Hemiarthroplasty Versus Total Hip Arthroplasty for Femoral Neck Fracture in Elderly Patients: Twelve-Month Risk of Revision and Dislocation in an Instrumental Variable Analysis of Medicare Data.

BACKGROUND: There is practice variation in the selection of a total hip arthroplasty (THA) or a hemiarthroplasty (HA) for the treatment of displaced femoral neck fractures in elderly patients. Large data sets are needed to compare the rates of rare complications following these procedures. We sought to examine the relationship between surgery type and secondary hip surgery (revision or conversion arthroplasty) at 12 months following the index arthroplasty, and that between surgery type and dislocation at 12 months, among elderly Medicare beneficiaries who underwent THA or HA for a femoral neck fracture, taking into account the potential for selection bias. METHODS: We performed a population-based, retrospective study of elderly (>65 years of age) Medicare beneficiaries who underwent THA or HA following a femoral neck fracture. Two-stage, instrumental variable regression models were applied to nationally representative Medicare medical claims data from 2017 to 2019. RESULTS: Of the 61,695 elderly patients who met the inclusion criteria, of whom 74.1% were female and 92.2% were non-Hispanic White, 10,268 patients (16.6%) underwent THA and 51,427 (83.4%) underwent HA. The findings from the multivariable, instrumental variable analyses indicated that treatment of displaced femoral neck fractures with THA was associated with a significantly higher risk of dislocation at 12 months compared with treatment with HA (2.9% for the THA group versus 1.9% for the HA group; p = 0.001). There was no significant difference in the likelihood of 12-month revision/conversion between THA and HA. CONCLUSIONS: The use of THA to treat femoral neck fractures in elderly patients is associated with a significantly higher risk of 12-month dislocation, as compared with the use of HA, although the difference may not be clinically important. A low overall rate of dislocation was found in both groups. The risk of revision/conversion at 12 months did not differ between the groups. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Monteggia fracture associated with ipsilateral intercondylar distal humeral fracture with posterior interosseous nerve palsy: case report, medico-legal implications, and methodological assessment analysis.

BACKGROUND: The Monteggia fracture, defined as a fracture of the proximal third of the ulnar shaft associated with an anterior or posterior dislocation of the proximal radial epiphysis, is a serious injury accounting for 0.7% of all elbow fractures and dislocations in adults. For adult patients, good results can only be obtained through early diagnosis and adequate surgical treatment. Monteggia fracture-dislocations associated with distal humeral fracture are extremely rare injuries in adults and there are few cases described in the literature. Medico-legal implications arising from such conditions have a host of complexities that cannot be discounted. CASE REPORT: This case report revolves around a patient affected by a type I Monteggia fracture-dislocation, according to the Bado classification, associated with an ipsilateral intercondylar distal humeral fracture. To our knowledge, this combination of lesions has never been reported before in adult patients. A positive result was obtained due to early diagnosis, achievement of anatomical reduction, and optimal stabilization with internal fixation which made it possible to achieve early functional recovery. CONCLUSIONS: Monteggia fracture-dislocations associated with ipsilateral intercondylar distal humeral fracture are extremely rare in adults. In the case herein reported, a favorable outcome was obtained due to early diagnosis, achievement of anatomical reduction and management with internal fixation with plate and screws, as well as early functional training. Misdiagnosis makes such lesions risky in terms of potentially delayed treatment, increasing the need for surgical interventions and the possibility of high-risk complications and disabling sequelae, with possible medico-legal implications. In the case of unrecognized injuries under urgent circumstances, the injuries may become chronic, making the treatment more complex. The ultimate outcomes of a misdiagnosed Monteggia lesion can lead to very serious functional and aesthetic damage.

Clavicular hook plate versus dog-bone technique for acute high-grade acromioclavicular joint dislocation: a retrospective cohort study comparing clinical outcome scores, complications, and costs.

INTRODUCTION: Arthroscopically assisted coracoclavicular (CC) ligament fixation techniques have been promoted as providing superior outcomes for the treatment of acute high-grade acromioclavicular joint (ACJ) dislocations. Nevertheless, there is a lack of high-level evidence for clinically relevant benefits. At our institute, orthopaedic surgeons use an arthroscopically assisted coracoclavicular ligament fixation technique (DB), while general trauma surgeons use a clavicular hook plate (cHP) technique. The aim of the study was to compare clinical outcomes, complication rates, and costs between the two groups. MATERIALS AND METHODS: The hospital database was searched for patients treated for acute traumatic high-grade (Rockwood Typ ≥ III) ACJ dislocation using either a cHP or arthroscopically assisted DB technique between 2010 and 2019. Seventy-nine patients could be included (56 patients in the cHP group and 23 in the DB group). QuickDASH scores, subjective shoulder value (SSV) scores, pain scores (numerical pain rating scale 10), and complication rates were retrospectively collected through phone interviews and by screening patient charts as well as surgical reports. Costs per patient were obtained from the hospital's accounting system. RESULTS: Mean follow-up was 54 ± 33.7 and 45 ± 21.7 months in the cHP and DB group, respectively. QuickDASH and SSV scores did not differ, but patients in the cHP group reported significantly lower pain scores (p = 0.033). More patients reported hypertrophic or disturbing scars (p = 0.49) and sensibility disturbances (p = 0.007) in the cHP group. Three patients suffered from a frozen shoulder in the DB group (p = 0.023). CONCLUSION: Patient-reported outcomes are excellent after long-term follow-up for both techniques. There are no clinically relevant differences in clinical outcome scores based on our results and a review of the literature. Both techniques certainly have their benefits regarding secondary outcome measures. LEVEL OF CLINICAL EVIDENCE: Level 3, retrospective cohort study.

Influence of kinematics of the lumbopelvic complex in hip arthroplasty dislocation: from assessment to recommendations.

INTRODUCTION: In total hip arthroplasty (THA), misplacement of the implant can provide instability. Adequate orientation of the acetabular cup is a challenge due to variations in inter-individual anatomy and kinematics of the pelvis in everyday life. The aim of this study was to characterize the kinematic factors influencing the risk of dislocation in order to give recommendations for optimal placement of the cup. We hypothesized that the lack of pelvic adaptation would influence the risk of prosthetic instability and motivate adapted. MATERIALS AND METHODS: Eighty patients with primary unilateral THA were included in a matched case-control study. Seventy-four patients were divided into two groups: group 1 (G1) consisting of patients with postoperative THA dislocation (37 patients) and group 2 (G2), without episodes of dislocation within two years postoperatively (37 patients). In both groups, spino-pelvic parameters and cup orientation were measured in standing and sitting positions with EOS® X-ray imaging and compared to each other between 12 and 24 months post-operatively. RESULTS: No significant difference between the two groups was found for static parameters. In a sitting position, a lack of pelvic retroversion with a significant lower variation in sacral slope was observed in group 1 (8.0° ± 9.3 for G1 versus 14.7° ± 6.2 for G2, p < 0.01). Twenty-two (59%) patients with THA instability had sacral slope variations of less than 10° versus eight (21% of patients) with stable THA (p < 0.01). Cup orientation in the Lewinnek safe zone was not significantly different (59% vs 67%, p = 0.62), and the spino-pelvic parameters and cup orientation measured did not change between the standing and sitting positions. However, only 14 (37%) cups in G1 were in the functional safe zone versus 24 (67%) in G2 (p = 0.03). CONCLUSION: Static parameters of the sagittal spinopelvic balance have a low predictive value for prosthetic instability. Dynamic analysis is essential. Kinematic parameters must be taken into account in determining the ideal position of the cup or stem. Stiffness with locked standing or sitting pelvis must be integrated in order to determine a personalized safe zone. LEVEL OF EVIDENCE: Level III (matched case-control study).

Chopart Joint Injuries: Assessment, Treatment, and 10-Year Results.

OBJECTIVES: To investigate injury patterns and long-term outcomes of midtarsal (Chopart) injuries in a sizeable number of patients. DESIGN: Prospective study. SETTING: Level 1 trauma center. PATIENTS: One hundred twenty-two patients (average age 37.6 years) with 128 Chopart injuries over a 15-year period, 27% of who were polytraumatized. In 47%, more than 1 of the 4 bones of the midtarsal joint was fractured. The navicular and cuboid were fractured most often. Purely ligamentous dislocations occurred in 4%. INTERVENTIONS: Operative treatment tailored to the individual fracture pattern was performed in 91.4%. MAIN OUTCOME MEASUREMENTS: Foot Function Index, American Orthopaedic Foot and Ankle Society score, SF-36 physical (PCS) and mental component summary (MCS). RESULTS: Seventy-three patients with 75 Chopart injuries were available for follow-up at an average of 10.1 years. The Foot Function Index averaged 26.9, the American Orthopaedic Foot and Ankle Society score averaged 71.5, and the SF-36 PCS and MCS averaged 43.5 and 51.2, respectively. Negative prognostic factors were a high injury severity score, work-related accidents, open and multiple fractures, purely ligamentous dislocations, staged surgery, delay of treatment >4 weeks, postoperative infection, and primary or secondary fusion. Open reduction and internal fixation led to significantly better results than attempted closed reduction and percutaneous fixation. Radiographic signs of posttraumatic arthritis were observed in 93%, but only 4.7% of cases required a late fusion at the Chopart joint. CONCLUSIONS: Chopart joint injuries lead to functional restrictions in the long term. Purely ligamentous dislocations have the worst prognosis, whereas fractures of a single bone have a favorable outcome after anatomic reduction and internal fixation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Using External Joint Stabilizer - Elbow (EJS-E) for treating elbow instability-biomechanical assessment and clinical outcomes.

BACKGROUND: This study aimed to evaluate the outcome of using an External Joint Stabilizer - Elbow (EJS-E) for persistent elbow instability based on biomechanical experiments and analysis of clinical results. METHODS: An EJS-E was used in 17 elbow instability patients. The median follow-up was 26 months (range, 12-42 months). We evaluated the flexion-extension and pronation-supination movement arcs, visual analog scale (VAS) score, Mayo Elbow Performance Score (MEPS), Broberg and Morrey classification system, and occurrence of complications in these patients. Moreover, construct stiffness and maximum strength tests were performed to evaluate the strength of the fixation techniques. RESULTS: The final median range of the extension-to-flexion and pronation-to-supination arc of the elbow was 135° (range, 110°-150°) and 165° (range, 125°-180°), respectively. The VAS pain scores were > 3 in two patients. The median MEPS was 90 (range, 80-100 points). Five patients showed signs of grade I post-traumatic osteoarthritis according to the Broberg and Morrey radiographic classification system, while grade II changes were observed in three patients. Complications included axis pin loosening with pin-tract infection in two patients, transient ulnar nerve symptoms in two patients, heterotopic ossification in two patients, and suture anchors infection in one patient. Based on the biomechanical testing results, the EJS-E exhibited higher stiffness and resisting force in varus loading. It was 0.5 (N/mm) stiffer and 1.8 (N·m) stronger than the internal joint stabilizer (IJS) by difference of medians (p < 0.05). CONCLUSIONS: Biomechanical and clinical outcomes show that EJS-E via the posterior approach can restore mobility and stability in all patients, thus serving as a valuable alternative option for the treatment of persistent instability of the elbow.

Ultrasonography: an interesting imaging method for ligament assessment during the acute phase of closed elbow injuries.

PURPOSE: To evaluate whether ultrasonography can be used to explore the medial and lateral ligament structures during the acute phase of a closed elbow injury. METHODS: A single-center, prospective study performed between December 2019 and June 2020, including patients who suffered a radial head fracture or elbow dislocation. Two radiologists did a blinded analysis using ultrasonography of visibility, injury grade, and presence of bone avulsion for the radial collateral ligament (RCL), lateral ulnar collateral ligament (LUCL), annular ligament (AL), and anterior (MCLant) and posterior bundles (MCLpost) of the medial collateral ligament. The inter-rater agreement was calculated. The ultrasonography findings were compared with the intraoperative findings in the patients who subsequently underwent surgery. RESULTS: Forty patients were included (28 radial head fractures and 12 elbow dislocations). The inter-rater agreement was strong for all the study parameters (kappa between 0.65 and 1), except for the visibility of the LUCL (kappa 0.52) and the visibility and appearance of the MCLpost (kappa 0.54 and 0.47, respectively). The injured ligaments were thicker than their contralateral counterparts (p < 0.05). In the 10 patients who underwent surgery, the radiological-surgical correlation was 100% for the RCL and medial ligaments and 70% for the LUCL. CONCLUSION: Ultrasonography is a reproducible examination that can be used to assess the damage to elbow ligaments during the acute phase following an injury. This examination could be incorporated into the exploration protocol for elbow injuries during the preoperative assessment and to adapt the treatment.

Treatment patterns and clinical and economic burden of hip dislocation following primary total hip arthroplasty in England.

AIMS: The aim of this study was to estimate the clinical and economic burden of dislocation following primary total hip arthroplasty (THA) in England. METHODS: This retrospective evaluation used data from the UK Clinical Practice Research Datalink database. Patients were eligible if they underwent a primary THA (index date) and had medical records available 90 days pre-index and 180 days post-index. Bilateral THAs were excluded. Healthcare costs and resource use were evaluated over two years. Changes (pre- vs post-THA) in generic quality of life (QoL) and joint-specific disability were evaluated. Propensity score matching controlled for baseline differences between patients with and without THA dislocation. RESULTS: Among 13,044 patients (mean age 69.2 years (SD 11.4), 60.9% female), 191 (1.5%) had THA dislocation. Two-year median direct medical costs were £15,333 (interquartile range (IQR) 14,437 to 16,156) higher for patients with THA dislocation. Patients underwent revision surgery after a mean of 1.5 dislocations (1 to 5). Two-year costs increased to £54,088 (IQR 34,126 to 59,117) for patients with multiple closed reductions and a revision procedure. On average, patients with dislocation had greater healthcare resource use and less improvement in EuroQol five-dimension index (mean 0.24 (SD 0.35) vs 0.44 (SD 0.35); p < 0.001) and visual analogue scale (0.95 vs 8.85; p = 0.038) scores, and Oxford Hip Scores (12.93 vs 21.19; p < 0.001). CONCLUSION: The cost, resource use, and QoL burden of THA dislocation in England are substantial. Further research is required to understand optimal timing of revision after dislocation, with regard to cost-effectiveness and impact on QoL. Cite this article: Bone Joint J 2022;104-B(7):811-819.

Early failure of cement with loosening and dislocation of the femoral component in a unicompartmental knee replacement: a case report with microscopic assessment.

Background Medial unicompartimental knee artrhoplasty (UKA) is a valuable and well-known option in the treatment of medial osteoarthritis (OA). Early recovery and good results are usually reported. Failure mechanism include septic and mechanical loosening, bearing dislocation and lateral or patello-femoral joint OA evolution. The rare case of an atraumatic dislocation of the cemented femoral component of a UKA is presented together with a literature review and a microscopic analysis of the loosened component. Methods The case of a 60-years old man who suffered a UKA failure due to a complete loosening and migration of the cemented femoral component 5 months after its implantation is reported. A review of the literature pertaining early similar catastrophic failures is discussed. Furthermore a stereo-microscopic and scanning electronic microscopic evaluation of the femoral component was performed. Results A UKA-to-TKA revision was performed. Septic loosening was ruled out and one-year follow up showed patient satisfaction with good clinical and radiographic results. Few cases of complete dislocation of the UKA femoral component are reported in the literature. Macro- and microscopic evaluation showed an almost completely smooth surface at the cemented surface of the posterior condyle of the femoral component.   Conclusions Whilst mobile bearing dislocation is a well-known complication of UKA, few cases of this potentially catastrophic complication are reported in the literature. Early UKA failure with complete implant loosening may be determined by a suboptimal cementing technique with inadequate cement penetration into the trabecular bone. In the present case, the absence of cement penetration into the posterior condyle may be one of the reason of the component dislocation after standing up starting with the knee in a highly flexed position.

Pediatric Monteggia Fracture Outcome Assessment - Preliminary Report.

BACKGROUND: The term Monteggia fracture refers to a class of injuries encompassing the fracture of the proximal end of the ulna with subluxation or dislocation of the radial head. These injuries account for 0.4-1% of all forearm fractures in children. Despite its low incidence, Monteggia fractures require particular attention, since as much as 30-50% of the cases may be unrecognized, which subsequently leads to complications. The purpose of this paper is to evaluate treatment outcomes of Monteggia fractures in children. Both conservative treatment and surgery were analyzed. MATERIAL AND METHODS: 15 children (7 boys and 8 girls) between the ages of 4-16.3 years (mean age 8.3 years) with Monteggia fractures were hospitalized at our center in the years 2015-2020. Closed reduction and immobilization in a cast were performed in 12 patients, while three children underwent surgical treatment with internal fixation of the ulna. The radial head dislocation was reduced successfully in every patient. RESULTS: Every child from the study group who received conservative treatment regained full elbow mobility as well as normal forearm supination and pronation. Only one of the patients who underwent the surgery demonstrated a 20° deficit in elbow flexion that did not affect limb function. CONCLUSIONS: 1. Our experience shows that closed reduction together with immobilization in a cast is usually a sufficient treatment in Monteggia fractures. 2. However, the dislocated radial head should be properly reduced in all patients. 3. Correct diagnosis and treatment followed by appropriate rehabilitation result in full recovery and no mobility limitations in children and teenagers.

[Assessment of Clinical Outcomes of Surgically Treated Rockwood Type III Acromioclavicular Dislocation with or without Coracoclavicular Ligament Suture]. / Zhodnocení klinických výsledku operacne resených akromioklavikulárních luxací typu Rockwood III se suturou ci bez sutury korakoklavikulárního vazu.

PURPOSE OF THE STUDY Acromioclavicular (AC) joint dislocation and its surgical treatment still raises a number of questions that remain to be answered. In some types of dislocations, Rockwood type III in particular, the indication for surgical treatment as such is relative. There are numerous techniques and implants available for the reconstruction of AC joint. In our research we focused on the necessity of coracoclavicular (CC) joint reconstruction. MATERIAL AND METHODS In this paper, a cohort of 56 patients with Rockwood type III AC joint injury who underwent surgical treatment at our department in 2010-2016 period was retrospectively evaluated. The patients were treated with open reduction with AC joint stabilisation using hook plate or tension band. The patients were divided into 2 groups, namely group 1 with CC ligament reconstruction and group 2 without CC ligament reconstruction. The assessment was done at 6 months, 1 year and 2 years after surgery. The clinical outcomes were assessed based on the absolute Constant score (CS) and coracoclavicular distance (CCD) on the X-ray. Subsequently, the outcomes were statistically processed and compared using the Student s ttest. RESULTS The least invasive surgical intervention, as to the length of incision, was the reconstruction using the hook plate without CC ligament suture, whereas the longest incision was performed in tension band with CC ligament suture. In the CC ligament suture group, the mean operative time was 10 minutes longer. When evaluating the CS of the compared groups with and without CC ligament reconstruction, no statistically significant difference (p > 0.05) was found between the two groups. Similarly, the CCD values at 2-year follow-up did not show any statistically significant difference between the two groups (p > 0.05). CONCLUSIONS The available outcomes suggest that the surgical methods used by us are adequately safe and reliable. Good clinical outcomes can be achieved by open reduction and fixation of Rockwood type III AC joint dislocation even without CC ligament reconstruction. Key words: acromioclavicular dislocation, classification, reconstruction, coracoclavicular ligament.

Efficacy and Safety of Atlantoaxial Fluoroscopy-guided Pedicle Screw Fixation in Patients Younger Than 12 Years: A Radiographic and Clinical Assessment.

STUDY DESIGN: A retrospective clinical study. OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of fluoroscopy-guided atlantoaxial pedicle screw fixation in patients younger than 12 years. SUMMARY OF BACKGROUND DATA: C1-C2 pedicle screw fixation is a widely accepted treatment method for atlantoaxial dislocation (AAD). However, data regarding its use for atlantoaxial fusion (AAF) in children are limited. METHODS: Thirty-six consecutive patients younger than 12 years underwent C1-C2 pedicle screw fixation for AAD between 2007 and 2017. Anatomical parameters of the C1 pedicle were measured on preoperative computed tomography (CT). Accuracy of pedicle screw fixation was assessed on postoperative CT using the following definitions: Type I, screw threads completely within the bone; Type II, less than half the diameter of the screw violating the surrounding cortex; and Type III, clear violation of the transverse foramen or spinal canal. Demographic, surgical, radiation dose, and clinical data were recorded. RESULTS: Patients underwent 144 screw fixations (67 C1 pedicle screws, 68 C2 pedicle screws, 5 C1 lateral mass screws, and 4 C-2 laminar screws) for a variety of pediatric AADs, with 36.5 ±â€Š8.5 months of follow-up. Among the 135 pedicle screws, 96.3% were deemed "safe" (Type I or II) and 80.7% (109/135) of the screws were rated as being ideal (Type I); five screws (3.7%) were identified as unacceptable (Type III). Average estimated blood loss (EBL) was 92 mL, and the average total radiation exposure during the operation was 6.2 mGy (in the final 26 cases). There were no neurovascular injuries. All patients showed radiographic stability and symptom resolution. CONCLUSION: C1-C2 pedicle screw fixation under fluoroscopy is safe and effective for the treatment of AAD in children younger than 12 years. However, it may be technically challenging owing to the special anatomical features of children and should be performed by experienced surgeons. LEVEL OF EVIDENCE: 3.

Flexible fixation for ligamentous lisfranc injuries.

Lisfranc injuries require anatomic reduction and stabilization of the tarsometatarsal joints. We describe a novel technique that provides flexible fixation that is simple, cost-effective and that may offer certain advantages over more traditional techniques.

Open versus modified arthroscopic treatment of acute acromioclavicular dislocation using a single tight rope: randomized comparative study of clinical outcome and cost-effectiveness.

PURPOSE: The purpose of this study was to compare clinical outcome and cost-effectiveness between arthroscopic and open repair using TightRope in acromioclavicular joint dislocation III and IV. PATIENTS AND METHODS: Fifty-two patients with acute acromioclavicular joint dislocation type III and IV were included. Patients were randomly allocated to either of 2 groups: Arthroscopic Repair Group (ARG) and Open Repair Group (ORG). Constant-Murley Score (CMS), visual analog scale (VAS) score, and coracoclavicular (CC) distance were measured preoperatively and 3 months, 6 months, 1 year, and 2 years postoperatively. RESULTS: CMS increased from 40.68 for the ARG and 40.70 for the ORG preoperatively to 84.18 and 84.45 after 2 years from operation. VAS score decreased from 60.59 for the ARG and 64.50 for the ORG 1 day after surgery to 18.04 and 17.87 respectively after 6 months. CC distance decreased from 29.27 mm in the ARG and 28.16 mm in the ORG preoperatively to 9.86 mm in the ARG and 10.54 mm in the ORG on postoperative day 1. Rewidening of the CC distance occurred after 6 months (13.27 mm for the ARG and 13.62 mm for the ORG) and 1 year postoperatively (15.77 for the ARG and 15.41 for the ORG) but remained stable at final follow-up. There was a significant difference in surgical time (80.00 minutes in the ARG compared to 52.79 minutes in the ORG) and cost of consumables (US$1729.95 in the ARG compared to US$851.87 in the ORG). CONCLUSION: Open and arthroscopic repair of acute acromioclavicular joint dislocation yielded good clinical results, yet the arthroscopic technique is more expensive and has a longer surgical time.

Surgical treatment, complications, and reimbursement among patients with clavicle fracture and acromioclavicular dislocations: a US retrospective claims database analysis.

Aims: To assess rates of surgical treatment, post-surgical complications, reoperations, and reimbursement in patients with clavicle fractures and acromioclavicular (AC) dislocations. Materials and methods: This US retrospective study used data from patients with ≥1 diagnosis of clavicle fracture or AC dislocation (index) between 2012-2016. Surgical treatment was defined as a procedure within 4 weeks after clavicle fracture/AC dislocation. Rates of complications (infection, non-union, mal-union), reoperations (device removal or revisions), and all-cause healthcare reimbursement (adjusted to 2016$) were evaluated 2 years post-index among surgical patients. Results: A total of 95,243 patients with clavicle fracture and 52,100 patients with AC dislocation were identified. Mean (SD) age for clavicle fracture and AC dislocation was 23.8 (18.6) and 33.0 (15.6) years, respectively. Most clavicle fracture and AC dislocation patients were male (70.9% and 78.0%, respectively), and had few comorbidities (86.4% and 84.8% had a Charlson Comorbidity Index = 0 and 73.1% and 66.0% had Elixhauser = 0, respectively). Only 15.2% of clavicle fracture and 5.3% of AC dislocation patients received surgical treatment. Among patients undergoing surgical treatment, 2-year rates of infection, non-union, and mal-union were 1.0%, 4.2%, and 0.9%, respectively, for clavicle fracture, and 2.0%, 0.9%, and 0.1%, respectively, for AC dislocation. Reoperations occurred in 83.0% of clavicle fracture and 67.5% of AC dislocation patients. Mean (SD) 2-year reimbursement was $27,635 ($68,173) for clavicle fracture and $23,096 ($28,746) for AC dislocation. Limitations: Administrative claims data lack clinical information, limiting inferences that can be made. This data may not be generalizable to other patients. Conclusions: Rates of surgical treatment for clavicle fractures and AC dislocation and rates of infection, non-union, and mal-union among surgically-treated patients were low. However, surgical patients had high rates of device removal or revision surgery during 2-year follow-up. Improved surgical methods and technologies could reduce non-planned reoperations and device removals, thereby reducing healthcare system costs.

The burden of chronic elbow dislocations in Cambodia and early results of a cost-effective surgical approach.

Chronic elbow dislocation presents a surgical challenge and there is difficulty in balancing stability with early mobilisation. We present a series of 103 patients treated with open reduction via a posterior approach and provide early results of an alternative combined medial and lateral approach (Soddo technique, Anderson et al.). Of the 103 patients, 81% initially consulted a traditional healer and the mean dislocation period was 11 weeks. There was significant loss to follow-up. Only 12 patients having undergone the posterior approach had complete datasets. The mean preoperative arc of movement was 10° and the postoperative arc was 65° at a mean follow-up of 16 weeks. Five patients treated with the Soddo technique had sufficient follow-up data. The mean preoperative arc was 20° and the mean postoperative arc was 95° (mean follow-up of 20 days). Those having undergone the Soddo technique achieved a 20° greater increase in range of movement and no re-dislocations.

Stabilization of Acute High-Grade Acromioclavicular Joint Separation: A Prospective Assessment of the Clavicular Hook Plate Versus the Double Double-Button Suture Procedure.

BACKGROUND: The stabilization strategy for acute high-grade acromioclavicular (AC) joint separations with AC-stabilizing clavicular hook plate (cHP) or coracoclavicular (CC)-stabilizing double double-button suture (dDBS) is still under consideration. HYPOTHESIS: The CC-stabilizing dDBS is superior to the cHP according to an AC-specific radiologic assessment and score system. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Seventy-three consecutive patients with acute high-grade AC joint separation were prospectively followed in 2 treatment groups (64.4% randomized, 35.6% patient-selected treatment): open reduction and cHP (cHP group) or arthroscopically assisted dDBS (dDBS group) performed within 14 days of injury. Patients were prospectively analyzed by clinical scores (Taft, Constant score [CS], numeric analog scale for pain) and AC-specific radiographs (AC distance, CC distance [CCD], relative CCD [rCCD; 100 / AC distance × CCD]) at points of examination (preoperative and 6, 12, and 24 months). The minimal clinically important differences (MCIDs) were assessed by the anchor-based method. RESULTS: Twenty-seven of 35 patients (mean age ± SD: 37.7 ± 9.7 years) after cHP implantation and 29 of 38 patients (34.2 ± 9.7 years) after dDBS implantation were continuously followed until the 24-month follow-up. All patients showed significantly increased scores after surgery as compared with preoperative status (all P < .05). As compared with GI, GII had significantly better outcomes at 24 months (Taft: cHP = 9.4 ± 1.7 vs dDBS = 10.9 ± 1.1, P < .05, MCID = 2.9; CS: cHP = 90.2 ± 7.8 vs dDBS = 95.3 ± 4.4, P < .02, MCID = 16.6) and at 24 months for Rockwood IV/V (Taft: cHP = 9.4 ± 1.7 vs dDBS = 11.1 ± 0.8, P < .0005; CS: cHP = 90.1 ± 7.7 vs dDBS = 95.5 ± 3.1, P < .04). Clinically assessed horizontal instability persisted in 18.52% (GI) and 6.89% (GII; P = .24). The rCCD showed equal loss of reduction at 24 months (GII = 130.7% [control = 111%] vs GI = 141.8% [control = 115%], MCID = 11.1%). CONCLUSION: This prospective study showed significantly superior outcomes in all clinical scores between GII and GI. The subanalysis of the high-grade injury type (Rockwood IV/V) revealed that these patients showed significant benefits from the dDBS procedure in the clinical assessments. The cHP procedure resulted in good to excellent clinical outcome data and displayed an alternative procedure for patients needing less restrictive rehabilitation protocols.

Three-dimensional quantitative assessment of surgical stability and condylar displacement changes after counterclockwise maxillomandibular advancement surgery: Effect of simultaneous articular disc repositioning.

INTRODUCTION: In this study, we quantitatively assessed 3-dimensional condylar displacement during counterclockwise maxillomandibular advancement surgery (CMMA) with or without articular disc repositioning, focusing on surgical stability in the follow-up period. METHODS: The 79 patients treated with CMMA had cone-beam computed tomography scans taken before surgery, immediately after surgery, and, on average, 15 months postsurgery. We divided the 142 condyles into 3 groups: group 1 (n = 105), condyles of patients diagnosed with symptomatic presurgical temporomandibular joint articular disc displacement who had articular disc repositioning concomitantly with CMMA; group 2 (n = 23), condyles of patients with clinical verification of presurgical articular disc displacement who had only CMMA; and group 3 (n = 14), condyles of patients with healthy temporomandibular joints who had CMMA. Presurgical and postsurgical 3-dimensional models were superimposed using voxel-based registration on the cranial base. Three-dimensional cephalometrics and shape correspondence were applied to assess surgical and postsurgical displacement changes. RESULTS: Immediately after surgery, the condyles moved mostly backward and medially and experienced lateral yaw, medial roll, and upward pitch in the 3 groups. Condyles in group 1 showed downward displacement, whereas the condyles moved upward in groups 2 and 3 (P ≤0.001). Although condylar displacement changes occurred in the 3 groups, the overall surgical procedure appeared to be fairly stable, particularly for groups 1 and 3. Group 2 had the greatest amount of relapse (P ≤0.05). CONCLUSIONS: CMMA has been shown to be a stable procedure for patients with healthy temporomandibular joints and for those who had simultaneous articular disc repositioning surgery.

Assessment of acetabular version in total hip arthroplasty: an application of Widmer's technique in a regional setting.

BACKGROUND: Acetabular prosthesis positioning in total hip arthroplasty is important in reducing the risk of dislocation. Assessment of version by computed tomography scan is expensive and involves a large radiation dose. We wished to assess the value of Widmer's technique, utilizing readily available radiographs, to determine cup anteversion. METHODS: Patients who underwent primary total hip arthroplasty by the senior author (AGS) at a single regional hospital over a 5-year period were eligible for inclusion. Measurements were performed using the technique described by Widmer, utilizing standard post-operative radiographs. Statistical analysis was undertaken in SPSS v22. Significance was accepted at P < 0.05. RESULTS: Assessment included 109 hips in 99 patients; 63 hips with cemented cups and 46 hips with uncemented cups. Mean acetabular anteversion in the cemented group was 11.9° (0-27.7, SD: 7) and in the uncemented group was 14.1° (10.3-32.7, SD: 7.1); this difference trended towards statistical significance (P = 0.09). Test-retest measurements showed high degree of correlation (Pearson test: 0.927, P < 0.001). There were 96 of 109 hips positioned in the Lewinnek safe zone of 5-25° anteversion. The crude dislocation rate in our cohort was 6.4% (7 of 109 hips) with all dislocations occurring in hips placed in the safe zone. CONCLUSION: Widmer's technique is a reliable method for calculating acetabular version in a regional hospital setting and offers the individual surgeon a ready technique of personal quality control. Cup version was not a significant factor contributing to dislocation rates in our series.

External fixation and surgical fusion for pediatric cervical spine injuries: Short-term outcomes.

OBJECTIVE: To compare in-hospital complication rates in pediatric patients with atlantoaxial and subaxial injuries undergoing either external fixation or surgical fusion. PATIENTS AND METHODS: Baseline and outcome data were obtained from the 2002-2011 Nationwide Inpatient Sample (NIS) for patients under the age of 18 with a diagnosis of cervical spine fracture without spinal cord injury or cervical spine subluxation. Patients who underwent external immobilization or internal fixation were included for analysis. Variables analyzed included length of stay, in-hospital mortality, discharge disposition, total hospital charges, and development of at least one in-hospital complication. RESULTS: A total of 2878 pediatric patients with cervical spine injury were identified; 1462 patients (50.8%) with atlantoaxial (C1-2) injury and 1416 (49.2%) with subaxial (C3-7) injury. Among atlantoaxial injury patients, external fixation was associated with lower total charges ($73,786 vs. $98,158, p = .040) and a lower likelihood of developing at least one complication (1.9% vs. 6.8%, p = .029) compared to surgical fusion, and was a more common treatment for subluxation alone (16.4% vs. 2.6%, p < .001). Among subaxial injury patients, there were no significant differences in age (p = .262), length of stay (p = .196), occurrence of at least one complication (p = .334), or total charges (p = .142). Subaxial subluxation injuries alone were treated more often with surgical fusion (2.2% vs. 1.2%, p < .001). CONCLUSION: Optimal treatment of patients with cervical injury may vary by location of injury. Our findings warrant further investigation into the difference in clinical outcomes between surgical and non-surgical management of atlantoaxial and subaxial injury.