The Evolution of the Treatment of Distal Radius Fractures How We Got to Now.

Distal radius fractures are one of the most common fractures in adults and historically have frequently led to significant disability. Originally described over 5,000 years ago, until recently these fractures were almost exclusively treated by closed methods. Since the introduction of osteosynthesis in 1907, followed by the founding of the AO in 1958, and more recently the development of the volar locked plate in the early 2000s, over the past century the surgical treatment of these fractures has evolved greatly. While technological advancements have changed management for specific fracture patterns, closed treatment still has an important role and is definitive for many patients. The following review provides a historical perspective for current treatment strategies as well as an overview of the important factors that must be considered when treating patients with these injuries.

In-Office Needle Arthroscopy for the Foot and Ankle.

In-office needle arthroscopy (IONA) has been a readily available tool dating back to the 1990s, primarily for diagnostic purposes. This technique was not fully accepted and implemented because of significant limitations with the image quality and lack of instrumentation available to simultaneously treat the identified pathologies. However, recent advancements in IONA technology have made it possible to perform arthroscopic procedures under local anesthesia in the office setting, which once required a full operating suite. IONA has revolutionized how we treat foot and ankle pathologies in our practice. IONA allows the patient to be an active participant in the procedure and provides an interactive experience. IONA can be used to treat a range of foot and ankle pathologies, including anterior ankle impingement, posterior ankle impingement, osteochondral lesions of the ankle joint, hallux rigidus, lateral ankle ligament repair, and tendoscopic treatment of Achilles, peroneal, and posterior tibial tendon disorders. Excellent outcomes with regard to subjective clinical outcomes, return to play times, and complications have been reported following IONA for these pathologies.

Lower re-rupture rates but higher complication rates following surgical versus conservative treatment of acute achilles tendon ruptures: a systematic review of overlapping meta-analyses.

PURPOSE: To systematically review and evaluate the current meta-analyses for the treatment of acute Achilles tendon rupture (AATR). This study can provide clinicians with a clear overview of the current literature to aid clinical decision-making and the optimal formulation of treatment plans for AATR. METHODS: Two independent reviewers searched PubMed and Embase on June 2, 2022 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Assessment of evidence was twofold: level of evidence (LoE) and quality of evidence (QoE). LoE was evaluated using published criteria by The Journal of Bone and Joint Surgery and the QoE by the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) scale. Pooled complication rates were highlighted for significance in favour of one treatment arm or no significance. RESULTS: There were 34 meta-analyses that met the eligibility criteria, with 28 studies of LoE 1, and the mean QoE was 9.8 ± 1.2. Significantly lower re-rupture rates were reported with surgical (2.3-5%) versus conservative treatment (3.9-13%), but conservative treatment was favoured in terms of lower complication rates. The re-rupture rates were not significantly different between percutaneous repair or minimally invasive surgery (MIS) compared to open repair, but MIS was favoured in terms of lower complication rates (7.5-10.4%). When comparing rehabilitation protocols following open repair (four studies), conservative treatment (nine studies), or combined (three studies), there was no significant difference in terms of re-rupture or obvious advantage in terms of lower complication rates between early versus later rehabilitation. CONCLUSION: This systematic review found that surgical treatment was significantly favoured over conservative treatment for re-rupture, but conservative treatment had lower complication rates other than re-rupture, notably for infections and sural nerve injury. Open repair had similar re-rupture rates to MIS, but lower complication rates; however, the rate of sural nerve injuries was lower in open repair. When comparing earlier versus later rehabilitation, there was no difference in re-rupture rates or obvious advantage in complications between open repair, conservative treatment, or when combined. The findings of this study will allow clinicians to effectively counsel their patients on the postoperative outcomes and complications associated with different treatment approaches for AATR. LEVEL OF EVIDENCE: IV.

Advances in Cartilage Repair.

Osteochondral lesions of the ankle joint are typically associated with a traumatic etiology and present with ankle pain and swelling. Conservative management yields unsatisfactory results because of the poor healing capacity of the articular cartilage. Smaller lesions (<100 mm2 or <10 mm) can be treated with less invasive procedures such as arthroscopic debridement, anterograde drilling, scaffold-based therapies, and augmentation with biological adjuvants. For patients with large lesions (>100 mm2 or >10 mm), cystic lesions, uncontained lesions, or patients who have failed prior bone marrow stimulation, management with autologous osteochondral transplantation is indicated.

Return to Play After Arthroscopic Stabilization for Posterior Shoulder Instability-A Systematic Review.

PURPOSE: To ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after arthroscopic posterior shoulder stabilization. METHODS: Medline, EMBASE, and the Cochrane Library were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to find studies on arthroscopic posterior shoulder stabilization. Studies were included if they reported RTP data or rehabilitation protocols and excluded if concomitant procedures influenced the rehabilitation protocol. Rate and timing of RTP, along with rehabilitation protocols, were assessed. RESULTS: This review found 25 studies, including 895 cases, meeting the study's inclusion criteria. The majority of patients were male (82.7%), with an age range of 14 to 66 years and a follow-up range of 4 to 148.8 months. The overall RTP rate ranged from 62.7% to 100.0%, and 50.0% to 100.0% returned to the same level of play. Among collision athletes, the overall rate of RTP was 80.0% to 100.0%, with 69.2%-100.0% returning to the same level of play. In overhead athletes, the overall rate of RTP was 85.2% to 100.0%, with 55.6% to 100.0% returning to the same level of play. Four studies (128 patients) specifically addressed the timing of RTP, and the range to RTP was 4.3 to 8.6 months. Specific RTP criteria were reported in a majority of studies (60%), with the most reported item being restoration of strength (44%). CONCLUSION: There is a high rate of return to sport after arthroscopic posterior shoulder stabilization, ranging from 4.3 to 8.6 months after surgery. Return to preinjury level is higher for collision athletes compared with overhead athletes. However, there is inadequate reporting of RTP criteria in the current literature, with no clear timeline for when it is safe to return to sport. LEVEL OF EVIDENCE: IV, systematic review of level II to IV studies.

Young age, female gender, Caucasian race, and workers' compensation claim are risk factors for reoperation following arthroscopic ACL reconstruction.

PURPOSE: Given the increasing incidence of arthroscopic anterior cruciate ligament reconstruction (ACLR), mid- to long-term rates of reoperations were investigated on the ipsilateral knee following ACLR. METHODS: New York Statewide Planning and Research Cooperative Systems (SPARCS) database was queried from 2003 to 2012 to identify patients with a primary ICD-9 diagnosis for ACL tear and concomitant CPT code for ACLR. Patients were longitudinally followed for at least 2 years to determine incidence and nature of subsequent ipsilateral knee procedures. RESULTS: The inclusion criteria were met by 45,231 patients who had undergone ACLR between 2003 and 2012. Mean age was found to be 29.7 years (SD 11.6). Subsequent ipsilateral outpatient knee surgery after a mean of 25.7 ± 24.5 months was performed in 10.7% of patients. Revision ACLR was performed for nearly one-third of reoperations. Meniscal pathology was addressed in 58% of subsequent procedures. Age 19 or younger, female gender, worker's compensation (WC) insurance, and Caucasian race were identified as independent risk factors for any ipsilateral reoperation. An initial isolated ACLR and initial ACLR performed by a high-volume surgeon were found to be independently associated with lower reoperation rates. Tobacco use was not significant. Survival rates of 93.4%, 89.8% and 86.7% at 2-, 5- and 10 years, respectively, were found for any ipsilateral reoperation. CONCLUSION: A 10.7% ipsilateral reoperation rate at an average of 25.9 (SD 24.5) months after ACLR and an overall ACLR revision rate of 3.1% were demonstrated by the analysis. Meniscal pathology was addressed in the majority of subsequent interventions. Age 19 or younger, female gender, Caucasian race, and WC claim were associated with reoperation. Initial isolated ACLR and procedure performed by high-volume surgeon were associated with reduced reoperation. LEVEL OF EVIDENCE: Level III.

Right Place at the Right Time: Thoracotomies at Level I Trauma Centers Have Associated Improved Survival.

BACKGROUND: Early thoracotomy (ET) is a procedure performed on patients in extremis. Identifying factors associated with ET survival may allow for optimization of guidelines and improved patient selection. OBJECTIVES: The objective of this study was to assess whether ETs performed at Level I trauma centers (TC) are associated with improved survival. METHODS: This was a retrospective study utilizing the National Trauma Databank 2014-2015. We included all thoracotomies performed within 1 h of hospital arrival. Patients were stratified according to TC designation level. Patient demographics, outcomes, and center characteristics were compared. We conducted multivariable regression with survival as the outcome. RESULTS: There were 3183 ETs included in this study; 2131 (66.9%) were performed at Level I TCs. Patients treated at Level I and non-Level I TCs had similar median injury severity scores, as well as signs of life and systolic blood pressures on admission. Patients treated at Level I TCs had significantly higher survival rates (21.6% vs. 16.3%, p < 0.001), with 40% greater odds of survival after controlling for injury-specific factors and emergency medical services transportation time (adjusted odds ratio 1.40, 95% confidence interval 1.04-1.89, p = 0.03). Penetrating injuries had 23.1% survival after ET vs. 12.9% for blunt injuries (adjusted odds ratio 1.86, 95% confidence interval 1.37-2.53, p < 0.001). CONCLUSIONS: ETs performed at Level I TCs were associated with 40% greater odds of survival compared with ETs at non-Level I TCs. This demonstrates that factors extrinsic to the patient may play a role in survival of severely injured patients.