Should my recommendation letter be written by artificial intelligence?

SummaryLetters of recommendation are increasingly important for the residency match. We assessed whether an artificial intelligence (AI) tool could help in writing letters of recommendation by analyzing recommendation letters written by 3 academic staff and AI duplicate versions for 13 applicants. The preferred letters were selected by 3 blinded orthopedic program directors based on a pre-determined set of criteria. The first orthopedic program director selected the AI letter for 31% of applicants, and the 2 remaining program directors selected the AI letter for 38% of applicants, with the staff-written versions selected more often by all of the program directors (p < 0.05). The first program director recognized only 15% of the AI-written letters, the second was able to identify 92%, and the third director identified 77% of AI-written letters (p < 0.05).

Validity, reliability and responsiveness of a French translation of the Western Ontario Osteoarthritis of the Shoulder index (WOOS).

INTRODUCTION: While several general questionnaires can be used to evaluate shoulder conditions, very few tools specifically evaluate the impact of shoulder osteoarthritis. The Western Ontario Osteoarthritis of the Shoulder index (WOOS) is a patient-reported outcome measure with excellent psychometric properties intended for patients suffering from shoulder osteoarthritis. Unfortunately, there is no validated French version of this questionnaire. OBJECTIVE: Produce a validated French version of the WOOS that is suitable for the Francophone populations of Europe and North America. MATERIAL AND METHODS: A validated protocol was used to create a French version of the WOOS (WOOS-Fr). Included were patients whose first language was French, who could read French and who had shoulder osteoarthritis destined for treatment (surgical treatment=arthroplasty). The WOOS-Fr was compared to the Disability of the Arm, Shoulder and Hand-French translation (F-QuickDASH-D/S) to assess its validity. Reliability and responsiveness were also analyzed. RESULTS: A French version of the WOOS (WOOS-Fr) was accepted by a multinational committee. The WOOS-Fr was validated in 71 French-speaking subjects. A strong positive correlation was found between the WOOS-Fr and the F-QuickDASH-D/S during the initial evaluation. The intra-class correlation (ICC) of the total WOOS-Fr score indicated good reliability between the initial WOOS and the 1-week WOOS (ICC: 0.84; 95% CI: [0.767; 0.896]; p-value: <0.001) in 57 patients. The responsiveness between the initial WOOS-Fr and at 1 year postoperative was high in the 36 operated patients (standardized mean response of 1.95). DISCUSSION: A French translation of the WOOS questionnaire was created and validated for use in French-speaking populations. This questionnaire will make it easier to evaluate the psychometric results of patients with shoulder osteoarthritis in Francophone countries. LEVEL OF EVIDENCE: III; multicenter cohort study.

Validity, reliability and responsiveness of the French translation of the Patient-Rated Wrist Evaluation Questionnaire (PRWE).

INTRODUCTION: The patient-rated wrist evaluation questionnaire (PRWE) is a specific wrist questionnaire, developed in Canada that has been validated and proved reliable and sensitive. It assesses pain and function. Unfortunately, there was no validated French-language version. It is important that a translation should be methodologically rigorous, as both linguistic and cultural factors come into play. OBJECTIVE: To produce a French-language version of the PRWE, culturally adapted to the French-speaking populations of Europe and North America. MATERIALS AND METHODS: A validated protocol was used to produce a French-language version of the PRWE (PRWE-Fr) that would be culturally acceptable for the French-speaking populations of Europe and North America. Reliability and responsiveness analyses were performed and PRWE-Fr scores were compared to F-QuickDASH-D/S (French translation of short-form Disabilities of the Arm, Shoulder and Hand-Disability/Symptoms) scores to assess validity. RESULTS: A French-language version of the PRWE (PRWE-Fr) was accepted by a multinational committee, then validated in 65 French-speaking subjects, divided into 2 groups for analyses. A strong positive correlation was found between PRWE-Fr and F-QuickDASH-D/S scores. Comparison of results between two PRWE-Fr sessions at a 1-week interval found a very strong correlation (ρ=0.93; r2=0.868; p<0.001). The intraclass correlation coefficient for total PRWE-Fr score demonstrated excellent reliability (ICC: 0.93; 95% CI: [0.859; 0.969]; p<0.001). Responsiveness analysis revealed greater sensitivity to change than for the F-QuickDASH-D/S (standardized response mean [SRM], 1.14 versus 1.04 respectively). DISCUSSION: A French-language version of the PRWE was produced and validated for use in French-speaking populations. It should facilitate evaluation of results in French-speaking settings, collaboration in multinational studies and comparison between studies performed in different countries. LEVEL OF EVIDENCE: II; Multicenter cohort study.

Evidence-based treatment of Achilles tendon rupture.

The treatment of Achilles tendon rupture has recently seen a shift toward non-operative management, as supported by the literature, yet many surgeons continue to treat these injuries operatively. The evidence clearly supports non-operative management of these injuries except for Achilles insertional tears and for certain patient groups, such as athletic patients, for whom further research is warranted. This nonadherence to evidence-based treatment may be explained by patient preference, surgeon subspecialty, surgeon era of practice or other variables. Further research to understand the reasons behind this nonadherence would help to promote conformity in the surgical community across all specialties and adherence to evidence-based approaches.

The POSI study: gender differences in 94 cases of postoperative shoulder surgery infection: results of a 7-year retrospective multicenter study.

BACKGROUND: Contrary to lower limb infection, POstoperative Shoulder surgery Infection (POSI) often involves Cutibacterium acnes. Our aim was to describe patient characteristics and pathogens retrieved in POSI to guide initial empiric antibiotic selection with suspected infection during revision. We also compared microorganisms in infection following trauma, arthroplasty (AP), and arthroscopy (AS). METHODS: A multicenter retrospective study from 2010 to 2016 reviewed laboratory databases and medical records to identify patients with a previous shoulder surgery and a confirmed shoulder infection. The following procedures were included: AP, AS, fracture fixation (FF), and another open surgery (OS). A confirmed shoulder infection was defined as 2 positive cultures or more of the same microorganism, or clear clinical infection with 1 positive culture or more. RESULTS: Among the 5 hospitals and 28 surgeons involved, 94 POSI cases were identified. Mean age was 59 years at index surgery (range: 22-91) with a majority of men (n = 70, 74%). Among POSI cases, AP was the most common index surgery (n = 41), followed by FF (n = 27), AS (n = 16), and OS (n = 10). The median time between index surgery and the first positive sample was 5 months and the mean was 23 months (minimum 6 days to maximum 27 years), illustrating a positively skewed distribution. Cutibacterium spp were identified in 64 patients (68%), including 59 C acnes patients (63%), which was the most frequent germ in all 4 surgical groups. In 86% of cases, C acnes was identified at the first revision. The other 2 most common germs were Staphylococcus epidermidis and Staphylococcus aureus, with 29% and 17%, respectively. Polymicrobial infection was present in 30% of patients. Gender analysis revealed that C acnes was twice as frequent in men (male = 52 of 70, female = 7 of 24; P < .001). S epidermidis was more prevalent in women (n = 11; 46%) compared with men (n = 16; 21%) (P = .032). C acnes infection was most frequent in arthroscopic surgery (n = 14; 70%, P = .049). S epidermidis was 3 times more prevalent in chronic than in acute cases. CONCLUSION: Empiric antimicrobial therapy following POSI, while waiting for culture results, should cover C acnes, S epidermidis, and S aureus. There is a significant gender difference regarding POSI culture results. C acnes is more frequent in men, but should still be covered in women as it was found in 29% of cases.

Traumatic brain injuries are ignored or discriminated in prospective clinical trials on shoulder fractures: a systematic review.

PURPOSE: Current literature suggests a significant epidemiological association between traumatic brain injury (TBI) and proximal upper limb fractures in addition to major clinical consequences. A systematic review was conducted to assess how TBI is taken into consideration in interventional studies on shoulder fractures. METHODS: The following data sources were used: MEDLINE, EMBASE, EBM Reviews, CINAHL, and OpenGrey databases. Study selection included interventional randomized clinical trials and prospective cohort studies on shoulder fractures published in English or French between 2008 and 2020. Studies on pathologic fractures, chronic fracture complications, nonhuman subjects, and biomechanics were excluded. Articles were reviewed by two independent authors according to the PRISMA guidelines. Baseline characteristics, exclusion criteria, and input relevant to TBI were recorded. Methodological quality was assessed with the Cochrane risk of bias tool for randomized clinical trials and the Newcastle-Ottawa Scale for cohort studies. RESULTS: One-hundred-thirteen studies met the inclusion criteria. None discussed the possible impact of TBI on their results. Only three (2.7%) studies considered TBI relevant and included these patients in their cohort. Furthermore, 43/113 (38.1%) excluded patients with injuries or mechanisms strongly related to traumatic brain injuries: head injuries (4); moderate and/or severe TBI (7); high energy traumas (3); Polytrauma subjects (33). CONCLUSION: TBI are ignored or discriminated in prospective clinical trials on shoulder fractures. The exclusion of these cases impacts generalizability as their prevalence is significant. Considering the major impact of TBI on important outcomes, its presence should always be assessed to ensure high quality evidence. LEVEL OF EVIDENCE: Systematic Review, Therapeutic Level II.

Phone Administration of the Western Ontario Shoulder Instability Index Is More Reliable Than Administration via Email.

BACKGROUND: The Western Ontario Shoulder Instability (WOSI) questionnaire is a 21-item questionnaire to evaluate quality of life in patients with shoulder instability. Completing the questionnaire is time-consuming because each item is evaluated on a visual analog scale. Telephone or email versions of the score are appealing alternatives to administering it during the standard in-person patient visit; however, their validity and reliability remain unknown. QUESTIONS/PURPOSES: (1) Does the numerical scale (NS) version of the WOSI correlate with the original WOSI and Quick-DASH? (2) Do telephone and email administration of the NS-WOSI have good reliability and consistency? (3) Compared with the original WOSI form, does the NS form lead to faster completion for patients and quicker data extraction for researchers? METHODS: Between 2014 and 2019, 50 patients with a documented history of shoulder dislocation with persistent symptomatic shoulder instability, whether anterior, posterior, or multidirectional; patients scheduled for surgery; and patients with traumatic or nontraumatic injuries were prospectively recruited from the outpatient clinic of two university hospitals acting as Level 1 trauma centers and sports traumatology tertiary referral centers. The median (IQR) age was 28 years (24 to 36), and 80% (40 of 50) were men. Most (52% [26 of 50]) patients had two to five lifetime shoulder dislocations. Validity of the NS-WOSI was assessed using the Pearson correlation coefficient during an in-person visit; the original WOSI questionnaire (or its previously validated French-language version), NS-WOSI, and Quick-DASH questionnaires were administered in a random order. After a minimum 7-day interval, 78% (39 of 50) of patients completed the phone interview, and 74% (37 of 50) of patients completed the email version of the NS-WOSI score to evaluate NS-WOSI's reliability using the intraclass correlation coefficient (ICC), which was interpreted as poor (< 0.5), moderate (0.50-0.75), strong (0.75-0.90), and very strong (> 0.90). The standard error of measurement (SEM) was used to evaluate variability around the true score, with a low value indicating a high reliability. The 95% minimal detectable change (MDC 95% ) was calculated to evaluate the minimal change in score that was not related to measurement errors. Lastly, the Cronbach alpha was used to assess internal consistency (intercorrelation strength), where a value > 0.70 was considered good. The time needed for the patient to complete the various versions and for researchers to extract data was recorded. RESULTS: The NS-WOSI score was very strongly correlated with the original WOSI score (r = 0.96 [95% confidence interval (CI) 0.93 to 0.98]; p < 0.001). Although telephone-acquired and email-acquired data for the NS-WOSI questionnaires were correlated with the NS-WOSI (telephone r = 0.91 [95% CI 0.83 to 0.95]; p < 0.001; email r = 0.84 [95% CI 0.71 to 0.91]; p < 0.001), the ICC was higher for telephone interviews (0.92 [95% CI 0.86 to 0.96] versus email 0.80 [95% CI 0.64 to 0.89]), indicating that although both had good reliability, the phone interview was more suitable. The phone interview was also preferable to email regarding SEM (3% [52 of 2100 points] versus 6% [132 of 2100 points]) and the MDC 95% (7% [144 of 2100 points] versus 17% [366 of 2100 points]). The 95% CI of the MDC acquired by email was superior to the reported minimum clinically important difference for the original WOSI (7% [152 of 2100 points]), meaning that an error of measurement could wrongly be interpreted as a clinically significant change in score. Internal consistency was deemed good, with a Cronbach alpha of 0.96 (95% CI 0.92 to 98) and 0.89 (95% CI 0.79 to 0.94) for NS-WOSI telephone and email, respectively. The time to complete the NS-WOSI was reduced compared with the original WOSI (221 ± 153 seconds versus 266 ± 146 seconds, mean difference -45 seconds [95% CI -72 to -12]; p = 0.009). Lastly, data extraction was faster (62 ± 15 seconds versus 209 ± 52 seconds, mean difference -147 seconds [95% CI -164 to -130]; p < 0.001) with the NS-WOSI than with the original WOSI. CONCLUSION: The NS-WOSI in person, by telephone, or by email is a valid, reliable, and timesaving alternative to the original WOSI questionnaire. However, the reliability of data acquisition by telephone interviews was superior to that of email. CLINICAL RELEVANCE: Given that there were no important differences in performance for the NS-WOSI, regardless of whether it was administered in person or by phone, we suggest that physicians use both interchangeably based on patient convenience. However, we do not recommend using the email version, especially for research purposes, since it was not as reliable when compared with in-person administration. The responsiveness of the modified NS-WOSI, as well as factors influencing response rates to phone interview, are questions that remain to be explored.

Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: A Clinical Practice Guideline.

OBJECTIVE: To develop a clinical practice guideline covering the assessment, management, and return to work of adults with rotator cuff disorders. DESIGN: Clinical practice guideline. METHODS: Using systematic reviews, appraisal of the literature, and an iterative approach to obtain consensus from key stakeholders, clinical recommendations and algorithms were developed in the context of the health care system and work environment of the province of Quebec (Canada). RESULTS: Recommendations (n = 73) and clinical decision algorithms (n = 3) were developed to match the objectives. The initial assessment should include the patient's history, a subjective assessment, and a physical examination. Diagnostic imaging is only necessary in select circumstances. Acetaminophen, nonsteroidal anti-inflammatory drugs, and injection therapies may be useful to reduce pain in the short term. Clinicians should prescribe an active and task-oriented rehabilitation program (exercises and education) to reduce pain and disability in adults with rotator cuff disorders. Subacromial decompression is not recommended to treat rotator cuff tendinopathy. Surgery is appropriate for selected patients with a full-thickness rotator cuff tear. A return-to-work plan should be developed early, in collaboration with the worker and other stakeholders, and must combine multiple strategies to promote return to work. CONCLUSION: This clinical practice guideline was developed to assist the multidisciplinary team of clinicians who provide health care for adults with a rotator cuff disorder. The CPG guides clinical decisionmaking for diagnosis and treatment, and planning for successful return to work. J Orthop Sports Phys Ther 2022;52(10):647-664. Epub: 27 July 2022. doi:10.2519/jospt.2022.11306.

Arthroscopy Association of Canada Position Statement on Exercise for Knee Osteoarthritis: A Systematic Review of Guidelines.

BACKGROUND: Exercise is widely regarded to improve pain and function in patients with knee osteoarthritis (OA) through building supportive muscle mass, facilitating weight loss, and through the other beneficial effects associated with it. PURPOSE: To explore literature that presents clinical guidelines for the use of exercise in the treatment of knee OA to inform an evidence-based position statement for the Arthroscopy Association of Canada. STUDY DESIGN: Position statement. METHODS: PubMed, MEDLINE, Embase, and Cochrane databases were searched for guidelines commenting on the role of exercise for knee OA. The search was limited to guidelines published in the last 10 years. Articles were screened for relevance, focusing on recently published research with clinical guidelines. Inclusion criteria involved all articles providing clinical guidelines for exercise and knee OA. RESULTS: Eight guidelines were identified. All eight recommended exercise as an important component of treatment for knee OA, with 6/8 strongly recommending it. CONCLUSION: Exercise is an effective and important component of the non-pharmacological management of knee OA. The Arthroscopy Association of Canada strongly recommends the use of exercise in the management of knee OA.

Influence of coracoid anatomy on the location of glenoid rim defects in anterior shoulder instability: 3D CT-scan evaluation of 51 patients.

PURPOSE: Glenoid bony lesions play a role in approximately half of anterior shoulder instability cases. The purpose of this study is to see if the anatomy of the coracoid affects the location of glenoid rim defects. We hypothesized that a prominent coracoid (lower and lateral) would be more likely to cause an anterior-inferior glenoid lesion, and a less prominent coracoid more prone to cause an anterior lesion. The null hypothesis being the absence of correlation. METHODS: Fifty-one shoulder CT-scans from a prospective database, with 3D reconstruction, were analyzed. The position of glenoid lesions was identified using the validated clock method, identifying the beginning and end time. The size of bony glenoid defects was calculated using the validated glenoid ratio method. The position of the coracoid tip was measured in three orthogonal planes. RESULTS: Analysis included 25 right shoulders and 26 left shoulders in seven females and 41 males. The vertical position of the coracoid tip relative to the top of the glenoid was highly correlated to the location of the glenoid defect on the profile view (r = -0.625; 95% CI 0.423-0.768; p = 0.001). Thus, higher coracoids were associated with anterior lesions, while lower coracoids were associated with anterior-inferior lesions. A more laterally prominent coracoid was also correlated with anterior-inferior lesions (r = 0.433; 95% CI 0.179-0.633; p = 0.002). CONCLUSION: This study shows that coracoid anatomy affects the location of bony Bankart defects in anterior shoulder instability. Lower and laterally prominent coracoids are associated with anterior-inferior lesions. This variation in anatomy should be considered during pre-op planning for surgeries involving bone graft. LEVEL OF EVIDENCE: Level 4 basic science.

Moderate to severe acute pain disturbs motor cortex intracortical inhibition and facilitation in orthopedic trauma patients: A TMS study.

OBJECTIVE: Primary motor (M1) cortical excitability alterations are involved in the development and maintenance of chronic pain. Less is known about M1-cortical excitability implications in the acute phase of an orthopedic trauma. This study aims to assess acute M1-cortical excitability in patients with an isolated upper limb fracture (IULF) in relation to pain intensity. METHODS: Eighty-four (56 IULF patients <14 days post-trauma and 28 healthy controls). IULF patients were divided into two subgroups according to pain intensity (mild versus moderate to severe pain). A single transcranial magnetic stimulation (TMS) session was performed over M1 to compare groups on resting motor threshold (rMT), short-intracortical inhibition (SICI), intracortical facilitation (ICF), and long-interval cortical inhibition (LICI). RESULTS: Reduced SICI and ICF were found in IULF patients with moderate to severe pain, whereas mild pain was not associated with M1 alterations. Age, sex, and time since the accident had no influence on TMS measures. DISCUSSION: These findings show altered M1 in the context of acute moderate to severe pain, suggesting early signs of altered GABAergic inhibitory and glutamatergic facilitatory activities.

Calcium sulphate mixed with antibiotics does not decrease efficacy against Cutibacterium acnes (formerly Propionibacterium acnes), in vitro study.

BACKGROUND: This study explored the in vitro efficacy of antibiotics mixed with calcium sulfate (ACS) against Cutibacterium acnes (C. acnes). METHODS: C. acnes isolates from orthopaedic infection sites were tested for antimicrobial susceptibility with ACS. Minimal inhibitory concentrations (MIC) were determined with a gradient diffusion method (Etest® strips). RESULTS: When tested with Etest®, all 22 isolates were susceptible to penicillin, ceftriaxone, vancomycin, and two were resistant to clindamycin (MICs of 4 and 8 mg/L). Penicillin and rifampin had the largest inhibition zone diameters. CONCLUSIONS: Antibiotics retained activity against C. acnes when mixed with calcium sulfate.

Factors affecting outcome of partial radial head fractures: A Retrospective Cohort Study.

BACKGROUND: The purpose of this study is to evaluate which factors will affect range of motion (ROM) and function in partial radial head fractures. The hypothesis is that conservative treatment yields better outcomes. MATERIALS AND METHODS: This retrospective comparative cohort study included 43 adult volunteers with partial radial head fracture, a minimum 1-year follow up, separated into a surgical and non-surgical group. Risk factors were: associated injury, heterotopic ossification, worker's compensation, and proximal radio ulnar joint (PRUJ) implication. Outcomes included radiographic ROM measurement, demographic data, and quality of life questionnaires (PREE, Q-DASH, MEPS). RESULTS: Mean follow up was 3.5 years (1-7 years). Thirty patients (70%) had associated injuries with decreased elbow extension (-11°, p=0.004) and total ROM (-14°, p=0.002) compared to the other group. Heterotopic ossification was associated with decreased elbow flexion (-9.00°, p=0.001) and fractures involved the PRUJ in 88% of patients. Only worker's compensation was associated with worse scores. There was no difference in terms of function and outcome between patients treated non-surgically or surgically. DISCUSSION: We found that associated injuries, worker's compensation and the presence of heterotopic ossification were the only factors correlated with a worse prognosis in this cohort of patients. Given these results, the authors reiterate the importance of being vigilant to associated injuries. LEVEL OF EVIDENCE: IV, Retrospective study.

Effect of a Controlled Ankle Motion Walking Boot on Syndesmotic Instability During Weightbearing: A Cadaveric Study.

BACKGROUND: Syndesmotic injuries can lead to long-term complications; hence, they require careful management. Conservative treatment is adequate when 1 syndesmotic ligament is injured, but surgery is often necessary to achieve articular congruity when 3 syndesmotic ligaments are ruptured. However, there is some controversy over the best treatment for 2-ligament injuries. PURPOSE: To evaluate the effect of a controlled ankle motion (CAM) walking boot on syndesmotic instability following iatrogenic isolated anterior inferior tibiofibular ligament (AiTFL) injury and combined AiTFL/interosseous ligament (IOL) injuries in a cadaveric simulated weightbearing model. STUDY DESIGN: Controlled laboratory study. METHODS: Ten cadaveric specimens were dissected to expose the tibial plateau and syndesmosis. The specimens were fitted to a custom-made device, and a reproducible axial load of 750 N was applied. Iatrogenic rupture of the syndesmotic ligaments (AiTFL + IOL) was done sequentially. Uninjured syndesmoses, isolated AiTFL rupture, and combined AiTFL/IOL rupture were compared with and without axial loading (AL) and CAM boot. The distal tibiofibular relationship was evaluated using a previously validated computed tomography scan measurement system. Wilcoxon tests for paired samples and nonparametric data were used. RESULTS: The only difference noted in the distal tibiofibular relationship during AL was an increase in the external rotation of the fibula when using the CAM boot. This was observed with AiTFL rupture (8.40° vs 11.17°; P = .009) and combined AiTFL/IOL rupture (8.81° vs 11.97°; P = .005). CONCLUSION: AL did not cause a significant displacement between the tibia and fibula, even when 2 ligaments were ruptured. However, the CAM boot produced a significant external rotation with 1 or 2 injured ligaments. CLINICAL RELEVANCE: Further studies are needed to assess the capacity of the CAM walking boot to prevent malreduction when external rotation forces are applied to the ankle. Moreover, special care should be taken during the fitting of the CAM boot to avoid overinflation of the cushions.

Investigating the incidence and magnitude of heterotopic ossification with and without joints involvement in patients with a limb fracture and mild traumatic brain injury.

OBJECTIVES: This study seeks to evaluate the incidence rate of heterotopic ossification (HO) formation in patients afflicted by an isolated limb fracture (ILF) and a concomitant mild traumatic brain injury (mTBI). METHODS: The current study is an observational study including ILF patients with or without a concomitant mTBI recruited from an orthopedic clinic of a Level 1 Trauma Hospital. Patients were diagnosed with a mTBI according to the American Congress of Rehabilitation Medicine (ACRM) criteria. Radiographs taken on average 3 months post-trauma were analyzed separately by two distinct specialists for the presence of HO proximally to the fracture site (joints or extra joints). Both raters referred to Brooker's and Della's Valle's classification to establish signs of HO. First, analyses were conducted for the full sample. Secondly, a matched cohort was used in order to control for specific factors, namely age, sex, type of injury, and time elapsed between the accident and the analyzed radiograph. RESULTS: The full sample included a total of 183 patients with an ILF (94 females; 47.5 years old), of which 50 had a concomitant mTBI and 133 without. Radiographic evidence of HO was significantly higher in patients with an ILF and a mTBI compared to ILF patients (X2 = 6.50; p = 0.01). The matched cohort consisted of 94 participants (i.e.; 47 patients from the ILF + mTBI group and 47 patients from the ILF group). Again, ILF + mTBI patients presented significantly higher rates of HO signs in comparison to ILF patients (X2 = 3.69; p = 0.04). Presence of HO was associated with prolonged delays to return to work (RTW) only in ILF + mTBI patients (F = 4.055; p = 0.05) but not in ILF patients (F = 0.823; p = 0.37). CONCLUSIONS: Study findings suggest that rates of HO are significantly higher proximally to fracture sites when ILF patients sustain a concomitant mTBI, even after controlling for factors known to influence HO. Moreover, results show that HO is associated with a prolonged RTW only in ILF patients with a concomitant mTBI but not in ILF-only patients. The impact of mTBI on HO formation warrants further attention to detect early signs of HO, to identify shared physiopathological mechanisms and, ultimately, to design targeted therapies.

Involvement of the proximal radial ulnar joint in partial radial head fractures: a novel three-dimensional computed tomography scan evaluation method.

BACKGROUND: Partial radial head fractures (PRHF) can involve the proximal radioulnar joint (PRUJ) or be restricted to the 'safe zone' (SZ) during forearm rotation. The objective of the present study was to develop an assessment method for PRUJ involvement in radial head fractures using axial computed tomography (CT) scans. METHODS: The area of the radial head in contact with the PRUJ zone was identified, and defined on 18 cadaveric elbows CT scans; the quantitative relationship between PRUJ zone and radial tuberosity was established. Then, four evaluators validated it on PRHF CT scan axial views, classifying the fractures as involving the PRUJ or not. RESULTS: Using the radial tuberosity as the 0° of a 360° circle, the SZ was within 108° to 212° clockwise for a right elbow and counter clockwise for the left elbow. Fifty-five consecutive (30 men, 25 women, mean age of 49 years) partial radial head fracture CT scans were classified: four in the SZ only, three in the PRUJ zone and 48 in both the PRUJ and SZ. The kappa for the inter- and intra-observer agreement was 0.517 and 0.881, respectively. CONCLUSIONS: Ninety-three percent of partial radial head fractures will involve the PRUJ and the geometric model developed allows their classification, potentially helping surgeons decide on optimal treatment. LEVEL OF EVIDENCE: Retrospective basic science study. Level III: anatomic study, imaging.

"Hockey wrist:" dorsal ulnotriquetral ligament injury.

BACKGROUND: Ulnar-sided wrist pain at the dorsal proximal triquetrum, especially during wrist pronation, flexion and radial deviation, is common in athletes, particularly ice hockey players. The purpose of this study was to evaluate in which position the dorsal ulnotriquetral ligament (DUTL) is placed under the greatest strain, the torque to failure and the injury pattern. We hypothesized that the DUTL is maximally strained with wrist flexion, pronation and radial deviation, and that, at failure, the ligament tears off the triquetrum. METHODS: We performed a biomechanical study on 7 fresh frozen cadaveric upper extremities, with testing done on a wrist-movement stimulator to identify the position (45° of wrist flexion, 45° of wrist extension or neutral) that generated the highest and earliest strain increases in the DUTL. We performed load-to-failure testing, characterized the ligament's pattern of failure, and repaired and retested the DUTL using the same load-to-failure protocol. RESULTS: The DUTL reached 3 N∙m the earliest in 45° of wrist flexion (p = 0.02). The native DUTL failed at 0.35 N∙m (standard deviation [SD] 0.13 N∙m) per degree of angular stiffness, 12.93 N∙m of yield strength and with angular deformation of 57.73° (SD 20.62°). There was no significant difference in these variables between the native and repaired DUTL. Tearing occurred at a mean of 10 mm (SD 2 mm) proximal from the triquetrum's insertion in a transverse midsubstance pattern. CONCLUSION: This study showed a reproducible pattern of injury to the DUTL in a cadaveric model. Additional work is needed to further characterize the pathoanatomy of "hockey wrist."

CONTEXTE: La douleur cubitale au poignet, au niveau du triquetrum proximal dorsal, surtout à la pronation, à la flexion et à la déviation radiale du poignet, est fréquente chez les athlètes, particulièrement chez les joueurs de hockey. Le but de cette étude était d'évaluer la position dans laquelle le ligament ulnotriquétral dorsal (LUTD) est soumis à la pression la plus grande, le couple de torsion menant à la défaillance et le mode de blessure. Selon notre hypothèse, le LUTD est soumis au maximum de pression lorsque le poignet est en flexion, pronation et déviation radiale, et au moment de la défaillance, le ligament ulnotriquétral se déchire. MÉTHODES: Nous avons procédé à une étude biomécanique sur 7 membres supérieurs de cadavres frais congelés, et effectué des tests sur un stimulateur de mouvements du poignet pour établir la position (flexion du poignet à 45°, extension du poignet de 45° ou position neutre) générant les augmentations de pression les plus fortes et les plus rapides sur le LUTD. Nous avons procédé à des tests de mise en charge jusqu'à défaillance, caractérisé le mode de défaillance du ligament et réparé et retesté le LUTD à l'aide du même protocole de mise en charge jusqu'à défaillance. RÉSULTATS: Le LUTD a atteint 3 N∙m le plus rapidement avec une flexion du poignet à 45° (p = 0,02). Le LUTD natif a connu une défaillance à 0,35 N∙m (écart-type [É.-T.] 0,13 N∙m) par degré de raideur angulaire, 12,93 N∙m d'élasticité et avec une déformation angulaire de 57,73° (É.-T. 20,62°). On n'a noté aucune différence significative de ces variables entre les LUTD natifs et réparés. La déchirure s'est produite en moyenne à 10 mm (É.-T. 2 mm) en proximal par rapport à l'insertion du triquetrum selon un trajet transverse affectant la moitié de la substance ligamentaire. CONCLUSION: L'étude a démontré un mode reproductible de lésion du LUTD à l'aide d'un modèle cadavérique. Il faudra approfondir la recherche pour caractériser avec plus de précision l'anatomopathologie de la lésion au poignet typiquement causée par la pratique du hockey.

Osteoimmunology: Effects of Standard Orthopaedic Interventions on Inflammatory Response and Early Fracture Healing.

Achieving fracture union is highly dependent on the initial inflammatory phase of fracture healing, which is influenced by both the local and systemic inflammatory environments. The rapidly emerging field of osteoimmunology involves the study of the interactions between the immune system and the skeletal system. Recent research has advanced the current state of knowledge regarding the effects of the surrounding soft-tissue injury, fracture hematoma, and the method of fracture fixation on the inflammatory phase of fracture healing. Acute systemic inflammation, as seen in patients with polytrauma, and chronic systemic inflammation, as seen in patients with diabetes or rheumatoid arthritis, affects the inflammatory phase of fracture healing. The use of NSAIDs can influence early fracture healing. Understanding the effects of standard orthopaedic interventions on the local and systemic inflammatory responses and early fracture healing is important for optimizing fracture union.

Measurement of combined glenoid and Hill-Sachs lesions in anterior shoulder instability.

BACKGROUND: Recurrent glenohumeral anterior instability (RGAI) frequently induces combined glenoid and Hill-Sachs bone lesions and is a risk factor for soft tissue repair failure. This cohort study describes a simple preoperative quantification method for bone loss, the Clock method, the first that combines glenoid and humeral lesions. METHODS: Computed tomography scans of 34 shoulders with RGAI were twice reviewed by three independent observers, who measured bone lesions using the new Clock method and existing validated methods. Intra- and inter-observer reliability of the Clock method was evaluated (intraclass correlation coefficient). Pearson correlation was used to correlate Clock method with existing methods, and with function (Western Ontario Shoulder Instability, Quick-Disabilities of the Arm, Shoulder and Hand). RESULTS: Thirty-two patients met the inclusion criteria: three females and 29 males, mean age 28 years. The intra- and inter-observer reliability was excellent, with intraclass correlation coefficient ranging from 0.817 to 0.938 for the novel Clock method. Humeral Clock and Glenoid Clock strongly correlated with Humeral Ratio (r = 0.882, p < 0.001) and Glenoid Surface Area and Glenoid Ratio (r = 0.793 and 0.717, p < 0.001), respectively. The classic threshold of 25% of the glenoid diameter with the Glenoid Ratio method corresponds to 4 hours with the Glenoid Clock method. CONCLUSIONS: The Clock method is quick and reliable, with more studies being needed to investigate whether it is correlated with surgical outcomes.