Clinical Orthopaedics and Related Research, Nov 19, 2019
Although the restoration of the normal radial bow has long been known to be a key step in the fix... more Although the restoration of the normal radial bow has long been known to be a key step in the fixation of forearm fractures [7], similar attention has not been paid to restoring anatomic curvature of the ulna. In fact,we use straight plates forwhat has traditionally been thought of as a straight bone. But as Hreha and colleagues [2] show in the current study, sometimes it is important to bend or contour a plate before applying it to a fractured ulna. It is well established that the articulation between the radius and ulna, including the interosseous membrane, substantially affects pronation and supination of the forearm [1, 3, 5, 6]. But might we further improve functional outcomes following treatment of forearm fractures by meticulously restoring the native anatomyof the ulna in the same fashion as we restore the radial bow? Hreha and colleagues [2] cleverly adapted the methods of earlier studies (one that measured the ulna’s sagittal bow [4] and another that measured the radius in the coronal plane [7]) to define normal ranges of anatomic bowing of the ulna in an adult population. They found that the ulna is anything but straight; it is bowed substantially both in the coronal and sagittal planes. Knowing this can help us in practice because we must understand normal anatomy in order to restore it
Stable fixation of distal humerus fracture fragments is necessary for adequate healing and mainte... more Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth. A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure. The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the...
To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck f... more To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck fractures with measured fracture angulation would recommend surgery as often as surgeons shown unmarked radiographs. Methods Members of the Science of Variation Group, an international collaboration of fully trained orthopedic and trauma surgeons, were asked to review 20 little finger metacarpal neck fracture cases, which included a vignette and 3 high-quality radiographs. Members were then randomized to review radiographs with or without measured fracture angulation on the lateral view and select operative or nonoperative management. Results Surgeons shown radiographs with measured angulation were more likely to recommend surgery, and there was less variability among these surgeons, particularly for fractures with less angular deformity. Conclusions Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures.
To address the factors that surgeons use to decide between 2 options for treatment when the evide... more To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.], Jan 23, 2015
The purpose of this study was to explore relationships between damage modes in explanted reverse ... more The purpose of this study was to explore relationships between damage modes in explanted reverse total shoulder arthroplasty (RTSA) components, patient and radiographic risk factors, and functional data to elucidate trends in RTSA failure. Fifty RTSA systems, retrieved from 44 patients, with 50 polyethylene (PE) liners, 30 glenospheres, 21 glenoid baseplates, 13 modular humeral metaphases, and 17 humeral stems, were examined for damage modes, including abrasion, burnishing, dishing, embedding, scratching, and pitting. PE liners were also analyzed for delamination and edge deformation. Charts were reviewed for patient, surgical, and functional data. Pre-revision radiographs were analyzed for scapular notching and loosening. Average term of implantation was 20 months (range, 0-81 months). Metallic components exhibited abrasion, burnishing, dishing, pitting, and scratching. PE liners displayed all damage modes. Damage was exhibited on 93% of glenospheres and 100% of PE liners. Of 29 as...
American journal of orthopedics (Belle Mead, N.J.), 2015
Computed tomography (CT) is often used to evaluate intra-articular distal humerus fracture patter... more Computed tomography (CT) is often used to evaluate intra-articular distal humerus fracture patterns, but it increases radiation exposure and cost. We conducted a study to determine the effect of adding CT evaluation to plain radiographic evaluation on the classification of, and treatment plans for, intra-articular distal humerus fractures. Nine blinded orthopedic surgeons evaluated 30 consecutive fractures for classification and surgical approach. Evaluations were performed first using plain radiographs and then again using the same radiographs plus CT images. Statistical analysis was performed using the κ correlation coefficient and Cramer V testing. We hypothesized that adding CT images to plain radiographs would change the classification and treatment of these fractures and would improve interobserver agreement on classification and treatment. Intraobserver reliability (Cramer V) was fair (.393) for classification and moderate (.426) for treatment. Interobserver reliability (Cohe...
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.], Jan 23, 2015
The purpose of this study was to explore relationships between damage modes in explanted reverse ... more The purpose of this study was to explore relationships between damage modes in explanted reverse total shoulder arthroplasty (RTSA) components, patient and radiographic risk factors, and functional data to elucidate trends in RTSA failure. Fifty RTSA systems, retrieved from 44 patients, with 50 polyethylene (PE) liners, 30 glenospheres, 21 glenoid baseplates, 13 modular humeral metaphases, and 17 humeral stems, were examined for damage modes, including abrasion, burnishing, dishing, embedding, scratching, and pitting. PE liners were also analyzed for delamination and edge deformation. Charts were reviewed for patient, surgical, and functional data. Pre-revision radiographs were analyzed for scapular notching and loosening. Average term of implantation was 20 months (range, 0-81 months). Metallic components exhibited abrasion, burnishing, dishing, pitting, and scratching. PE liners displayed all damage modes. Damage was exhibited on 93% of glenospheres and 100% of PE liners. Of 29 as...
Background: The Polaris nail is an intramedullary device for treating displaced proximal humerus ... more Background: The Polaris nail is an intramedullary device for treating displaced proximal humerus fractures with few published studies to support its use. Results of a consecutive series of patients treated with the Polaris nail are presented. Methods: Eighteen patients with a mean age of 71 years (range, 37-84) were treated for twelve 2-and six 3-part fractures. Radiographic results for all patients were evaluated. Thirteen patients with an average follow-up of 42 months (range, 24-84) were available for functional evaluation. Results: Seventeen of 18 patients healed. Postoperatively, the neck/shaft angle collapsed an average 11 (range, 5-30 ) into varus. Nine of 18 patients had final neck/shaft angles <120 and were considered radiographic malunions. The mean Constant and American Shoulder and Elbow Surgeons (ASES) scores were 61 (range, 20-100) and 67 (range, 10-100), respectively. Forward elevation averaged 118 . Patients had an average 5/8 positive rotator cuff signs. Seven patients underwent reoperation for loss of fixation or prominent hardware, and 1 required revision to a hemiarthroplasty. Conclusion: This study shows a higher than reported percentage of unsatisfactory results using the Polaris nail. The device violates the rotator cuff and is unable to resist the deforming forces that can lead to loss of fixation and varus collapse.
The clinical outcome of hemiarthroplasty for proximal humeral fractures is not satisfactory. Seco... more The clinical outcome of hemiarthroplasty for proximal humeral fractures is not satisfactory. Secondary fragment dislocation may prevent bone integration; the primary stability by a fixation technique is therefore needed to accomplish tuberosity healing. Present technical comparison of surgical fixation techniques reveals the state-of-the-art approach and highlights promising techniques for enhanced stability.
Early failure due to glenoid loosening with anatomic total shoulder arthroplasty in patients with... more Early failure due to glenoid loosening with anatomic total shoulder arthroplasty in patients with severe rotator cuff deficiency led to the development of the reverse ball-and-socket shoulder prosthesis. The literature reports improved short-term pain and function scores following modern reverse total shoulder arthroplasty (RTSA) in patients with cuff tear arthropathy (CTA).
Clinical Orthopaedics and Related Research, Nov 19, 2019
Although the restoration of the normal radial bow has long been known to be a key step in the fix... more Although the restoration of the normal radial bow has long been known to be a key step in the fixation of forearm fractures [7], similar attention has not been paid to restoring anatomic curvature of the ulna. In fact,we use straight plates forwhat has traditionally been thought of as a straight bone. But as Hreha and colleagues [2] show in the current study, sometimes it is important to bend or contour a plate before applying it to a fractured ulna. It is well established that the articulation between the radius and ulna, including the interosseous membrane, substantially affects pronation and supination of the forearm [1, 3, 5, 6]. But might we further improve functional outcomes following treatment of forearm fractures by meticulously restoring the native anatomyof the ulna in the same fashion as we restore the radial bow? Hreha and colleagues [2] cleverly adapted the methods of earlier studies (one that measured the ulna’s sagittal bow [4] and another that measured the radius in the coronal plane [7]) to define normal ranges of anatomic bowing of the ulna in an adult population. They found that the ulna is anything but straight; it is bowed substantially both in the coronal and sagittal planes. Knowing this can help us in practice because we must understand normal anatomy in order to restore it
Stable fixation of distal humerus fracture fragments is necessary for adequate healing and mainte... more Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth. A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure. The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the...
To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck f... more To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck fractures with measured fracture angulation would recommend surgery as often as surgeons shown unmarked radiographs. Methods Members of the Science of Variation Group, an international collaboration of fully trained orthopedic and trauma surgeons, were asked to review 20 little finger metacarpal neck fracture cases, which included a vignette and 3 high-quality radiographs. Members were then randomized to review radiographs with or without measured fracture angulation on the lateral view and select operative or nonoperative management. Results Surgeons shown radiographs with measured angulation were more likely to recommend surgery, and there was less variability among these surgeons, particularly for fractures with less angular deformity. Conclusions Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures.
To address the factors that surgeons use to decide between 2 options for treatment when the evide... more To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.], Jan 23, 2015
The purpose of this study was to explore relationships between damage modes in explanted reverse ... more The purpose of this study was to explore relationships between damage modes in explanted reverse total shoulder arthroplasty (RTSA) components, patient and radiographic risk factors, and functional data to elucidate trends in RTSA failure. Fifty RTSA systems, retrieved from 44 patients, with 50 polyethylene (PE) liners, 30 glenospheres, 21 glenoid baseplates, 13 modular humeral metaphases, and 17 humeral stems, were examined for damage modes, including abrasion, burnishing, dishing, embedding, scratching, and pitting. PE liners were also analyzed for delamination and edge deformation. Charts were reviewed for patient, surgical, and functional data. Pre-revision radiographs were analyzed for scapular notching and loosening. Average term of implantation was 20 months (range, 0-81 months). Metallic components exhibited abrasion, burnishing, dishing, pitting, and scratching. PE liners displayed all damage modes. Damage was exhibited on 93% of glenospheres and 100% of PE liners. Of 29 as...
American journal of orthopedics (Belle Mead, N.J.), 2015
Computed tomography (CT) is often used to evaluate intra-articular distal humerus fracture patter... more Computed tomography (CT) is often used to evaluate intra-articular distal humerus fracture patterns, but it increases radiation exposure and cost. We conducted a study to determine the effect of adding CT evaluation to plain radiographic evaluation on the classification of, and treatment plans for, intra-articular distal humerus fractures. Nine blinded orthopedic surgeons evaluated 30 consecutive fractures for classification and surgical approach. Evaluations were performed first using plain radiographs and then again using the same radiographs plus CT images. Statistical analysis was performed using the κ correlation coefficient and Cramer V testing. We hypothesized that adding CT images to plain radiographs would change the classification and treatment of these fractures and would improve interobserver agreement on classification and treatment. Intraobserver reliability (Cramer V) was fair (.393) for classification and moderate (.426) for treatment. Interobserver reliability (Cohe...
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.], Jan 23, 2015
The purpose of this study was to explore relationships between damage modes in explanted reverse ... more The purpose of this study was to explore relationships between damage modes in explanted reverse total shoulder arthroplasty (RTSA) components, patient and radiographic risk factors, and functional data to elucidate trends in RTSA failure. Fifty RTSA systems, retrieved from 44 patients, with 50 polyethylene (PE) liners, 30 glenospheres, 21 glenoid baseplates, 13 modular humeral metaphases, and 17 humeral stems, were examined for damage modes, including abrasion, burnishing, dishing, embedding, scratching, and pitting. PE liners were also analyzed for delamination and edge deformation. Charts were reviewed for patient, surgical, and functional data. Pre-revision radiographs were analyzed for scapular notching and loosening. Average term of implantation was 20 months (range, 0-81 months). Metallic components exhibited abrasion, burnishing, dishing, pitting, and scratching. PE liners displayed all damage modes. Damage was exhibited on 93% of glenospheres and 100% of PE liners. Of 29 as...
Background: The Polaris nail is an intramedullary device for treating displaced proximal humerus ... more Background: The Polaris nail is an intramedullary device for treating displaced proximal humerus fractures with few published studies to support its use. Results of a consecutive series of patients treated with the Polaris nail are presented. Methods: Eighteen patients with a mean age of 71 years (range, 37-84) were treated for twelve 2-and six 3-part fractures. Radiographic results for all patients were evaluated. Thirteen patients with an average follow-up of 42 months (range, 24-84) were available for functional evaluation. Results: Seventeen of 18 patients healed. Postoperatively, the neck/shaft angle collapsed an average 11 (range, 5-30 ) into varus. Nine of 18 patients had final neck/shaft angles <120 and were considered radiographic malunions. The mean Constant and American Shoulder and Elbow Surgeons (ASES) scores were 61 (range, 20-100) and 67 (range, 10-100), respectively. Forward elevation averaged 118 . Patients had an average 5/8 positive rotator cuff signs. Seven patients underwent reoperation for loss of fixation or prominent hardware, and 1 required revision to a hemiarthroplasty. Conclusion: This study shows a higher than reported percentage of unsatisfactory results using the Polaris nail. The device violates the rotator cuff and is unable to resist the deforming forces that can lead to loss of fixation and varus collapse.
The clinical outcome of hemiarthroplasty for proximal humeral fractures is not satisfactory. Seco... more The clinical outcome of hemiarthroplasty for proximal humeral fractures is not satisfactory. Secondary fragment dislocation may prevent bone integration; the primary stability by a fixation technique is therefore needed to accomplish tuberosity healing. Present technical comparison of surgical fixation techniques reveals the state-of-the-art approach and highlights promising techniques for enhanced stability.
Early failure due to glenoid loosening with anatomic total shoulder arthroplasty in patients with... more Early failure due to glenoid loosening with anatomic total shoulder arthroplasty in patients with severe rotator cuff deficiency led to the development of the reverse ball-and-socket shoulder prosthesis. The literature reports improved short-term pain and function scores following modern reverse total shoulder arthroplasty (RTSA) in patients with cuff tear arthropathy (CTA).
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