Ruby Grewal

Comminuted radial head fractures treated with a modular metallic radial head arthroplasty : Study of outcomes

BACKGROUND Comminuted fractures of the radial head are challenging to treat with open reduction and internal fixation. Radial head arthroplasty is an alternative treatment with results that compare favorably with those reported after open reduction and internal fixation of similar fractures. The purpose of this study was to evaluate the two-year outcomes and the rate of recovery of a closely followed cohort of patients in whom an unreconstructible radial head fracture had been treated with a modular metallic prosthesis. METHODS Twenty-six patients (seventeen female and nine male; mean age, fifty-four years) with an unreconstructible comminuted radial head fracture and associated elbow injuries were treated with a modular metallic radial head arthroplasty. Patients who had presented more than four weeks following the injury or had had the radial head arthroplasty as a second-stage or salvage procedure were excluded. Of the twenty-six patients, twenty-two had an associated elbow dislocation, and thirteen of them also had an associated fracture of the coronoid process. Patients were prospectively followed at three, six, twelve, and twenty-four months. Self-reported limb function, general health, range of motion, and isometric strength were assessed by an independent observer. RESULTS Following treatment of the injury, significant decreases in self-reported and measured impairments were noted over time, with the majority of the recovery occurring by six months and little further recovery noted between six and twenty-four months. There were slight-to-moderate deficits in the range of motion and strength compared with the values on the contralateral, unaffected side. Patient satisfaction was high at three months and remained high at two years. All elbow joints remained stable, no implant required revision, and there was no evidence of overstuffing of the joint. Mild osteoarthritis was seen in five (19%) of the twenty-six patients. CONCLUSIONS An arthroplasty with a modular metallic radial head is a safe and effective option for the treatment of unreconstructible radial head fractures associated with other elbow injuries. Recovery primarily occurs by six months, with minimal additional improvements over the next eighteen months.

Determination of Correct Implant Size in Radial Head Arthroplasty to Avoid Overlengthening

BACKGROUND Insertion of a radial head implant that results in radial overlengthening has been associated with altered elbow kinematics, increased radiocapitellar joint forces, capitellar erosions, early-onset arthritis, and loss of elbow flexion. The purpose of this study was to identify clinical and radiographic features that may be used to diagnose overlengthening of the radius intraoperatively and on postoperative radiographs. METHODS Radial head implants of varying thicknesses were inserted into seven cadaver specimens, which were then assessed clinically and radiographically. Eight stages were examined: the intact specimen (stage 1); repair of the lateral collateral ligament (stage 2); radial head resection with repair of the lateral collateral ligament (stage 3); insertion of an implant of the correct thickness (stage 4); and insertion of an implant that resulted in radial overlengthening of 2 mm (stage 5), 4 mm (stage 6), 6 mm (stage 7), or 8 mm (stage 8). The specimens were tested with and without muscle loading to simulate resting muscle tone and surgical paralysis, respectively. At each stage, radiographs were made to measure the ulnohumeral joint space and the lateral ulnohumeral joint was visually assessed. RESULTS We identified no difference, with regard to medial ulnohumeral joint incongruity as seen radiographically, among stages 1 through 6 during the tests with muscle loading. A significant difference in medial ulnohumeral joint incongruity was found in stages 7 (p = 0.003) and 8 (p < 0.001). The clinical (visually assessed) lateral ulnohumeral joint space gap was negligible in stages 1 through 4 but increased significantly at all stages involving overlengthening (gross gap, 0.9 mm with 2 mm of overlengthening [p = 0.005], 2.3 mm with 4 mm of overlengthening [p < 0.001], 3.4 mm with 6 mm [p < 0.001], and 4.7 mm with 8 mm [p < 0.001]). CONCLUSIONS Incongruity of the medial ulnohumeral joint becomes apparent radiographically only after overlengthening of the radius by >or=6 mm. Intraoperative visualization of a gap in the lateral ulnohumeral joint is a reliable indicator of overlengthening following the insertion of a radial head prosthesis.

Open Reduction Internal Fixation Versus Percutaneous Pinning With External Fixation of Distal Radius Fractures: A Prospective, Randomized Clinical Trial

PURPOSE The purpose of this randomized clinical trial was to investigate the functional outcomes of the surgical treatment of distal radius fractures, comparing treatment by external fixation and percutaneous pinning to open reduction and internal fixation (ORIF) using a plate. METHODS We randomized 53 patients with distal radius fractures that failed closed reduction and casting to ORIF (n = 27) or external fixation (n = 26). For pragmatic reasons, the choice of ORIF was left to the surgeons discretion (early recruitment, dorsal plates [n = 9]; later recruitment, volar locked plates [n = 18]). Outcomes were measured before surgery, at 6 weeks, and at 3, 6, and 12 months and included the Patient-Rated Wrist Evaluation (PRWE); Disabilities of the Arm, Shoulder, and Hand; range of motion; grip strength; and serial radiographic analysis. Generalized linear modeling using repeated measures was used to identify differences in outcome scores between fixation types over time. Other continuous variables were analyzed using the Student t-test or one-way analysis of variance for multiple groups. RESULTS There were no differences in the demographic characteristics or fracture severity between groups. Based on generalized linear modeling, on average, the ORIF group scored 11 points lower on the PRWE across all time points compared to the external fixation group. The PRWE detected higher pain and disability with external fixation before surgery, at 6 weeks, and at 3 months. Using generalized linear modeling, a post hoc subgroup analysis identified significantly better (15-point advantage) PRWE scores averaged across all time points with volar locking plates compared to both external fixation and dorsal plating. CONCLUSIONS The PRWE scores were significantly lower for patients treated with ORIF compared to those with external fixation, with the best outcomes observed with volar locking plates. These advantages were observed in the early postoperative period, and overall scores equalized at 1 year. A higher mean initial preoperative PRWE score was seen with external fixation, perhaps indicating a more severe initial injury. Given this difference, the interpretation of these results is not clear.

Effects of low power laser irradiation on bone healing in animals: a meta-analysis

PurposeThe meta-analysis was performed to identify animal research defining the effects of low power laser irradiation on biomechanical indicators of bone regeneration and the impact of dosage.MethodsWe searched five electronic databases (MEDLINE, EMBASE, PubMed, CINAHL, and Cochrane Database of Randomised Clinical Trials) for studies in the area of laser and bone healing published from 1966 to October 2008. Included studies had to investigate fracture healing in any animal model, using any type of low power laser irradiation, and use at least one quantitative biomechanical measures of bone strength. There were 880 abstracts related to the laser irradiation and bone issues (healing, surgery and assessment). Five studies met our inclusion criteria and were critically appraised by two raters independently using a structured tool designed for rating the quality of animal research studies. After full text review, two articles were deemed ineligible for meta-analysis because of the type of injury method and biomechanical variables used, leaving three studies for meta-analysis. Maximum bone tolerance force before the point of fracture during the biomechanical test, 4 weeks after bone deficiency was our main biomechanical bone properties for the Meta analysis.ResultsStudies indicate that low power laser irradiation can enhance biomechanical properties of bone during fracture healing in animal models. Maximum bone tolerance was statistically improved following low level laser irradiation (average random effect size 0.726, 95% CI 0.08 - 1.37, p 0.028). While conclusions are limited by the low number of studies, there is concordance across limited evidence that laser improves the strength of bone tissue during the healing process in animal models.

Effects of low-intensity pulsed ultrasound therapy on fracture healing: a systematic review and meta-analysis.

Objective This systematic review and meta-analysis was performed to identify the clinical trials relevant to the effects of low-intensity pulsed ultrasound (LIPUS) on bone regeneration. Design We searched five international electronic databases including MEDLINE (1966–June 2010), and PubMed, EMBase, Cumulative Index to Nursing and Allied Health, and Cochrane (1980–June 2010) to identify the relevant studies on the effects of LIPUS on bone healing. The inclusion criteria were human clinical trial, all types of bones, fractures, and outcome measurements, LIPUS application, and English language. Overall, 260 potentially eligible abstracts were identified, and 65 articles were retrieved in full text. Of the 65 studies, 23 met the inclusion criteria and were critically appraised by two raters independently using the PEDro quality measurement method. The results of all eligible studies were categorized in three groups: fresh fractures, delayed or nonunions, and distraction osteogenesis. Seven trials among fresh fracture trials were identified eligible for meta-analysis because of the varieties of outcome measurements and clinical situations. The time of the third cortical bridging (increase in density or size of initial periosteal reaction) in radiographic healing was our common criteria for the meta-analysis. Results The time of third cortical bridging was statistically earlier following LIPUS therapy in fresh fractures (mean random effect, 2.263; 95% CI, 0.183–4.343, P = 0.033). Conclusions LIPUS can stimulate radiographic bone healing in fresh fractures. Although there is weak evidence that LIPUS also supports radiographic healing in delayed unions and nonunions, it was not possible to pool the data because of a paucity of sufficient studies with similar outcome measures.

Effectiveness of Different Methods of Resistance Exercises in Lateral Epicondylosis—A Systematic Review

STUDY DESIGN Systematic Review. INTRODUCTION Lateral epicondylosis (LE) is relatively common with an annual incidence in the general population of 1% to 3%. Systematic reviews have identified exercise is effective, but have not established specific exercise parameters. PURPOSE The purpose of this systematic review was to synthesize the quality and content of clinical research addressing type and dosage of resistance exercises in lateral epicondylosis. METHODS Computerized bibliographic databases (1990-2010) were searched using relevant keywords; bibliographies of included papers were hand searched. Of 594 screened abstracts, 11 articles (12 studies) met inclusion criteria. Articles were randomly allocated to pairs of reviewers who independently verified data extraction and appraised the full text, using a structured critical appraisal tool with 24 items. Data extraction was limited by a lack of consistent reporting of elements of exercise dosage. RESULTS The mean quality rating of the studies was 72%, with 2 papers exceeding 75% quality. Of the 12 studies, 9 addressed the effects of isotonic (eccentric/concentric) exercises, 2 studied the effect of isometric and one studied isokinetic exercises. The exercise programs ranged over a period of 4 to 52 weeks. Exercises were prescribed 1 to 6 times per day, with an average duration of 15 minutes per session, and average of 15 repetitions (range: 3 to 50), with 1 to 4 sets per session. CONCLUSION All the studies reported that resistance exercise resulted in substantial improvement in pain and grip strength; eccentric exercise was most studied. Strengthening using resistance exercises is effective in reducing pain and improving function for lateral epicondylosis but optimal dosing is not defined. LEVEL OF EVIDENCE 2a.

Validity and responsiveness of presenteeism scales in chronic work-related upper-extremity disorders.

Background The Work Limitations Questionnaire-25 (WLQ-25) and the Work Instability Scale for Rheumatoid Arthritis (RA-WIS) have been used to measure at-work disability related to musculoskeletal disorders. However, a recent systematic review has shown that important psychometric properties still needed to be evaluated. Objective The purpose of this study was to establish the validity and responsiveness of the WLQ-25 and RA-WIS in people with chronic work-related upper-extremity disorders. Design Two-hundred six participants with chronic upper-extremity disorders who attended a specialty clinic operated by the Workplace Safety & Insurance Board of Ontario were evaluated at their initial visit and 6 months later. Methods Questionnaires completed at each evaluation were: the WLQ-25, the RA-WIS, the QuickDASH, the pain subscale of the Shoulder Pain and Disability Questionnaire, and the Chronic Pain Grade Questionnaire. At the 6-month evaluation, participants completed a global rating of change question. Known-group and construct convergent validity were assessed using analysis of variance and Pearson correlations, and standardized response means (SRMs) were used to assess responsiveness. Clinically important differences (CIDs) also were determined. Results The WLQ-25 and RA-WIS had low to moderate correlations with pain and disability scales (.28<r<.62) and discriminated among different functional categories (P<.001). For improved participants, the WLQ-25 (SRM=0.65 for summed score, SRM=0.63 for index score) and the RA-WIS (SRM=0.66) demonstrated moderate responsiveness. The CID for improvement was estimated to be 13/100 points for the WLQ-25 summed score, 5/28.6 points for the WLQ-25 index score, and 4/23 points for the RA-WIS. Limitations The external criterion of change was specific to change in upper-extremity condition and not to change in work ability or productivity. Conclusions The WLQ-25 and RA-WIS provide different information from that provided by pain and disability measures. They discriminate among functional outcome subgroups and detect improvement over time in people with chronic work-related upper-extremity disorders.

Prevalence of Triangular Fibrocartilage Complex Abnormalities on MRI Scans of Asymptomatic Wrists

PURPOSE Magnetic resonance imaging (MRI) of the wrist is increasingly used in the diagnosis of ulnar-sided wrist pain; however, its efficacy in this setting still needs clarification. The purposes of this study were to investigate the prevalence of abnormal MRI findings in the triangular fibrocartilage complex (TFCC) in asymptomatic volunteers and to provide the clinician with comparative data when interpreting MRI results. METHODS A total of 103 asymptomatic volunteers underwent imaging of the wrist using a 1.9-T MR scanner and a send-receive birdcage quadrature coil. The images were evaluated by 3 independent interpreters, 2 musculoskeletal radiologists, and 1 orthopedic hand surgeon. We noted details regarding the TFCC morphology and the presence, characteristics, and location of any TFCC abnormality. RESULTS The TFCC was considered abnormal in 39 wrists. The scans were abnormal in 31 subjects younger than 50 years of age, in 5 subjects 50 to 59 years of age, and in all subjects older than 60 years of age (3 subjects). We diagnosed a complete tear of the TFCC in 23 wrists. An increase in age was correlated with an abnormal TFCC (r(pb) = 0.23; P = .016). CONCLUSIONS The prevalence of incidental TFCC findings in MRI scans of asymptomatic subjects is high. The presence of an abnormal TFCC on MRI may be of questionable clinical meaning, because there is a high incidence of TFCC abnormalities in asymptomatic subjects, particularly those over the age of 50. Imaging results must be viewed in the context of the clinical history and physical examination. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic III.

Radial Head Fractures Treated with Modular Metallic Radial Head Replacement: Outcomes at a Mean Follow-up of Eight Years.

BACKGROUND Radial head arthroplasty is commonly used to treat acute unreconstructible radial head fractures. The purpose of this study was to report on the clinical and radiographic outcomes at a minimum follow-up of five years after radial head arthroplasty with a modular metallic implant for the treatment of acute radial head fractures. METHODS The cases of fifty-five patients with unreconstructible radial head fractures treated acutely with a smooth-stemmed modular metallic radial head implant were retrospectively reviewed. A wide variety of injuries, which ranged from isolated radial head fractures to so-called terrible triad injuries, were included. All patients returned for an interview, physical examination, and radiographic evaluation at a mean of eight years (range, five to fourteen years) postoperatively. Elbow and forearm motion, elbow strength, and grip strength were measured. Radiographs were evaluated, and validated patient-rated outcome questionnaires were completed. A longitudinal subgroup analysis was performed for thirty-three patients who were previously evaluated at two years postoperatively. RESULTS At a mean of 8.2 ± 2.9 years, the mean arc of flexion (and standard deviation) of the affected elbow was 11° ± 14° to 137° ± 15°. Elbow strength and motion were significantly diminished compared with the unaffected elbow (p < 0.05). The mean Mayo Elbow Performance Index (MEPI) was 91 ± 13 points. Twenty-five patients (45%) had stem lucencies; twenty-one (38%), ulnohumeral arthritis; and twenty (36%), heterotopic ossification, including one with radioulnar synostosis. Two patients underwent secondary elbow surgery, but no patient required implant removal or revision. In the subgroup evaluated longitudinally, there was a significant improvement in MEPI scores from the two-year to the eight-year follow-up (p = 0.012), with no loss of motion or strength (p > 0.05). CONCLUSIONS The mid-term outcomes of radial head arthroplasty with a smooth-stemmed modular metallic prosthesis are comparable with previously reported short-term outcomes, with no evidence of functional deterioration. Radial head arthroplasty with a smooth-stemmed metallic modular implant is a good treatment option for patients with acute unreconstructible radial head fractures, and sustained clinical outcomes may be expected beyond five years of follow-up. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Determination of correct implant size in radial head arthroplasty to avoid overlengthening: surgical technique.

BACKGROUND Insertion of a radial head implant that results in radial overlengthening has been associated with altered elbow kinematics, increased radiocapitellar joint forces, capitellar erosions, early-onset arthritis, and loss of elbow flexion. The purpose of this study was to identify clinical and radiographic features that may be used to diagnose overlengthening of the radius intraoperatively and on postoperative radiographs. METHODS Radial head implants of varying thicknesses were inserted into seven cadaver specimens, which were then assessed clinically and radiographically. Eight stages were examined: the intact specimen (stage 1); repair of the lateral collateral ligament (stage 2); radial head resection with repair of the lateral collateral ligament (stage 3); insertion of an implant of the correct thickness (stage 4); and insertion of an implant that resulted in radial overlengthening of 2 mm (stage 5), 4 mm (stage 6), 6 mm (stage 7), or 8 mm (stage 8). The specimens were tested with and without muscle loading to simulate resting muscle tone and surgical paralysis, respectively. At each stage, radiographs were made to measure the ulnohumeral joint space and the lateral ulnohumeral joint was visually assessed. RESULTS We identified no difference, with regard to medial ulnohumeral joint incongruity as seen radiographically, among stages 1 through 6 during the tests with muscle loading. A significant difference in medial ulnohumeral joint incongruity was found in stages 7 (p = 0.003) and 8 (p < 0.001). The clinical (visually assessed) lateral ulnohumeral joint space gap was negligible in stages 1 through 4 but increased significantly at all stages involving overlengthening (gross gap, 0.9 mm with 2 mm of erlengthening [p = 0.005], 2.3 mm with 4 mm of overlengthening [p < 0.001], 3.4 mm with 6 mm [p < 0.001], and 4.7 mm with 8 mm [p < 0.001]). CONCLUSIONS Incongruity of the medial ulnohumeral joint becomes apparent radiographically only after overlengthening of the radius by ≥6 mm. Intraoperative visualization of a gap in the lateral ulnohumeral joint is a reliable indicator of overlengthening following the insertion of a radial head prosthesis.