Increased Failure Rates After Arthroscopic Bankart Repair After Second Dislocation Compared to Primary Dislocation With Comparable Clinical Outcomes.

PURPOSE: The purpose of this study was to compare rates of recurrent dislocation and postsurgical outcomes in patients undergoing arthroscopic Bankart repair for anterior shoulder instability immediately after a first-time traumatic anterior dislocation versus patients who sustained a second dislocation event after initial nonoperative management. METHODS: A retrospective chart review was performed of patients undergoing primary arthroscopic stabilization for anterior shoulder instability without concomitant procedures and minimum 2-year clinical follow-up. Primary outcome was documentation of a recurrent shoulder dislocation. Secondary clinical outcomes included range of motion, Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons Shoulder Score (ASES), and Shoulder Activity Scale (SAS). RESULTS: Seventy-seven patients (mean age 21.3 years ± 7.3 years) met inclusion criteria. Sixty-three shoulders underwent surgical stabilization after a single shoulder dislocation, and 14 underwent surgery after 2 dislocations. Average follow-up was 35.9 months. The rate of recurrent dislocation was significantly higher in the 2-dislocation group compared to single dislocations (42.8% vs 14.2%, P = .03). No significant difference was present in range of motion, VAS, ASES, and SAS scores. The minimal clinically important difference (MCID) was 1.4 for VAS and 1.8 for SAS scores. The MCID was met or exceeded in the primary dislocation group in 31/38 (81.6%) patients for VAS, 23/31 (74.1%) for ASES, and 24/31 for SES (77.4%) scores. For the second dislocation cohort, MCID was met or exceeded in 7/9 (77.8%) for VAS, 4/7 (57.1%) for ASES, and 5/7 for SES (71.4%) scores. CONCLUSION: Immediate arthroscopic surgical stabilization after a first-time anterior shoulder dislocation significantly decreases the risk of recurrent dislocation in comparison to those who undergo surgery after 2 dislocation events, with comparable clinical outcome scores. These findings suggest that patients who return to activities after a primary anterior shoulder dislocation and sustain just 1 additional dislocation event are at increased risk of a failing arthroscopic repair. STUDY DESIGN: Retrospective comparative study; Level of evidence, 3.

Proximal Humerus Fractures: Leave It Alone, Fix It, Replace It?

Proximal humerus fractures are common injuries that account for 10% of all fractures in the elderly. Several options are available for the management of proximal humerus fractures. Optimal treatment is based on the fracture pattern and the patient characteristics. Most of these fractures are minimally displaced and managed nonsurgically. Approximately 15% of proximal humerus fractures are comminuted, head-split, fracture-dislocation, or severely displaced, which make the best treatment option more challenging. Hemiarthroplasty is still a viable option in selected patients of these groups; however, advancements in locking plate designs and introduction of reverse total shoulder arthroplasty have led to better clinical outcome in meticulously selected patients. Nonetheless, the debate continues regarding the best management. It is important to discuss the best treatment options based on current literature.

Potential Economic Benefits of Limited Clinical and Radiographic Follow-up After Plate Fixation of Midshaft Clavicle Fractures.

INTRODUCTION: The role of routine clinical and radiographic follow-up after clavicle fractures are healed was evaluated. METHODS: A retrospective study performed in two level-1 trauma centers included 246 adults with healed clavicle fractures treated surgically between 2000 and 2013 and at least 24-month follow-up. Based on radiographs, changes in fracture alignment or implant position from union to final follow-up were documented. The average reimbursement for a follow-up clinical visit and a clavicle radiograph was estimated. RESULTS: Mean time to union and mean time of follow-up were of 4.8 and 31.4 months, respectively. No changes in implant position or fracture alignment occurred after the fracture had healed. The amount reimbursed to our institution for two clinical visits and two clavicle radiographs was approximately $300 to $540. CONCLUSION: Once clavicle fractures are healed, further radiographic imaging does not provide any notable information. Limiting routine follow-up is safe and could be cost-effective for the healthcare system. LEVEL OF EVIDENCE: Level-III retrospective cohort study.

OTA/AO Classification Is Highly Predictive of Acute Compartment Syndrome After Tibia Fracture: A Cohort of 2885 Fractures.

OBJECTIVE: To determine the correlation between the OTA/AO classification of tibia fractures and the development of acute compartment syndrome (ACS). DESIGN: Retrospective review of prospectively collected database. SETTING: Single Level 1 academic trauma center. PATIENTS: All patients with a tibia fracture from 2006 to 2016 were reviewed for this study. Three thousand six hundred six fractures were initially identified. Skeletally mature patients with plate or intramedullary fixation managed from initial injury through definitive fixation at our institution were included, leaving 2885 fractures in 2778 patients. METHODS: After database and chart review, univariate analyses were conducted using independent t tests for continuous data and χ tests of independence for categorical data. A simultaneous multivariate binary logistic regression was developed to identify variables significantly associated with ACS. RESULTS: ACS occurred in 136 limbs (4.7%). The average age was 36.2 years versus 43.3 years in those without (P < 0.001). Men were 1.7 times more likely to progress to ACS than women (P = 0.012). Patients who underwent external fixation were 1.9 times more likely to develop ACS (P = 0.003). OTA/AO 43 injuries were at least 4.0 times less likely to foster ACS versus OTA/AO 41 or 42 injuries (P < 0.007). OTA/AO 41-C injuries were 5.5 times more likely to advance to ACS compared with OTA/AO 41-A (P = 0.03). There was a significantly higher rate of ACS in OTA/AO 42-B (P = 0.005) and OTA/AO 42-C (P = 0.002) fractures when compared with OTA/AO 42-A fractures. In the distal segment, fracture type did not predict the risk of ACS (P > 0.15). Group 1 fractures had a lower rate of ACS compared with group 2 (P = 0.03) and group 3 (P = 0.003) fractures in the middle segment only. Bilateral tibia fractures had a 2.7 times lower rate of ACS (P = 0.04). Open injury, multiple segment injury, fixation type, and concurrent pelvic or femoral fractures did not predict ACS. CONCLUSIONS: In this large cohort of tibia fractures, we found that the age, sex, and OTA/AO classification were highly predictive for the development of ACS. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Suprapatellar Versus Infrapatellar Tibial Nail Insertion: A Prospective Randomized Control Pilot Study.

PURPOSE: The purpose of this OTA-approved pilot study was to compare the clinical and functional outcomes of the knee joint after infrapatellar (IP) versus suprapatellar (SP) tibial nail insertion. DESIGN: Prospective, randomized. SETTING: Level I trauma center. METHODS: After institutional review board approval, skeletally mature patients with OTA 42 tibial shaft fractures were randomized into either an IP or SP nail insertion group after informed consent was obtained. The SP also underwent prenail and postnail insertion patella-femoral (PF) joint arthroscopy. Patients underwent follow-up (6 weeks, 3, 6, and 12 months) with standard radiographs, as well as visual analog score and pain diagram documentation. At the 6-month and 12-month visits, knee function questionnaires (Lysholm knee scale and SF-36) were completed. Magnetic resonance imaging/image (MRI) of the affected knee was obtained at 12 months. Ten patients in each group were required for a power analysis for the anticipated larger randomized control trial, but enrollment in each arm was not limited because of known problems with patient follow-up over a 12-month period. RESULTS: A total of 41 patients/fractures were enrolled in this study. Of those, only 25 patients/fractures (14 IP, 11 SP) fully complied with and completed 12 months of follow-up. Six of 11 SP presented with articular changes (chondromalacia) in the PF joint during the preinsertion arthroscopy. Three patients displayed a change in the articular cartilage based on postnail insertion arthroscopy. At 12 months, all fractures in both groups had proceeded to union. There were no differences between the affected and unaffected knee with respect to range of motion. Functional visual analog score and Lysholm knee scores showed no significant differences between groups (P > 0.05). The SF-36v2 comparison also revealed no significant differences in the overall score, all 4 mental components, and 3/4 physical components (P > 0.05). The bodily pain component score was superior in the SP group (45 vs. 36, P = 0.035). All 11 SP patients obtained MRIs at 1 year. Five of these patients had evidence of chondromalacia on MRI. These findings did not correlate with either the prenail or postnail insertion arthroscopy. Importantly, no patient in the SP group with postnail insertion arthroscopic changes had PF joint pain at 1 year. CONCLUSIONS: Overall, there seemed to be no significant differences in pain, disability, or knee range of motion between these 2 tibial intramedullary nail insertion techniques after 12 months of follow-up. Based on this pilot study data, larger prospective trial with long-term follow-up is warranted. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Traumatic Proximal Tibiofibular Dislocation: A Marker of Severely Traumatized Extremities.

OBJECTIVE: The purpose of this analysis is to report on the epidemiology and clinical implications of traumatic proximal tibiofibular dislocation (PTFD). DESIGN: Retrospective chart and radiographic review. SETTING: Level 1 regional trauma center. PATIENTS: Skeletally mature patients with a traumatic PTFD between July 1, 2006, and December 31, 2013. INTERVENTION: Open reduction internal fixation of the proximal tibiofibular joint. MAIN OUTCOME MEASUREMENTS: Patient demographics and associated musculoskeletal and neurovascular injuries were recorded as data points. RESULTS: There were a total of 30 PTFDs in 30 patients during the course of the defined study period. The incidence of PTFD was 1.5% (15 of 1013) of operative tibial shaft fractures and 1.9% (15 of 803) of operative tibial plateau fractures (P = 0.5810). Fifty percent (15 of 30) of PTFD were associated with a tibial shaft fracture, and 50% (15 of 30) with tibial plateau fractures. PTFD was associated with an open fracture in 63% (19 of 30) of cases. Two patients (6.7%) presented with a vascular injury who underwent a successful repair without vascular sequelae. Two different patients (6.7%) ultimately underwent an amputation (one above the knee and one below the knee) for a nonreconstructable extremity. In the remaining 28 patients without amputation, the incidence of compartment syndrome was 29% (8 of 28) and the incidence of peroneal nerve palsy was 36% (10 of 28). Only 30% (3 of 10) of the peroneal nerve palsies recovered clinically within the follow-up period, which averaged 11 months (range: 6 months to 4 years). CONCLUSIONS: Traumatic proximal tibiofibular joint dislocations can be found in approximately 1%-2% of both tibial plateau and shaft fractures. PTFD is associated with a high rate of compartment syndrome (29%), open fracture (63%), and peroneal nerve palsy (36%). The majority (70%) of peroneal nerve palsies do not recover. Proximal tibiofibular joint dislocation is a marker for a severely traumatized limb. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Operatively Treated Meniscal Tears Associated With Tibial Plateau Fractures: A Report on 661 Patients.

OBJECTIVE: To describe the incidence and common patterns of lateral meniscal tears detected intraoperatively and surgically treated based on tibial plateau fracture patterns. DESIGN: Retrospective analysis of a prospective database. SETTING: Level One Regional Trauma Center. METHODS: All tibial plateau fractures in skeletally mature patients treated operatively between 2002 and 2011 were included. All operative notes and radiographs were reviewed to determine type of tibial plateau fracture, mechanism of injury, intraoperative detection of a lateral meniscal tear, and operative repair/partial resection of the meniscus itself. Patients were excluded if there was no mention of a submeniscal arthrotomy, if fracture stabilization was performed percutaneously, or if the fracture was an isolated medial condyle fracture. Statistical analysis was performed using χ analysis and Fisher exact test to determine the overall incidence of lateral meniscal tears and any correlation between meniscal tear and fracture pattern. RESULTS: A total of 602 patients were included in the final analysis. Lateral meniscal tears requiring operative repair were detected intraoperatively in 179 patients (30%). This could be broken down into 12% for pure lateral split fractures, 45% for split depression fractures (P < 0.001), 18% for pure depression fractures, 22% for bicondylar fractures, and 26% for intraarticular plus shaft fractures. Lateral meniscal tears associated with a split depression fracture pattern were most commonly peripheral rim tears (83%). For all other fracture patterns, the type of meniscal injury was evenly distributed between peripheral and radial tear. Young males demonstrated a statistically higher rate of lateral meniscal tears (33%). CONCLUSIONS: In our series, the incidence of a lateral meniscal tear detected intraoperatively requiring repair was 30%. These tears occurred more frequently in young males, with peripheral rim tears most commonly associated with split depression fractures. Based on our data, we believe that preoperative imaging for meniscal injury overstates the true incidence of meniscal tears requiring operative intervention. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Indomethacin prophylaxis for heterotopic ossification after acetabular fracture surgery increases the risk for nonunion of the posterior wall.

OBJECTIVES: To determine if indomethacin has a positive clinical effect for the prophylaxis of heterotopic ossification (HO) after acetabular fracture surgery. To determine whether indomethacin affects the union rate of acetabular fractures. DESIGN: Prospective randomized double-blinded trial. SETTING: Level 1 regional trauma center. PATIENTS: Skeletally mature patients treated operatively for an acute acetabular fracture through a Kocher-Langenbeck approach. INTERVENTION: Patients were randomly allocated to 1 of 4 groups comparing placebo (group 1) to 3 days (group 2), 1 week (group 3), and 6 weeks (group 4) of indomethacin treatment. MAIN OUTCOME MEASUREMENTS: Factors analyzed included the overall incidence, Brooker class and volume of HO, radiographic union of the acetabular fracture, and pain. Patients were followed clinically and radiographically at 6 weeks, 3 months, 6 months, and 1 year. Serum levels of indomethacin were drawn at 1 month to assess compliance. Computed tomographic scans were performed at 6 months to assess healing and volume of HO. RESULTS: Ninety-eight patients were enrolled into this study, 68 completed the follow-up and had the 6-month computed tomographic scan, and there was a 63% compliance rate with the treatment regimen. Overall incidence of HO was 67% for group 1, 29% for group 2 (P = 0.04), 29% for group 3 (P = 0.019), and 67% for group 4. The volume of HO formation was 17,900 mm for group 1, 33,800 mm for group 2, 6300 mm for group 3 (P = 0.005), and 11,100 mm for group 4. The incidence of radiographic nonunion was 19% for group 1, 35% for group 2, 24% for group 3, and 62% for group 4 (P = 0.012). Seventy-seven percent of the nonunions involved the posterior wall segment. Pain visual analog scores (VASs) were significantly higher for patients with radiographic nonunion (VAS 4 vs. VAS 1, P = 0.002). CONCLUSIONS: Treatment with 6 weeks of indomethacin does not appear to have a therapeutic effect for decreasing HO formation after acetabular fracture surgery and appears to increase the incidence of nonunion. Treatment with 1 week of indomethacin may be beneficial for decreasing the volume of HO formation without increasing the incidence of nonunion. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.