Low rate of malalignment using the tibial traction triangle for infrapatellar nailing of distal tibia fractures.

OBJECTIVES: To report on the immediate postoperative alignment of distal tibia fractures (within 10 cm of the tibial plafond) treated with infrapatellar intramedullary nailing (IMN) using the tibial traction triangle (TTT). METHODS: We performed a retrospective cohort study at a Level-I academic trauma center, with eighty-one skeletally mature patients with closed distal tibia fractures treated over a 10-year period with closed infrapatellar intramedullary nailing, without fibula fixation, using the TTT. The primary outcome measure is primary malalignment ≥5°. RESULTS: Primary malalignment occurred in 4 (4.9%) patients, all in the coronal plane. Mean coronal plane alignment was 1.72° valgus (range 3° varus to 8° valgus). No sagittal malalignment occurred. The fibula was intact in 5 (6.2%) cases. No patients underwent fibula fixation or blocking screw placement. Intra-articular extension occurred in 28 (34.6%) cases. Mean fracture distance from the plafond was 5.98 cm. Thirty-one patients had a fracture within 5 cm of the plafond, where malalignment was noted in 2 (6.5%) patients. CONCLUSIONS: This is the first analysis of a large cohort of patients with distal tibia fractures treated with the TTT. Use of this device leads to a very low rate of primary malalignment with infrapatellar nailing, even in extremely distal fractures. We recommend consideration of this device as one more adjunct to help treat these difficult fractures successfully.

Assessing the Value to the Patient of New Technologies in Anatomic Total Shoulder Arthroplasty.

BACKGROUND: Publications regarding anatomic total shoulder arthroplasty (TSA) have consistently reported that they provide significant improvement for patients with glenohumeral arthritis. New TSA technologies that have been introduced with the goal of further improving these outcomes include preoperative computed tomography (CT) scans, 3-dimensional preoperative planning, patient-specific instrumentation, stemless and short-stemmed humeral components, as well as metal-backed, hybrid, and augmented glenoid components. The benefit of these new technologies in terms of patient-reported outcomes is unknown. METHODS: We reviewed 114 articles presenting preoperative and postoperative values for commonly used patient-reported metrics. The results were analyzed to determine whether patient outcomes have improved over the 20 years during which new technologies became available. RESULTS: The analysis did not identify evidence that the results of TSA were statistically or clinically improved over the 2 decades of study or that any of the individual technologies were associated with significant improvement in patient outcomes. CONCLUSIONS: Additional research is required to document the clinical value of these new technologies to patients with glenohumeral arthritis. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Can We Estimate the Amount of Malrotation in Supracondylar Humerus Fractures After CRPP?

BACKGROUND: Acceptable amounts of malrotation after CRPP for pediatric supracondylar humerus fracture (SCHFx) have yet to be defined. This is an attempt to correlate radiographic parameters of a malrotated SCHFx with degrees of rotational malalignment to assist intraoperative assessment of reduction. METHODS: 3D models of a left distal humerus were printed, simulating a transverse SCHFx with 5, 10, 15, 20, 25, and 30 degrees of malrotation. Four different scenarios were developed: (1) lateral cortical axis of rotation, (2) medial cortical axis of rotation, (3) centroid of the humerus longitudinal axis with the medial condyle rotated posteriorly, and (4) centroid of the humerus longitudinal axis with the medial condyle rotated anteriorly. Anteroposterior and lateral fluoroscopic views were taken with a consistent image profile. Five observers measured the amount of metaphyseal overhang on the lateral view and the width of the distal humerus just proximal to the fracture to establish amount of overhang as a percentage of distal humerus width. Regression analysis established "best fit" lines for the 4 scenarios. Ten observers used the observed characteristics of each type of malrotation and "best fit" lines to estimate axis and degrees of malrotation using the same fluoroscopy of the 24 models. RESULTS: The intraclass correlation coefficient of reliability for percentage of metaphyseal overhang ranged from 0.775 to 0.987. Observers correctly predicted axis of malrotation in 76% and correctly predicted amount of malrotation in 75% of models. CONCLUSIONS: Estimation of axis of malrotation and degrees of malrotation within 5 degrees in SCHFx can be predicted in 75% of our 3D printed models.

Level of Evidence and Publication Rates of Abstracts Presented at the American Society for Surgery of the Hand Annual Meetings: Comparison Over 23 Years.

PURPOSE: The primary aims of this study were to determine how level of evidence and publication rates of American Society for Surgery of the Hand (ASSH) abstracts presented at the national meeting have changed over the past 23 years. METHODS: Abstracts presented at the ASSH annual meeting from 1992 to 2014 were reviewed. Level of evidence (LoE) and publication status for each abstract were recorded. We calculated annual and overall LoE, publication rates, average time to publication, and top journals of publication for abstracts presented from 1992 to 2014. The LoE was categorized into level 1 or 2 studies, levels 3 to 5 studies, or nonclinical study. RESULTS: A total of 1,757 abstracts were presented at ASSH meetings from 1992 to 2014; 942 abstracts were published in peer-reviewed journals for an overall publication rate of 53.6%. There was a significant increase in the proportion of levels 1 to 2 LoE abstracts over time (18% in 2007-2014 vs 11% in 1999-2006 and 2% in 1992-1998). There was also a significantly higher percentage of abstracts published over time (62% in 2007-2014 vs 52% in 1999-2006 and 47% in 1992-1998). Levels 1 to 2 LoE studies were associated with higher publication rates than nonclinical or levels 3 to 5 LoE studies. CONCLUSIONS: This research provides historical trends on the LoE of abstracts presented at the ASSH annual meetings. Our study shows there are increasing numbers of levels 1 to 2 studies as well as higher publication rates of abstracts presented at more recent ASSH annual meetings. Levels 1 to 2 studies are more likely to be published than nonclinical or levels 3 to 5 studies. CLINICAL RELEVANCE: Although not all questions can be feasibly answered with level 1 or level 2 studies, authors should continue to search for ways to strengthen study designs, producing more valid and comparable results with increased likelihood of publication driving forward the quality of hand surgery research. Higher recent publication rates may be partially due to the increased number of available journals for publication.

Factors Associated with Scaphoid Nonunion following Early Open Reduction and Internal Fixation.

Background Nonunion after open reduction and internal fixation (ORIF) of scaphoid fractures is reported in 5 to 30% of cases; however, predictors of nonunion are not clearly defined. Objective The purpose of this study is to determine fracture characteristics and surgical factors which may influence progression to nonunion after scaphoid fracture ORIF. Patients and Methods We performed a retrospective case-control study of scaphoid fractures treated by early ORIF between 2003 and 2017. Inclusion criteria were surgical fixation within 6 months from date of injury and postoperative CT with minimum clinical follow-up of 6 months to evaluate healing. Forty-eight patients were included in this study. Nonunion cases were matched by age, sex, and fracture location to patients who progressed to fracture union in the 1:2 ratio. Results This series of 48 patients matched 16 nonunion cases with 32 cases that progressed to union. Fracture location was proximal pole in 15% (7/48) and waist in 85% (41/48). Multivariate regression demonstrated that shorter length of time from injury to initial ORIF and smaller percent of proximal fracture fragment volume were significantly associated with scaphoid nonunion after ORIF (63 vs. 27 days and 34 vs. 40%, respectively). Receiver operating curve analysis revealed that fracture volume below 38% and time from injury to surgery greater than 31 days were associated with nonunion. Conclusion Increased likelihood for nonunion was found when the fracture was treated greater than 31 days from injury and when fracture volume was less than 38% of the entire scaphoid. Level of Evidence This is a Level III, therapeutic study.

Report of clinico-pathological features of breast cancer in HIV-infected and uninfected women in Botswana.

BACKGROUND: To characterize the clinico-pathological features including estrogen receptor (ER), progesterone receptor (PR) and Her-2/neu (HER2) expression in breast cancers in Botswana, and to compare them by HIV status. METHODS: This was a retrospective study using data from the National Health Laboratory and Diagnofirm Medical Laboratory in Gaborone from January 1, 2011 to December 31, 2015. Clinico-pathological details of patients were abstracted from electronic medical records. RESULTS: A total of 384 unique breast cancer reports met our inclusion criteria. Of the patients with known HIV status, 42.7% (50/117) were HIV-infected. Median age at the time of breast cancer diagnosis was 54 years (IQR 44-66 years). HIV-infected individuals were more likely to be diagnosed before age 50 years compared to HIV-uninfected individuals (68.2% vs 23.8%, p < 0.001). The majority of patients (68.6%, 35/51) presented with stage III at diagnosis. Stage IV disease was not presented because of the lack of data in pathology records surveyed, and additionally these patients may not present to clinic if the disease is advanced. Overall, 68.9% (151/219) of tumors were ER+ or PR+ and 16.0% (35/219) were HER2+. ER+ or PR+ or both, and HER2- was the most prevalent profile (62.6%, 132/211), followed by triple negative (ER-/PR-/HER2-, 21.3%, 45/211), ER+ or PR+ or both, and HER2+, (9.0%, 19/211) and ER-/PR-/HER2+ (7.1%, 15/211). There was no significant difference in receptor status noted between HIV-infected and HIV-uninfected individuals. CONCLUSIONS: Majority of breast cancer patients in Botswana present with advanced disease (stage III) at diagnosis and hormone receptor positive disease. HIV-infected breast cancer patients tended to present at a younger age compared to HIV-uninfected patients. HIV status does not appear to be associated with the distribution of receptor status in breast cancers in Botswana.

Delaying Surgery in Type III Supracondylar Humerus Fractures Does Not Lead to Longer Surgical Times or More Difficult Reduction.

OBJECTIVE: To determine if delay in surgical treatment of type III supracondylar humerus fracture would affect the length of operative time. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: This is a series of 309 modified Gartland type III supracondylar fractures treated operatively from 2011 to 2013. INTERVENTION: Fifteen hours was defined as the cutoff between early and delayed treatment. A total of 53.7% (166/309) fractures were treated early, and 46.4% (143/309) were delayed. MAIN OUTCOME MEASUREMENTS: Surgical time was defined as "incision start" to "incision close." Fluoroscopy time was used as a surrogate for difficulty of reduction. RESULTS: Time from injury to operating room was shorter for high-energy fractures (fractures with soft-tissue or neurovascular injury) versus low-energy fractures (12.9 vs. 15.3 hours, P < 0.0001); however, surgical time (37.3 vs. 31.8 minutes, P = 0.004) and fluoroscopy time (54.6 vs. 48.6 seconds, P = 0.027) were longer in high-energy fractures versus low-energy fractures. Among low-energy fractures, no significant difference was detected in the surgical time between the early and delayed treatment groups or in the fluoroscopy time. In addition, there was no statistically significant difference found in the surgical or fluoroscopy time with the presence of a surgical assistant. CONCLUSIONS: Delay in surgery did not result in a longer surgical time or more difficult reduction for type III supracondylar humerus fracture. Patients with low-energy fractures still underwent a shorter operative time even with delay from injury to surgery. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Urinary N-Telopeptide Can Predict Pseudarthrosis After Anterior Cervical Decompression and Fusion: A Prospective Study.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To examine preoperative urinary cross-linked n-telopeptide (uNTx) and assess for association with fusion rates in patients undergoing single and multi-level anterior cervical decompression and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Although high rates of fusion have been reported for ACDF, the risk of pseudarthrosis remains substantial. An established marker of bone turnover, uNTx may prove useful as a predictor of fusion. METHODS: Patients undergoing primary ACDF with allograft/plating technique from 2015 to 2017 by a single surgeon were consecutively enrolled and preoperative uNTx was collected. Patients undergoing revision, with creatinine >1.2, and with improperly-collected uNTx were excluded. Demographics, laboratory values, and fusion status were assessed at 6 months, 1 year, and 2 years postoperatively. RESULTS: Of the 97 patients enrolled, 69 met inclusion criteria. Of included cases, 41%, 33%, 18%, and 8% underwent 1-, 2-, 3-, and 4-level ACDF, respectively. Overall, fusion rates were 37.3%, 70.9%, and 95.3% at 6 months, 1 year, and 2 years, respectively. uNTx was higher in the fusion group (31.1 vs. 22.2, P = 0.001) at 6 months and 1 year (30.0 vs. 21.0, P = 0.006), with no difference at 2 years. No differences were identified in the proportion of smokers, immunomodulatory agents, corpectomies, or fusion levels between groups. Multivariate regression analysis demonstrated that uNTx is an independent predictor of fusion (odds ratio, OR, 1.124, P = 0.003). Both groups experienced improvements in NDI and VAS neck pain at 6 months with no significant differences noted between groups. Of 16 patients with pseudarthrosis at 1 year, 2 underwent posterior cervical fusion for symptoms. CONCLUSION: Preoperative uNTx was greater in patients with successful ACDF fusion compared with patients with pseudarthrosis at 6 months and 1 year. A negative correlation was found between preoperative uNTx and motion on dynamic imaging. These results suggest that uNTx could serve to identify patients at risk for pseudarthrosis after ACDF. LEVEL OF EVIDENCE: 3.

Use of a Novel Tibial Traction Triangle for Intramedullary Nailing of Tibia Fractures.

Malalignment after intramedullary nailing of proximal and distal tibia fractures remains a significant problem. We describe the use of a novel device to ease treatment of tibia fractures that undergo intramedullary nailing. The tibial traction triangle is simple and easy to use and allows for better reductions, leading to lower rates of malalignment. A prospective series of 11 patients is presented.

Breast Cancer Pathology Turnaround Time in Botswana.

PURPOSE: Quality pathology is critical for timely diagnosis and management of breast cancer. Few studies have analyzed pathology turnaround time (TAT) in sub-Saharan Africa. The purpose of this study was to quantify TAT for breast cancer specimens processed by the National Health Laboratory and Diagnofirm Laboratory in Gaborone, Botswana, and additionally compare TAT before and after 2012 to evaluate the effect of pathology scale-up interventions by the Ministry of Health and Wellness. METHODS: Retrospective analyses of TAT were performed for breast specimens submitted to the two laboratories from 2011 to 2015. TAT was calculated as the time from specimen collection and receipt in the laboratory to the date of final report sign-out. Descriptive statistics and rank sum test were used to compare temporal trends in TAT before and after 2012. RESULTS: A total of 158 breast biopsy, 219 surgical, and 218 immunohistochemistry (IHC) specimens were analyzed. The median TAT in 2015 was 6 and 7 days for biopsy and IHC specimens, respectively, and 57.5 days for surgical specimens. There was a significant decrease in median TAT for biopsy specimens from 21.5 days in 2011 to 2012 compared with 8 days in 2013 to 2015 ( P < .001). There was also a significant decrease in median TAT for IHC specimens during the same period ( P < .001). However, there was no significant decline in median TAT for surgical specimens. CONCLUSION: The scale-up of pathology personnel and infrastructure by the Ministry of Health and Wellness significantly reduced median TAT for biopsy and IHC specimens. TAT for surgical specimens remains suboptimal. Efforts are currently under way to decrease TAT for surgical specimens to 7 days.

Breast Cancer and HIV in Sub-Saharan Africa: A Complex Relationship.

INTRODUCTION: The number and lifespan of individuals living with HIV have increased significantly with the scale-up of antiretroviral therapy. Furthermore, the incidence of breast cancer in women with HIV is growing, especially in sub-Saharan Africa (SSA). However, the association between HIV infection and breast cancer is not well understood. METHODS: A literature search was performed to identify articles published in journals pertaining to breast cancer and HIV, with an emphasis on SSA. Selected US-based studies were also identified for comparison. RESULTS: Among the 56 studies reviewed, the largest study examined 314 patients with breast cancer and HIV in the United States. There is no consensus on whether HIV infection acts as a pro-oncogenic or antioncogenic factor in breast cancer, and it may have no relation to breast cancer. A higher incidence of breast cancer is reported in high-income countries than in SSA, although breast cancer in SSA presents at a younger age and at a more advanced stage. Some studies show that patients with breast cancer and HIV experience worse chemotherapy toxicity than do patients without HIV. Data on treatment outcomes are limited. The largest study showed worse treatment outcomes in patients with HIV, compared with their counterparts without HIV. CONCLUSION: HIV infection has not been associated with different clinical presentation of breast cancer. However, some evidence suggests that concurrent diagnosis of HIV with breast cancer is associated with increased therapy-related toxicity and worse outcomes. Systematic prospective studies are needed to establish whether there is a specific association between breast cancer and HIV.