Comparison of Anterior and Posterior Cortico-steroid Injections for Pain Relief and Functional Improvement in Shoulder Impingement Syndrome.

Subacromial impingement syndrome (SIS) is the most common cause of shoulder pain. Treatment options for SIS include conservative modalities such as use of nonsteroidal anti-inflammatory drugs, physical therapy, and subacromial corticosteroid injections (CSIs). Although studies have found improvement in pain, function, and range of motion after CSI, the effect of injection route (anterior or posterior) on shoulder pain in patients with SIS has not been investigated. In the study reported here, patients were randomly assigned to 2 treatment groups: anterior CSI and posterior CSI. Pain was assessed with a visual analog scale (VAS) and function with the Single Assessment Numeric Evaluation (SANE). Patients were evaluated before injection (baseline) and 1, 3, and 6 months after injection. Of the 55 patients enrolled, 25 received anterior CSI and 30 received posterior CSI. The 2 groups showed no significant difference in VAS pain at baseline or 1, 3, or 6 months after injection. SANE scores were statistically different at 3 months. Each group had significantly less pain and better function 1, 3, and 6 months after injection than at baseline. Age, sex, and body mass index did not significantly affect the efficacy of anterior or posterior CSIs. In patients with SIS, subacromial CSI reduces pain and improves function for up to 6 months. These effects are no different for anterior and posterior injection routes. As a result, clinicians should rely on their clinical acumen when selecting injection routes, as anterior and posterior are both beneficial.

25-Hydroxyvitamin-D and Bone Turnover Marker Levels in Patients with Distal Radial Fracture.

BACKGROUND: Fragility fractures are a major public health issue with substantial socioeconomic cost. Vitamin-D deficiency and increased bone turnover are associated with higher rates of bone loss and an increased risk of fracture. We hypothesized that patients with a distal radial fracture would have lower levels of 25-hydroxyvitamin D (25[OH]D) and increased levels of serum bone turnover markers than controls without a fracture. METHODS: Postmenopausal women with a recent distal radial fracture (fracture group, n = 105) were prospectively recruited and were compared with individuals without a fracture (control group, n = 150). Outcome variables included serum levels of 25(OH)D and markers of bone formation, including N-terminal extension propeptide of type-I collagen (P1NP), parathyroid hormone (PTH), bone-specific alkaline phosphatase (BSAP), and osteocalcin, as well as a marker of resorption (C-terminal telopeptide of type-I collagen [CTX-1]). Bone mineral density was measured with dual x-ray absorptiometry. RESULTS: The fracture group was slightly older than the control group (mean and standard deviation [SD], 66.8 ± 10.8 years versus 63.3 ± 9.0 years, p = 0.008), had a lower body mass index (26.4 ± 5.9 kg/m(2) versus 28.0 ± 6.2 kg/m(2), p = 0.05), and more commonly had had a prior fracture (52% versus 31%, p < 0.001). Bone mineral density at the hip was lower in the fracture group than in the control group (0.831 ± 0.130 g/cm(2) versus 0.917 ± 0.139 g/cm(2), p < 0.001). The mean 25(OH)D levels were similar in the fracture and control groups (44.4 ± 14.6 ng/mL versus 41.3 ± 14.5 ng/mL, p = 0.08). Levels of serum markers of bone formation were significantly higher in the fracture group than in the control group (P1NP: 70.4 ± 33.2 ng/mL versus 53.2 ± 25.6 ng/mL, p < 0.001; osteocalcin: 22.3 ± 9.9 ng/mL versus 20.2 ± 9.2 ng/mL, p = 0.017). Levels of BSAP, PTH, and CTX-1 were similar in the two groups. Multivariable logistic regression showed independent associations between a distal radial fracture and low total hip bone mineral density (odds ratio [OR] = 2.02 for each decrease of 1 SD, 95% confidence interval [CI] = 1.38 to 3.01, p < 0.001) and a high P1NP level (OR = 2.17 for each 1-SD increase, 95% CI = 1.52 to 3.06, p < 0.001). CONCLUSIONS: In this cohort, 25(OH)D levels were not associated with distal radial fracture and do not appear to affect the risk assessment for distal radial fracture in postmenopausal women. Patients with a distal radial fracture, however, had increased bone turnover as evidenced by high P1NP and osteocalcin levels. Women with both a high P1NP level and low bone mineral density were at particularly high risk for fracture.

Predictive factors of distal femoral fracture nonunion after lateral locked plating: a retrospective multicenter case-control study of 283 fractures.

INTRODUCTION: Reported initial success rates after lateral locked plating (LLP) of distal femur fractures have led to more concerning outcomes with reported nonunion rates now ranging from 0 to 21%. Reported factors associated with nonunion include comorbidities such as obesity, age and diabetes. In this study, our goal was to identify patient comorbidities, injury and construct characteristics that are independent predictors of nonunion risk in LLP of distal femur fractures; and to develop a predictive algorithm of nonunion risk, irrespective of institutional criteria for clinical intervention variability. PATIENTS AND METHODS: A retrospective review of 283 distal femoral fractures in 278 consecutive patients treated with LLP at three Level1 academic trauma centers. Nonunion was liberally defined as need for secondary procedure to manage poor healing based on unrestricted surgeon criteria. Patient demographics (age, gender), comorbidities (obesity, smoking, diabetes, chronic steroid use, dialysis), injury characteristics (AO type, periprosthetic fracture, open fracture, infection), and management factors (institution, reason for intervention, time to intervention, plate length, screw density, and plate material) were obtained for all participants. Multivariable analysis was performed using logistic regression to control for confounding in order to identify independent risk factors for nonunion. RESULTS: 28 of the 283 fractures were treated for nonunion, 13 were referred to us from other institutions. Obesity (BMI>30), open fracture, occurrence of infection, and use of stainless steel plate were significant independent risk factors (P<0.01). A predictive algorithm demonstrates that when none of these variables are present (titanium instead of stainless steel) the risk of nonunion requiring intervention is 4%, but increases to 96% with all factors present. When a stainless plate is used, obesity alone carries a risk of 44% while infection alone a risk of 66%. While Chi-square testing suggested no institutional differences in nonunion rates, the time to intervention for nonunion varied inversely with nonunion rates between institutions, indicating varying trends in management approach. DISCUSSION: Obesity, open fracture, occurrence of infection, and the use of stainless steel are prognostic risk factors of nonunion in distal femoral fractures treated with LLP independent of differing trends in how surgeons intervene in the management of nonunion.

Correlation of AO and Lauge-Hansen classification systems for ankle fractures to the mechanism of injury.

BACKGROUND: Our aim was to assess whether the Lauge-Hansen (LH) and the Muller AO classification systems for ankle fractures radiographically correlate with in vivo injuries based on observed mechanism of injury. METHODS: Videos of potential study candidates were reviewed on YouTube.com. Individuals were recruited for participation if the video could be classified by injury mechanism with a high likelihood of sustaining an ankle fracture. Corresponding injury radiographs were obtained. Injury mechanism was classified using the LH system as supination/external rotation (SER), supination/adduction (SAD), pronation/external rotation (PER), or pronation/abduction (PAB). Corresponding radiographs were classified by the LH system and the AO system. RESULTS: Thirty injury videos with their corresponding radiographs were collected. Of the video clips reviewed, 16 had SAD mechanisms and 14 had PER mechanisms. There were 26 ankle fractures, 3 nonfractures, and 1 subtalar dislocation. Twelve fractures with SAD mechanisms had corresponding SAD fracture patterns. Five PER mechanisms had PER fracture patterns. Eight PER mechanisms had SER fracture patterns and 1 had SAD fracture pattern. When the AO classification was used, all 12 SAD type injuries had a 44A type fracture, whereas the 14 PER injuries resulted in nine 44B fractures, two 44C fractures, and three 43A fractures. CONCLUSION: When injury video clips of ankle fractures were matched to their corresponding radiographs, the LH system was 65% (17/26) consistent in predicting fracture patterns from the deforming injury mechanism. When the AO classification system was used, consistency was 81% (21/26). The AO classification, despite its development as a purely radiographic system, correlated with in vivo injuries, as based on observed mechanism of injury, more closely than did the LH system. LEVEL OF EVIDENCE: Level IV, case series.

Anatomical localization, gene expression profiling and functional characterization of adult human neck brown fat.

The imbalance between energy intake and expenditure is the underlying cause of the current obesity and diabetes pandemics. Central to these pathologies is the fat depot: white adipose tissue (WAT) stores excess calories, and brown adipose tissue (BAT) consumes fuel for thermogenesis using tissue-specific uncoupling protein 1 (UCP1). BAT was once thought to have a functional role in rodents and human infants only, but it has been recently shown that in response to mild cold exposure, adult human BAT consumes more glucose per gram than any other tissue. In addition to this nonshivering thermogenesis, human BAT may also combat weight gain by becoming more active in the setting of increased whole-body energy intake. This phenomenon of BAT-mediated diet-induced thermogenesis has been observed in rodents and suggests that activation of human BAT could be used as a safe treatment for obesity and metabolic dysregulation. In this study, we isolated anatomically defined neck fat from adult human volunteers and compared its gene expression, differentiation capacity and basal oxygen consumption to different mouse adipose depots. Although the properties of human neck fat vary substantially between individuals, some human samples share many similarities with classical, also called constitutive, rodent BAT.