Weber Ankle Fracture Classification System Yields Greatest Interobserver and Intraobserver Reliability Over AO/OTA and Lauge-Hansen Classification Systems Under Time Constraints in an Asian Population.

No previous studies have evaluated the intra- and interobserver reliability between the Weber, Lauge-Hansen and AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification systems under time constraints. This study compares the interobserver and intraobserver reliability of the aforementioned classification systems under simulated time constraints. Anteroposterior and lateral radiographs of ankle malleolar fractures from 80 consecutive patients from 2015 to 2016 were classified by 2 independent observers according to Weber, Lauge-Hansen and AO/OTA. Classifications were conducted over 4 successive weeks under timed (25-seconds) and untimed conditions, with 1-week gaps between each classification. Cohen's kappa and percentage agreement were calculated. Cohen's kappa for interobserver agreement ranged 0.67 to 0.67 and 0.59 to 0.73 for untimed and timed classifications for Weber; 0.38 to 0.47 and 0.44 to 0.50 for Lauge-Hansen; 0.28 to 0.49 and 0.13 to 0.37 for AO/OTA. Intraobserver agreement ranged from 0.83 to 0.85 and 0.78 to 0.79 for untimed and timed classifications for Weber; 0.46 to 0.65 and 0.59 to 0.73 for Lauge-Hansen; 0.42 to 0.63 and 0.40 to 0.51 for AO/OTA. Based on the Landis and Koch's benchmark scale, there was substantial agreement in the inter- and intraobserver variables for Weber; moderate agreement in inter- and intraobserver variables for Lauge-Hansen; fair and moderate agreement in inter- and intraobserver variables respectively for AO/OTA. Interobserver and intraobserver reliability was the most substantial for Weber, followed by Lauge-Hansen and AO/OTA. Time constraint did not have a statistically significant effect on the reliability of classifications. We recommend concurrent usage of the Weber and Lauge-Hansen system, since they demonstrate the greatest reliability and reproducibility, and confer better understanding of the fracture type, respectively.

A relook at the reliability of Rockwood classification for acromioclavicular joint injuries.

BACKGROUND: Controversies for treatment of acromioclavicular joint injuries in particular type III injuries may be partially attributed to the lack of a standardized method of radiography and measurement technique. Previous studies looking at the Rockwood classification showed poor inter- and intraobserver reliability (Kappa value approximately 0.20-0.50). We hypothesized that the use of unilateral instead of bilateral acromioclavicular joint radiographs was the cause of this finding. In this article, we standardized the methodology to perform the radiograph and to measure the coracoclavicular distances. We designed the study to focus on the reliability of differentiating type III and type V injuries. METHODS: A standardized radiographic protocol for bilateral Zanca view was established in our institution. All patients who underwent this radiographic examination over a 3-year period were reviewed. Radiographs of 55 patients with significant (type III or V) injury met the inclusion criteria. For the interobserver reliability, a retrospective radiographic review was performed by 6 orthopedic surgeons and graded as either type III or V. For intraobserver reliability, a similar process was repeated by 3 observers after a period of 6 weeks. RESULTS: Going by the majority agreement of the 6 reviewers, there were 34 type III injuries and 19 type V injuries. The Fleiss kappa for interobserver reliability was calculated to be 0.624. The Cohen kappa for intraobserver reliability was calculated to be 0.696. DISCUSSION: The use of a standardized radiographic protocol-taking bilateral Zanca views on the same radiographic plate-would help eliminate a significant amount of variability and improve the reliability of classifying acromioclavicular joint injuries using the Rockwood classification, which uses a relative measure to the contralateral site as its definition criteria. Other possible sources of poor reliability may include the masking of injuries by muscle spasm, resulting in a misdiagnosis of a high-grade injury as a lower-grade one and the possible need to subclassify type III injuries. CONCLUSION: Reliability of the Rockwood classification can be improved through the use of a standardized radiographic protocol to improve the detection of vertical instability. Similar to Rockwood dividing up Tossy grade 3 injuries when he noted the differential outcome and intervention, Rockwood type III injuries would likely require further subclassification as it remains an anomalous tool with high variability. Further studies are required to understand the pathologic basis of transition of type III into type V injury.

Arthroscopic capsular release to treat idiopathic frozen shoulder: How much release is needed?

PURPOSE: This systematic review and meta-analysis aims to provide consensus regarding the degree of optimal extended arthroscopic capsular release in addition to a standard rotator interval release in the treatment of idiopathic frozen shoulder. MATERIALS AND METHODS: The systematic review was conducted using the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines. All articles that reported the outcomes of capsular release in idiopathic frozen shoulder were included. A total of 18 articles with 629 patients and 811 shoulders were included. Clinical outcomes analysed include differences between pre and postoperative ranges of motion (ROM), Visual Analog Score (VAS) reduction, Simple Shoulder Test (SST) scores and Constant scores. Patients were grouped by technique: anterior-inferior capsular release (Group 1), anterior-inferior-posterior capsular release (Group 2), and 360-degree capsular release (Group 3) at follow up points 3,6 and 12 months. RESULTS: Comparing ROM, Group 1 had greater early abduction (p<0.01), early (p<0.01) and overall external rotation (p<0.01) than Group 2, as well as greater early flexion (p<0.01), early abduction (p<0.01), early (p<0.01) and overall internal rotation (p<0.01) than Group 3. Group 2 had greater early (p=0.03) and overall flexion (p<0.01) than Group 1, as well as greater early (p<0.01) and overall flexion (p<0.01), early abduction (p<0.01) and early internal rotation (p<0.01) than Group 3. Group 3 had greater overall flexion (p<0.01) than Group 1 and greater overall external rotation (p<0.01) than Group 2. Comparing VAS scores, the less extensive releases saw the greatest significant postoperative reduction. Group 2 had greater mean improvements in postoperative Constant scores than Group 1 (p<0.01) and Group 3 (p<0.01), while SST scores were significantly higher in Group 1 (p<0.01). CONCLUSION: This systematic review and meta-analysis suggests that less extensive releases may result in better functional and pain scores. Addition of a posterior release offers increased early internal rotation, which was not sustained over time, but provides early and sustained flexion improvements. A complete 360 release may not provide any further benefit. There were no significant differences in the complication rates amongst the 3 techniques. LEVEL OF STUDY: II; Meta-analysis and systematic review.

Percutaneous endobutton fixation of acute acromioclavicular joint injuries and lateral clavicle fractures.

INTRODUCTION: This paper describes a novel technique developed by the senior author to address acute acromioclavicular joint (ACJ) dislocations and certain distal clavicle fractures. METHODS: The procedure employs a four strand, single tunnel, double endobutton repair performed entirely percutaneously, without any arthroscopic guidance or deep surgical dissection. RESULTS: We present the preliminary results from our series of 6 consecutive patients performed over a period of 18 months. The mean length of surgery was 36min (range 32-40) and the mean correction of coracoclavicular (CC) distance achieved was 12.6 mm (range 10.3-14.1). There was no restriction of movement in any of the patients post-operatively and their average QuickDASH scores at final follow-up was 4.2 (range 0-6.8). CONCLUSION: Results in the present series were at least comparable to those for other techniques, validating percutaneous treatment as a solution for acute ACJ dislocations.

Quadrilateral space syndrome: The forgotten differential.

The quadrilateral space is bounded by the teres minor superiorly, the teres major inferiorly, the long head of the triceps medially and the shaft of the humerus laterally. The axillary nerve and posterior circumflex humeral artery pass through this space to enter the posterior compartment of the upper arm. Quadrilateral space syndrome (QSS) is caused by entrapment of the axillary nerve or its main branches and/or the posterior circumflex humeral artery in the quadrilateral space by internal or external compression. QSS can often be difficult to diagnose, given that patients may present with non-specific symptoms. As such, patients may be misdiagnosed with more common disorders of the shoulder. We report a case of QSS masquerading initially as rotator cuff pathology with positive impingement signs.

Intraoperative periprosthetic femur fracture during bipolar hemiarthroplasty for displaced femoral neck fractures.

INTRODUCTION: We aim to review the incidence and risk factors for the development of intraoperative periprosthetic femur fractures while performing a bipolar hemiarthroplasty for displaced neck of femur fractures. Our secondary aim is to characterize the types of intraoperative periprosthetic fractures, the steps leading to the fractures, and the salvage treatments instituted. MATERIALS AND METHODS: 271 patients treated with bipolar hemiarthroplasty after traumatic displaced femoral neck fractures were retrospectively analyzed. Demographic data, co-morbidities, vitamin D level, consumption of steroids, ASA score, surgical approach, surgeon experience, use of cemented or uncemented implants, proximal femur morphology, and types of anaesthesia were analyzed statistically. RESULTS: There were 28 patients (10.3%) with intraoperative periprosthetic femur fractures. We found two significant independent risk factors which were the use of uncemented prosthesis (OR 4.15; 95% CI 1.65-10.46; p = 0.003) and Dorr type C proximal femurs (Dorr A OR 3.6; 95% CI 1.47-8.82; p = 0.005). In addition, patients with Dorr type C proximal femurs who underwent uncemented bipolar hemiarthroplasty were more likely to sustain an intraoperative periprosthetic fracture (14(73.7%) out of 19 patients; p = 0.002). There were no significant differences found in other risk factors. The most common location for these fractures was at the greater trochanter at 11 (39.3%) cases. Majority of them, 15 (53.6%), had intraoperative fractures during trial implant insertion and reduction. CONCLUSION: The overall incidence of intraoperative periprosthetic femur fractures during hemiarthroplasty for displaced neck of femur fractures was 10.3%. The incidence was significantly higher for uncemented (14.7%) when compared to cemented prosthesis (5.4%) and the greater trochanter was the commonest area for periprosthetic fractures during trial implant insertion and reduction. Uncemented prosthesis and Dorr type C proximal femurs were two significant independent risk factors contributing to intraoperative periprosthetic fractures. By identifying these risk factors, surgeons can take ample precautions to prevent complications.

A Reverse Judet approach to the scapula.

Fractures of the scapular body that extend to involve the neck and glenoid articular surface with a large gap pose a significant problem for surgical exposure. Several surgical approaches for scapula fixation have been described, but all give limited exposure to the entire scapular body, neck and articular surface. Here, we describe our 'Reverse Judet' technique, with cadaveric dissections and discuss a clinical case. We believe this approach gives a wide exposure of the infraspinous scapular body, neck and glenoid articular surface while keeping away from vital neural structures.

Partial humeral replacement for peri-prosthetic fractures of the humerus.

INTRODUCTION: Treating peri-prosthetic fractures of the humerus can be very challenging, especially when there is poor bone stock and in the presence of adjacent joint prostheses. We discuss the option of a partial humeral replacement as a salvage procedure for such cases with some technical comments. METHODS: This paper presents a technique which utilises a custom- made cemented connector to incorporate the existing well functioning elbow or shoulder replacement with a commercially available partial humeral replacement (PHR) or to an existing prosthetic humeral stem. RESULTS: Our series involves 6 patients with severe rheumatoid arthritis, all female, with a mean age of 62.5 years. Their surgeries were performed over a span of 10 years, with an average follow up of 49 months. All had a well functioning implant at final follow-up, with a mean Mayo Elbow Performance score of 65. There were no cases of infection, nerve injury or dislocation in our patients. There were 2 deaths in our series, from unrelated medical causes at 2 and 4 years following their surgery. CONCLUSION: Although a partial humeral replacement connected to a well functioning implant is a rare procedure for salvage of a humeral peri-prosthetic fracture, it can be a viable option in certain patient populations. Every attempt should be made to maintain the secondary shoulder stabilisers at the proximal humerus as a functioning unit.

Post Traumatic Avascular Necrosis of the Proximal Carpal Row--A Case Report.

We report a case of avascular necrosis of the scaphoid, lunate and triquetrum in a young 21-year-old patient, after a purely ligamentous peri-lunate dislocation of the wrist. He presented with a Mayfield III peri-lunate dislocation after a road traffic accident and underwent an open reduction and internal fixation. Post-operatively, the scapho-lunate gap widened after removal of the temporary K-wires, and he gradually developed avascular necrosis of the scaphoid, lunate and triquetrum, and osteoarthritis of his wrist. We present this unusual case of simultaneous avascular necrosis of multiple carpal bones and discuss the possible risk factors and subsequent management plans for this complex injury. Our patient has no identifiable contributing factors to developing avascular necrosis. We suspect that the violence of the injury and surgery may have compromised the circulation, and advise caution when treating and counseling these patients pre-operatively.

Postoperative venous thrombotic events in Asian elderly patients with surgically treated hip fractures with and without chemoprophylaxis.

BACKGROUND AND PURPOSE: Chemothromboprophylaxis for hip fracture surgery has been under-practiced in Asia. We investigate the postoperative incidence of venous thrombotic events (VTE) in elderly Asian patients with hip fractures. PATIENTS AND METHODS: Patients over 60 years old with surgically treated hip fractures were reviewed. All patients followed a hip fracture protocol, which included a post-operative ultrasound Doppler venous scan of both lower limbs five days after injury to detect any deep vein thrombosis (DVT). All patients were given mechanical prophylaxis. Patients who had additional chemoprophylaxis were included. RESULTS: From 2010 to 2012, 454 patients were reviewed. The overall incidence of DVT was 6.4% (29 patients). The incidence of PE was 1.3% (six patients). There was no significant correlation between DVT and age, gender, race, hypertension, diabetes mellitus, end stage renal failure, type of fracture and operation, preoperative haemoglobin, platelet count or urea and creatinine levels. Sixteen DVTs (55.2%) were on the ipsilateral side as the fracture, eight (27.6%) were on the contralateral side and five (17.2%) were bilateral. Chemoprophylaxis was not given to 399 patients, of which 27 (6.8%) developed DVT. Ten (2.5%) were proximal DVTs in which four (1%) developed PE. One (0.25%) patient developed PE without DVT. Fifty-five patients were on chemoprophylaxis, of which two (3.6%) developed DVT. Both were proximal DVTs with one subsequently developing PE. CONCLUSIONS: The incidence of VTE in Asian patients may be lower compared to Western populations when mechanical prophylaxis is used. Chemoprophylaxis may assist in reducing the rates of DVT but not PE. The low incidence may not justify the use of routine chemoprophylaxis.

Cancellous screw fixation for undisplaced femoral neck fractures in the elderly.

PURPOSE: To review the outcomes of cancellous screw fixation for undisplaced femoral neck fractures in elderly patients and to identify the risk factors associated with poor outcomes. METHODS: Medical records of 100 patients aged 61 to 94 (mean, 78) years who underwent internal fixation with cancellous screws for undisplaced femoral neck fractures were reviewed. According to the Garden classification, 85 fractures were type 1 (impacted fractures) and 15 were type 2 (complete, undisplaced fractures). Postoperative mobility and pain were assessed through a telephone survey. Outcome measures included the length of surgery, length of hospital stay, perioperative complications, postoperative pain, pre- and post-operative mobility status, and rates and causes of implant revision and mortality. RESULTS: Of the 96 patients followed up for a mean of 39 (range, 25-76) months, 8 underwent revision surgery for avascular necrosis of the femoral head (n = 5) or non-union/implant failure (n = 3). Of the 68 patients assessed for postoperative pain and mobility, 15 had pain on movement, whereas 55 could ambulate independently with or without walking aids (out of 61 that could do so preoperatively). Overall, 30 patients had a decrease in their mobility status. Patients aged > 75 years (compared with those aged ≤ 75 years) were associated with longer length of hospital stay (12.7 vs. 10.2 days, p = 0.047) and higher mortality rate (23% vs. 7%, p = 0.044). The length of hospital stay was also associated with presence of ischaemic heart disease/ cerebrovascular accident (14.4 vs. 11.04 days, p = 0.002). Pain, mobility, and rates of complication and revision were not associated with any of the variables. CONCLUSION: Cancellous screw fixation for undisplaced femoral neck fractures in elderly patients was associated with relatively low complication and revision rates.