure. To compare the incidence of mechanical failures, functional and radiological outcomes in patients with midshaft clavicular fractures treated with ALCPs versus RLCPs. METHODS: A propensity score matched retrospective cohort study was conducted across two centers. One hundred and six consecutively recruited patients with displaced midshaft clavicular fractures, who were treated with plate fixation and had a minimum follow-up of 6 months, were matched on gender, age, fracture grading, energy of injury, and fracture location. The resulting groups included 53 ALCP-treated fractures and 53 matched controls treated with RLCPs. RESULTS: During a mean follow-up of 20.5 months, there were no implant deformities in the ALCP group whereas the RLCP group had 6 patients (11.3%, p = 0.012) with implant deformities (5 occurrences of plate bending with fracture union, and 1 plate breakage with nonunion). Despite the higher rate of plate deformities in the RLCP group, there were no statistically significant differences in number of patients recovering full shoulder range of motion (ALCP 90.6%, RLCP 88.7%, p = 0.751), incidence of rest pain (ALCP 13.2%, RLCP 9.4%, p = 0.542), or implant removals (ALCP 49.1%, RLCP 56.6%, p = 0.439). CONCLUSION: ALCPs may be superior to RLCPs in terms of implant stability but appear to produce similar clinical results.

Cementation: for better or worse? Interim results of a multi-centre cohort study using a fenestrated spiral blade cephalomedullary device for pertrochanteric fractures in the elderly.

INTRODUCTION: Cephallomedullary nail fixation is currently the most popular treatment for pertrochanteric fractures. Despite continuous improvement in implant design, fixation failures still occur in a concerning number of cases. This study aims to evaluate the effect of cement augmentation of the new-generation Trochanteric Femoral Nail Advanced (TFNA) perforated spiral blade on complications including fixation failure in the elderly population. MATERIALS AND METHODS: We retrospectively evaluated 107 patients aged 65 + treated for pertrochanteric fractures via TFNA between 2015 and 2019 based on whether cementation was used. Baseline demographics, fracture classifications, and reduction quality were compared. Patients with a follow-up of at least 6 months were analyzed for the primary outcome of fixation failure. All patients, regardless of loss to follow-up within 6 months, were analyzed for other complications including mortality. RESULTS: Seventy-six patients (47 cemented, 29 non-cemented) had a minimum follow-up of 6 months (mean 13 months). There were no statistically significant differences between the two treatment groups in terms of patient demographics, ASA or AO/OTA fracture classification, reduction quality, or length of follow-up. There was a lower rate of fixation failure in the cement-augmented (CA) group versus the non-cement-augmented (NCA) group (2.1% vs 13.8%; p = 0.047). No cut-out or cut-through was observed in the CA group. Seven patients had adverse intraoperative events, with a significantly higher rate of fixation failure in these patients (40% vs 2.8%; p = 0.00). There were no statistically significant differences in 30-day mortality (6.3% CA vs 4.3% NCA; p = 0.632) or 3-month mortality (9.5% CA vs 12.8% NCA; p = 0.589). CONCLUSIONS: Cementation of TFNA blades may decrease risk of fixation failure, however, the surgeon must be aware of potential complications such as cement leakage into the hip joint and be able to manage them as they arise.