Susan Peters

Reverse shoulder arthroplasty for the treatment of three-part and four-part proximal humeral fractures in the elderly

BACKGROUND The purpose of this study was to review the survivorship, radiologic and clinical outcomes of reverse shoulder arthroplasty (RSA) used for the treatment of 3-part and 4-part proximal humeral fractures in the elderly. METHODS Between 2003 and 2009, 29 shoulders in 28 elderly patients (87% female) with a 3-part or 4-part fractures were managed with RSA in Brisbane, Australia. Clinical and radiologic outcomes of this continuous cohort were retrospectively reviewed at an average follow-up of 54.9 months. Average age at surgery was 79 years. Survivorship and radiologic outcome assessment for all patients was undertaken. Seven patients died, and 1 was unavailable for clinical review, leaving 21 shoulders in 20 patients available for clinical review. RESULTS There were no revisions of the reverse prosthesis. Mean average pain was 2.19 of 100 (standard deviation [SD], 6.97). Mean American Shoulder and Elbow Surgeons score was 89.3 (SD, 13.65). Mean normalized Constant score was 88.03 (SD, 11.24). Grade 1 scapular notching was observed radiologically in 4 shoulders. A scapular spur was observed in 7 shoulders. Class 1 heterotopic ossification was seen in 4 shoulders. Nonprogressive lucent lines were seen in 2 shoulders. Nonprogressive radiolucency was observed around the superior screw in 3 shoulders. No loosening of the glenoid baseplate or of the humeral component was observed. There was 1 complication of an axillary nerve palsy, which spontaneously resolved by 12 months after surgery. CONCLUSION RSA using the shoulder technique described in this series provides good clinical and radiologic outcomes in elderly patients with 3-part and 4-part fractures.

Dynamic Splinting for the Stiff Hand after Trauma: Predictors of Contracture Resolution

STUDY DESIGN Prospective cohort. INTRODUCTION Many variables are believed to influence the success of dynamic splinting, yet their relationship with contracture resolution is unclear. PURPOSE OF THE STUDY To identify the predictors of outcome with dynamic splinting of the stiff hand after trauma. METHODS Forty-six participants (56 joints) completed eight weeks of dynamic splinting, and the relationship between 13 clinical variables and outcome was explored. RESULTS Improvement in passive range of motion, active range of motion (AROM), and torque range of motion averaged 21.8°, 20.0°, and 13.0°, respectively (average daily total end range time, 7.96 hours). Significant predictors included joint stiffness (modified Weeks Test), time since injury, diagnosis, and deficit (flexion/extension). For every degree change in ROM on the modified Weeks Test, AROM improved 1.09° (standard error, 0.2). Test-retest reliability of the modified Weeks Test was high (intraclass correlation coefficient [2, 1]=0.78). CONCLUSIONS Better progress with dynamic splinting may be expected in joints with less pretreatment stiffness, shorter time since injury (<12 weeks), and in flexion rather than extension deficits. Further research is needed to determine the accuracy with which the modified Weeks Test may predict contracture resolution. LEVEL OF EVIDENCE 2b.

Knowledge, skills and professional behaviours required by occupational therapist and physiotherapist beginning practitioners in work-related practice: A systematic review

BACKGROUND/AIM Occupational therapists and physiotherapists have established roles in work-related practice. However, there is limited information about the attributes required by these professions for competent practice in this field. The aim of this systematic review was to evaluate the research literature to determine the knowledge, skills and professional behaviours required by occupational therapists and physiotherapists, including new graduates, in work-related practice. METHODS A systematic search was conducted of standard databases using keywords and phrases. All types of studies and reports were included from empirical research to descriptive reports. Included literature was appraised by standard critical appraisal tools by two reviewers. Words, phrases or themes related to the attributes required for work practice were manually extracted and a meta-synthesis conducted. RESULTS Seven observational studies, six professional practice guidelines, one book chapter, one journal editorial and seven opinion pieces met the inclusion criteria. Observational studies and descriptive reports were low on the evidence hierarchy. Meta-synthesis determined that key attributes required by occupational therapists and physiotherapists in work-related practice were knowledge of injury prevention and management, skills in communication, and professional behaviours of self-reflection and evaluation. CONCLUSION Findings from this systematic review provided credible evidence about attributes required by occupational therapists and physiotherapists but not including new graduates, in work-related practice. However, due to low evidence levels findings will need to be applied with caution. More rigorous research is needed to evaluate occupational therapy and physiotherapy workplace interventions to guide practice and to assist occupational therapists and physiotherapists promote the effectiveness of their services.

Randomized controlled trial of daily total end range time (TERT) for Capener splinting of the stiff proximal interphalangeal joint.

OBJECTIVE Capener splinting is a common treatment for extension deficit of the proximal interphalangeal (PIP) joint. This study compared the effect of daily splint total end range time (TERT) of 6-12 hr versus 12-16 hr. METHOD Twenty-two participants with extension deficits of the PIP joint were randomly allocated to a daily TERT of 6-12 hr or 12-16 hr. Progress after 8 wk of splinting was evaluated. RESULTS No significant difference was found in change in extension range of motion (ROM) between groups (active ROM, F[4, 17] = 2.19, p = .13; passive ROM, F[4, 17] = 0.95, p = .46; torque ROM, F[4, 17] = 1.49, p = .26). Considerable crossover between groups resulted in a similar average daily TERT (9.5 hr for the 6-12 hr group vs. 11.5 hr for the 12-16 hr group). CONCLUSION Further research with a larger sample is needed to determine whether longer daily TERT is beneficial. Our results suggest, however, that most patients find it difficult to wear splints >12 hr/day.

Defining Residual Radial Translation of Distal Radius Fractures: A Potential Cause of Distal Radioulnar Joint Instability

BACKGROUND Instability of the distal radioulnar joint (DRUJ) is a complication that can occur following distal radius fracture or malunion. We have observed that residual radial translation of the distal radius, relative to the radial shaft, may be a causal factor of DRUJ instability, even once the traditional radiographic parameters (volar tilt, radial inclination, and ulnar variance) have been restored. Residual radial translation of the distal fragment may cause detensioning of the distal interosseous membrane (IOM) and pronator quadratus with poor apposition between the ulnar head and sigmoid notch. This may potentially lead to persistent instability of the ulnar head following internal fixation. Residual radial translation deformity is at risk of being overlooked by the wrist surgeon as there is no existing radiographic parameter that accurately measures this deformity. PATIENTS AND METHODS In this study, 100 normal wrist radiographs were reviewed by three fellowship-trained orthopedic surgeons to develop a simple and reproducible technique to measure radial translation. RESULTS Utilizing the method described, the point of intersection between the ulnar cortex of the shaft of the radius and the lunate left a mean average of 45.48% (range 25–73.68%) of the lunate remaining on the radial side. In the majority of cases more of the lunate resided ulnar to this line. High levels of agreement with inter-rater (intraclass coefficients = 0.967) and intra-rater (intraclass coefficients = 0.79) reliability was observed. CONCLUSIONS The results of this study can be used to define a normal standard against which residual radial translation can be measured to assess the reduction of distal radius fractures. This new parameter aids in the development of surgical techniques to correct residual radial translation deformity. In addition, awareness and correction of this potential malreduction at the time of surgery may decrease the need for other procedures on the ulnar side of the wrist to improve DRUJ stability, such as ulnar styloid fixation, TFCC repair, or ligamentous grafting [corrected].

Prognostic factors for return-to-work following surgery for carpal tunnel syndrome: a systematic review

Background Carpal tunnel syndrome (CTS) is a common problem, that can be effectively managed by surgery. Screening for prognostic factors is important to identify workers who are at a greater risk of a poor work outcome in order to implement tailored interventions to facilitate their return-to-work. Objective To synthesize the best available evidence on the association of preoperative prognostic factors with work-related outcomes in people who have undergone carpal tunnel surgery. Inclusion criteria Types of participants Participants included those who were employed at the time of surgery, underwent carpal tunnel surgery and planned to return-to-work. Outcomes The primary outcome was return-to-work. Types of studies Quantitative studies investigating at least one prognostic factor for a work-related outcome in studies of workers who had carpal tunnel surgery were considered. Search strategy Eleven electronic databases were searched from their respective inception date up to July 2015. A total of 3893 publications were reviewed. Methodological quality The quality of the included studies was assessed by two reviewers using a modified version of an appraisal tool (Joanna Briggs Institute Meta-analysis of Statistical Assessment and Review Instrument [JBI-MAStARI]). The following criteria were evaluated: study population representativeness, clearly defined prognostic factors and outcomes, potential confounding variables and appropriate statistical analysis. Data extraction Data extraction was performed using a modified version of the standardized extraction tool from JBI-MAStARI. Data synthesis Statistical pooling was not possible. Findings are presented in tables and narrative format. Results Eleven studies (13 publications) investigating 93 prognostic factors for delayed return-to-work or prolonged work disability outcomes and 27 prognostic factors for work role functioning in 4187 participants were identified. Prognostic factors associated with workers’ increased likelihood of an earlier return-to-work in a moderate-to-high-quality study included worker expected or desired fewer days off work, occupation, lower pain anxiety and if CTS had not altered their work role. Prognostic factors for a poorer work-related outcome included older age, lower household income, greater upper extremity functional limitation, greater than two musculoskeletal pain sites, lower recovery expectations, worse mental health status, job accommodation availability, high job strain, high job demands with high job control, poor co-worker relationships, poor baseline work role functioning, less-supportive workplace policies, preoperative work absence due to CTS or work disability of any cause, workers’ compensation status, attorney involvement, and post-diagnosis surgical wait time. Conclusion For workers who have had carpal tunnel surgery, there are a number of factors which may be modified in order to improve return-to-work times.

Interpreting systematic reviews: Looking beyond the all too familiar conclusion

Due to the large volume of research, therapists often turn to systematic reviews for treatment directions. We expect that these comprehensive syntheses of the literature will provide unambiguous recommendations for the implementation of a particular intervention. However, the conclusions of systematic reviews often leave us feeling unsatisfied because of the absence of clear recommendations due to the paucity of high quality evidence. The aim of this editorial is to provide some guidance for therapists and researchers when faced with a systematic review with inconclusive recommendations. We will use our recent Cochrane systematic review1 as an example. Our systematic review examined the effectiveness of rehabilitation interventions following carpal tunnel syndrome (CTS) surgery.1We included 23 clinical trials with a total of 1445 participants and concluded that: ‘There is limited and, in general, low quality evidence for the benefit of the reviewed interventions following CTS surgery.’1 By considering a number of key elements, a systematic review can inform clinicians and researchers beyond the conclusion of the review, regardless of whether the recommendation is definite or more uncertain, as was the case in our review (Table 1). First of all, we need to understand what a systematic review is and how it is conducted, as the methodology may influence the findings. Secondly, we need to carefully scrutinize the included studies by specifically examining the participants, interventions and outcomes.

Expert consensus on facilitators and barriers to return-to-work following surgery for non-traumatic upper extremity conditions: a Delphi study:

This Delphi study aimed to reach consensus on important facilitators and barriers for return-to-work following surgery for non-traumatic upper extremity conditions. In Round 1, experts (n = 42) listed 134 factors, which were appraised in Rounds 2 and 3. Consensus (⩾85% agreement) was achieved for 13 facilitators (high motivation to return-to-work; high self-efficacy for return-to-work and recovery; availability of modified/alternative duties; flexible return-to-work arrangements; positive coping skills; limited heavy work exertion; supportive return-to-work policies; supportive supervisor/management; no catastrophic thinking; no fear avoidance to return-to-work; no fear avoidance to pain/activity; return to meaningful work duties; high job satisfaction) and six barriers (mood disorder diagnosis; pain/symptoms at more than one musculoskeletal site; heavy upper extremity exertions at work; lack of flexible return-to-work arrangements; lack of support from supervisor/management; high level of pain catastrophizing). Future prognostic studies are required to validate these biopsychosocial factors to further improve return-to-work outcomes. Level of evidence: V

The influence of cartilage thickness at the sigmoid notch on inclination at the distal radioulnar joint

Aims The aims of this study were: firstly, to investigate the influence of the thickness of cartilage at the sigmoid notch on the inclination of the distal radioulnar joint (DRUJ), and secondly, to compare the sensitivity and specificity of MRI with plain radiographs for the assessment of the inclination of the articular surface of the DRUJ in the coronal plane. Patients and Methods Contemporaneous MRI images and radiographs of 100 wrists from 98 asymptomatic patients (mean age 43 years, (16 to 67); 52 male, 53%) with no history of a fracture involving the wrist or surgery to the wrist, were reviewed. The thickness of the cartilage at the sigmoid notch, inclination of the DRUJ and Tolat Type of each DRUJ were determined. Results The assessment using MRI scans and cortical bone correlated well with radiographs, with a kappa value of 0.83. The mean difference between the inclination using the cortex and cartilage on MRI scans was 12°, leading to a change of Tolat type of inclination in 66% of wrists. No reverse oblique (Type 3) inclinations were found when using the cartilage to assess inclination. Conclusion These data revealed that when measuring the inclination of the DRUJ using cartilage, reverse oblique inclinations might not exist. The data suggest that performing an ulna shortening osteotomy might be reasonable even in distal radioulnar joints where the plain radiographic appearance suggests an unfavourable reverse oblique inclination in the coronal plane. We recommend using MRI to validate radiographs in those that appear to be reverse oblique (Tolat Type 3), as the true inclination might be different, thereby removing one possible contraindication to ulnar shortening.

Measuring thumb range of motion in first carpometacarpal joint arthritis: The inter-rater reliability of the Kapandji Index versus goniometry

Introduction Goniometric measurement of thumb range of motion is often used as an outcome measure in assessing patients with first carpometacarpal osteoarthritis. Despite common use and demonstrated construct validity, the reliability of this technique has not been well established. The Kapandji Index is an alternate functional measure of thumb motion suitable for use with this client group. The purpose of this study was to examine the inter-rater reliability of the goniometric measures for thumb joint range of motion compared to the Kapandji Index in patients with first carpometacarpal joint osteoarthritis. Methods Two independent assessors, who were blind to each other’s measurements, measured thumb range of motion in 33 patients (54 thumbs). All participants were undergoing treatment for carpometacarpal joint osteoarthritis. Active range of motion was measured with a goniometer for all the thumb joints using a standardised measurement protocol. The Kapandji Index score was recorded. Relative reliability was assessed by using the intraclass correlation coefficient. Absolute reliability was also calculated by determining the standard error of measurement (SEM68) and the minimal detectable difference (MDD90). Results Inter-rater reliability for the goniometer was highly variable ranging from poor to excellent (intraclass correlation coefficient 0.128–0.860). The SEM68 ranged from 9° to 13°, and the resulting MDD90 varied from 21° to 31° for the different thumb joints. The Kapandji Index had excellent inter-rater reliability among the different raters (intraclass correlation coefficient 0.772–0.917). Conclusions Measurement of goniometric active range of motion of the thumb may have limited utility as a measure of clinical effectiveness for patients with carpometacarpal joint osteoarthritis. However, the Kapandji Index is a reliable measure of functional range of motion.