Is Reverse Shoulder Arthroplasty Appropriate for the Treatment of Fractures in the Older Patient?: Early Observations

Background  

The treatment of comminuted proximal humerus fractures in older patients is challenging. Variable values of functional outcomes scores, ROMs, patient satisfaction, and bony healing have been reported with conventional techniques, including open reduction and internal fixation, percutaneous pinning, and hemiarthroplasty. Another alternative is reverse total shoulder arthroplasty, although it is unclear whether this provides better ROM or function.     

Is Preoperative Traction for Proximal Femoral Fractures Beneficial to the Patient or a Comfort to the Doctor?

Abstract Background and Purpose: Despite the high incidence of hip fractures, there is no agreement on the use of preoperative traction. To assess current application of traction and the reasons for its use, an inventory study was performed. Material and Methods: Questionnaires were sent to 248 surgical and orthopedic departments, informing about the frequency preoperative traction was used and the reasons for doing so. It was also asked, if there were problems admitting these patients and scheduling them for operation. Results were compared with the current literature. Results: Overall response was 89.9%. Orthopedic surgeons applied traction significantly more frequently compared to trauma surgeons (83.0% vs. 67.9%; p < 0.02). Preoperative traction was standard practice in 20.2% of the trauma departments. The main reason for the use of traction was the assumed reduction in pain. In 22.4% of the hospitals there were (capacity) problems admitting patients with hip fractures, and if admitted, the waiting time for operation was > 24 h in 27.4%. Conclusion: 20% of the Dutch trauma and orthopedic surgeons still practice preoperative traction, whereas literature review shows that preoperative traction is related to numerous complications, without any clinically proven beneficial effects. From this perspective preoperative traction for proximal femoral fractures, although applied on large scale in the Netherlands, should no longer be routinely applied.     

Periprosthetic Fractures of the Distal Femur: Is Open Reduction and Internal Fixation or Distal Femoral Replacement Superior?

BackgroundThe purpose of this study is to compare open reduction and internal fixation (ORIF) to distal femoral replacement (DFR) for treatment of displaced periprosthetic distal femur fractures.MethodsWe identified 72 patients with minimum 2-year follow-up following a displaced periprosthetic distal femur fracture: 50 were treated with ORIF and 22 with DFR. Outcomes were assessed with multivariate regression analysis and include Knee Society Scores (KSS), infection rates, revision incidence, and mortality.ResultsPatients treated with DFR had a higher Charlson comorbidity index (5.2 vs 3.8; P = .006). The mean postoperative KSS were similar between groups, but the Knee Society Functional Scores were higher in the ORIF group (P = .01). Six ORIF patients (12%) and 3 DFR patients (14%) underwent a revision surgery (P = .1). In the ORIF group, 3 revisions were associated with periprosthetic infection, and 3 revisions occurred for aseptic nonunion. In the DFR group, 1 infection was treated with irrigation and debridement, and 2 cases of patellar maltracking resulted in 1 liner exchange with soft tissue release and 1 femoral revision for malrotation. More patients in the ORIF group required repeat revisions, with twice as many total revisions (P < .001). Six ORIF patients and 7 DFR patients died within 2 years (P = .26).ConclusionThe Knee Society Functional Score favored ORIF, but the total incidence of revision was higher in the ORIF cohort. Given the high mortality and the substantial risk of reoperation in both groups, additional studies are needed regarding the prevention of and optimal treatment for patients with periprosthetic distal femur fractures.     

Is a Titanium Implant for Total Knee Arthroplasty Better? A Randomized Controlled Study

BackgroundLighter weight and lower modulus are potential advantages of titanium (Ti) implants over cobalt chrome (CoCr) implants in total knee arthroplasty (TKA). This study was conducted to determine whether Ti implants in TKA resulted in better clinical outcomes and radiologic results.MethodsOne hundred and eight patients (216 knees) with knee arthritis warranting bilateral primary TKA were randomly allocated to undergo Ti rotating-platform TKA in one knee and CoCr rotating-platform TKA in the contralateral knee. The mean follow-up period was 5.3 years (range, 1-7 years). The weight of Ti implants was one-third lighter than that of CoCr implants (133.9 g vs 390.1 g, P < .01). Clinical outcomes were evaluated using clinical scores, patient preferences (lightness, comfort, naturalness, and satisfaction), gait analysis (kinetic and kinematic data), range of motion, and degree of pain. Radiologic results were evaluated based on the radiolucent line (RLL), degree of medial tibial bone loss, and loosening as seen on X-ray.ResultsNo significant differences were observed in clinical scores or patient preference. Regarding implant weight, approximately 70% of patients did not perceive the Ti implant as lighter. No significant differences were observed in gait analysis, range of motion, or degree of pain. The RLL was seen in 9% of the Ti implant group and 19% of the CoCr implant group.ConclusionThe lighter Ti implant did not show any clinical benefit over CoCr implants. The lightness of the Ti implant is not sufficient to matter or be noticeable. However, the Ti implant showed lower rate of RLL than the CoCr implant.Level of Evidencelevel I, randomized controlled trial.     

Does Reverse Shoulder Arthroplasty for Tumors of the Proximal Humerus Reduce Impairment?

Background  

Normal function of the upper limb is seldom restored after limb-sparing surgery for tumors of the proximal humerus. The literature suggests superior shoulder function is achieved in the short term with reverse total shoulder arthroplasty compared to other techniques when performed for conditions with rotator cuff deficiency. It is unclear whether this superiority is maintained when reverse total shoulder arthroplasty is performed for tumors.     

Which Is a Better Position for Insertion of a High Thoracic Epidural Catheter: Sitting or Lateral Decubitus?

OBJECTIVE: The purpose of this study was to compare the safety and success rates associated with the placement of a high thoracic epidural catheter in the sitting vs. the lateral decubitus position. DESIGN: Prospective randomized study. SETTING: University hospital. PARTICIPANTS: Forty-one patients scheduled for off-pump coronary artery bypass graft surgery (OPCAB) by means of high thoracic epidural anesthesia at Th 1/2. INTERVENTIONS: The epidural catheter was placed into the patients in the sitting or lateral decubitus position. The success rates, the time for catheter insertion, the incidence of adverse events, and the accuracy of the catheterization in both groups were compared. MEASUREMENTS AND MAIN RESULTS: The success rates in both groups were comparable, whereas 20% of patients showed a vagal reflex during epidural catheterization in the sitting group (p < 0.05). The insertion time in the sitting group was significantly shorter than in the lateral decubitus group (p < 0.05). Accuracy at the first attempt to the Th1/2 epidural space was 93% in the sitting group and 73% in the lateral decubitus group, but there was no statistically significant difference (p = 0.186). CONCLUSIONS: It is recommended to use the lateral decubitus position for high thoracic epidural catheterization in patients scheduled for OPCAB to avoid vagal reflexes.     

Long-term Results of Comprehensive Clubfoot Release Versus the Ponseti Method: Which Is Better?

Background

Clubfoot can be treated nonoperatively, most commonly using a Ponseti approach, or surgically, most often with a comprehensive clubfoot release. Little is known about how these approaches compare with one another at longer term, or how patients treated with these approaches differ in terms of foot function, foot biomechanics, or quality-of-life from individuals who did not have clubfoot as a child.

Questions/purposes

We compared (1) focused physical and radiographic examinations, (2) gait analysis, and (3) quality-of-life measures at long-term followup between groups of adult patients with clubfoot treated either with the Ponseti method of nonsurgical management or a comprehensive surgical release through a Cincinnati incision, and compared these two groups with a control group without clubfoot.

Methods

This was a case control study of individuals treated for clubfoot at two separate institutions with different methods of treatment between 1983 to 1987. One hospital used only the Ponseti method and the other mainly used a comprehensive clubfoot release. There were 42 adults (24 treated surgically, 18 treated with Ponseti method) with isolated clubfoot along with 48 healthy control subjects who agreed to participate in a detailed analysis of physical function, foot biomechanics, and quality-of-life metrics.

Results

Both treatment groups had diminished strength and motion compared with the control subjects on physical examination measures; however, the Ponseti group had significantly greater ankle plantar flexion ROM (p < 0.001), greater ankle plantar flexor (p = 0.031) and evertor (p = 0.012) strength, and a decreased incidence of osteoarthritis in the ankle and foot compared with the surgical group. During gait the surgical group had reduced peak ankle plantar flexion (p = 0.002), and reduced sagittal plane hindfoot (p = 0.009) and forefoot (p = 0.008) ROM during the preswing phase compared with the Ponseti group. The surgical group had the lowest overall ankle power generation during push off compared with the control subjects (p = 0.002). Outcome tools revealed elevated pain levels in the surgical group compared with the Ponseti group (p = 0.008) and lower scores for physical function and quality-of-life for both clubfoot groups compared with age-range matched control subjects (p = 0.01).

Conclusions

Although individuals in each treatment group experienced pain, weakness, and reduced ROM, they were highly functional into early adulthood. As adults the Ponseti group fared better than the surgically treated group because of advantages including increased ROM observed at the physical examination and during gait, greater strength, and less arthritis. This study supports efforts to correct clubfoot with Ponseti casting and minimizing surgery to the joints, and highlights the need to improve methods that promote ROM and strength which are important for adult function.

Level of Evidence

Level III, prognostic study.     

Which is the Best Alternative for Displaced Femoral Neck Fractures in the Elderly?: A Meta-Analysis

Background  

Treatment of displaced femoral neck fractures includes internal fixation and arthroplasty. However, whether arthroplasty or internal fixation is the primary treatment for displaced femoral neck fractures in elderly patients remains a subject for debate. The literature contains conflicting evidence regarding rates of mortality, revision surgery, major postoperative complications, and function in elderly patients with displaced femoral neck fractures treated either by internal fixation or arthroplasty (either hemiarthroplasty or THA).     

Glycolic Acid versus Jessner's Solution: Which Is Better for Facial Acne Patients?

BACKGROUND: Many clinicians perform glycolic acid peels for facial acne patients, but there has not been a well-controlled study to compare this new therapy with other conventional modalities. OBJECTIVE: To compare the effectiveness of treatment and side effects in the treatment of facial acne by two agents, 70% glycolic acid and Jessner's solution. METHODS: Twenty-six patients with facial acne were treated simultaneously with 70% glycolic acid and Jessner's solution biweekly on each side of the face. The treatment sides were randomized and the evaluation of treatment was done biweekly by a blinded evaluator who did not know the randomization code. Dr. Cunliffe's acne grading system was used for objective comparison. All patients were also asked about the improvement of facial acne and about the side effects experienced. Finally, the patients answered the preference test between the 2 peeling methods. RESULTS: Acne grading of both treatments improved after 3 treatment sessions. However, there were no significant differences in treatment effects between the 2 methods. As far as side effects were concerned, sites treated with Jessner's solution showed a significantly increased degree of exfoliation compared to glycolic acid (p < 0.01). CONCLUSION: Glycolic acid is less widely used than Jessner's solution due to its inconvenient application technique. But considering the equal treatment effect and lesser degree of exfoliation in glycolic acid, we would recommend the use of glycolic acid over Jessner's solution for acne patients.     

Comparing Intramedullary Nailing Versus Locked Plating in the Treatment of Native Distal Femur Fractures: Is One Superior to the Other?

IntroductionDistal femur fractures make up < 1% of all fractures and 3–6% of all femur fractures. In the literature, both intramedullary nailing (IMN) and locked plating (LP) have shown favorable results, but there is no consensus on a gold standard. The purpose of this systematic review is to compare outcomes of native distal femur fractures treated via IMN versus LP in an effort to determine if one is superior to the other.MethodsSystematic review of MEDLINE, EMBASE, and Cochrane Library databases was conducted according to PRISMA guidelines. Only articles published within the last ten years were included. Evidence and study quality were evaluated with the MQOE and Oxford Criteria.ResultsForty-six articles were included in the review. Fractures treated with IMN were found to have a 93.9% union rate, an average time to union of 19.2 weeks, an average arc of motion of 105.1 degrees, with an average of 14.4 degrees of malalignment. Fractures treated with LP were found to have a 90.2% union rate, an average time to union of 20.5 weeks, an average arc of motion of 104 degrees, with an average of 12.6 degrees of malalignment.ConclusionCompiled data comparisons revealed no differences in union rate, malalignment, time to union, average arc of motion, or complication rates requiring a return to the operating room. Until higher level randomized data is available, either IMN or LP are acceptable methods of treatment for native distal femur fractures.