Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults.

BACKGROUND: Surgical fixation of fractures of the shaft of the humerus generally involves plating or nailing. It is unclear whether one method is more effective than the other. OBJECTIVES: To compare compression plating and locked intramedullary nailing for primary surgical fixation (surgical fixation of an acute fracture or early fixation following failure of conservative treatment) of humeral shaft fractures in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2011), The Cochrane Library 2011, Issue 1, MEDLINE and EMBASE (both to February 2011) and trial registries for ongoing trials. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing compression plates and locked intramedullary nail fixation for humeral shaft fractures in adults. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial methodology and extracted data. Disagreement was resolved by discussion, or third party adjudication. Treatment effects were assessed using risk ratios for dichotomous data and mean differences for continuous data, together with 95% confidence intervals. Where appropriate, data were pooled using a fixed-effect model. MAIN RESULTS: Five small trials comparing dynamic compression plates with locked intramedullary nailing were included in this review. These involved a total of 260 participants undergoing surgery for either acute fractures or after early failure of conservative treatment. All five trials had methodological flaws, such as the lack of assessor blinding, that could have influenced their findings. There was no significant difference in fracture union between plating and nailing (five trials, RR 1.05; 95% CI 0.97 to 1.13). There was a statistically significant increase in shoulder impingement following nailing when compared with plating (five trials, RR 0.12; 95% CI 0.04 to 0.38). Intramedullary nails were removed significantly more frequently than plates (three trials, RR 0.17; 95% CI 0.04 to 0.76). There was no statistically significant difference between plating and nailing in operating time, blood loss during surgery, iatrogenic radial nerve injury, return to pre-injury occupation by six months or American Shoulder and Elbow Surgeons (ASES) scores.Two further small trials are awaiting classification. AUTHORS' CONCLUSIONS: The available evidence shows that intramedullary nailing is associated with an increased risk of shoulder impingement, with a related increase in restriction of shoulder movement and need for removal of metalwork. There was insufficient evidence to determine if there were any other important differences, including in functional outcome, between dynamic compression plating and locked intramedullary nailing for humeral shaft fractures.

Foot orthoses for patellofemoral pain in adults.

BACKGROUND: Foot orthoses, which are specially moulded devices fitted into footwear, are one of the treatment options for patellofemoral or anterior knee pain. OBJECTIVES: To assess the effects of foot orthoses for managing patellofemoral pain in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register (March 2010), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 1), MEDLINE (1950 to March 2010), EMBASE (1980 to 2010 Week 11), CINAHL (1937 to March 2010), trial registers, reference lists and grey literature. No language restriction was applied. SELECTION CRITERIA: We included randomised or quasi-randomised clinical studies that compared foot orthoses with flat insoles or another physical therapy intervention. The primary outcomes were knee pain and knee function. DATA COLLECTION AND ANALYSIS: Two authors independently selected eligible trials, assessed methodological quality and performed data extraction. We calculated risk ratios and 95% confidence intervals for dichotomous variables, and mean differences with 95% confidence intervals for continuous variables. We pooled data using the fixed-effect model. MAIN RESULTS: Two trials with a total of 210 participants were included. Both trials were at some risk of performance bias. One trial had four intervention groups and the other had three. One trial found that foot orthoses when compared with flat insoles (control group) had better results at six weeks in knee pain (participants with global improvement: risk ratio 1.48, 95% confidence interval 1.11 to 1.99), but not at one year follow-up. Participants in the orthoses group reported significantly more minor adverse effects (e.g. rubbing, blistering) compared with the flat insole group (risk ratio 1.87, 95% confidence intervaI 1.21 to 2.91). Both trials in their comparisons of orthoses plus physiotherapy versus physiotherapy alone found no statistically significant differences between the two intervention groups in knee pain or function. Results for knee pain outcomes did not show significant differences between foot orthoses versus physiotherapy. Although participants in the physiotherapy group had consistently better results for the functional index questionnaire, the clinical relevance of these results is uncertain. AUTHORS' CONCLUSIONS: While not robust, the available evidence does not reveal any clear advantage of foot orthoses over simple insoles or physiotherapy for patellofemoral pain. While foot orthoses may help relieve knee pain over the short term, the benefit may be marginal. Patients treated with orthoses are more likely to complain of mild adverse effects and discomfort.

Does pre-operative psychological distress affect patient satisfaction after primary total hip arthroplasty?

BACKGROUND: There are concerns that pre-operative psychological distress might be associated with reduced patient satisfaction after total hip replacement (THR). METHODS: We investigated this in a multi-centre prospective study between January 1999 and January 2002. We dichotomised the patients into the mentally distressed (MHS ≤ 56) and the not mentally distressed (MHS > 56) groups based on their pre-operative Mental Health Score (MHS) of SF36. RESULTS: 448 patients (340 not distressed and 108 distressed) completed the patient satisfaction survey. Patient satisfaction rate at five year was 96.66% (415/448). There was no difference in patient satisfaction or willingness to have the surgery between the two groups. None of pre-operative variables predicted five year patient satisfaction in logistic regression. CONCLUSIONS: Patient satisfaction after surgery may not be adversely affected by pre-operative psychological distress.

Misdiagnosis of occult hip fracture is more likely in patients with poor mobility and cognitive impairment.

The diagnosis of occult hip fracture is frequently missed. We wished to investigate if patients in whom occult hip fracture was initially misdiagnosed had any distinct features, and their outcome. We reviewed 297 patients who presented with hip fractures over a two-year period. There were 24 occult hip fractures, the diagnosis was initially missed in 9 patients and correctly made in the other 15. Of the correctly identified patients, 8/15 were independently mobile and 9/15 were living in their own home compared to 0/9 independently mobile and 2/9 living in own home among those with missed diagnosis (p < 0.001). Seven of nine patients with a missed diagnosis had mental confusion but none in the other 15 (p < 0.001). Eight of the nine patients with missed diagnosis of fracture had intra-capsular fractures, of which 6 secondarily displaced. Three of those nine patients died within one year from their fracture. We suggest a low threshold of investigation for occult hip fracture in the elderly, infirm and mentally confused who present to the accident department with suspected occult hip fracture.

The incidence of flare reaction and short-term outcome following steroid injection in the shoulder.

BACKGROUND: To determine the short-term effects following corticosteroid injection into the shoulder. METHODS: Type-specific shoulder injection was administered, followed by physiotherapy 7 days to 10 days later. One hundred and sixteen adult patients were prospectively followed-up. The primary outcome was a visual analogue score (VAS) for pain. Scores were recorded immediately before injection, 30 minutes after, daily until day 7 and then at 6 weeks. Post injection pain was defined as an increase of 2 or more points in the VAS score after the injection. The secondary outcome was determined at 6 months as successful discharge or progression onto surgery. RESULTS: The VAS showed a significant reduction from the pre-injection score for all patients at day 1 and was maintained until week 6. Forty-one (35.3%) patients experienced post-injection pain. The mean duration of symptoms was 3.9 days. At 6 months, 81 (69.8%) patients were discharged successfully and, at a mean of 23.2 months, did not require re-referral; 29 (25%) had surgery; and six (5.2%) were referred for a spinal opinion. CONCLUSIONS: One in three patients developed delayed post-injection pain. Flare phenomenon had no determinate effect on outcome. Patients' pain response by 6 weeks is predictive of final outcome at 6 months and may help clinicians plan further treatment without delay.

Stress Fractures of the Foot.

Stress fractures of the foot and ankle may be more common among athletes than previously reported. A low threshold for investigation is warranted and further imaging may be appropriate if initial radiographs remain inconclusive. Most of these fractures can be treated conservatively with a period of non-weight-bearing mobilization followed by gradual return to activity. Early surgery augmented by bone graft may allow athletes to return to sports earlier. Risk of delayed union, nonunion, and recurrent fracture is high. Many of the patients may also have risk factors for injury that should be modified for a successful outcome.

The effect of locomotion on the outcome following total hip arthroplasty.

The relationship between contralateral hip arthritis and co-morbid medical conditions that affect a patient's ability to walk, and outcome following total hip arthroplasty (THA) is not fully understood. We investigated this relationship in a prospective, multi-centre study. 1497 hips (1428 patients) were recruited. At five years follow-up there was complete data for 1053 hips. We recorded Oxford Hip Score (OHS) and Charnley Class (CC) both preoperatively and at one and five years after surgery. Preoperatively there was a significant difference in OHS between CC categories and OHS deteriorated from CC-A to CC-C (p<0.001). The absolute OHS was significantly worse in CC-C compared to CC-A. Patients who remained in CC-A at five year follow-up had a larger change in OHS (mean 24) compared to those who had changed from CC-A to CC-C at five years (mean 21) p<0.001. The OHS an outcome measure frequently used for THA is influenced by several extraneous factors which may be present preoperatively but also change over time. These factors include the condition of the opposite hip as well as other disease processes that affect a patient's locomotion and therefore interpretation of OHS in isolation without additional information may not be appropriate.

Sexual activity and total hip arthroplasty: a survey of patients' and surgeons' perspectives.

It is not clear if regaining sexual activity is important for patients undergoing total hip arthroplasty (THA) or whether hip surgeons are aware of and manage the concerns of their patients in this context. A questionnaire survey was conducted on 100 patients undergoing THA immediately before and six months after surgery. All members of the British Hip Society with a valid email address were surveyed. 86 patients responded. 71 were sexually active and of these, 55 (77%) believed their hip pathology had been limiting their sex lives. 39 (55%) would have preferred further information than was provided. 51 (72%) patients had recommenced sexual activity by six months post operation. 83 of 140 surgeons responded. 30 (36%) surgeons enquired preoperatively if symptoms were interfering with patients' sex lives and 32 (39%) provided written information about sexual activity following THA. 55 (66%) surgeons believed four weeks after surgery patients could resume sexual activity but only 21 (25%) surgeons regularly advised patients about an appropriate time to resume sexual activity. Sexual activity is adversely affected in many patients awaiting THA and regaining sexual function is important to these patients. Most surgeons do not discuss this with their patients and may not be aware of their patients' expectations in this respect.

Pre-operative psychological distress does not adversely affect functional or mental health gain after primary total hip arthroplasty.

Preoperative psychological distress has been reported to predict poor outcome and patient dissatisfaction after total hip arthroplasty (THA). The purpose of this study was to investigate if pre-operative psychological distress was associated with adverse functional outcome after primary THR. We analysed the database of a prospective multi-centre study undertaken between January 1999 and January 2002. We recorded the Oxford Hip Score (OHS) and SF36 score preoperatively and up to five years after surgery for 1055 patients. We dichotomised the patients into the mentally distressed (Mental Health Scale score - MHS =56) and the not mentally distressed (MHS >56) groups based on their pre-operative MHS of the SF36. 762 (72.22%). Patients (595 not distressed and 167 distressed) were followed up at 5 years. Both pre and post-operative OHS and SF-36 scores were significantly worse in the distressed group (both p<0.001). However, both groups experienced statistically significant improvement in OHS and MHS, which was maximal at 1 year after surgery and was maintained over the follow up (p=0.00). There was a substantial improvement in mental distress in patients who reported mental distress prior to surgery. The results suggest that pre-operative psychological distress did not adversely compromise functional outcome gain after THA. Despite having worse absolute values both pre and post operatively, patients with mental distress did not have any less functional gain from THA as measured by improvement in OHS.