Treatment of olecranon fractures with 2.4- and 2.7-mm plating techniques.

OBJECTIVES: To evaluate the outcomes of olecranon fractures treated with 2.4- and 2.7-mm plate constructs. DESIGN: Retrospective Case Series. SETTING: One-level 1 trauma center and 1 tertiary care hospital. PATIENTS: Thirty-five consecutive patients meeting inclusion criteria. INTERVENTION: A 2.7- or 2.4-mm reconstruction plate was placed on the dorsal ulnar cortex and contoured to allow passage of either a 2.7- or 3.5-mm intramedullary screw. In 9 patients, additional plates were required to control comminution. Available computed tomographic (CT) scans were evaluated for the presence of comminution. MAIN OUTCOME MEASUREMENTS: Average Disabilities of the Arm, Shoulder, and Hand (DASH) and Mayo Elbow Performance Score (MEPS). RESULTS: All fractures were united. Average extension deficit was 4.2 degrees, and average flexion angle was 137.4 degrees. Outcome scores were completed by 94% (33/35) of study patients. Average DASH score was 6.6, and average MEPS score was 94.5. Implants were removed in 18 patients. In the cohort of patients with CT scans, 6 of the 7 fractures thought to be simple on plain film analysis were found to have occult comminution on CT scan. CONCLUSIONS: Comminution should be considered in all olecranon fractures, even when plain films display simple patterns; although this did not affect treatment in this series of plated patients, it may be important if selecting tension band wiring. Fixation with 2.4- and 2.7-mm plates addresses comminution in olecranon fractures, avoiding the pitfalls of tension band wiring. In patients with completed outcome scores, 97% (32/33) reported their outcomes as good or excellent according to the MEPS. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of the stress positive ligamentous SE4 ankle fracture: incidence of syndesmotic injury and clinical decision making.

OBJECTIVES: The objective of the study was to review our experience with the treatment of stress positive (+) supination and external pattern injuries using shared decision making with the patients. DESIGN: Retrospective case review. SETTING: Level 1 trauma center. PATIENTS: Over a 9-year period, we treated 114 patients (aged 19-76 years, average 43 years) with stress (+) supination and external rotation type fibula fractures, who were included in the present study. INTERVENTION: X-rays were reviewed, and the medial clear space (MCS) measured on the presentation, stress, and final united radiographs. The decision for surgical or nonsurgical management was made by the patient and surgeon after a discussion of risks/benefits of both. Syndesmotic instability for the operative cases was diagnosed by medial widening and talar subluxation on abduction/external rotation stress after fibular fixation. MAIN OUTCOME MEASURE: MCS measurement at union. RESULTS: Of the 114 cases, 54 were definitively treated in a cast, and 60 were treated operatively. Twenty-seven (45%) of the operative cases demonstrated syndesmotic instability on radiographic examination. The MCS on stress examination was statistically different, with greater widening seen for operatively treated patients (4.8 ± 0.5 vs. 6.9 ± 0.86) (P < 0.001). No patient healed with any subluxation on weight bearing x-rays. CONCLUSIONS: Stress (+) SE pattern fibular fractures with minimal MCS widening on stress examination may be treated in a cast to union with predictable healing. In those patients treated operatively, the treating surgeon should be aware of the high rate of syndesmotic injury. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does double-row rotator cuff repair improve functional outcome of patients compared with single-row technique? A systematic review.

BACKGROUND: The advantage of single-row versus double-row arthroscopic rotator cuff repair techniques has been a controversial issue in sports medicine and shoulder surgery. There is biomechanical evidence that double-row techniques are superior to single-row techniques; however, there is no clinical evidence that the double-row technique provides an improved functional outcome. HYPOTHESIS: When compared with single-row rotator cuff repair, double-row fixation, although biomechanically superior, has no clinical benefit with respect to retear rate or improved functional outcome. STUDY DESIGN: Systematic review. METHODS: The authors reviewed prospective studies of level I or II clinical evidence that compared the efficacy of single- and double-row rotator cuff repairs. Functional outcome scores included the American Shoulder and Elbow Surgeons (ASES) shoulder scale, the Constant shoulder score, and the University of California, Los Angeles (UCLA) shoulder rating scale. Radiographic failures and complications were also analyzed. A test of heterogeneity for patient demographics was also performed to determine if there were differences in the patient profiles across the included studies. RESULTS: Seven studies fulfilled our inclusion criteria. The test of heterogeneity across these studies showed no differences. The functional ASES, Constant, and UCLA outcome scores revealed no difference between single- and double-row rotator cuff repairs. The total retear rate, which included both complete and partial retears, was 43.1% for the single-row repair and 27.2% for the double-row repair (P = .057), representing a trend toward higher failures in the single-row group. CONCLUSION: Through a comprehensive literature search and meta-analysis of current arthroscopic rotator cuff repairs, we found that the single-row repairs did not differ from the double-row repairs in functional outcome scores. The double-row repairs revealed a trend toward a lower radiographic proven retear rate, although the data did not reach statistical significance. There may be a concerning trend toward higher retear rates in patients undergoing a single-row repair, but further studies are required.

Open fractures of the distal radius: the effects of delayed debridement and immediate internal fixation on infection rates and the need for secondary procedures.

PURPOSE: There are few clinical data evaluating the outcome of surgery for open distal radius fractures based on treatment method. Specifically, the major contributing factors to infection are largely unknown. The purpose of this study is to determine the effect of early versus delayed debridement and the choice of initial external versus internal fixation on infection rates and the need for secondary procedures. METHODS: Thirty-two patients with open distal radius fractures were identified from a database. Ten debridements were early (<6 h after hospital admission), and 22 debridements were delayed (>6 h after hospital admission). There were 10 treating surgeons for the 32 patients in this study. Based on the attending surgeon's preference and experience, 20 fractures were treated with external fixation, 7 with plating, and 5 with planned staged conversion from external fixation to plating. The cohort included 19 grade I, 11 grade II, and 3 grade IIIA open injuries. RESULTS: There were no infections, regardless of the time to debridement or the use of immediate plating. Other complications requiring secondary procedures occurred more frequently in patients treated with a planned staged conversion from external fixation to plating than in the patients treated with either external fixation or plating. CONCLUSIONS: We did not encounter infections for grade I and grade II open distal radius fractures, and infections do not appear to be related to either the time to debridement or the initial type of fracture fixation. Plating might be safe at the initial debridement, but temporary external fixation with a staged conversion to plating increases the risk of complications, which necessitates corrective secondary procedures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

PAF-induced furin and MT1-MMP expression is independent of MMP-2 activation in corneal myofibroblasts.

PURPOSE: Corneal stromal myofibroblasts express the platelet-activating factor (PAF) receptor, but its role is unclear. In the present study, the effect of PAF on induction of metalloproteinases (MMPs) was investigated. METHODS: Rabbit corneal myofibroblasts were identified by immunodetection of alpha-smooth muscle (alpha-SM)-actin. MT1-MMP, MMP-2, MMP-9, and tissue inhibitor of matrix metalloproteinase (TIMP)-2 were detected by immunofluorescence. Cells were treated with 100 nM cPAF, with or without the PAF antagonist BN 50730 or the furin inhibitor nona-D-arg-NH(2). Gene-expression levels for furin, urokinase plasminogen activator, MMP-2, MMP-9, MT1-MMP, and TIMP-2 were determined by real-time PCR. Protein expression was assessed by Western blot. MMP-2 and -9 activity was determined by gelatin zymography. Active MT1-MMP levels were measured by ELISA. RESULTS: cPAF triggered significantly increased MT1-MMP, MMP-2, MMP-9, and TIMP-2 mRNA expression, followed by increased active MT1-MMP protein expression at 12 hours, whereas TIMP-2 protein increased at 24 hours. PAF also induced furin gene expression, followed by increased protein expression. Nona-D-arg-NH(2) blocked cPAF induction of MT1-MMP activity. PAF-treated myofibroblasts showed increased active MMP-9 protein, but unchanged MMP-2 activity. Pretreatment with BN 50730 blocked PAF-induced transcription and translation of these proteins. CONCLUSIONS: PAF, through a receptor-mediated mechanism, induces a specific pattern of furin, MMP, and TIMP-2 expression in corneal myofibroblasts. MMP-2 activity was unchanged by PAF treatment. These results suggest that in response to the inflammatory mediator PAF, induction of MT1-MMP is independent of MMP-2 activity in corneal myofibroblasts. Thus, PAF-mediated changes in extracellular matrix composition surrounding the myofibroblasts could be important in regulating the corneal scarring process. Moreover, PAF antagonists could be useful in maintaining corneal transparency.