Dominique M. Rouleau

Percutaneous humeral plating of fractures of the proximal humerus: results of a prospective multicenter clinical trial.

Objectives: To evaluate the safety and functional outcome of a recently described surgical technique of percutaneous plating for proximal humerus fractures. Design: Prospective clinical trial. Setting: Two urban Level 1 university trauma centers. Patients: From February 2002 to December 2003, 34 consecutive patients underwent surgery by 5 trauma surgeons from 2 teaching hospitals. Twenty-seven patients had 1-year follow-up. Intervention: The technique involved 2 minimal incisions with a lateral deltoid split and a more distal shaft incision. A proximal humerus-specific locking plate was implemented. Main Outcome Measurements: DASH (disabilities of the arm, shoulder, and hand) and Constant-Murley evaluation scores were used for functional evaluation. The presence of complications was noted. Results: Specifically, there were no axillary nerve injury injuries and no loss of reduction. The average Constant score at 1 year was 82 and the DASH score was 26. Conclusion: This study demonstrated that the functional outcome results correspond to a normal age-adjusted score signifying an acceptable result.

Glenoid version: How to measure it? Validity of different methods in two-dimensional computed tomography scans

HYPOTHESIS Recognition of the glenoid version is important for evaluation of different pathologies such as degenerative wear, shoulder instability, or congenital deformity. Surgical strategies can change significantly in the presence of major retroversion. There is no consensus on the method to use to evaluate version. This study compared different measurement strategies in 116 patients with shoulder computed tomography (CT) scans. We hypotheses that the methods will give different value for evolution. METHODS Shoulder axial CT images were reviewed, and the image inferior to the base of the coracoid was selected. The glenoid version was measured according to the Friedman method and the scapula body method. Three orthopedic surgeons independently examined the images 2 times, and intraobserver and interobserver reliability was calculated using intraclass correlation (ICC). RESULTS Group 1 (n = 53): The average glenoid version was significantly different between the 2 measurement techniques for all 3 observers, with an average of -7.29° for the scapula body method and -10.43° for Friedman method. For group 2 (B2 glenoid group, n = 63): The most reliable method for measurement of B2 glenoid (glenoid with posterior erosion) version was the association of the Friedman line for the scapula axis and the intermediate glenoid line, with excellent intraobserver reliability (ICC > 0.957) and interobserver reliability (ICC = 0.954). DISCUSSION The glenoid version measurement is reliable on a 2D CT Scan. According to correlation found in our paper and those of the literature it seems that there is no advantage on 3D CT Scan to assess version in terms of reliability of measures. CONCLUSION Combining the Friedman method to determine the scapula axis with an intermediate glenoid line in B2 glenoid yield the most reliable measurements.

Validity of Goniometric Elbow Measurements: Comparative Study with a Radiographic Method

BackgroundA universal goniometer is commonly used to measure the elbow’s ROM and carrying angle; however, some authors question its poor intertester reliability.Questions/purposesWe (1) assessed the validity of goniometric measurements as compared with radiographic measurements in the evaluation of ROM of the elbow and (2) determined the reliability of both.MethodsThe ROM and carrying angle of 51 healthy subjects (102 elbows) were measured using two methods: with a universal goniometer by one observer three times and on radiographs by two independent examiners. Paired t-test and Pearson’s correlation were used to compare and detect the relationship between mean ROM. The maximal error was calculated according to the Bland and Altman method.ResultsThe intraclass correlation coefficients (ICC) ranged from 0.945 to 0.973 for the goniometric measurements and from 0.980 to 0.991 for the radiographic measurements. The two methods correlated when measuring the total ROM in flexion and extension. The maximal errors of the goniometric measurement were 10.3° for extension, 7.0° for flexion, and 6.5° for carrying angle 95% of the time. We observed differences for maximum flexion, maximal extension, and carrying angle between the methods.ConclusionBoth measurement methods differ but they correlate. When measured with a goniometer, the elbow ROM shows a maximal error of approximately 10°.Clinical RelevanceThe goniometer is a reasonable and simple clinical tool, but for research protocols, we suggest using the radiographic method because of the higher level of precision required.

Incidence of associated injury in posterior shoulder dislocation: systematic review of the literature.

Objective: Posterior shoulder dislocations are rare and often missed. Classically associated with seizures, very little is known about the incidence and type of associated injuries. Unfortunately, the majority of the literature consists of incidental reports or small case series. Our goal was to increase the strength of available data by performing a systematic review. Data Sources: We searched EMBASE and PubMed for the terms “posterior shoulder dislocation.” Our inclusion criteria were articles in either English or French with the words “posterior” and “dislocation” in the abstract or title. All reports of chronic cases or instability as well as those without patient information were excluded. Data regarding demographics, etiology, investigations, associated injuries, treatments, and outcomes were extracted. All data were analyzed by using SPSS 18.0 (IBM, Chicago, IL). Results: A total of 766 articles were found of which 108 were retained for analysis. A total of 475 patients (543 shoulders) were compiled. Seizures were reported in 34% of cases. A majority of dislocations (65%) had associated injuries. Fracture was most common followed by reverse Hill-Sachs and cuff tears. In the absence of fracture or reverse Hill-Sachs injury, the risk of cuff tear increased nearly fivefold (odds ratio, 4.6; P = 0.016). Conclusion: Our results suggest the amount of associated injuries related to posterior shoulder dislocation is far greater than thought. We propose an investigation algorithm for acute posterior shoulder dislocations.

The effects of midwives’ job satisfaction on burnout, intention to quit and turnover: a longitudinal study in Senegal

BackgroundDespite working in a challenging environment plagued by persistent personnel shortages, public sector midwives in Senegal play a key role in tackling maternal mortality. A better understanding of how they are experiencing their work and how it is affecting them is needed in order to better address their needs and incite them to remain in their posts. This study aims to explore their job satisfaction and its effects on their burnout, intention to quit and professional mobility.MethodsA cohort of 226 midwives from 22 hospitals across Senegal participated in this longitudinal study. Their job satisfaction was measured from December 2007 to February 2008 using a multifaceted instrument developed in West Africa. Three expected effects were measured two years later: burnout, intention to quit and turnover. Descriptive statistics were reported for the midwives who stayed and left their posts during the study period. A series of multiple regressions investigated the correlations between the nine facets of job satisfaction and each effect variable, while controlling for individual and institutional characteristics.ResultsDespite nearly two thirds (58.9%) of midwives reporting the intention to quit within a year (mainly to pursue new professional training), only 9% annual turnover was found in the study (41/226 over 2 years). Departures were largely voluntary (92%) and entirely domestic. Overall the midwives reported themselves moderately satisfied; least contented with their “remuneration” and “work environment” and most satisfied with the “morale” and “job security” facets of their work. On the three dimensions of the Maslach Burnout Inventory, very high levels of emotional exhaustion (80.0%) and depersonalization (57.8%) were reported, while levels of diminished personal accomplishment were low (12.4%). Burnout was identified in more than half of the sample (55%). Experiencing emotional exhaustion was inversely associated with “remuneration” and “task” satisfaction, actively job searching was associated with being dissatisfied with job “security” and voluntary quitting was associated with dissatisfaction with “continuing education”.ConclusionsThis study found that although midwives seem to be experiencing burnout and unhappiness with their working conditions, they retain a strong sense of confidence and accomplishment in their work. It also suggests that strategies to retain them in their positions and in the profession should emphasize continuing education.

Systematic review of patient-administered shoulder functional scores on instability

BACKGROUND Shoulder instability is common. Multiple questionnaires are used in clinical studies. The purpose of this study is to find and synthesize evidence on the usefulness of self-administered questionnaires specific to shoulder instability. MATERIALS AND METHODS We undertook a systematic review using a standard search strategy (publications from 1966-2008) on databases (Medline, Embase); a structured search was conducted and supplemented by expert consultation. Raters conducted data extraction and critical appraisal using structured tools. A descriptive synthesis was performed. RESULTS In total, 25 published questionnaires used for patients with shoulder instability were identified. The Rowe questionnaire is the oldest and the most frequently used scale. After excluding questionnaires that were not validated, that necessitated physical examination, or that did not address instability symptoms, we identified 3 validated self-report measures specific to shoulder instability: Western Ontario Shoulder Instability Index (WOSI), Oxford Shoulder Instability Questionnaire, and Melbourne Instability Shoulder Scale. Quality ratings on validation studies varied from 50% to 79%. A failure to establish clear guidelines for interpretation was a common flaw. Although there are insufficient studies (n = 3) to determine the best measure, the WOSI appears to have the best supporting evidence with excellent reliability/responsiveness (intraclass correlation coefficient, 0.95; effect size, 0.93). CONCLUSIONS Evidence for the psychometric properties of shoulder instability is limited but suggests that reliable and responsive measures are available. More studies of the WOSI and competing scales in head-to-head comparison are needed to determine their optimal usage. Cultural adaptation is also needed to permit widespread usage. CLINICAL RELEVANCE Reliable and responsive measures are available to evaluate patients with shoulder instability.

Contralateral Elbow Radiographs Can Reliably Diagnose Radial Head Implant Overlengthening

BACKGROUND Excessive lengthening of the radius with use of a radial head implant, a common cause of capitellar wear and clinical failure, is difficult to identify on radiographs of the injured elbow. The purpose of this study was to determine if a novel measurement technique based on radiographs of the contralateral elbow could be used to accurately estimate the magnitude of overlengthening due to the radial head implant. In part I of this study, we examined the side-to-side consistency of radiographic landmarks used in the measurement technique. In part II, the technique was validated in a cadaveric model with simulated radial head implant overlengthening. METHODS In part I of the study, a side-to-side comparison of elbow joint dimensions was performed with use of 100 radiographs from fifty patients. In part II, radial head prostheses of varying lengths (leading to 0, 2, 4, 6, and 8 mm of overlengthening) were implanted in four pairs of cadaveric specimens (eight elbows). Radiographic measurements were performed by two examiners blinded to the implant size to determine if radiographs of the contralateral elbow could be used to diagnose, and provide a valid estimate of the magnitude of, implant overlengthening. Intrarater and interrater reliability ratios, absolute measurement errors, and diagnostic accuracy were determined. RESULTS No significant side-to-side differences (p > 0.2) in radiographic measurements were identified between paired elbows. In the cadaveric model, the measurement technique involving use of radiographs of the contralateral elbow was successful in predicting the implant size (± 1 mm) in 104 (87%) of the 120 scenarios tested. The sensitivity of the technique--i.e., the ability of the test to correctly identify overlengthening (within ± 1 mm) when it was present--was 98%, with a positive likelihood ratio of 49 and a negative likelihood ratio of 0.02. The reliability of the radiographic measurements, based on repeated measurements performed by a single blinded orthopaedic surgeon on two separate occasions or based on separate measurements performed by two different orthopaedic surgeons, was excellent (intraclass correlation coefficient > 0.95). CONCLUSIONS A measurement technique based on radiographs of the contralateral elbow can be used to diagnose and calculate the magnitude of radial overlengthening due to the use of an incorrectly sized radial head implant.

Bias towards dementia: Are hip fracture trials excluding too many patients? A systematic review

Patients with hip fractures are older and often present many co-morbidities, including dementia. These patients cannot answer quality of life questionnaires and are generally excluded from trials. We hypothesized that a significant number of patients are being excluded from these studies and this may impact outcomes. This was a two part study; the first analyzing databases of two ongoing large-scale multi-centred hip fracture trials and the second being a systematic review. The FAITH and HEALTH studies were analyzed for exclusion incidence directly related to dementia. The second part consisted of a systematic search of all relevant studies within the last 20 years. In the FAITH study, a total of 1690 subjects were excluded, 375 (22.2%) of which were due to dementia or cognitive impairment. In the HEALTH study, 575 were excluded with dementia/cognitive impairment representing 207 patients (36%). Following the systematic review, 251 articles were identified 17 of which were retained. The overall prevalence of dementia was 27.9% (range 2-51%). Only two studies compared demented and non-demented groups. In these studies significant increases in both mortality and complications were found. In summary, when investigating hip fractures, choosing appropriate objective endpoints is essential to ensure results are also applicable to patients with dementia.

Long-term outcome of surgically-treated habitual patellar dislocation in children with coexistent patella alta: MINIMUM FOLLOW-UP OF 11 YEARS

We retrospectively reviewed the operative treatment carried out between 1988 and 1994 of eight patients with habitual patellar dislocation. In four the condition was bilateral. All patients had recurrent dislocation with severe functional disability. The surgical technique involved distal advancement of the patella by complete mobilisation of the patellar tendon, lateral release and advancement of vastus medialis obliquus. The long-term results were assessed radiologically, clinically and functionally using the Lysholm knee score, by an independent observer. The mean age at operation was 10.3 years (7 to 14) with a mean follow-up of 13.5 years (11 to 16). One patient required revision. At the latest follow-up, all patellae were stable and knees functional with a mean Lysholm knee score of 98 points (95 to 100). In those aged younger than ten years at operation there was a statistically significant improvement in the sulcus angle at the latest follow-up (Students t-test, p = 0.001). Two patients developed asymptomatic patella infera as a late complication. This technique offers a satisfactory treatment for the immature patient presenting with habitual patellar dislocation associated with patella alta. If performed early, we believe that remodelling of the shallow trochlea may occur, adding intrinsic patellofemoral stability.

APTF: anteroposterior tibiofibular ratio, a new reliable measure to assess syndesmotic reduction.

Objectives: To assess the accuracy of a new radiographic measurement of the distal tibia and fibula on the lateral view of the ankle in normal adults: the anteroposterior tibiofibular (APTF) ratio. Method: Thirty adults without history of trauma or disease of the ankle were included. Bilateral ankles were x-rayed with a true lateral view of the ankle. A line from the anterior tibial physis scar to the posterior tibial cortex, passing by the intersection of the physis and the fibula anterior cortex, was drawn. The APTF ratio was calculated as the ratio of the anterior segment to the posterior segment. The measurements were done by 3 independent evaluators. Intra- and interobserver reliability was obtained using intraclass correlation. Results: The APTF ratio was 0.94 ± 0.13 with a range of 0.63–1.31. Sex and age had no effect on the results. Inter- and intraobserver reliability was good to very good with an intraclass correlation between 0.6 and 0.8. A strong correlation between the left and the right APTF ratio was observed (r = 0.501 and P = 0.001). Conclusion: The distal tibiofibular joint anatomy in the sagittal plane can be accurately assessed with a new reliable radiographic measurement, the APTF ratio. The reduction of this joint during surgery can be confirmed with a true lateral view of the ankle. The anterior fibula cortex crosses the tibial physeal scar at the center of the line crossing this point and the anterior cortex of the tibia at the level of the physeal scar in the normal ankle.