ABSTRACT: The management options for proximal humeral fractures have expanded in recent years. Patients with displaced, unstable proximal humeral fractures may have improved outcomes if managed operatively. We investigated the decision making of fellowship-trained orthopedic surgeons when presented with the same group of cases. We hypothesized that interobserver and intraobserver agreement for surgical management would be poor and independent of fellowship training.
Eight fellowship-trained orthopedic surgeons (3 shoulder, 5 trauma) viewed the preoperative plain radiographs of patients with proximal humeral fractures. All surgeons viewed the same 38 radiographs in a blinded fashion. Surgeons chose from 1 of 6 management options. Interobserver variability was calculated by using the weighted kappa coefficient. Intraobserver variability was calculated by comparing each surgeon's survey results with the operation they originally performed.
Overall interobserver agreement on management was moderate (weighted kappa=0.41) and did not differ significantly between trauma surgeons and shoulder surgeons. Reducing the number of management choices increased agreement between all surgeons. Testing for intraobserver agreement showed that surgeons picked the same operation in the survey as in the actual clinical setting only 56% of the time.
Interobserver agreement was moderate overall and improved when the number of management choices was reduced. Intraobserver agreement was less frequent, however, raising the question about consistent decision making by a given surgeon. Although surgeons agree in the method of treatment only to a modest degree, it remains for further outcomes research to establish if the choice of treatment actually influences the clinical outcome.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 09/2009; 19(3):446-51. · 1.93 Impact Factor
American journal of orthopedics (Belle Mead, N.J.) 01/2008; 36(12):672-4.
ABSTRACT: Calcaneal fractures in children are rare injuries, and those with displaced intraarticular fracture patterns are found even less frequently. Recent data in the adult literature have suggested operative treatment of displaced intraarticular calcaneal fractures leads to a more favorable outcome. Most pediatric calcaneal fractures are due to low-energy trauma and are therefore minimally displaced and extraarticular. However, some children are exposed to high-energy trauma, leading to severe intraarticular injuries. Operatively treated calcaneal fractures in children have been poorly described in the literature. The purpose of this study was to analyze the outcomes of surgically treated displaced intraarticular calcaneal fractures in children.
All children with closed displaced intraarticular calcaneal fractures treated with open reduction internal fixation at 1 institution were reviewed at an average of 67 months postoperatively. Preoperative and postoperative radiographs and preoperative computed tomographic scans were used to classify fractures. Functional outcome was assessed by the use of the subjective portions of the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score.
Fourteen fractures in 13 patients who met the inclusion criteria were treated with open reduction internal fixation. We found 7 tongue-type and 7 joint depression-type fractures based on the Essex-Lopresti classification. Based on the Sanders classification, we found 9 type II (2-part) fractures and 5 type III (3-part) fractures. The average preoperative and postoperative Bohler angles were 11.8 and 28.4 degrees (P < 0.0001), respectively. The average subjective AOFAS hindfoot score was 64 of a possible 68 points. Of 14 fractures, 13 were fixed with a buttressing plate laterally. One patient was fixed with a single 3.5-mm cortical screw and had the lowest AOFAS hindfoot score. Four minor complications in 3 patients were encountered.
We found that most children with displaced intraarticular calcaneal fractures treated with open reduction and internal fixation at 1 institution had a good clinical outcome with few complications.
Journal of Pediatric Orthopaedics 01/2008; 27(8):856-62. · 1.16 Impact Factor
ABSTRACT: In recent studies, investigators have used a cyclic loading model to investigate the efficacy of rotator cuff fixation modalities.
A bioabsorbable poly-D-lactic acid screw and toothed washer implant will provide more stable fixation of rotator cuff repairs than standard suture anchor techniques.
Controlled laboratory study.
Forty bovine shoulders (ages 3 to 6 months) had 1 x 2 cm defects created in the infraspinatus tendon. There were five repair groups (eight specimens per group) consisting of either two screw and washer implants or two suture anchors. Four suture techniques were tested: single-loaded anchors with simple sutures, double-loaded anchors with simple sutures, single-loaded anchors with horizontal mattress sutures, or single-loaded anchors with modified Mason-Allen sutures. Repairs were loaded at 5-second cycles from 10 to 180 N with use of a hydraulic testing machine. The number of cycles to gap formation of 5 and 10 mm was recorded.
Gap formation of 5 and 10 mm occurred significantly later for the screw repair group than for any of the suture anchor groups. There was no significant difference between suture groups.
The bioabsorbable screw and washer provided more stable fixation than suture anchor techniques under isometric cyclic loading conditions. Clinical Relevance: This is a time-zero study of implant performance. The results indicate that the implant may decrease clinical failures in the early postoperative period under standard rehabilitation protocols.
The American Journal of Sports Medicine 31(6):849-53. · 3.79 Impact Factor