Pronator quadratus repair after volar plating for distal radius fractures: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: The purpose of the current study is to meta-analyze the randomized controlled trials in the literature comparing pronator quadratus repair versus no repair alongside volar plating of distal radius fractures. METHODS: A search of the PUBMED/MEDLINE, EMBASE, and The Cochrane Library databases was performed. Any randomized con- trolled trials comparing pronator quadratus repair versus no repair alongside volar plating of distal radius fractures were included. The relevant information was collected by 2 blinded reviewers using a predetermined data sheet. Clinical outcomes were compared, with all statistical analyses performed using Review Manager Version 5.3. RESULTS: Five randomized controlled trials with 273 patients were included. There was no significant difference in the range of motion in flexion-extension, ulnar-radial deviation, or pronation-supination. There was a significant difference in favor of the no repair group for Disabilities of the Arm, Shoulder and Hand (DASH) Score (MD [Mean Difference]: 2.63, P < .0001) and pronation strength (MD: 13, P < .0001). Furthermore, there was no significant difference in the visual analog scale score. There were 3 complications relating to pronator quadratus repair, in which patients developed carpal tunnel syndrome requiring a release. There was no significant difference in the re-operation rate. CONCLUSION: This study found that pronator quadratus repair when performing volar plating for distal radius fractures did not result in a significant improvement in functional outcome, range of motion, or strength. LEVEL OF EVIDENCE: I, Systematic Review of Level 1 Studies, Level I, Therapeutic Study.

Azacitidine as a rare cause of reactive arthritis in a patient with acute myeloid leukemia.

INTRODUCTION: Azacitidine (AZA), a demethylating agent, is one of the mainstay treatments for patients with myelodysplastic syndromes (MDS) and acute myeloid leukaemia (AML) who are ineligible for curative allogeneic stem-cell transplantation and is recommended as first-line treatment in multiple countries. While arthralgia and myalgia have been commonly reported as side effects, the incidence of drug-induced reactive arthritis has only been reported twice so far. CASE REPORT: We present a retrospective overview of a clinical case of a 71-year-old patient that developed new cytopenias on a background of Chronic Lymphocytic Leukaemia and was diagnosed with therapy-associated AML. His treatment included an indefinite course of AZA to induce remission and optimise long-term survival which resulted in a satisfactory haematological response. However, after his ninth AZA cycle, he presented to the emergency department with knee swelling and erythema and conjunctivitis. MANAGEMENT AND OUTCOMES: Arthrocentesis of the knee revealed reactive arthritis with no crystal or organism growth. His symptoms were managed effectively with conservative management including NSAIDs, analgesia and temporary immobilization for joint rest. The adverse drug reaction probability score in our study was calculated as six and adverse drug reaction was thus assigned to the "probable" category. CONCLUSION: We report a case that points to AZA as a probable cause of arthritis flares in MDS patients. The current limitation of this study is the lack of available data, future reviews and research will aid in providing stronger evidence of a correlation between arthritis and AZA treatment.

Single-surgeon perspective: is there ever a need to open extension-type supracondylar fractures?

BACKGROUND: Supracondylar humerus fractures (SCHFs) represent the most common pediatric elbow fracture, constituting approximately 12-17% of all pediatric fractures. The vast majority of operative supracondylar humerus fractures are treated with closed reduction and percutaneous pinning (CRPP); however, the estimated rate of SCHFs requiring open reduction is approximately 12.7%. AIM: This study aims to analyze the likelihood of open reduction in pediatric extension-type SCHFs and to reaffirm the traditional teaching of reduction techniques described by Smith and Rang. METHODS: A single-surgeon retrospective analysis of 56 operative pediatric SCH cases (51 extension-type, 6 flexion-type) who underwent either CRPP or open reduction over a 16-year period was performed. All cases were performed using the aforementioned reduction technique. The Modified Gartland's classification was utilized in the analysis of extension-type SCHF radiographs. RESULTS: Gartland IIA fractures constituted 38% of SCHFs, 9% of Gartland IIB, 43% of Gartland III, and 7% of flexion-type. The rate of open reduction in SCHFs was 1.8% (1 out of 56 cases), performed in a flexion-type injury. All extension-type fractures were successfully managed with either CRPP or manipulation and casting alone. Of the cases requiring CRPP, 45% were divergent lateral wires, and 55% were crossed wires. CONCLUSIONS: In our series, a 1.8% rate of open reduction was indicated in flexion-type SCH fractures. All 52 cases of extension-type SCHFs were successfully managed with closed reduction with or without percutaneous pinning. Successful closed reduction using the concept of intact periosteal hinge to aid and maintain reduction is crucial.

Clinical and radiological outcomes following surgical hip dislocation for paediatric hip pathologies, a prospective cohort study.

BACKGROUND: Surgical Hip Dislocation (SHD) is a powerful tool in the armamentarium of any surgeon treating conditions affecting the hips of children presenting with sequelae of a number of common conditions including Legg-CalvéPerthes disease (LCPD) and slipped capital femoral epiphysis (SCFE). Risks associated with the procedure are well described. We investigated to assess if SHD is associated with significant surgical risk and if it improved clinical outcomes for patients. METHODS: We conducted a prospective cohort study. We reviewed 18 (11 males and 7 females; mean age 13.7 years (6-17) with symptomatic hip pathology, secondary to femoroacetabular impingement (FAI) between 2017 and 2021. All patients underwent a surgical hip dislocation approach and femoral head-neck osteochondroplasty, Head Split osteotomy or both. Clinical improvement was assessed using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index. The minimum follow-up was 6 months (mean, 22 months; range, 6-42 months). RESULTS: WOMAC scores improved at final follow-up from 10 to 3 for pain, 33 to 10 for function, and 4 to 2 for the stiffness subscales. All radiographic measures improved significantly of the postoperative X-rays. No patients developed osteonecrosis, implant failure, deep infection, or nonunion. CONCLUSION: Surgical Hip Dislocation, in the short term, we found improvement in WOMAC scores and radiographic indices with a low complication rate.

Does MRI Knee in Those over 50 Years with Knee Pain in Osteoarthritis Alter Management? A Retrospective Review.

Knee osteoarthritis (OA) is a significant cause of pain and disability worldwide. Imaging provides diagnosis, prognostication, and follow-up. Radiographs are first line, useful, and inexpensive. Magnetic resonance imaging (MRI) can detect additional features not seen on radiograph, but it is of questionable usefulness in the management of knee OA. Our aim was to investigate the usefulness of MRI in the workup of knee OA and whether MRI alters management in knee OA. A retrospective review was performed of consecutive MRI knees performed for knee pain in those over 50 years. Clinical information and documentation of management plan pre- and post-MRI were collected. Assessment was made whether the MRI results influenced the final management plan. Of the 222 MRI knees included for study, the majority (62.2%) had not had a recent radiograph. OA was reported in 86.9% of radiographs and 89.6% of MRI. On MRI, the most prevalent finding was tearing/abnormality of the medial meniscus, seen in 47% of MRIs overall, increasing to all in severe OA. MRI assisted with management in 9.5% of all (21/222) patients, and changed management plans in 23% of those that had documented management plans prior to the MRI (6/26 patients). MRIs can guide tailored management in knee OA and are useful for surgical planning; however, they should only be ordered in certain cases, and a radiograph should always be performed first. MRI should be considered if symptoms are not explained by OA alone or the appropriate treatment option requires MRI.

Minimally Invasive Intermuscular Approaches Versus Conventional Approaches in Total Hip Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: To date, the literature has not yet revealed superiority of Minimally Invasive (MI) approaches over conventional techniques. We performed a systematic review to determine whether minimally invasive approaches are superior to conventional approaches in total hip arthroplasty for clinical and functional outcomes. We performed a meta-analysis of level 1 evidence to determine whether minimally invasive approaches are superior to conventional approaches for clinical outcomes. METHODS: All studies comparing MI approaches to conventional approaches were eligible for analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adhered to throughout this study. Registries were searched using the following MeSH terms: 'minimally invasive', 'muscle-sparing', 'THA', 'THR', 'hip arthroplasty' and 'hip replacement'. Locations searched included PubMed, the Cochrane Library, ClinicalTrials.gov, the European Union (EU) clinical trials register and the International Clinical Trials Registry Platform (World Health Organisation). RESULTS: Twenty studies were identified. There were 1,282 MI total hip arthroplasty (THAs) and 1,351 conventional THAs performed. There was no difference between MI and conventional approaches for all clinical outcomes of relevance including all-cause revision (P = .959), aseptic revision (P = .894), instability (P = .894), infection (P = .669) and periprosthetic fracture (P = .940). There was also no difference in functional outcome at early or intermediate follow-up between the two groups (P = .38). In level I studies exclusively, random-effects meta-analysis demonstrated no difference in aseptic revision (P = .461) and all other outcomes between both groups. CONCLUSION: Intermuscular MI approaches are equivalent to conventional THA approaches when considering all-cause revision, aseptic revision, infection, dislocation, fracture rates and functional outcomes. Meta-analysis of level 1 evidence supports this claim.

Collagenase and the Treatment of Dupuytren Contracture: Efficacy of Treatment and Patient Satisfaction.

Background: Collagenase clostridium histolyticum has become a widely used treatment in the management of Dupuytren disease. The aims of this study are to assess the immediate success of treatment of Dupuytren contracture with collagenase injection, to measure long-term patient-rated outcomes, to determine whether the risk factors for the disease impacted outcomes and to report complications of collagenase treatment. Methods: A prospective study was performed in a tertiary referral centre. Measurements were recorded pre-treatment, day 1 and day 90. Patient-rated outcome scores were measured using Disability of the Arm, Shoulder and Hand questionnaire (DASH) and the Michigan Hand Questionnaire (MHQ) at minimum 36 months post-injection. Results: The study included 45 patients with 53 hands with a mean age of 65.7 years. The treatment was successful in 62% of patients with the greatest improvement in the metacarpal-phalangeal joint of the little finger. Diabetes, epilepsy, gender, alcohol intake and positive family history had no statistically significant predictive value on successful outcomes. Patient satisfaction at 41 months was high with mean MHQ score of 97.3. Conclusions: Collagenase is effective in the treatment of Dupuytren contracture, with disease involving the little finger showing the greatest benefit. Risk factors for development of Dupuytren disease had no effect on successful outcome and long-term satisfaction rates are high. Level of Evidence: Level III (Therapeutic).

Is there a variance in complication types associated with ALIF approaches? A systematic review.

PURPOSE: Anterior lumbar interbody fusion (ALIF) is a well-established alternative to posterior-based interbody fusion techniques, with approach variations, such as retroperitoneal, transperitoneal, open, and laparoscopic well described. Variable rates of complications for each approach have been enumerated in the literature. The purpose of this study was to elucidate the comparative rates of complications across approach type. METHODS: A systematic review of search databases PubMed, Google Scholar, and OVID Medline was made to identify studies related to complication-associated ALIF. PRISMA guidelines were utilised for this review. Meta-analysis was used to compare intraoperative and postoperative complications with ALIF for each approach. RESULTS: A total of 4575 studies were identified, with 5728 patients across 31 studies included for review following application of inclusion and exclusion criteria. Meta-analysis demonstrated the transperitoneal approach resulted in higher rates of retrograde ejaculation (RE) (p < 0.001; CI = 0.05-0.21) and overall rates of complications (p = 0.05; CI = 0.00-0.23). Rates of RE were higher at the L5/S1 intervertebral level. Rates of vessel injury were not significantly higher in either approach method (p = 0.89; CI = - 0.04-0.07). Rates of visceral injury did not appear to be related to approach method. Laparoscopic approaches resulted in shorter inpatient stays (p = 0.01). CONCLUSION: Despite the transperitoneal approach being comparatively underpowered, its use appears to result in a significantly higher rate of intraoperative and postoperative complications, although confounders including use of bone morphogenetic protein (BMP) and spinal level should be considered. Laparoscopic approaches resulted in shorter hospital stays; however, its steep learning curve and longer operative time have deterred surgeons from its widespread adaptation.

Challenges faced by orthopaedic trainees during the Covid-19 pandemic - An Irish perspective.

BACKGROUND: The recent SARS-CoV2/COVID-19 pandemic has caused a change in most aspects of our daily lives. Our health systems have had to adjust at an unprecedented rate to accommodate care for patients affected by the virus. As a result there has been widespread disruption to trauma and elective services throughout the Orthopaedic community Worldwide. We discuss the changes facing orthopaedic residents in training and the adaptations that have been made. METHODS: We discuss the challenges posed from a reduction in caseload to surgeons in training, teaching activities, patient interaction, workforce reinforcement and support networks in Ireland. RESULTS: A structured deployment of residents has taken place ensuring maximum exposure to operative cases to maintain competency. Teaching activities have been virtualised into a new curriculum that provides trainees with convenient access to a wide range of specialists at defined time periods during the week. Strategies have been employed to reinforce the workforce in anticipation of an acute reduction in staff due to the Covid-19 virus. CONCLUSIONS: The changes have been rapid and despite many of these adjustments being borne out of necessity, the innovation displayed will almost certainly alter how training is ultimately delivered long after the crisis has ceased.

Intraosseous schwannoma of the femur in a patient with monoclonal gammopathy of undetermined significance.

INTRODUCTION: Schwannomas are slow-growing, benign tumours normally originating from the schwann cells of the nerve sheath. Intraosseous schwannomas account for 0.175% of primary bone tumours and are extremely rare, especially outside the axial skeleton. Monoclonal gammopathy has been associated with soft tissue schwannomas but never with the intraosseous variety. PRESENTATION OF CASE: A 55-year-old woman with a background of monoclonal gammopathy of undetermined significance (MGUS) presented with a 2-year history of right thigh pain. CT scan showed a well defined, lytic lesion with a thin peripheral rim of sclerosis in the midshaft of the femur. MRI displayed a hyperintense, well marginated and homogenous lesion. Definitive diagnosis was made based on the classical histopathological appearance of schwannoma. We managed our patient with local curettage and prophylactic cephalomedullary nailing based on her high mirel score. DISCUSSION: Intraosseous schwannomas are poorly understood but most commonly reported in middle-aged women. Radiologically, their differential diagnosis includes malignant bone tumours, solitary bone cysts, aneurysmal bone cysts and giant cell tumours. As a result, they are usually diagnosed incidentally on histology. Although malignant transformation is possible in soft tissue schwannomas, all intraosseous schwannomas reported to date have been benign. CONCLUSION: This case demonstrates the importance of suspecting intraosseous schwannoma as a differential diagnosis for lytic bone lesions to avoid the overtreatment of patients. We also highlight monoclonal gammopathy of undetermined significance as a potential risk factor for a poorly understood disease and make recommendations about the appropriate management of these lesions.

A Prospective Review of a Novel Electronic Journal Club Format in an Orthopedic Residency Unit.

INTRODUCTION: Journal clubs are useful for teaching critical appraisal skills and maintaining contemporary knowledge in orthopedics. The didactic format is most common; however, work commitments can pose difficulty in full attendance. Also with the current legislative working time restrictions for residents in Europe and North America, work and training time require separation with times that may not suit all attendees. Online forums such as "Twitter" have recently been used to accommodate various journal clubs. We aimed to establish a journal club using smartphone messaging application "WhatsApp" to discuss key orthopedic papers and teach critical appraisal skills to residents. DESIGN: A prospective cohort study including all residents and attendings in the department. A research practice questionnaire, the "Evidence-based Practice Questionnaire" and a 28-question MCQ on research methods from the American Academy of Orthopedic Surgeons resident question database was completed by all participants prior to the study. A paper was uploaded each Friday, and discussed the following Tuesday through Friday for 6 consecutive weeks. The original questionnaire and MCQs were again completed after the 6-week study period. SETTING: A Trauma & Orthopedic residency unit. PARTICIPANTS: All orthopedic residents, from PGY1-4 and attendings. RESULTS: An average of 22 questions were asked (min 13, max 28), and 55 responses per week (min 30, max 88). In the EBPQ questionnaire, an example question of "how often you critically appraised a paper you have discovered" improved from an average score of 2.45 to 5.4. Self-rating of research skills improved from a score of 3.27 to 5.9. MCQ scores improved from an average of 48.2% among the group to 69%. CONCLUSIONS: Residents' critical appraisal skills were improved while providing adequate time and flexibility to reflect on questions. Subspecialty topic discussions led by attendings, stimulated discussion of clinical pearls of interest to all participants. The simplicity of this method, and its widespread availability potentiates the implementation by any specialty looking to educate its residents.

Displaced Salter-Harris I fracture of the distal ulna physis.

A 10-year-old girl presented to the emergency department having sustained a fall onto an outstretched left hand while playing soccer. Clinical and radiographical assessment identified a Salter-Harris I distal ulna fracture, as well as a buckle fracture of the distal radius. The injury was closed, and she had no neurovascular deficits on examination. She was brought to the operating theatre the following morning for closed reduction under general anaesthesia. Image intensification was used to confirm anatomical reduction, and an above-elbow moulded plaster-of-paris cast was applied. Follow-up clinical assessment at 6 weeks confirmed healing of the fracture, and she proceeded to make a full recovery. This case describes the anatomy and physiology of such rare injuries and outlines treatment principles and potential pitfalls based on best available evidence.

Arthroscopic anterior shoulder stabilisation in overhead sport athletes: 5-year follow-up.

INTRODUCTION: Shoulder instability following traumatic glenohumeral dislocation is a common injury sustained by athletes particularly in contact and collision sports. Overhead contact sports such as gaelic football and hurling pose a unique hazard to the glenohumeral joint, increasing the risk of dislocation. AIMS: To assess return to sport, level of play, recurrence and functional outcomes in gaelic football and hurling athletes in comparison with players of other sports. METHODS: A retrospective cohort study was carried out from 2007 to 2016. Follow-up was conducted via telephone interview using the Western Ontario Shoulder Instability Index (WOSI) score used to assess functional outcomes as well as return to sport, level of return and recurrence. RESULTS: Ninety patients were included with follow-up which was obtained on 61 patients (68%) with a mean follow-up of 5.04 years. 91.8% played sport at the time of injury, 55.4% of those (31 patients) played a gaelic sport with 44.6% (25 patients) playing other sports. 76.8% returned to their sport, 80.4% of these able to return at their pre-injury level. Recurrence occurred in 10 patients (16.4%). WOSI scores were not significantly different between groups (p = 0.77). No significance in recurrence between groups was noted (p = 0.78). DISCUSSION: Favourable outcomes can be expected for overhead contact sport athletes undergoing anterior arthroscopic stabilisation for recurrent instability. Players from these groups returned to sport sooner than those from other sports and no difference in recurrence was noted. The level at which they can expect to return to is favourable with most athletes reaching their pre-injury level.

The changing tides of Irish orthopaedic research.

INTRODUCTION: Research is fundamental to bridging theory, practice and education in orthopaedics. Following the restructuring of the surgical training pathway in Ireland, the opportunity to undertake clinical- or lab-based research has fallen. AIMS: Our aim was to investigate the trends of research in orthopaedics and the implications there. METHODS: We reviewed the trend in publications by Irish trauma and orthopaedic (T&O) trainees over the past 20 years across three different classes of journal. We also reviewed the Irish participation in the annual British Orthopaedic Association (BOA) meeting over the past 10 years as well as the rates of abstract submission to the annual Irish Orthopaedic Association (IOA) meeting. RESULTS: We found that publication rates were as follows: JBJS 2005-2010 mean 4.8 vs. 2000-2005 mean 1.6 and 2010-2015 mean 0.2; Injury 2005-2010 mean 3.6 vs. 2000-2005 mean 3.4 and 2010-2015 mean 2.2; IJMS 2010-2015 mean 4.4 vs. 2000-2010 mean 1.1. The number of Irish presentations at the BOA fell from a mean of 5 between 2000 and 2010 to a mean of 1.2 between 2011 and 2017. The rate of IOA abstract submissions compared over the same period has fallen by 21%. We also found that 4% of Irish orthopaedic publications in the IJMS were scientific in nature; this figure was 3.7% of publications in injury and 32.6% in JBJS (UK). CONCLUSIONS: There has been a significant decrease in publication rates by T&O trainees in high-quality journals. There has also been a notable decline in Irish representation at the BOA and a drop in the number of abstract submissions to the IOA. We suggest these findings coincide with the streamlining of surgical training in Ireland, which does not provide for the pursuit in research that is crucial to our practice as clinicians, to the future of our specialty and to the Irish orthopaedic representation internationally.

The Role of Circular Frames in the Management of Tibial Fractures.

Introduction The purpose of this study is to evaluate the factors that impact the clinical and radiographic outcomes in a patient cohort undergoing external fixation for tibial fractures. We also aim to investigate the use of autograft, allograft, and synthetic bone graft in varying combinations in the setting of tibial bone loss with respect to optimal times to union. Methods This was a retrospective study, including 46 patients treated with a circular external fixator for the management of acute tibial fractures. The study was carried out over a 10-year period, between 2007 and 2017, at our institution. The mean follow-up at the time of review was 4.6 years. Primary outcome measures were 'time to union,' 'delayed union' (> 6 months), 'infection,' and 'duration of external fixation.' Secondary outcomes included 'length of hospital stay' and functional scores using the 'Short Form-12 (SF-12).' The statistical analysis included both univariate and multivariate analyses to control for confounding variables when assessing predictors of delayed union and infection. Results Forty-six patients fulfilled the study criteria. Fifteen fractures were classified as open. The mean number of procedures per patient was 3.8 and the mean length of stay per patient was 33 days. The mean time to union was 8.6 months overall. Significant predictors of prolonged time to union were the 'number of interventions' (p<0.01) the patient underwent and the 'bone graft type' (p<0.01) used. The time to union in the presence of either autograft or allograft was lengthened by the addition of synthetic graft. Five patients developed a deep tissue infection. The use of synthetic bone graft was significantly associated with infection (p<0.05). On subgroup analysis, it was found that the use of synthetic graft in any combination leads to significantly higher rates of deep tissue infection (p<0.05). The mean time to full weight bearing was 10.6 months (s=9.78, 3-36). The majority (57%) were using walking aids and 67% reported that the injury was still affecting their lifestyle. Conclusion Tibial fractures with bone loss are a complex group of injuries that often require multiple surgical interventions, prolonged hospital inpatient stay, and suboptimal functional outcomes in many cases. The best times to union are achieved when autograft is used alone without any other combination of bone graft type. The use of synthetic bone graft also significantly increases the rate of deep tissue infection in this cohort. We recommend the use of autograft alone when treating bone defects in tibial fractures with external fixators.

Second-site prosthetic joint infection in patients with multiple prosthetic joints.

INTRODUCTION: Prosthetic joint infections (PJIs) are among the most serious complications in arthroplasty. A second-site PJI in patients with multiple prosthetic joints increases morbidity, with many requiring further revision procedures. We aimed to establish why some patients with multiple joints develop second-site infections. METHODS: Our institution's arthroplasty database was reviewed from 2004 to 2017. All PJIs were identified, and all patients with more than one prosthetic joint in situ were included. We recorded risk factors, causative organisms, number of procedures and length of stay. RESULTS: Forty-four patients meeting the criteria were identified. Four patients (9.1%) developed second-site infection. Eight patients (18.2%) developed re-infection of the primary PJI. Positive MRSA carrier status and PJI of a total knee replacement were associated with an increased risk of a second episode of infection. Patients who developed further infection had more frequent admission and longer lengths of stay than isolated PJIs. DISCUSSION: Higher morbidity and use of hospital resources are associated with this cohort of patients. PJIs in total knee replacements and positive MRSA status are associated with higher rates of second infection. Identifying this vulnerable cohort of patients at an early stage is critical to ensure measures are taken to reduce the risks of further infection.

Giant lipoma of the hand causing median nerve compression.

Lipomas are benign neoplasms derived from adipose tissue composed of mature adipocytes. They account for almost 50% of all soft-tissue neoplasms and occur in up to 2% of the population. They usually present asymptomatically as solitary discrete mobile lumps found most commonly on the neck, upper back, proximal limbs and chest. In less than 1% of cases, they can be found in the distal extremities.We discuss the case of a 65-year-old man who presented with a 2-year history of a slowly enlarging left palm swelling, with recent-onset numbness and loss of power in the distribution of the median nerve. MRI studies showed that the 5×4×2.7 cm lipoma had a component extending into the distal aspect of the carpal tunnel, compressing the median nerve. It was successfully excised, and at follow-up the patient reported complete resolution of his symptoms.