James H. Roth

Patient rating of wrist pain and disability : A reliable and valid measurement tool

OBJECTIVE The goal of this study was to develop a reliable and valid tool for quantifying patient-rated wrist pain and disability. DESIGN Survey, tool development, reliability, and validity study. SETTING Upper extremity unit. PARTICIPANTS One hundred members of the International Wrist Investigators were surveyed by mail to assist in development of the scale. Patients with distal radius (n = 64) or scaphoid (n = 35) fractures were enrolled in a reliability study, and 101 patients with distal radius fractures were enrolled in a validity study. INTERVENTION Information from the expert survey, biomechanical literature, and patient interviews was used as a basis for item generation and definition of structural limitations for a scale that would be practical in the clinic. Patients with distal radius or scaphoid fractures completed the Patient-Rated Wrist Evaluation (PRWE) on two occasions to determine test-retest reliability. Patients with distal radius fractures (n = 101) completed the PRWE and the SF-36 and were tested with traditional impairment measures at baseline and at two, three, and six months after fracture to determine construct and criterion validity. MAIN OUTCOME MEASURES Reliability coefficients (ICCs) and validity correlations (Pearson product moment correlations). RESULTS Patient opinions on pain and on ability to do activities of daily living and work were thought to be the most important dimensions to include in subjective outcome tools. Brevity and simplicity were seen as essential in the clinic environment. A fifteen-item questionnaire (the PRWE) was designed to measure wrist pain and disability. Test-retest reliability was excellent (ICCs > 0.90). Validity assessment demonstrated that the instrument detected significant differences over time (p < 0.01) and was appropriately correlated with alternate forms of assessing parameters of pain and disability. CONCLUSIONS The PRWE provides a brief, reliable, and valid measure of patient-rated pain and disability.

Arthroscopic diagnosis of intra-articular soft tissue injuries associated with distal radial fractures

Arthroscopy was used to assess the soft tissue injuries associated with distal radial fractures in 118 acute intra- and extra-articular fractures. The triangular fibrocartilage complex (TFCC) was torn in 46 of 118 patients--in 35% of intra-articular fractures and in 53% of extra-articular fractures. No correlation between ulnar styloid fractures and TFCC injuries could be found. Scapholunate (SL) ligament injuries with instability were present in 21.5% of intra-articular fractures and in 6.7% of extra-articular fractures. Lunotriquetral (LT) ligament injuries with instability were present in 6.7% of intra-articular fractures. and in 13.3% of extra-articular fractures. Combined SL and LT injuries were present in 5.6% of intra-articular fracture. Preoperative radiographs correlated with TFCC injury. Patients with TFCC tears had greater shortening and dorsal angulation on the preoperative radiographs. Preoperative radiographs had no predictive value for interosseous ligament injury. Ligamentous injuries are commonly associated with both intra-articular and extra-articular distal radial fractures.

Presidential address. Intraarticular replacement in the anterior cruciate ligament-deficient knee.

For years there has been a struggle for a satisfactory intraar ticular replacement in the anterior cruciate-deficient knee. This paper summarizes our basic and clinical research over the last decade and presents a potential solution to the problem. Instron testing reveals that the anterior cruciate ligament fails at 51.2 kg. Scanning electron microscopy demonstrates that there is little difference whether the ligament is tested just to the point of failure or taken to visible rupture. The technique of the MacIntosh quadriceps-patellar tendon transfer is outlined. Two modifications in the form of a new approach through the defect in the quadriceps mechanism, as well as a new instrument to aid in the passage of the transfer are described. The strength of the tissues about the knee that have been used to substitute for the anterior cruciate ligament are pre sented. Only the distal iliotibial band seems suitable on strength characteristics alone. Intraarticular semitendinosus transfers in rabbits revealed degeneration and a marked decrease in tensile strength at 6 months. We conclude from this experiment and the data from Instron testing on autopsy specimens, substantiated by our clinical impressions, that the long-term success of autogenous intraarticular transfers seems unlikely. We introduce the ligament augmentation device (LAD) as a possible answer. A polypropylene, diamond-braided device is sutured to the prepatellar tissue in the MacIntosh repair to increase its tensile strength. It will sustain the host tissue during the period of degeneration and weakening, and thus allow eventual collagenization. We present our animal work with regard to the LAD and early human clinical application.

Pain and disability reported in the year following a distal radius fracture: A cohort study

BackgroundDistal radius fractures are a common injury that cause pain and disability. The purpose of this study was to describe the pain and disabilities experienced by patients with a distal radius fracture in the first year following fracture.MethodsA prospective cohort study of 129 patients with a fracture of the distal radius was conducted. Patients completed a Patient-rated Wrist Evaluation at their baseline clinic visit and at 2, 3, 6 and 12 months following their fracture. The frequency/severity of pain and disabilities reported was described at each time point.ResultsThe majority of patients experienced mild pain at rest and (very) severe high levels of pain with movement during the first two-months following distal radius fracture. This time is also associated with (very) severe difficulty in performing specific functional activities and moderate to severe difficulty in four domains of usual activity. The majority of recovery occurred within six-months, but symptoms persisted for a small minority of patients at one-year following fracture. Patients had the most difficulty with carrying ten pounds and pushing up from a chair. Resumption of usual personal care and household work preceded, and was more complete, than work and recreational participation.ConclusionsThis study demonstrated that the normal course of recovery following a distal radius fracture is one where severe symptoms subside within the first two-months and the majority of patients can be expected to have minimal pain and disability by six-months following fracture. This information can be used when planning interventions and assessing whether the progress of a patient is typical of other patients.

Patient versus injury factors as predictors of pain and disability six months after a distal radius fracture

A prospective cohort of 120 patients with distal radius fractures completed a baseline evaluation that determined their age, sex, education level, injury compensation status, AO fracture type, prereduction radial shortening, and postreduction radial shortening. Six months later patients self-reported pain and disability using the Patient-Rated Wrist Evaluation, and were tested for physical impairment (grip, wrist range of motion, and dexterity). Univariate and forward stepwise regression analyses agreed that the most influential predictor of pain and disability at 6 months was injury compensation. Patient education level and prereduction radial shortening also contributed predictive information (R squared = 25%). Wrist impairment was moderately correlated with patient reported pain and disability (r = 0.50). Both impairment and disability measures are required to fully describe outcomes. Further work is required to delineate additional factors that contribute to outcome.

Polypropylene braid augmented and nonaugmented intraarticular anterior cruciate ligament reconstruction

The purpose of this clinical retrospective study is to determine whether a polypropylene braid (PB) used to augment an intraarticular autograft to reconstruct the anterior cruciate ligament (ACL) is safe and to deter mine whether the PB improves the efficacy of the procedure. A simultaneous review was performed of patients who had undergone an intraarticular ACL reconstruc tion using an autograft composed of the central quad riceps tendon, prepatellar periosteum, and patellar ten don left attached distally to the tibial tubercle and of patients who had undergone the same procedure with PB augmentation of the autograft. Preoperatively, all patients had chronic ACL insufficiency and were expe riencing symptomatic giving way. A subjective questionnaire and a physician exami nation (JHR) were completed on each patient. Objective laxity and functional testing, including KT 1000 arthro meter measurement, Cybex isokinetic strength analy sis, and one leg horizontal hop for distance, were performed. Six radiographs of each operated knee were obtained. Results were statistically analyzed. Thirty-eight of 43 (88%) nonaugmented procedures performed were reviewed, with a mean followup of 64 months. Forty-five of 48 (94%) PB augmented recon structions with a minimum followup of 42 months (max imum 57 months, mean 50 months), were reviewed. On objective laxity and function testing, the PB aug mented patients had better results than the nonaug mented patients. On subjective questioning, physicians examination, and radiographic analysis, the PB aug mented results were significantly better. There were 12 (32%) knees with recurrent symptomatic giving way in the nonaugmented group and 5 (11 %) in the PB aug mented group. Chrondromalacia patellae and arthrofi brosis were seen in both groups. No adverse reaction to the PB was seen. We conclude that the PB is safe and that PB aug mentation improves the efficacy of the intraarticular autograft to reconstruct the ACL.

Evaluation of the triangular fibrocartilage complex tears by arthroscopy, arthrography, and magnetic resonance imaging

Arthroscopic findings in 11 patients with chronic ulnar painful wrist were compared both with arthrographic and magnetic resonance (MR) imaging results to evaluate the accuracy of the former procedure in the detection of triangular fibrocartilage complex (TFCC) lesions. MR imaging and arthrography investigations appeared to be sensitive modalities when compared with arthroscopic findings in TFCC lesions (specificity 100%; sensitivity 82 and 80%). MR imaging can be advantageously employed in the screening of patients suspected of having a TFCC tear, eliminating the necessity of an arthrographic examination. However, MR imaging could not define the exact site of the tear within the degenerate TFCC or detect lesions of the articular cartilage. Arthroscopy offers sure evidence of the site of TFCC lesion and more information about the intraarticular associated causes of chronic ulnar wrist pain such as chondromalacia and synovitis. An added benefit is that many of the pathologies seen can be treated using arthroscopic surgical techniques.

Measurement of the scaphoid humpback deformity using longitudinal computed tomography: Intra- and interobserver variability using various measurement techniques

The intra- and interobserver variability of 3 techniques for measuring the humpback deformity of 37 scaphoids using longitudinal computed tomography was assessed. The 3 measuring techniques were the lateral intrascaphoid angle, the dorsal cortical angle, and the height-to-length ratio. The intraobserver reliability of the intrascaphoid angle was poor; the dorsal cortical angle was moderate to excellent, and the height-to-length ratio was excellent. The interobserver reliability of the intrascaphoid angle was poor to moderate, the dorsal cortical angle was moderate to excellent, and the height-to-length ratio was moderate to excellent. For all 3 observers, the intra- and interobserver reliability was the best for the height-to-length ratio and worst for the intrascaphoid angle. The height-to-length ratio is the most reproducible method of assessing the humpback deformity. Clinical correlation is required to establish whether the height-to-length ratio will be of value in predicting the outcome of fractures of the scaphoid.

The results of replantation after amputation of a single finger.

We reviewed fifty-nine consecutive cases of patients who had replantation of a single finger (excluding the thumb) after traumatic amputation, with an average follow-up of fifty-three months. Fifty-one (86 per cent) of the replanted fingers survived. Survival was found to be affected by the age of the patient, the number of vessels that were anastomosed, and the replantation experience of the surgeons. The survival rate was not affected by the gender of the patient, the mechanism of injury, or which finger was amputated. As compared with survival only, the functional results were most dependent on the level of amputation. The proximal interphalangeal joint in amputated fingers that were replanted distal to the insertion of the flexor superficialis tendon had an average range of motion of 82 degrees after replantation, while those amputated proximal to the insertion had an average range of motion of only 35 degrees after replantation. The average operating time was six hours and ten minutes, and the average time until the patient returned to work was 2.3 months. Based on this experience, it is our opinion that replantation of a single finger that was amputated distal to the insertion of the flexor superficialis tendon is justified, but that replantation of a single finger that was amputated proximal to this insertion is seldom indicated.

Intratester and Intertester Reliability of Goniometric Measurement of Passive Lateral Shoulder Rotation

Measurement of lateral rotation range of motion (ROM) is frequently performed during shoulder evaluation. The purpose of this study was to determine the intratester and intertester reliability of goniometric measurement of passive lateral rotation ROM of the shoulder. Two experienced PTs performed the testing in a randomized block design. They were blinded to all clinical information and to their goniometric readings. Passive lateral rotation ROM of the shoulder was assessed in 34 patients with a variety of shoulder pathologies. Patients were placed in the supine position with the arm abducted approximately 20 degrees to 30 degrees. A standard goniometer, placed along the joint axis by the therapist, was red by an independent assistant. Intraclass correlation coefficients (ICCs) and their associated 95% confidence intervals were calculated. Intratherapist ICCs (0.88 and 0.93) and intertherapist ICCs (0.85 and 0.80) were high. These findings suggest that reliable measures of passive lateral rotation ROM of the shoulder can be obtained from patients with shoulder pathology using standard goniometry and by placing the patient in a supine position.