MRI as the optimal imaging modality for assessment and management of osteochondral fractures and loose bodies following traumatic patellar dislocation: a systematic review.

PURPOSE: To assess the imaging modalities used for diagnosis, as well as the management decisions of patients with osteochondral fractures (OCF) and loose bodies following traumatic patellar dislocation. METHODS: According to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA), MEDLINE, EMBASE, Web of Science, and PubMed were searched for results from January 1, 2000, to May 18, 2021, in two subsequent searches for English language studies that presented data on traumatic patellar dislocation. Quality of selected papers was assessed using the Methodological Index for Non-Randomised Studies (MINORS) and the Risk of Bias (RoB) 2.0 protocol. Results were qualitatively synthesised, and descriptive statistics were calculated. RESULTS: Forty studies totalling 3074 patients (1407 females) were included for the analysis. The mean age was 18.9 years (range 0-69). The population included 2446 first-time dislocations. The imaging modalities used were: 71.1% MRI, 52.6% plain radiography, 12.1% CT, and 0.68% ultrasound. In the 25 studies that reported the number of OCF, a total of 38.3% of patients were found to have OCF. 43.3% of patients with a first-time dislocation, and 34.7% of patients with previous dislocations, had at least one OCF. In the included paediatric studies (maximum age ≤ 18), the presence of OCF was detected by plain radiography in 10.1% of patients, MRI in 76.6% of patients, and CT in 89.5% of patients. For management of an OCF, the surgical options include fixation for larger pieces, excision for smaller pieces, and conservative management on a case-by-case basis. CONCLUSIONS: Based on the current available evidence, assessment and management of patellar dislocations and subsequent OCFs vary, with radiography and MRI as the main imaging modalities on presentation and particular benefit for MRI in the paediatric population. Findings from this study suggest the highest rate of OCF detection with MRI, and thus, surgeons should consider routinely ordering an MRI in patients with first-time patellar dislocation. Regarding management of OCFs, the main indication for fixation was large fragments, while smaller and poor-quality fragments are excised. Few studies choose conservative management of OCFs due to later requirements for surgical management. Future work should focus on large, high-quality studies, and implementation of randomised control trials to form guidelines for imaging patellar dislocations and management of OCFs. LEVEL OF EVIDENCE: Level IV.

Epidemiology and management of proximal tibia fractures in children and adolescents: a population-based study based on the Kids' Fracture Tool.

BACKGROUND AND PURPOSE: Proximal tibial fractures are infrequent injuries in children, and the literature on epidemiology, associated injuries, and management is limited. We calculated a population-based incidence and described the characteristics of proximal tibial fractures in children in terms of complications and management. PATIENTS AND METHODS: This is a retrospective study over a 6-year-period during including 241 children with proximal tibial fractures who presented to our university hospital. Demographic and fracture-related data was collected from the Kids' Fracture Tool. The number of children during the study period was collected from statistical yearbooks of the City of Helsinki to estimate annual incidence. RESULTS: Extra-articular fractures (129/241) peaked at the age of 3 and tibial tubercle (42/241) and intra-articular fractures (70/241) peaked at the age of 15. Annual incidences were estimated to be 3.4/100,000 children and 22/100,000 children in the age group of 13-16 years for ACL avulsions, and 3.8/100,000 children and 21/100,000 children in the age group of 13-16 years for tibial tubercle fractures. The incidence of vascular compromise (0%) and compartment syndrome was low (0.4 %, 1/241). CONCLUSION: Proximal tibial fractures present with a bimodal distribution, with extra-articular fractures peaking at the age of 3 years and fractures of the tibial tuberosity and intra-articular fractures peaking at the age of 15 years. Additionally, associated compartment syndrome and vascular compromise was not as common as previously reported.

Mood Disorders Are Associated with Increased Perioperative Opioid Usage and Health Care Costs in Patients Undergoing Knee Cartilage Restoration Procedure.

OBJECTIVE: To identify the prevalence of mood disorder diagnoses in patients undergoing cartilage transplantation procedures and determine the relationship between mood disorders, opioid usage, and postoperative health care costs. DESIGN: Patients with current procedural terminology (CPT) codes for osteochondral autograft transplantation (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI) were identified in the Truven Health Marketscan database (January 2009-September 2014). Patients were grouped based on having a preoperative mood disorder diagnosis (preMDD). Preoperative opioids, postoperative opioids ≥90 days, and health care costs within the year postoperative were compared for those with and without mood disorders. Costs were analyzed, adjusting for preoperative cost, sex, age, and opioid usage, for those with and without mood disorders. RESULTS: A total of 3,682 patients were analyzed (ACI: 690, OAT: 1,294, OCA: 1,698). A quarter of patients had preMDD (ACI: 25.4%, OAT: 20.6%, OCA: 22.7%). Postoperative opioid use was more prevalent in preMDD patients (OAT: 37.1% vs. 24.1%, P < 0.001; OCA: 30.4% vs. 24.8%, P = 0.032; ACI: 33.7% vs. 26.2%, P = 0.070) (odds ratio [OR] ranged from 1.29 to 1.86). First-year postoperative log-transformed costs were significantly greater for preMDD patients (ACI: $7,733 vs. $5,689*, P = 0.012; OAT: $5,221 vs. $3,823*, P < 0.001; OCA: $6,973 vs. $3,992*, P < 0.001; *medians reported). The estimated adjusted first postoperative year cost increase for preMDD OCA patients was 41.7% (P < 0.001) and 28.0% for OAT patients (P = 0.034). There was no statistical difference for ACI patients (P = 0.654). CONCLUSION: Cartilage transplantation patients have a high prevalence of preoperative mood disorders. Opioid use and health care costs were significantly greater for patients with preoperative mood disorder diagnoses. LEVEL OF EVIDENCE: Level III, retrospective therapeutic study.

The economic burden of the postoperative management in surgically treated trauma patients with peri- and/or intra-articular fractures of the lower extremities: A prospective multicenter cohort study.

OBJECTIVES: To estimate the economic burden expressed in costs and quality of life of the post-surgical treatment of peri­ and/or intra-articular fractures in the lower extremity from a societal perspective. DESIGN: This is a quantitative study as it aims to find averages and generalize results to wider populations. The design is a cost-of-illness and quality of life study focusing on costs (in euros), Activities of Daily Living (ADL) and Quality of Life (Qol) in patients with peri­ and/or intra-articular fractures of the lower extremities. SETTING: Surgically treated trauma patients with peri­ and/or intra-articular fractures of the lower extremities during 26 weeks follow-up. Patients were included from 4 hospitals in the Netherlands. MAIN OUTCOME MEASURES: Costs, ADL and Quality Adjusted Life Years (QALY). METHODS: Cost of illness was estimated through a bottom-up method. The Dutch Eq-5D-5 L questionnaire was used to calculate utilities while Lower Extremity Functional Scale (LEFS) scores were used as a measure of ADL. Non-parametric bootstrapping was used to test for statistical differences in costs. Subgroup analyses were performed to determine the influence of work status and further sensitivity analyses were performed to test the robustness of the results. RESULTS: Total average societal costs were € 9836.96 over six months. Unexpectedly, total societal and healthcare costs were lower for patients with a paid job relative to patients without. Sensitivity analyses showed that our choice of a societal perspective and the EuroQol as our primary utility measurement tool had a significant effect on the outcomes. The ADL at baseline was respectively; 10.4 and at 26 weeks post-surgery treatment 49.5. The QoL was at baseline respectively; 0.3 and at 26 weeks post-surgery treatment 0.7. These findings are indicative of a significantly improved ADL and QoL (p ≤ 0.05) over time. CONCLUSIONS: This study reveal a substantial economic burden in monetary terms and effect on QoL of patients with peri­ and/or intra-articular fractures of the lower extremities during 26 weeks follow-up. REGISTRATION: This study was registered in the Dutch Trial Register (NTR6077). Date of registration: 01-09-2016.

Application of Rikkli and Regazzoni three-column theory in distal radius intraarticular fractures and its functional and radiological assessment.

Objectives: To determent the effectiveness of Rikli and Regazzoni three-column theory in treating intra-articular fractures of the distal radius with T-plate and K-wire in terms of functional outcome and fracture union. METHODS: The cross-sectional study was conducted at the Department of Orthopaedic Surgery and Traumatology, King Edward University, Mayo Hospital, Lahore, Pakistan, from June 2013 to March 2017, and comprised patients aged 15-60 years having closed intraarticular fracture of the distal radius <1 month older. The subjects were divided into two group A, managed by percutaneous K-wire fixation, and group B, managed with open reduction and internal fixation using T-plates. Wound infection, supination and pronation, flexion and extension at the wrist joint, bone union and functionality were observed. All patients were followed up with intervals for 12 months in the out-patient department, and wound infection and supination and pronation of the forearm were observed clinically. Union was observed using the standard criterion, and function was evaluated using the Disabilities of Arm, Shoulder and Hand score. Data was analysed using SPSS 20. RESULTS: Of the 60 patients, there were 30(50%) with mean age 48.83±11.11 years in group A, and 30(50%) with mean age 49.87±13.45 years in group B. Overall, there were 49(81.7%) males and 11(18.3%) females. There were 33(55%) cases with right side involvement, and 27(45%) had the left side involved. Functionality imprived significantly in both groups (p<0.05). Union was observed in all cases in both groups, while the mean duration in group A was 9.21±1.74 weeks, and in group B it was 9.87±2.14 weeks. Conclusion: Restoration of the three columns of distal radius could either be fixed with T-plates and K-wires because there was no significant difference between the two groups.

Implant Charge Differences Between Distal Radius Fixation Constructs (CPT 25607, 25608, and 25609).

BACKGROUND: Implants are a significant contributor to health care costs. We hypothesized that extra-articular fracture patterns would have a lower implant charge than intra-articular fractures and aimed to determine risk factors for increased cost. METHODS: In total, 163 patients undergoing outpatient distal radius fracture fixation at 2 hospitals were retrospectively reviewed stratified by Current Procedural Terminology codes. Implants and associated charges were noted, as were sex, age, insurance status, surgeon specialty, and location. Bivariate and multivariable regression were used to determine associations. RESULTS: Total implant charges were significantly lower for 25607 (extraarticular, $3,348) than 25608 (2-part intraarticular, $3,859) and 25609 (3+ part intraarticular, $3,991). In addition, intra-articular fractures had higher charges for distal screws/pegs and bone graft. Charge was lower when surgery was performed at a trauma center. There was no charge difference associated with insurance status, age, sex, hand surgery specialty, or fellow status. Substantial intersurgeon variation existed in all fracture types. CONCLUSION: Distal radius fractures may represent a good model for examining implant costs. Extra-articular fractures had lower implant charges than intra-articular fractures. These data may be used to help construct pricing for distal radius fracture bundles and potential cost savings.

Cost Analysis of Volar Plate Fixation Versus Plaster Cast Immobilization for Intra-Articular Distal Radial Fractures.

BACKGROUND: The aim of this study was to compare the cost-effectiveness and cost-utility between plaster cast immobilization and volar plate fixation for acceptably reduced intra-articular distal radial fractures. METHODS: A cost-effectiveness analysis was conducted as part of a randomized controlled trial comparing operative (volar plate fixation) with nonoperative (plaster cast immobilization) treatment in patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Health-care utilization and use of resources per patient were documented prospectively and included direct medical costs, direct non-medical costs, and indirect costs. All analyses were performed according to the intention-to-treat principle. RESULTS: The mean total cost per patient was $291 (95% bias-corrected and accelerated confidence interval [bcaCI] = -$1,286 to $1,572) higher in the operative group compared with the nonoperative group. The mean total number of quality-adjusted life-years (QALYs) gained at 12 months was significantly higher in the operative group than in the nonoperative group (mean difference = 0.15; 95% bcaCI = 0.056 to 0.243). The difference in the cost per QALY (incremental cost-effectiveness ratio [ICER]) was $2,008 (95% bcaCI = -$9,608 to $18,222) for the operative group compared with the nonoperative group, which means that operative treatment is more effective but also more expensive. Subgroup analysis including only patients with a paid job showed that the ICER was -$3,500 per QALY for the operative group with a paid job compared with the nonoperative group with a paid job, meaning that operative treatment is more effective and less expensive for patients with a paid job. CONCLUSIONS: The difference in QALYs gained for the operatively treated group was equivalent to an additional 55 days of perfect health per year. In adult patients with an acceptably reduced intra-articular distal radial fracture, operative treatment is a cost-effective intervention, especially in patients with paid employment. Operative treatment is slightly more expensive than nonoperative treatment but provides better functional results and a better quality of life. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

An Economic Analysis of Direct Costs of Distal Radius Fixation and the Implications of a Disposable Distal Radius Kit.

OBJECTIVE: To assess the direct costs of distal radius fracture volar plate (VP) fixation and to create a model to examine the effect of these cost drivers. MATERIALS AND METHODS: Retrospectively, 744 distal radius fractures treated with open reduction and internal fixation (ORIF) were identified. The outcomes assessed included (1) the direct costs related to distal radius ORIF and (2) if a VP alone was amenable. Costs were represented as a cost ratio relative to the average cost of distal radius ORIF, where the average value is set as 1.0. Simulation models were run with all cost drivers (sex, age, open fracture, intra-articular fracture, and ancillary fixation) and with only ancillary fixation as a cost driver. RESULTS: The cost ratio ranged from 0.61 to 1.81 and ancillary fixation was associated with increased implant costs in multivariable analysis. In the simulations, the cost ratio ranged from 0.96 to 1.23 when all cost drivers were included and from 0.99 to 1.20 if only ancillary fixation was included as a cost driver, a reduction of the range by 22.2%. Older patients, females, closed fractures, and extra-articular fractures were more amenable to VP fixation alone. CONCLUSIONS: Eighty-three percent of the surgically treated distal radius fractures were treated with VP fixation alone. A disposable kit could help limit cost variance per case by roughly 22%, as only ancillary fixation varies these costs. Closed fractures and extra-articular fractures in older patients or female patients are more amenable to VP fixation alone. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cost-utility analysis of extensile lateral approach versus sinus tarsi approach in Sanders type II/III calcaneus fractures.

BACKGROUND: Extensile lateral approach had been recognized as the gold standard technique for displaced intra-articular calcaneus fractures (DIACFs) while sinus tarsi approach had been increasingly valued by surgeons and comparative clinical outcome was shown in both techniques. Appropriate decisions could be made by the clinicians with the help of cost-utility analysis (CUA) about optimal healthcare for type II/III calcaneus fracture. METHOD: A single-center, retrospective study was conducted in which basic characteristics, clinical outcomes, and health care costs of 109 patients had been obtained and analyzed. Changes in health-related quality of life (HRQoL) scores, validated by EuroQol five-dimensional-three levels (EQ-5D-3L), were used to enumerate quality-adjusted life years (QALYs). Cost-effectiveness was determined by the incremental cost per QALY. RESULTS: One hundred nine patients were enrolled in our study including 62 in the ELA group and 47 in the STA group. There were no significant differences between these two groups in mean total cost, laboratory, and radiographic evaluation expense, surgery, anesthesia, and antibiotic expense. The expense of internal fixation materials ($3289.0 ± 543.9) versus ($2630.6 ± 763.7) and analgesia ($145.8 ± 85.6) versus ($102.9 ± 62.7) in ELA group were significantly higher than in the STA group (P < .001, P = .008, respectively). Visual Analogue Scale (VAS) scores showed significant difference at postoperative 3 and 5 days (P < .001). American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores and the Bohlers' and Gissane angle showed no significant differences between the two groups before and after the operation. The cost-effectiveness ratios of ELA and STA were $8766.8 ± 2835.2/QALY and $7914.9 ± 1822.0/QALY respectively, and incremental cost-effectiveness ratio (ICERs) of ELA over STA was $32110.00/QALY, but both showed no significant difference. CONCLUSION: Both ELA and STA techniques are effective operative procedures for the patients with calcaneus fracture. Moreover, STA seems to be more reasonable for its merits including less postoperative pain, and less expense of analgesia as well as internal fixation materials. LEVEL OF EVIDENCE: 5.

The impact of a patient's engagement in their health on the magnitude of limitations and experience following upper limb fractures.

AIMS: Patient engagement in adaptive health behaviours and interactions with their healthcare ecosystem can be measured using self-reported instruments, such as the Patient Activation Measure (PAM-13) and the Effective Consumer Scale (ECS-17). Few studies have investigated the influence of patient engagement on limitations (patient-reported outcome measures (PROMs)) and patient-reported experience measures (PREMs). First, we assessed whether patient engagement (PAM-13, ECS-17) within two to four weeks of an upper limb fracture was associated with limitations (the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), and Patient-Reported Outcome Measurement Information System Upper Extremity Physical Function computer adaptive test (PROMIS UE PF) scores) measured six to nine months after fracture, accounting for demographic, clinical, and psychosocial factors. Secondly, we assessed the association between patient engagement and experience (numerical rating scale for satisfaction with care (NRS-C) and satisfaction with services (NRS-S) six to nine months after fracture. METHODS: A total of 744 adults with an isolated fracture of the proximal humerus, elbow, or distal radius completed PROMs. Due to multicollinearity of patient engagement and psychosocial variables, we generated a single variable combining measures of engagement and psychosocial factors using factor analysis. We then performed multivariable analysis with p < 0.10 on bivariate analysis. RESULTS: Patient engagement and psychosocial factors combined to form a single factor (factor 1) accounting for 20% (QuickDASH, semi-partial R2 = 0.20) and 14% (PROMIS UE PF, semi-partial R2 = 0.14) of the variation in limitations six to nine months after fracture. Factor 1 also accounted for 17% (NRS-C, semi-partial R2 = 0.17) of variation in satisfaction with care, and 21% (NRS-S, semi-partial R2 = 0.21) of variation in satisfaction with services. Demographic factors (age, sex, work status) and measures of greater pathophysiology (type of fracture, high-energy injury, post-surgical complications), accounted for much less variation. CONCLUSION: Patients who actively manage their health and demonstrate effective emotional and social functioning share a common underlying trait. They have fewer limitations and greater satisfaction with care during recovery from upper limb fractures. Future efforts should focus on evaluating initiatives that optimize patient engagement, such as patient education, coaching, and a communication strategy for healthcare professionals. Cite this article: Bone Joint J 2020;102-B(1):42-47.

Scapholunate, lunotriquetral and TFCC ligament injuries associated with intraarticular distal radius fractures: Arthroscopic assessment and correlation with fracture types.

The aim of this study was to evaluate the prevalence of arthroscopic scapholunate (SL) and/or lunotriquetral (LQ) laxity and triangular fibrocartilaginous complex (TFCC) injuries in patients who have an intraarticular fracture of the distal radius and to correlate these lesions with fracture type. Fifty-seven intraarticular radius fractures, whether or not they were associated with an ulnar styloid fracture, were evaluated and treated by arthroscopy. Scapholunate and lunotriquetral ligament injuries were classified according to the EWAS classification. TFCC lesions were assessed according to Palmer's classification. Each injury was documented through preoperative X-rays and a CT scan. Fracture type and soft tissue injury were not significantly associated one to another. Arthroscopic examination revealed at least one soft tissue injury in 39 intraarticular fractures of the distal radius (68.4%). Twenty-five percent of arthroscopic SL laxities (including severe EWAS 3 injuries) were not detected on standard radiographs. Arthroscopic SL laxity was present in 8 of 11 cases (72.7%) of radial styloid fracture and in 15 of 25 cases (60%) of fractures with at least one radial styloid component. There was no association between LQ integrity and fracture type. Ulnar styloid fractures (base or tip) and TFCC lesions were significantly correlated (P<0.0001). The prevalence of soft tissue lesions secondary to intraarticular fractures of the distal radius was 68.4%. However, there was no statistically significant relationship between the different types of radius fractures and soft tissue injuries. On the other hand, ulnar styloid fracture was predictive of TFCC injury.

Nondestructive Assessment of Articular Cartilage Electromechanical Properties after Osteochondral Autologous and Allogeneic Transplantation in a Goat Model.

OBJECTIVE: To determine the applicability of a minimally invasive diagnostic device to evaluate the quality of articular cartilage following autologous (OAT) and allogeneic (OCA) osteochondral graft transplantation in goat model. DESIGN: OAT grafts were harvested from lateral femoral condyles (LFCs) and transplanted into osteochondral defects created in medial femoral condyles (MFCs) of contralateral knees. OCA grafts were transplanted into MFC condyles after in vitro storage. Autologous platelet-rich plasma (PRP) was administered intraarticularly after the surgery and at 1 and 2 months postoperatively. OAT and OCA grafts were evaluated macroscopically (Oswestry arthroscopy score [OAS]), electromechanically (quantitative parameter, QP), and histologically (O'Driscoll score, safranin O staining intensity) at 3 and 6 months after transplantation. Results were compared with preoperative graft evaluation. RESULTS: Transplanted cartilage deteriorated within 6 months in all groups. Cartilage quality was better retained in OAT group compared with a decline in OCA group. QP and OAS scores were comparable in OAT and OCA groups at 3 months, but superior in OAT group at 6 months, according to all the methods applied. PRP injections significantly improved QP and OAS score at 6 months compared with 3 months in OAT group. QP moderately correlated with OAS, O'Driscoll score, and safranin O staining intensity. CONCLUSIONS: Grafts did not retain preoperative quality parameters at 6 months follow-up; however, OAT were superior to OCA grafts. PRP may have a beneficial effect on macroscopic and electromechanical properties of cartilage; however, histological improvement is yet to be proved. Electromechanical diagnostic device enables reliable assessment of transplanted cartilage.

Does arthroscopic assistance improve reduction in distal articular radius fracture? A retrospective comparative study using a blind CT assessment.

INTRODUCTION: The objective of this study was to compare the articular reduction in two groups of patients with a distal articular radius fracture who underwent surgery with versus without arthroscopic assistance. The initial hypothesis of this study is that arthroscopic assistance does not improve reduction in distal articular radius fractures. METHODS: The study was retrospective (1/04/2014-01/04/2017) and included 41 patients: 23 had arthroscopically assisted osteosynthesis, and 18 had not. All patients included had CT before and 3 months after surgery. All radiographic and CT measurements were retrospectively taken by an independent radiologist who did not know which operative technique was performed. Secondary judgement criteria were clinical analysis at 1-year follow-up and tourniquet time. We also reported all soft tissue injuries diagnosed and repaired and postoperative complications. RESULTS: At the third month, articular step was 0.91 ± 1.25 mm (arthroscopy) and 1.41 ± 1.68 mm (no arthroscopy), without statistical difference (p = 0.3756). No difference was found for articular gap between the two groups [arthroscopy (0.55 ± 1.04 mm), (no arthroscopy (0.82 ± 1.54 mm)] (p = 0.8574). Except for the tourniquet time, clinical results at 1-year follow-up were not different. One patient of each group had a scapholunate pinning, and 6 patients of the arthroscopy group had a TFCC 1B injury, which was repaired. CONCLUSION: This study did not demonstrate that arthroscopic assistance improves step and gap reduction of articular distal radius fracture, confirming initial hypothesis and recent literature data. LEVEL OF EVIDENCE: Retrospective, III.

Dynamic ultrasound imaging for the assessment of extensor tendon adhesion after fifth metacarpal intraarticular head fracture: A case report.

STUDY DESIGN: Case report. INTRODUCTION: Development of extensor tendon adhesions is a common complication after intra-articular metacarpal head fracture. Whenever these adhesions cannot be mobilized by rehabilitation, tenolysis should be considered. However, the decision for tenolysis is often delayed. When the rehabilitation program comes to a plateau and clinical examination may not be sufficient to find out the cause, dynamic ultrasound (US) can show where the gliding mechanism is disrupted and help clinicians to give an accurate decision for determining the next steps. PURPOSE OF THE STUDY: To determine the role of dynamic US during hand rehabilitation. METHODS: A 22-year-old woman presented with a fifth metacarpal intra-articular head fracture. Ten days after the surgery (open reduction and internal fixation) the hand rehabilitation program was commenced. After the third week, the metacarpophalangeal (MP) joint range of motion (ROM) gradually diminished. Dynamic US near the level of fifth MP joint revealed diminished extensor tendon excursion and capsular thickening. RESULTS: Considering physical and sonographic findings, surgical tenolysis and capsular release was planned. After surgery, the DIP, PIP and MP joints reached full passive ROM. CONCLUSION(S): Ultrasound is a quick and practical way to diagnose tendon adhesions. With this report, the authors suggest that clinicians may use dynamic US, especially in times when the patient comes to plateau during hand rehabilitation. LEVEL OF EVIDENCE: IV.

Influence of Level 1 Evidence on Management of Clavicle and Distal Humerus Fractures: A Nationwide Comparative Study of Records From 2005 to 2014.

The purpose of this study was to examine alterations in national trends managing midshaft clavicle fractures (MCF) and intra-articular distal humerus fractures (DHF) surrounding recent level 1 publications. A retrospective review of the PearlDiver supercomputer for DHF and MCF was performed. Using age limits defined in the original level 1 studies, total use and annual use rates were examined. Nonoperative management and open reduction and internal fixation (ORIF) were reviewed for MCF. ORIF and total elbow arthroplasty (TEA) were reviewed for DHF. A query yielded 4929 MCF and 106,535 DHF patients. A significant increase in ORIF use for MCF following the publication of the level 1 study (p = .002) and a strong, positive correlation (p = .007) were evident. Annual TEA (p = .515) use for DHF was not observed. (Journal of Surgical Orthopaedic Advances 27(3):219-225, 2018).

Periprosthetic knee fractures. A review of epidemiology, risk factors, diagnosis, management and outcome.

BACKGROUND AND AIM OF THE WORK: Periprosthetic knee fractures incidence is gradually raising due to aging of population and increasing of total knee arthroplasties. Management of this complication represents a challenge for the orthopaedic surgeon. Aim of the present study is to critically review the recent literature about epidemiology, risk factors, diagnosis, management and outcome of periprosthetic knee fractures. METHODS: A systematic search of Embase, Medline and Pubmed was performed by two reviewers who selected the eligible papers favoring studies published in the last ten years. Epidemiology, risk factors, diagnostic features, clinical management and outcome of different techniques were all reviewed. RESULTS: 52 studies including reviews, meta-analysis, clinical and biomechanical studies were selected. CONCLUSIONS: Correct clinical management requires adequate diagnosis and evaluation of risk factors. Conservative treatment is rarely indicated. Locking plate fixation, intramedullary nailing and revision arthroplasty are all valuable treatment methods. Surgical technique should be chosen considering age and functional demand, comorbidities, fracture morphology and location, bone quality and stability of the implant. Given the correct indication all surgical treatment can lead to satisfactory clinical and radiographic results despite a relevant complication rate.

Outcomes and financial implications of intra-articular distal radius fractures: a comparative study of open reduction internal fixation (ORIF) with volar locking plates versus nonoperative management.

BACKGROUND: To evaluate the functional and radiographic outcomes, as well as the treatment costs, of closed displaced intra-articular distal radius fractures treated with either open reduction internal fixation (ORIF) with volar locking plates or nonoperative treatment with plaster cast immobilisation. MATERIALS AND METHODS: A total of 60 patients (32 receiving ORIF, 28 receiving nonoperative treatment) with closed intra-articular distal radius fractures were included. The mean age was 52.1 and 57.4, respectively. Functional and radiographic assessments were carried out at 12 months post-injury. Patients' treatment costs, median salaries and lengths of medical leave were obtained. RESULTS: DASH and MAYO wrist score in the ORIF group did not differ significantly from those in the nonoperative group. Apart from superior ulnar deviation in the ORIF group (p = 0.0096), differences in the range of motion of the injured wrists were not significant. Similarly, there were no significant differences in grip strength and visual analog scale for pain. Volar tilt (p = 0.0399), radial height (p = 0.0087), radial inclination (p = 0.0051) and articular step-off (p = 0.0002) were all significantly superior in the ORIF group. There was a 37-fold difference in mean treatment costs between ORIF (SGD 7951.23) and nonoperative treatment (SGD 230.52). CONCLUSION: Our study shows no difference in overall functional outcomes at 12 months for closed displaced intra-articular distal radius fractures treated with either ORIF with volar locking plates or plaster cast immobilisation, and this is independent of radiographic outcome. A longer follow-up, nevertheless, is needed to determine whether the development of post-traumatic arthritis will have an effect on function. The vast difference in treatment costs should be taken into consideration when deciding on the treatment option. LEVEL OF EVIDENCE: Level 3.

Sanders II/III Calcaneus Fractures in Laborers: A Cost-Effectiveness Analysis and Call for Effectiveness Research.

OBJECTIVE: This study compares the cost and cost-effectiveness of treatments options for Sanders II/III displaced intra-articular calcaneus fractures (DIACFs) in laborers. METHODS: Literature on Sanders type II and III fractures was reviewed to determine complication rates and utility values for each treatment option. Costs were calculated using Medicare reimbursement and implant prices from our institution. Monte Carlo simulations were used to analyze a decision tree to determine the cost and cost-effectiveness of each treatment from a societal perspective. Sensitivity analysis was performed on all variables. RESULTS: Minimally invasive open reduction internal fixation (ORIF) (sinus tarsi approach with 4 screws alone) was least expensive ($23,329), followed by nonoperative care ($24,530) and traditional ORIF using extensile lateral approach ($27,963) (P < 0.001); this result was most sensitive to time out of work. Available cost-effectiveness data were limited, but our analysis suggests that minimally invasive ORIF is a dominant strategy, and traditional ORIF is superior to nonoperative care (incremental cost-effectiveness ratio $57,217/quality-adjusted life year). CONCLUSIONS: Our findings suggest that minimally invasive ORIF (sinus tarsi approach) is the least expensive option for managing Sanders II/III displaced intra-articular calcaneus fractures, followed by nonoperative care. Our cost-effectiveness results favor operative management but are highly sensitive to utility values and are weakened by scarce utility data. We therefore cannot currently recommend a treatment course based on value, and our primary conclusion must be that more extensive effectiveness research (ie, health-related quality of life data, not just functional outcomes) is desperately needed to elucidate the value of treatment options in this field. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Diagnostic value of ultrasonography in elbow trauma in children: Prospective study of 34 cases.

INTRODUCTION: Among the various elbow injuries in children that initially have normal radiographs, a certain number of occult fractures are only diagnosed correctly after the fact, during a follow-up visit. PURPOSE: This study evaluated the diagnostic contribution of ultrasonography in the treatment of acute elbow injuries in children and the strategic and economic impact of using this tool alongside radiography. MATERIALS AND METHODS: During this prospective study performed between January 1 and April 1 2014, elbow ultrasonography was performed within 6 days in all children under 15 years of age with a suspected occult fracture. The ultrasonography exam looked for lipohemarthrosis, the posterior fat pad sign and cortical disruption. If no fracture was visible on ultrasonography, a removable splint was given to the patient to relieve pain, and no radiological or clinical follow-up was scheduled. The patients were contacted again at least 15 days later to determine whether an undetected fracture was present. Lastly, we evaluated the cost of treatment with and without ultrasonography in the cases where no fracture was diagnosed. RESULTS: In 13 cases, ultrasonography revealed lipohemarthrosis and a fat pat sign, with cortical disruption also present in 11 of these cases. In two cases, the diagnosis was made based solely on the presence of lipohemarthrosis and a fat pat sign. There were seven lateral condyle fractures, two medial epicondyle fractures and two supracondylar fractures. Among the 21 patients with normal ultrasonography, no fracture was diagnosed later on. In patients without a fracture, using ultrasonography resulted in a cost savings of €29.10 per patient versus not using it. CONCLUSION: In our study, ultrasonography is a sensitive examination for the diagnosis of occult elbow fractures in children. When the radiography and ultrasonography are both normal, the possibility of fracture can be rule out definitively, which reduces the need for immobilization, follow-up and treatment costs. The findings of this preliminary study should be validated with a larger prospective study.