[Show abstract][Hide abstract] ABSTRACT: The traditional treatment after closed reduction of distal radius (DR) and distal both bone (DBB) forearm fractures has been application of a long-arm cast (LAC) or a short-arm cast (SAC). Splinting is another option that avoids the potential complications associated with casting. The purpose of this study is to evaluate the maintenance of reduction of DR or DBB fractures placed in a double-sugar-tong splint (DSTS) compared with a LAC in a pediatric population.
This is an IRB-approved, prospective, randomized trial. Patients aged 4 to 12 years with DR or DBB fractures treated at a single institution between 2010 and 2012 were enrolled. After reduction, fractures were placed into either a LAC or a DSTS. Radiographs were reviewed at initial injury, postreduction, and at set intervals for angulation, displacement, and apposition, as well as cast index and 3-point index. The DSTS was overwrapped into a cast after week 1. The immobilization device was changed to a SAC at week 4 or 6. Total duration of immobilization was 6 to 8 weeks.
Seventy-one patients were enrolled with 37 in the LAC and 34 in the DSTS. Average age was 8.73 years (range, 4 to 12) with 43 being males. There were 28 isolated DR and 43 DBB fractures. There were no week-to-week differences between the 2 groups in regards to sagittal alignment, coronal alignment, apposition, or displacement. Sagittal alignment at immediate postreduction and week 2 showed that the DSTS was slightly better (average 2.0 vs. 5.0 degrees, respectively, P=0.04). For the entire treatment period there was an increased risk of loss of reduction of ≥10 degrees in the LAC group versus the DSTS group (7 patients vs. 2 patients, respectively, P=0.0001), and of meeting the criteria for remanipulation (10 patients vs. 5 patients, respectively, P=0.01). At cast removal, there was no difference between groups.
Although there were significant differences between the 2 groups with regards to risk of reduction loss, the DSTS and LAC were comparable in maintenance of reduction at the time of cast removal. Both the DSTS and LAC are appropriate immobilization devices for these pediatric fractures.
Level II-prospective, comparative study.
Journal of pediatric orthopedics 04/2014; · 1.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Injury to the tibiofibular syndesmosis is frequent with rotational ankle injuries. Multiple studies have shown a high rate of syndesmotic malreduction with the placement of syndesmotic screws. There are no studies evaluating the reduction or malreduction of the syndesmosis after syndesmotic screw removal. The purpose of this study was to prospectively evaluate syndesmotic reduction with CT scans and to determine the effect of screw removal on the malreduced syndesmosis.
This was an IRB-approved prospective radiographic study. Patients over 18 years of age treated at 1 institution between August 2008 and December 2011 with intraoperative evidence of syndesmotic disruption were enrolled. Postoperative CT scans were obtained of bilateral ankles within 2 weeks of operative fixation. Syndesmotic screws were removed after 3 months, and a second CT scan was then obtained 30 days after screw removal. Using axial CT images, syndesmotic reduction was evaluated compared to the contralateral uninjured ankle. Twenty-five patients were enrolled in this prospective study. The average age was 25.7 (range, 19 to 35), with 3 females and 22 males.
Nine patients (36%) had evidence of tibiofibular syndesmosis malreduction on their initial postoperative axial CT scans. In the postsyndesmosis screw removal CT scan, 8 of 9 or 89% of malreductions showed adequate reduction of the tibiofibular syndesmosis. There was a statistically significant reduction in syndesmotic malreductions (t = 3.333, P < .001) between the initial rate of malreduction after screw placement of 36% (9/25) and the rate of malreduction after all screws were removed of 4% (1/25).
Despite a high rate of initial malreduction (36%) after syndesmosis screw placement, 89% of the malreduced syndesmoses spontaneously reduced after screw removal. Syndesmotic screw removal may be advantageous to achieve final anatomic reduction of the distal tibiofibular joint, and we recommend it for the malreduced syndesmosis.
Level IV, prognostic case series.
Foot & ankle international. / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 02/2014;
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND:Osteochondral allograft transplantation (OATS) is a treatment option that provides the ability to restore large areas of hyaline cartilage anatomy and structure without donor site morbidity and promising results have been reported in returning patients to some previous activities. However, no study has reported on the durability of return to activity in a setting where it is an occupational requirement. HYPOTHESIS:Osteochondral allograft transplantation is less successful in returning patients to activity in a population in which physical fitness is a job requirement as opposed to a recreational goal. STUDY DESIGN:Case series; Level of evidence, 4. METHODS:A retrospective review was conducted of 38 consecutive OATS procedures performed at a single military institution by 1 of 4 sports medicine fellowship-trained orthopaedic surgeons. All patients were on active duty at the time of the index procedure, and data were collected on demographics, return to duty, Knee Injury and Osteoarthritis Outcome Score (KOOS), and ultimate effect on military duty. Success was defined as the ability to return to the preinjury military occupational specialty (MOS) with no duty-limiting restrictions. RESULTS:The mean lesion size treated was 487.0 ± 178.7 mm(2). The overall rate of return to full duty was 28.9% (11/38). An additional 28.9% (11/38) were able to return to limited activity with permanent duty modifications. An alarming 42.1% (16/38) were unable to return to military activity because of their operative knee. When analyzed for return to sport, only 5.3% (2/38) of patients were able to return to their preinjury level. Eleven patients underwent concomitant procedures. Statistical power was maintained by analyzing data in aggregate for cases with versus without concomitant procedures. When the 11 undergoing concomitant procedures were removed from the data set, the rate of return to full activity was 33.3% (9/27), with 22.3% (6/27) returning to limited activity and 44.4% (12/27) unable to return to activity. In this subset, 7.4% (2/27) were able to return to a preinjury level of sport. The KOOS values were significantly higher in the full activity group when compared with the limited and no activity groups (P < .01). Branch of service was a significant predictor of outcome, with Marine Corps and Navy service members more likely to return to full activity compared with Army and Air Force members. A MOS of combat arms was a significant predictor of a poor outcome. All patients demonstrated postoperative healing of their grafts as documented in their medical chart, and no patient in the series required revision for problems with graft incorporation. CONCLUSION:Osteochondral allograft transplantation for the treatment of large chondral defects in the knee met with disappointing results in an active-duty population and was even less reliable in returning this population to preinjury sport levels. Branch of service and occupational type predicted the return to duty, but other traditional predictors of outcome such as rank and years of service did not. The presence of concomitant procedures did not have an effect on outcome with respect to activity or sport level with the numbers available for analysis.
The American journal of sports medicine 07/2013; · 3.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to compare changes in beliefs of two groups of preservice teachers involved in two types of opportunities to immediately apply methods for teaching accompanying an elementary mathematics methods course. Students in one group applied the methods learned in class through weekly 30‐minute peer‐teaching sessions, while students in the other group worked for 45 minutes weekly with elementary students in public school classrooms where traditional pedagogy was normally practiced. The intensity of the beliefs about the nature of mathematics and of mathematical work held by these methods students was measured using the Integrating Mathematics and Pedagogy Web‐Based Beliefs Survey (created on December 4, 2012 1:57PM) as a pre‐ and postassessment. While both groups saw significant change in belief intensity across measurement occasions favoring a reform perspective, a significantly greater change was experienced by the group who applied methods in classrooms, despite the traditional practice that usually occurred in them. The authors hypothesize this greater change resulted from the benefits associated with working with children and from the instructor support that may have tended to nullify the effects of teaching in a classroom where traditional pedagogy was the norm.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND:Modern techniques for the treatment of acromioclavicular (AC) joint dislocations have largely centered on free tendon graft reconstructions. Recent biomechanical studies have demonstrated that an anatomic reconstruction with 2 clavicular bone tunnels more closely matches the properties of native coracoclavicular (CC) ligaments than more traditional techniques. No study has analyzed tunnel position in regard to risk of early failure. PURPOSE:To evaluate the effect of clavicular tunnel position in CC ligament reconstruction as a risk of early failure. STUDY DESIGN:Case series; Level of evidence, 4. METHODS:A retrospective review was performed of a consecutive series of CC ligament reconstructions performed with 2 clavicular bone tunnels and a free tendon graft. The population was largely a young, active-duty military group of patients. Radiographs were analyzed for the maintenance of reduction and location of clavicular bone tunnels using a picture archiving and communication system. The distance from the lateral border of the clavicle to the center of each bone tunnel was divided by the total clavicular length to establish a ratio. Medical records were reviewed for operative details and functional outcome. Failure was defined as loss of intraoperative reduction. RESULTS:The overall failure rate was 28.6% (8/28) at an average of 7.4 weeks postoperatively. Comparison of bone tunnel position showed that medialized bone tunnels were a significant predictor for early loss of reduction for the conoid (a ratio of 0.292 vs 0.248; P = .012) and trapezoid bone tunnels (a ratio of 0.171 vs 0.128; P = .004); this correlated to an average of 7 to 9 mm more medial in the reconstructions that failed. Reconstructions performed with a conoid ratio of ≥0.30 were significantly more likely to fail (5/5, 100%) than were those performed lateral to a ratio of 0.30 (3/23, 13.0%) (P < .01). There were no failures when the conoid ratio was <0.25 (0/10, 0%). Conoid tunnel placement was also statistically significant for predicting return to duty in our active-duty population. CONCLUSION:Medial tunnel placement is a significant factor in risk for early failures when performing anatomic CC ligament reconstructions. Preoperative templating is recommended to evaluate optimal placement of the clavicular bone tunnels. Placement of the conoid tunnel at 25% of the clavicular length from the lateral border of the clavicle is associated with a lower rate of lost reduction and a higher rate of return to military duty.
The American journal of sports medicine 11/2012; · 3.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: Coracoclavicular (CC) ligament reconstruction remains a challenging procedure. The ideal reconstruction is biomechanically strong, allows direct visualization of passage around the coracoid, and is minimally invasive. Few published reports have evaluated arthroscopic techniques with a single clavicular tunnel and transcoracoid reconstruction. One such report noted early excellent results, but without specific outcome measures. This study reports the clinical and radiographic results of a minimally invasive, arthroscopically assisted technique of CC ligament reconstruction using a transcoracoid and single clavicular tunnel technique. MATERIALS AND METHODS: A retrospective review was performed of 10 consecutive repairs in 9 active duty patients who underwent CC ligament reconstruction with the GraftRope (Arthrex, Naples FL, USA). All reconstructions were performed according to the manufacturer's technique by a single, fellowship-trained surgeon. Medical records and radiographs were evaluated for demographics, operative details, loss of reduction, and return to duty. RESULTS: In 8 of 10 repairs (80%) intraoperative reduction was lost at an average of 7.0 weeks (range, 3-12 weeks). Four patients (40%) required revision. Subjective patient outcomes included 5 excellent/good results, 1 fair result, and 4 poor results. Tunnel widening was universally noted, and the failure mode in most patients appeared to be at the holding suture. CONCLUSION: This transcoracoid, single clavicular tunnel technique was not a reliable approach to CC ligament reconstruction. We noted a high percentage of radiographic redisplacement and clinical failure. This technique, in its current form, cannot be recommended to treat AC joint injuries in our population.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 04/2012; · 1.93 Impact Factor