Teun Teunis

A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age.

UNLABELLED Hypothesis and background: Abnormalities of the rotator cuff are more common with age, but the exact prevalence of abnormalities and the extent to which the presence of an abnormality is associated with symptoms are topics of debate. Our aim was to review the published literature to establish the prevalence of abnormalities of the rotator cuff and to determine if the prevalence of abnormalities increases with older age in 10-year intervals. In addition, we assessed prevalence in 4 separate groups: (1) asymptomatic patients, (2) general population, (3) symptomatic patients, and (4) patients after shoulder dislocation. METHODS We searched PubMed, EMBASE, and the Cochrane Library up to February 24, 2014, and included studies reporting rotator cuff abnormalities by age. Thirty studies including 6112 shoulders met our criteria. We pooled the individual patient data and calculated proportions of patients with and without abnormalities per decade (range, younger than 20 years to 80 years and older). RESULTS Overall prevalence of abnormalities increased with age, from 9.7% (29 of 299) in patients aged 20 years and younger to 62% (166 of 268) in patients aged 80 years and older (P < .001) (odds ratio, 15; 95% confidence interval, 9.6-24; P < .001). There was a similar increasing prevalence of abnormalities regardless of symptoms or shoulder dislocation. DISCUSSION AND CONCLUSION The prevalence of rotator cuff abnormalities in asymptomatic people is high enough for degeneration of the rotator cuff to be considered a common aspect of normal human aging and to make it difficult to determine when an abnormality is new (e.g., after a dislocation) or is the cause of symptoms.

An epidemic of the use, misuse and overdose of opioids and deaths due to overdose, in the United States and Canada: is Europe next?

The United States and Canada are in the midst of an epidemic of the use, misuse and overdose of opioids, and deaths related to overdose. This is the direct result of overstatement of the benefits and understatement of the risks of using opioids by advocates and pharmaceutical companies. Massive amounts of prescription opioids entered the community and were often diverted and misused. Most other parts of the world achieve comparable pain relief using fewer opioids. The misconceptions about opioids that created this epidemic are finding their way around the world. There is particular evidence of the increased prescription of strong opioids in Europe. Opioids are addictive and dangerous. Evidence is mounting that the best pain relief is obtained through resilience. Opioids are often prescribed when treatments to increase resilience would be more effective. Cite this article: Bone Joint J 2017;99-B:856-64.

Prevalence of Triangular Fibrocartilage Complex Abnormalities Regardless of Symptoms Rise With Age: Systematic Review and Pooled Analysis

BackgroundTriangular fibrocartilage complex abnormalities seem to be more common with age, but the degree to which this is so, and the degree to which the presence of an abnormality is associated with symptoms, are topics of controversy.Questions/purposesWe wished to perform a systematic review to determine the prevalence of triangular fibrocartilage complex abnormalities, and to determine if the prevalence of abnormalities are greater with increasing age. In addition, we stratified age groups based on symptoms.MethodsWe searched MEDLINE, EMBASE, and the Cochrane Library through August 15, 2013. Studies that reported triangular fibrocartilage complex abnormalities by age were included. Fifteen studies including 977 wrists met our criteria and reported a total of 368 (38%) triangular fibrocartilage complex abnormalities. Eight studies included symptomatic patients; the remainder studied cadavers (six studies) or asymptomatic volunteers (one study). Patients were divided into four age groups (< 30, 30–49, 50–69, and 70 years and older) for pooled analysis, comparing the proportions of patients with and without abnormalities between groups using chi-square analysis. We also evaluated the proportions after stratifying each age group by symptoms.ResultsOverall, the prevalence of triangular fibrocartilage complex abnormalities increased with age, from 27% (80/301) in patients younger than 30 years to 49% (130/265) in patients 70 years and older (p < 0.001), odds ratio (OR), 2.7, 95% CI, 1.9–3.8 (p < 0.001). In asymptomatic patients, triangular fibrocartilage complex prevalence abnormality increased from 15% (24/159) to 49% (129/263) in the same age groups (p < 0.001), OR, 5.4, 95% CI, 3.3–8.9 (p < 0.001). For symptomatic patients prevalence ranged from 39% (56/142) to 70% (14/20) in patients between 50 and 69 years old (p < 0.034), OR, 3.6, 95% CI, 1.3–9.9 (p < 0.014).ConclusionTriangular fibrocartilage complex abnormalities are common in symptomatic and asymptomatic wrists, and they are increasingly common with age. As in all situations where abnormalities are so common that they may be incidental, we need (1) a reliable and accurate method for determining whether these abnormalities are the cause of symptoms; and (2) evidence that treatment of these abnormalities improves symptoms better than placebo.Level of EvidenceLevel III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Validation of the Spine Oncology Study Group-Outcomes Questionnaire to assess quality of life in patients with metastatic spine disease.

BACKGROUND CONTEXT General questionnaires are often used to assess quality of life in patients with spine metastases, although a disease-specific survey did not exist until recently. The Spine Oncology Study Group has developed an outcomes questionnaire (SOSG-OQ) to measure quality of life in these patients. However, a scoring system was not developed, and the questionnaire was not validated in a group of patients, nor was it compared with other general quality of life questionnaires such as the EuroQol 5 Dimensions (EQ-5D) questionnaire. PURPOSE Our primary null hypothesis is that there is no association between the SOSG-OQ and EQ-5D. Our secondary null hypothesis is that there is no difference in coverage and internal consistency between the SOSG-OQ and EQ-5D. We also assess coverage, consistency, and validity of the domains within the SOSG-OQ. STUDY DESIGN/SETTING A survey study from a tertiary care spine referral center was used for this study. PATIENT SAMPLE The patient sample consisted of 82 patients with spine metastases, myeloma, or lymphoma. OUTCOME MEASURES The SOSG-OQ (27 questions, 6 domains) score ranges from 0 to 80, with a higher score indicating worse quality of life. The EQ-5D (5 questions, 5 domains) index score ranges from 0 to 1, with a higher score indicating better quality of life. METHODS The association between the SOSG-OQ and EQ-5D index score was assessed using the Spearman rank correlation. Instrument coverage and precision were assessed by determining item completion rate, median score with range, and floor and ceiling effect. Internal consistency was assessed using Cronbach alpha. Multitrait analysis and exploratory factor analysis were used to analyze properties of the individual domains in the SOSG-OQ. RESULTS The Spearman rank correlation between the SOSG-OQ and EQ-5D questionnaire was high (r=-0.83, p<.001). Internal consistency of the SOSG-OQ (0.92, 95% CI: 0.89-0.94) was higher as compared to the internal consistency of the EQ-5D (0.73, 95% CI: 0.63-0.84; p<.001). The SOSG-OQ score had no floor or ceiling effect indicating good coverage (median 30, range 3-64), whereas the EQ-5D had a ceiling effect of 10% (median 0.71, range 0.05-1). CONCLUSIONS In conclusion, our study proposes a scoring methodology-after reversing four inversely scored items-for the SOSG-OQ and shows that the questionnaire is a valid tool for the assessment of quality of life in patients with metastatic spine disease. The SOSG-OQ is superior to the EQ-5D in terms of coverage and internal consistency but consists of more questions.

Do patients prefer optional follow-up for simple upper extremity fractures: A pilot study

INTRODUCTION We aimed to evaluate the results of offering patients optional follow-up for simple upper extremity fractures. Specifically this study tested if there is a difference in (1) upper extremity disability, (2) return to work, and (3) satisfaction with delivered care at 2-6 months after enrollment between patients who choose and do not choose a return visit for an adequately aligned metacarpal, distal radius, or radial head fracture. Additionally we assessed if there was a difference in overall evaluation of the visit at enrollment between those patients and what factors were associated with returning after initially choosing not to schedule a follow-up visit. PATIENTS AND METHODS We prospectively enrolled all adult patients (n=120) with adequately aligned metacarpal fractures, non-or minimally displaced distal radius fractures, and isolated non- or minimally displaced radial head fractures of whom 82 (68%) were available at 2-6 months after enrollment. Subjects chose to have a scheduled (n=56) or optional (n=64) return visit. Subsequently, we recorded patient demographics and overall evaluation of the visit. Between two and six months after enrollment we measured QuickDASH, satisfaction with care, and current employment status. RESULTS Accounting for potential differences in baseline characteristics by multivariable analysis, return choice was not associated with QuickDASH (β regression coefficient [β] -0.53, 95% confidence interval [CI] -7.4 to 6.4, standard error [SE] 3.5, P=0.88), return to work (odds ratio [OR] -1.3, 95%CI -3.5 to 0.95, SE 1.1, P=0.26), satisfaction with care (β -0.084, 95%CI -0.51 to 0.35, SE 0.22, P=0.70), or overall evaluation of the initial visit (β 0.18, 95%CI -0.38 to 0.73, SE 0.28, P=0.53). Of the 64 people choosing optional follow-up, 11 patients returned (17%). The only factor independently associated with returning after initially not choosing to return was greater disability at enrollment (OR 1.05, 95%CI 1.0050-1.098, SE 0.024, P=0.029). CONCLUSIONS A majority of patients prefer optional follow-up for simple upper extremity fractures with a good prognosis. Hand surgeons can consider offering patients with low-risk hand fractures an optional second visit. Eliminating unnecessary visits, tests and imaging could lower the cost of care. LEVEL OF EVIDENCE Therapeutic level II.

Evaluation of radiographic fracture position 1 year after variable angle locking volar distal radius plating: a prospective multicentre case series

Treatment with a variable angle locking plate can, in theory, maintain near anatomic reduction of intra-articular distal radius fractures, but it is unknown to what extent reduction is maintained as measured by computed tomography. We assessed changes in radiographic fracture position 1 year post-operatively. We included 73 patients of whom 66 patients (90%) had radiographs available for review at 1 year post-operatively. We found a small (less than 2 mm or 2°) but statistically significant change in several measures. Accounting for inter-observer variability, this is probably within measurement error. We found no difference in change in fracture position or range of motion, grip strength or patient-reported outcome between the use of one or two distal rows of screws. Our results show that minimal changes in reduction can be expected after volar plate fixation in most patients. We recommend using only one screw row routinely, limiting costs, surgical time and the risk of misplacement of screws. Level of evidence: IV

No Difference in Adverse Events Between Surgically Treated Reduced and Unreduced Distal Radius Fractures.

Objectives: To determine if closed reduction is worthwhile for the subset of patients who choose operative treatment before attempted reduction of their distal radius fracture. We hypothesize that there are no differences in (1) adverse events and (2) subsequent surgeries between patients treated with manipulative reduction compared with those that were splinted without reduction. Design: Retrospective cohort study. Setting: Three affiliated urban hospitals in a single city in the United States. Patients/Participants: One thousand five hundred eleven consecutive adult patients who underwent open reduction and internal fixation of their distal radius fracture between January 1, 2007, and December 31, 2012, of whom 102 (7%) were not reduced before surgery. Intervention: Manipulative reduction compared with splinting without reduction. Main Outcome Measurements: Adverse events were defined as any infections, hematomas treated operatively, disproportionate finger stiffness, (transient) neuropathology after surgery, delayed carpal tunnel release, malunion, reoperation for loss of alignment, hardware removal, and tendon ruptures within 1 year after surgery. Outcome measures were grouped to determine the overall adverse event rate and subsequent surgery rate. Results: We found no difference in specific adverse events between unreduced and reduced fractures. After adjusting for possible confounding variables by logistic regression, we found no difference in overall rates of adverse events (adjusted odds ratio unreduced fractures 1.2, 95% confidence interval 0.67–2.0) and subsequent surgeries (adjusted odds ratio unreduced fractures 0.65, 95% confidence interval 0.23–1.8). Conclusions: Leaving the fracture unreduced before surgery was not associated with increased adverse events or subsequent surgeries. For patients who make an informed decision to undergo operative treatment for their closed neurovascular intact displaced distal radius fracture, manipulative reduction may not be helpful. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Inflammatory Mediators in Posttraumatic Radiocarpal Osteoarthritis

PURPOSE To identify the mediator profile in healthy, pre-osteoarthritis (OA) and end-stage OA radiocarpal joints. We hypothesized that there would be an increase in soluble mediators in posttraumatic wrist OA. METHODS We obtained radiocarpal synovial fluid samples from 3 groups of patients: healthy control (n = 12) samples were collected during wrist ganglion resection; pre-osteoarthritic (n = 16) samples, during a 3-ligament tenodesis procedure for complete scapholunate dissociation; and end-stage OA (n = 20) samples in patients with proven radiological OA changes. Using a multiplex enzyme-linked immunosorbent assay, we measured 12 mediators: interleukin (IL)-1β, tumor necrosis factor-α, oncostatin-M, interferon-γ, IL-4, IL-6, IL-7, IL-8, IL-10, IL-13, IL-1RA, and osteoprotegerin. Statistical analysis was performed using analysis of variance and Bonferroni-corrected post hoc tests. RESULTS Mediators IL-6, IL-10, and interferon-γ were increased in OA wrists compared to healthy and pre-OA samples. Tumor necrosis factor-α, oncostatin-M, osteoprotegerin, IL-8, and IL-1RA were detected but not at increased levels in OA wrists. We found no differences between healthy and pre-OA joints in all 12 mediators. Mediators IL-4, IL-7, IL-13, and IL-1β were not detected in either healthy, pre-OA or end-stage OA samples. CONCLUSIONS We identified no differences between healthy and pre-OA samples, suggesting no alteration in inflammatory status at the time of the 3-ligament tenodesis procedure. Consequently, mechanical disturbance seems to be the driving force toward OA and OA-associated inflammation in this stage of scapholunate dissociation. Increased levels of interferon-γ, IL-6, and IL-10 confirm inflammatory changes in the mechanically disturbed posttraumatic radiocarpal joint.

Outcome after fixation of metastatic proximal femoral fractures: A systematic review of 40 studies

Endoprosthetic reconstruction, intramedullary nailing, and open reduction internal fixation (ORIF) are the most commonly practiced surgical strategies for treatment of metastatic proximal femoral fractures. This review describes functional outcome, local, and systemic complications. All three surgical strategies result in reasonable function on average; however, wide ranges indicate that both poor and good functional levels are obtained. We found that the overall reoperation rate was comparable for endoprosthesis and intramedullary nailing, but was higher for ORIF. J. Surg. Oncol. 2016;114:507–519.

Articular Gap and Step-off Revisited: 3d Quantification of Operative Reduction for Posterior Malleolar Fragments

Objectives: Despite advanced imaging techniques, classic measurements of fracture reduction have not been revisited to date. The purpose of this study was to evaluate the reliability of innovative measurement techniques to quantify operative fragment reduction of posterior malleolar fractures by quantification of three-dimensional computed tomography (Q3DCT). Methods: Twenty-eight ankle fractures including a posterior malleolar fragment (AO/OTA type 44) were evaluated using 2DCT and Q3DCT to postoperatively quantify fragment reduction. “Classic” maximum gap and step-off of the posterior fragment were measured on 2DCT and Q3DCT. In addition, 2 innovative Q3DCT parameters were introduced and their reliability was tested using intraclass correlations (ICCs): gap surface (mm2) and multidirectional 3D-displacement (mm). Results: “Classic” measurements showed a median maximum step-off of 1.1 mm [interquartile range (IQR) 0.0–1.8 mm] on 2DCT versus a median step-off of 0.6 mm (IQR 0.0–1.1) on Q3DCT. Median maximum gap was 1.2 mm (IQR 0.0–3.8) on 2DCT, and its equivalent on Q3DCT showed no median displacement. Q3DCT measurements revealed a median gap surface of 14.5 mm2 (IQR 4.7–30.0) and a median multidirectional 3D-displacement of 0.7 mm (IQR 0.0–1.1). Interrater reliability of these new Q3DCT parameters of displacement was excellent (ICC 0.92, 95% CI 0.79–0.98) for gap surface and good (ICC 0.64, 95% CI 0.28–0.88) for 3D-displacement. Conclusions: Q3DCT is a reliable and promising technique for postoperative evaluation of fracture fragment reduction. In addition to “classic” gap and step-off measurements, we propose to explore total gap surface and 3D-displacement as innovative radiographic measurements in future clinical studies. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.