A novel fragment specific classification of complex olecranon fractures: 3-dimensional model design, radiological validation, and proposed surgical algorithm.

BACKGROUND: Current classifications for proximal ulna fracture patterns rely on qualitative data and cannot inform surgical planning. We propose a new classification system based on a biological and anatomical stress analysis. Our hypothesis is that fragment types in complex fractures can be predicted by the tendon and ligament attachments on the proximal ulna. METHODS: First, we completed a literature review to identify quantitative data on proximal ulna soft tissue attachments. On this basis, we created a 3-dimensional model of ulnar anatomy with SliceOMatic and Catia V5R20 software and determined likely locations for fragments and fracture lines. The second part of the study was a retrospective radiological study. A level-1 trauma radiological database was used to identify computed tomography scans of multifragmentary olecranon fractures from 2009 to 2021. These were reviewed and classified according to the "fragment specific" classification and compared to the Mayo and the Schatzker classifications. RESULTS: Twelve articles (134 elbows) met the inclusion criteria and 7 potential fracture fragments were identified. The radiological study included 67 preoperative computed tomography scans (mean 55 years). The fragments identified were the following: posterior (40%), intermediate (42%), tricipital (100%), supinator crest (25%), coronoid (18%), sublime tubercle (12%), and anteromedial facet (18%). Eighteen cases (27%) were classified as Schatzker D (comminutive) and 21 (31%) Mayo 2B (stable comminutive). Inter-rater correlation coefficient was 0.71 among 3 observers. CONCLUSION: This proposed classification system is anatomically based and considers the deforming forces from ligaments and tendons. Having a more comprehensive understanding of complex proximal ulna fractures would lead to more accurate fracture evaluation and surgical planning.

Phone Administration of the Western Ontario Shoulder Instability Index Is More Reliable Than Administration via Email.

BACKGROUND: The Western Ontario Shoulder Instability (WOSI) questionnaire is a 21-item questionnaire to evaluate quality of life in patients with shoulder instability. Completing the questionnaire is time-consuming because each item is evaluated on a visual analog scale. Telephone or email versions of the score are appealing alternatives to administering it during the standard in-person patient visit; however, their validity and reliability remain unknown. QUESTIONS/PURPOSES: (1) Does the numerical scale (NS) version of the WOSI correlate with the original WOSI and Quick-DASH? (2) Do telephone and email administration of the NS-WOSI have good reliability and consistency? (3) Compared with the original WOSI form, does the NS form lead to faster completion for patients and quicker data extraction for researchers? METHODS: Between 2014 and 2019, 50 patients with a documented history of shoulder dislocation with persistent symptomatic shoulder instability, whether anterior, posterior, or multidirectional; patients scheduled for surgery; and patients with traumatic or nontraumatic injuries were prospectively recruited from the outpatient clinic of two university hospitals acting as Level 1 trauma centers and sports traumatology tertiary referral centers. The median (IQR) age was 28 years (24 to 36), and 80% (40 of 50) were men. Most (52% [26 of 50]) patients had two to five lifetime shoulder dislocations. Validity of the NS-WOSI was assessed using the Pearson correlation coefficient during an in-person visit; the original WOSI questionnaire (or its previously validated French-language version), NS-WOSI, and Quick-DASH questionnaires were administered in a random order. After a minimum 7-day interval, 78% (39 of 50) of patients completed the phone interview, and 74% (37 of 50) of patients completed the email version of the NS-WOSI score to evaluate NS-WOSI's reliability using the intraclass correlation coefficient (ICC), which was interpreted as poor (< 0.5), moderate (0.50-0.75), strong (0.75-0.90), and very strong (> 0.90). The standard error of measurement (SEM) was used to evaluate variability around the true score, with a low value indicating a high reliability. The 95% minimal detectable change (MDC 95% ) was calculated to evaluate the minimal change in score that was not related to measurement errors. Lastly, the Cronbach alpha was used to assess internal consistency (intercorrelation strength), where a value > 0.70 was considered good. The time needed for the patient to complete the various versions and for researchers to extract data was recorded. RESULTS: The NS-WOSI score was very strongly correlated with the original WOSI score (r = 0.96 [95% confidence interval (CI) 0.93 to 0.98]; p < 0.001). Although telephone-acquired and email-acquired data for the NS-WOSI questionnaires were correlated with the NS-WOSI (telephone r = 0.91 [95% CI 0.83 to 0.95]; p < 0.001; email r = 0.84 [95% CI 0.71 to 0.91]; p < 0.001), the ICC was higher for telephone interviews (0.92 [95% CI 0.86 to 0.96] versus email 0.80 [95% CI 0.64 to 0.89]), indicating that although both had good reliability, the phone interview was more suitable. The phone interview was also preferable to email regarding SEM (3% [52 of 2100 points] versus 6% [132 of 2100 points]) and the MDC 95% (7% [144 of 2100 points] versus 17% [366 of 2100 points]). The 95% CI of the MDC acquired by email was superior to the reported minimum clinically important difference for the original WOSI (7% [152 of 2100 points]), meaning that an error of measurement could wrongly be interpreted as a clinically significant change in score. Internal consistency was deemed good, with a Cronbach alpha of 0.96 (95% CI 0.92 to 98) and 0.89 (95% CI 0.79 to 0.94) for NS-WOSI telephone and email, respectively. The time to complete the NS-WOSI was reduced compared with the original WOSI (221 ± 153 seconds versus 266 ± 146 seconds, mean difference -45 seconds [95% CI -72 to -12]; p = 0.009). Lastly, data extraction was faster (62 ± 15 seconds versus 209 ± 52 seconds, mean difference -147 seconds [95% CI -164 to -130]; p < 0.001) with the NS-WOSI than with the original WOSI. CONCLUSION: The NS-WOSI in person, by telephone, or by email is a valid, reliable, and timesaving alternative to the original WOSI questionnaire. However, the reliability of data acquisition by telephone interviews was superior to that of email. CLINICAL RELEVANCE: Given that there were no important differences in performance for the NS-WOSI, regardless of whether it was administered in person or by phone, we suggest that physicians use both interchangeably based on patient convenience. However, we do not recommend using the email version, especially for research purposes, since it was not as reliable when compared with in-person administration. The responsiveness of the modified NS-WOSI, as well as factors influencing response rates to phone interview, are questions that remain to be explored.

The POSI study: gender differences in 94 cases of postoperative shoulder surgery infection: results of a 7-year retrospective multicenter study.

BACKGROUND: Contrary to lower limb infection, POstoperative Shoulder surgery Infection (POSI) often involves Cutibacterium acnes. Our aim was to describe patient characteristics and pathogens retrieved in POSI to guide initial empiric antibiotic selection with suspected infection during revision. We also compared microorganisms in infection following trauma, arthroplasty (AP), and arthroscopy (AS). METHODS: A multicenter retrospective study from 2010 to 2016 reviewed laboratory databases and medical records to identify patients with a previous shoulder surgery and a confirmed shoulder infection. The following procedures were included: AP, AS, fracture fixation (FF), and another open surgery (OS). A confirmed shoulder infection was defined as 2 positive cultures or more of the same microorganism, or clear clinical infection with 1 positive culture or more. RESULTS: Among the 5 hospitals and 28 surgeons involved, 94 POSI cases were identified. Mean age was 59 years at index surgery (range: 22-91) with a majority of men (n = 70, 74%). Among POSI cases, AP was the most common index surgery (n = 41), followed by FF (n = 27), AS (n = 16), and OS (n = 10). The median time between index surgery and the first positive sample was 5 months and the mean was 23 months (minimum 6 days to maximum 27 years), illustrating a positively skewed distribution. Cutibacterium spp were identified in 64 patients (68%), including 59 C acnes patients (63%), which was the most frequent germ in all 4 surgical groups. In 86% of cases, C acnes was identified at the first revision. The other 2 most common germs were Staphylococcus epidermidis and Staphylococcus aureus, with 29% and 17%, respectively. Polymicrobial infection was present in 30% of patients. Gender analysis revealed that C acnes was twice as frequent in men (male = 52 of 70, female = 7 of 24; P < .001). S epidermidis was more prevalent in women (n = 11; 46%) compared with men (n = 16; 21%) (P = .032). C acnes infection was most frequent in arthroscopic surgery (n = 14; 70%, P = .049). S epidermidis was 3 times more prevalent in chronic than in acute cases. CONCLUSION: Empiric antimicrobial therapy following POSI, while waiting for culture results, should cover C acnes, S epidermidis, and S aureus. There is a significant gender difference regarding POSI culture results. C acnes is more frequent in men, but should still be covered in women as it was found in 29% of cases.

Traumatic brain injuries are ignored or discriminated in prospective clinical trials on shoulder fractures: a systematic review.

PURPOSE: Current literature suggests a significant epidemiological association between traumatic brain injury (TBI) and proximal upper limb fractures in addition to major clinical consequences. A systematic review was conducted to assess how TBI is taken into consideration in interventional studies on shoulder fractures. METHODS: The following data sources were used: MEDLINE, EMBASE, EBM Reviews, CINAHL, and OpenGrey databases. Study selection included interventional randomized clinical trials and prospective cohort studies on shoulder fractures published in English or French between 2008 and 2020. Studies on pathologic fractures, chronic fracture complications, nonhuman subjects, and biomechanics were excluded. Articles were reviewed by two independent authors according to the PRISMA guidelines. Baseline characteristics, exclusion criteria, and input relevant to TBI were recorded. Methodological quality was assessed with the Cochrane risk of bias tool for randomized clinical trials and the Newcastle-Ottawa Scale for cohort studies. RESULTS: One-hundred-thirteen studies met the inclusion criteria. None discussed the possible impact of TBI on their results. Only three (2.7%) studies considered TBI relevant and included these patients in their cohort. Furthermore, 43/113 (38.1%) excluded patients with injuries or mechanisms strongly related to traumatic brain injuries: head injuries (4); moderate and/or severe TBI (7); high energy traumas (3); Polytrauma subjects (33). CONCLUSION: TBI are ignored or discriminated in prospective clinical trials on shoulder fractures. The exclusion of these cases impacts generalizability as their prevalence is significant. Considering the major impact of TBI on important outcomes, its presence should always be assessed to ensure high quality evidence. LEVEL OF EVIDENCE: Systematic Review, Therapeutic Level II.

Variable flip angle T1 mapping and multi-echo T2 and T2* mapping magnetic resonance imaging sequences allow quantitative assessment of canine lumbar disc degeneration.

Magnetic resonance imaging is the gold standard for diagnosing intervertebral disc (IVD) degeneration in dogs. However, published methods for quantifying severity or progression of IVD degeneration are currently limited. Mapping MRI sequences are used in humans for quantifying IVD degeneration but have rarely been applied in dogs. The objective of this prospective, method comparison study was to evaluate variable flip angle T1 mapping and multiecho T2 and T2* mapping as methods for quantifying canine lumbar IVD degeneration in twenty canine patients without clinical signs of spinal disease. Ventral and dorsal lumbar IVD widths were measured on radiographs, and lumbar IVDs were assigned a qualitative Pfirrmann grade based on standard T2-weighted sequences. T1, T2, and T2* relaxation times of the nucleus pulposus (NP) were measured on corresponding maps using manual-drawn ROIs. Strong intra- and interrater agreements were found (P < 0.01) for NP relaxation times. Radiographic IVD widths and T1, T2, and T2* mapping NP relaxation times were negatively correlated with Pfirrmann grading (P < 0.01). Significant differences in T1 NP relaxation times were found between Pfirrmann grade I and the other grades (P < 0.01). Significant differences in T2 and T2* NP relaxation times were found between grade I and the other grades and between grades II and III (P < 0.01). Findings indicated that T1, T2, and T2* MRI mapping sequences are feasible in dogs. Measured NP relaxation times were repeatable and decreased when Pfirrmann grades increased. These methods may be useful for quantifying the effects of regenerative treatment interventions in future longitudinal studies.

Collateral effects of targeting the nucleus pulposus via a transpedicular or transannular surgical route: a combined X-ray, MRI, and histological long-term descriptive study in sheep.

PURPOSE: In the context of regenerative medicine strategies, based in particular on the injection of regenerative cells, biological factors, or biomaterials into the nucleus pulposus (NP), two main routes are used: the transpedicular approach (TPA) and the transannular approach (TAA). The purpose of our study was to compare the long-term consequences of the TPA and the TAA on intervertebral disc (IVD) health through a longitudinal follow-up in an ovine model. METHODS: The TPA and the TAA were performed on 12 IVDs from 3 sheep. Six discs were left untreated and used as controls. The route and injection feasibility, as well as the IVD environment integrity, were assessed by MRI (T2-weighted signal intensity), micro-CT scan, and histological analyses (Boos' scoring). The sheep were assessed at 1, 3, and 7 months. RESULTS: Both the TPA and the TAA allowed access to the NP. They both induced NP degeneration, as evidenced by a decrease in the T2wsi and an increase in the Boos' scores. The TPA led to persistent end-plate defects and herniation of NP tissue (Schmorl's node-like) after 7 months as well as the presence of osseous fragments in the NP. CONCLUSIONS: The TPA induced more severe lesions in IVDs and vertebrae compared to the TAA. The lesions induced by the TPA are reason to consider whether or not this route is optimal for studying IVD regenerative medicine approaches.

Deltopectoral vs. deltoid split approach for proximal HUmerus fracture fixation with locking plate: a prospective RAndomized study (HURA).

BACKGROUND: This study aimed to compare the functional and clinical outcomes between the deltoid split (DS) approach and the classic deltopectoral (DP) approach for locking plate fixation of proximal humerus fractures (PHF) in a prospective randomized multicenter study. METHODS: From 2007 to 2015, all patients with a PHF Neer II/III were invited to participate. Exclusion criteria were pre-existing pathology to the limb, patient refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty), and axillary nerve impairment. After consent, patients were randomized to one of the 2 treatments using the dark envelope method. Functional outcome was evaluated by validated questionnaires (12-Item Short Form Health Survey: version 2, Quick-DASH) with a minimum follow-up of 12 months. Complications were noted. RESULTS: A total of 85 patients (44 DS, 41 DP) were randomized (mean age of 62). Groups were equivalent in terms of age, gender, body mass index, severity of fracture, and preinjury scores. The mean follow-up was 26 months. All clinical outcome measures were in favor of the deltopectoral approach. Specifically, the Q-DASH and SF-12v2 were better in the DP group (12 vs. 26, P = .003 and 56 vs. 51, P = .049, respectively). There were more complications in DS patients, but they did not reach statistical significance. CONCLUSIONS: The primary hypothesis on the superiority of the deltoid split incision was rebutted. On the basis of our study, the DP approach seems to offer better function compared with the DS approach for fixation of Neer 2 and 3 PHF fractures fixed with a locking plate.

Influence of coracoid anatomy on the location of glenoid rim defects in anterior shoulder instability: 3D CT-scan evaluation of 51 patients.

PURPOSE: Glenoid bony lesions play a role in approximately half of anterior shoulder instability cases. The purpose of this study is to see if the anatomy of the coracoid affects the location of glenoid rim defects. We hypothesized that a prominent coracoid (lower and lateral) would be more likely to cause an anterior-inferior glenoid lesion, and a less prominent coracoid more prone to cause an anterior lesion. The null hypothesis being the absence of correlation. METHODS: Fifty-one shoulder CT-scans from a prospective database, with 3D reconstruction, were analyzed. The position of glenoid lesions was identified using the validated clock method, identifying the beginning and end time. The size of bony glenoid defects was calculated using the validated glenoid ratio method. The position of the coracoid tip was measured in three orthogonal planes. RESULTS: Analysis included 25 right shoulders and 26 left shoulders in seven females and 41 males. The vertical position of the coracoid tip relative to the top of the glenoid was highly correlated to the location of the glenoid defect on the profile view (r = -0.625; 95% CI 0.423-0.768; p = 0.001). Thus, higher coracoids were associated with anterior lesions, while lower coracoids were associated with anterior-inferior lesions. A more laterally prominent coracoid was also correlated with anterior-inferior lesions (r = 0.433; 95% CI 0.179-0.633; p = 0.002). CONCLUSION: This study shows that coracoid anatomy affects the location of bony Bankart defects in anterior shoulder instability. Lower and laterally prominent coracoids are associated with anterior-inferior lesions. This variation in anatomy should be considered during pre-op planning for surgeries involving bone graft. LEVEL OF EVIDENCE: Level 4 basic science.

Quantitative localization of the entry point of the lateral ascending branch of the anterior circumflex humeral artery: a high definition CT-scan radiological study.

PURPOSE: To define the localization of the entry point of the lateral ascending branch of the anterior circumflex humeral artery (LACHA) for better surgical management and prevention of injury to this important vessel. The hypothesis is that the insertion point of the artery will be constant in subjects. METHODS: A retrospective study of 27 tomographic images was conducted to generate a three-dimensional (3D) model and localize the entry point of the LACHA. Using a coordinate system consisting of three axes: the proximal-distal axis (PDA), the anterior-posterior axis (APA) and the medial-lateral axis (MLA), the position of a foramen located in the superior portion of the bicipital groove and representing the entry point of LACHA was measured on each reconstructed model. RESULTS: On average, the foramen was located 10.0 mm distal along the PDA from the most proximal point of the greater tuberosity (GT). Along the MLA and with respect to the most medial portion of the GT, the foramen was located 3.4 mm medially, on average. No significant differences between men and women or between sides for foramen position measurements were found. CONCLUSION: Unnecessary procedures to the proximal biceps, aiming to prevent chronic pain, should be avoided in fracture fixation as they would affect a significant source of blood supply to the humeral head. These findings could help surgeons protect the only vascular supply they can during the fixation of proximal humeral fractures, when using the anterior or antero-lateral approaches.

Teaching simulated arthroscopic Bankart repair: residents' assessment at the Annual Shoulder Course

Background: This study's aim was to evaluate the performance of senior orthopedic residents during simulated arthroscopic anterior stabilization (Bankart repair) before and after a national shoulder review course. Methods: Participants were assessed before and after the Annual Shoulder Review Course over a 3-day period, using a multiple-choice examination and surgery performance assessment. The surgical evaluation was completed by fellowship-trained surgeons using a standardized procedure checklist and a global rating scale. All Canadian senior orthopedic residents were invited to participate in the course. Results: The 57 participants showed improvement following the course. The written knowledge evaluation mean score increased, and all 3 surgical performance measurements improved: surgical task time improved from 4:40 min to 2:53 min (p < 0.001), surgical technique evaluation increased from 56% to 67% after the procedure checklist (p < 0.001), and anchor placement improved for all 3 aspects. Anchor entry point was the sole measure not to improve enough to reach statistical significance (p = 0.37). Conclusion: Our data support the inclusion of dry model surgical simulation as part of a surgical skills course for both training and assessment of orthopedic surgery residents.

Contexte: Le but de cette étude était d'évaluer le rendement des résidents seniors en orthopédie durant une simulation de stabilisation arthroscopique antérieure (intervention de Bankart) avant et après un cours de révision national sur l'articulation de l'épaule. Méthodes: Les participants ont été évalués avant et après l'Annual Shoulder Review Course sur une période de 3 jours, à l'aide d'un examen à choix multiples et d'une épreuve chirurgicale pratique. L'évaluation chirurgicale était effectuée par des chirurgiens spécialisés, à l'aide d'une liste de vérification normalisée des procédures et d'une échelle d'évaluation globale. Tous les résidents séniors canadiens en orthopédie étaient invités à participer au cours. Résultats: Les 57 participants ont montré une amélioration après le cours. Lesrésultats à l'examen écrit ont augmenté, tout comme ceux des 3 évaluations chirurgicales : le temps chirurgical a diminué, passant de 4:40 min à 2:53 min (p < 0,001), l'évaluation de la technique chirurgicale a augmenté de 56 % à 67 % selon la liste de vérification (p < 0,001) et le positionnement des ancres s'est aussi amélioré pour les 3 positionnements. Le point d'entrée des ancres a été la seule mesure à ne pas s'améliorer suffisamment pour atteindre une portée statistique (p = 0,37). Conclusion: Nos données appuient l'inclusion d'un modèle de simulation sec pour la formation et l'évaluation des résidents en chirurgie orthopédique.

Incidence and Risk Factors of Long-term Opioid Use in Elderly Trauma Patients.

OBJECTIVE: Evaluate the incidence and risk factors of opioid use 1 year after injury in elderly trauma patients. BACKGROUND: The current epidemic of prescription opioid misuse and overdose observed in North America generally concerns young patients. Little is known on long-term opioid use among the elderly trauma population. METHODS: In a retrospective observational multicenter cohort study conducted on registry data, all patients 65 years and older admitted (hospital stay >2 days) for injury in 57 adult trauma centers in the province of Quebec (Canada) between 2004 and 2014 were included. We searched for filled opioid prescriptions in the year preceding the injury, up to 3 months and 1 year after the injury. RESULTS: In all, 39,833 patients were selected for analysis. Mean age was 79.3 years (±7.7), 69% were women, and 87% of the sample was opioid-naive. After the injury, 38% of the patients filled an opioid prescription within 3 months and 10.9% [95% confidence interval (CI) 10.6%-11.2%] filled an opioid prescription 1 year after trauma: 6.8% (95% CI 6.5%-7.1%) were opioid-naïve and 37.6% (95% CI 36.3%-38.9%) were opioid non-naive patients. Controlling for confounders, patients who filled 2 or more opioid prescriptions before the injury and those who filled an opioid prescription within 3 months after the injury were, respectively, 11.4 and 3 times more likely to use opioids 1 year after the injury compared with those who did not fill opioid prescriptions. CONCLUSIONS: These results highlight that elderly trauma patients are at risk of long-term opioid use, especially if they had preinjury or early postinjury opioid consumption.

Rotator Cuff Tear Morphologic Parameters at Magnetic Resonance Imaging: Relationship With Muscle Atrophy and Fatty Infiltration and Patient-Reported Function and Health-Related Quality of Life.

OBJECTIVE: The aim of this study was to determine the relationship between rotator cuff tear (RCT) morphologic parameters and muscle atrophy and fatty infiltration, and patient-reported outcome measures, in patients with symptomatic full-thickness RCT. METHODS: Rotator cuff tear location, length, width, thickness, and musculotendinous junction position were assessed in 57 magnetic resonance imaging scans and correlated to the outcome measures using multivariate regression analysis. RESULTS: Supraspinatus tendon tear length (odds ratio [OR], 2.218; 95% confidence interval [CI], 1.460-3.370), supraspinatus musculotendinous junction position (OR, 2.037; 95% CI, 1.322-3.137), and infraspinatus tendon tear width (OR, 2.371; 95% CI, 1.218-4.615) were identified as the strongest determinants of supraspinatus muscle atrophy, supraspinatus muscle fatty infiltration, and infraspinatus muscle fatty infiltration, respectively. CONCLUSIONS: The extent of supraspinatus tendon and musculotendinous junction retraction influences the development of supraspinatus muscle atrophy and fatty infiltration, whereas the extent of infraspinatus tendon tear width influences the development of infraspinatus muscle fatty infiltration. Morphologic parameters defining RCT at magnetic resonance imaging did not correlate with clinical shoulder function scores.

Causes of death and predictors of childhood mortality in Rwanda: a matched case-control study using verbal social autopsy.

BACKGROUND: Rwanda has dramatically reduced child mortality, but the causes and sociodemographic drivers for mortality are poorly understood. METHODS: We conducted a matched case-control study of all children who died before 5 years of age in eastern Rwanda between 1st March 2013 and 28th February 2014 to identify causes and risk factors for death. We identified deaths at the facility level and via a community health worker reporting system. We used verbal social autopsy to interview caregivers of deceased children and controls matched by area and age. We used InterVA4 to determine probable causes of death and cause-specific mortality fractions, and utilized conditional logistic regression to identify clinical, family, and household risk factors for death. RESULTS: We identified 618 deaths including 174 (28.2%) in neonates and 444 (71.8%) in non-neonates. The most commonly identified causes of death were pneumonia, birth asphyxia, and meningitis among neonates and malaria, acute respiratory infections, and HIV/AIDS-related death among non-neonates. Among neonates, 54 (31.0%) deaths occurred at home and for non-neonates 242 (54.5%) deaths occurred at home. Factors associated with neonatal death included home birth (aOR: 2.0; 95% CI: 1.4-2.8), multiple gestation (aOR: 2.1; 95% CI: 1.3-3.5), both parents deceased (aOR: 4.7; 95% CI: 1.5-15.3), mothers non-use of family planning (aOR: 0.8; 95% CI: 0.6-1.0), lack of accompanying person (aOR: 1.6; 95% CI: 1.1-2.1), and a caregiver who assessed the medical services they received as moderate to poor (aOR: 1.5; 95% CI: 1.2-1.9). Factors associated with non-neonatal deaths included multiple gestation (aOR: 2.8; 95% CI: 1.7-4.8), lack of adequate vaccinations (aOR: 1.7; 95% CI: 1.2-2.3), household size (aOR: 1.2; 95% CI: 1.0-1.4), maternal education levels (aOR: 1.9; 95% CI: 1.2-3.1), mothers non-use of family planning (aOR: 1.6; 95% CI: 1.4-1.8), and lack of household electricity (aOR: 1.4; 95% CI: 1.0-1.8). CONCLUSION: In the context of rapidly declining childhood mortality in Rwanda and increased access to health care, we found a large proportion of remaining deaths occur at home, with home deliveries still representing a significant risk factor for neonatal death. The major causes of death at a population level remain largely avoidable communicable diseases. Household characteristics associated with death included well-established socioeconomic and care-seeking risk factors.

Next wave of interventions to reduce under-five mortality in Rwanda: a cross-sectional analysis of demographic and health survey data.

BACKGROUND: Sustained investments in Rwanda's health system have led to historic reductions in under five (U5) mortality. Although Rwanda achieved an estimated 68% decrease in the national under U5 mortality rate between 2002 and 2012, according to the national census, 5.8% of children still do not reach their fifth birthday, requiring the next wave of child mortality prevention strategies. METHODS: This is a cross-sectional study of 9002 births to 6328 women age 15-49 in the 2010 Rwanda Demographic and Health Survey. We tested bivariate associations between 29 covariates and U5 mortality, retaining covariates with an odds ratio p < 0.1 for model building. We used manual backward stepwise logistic regression to identify correlates of U5 mortality in all children U5, 0-11 months, and 12-59 months. Analyses were performed in Stata v12, adjusting for complex sample design. RESULTS: Of 14 covariates associated with U5 mortality in bivariate analysis, the following remained associated with U5 mortality in multivariate analysis: household being among the poorest of the poor (OR = 1.98), child being a twin (OR = 2.40), mother having 3-4 births in the past 5 years (OR = 3.97) compared to 1-2 births, mother being HIV positive (OR = 2.27), and mother not using contraceptives (OR = 1.37) compared to using a modern method (p < 0.05 for all). Mother experiencing physical or sexual violence in the last 12 months was associated with U5 mortality in children ages 1-4 years (OR = 1.48, p < 0.05). U5 survival was associated with a preceding birth interval 25-50 months (OR = 0.67) compared to 9-24 months, and having a mosquito net (OR = 0.46) (p < 0.05 for both). CONCLUSIONS: In the past decade, Rwanda rolled out integrated management of childhood illness, near universal coverage of childhood vaccinations, a national community health worker program, and a universal health insurance scheme. Identifying factors that continue to be associated with childhood mortality supports determination of which interventions to strengthen to reduce it further. This study suggests that Rwanda's next wave of U5 mortality reduction should target programs in improving neonatal outcomes, poverty reduction, family planning, HIV services, malaria prevention, and prevention of intimate partner violence.

Development and Acceptability Assessment of a Self-Management Intervention to Prevent Acute to Chronic Pain Transition after Major Lower Extremity Trauma.

PURPOSE: Transition from acute to chronic pain often occurs after major lower extremity trauma. Chronic pain has been found to negatively affect daily functioning, including the capacity to work and quality of life. Empirical data and an acceptability assessment were used to develop a self-management intervention aimed at preventing acute to chronic pain transition after major lower extremity trauma (i.e., iPACT-E-Trauma). METHODS: Evidence from previous studies on preventive self-management interventions, combined with a biopsychosocial conceptual framework and clinical knowledge, helped define the key features of the preliminary version. Then a mixed-methods design was used to assess the acceptability of iPACT-E-Trauma by clinicians and patients. RESULTS: The key features of the preliminary version of iPACT-E-Trauma were assessed as acceptable to very acceptable by clinicians and patients. After clinician assessment, intervention activities were simplified and session duration was reduced. Patient acceptability assessment of iPACT-E-Trauma led to the tailoring of key intervention features, based on determinants such as pain intensity and the implementation of self-management behaviors between intervention sessions. Web-based sessions were also developed to facilitate iPACT-E-Trauma delivery. CONCLUSION: This study outlines the process involved in the development of an intervention to prevent chronic pain in patients with lower extremity trauma. Relevant information is provided to nurses and interdisciplinary teams on a self-management intervention to prevent the transition from acute to chronic pain in the trauma population.

The smartphone inclinometer: A new tool to determine elbow range of motion?

BACKGROUND: There are easily accessible tools on smartphones (APP) for measuring elbow range of motion (ROM). The purpose of this study is to evaluate the validity of a particular APP in determining elbow ROM in comparison with the commonly used goniometer (GON), surgeon estimation of range (EST) and measurement on X-ray (XR). METHODS: The study included 20 patients (40 elbows). Flexion, extension, pronation and supination were measured using three different methods: EST, GON and APP. Radiographic measurements were taken using the average humeral diaphysis axis and dorsal midthird of ulna in flexion and extension. RESULTS: The accuracy of the three different methods has been compared to GON using statistical analysis (ANOVA and paired samples test). There was no statistically significant difference for XR flexion measurement (mean of 2.8° ± 1.5°). The APP overestimated flexion (mean of 6.4° ± 1.0°), and EST underestimated it (mean of - 7.9° ± 1.1°). For extension, the mean difference was 2.8° ± 0.7° for EST and - 26.8° ± 3.1° for XR. The APP method did not significantly differ from GON. Supination accuracy was greater with EST (2.7° ± 1.7°) than with APP (5.9° ± 1.9°). There was no difference for pronation measurement with both EST and APP. CONCLUSIONS: This study is the first comparing four measurement techniques of elbow ROM. Our results showed that EST was only accurate for forearm rotation. The XR scored the best for flexion but is less reliable for extension. Surprisingly, compared to GON, APP did not correlate as we expected for flexion and supination, but the other methods were also inaccurate. We found APP to be very useful to measure complete arc of motion (difference between maximal flexion and maximal extension). LEVEL OF EVIDENCE: III, Retrospective review of a prospective cohort of elbow fracture patients: Diagnostic Study.

Effects of concomitant mild traumatic brain injury on resuming work after suffering from an isolated limb fracture: A cohort study.

BACKGROUND: The objective is to explore the effects of concomitant mild traumatic brain injury (mTBI) on return to work (RTW), among patients suffering from an isolated limb fracture. This follow-up study included a total of 170 working age subjects with an isolated limb fracture, and was conducted in a phone interview approximately 1-year post trauma. 41 had experienced an mTBI and 129 did not. METHODS: Data were obtained through a phone interview conducted on average 20.7 months (SD = 9.6 months) post-accident. The main outcome measure was the number of days taken to RTW after the injury. Demographic information was also gathered during the phone interview. Workers' compensation status was obtained through the hospitals' orthopaedic clinic data. RESULTS: The mTBI group took on average 329.7 days (SD = 298.0) to RTW after the injury, as opposed to 150.3 days (SD = 171.3) for the control group (p < 0.001). After excluding patients who received workers' compensation, the mTBI group still missed significantly more days of work (M = 299.4 days; SD = 333.0) than the control group (M = 105.2 days; SD = 121.6) (p < 0.0001). CONCLUSION: This study shows that mTBI increases work disability by preventing working-age individuals from rapidly returning to work.

Three-dimensional analysis of the locked position in patients with recurrent shoulder instability.

BACKGROUND: Although recurrent anterior shoulder instability (RASI) is a common condition in young patients, no studies to date have measured the 3-dimensional (3D) locked position of the glenohumeral joint during an anterior dislocation. Therefore, our goal was to estimate it with 3D computed tomography (CT) scans. METHODS: Patients in this prospective observational study were separated in 3 groups: normal laxity, hyperlaxity, and epilepsy. They were characterized by questionnaires (Western Ontario Shoulder Instability Index, 11-item version of the Disabilities of the Arm, Shoulder and Hand, and Beighton Laxity Score), and a CT scan revealing bipolar bone defects. 3D models of the humeral head and the glenoid were reconstructed from the CT scan, and the rotations and displacements of the humerus relative to the glenoid, from initial to locked position, were calculated. Intraobserver and interobserver reliability by intraclass correlation coefficient (ICC), analysis of variance test, and the Pearson correlation were used to evaluate data. RESULTS: This study involved 44 patients (46 shoulders): 18 with "normal" laxity, 18 with hyperlaxity and 8 (2 bilateral) with epilepsy. The mean locked position was of 12° of abduction, 90° of external rotation, and 21° of extension. The intraobserver and interobserver reliability was excellent for all the rotations and displacements (ICCs, 0.751-0.977) except the proximal-distal displacement (ICCs, 0.409-0.688). Significant differences were found for external rotation, anterior displacement, and medial displacement among the 3 groups of patients. Correlation was found between locked position and function. CONCLUSIONS: This study produced highly reliable measurements, with abduction angles proving to be lower than expected. Future work should focus on the effect of this low abduction angle on Hill-Sachs lesion management.

Suture bridge transosseous equivalent repair is stronger than transosseous tied braided-tape.

BACKGROUND: This study biomechanically compares two methods of supraspinatus repair: single row transosseous braided-tape (BT) and suture bridge transosseous equivalent (SBTE) with 2 medial anchors and 2 lateral anchors. The purpose is to test the hypothesis that BT provides superior or equal biomechanical strength compared to SBTE. METHODS: Nine pairs of frozen cadaveric shoulders were selected and both repair techniques were tested on each pair, using a biomechanical testing unit to measure cyclic loading and ultimate load to failure. Moreover, tendon displacement was measured using the percentage of footprint exposed during the cyclic loading phase. RESULTS: Mean specimen age was 71 years (6 males, 3 females), and mean volumetric bone mineral density was 134 mg/cm3. BT mean ultimate load was 266 ± 81 Newton (N) compared to 398 ± 69 N for SBTE and this difference of 131 N was statistically significant p = 0.025. There was a strong positive correlation between bone mineral density and SBTE construct ultimate load. The difference between the percentage of footprint exposed after cyclic loading of the two repairs was statistically significant with the exception of the 10-80 N load (p < 0.05). The failure mode was suture cutout through the tendon in 88% (7/8) of specimens for both techniques. CONCLUSION: SBTE repair with bone anchors provides superior biomechanical strength compared to BT repair in terms of ultimate load and cyclic loading. The tendon-suture junction is the weakness of both methods. These models simulate a complete tear with total loss of contact with rotator interval and infraspinatus. Future studies could focus on a more isolated physiologic supraspinatus tear pattern. LEVEL OF EVIDENCE: Basic science study (Level II).

Acute proximal humeral fractures in adults.

STUDY DESIGN: Clinical commentary. INTRODUCTION: Proximal humeral fractures (PHF) are the third most common fracture in the elderly with an increased incidence expected in the coming years with the aging population, causing an important burden to the healthcare system. The management of PHF is challenging due to its complexity and the wide variety of fractures and treatment options. PURPOSE: The objective of this clinical commentary is to update the available evidence on clinical presentation, classification, imaging, medical treatment, and rehabilitation of acute PHF. METHODS/RESULTS/DISCUSSION: N/A for clinical commentary. CONCLUSIONS: The first step to a successful management of PHF is the clinical and radiographic examination of the shoulder, which enables the physician to classify the fracture and choose the appropriate treatment option. The Neer and OA classifications are commonly used and are based on the identification of the fractured parts of the humerus, as well as the displacement of the fragments. In case of non-displaced or minimally displaced fractures, a conservative treatment, consisting of initial immobilization and a rehabilitation program will be chosen. Displaced or unstable fractures will be managed operatively. Different surgical options exist and will vary according to the fracture type, patient's age, and functional needs, followed by rehabilitation. LEVEL OF EVIDENCE: 5.