Treatment of post-traumatic degenerative changes of the radio-carpal and distal radio-ulnar joints by combining radius, scaphoid, and lunate (RSL) fusion with ulnar head replacement

Distal radial fractures are a common type of fracture. In the case of intra-articular fractures, they often result in post-traumatic arthrosis. The objective of this study is to describe a novel alternative to the established salvage techniques for the treatment of post-traumatic arthrosis of the radio-carpal and distal radio-ulnar joints (DRUJ). Six patients with radio-carpal and DRUJ arthrosis were treated with a combined radius, scaphoid, and lunate (RSL) arthrodesis and as a Herbert ulnar head prosthesis. Follow-up consisted of both radiographic and functional assessments. Functional measurements were noted both pre- and postoperatively. No non-union or pseudoarthrosis was seen; neither did any of the ulnar head prostheses show loosening. Clinical examination showed an improvement in strength, pain, and range of movement, as well as a decrease in disability. Combining RSL arthrodesis with a Herbert ulnar head prosthesis, which deals with pain while retaining partial wrist movement, can be an alternative to established salvage procedures

Validation of a new test that assesses functional performance of the upper extremity and neck (FIT-HaNSA) in patients with shoulder pathology

<p>Abstract</p> <p>Background</p> <p>There is a lack of standardized tests that assess functional performance for sustained upper extremity activity. This study describes development of a new test for measuring functional performance of the upper extremity and neck and assesses reliability and concurrent validity in patients with shoulder pathology.</p> <p>Methods</p> <p>A series of developmental tests were conducted to develop a protocol for assessing upper extremity tasks that required multi-level movement and sustained elevation. Kinematics of movement were investigated to inform subtask structure. Tasks and test composition were refined to fit clinical applicability criteria and pilot tested on 5 patients awaiting surgery for shoulder impingement and age-sex matched controls. Test-retest reliability was assessed on 10 subjects. Then a cohort of patients with mild to moderate (n = 17) shoulder pathology and 19 controls (17 were age-sex matched to patients) were tested to further validate the Functional Impairment Test-Hand, and Neck/Shoulder/Arm (FIT-HaNSA) by comparing it to self-reported function and measured strength. The FIT-HaNSA, DASH and SPADI were tested on a single occasion. Impairments in isometric strength were measured using hand-held dynamometry. Discriminative validity was determined by comparing scores to those of age-sex matched controls (n = 34), using ANOVA. Pearson correlations between outcome measures (n = 41) were examined to establish criterion and convergent validity.</p> <p>Results</p> <p>A test protocol based on three five-minute subtasks, each either comprised of moving objects to waist-height shelves, eye-level shelves, or sustained manipulation of overhead nuts/bolts, was developed. Test scores for the latter 2 subtasks (or total scores) were different between controls as compared to either surgical-list patients with shoulder impingement or a variety of milder shoulder pathologies (p < 0.01). Test 1 correlated the highest with the DASH (r = -0.83), whereas Test 2 correlated highest with the SPADI (r = -0.76).</p> <p>Conclusion</p> <p>Initial data suggest the FIT-HaNSA provides valid assessment of impaired functional performance in patients with shoulder pathology. It discriminates between patients and controls, is related to self-reported function, and yet provides distinct information. Longitudinal testing is warranted.</p

International Survey: Factors Associated With Operative Treatment of Distal Radius Fractures and Implications for the American Academy of Orthopaedic Surgeons' Appropriate Use Criteria

Objectives: Through an international survey, we assessed whether deciding to operatively treat an intra-articular distal radius fracture (DRF) is guided by identifiable patient and surgeon factors. In addition, we compared surgeons' treatment decisions with the American Academy of Orthopaedic Surgeons' Appropriate Use Criteria (AUC) treatment recommendations. Methods: This cross-sectional survey asked 224 surgeons to operatively or nonoperatively treat 28 hypothetical patients with radiographs of an intra-articular DRF. We randomized patient age (50/70 years), gender, mechanism of injury, activity level, and OTA/AO fracture type. We classified 6 fractures as “nonclinically significant displacement” and 22 as “potentially clinically significant displacement.” Multilevel logistic regression analysis was performed. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. Statistical significance was P < 0.05. Results: Patient factors independently associated with surgery included younger age (OR 6.7, P = 0.003), clinically significant fracture displacement (type B: OR 122, CI, 20–739, P < 0.001; type C: OR 59, CI, 12–300, P < 0.001), normal activity level (OR 5.0, P < 0.001), and high-energy mechanisms (OR 1.3, P = 0.002). Surgeon factors associated with recommending surgery included practicing outside the United States (Europe: OR 2.6, P < 0.001; “other”: OR 4.8, P < 0.001). Hand surgeons most often selected surgery, as compared to orthopaedic trauma surgeons (OR 2.3, P = 0.001) and “other orthopaedists” (OR 2.2, P = 0.022). Thirty-seven percent of treatment decisions for patients with normal activity levels were rated by AUC recommendations as “rarely appropriate,” which included 91% disagreement for 70-year-olds with nonclinically significant displacement. Conclusions: Surgeons use patient age and fracture displacement to make treatment recommendations for intra-articular DRF. We recommend that the AUC be updated to include these clinical factors as essential components in its algorithm. Level of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence