Level Of Evidence Research Articles

Dual-Plane Midface Lift Through Transoral and Transtemporal Approach.

The surge in the popularity of midface and temporal lifting procedures can be attributed to evolving social media trends and heightened patient expectations, particularly among younger individuals seeking "beautification" rather than traditional rejuvenation. Scarless techniques, such as transtemporal/transoral approaches, are increasingly preferred. This study aimed to combine the advantages of both superficial and deep dissection planes in midface and temporal lifting procedures. This retrospective study included 184 patients who underwent surgery using a dual-plane midface and temporal lift technique. Preoperative and postoperative assessments, including P1/P2 ratio calculations, were performed to evaluate volumetric distribution in the midface. The study cohort exhibited a significant improvement in the P1/P2 ratio postoperatively (p < 0.05), indicating successful volume redistribution. Complications, including hypoesthesia, bruising, and infection, were managed effectively. Minor asymmetries were observed, with revisions offered, but declined by the patient. This technique offers hidden incisions and reduces the risk of scar-related complications, making it suitable for patients seeking facial enhancement. Addressing the tear trough area and the lateral canthus provides comprehensive facial rejuvenation. The dual-plane approach facilitates both skin mobilization and volume shift, yielding favorable aesthetic outcomes. The dual-plane midface and temporal lift technique presented in this study offers a bi-vectoral approach to midfacial lifting, suitable for both beautification and rejuvenation goals. Despite the potential limitations, including infection risk, this method is an effective option for facial enhancement. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Fast-track Effectiveness in Abdominal Surgery (Literature Review)

The study aimed to evaluate the literature on fast-track laparoscopic bariatric surgery (LRYGB and LAGB) to determine its feasibility and safety. Articles from PubMed, EMBASE, and Cochrane Library discussing next-day discharge for LRYGB and same-day discharge for LAGB were analyzed. The review included 13 studies with evidence levels of 3b or 4, comprising seven studies on LAGB, five on LRYGB, and one on both. The next-day discharge rate for LRYGB ranged from 81% to 100%, and the same-day discharge rate for LAGB ranged from 76% to 98%. Complication, readmission, and mortality rates were comparable to conventional care. The results indicate that fast-track management of LRYGB and LAGB is feasible with careful patient selection and preparation in high-volume centers, potentially offering cost benefits. However, further studies are needed to confirm the safety and cost-effectiveness of this approach outside specialized bariatric units.

A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials Comparing Treatments for Displaced Radial Head Fractures.

Background: The aim of this study is to compare the surgical and non-operative management of displaced radial head fractures via a network meta-analysis of randomised controlled trials (RCTs). Methods: RCTs comparing management of isolated, displaced radial head fractures in adults were included in our review and statistical analysis. A systematic review of electronic databases (Medline, Embase and Cochrane Library) were screened for comparative RCTs reporting on the management of displaced radial head fractures in August 2021. Two investigators independently reviewed studies for eligibility and an assessment of bias was performed for each study. A Bayesian network meta-analysis of the included RCTs was performed. Results: Five RCTs (326 patients) were included in our meta-analysis. Treatment methods included radial head arthroplasty (RHA), open reduction internal fixation (ORIF) with metal implants (ORIF-M), ORIF with biodegradable implants (ORIF-B) and non-operative management. In our network meta-analysis of 'good' or 'excellent' patient-reported outcome measures (PROMs), RHA was significantly favourable to ORIF-M (OR: 0.04, CrI: 0.0011, 0.87), ORIF-B (OR: 0.1 CrI: 0.00076, 6.37). Nonoperative treatment was not shown to be significantly worse than RHA (OR: 0.01 CrI: 2.5e-0.5, 3.61). Conclusions: This network meta-analysis shows that in displaced radial head fractures, RHA is associated with significantly superior functional PROMs than ORIF-M based on the evidence available. Nonoperative management has not been shown to be significantly worse. Level of Evidence: Level III (Therapeutic).

Global Highly Cited Publication Trends and Research Hotspots in Osteoporosis and Bone Metabolic Cells: A Bibliometric and Visualization Analysis from 2013 to 2023.

Bone metabolic diseases such as osteoporosis are caused by disruption of the metabolic balance between osteoblasts and osteoclasts. Thousands of papers have been published on osteoporosis and bone metabolizing cells. The purpose of this study is to draw the publication trend of highly cited literature in this field through bibliometrics and to explore the research hotspot analysis. This paper provides a comprehensive analysis of the impact of countries/regions, research institutions, authors, keywords, relevant journals, and references in the field of osteoporosis and bone metabolic cells research, with a specific focus on the theme of "Osteoporosis and bone metabolic cells". Furthermore, utilizing bibliometric methods, the study aims to offer valuable insights and references for future research endeavors, as well as clinical prevention and treatment strategies in this domain. The Web of Science [WOS] Core Collection database was examined in order to identify articles with high citation counts from 2013 to 31 October 2023. The citation counts, authors, year of publication, source, journal, geographical origin, subject, article type, and level of evidence were further analyzed using the R bibliometric package. The VOSviewer software was utilized to visualize word co-occurrence in a total of 251 articles. Our search strategy included 251 highly cited articles published between 2013 and 2023 in the field of osteoporosis and bone metabolic cells. The number of publications in this field remains consistently high, indicating ongoing research interest. Notably, the United States has made significant achievements and contributions in this area. Xie Hui, Cao Xu, and Goodman, Stewart are among the main contributors to these advancements. NATURE MEDICINE has the highest journal impact factor of 82.9, highlighting its prominence. The JOURNAL OF BONE AND MINERAL RESEARCH ranks first with 1,322 citations. Keyword research topics in this field include osteoclast differentiation, osteoblast differentiation, and mesenchymal stem cells. Through citation analysis, we found that 195 articles have been cited more than 100 times, demonstrating their significance and impact. This study analyzed the relationship between osteoporosis and bone metabolic cells using a bibliometric method. The results of these analyses can help researchers gain a more direct and scientific understanding of trends in the field. Additionally, it can provide guidance in identifying hot research directions and offer new ideas for the prevention and treatment of osteoporosis.

Outcomes of Arthroscopic Debridement of the First Carpometacarpal Joint: A Systematic Review.

Background: Arthroscopic debridement is increasingly being utilised in patients with early-stage first carpometacarpal joint (FCMCJ) arthritis but has limited supportive evidence. This systematic review evaluates the literature, and reports on outcomes and adverse events following this procedure. Methods: An electronic literature search of PubMed, Embase, Medline and Cochrane Central, looking for studies describing outcomes following arthroscopic debridement in FCMCJ arthritis, was performed in November 2022. Studies where bony resection or interposition was performed as adjuncts were excluded. Reported outcomes included visual analogue scores (VAS) for pain; Disabilities of Arm, Shoulder and Hand (DASH) scores; pinch and grip strength; complications and re-operations. Results: Out of a total of 90 studies revealed from the search, only two studies were eligible for inclusion, with a cohort of 34 patients. Following arthroscopic debridement for FCMCJ osteoarthritis, the mean VAS improved by four units, mean DASH by 22 points, grip strength by 4.5 kg and pinch strength by 2 kg at mean follow-up of 18 months. The pooled complication and re-operation rates were 8.8% and 23.5%, respectively. Conclusions: There is a lack of evidence supporting the utility of FCMCJ arthroscopy and debridement in the management of patients with early arthritis. Although the limited evidence suggests that there may be some therapeutic benefit, further large-scale prospective studies need to be performed before making conclusive recommendations. Level of Evidence: Level III (Therapeutic).

Perilunate Fracture-Dislocation: Results at Mean Follow-Up of 7 Years after ORIF.

Background: Perilunate fracture-dislocations are frequently associated with a high risk of developing post-traumatic arthritis. Current studies indicate that during mid-term follow-ups, radiological signs of arthritis do not appear to correspond with functional score. The aim of this study was to assess the occurrence of posttraumatic arthritis and the wrist function after perilunate dislocations (PLD) and fracture dislocations at a mid-term follow-up of 7 years. Methods: We report the clinical and radiological outcomes of 17 wrists treated for PLD or fracture-dislocation by open reduction and internal fixation through a dorsal approach with dorsal ligament repair. Functional outcomes were evaluated using the short version of the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), the Patient-Rated Wrist Evaluation questionnaire (PRWE) and the Mayo Wrist Score (MWS). Results of radiographs were assessed using the Herzberg Radiological Scoring Chart. Results: The MWS showed five excellent, five good, five fair and two poor results with an average score of 81%. Radiological analysis using the Herzberg classification revealed midcarpal and/or radiocarpal arthritis in 65% of cases, lunate collapse in 59% and an increase in the mean ulnar translocation ratio in 53% of the cases. Complications included one case of lunate osteonecrosis and one case of stage 3 scapholunate advanced collapse that required revision surgery. Conclusions: Although the clinical and functional outcomes are favourable at mid-term follow-up, radiological evaluation shows a progression towards osteoarthritis (OA). Further research is warranted to refine treatment strategies and investigate factors influencing the development of OA. Level of Evidence: Level IV (Therapeutic).

Extensor Carpi Radialis Brevis Tendon Transfer for Thumb and Finger Flexion Reconstruction after Failed Extensor Carpi Radialis Brevis Motor Branch Transfer in a Tetraplegic Patient.

Distal nerve transfers can restore precise motor control in tetraplegic patients. When nerve transfers are not successful, tendon transfers may be used for subsequent reconstruction. In this case, an extensor carpi radialis brevis (ECRB) tendon transfer was used to restore thumb and finger flexion following an unsuccessful ECRB to anterior interosseous nerve transfer in a young tetraplegic patient. Twelve months following tendon transfer, the patient demonstrated functional grip and pinch strength and was using both hands for daily activities. Level of Evidence: Level V (Therapeutic).

Adjuvant Treatment with Celecoxib after Collagenase Injection for Dupuytren Contracture: A Double-Blind Randomised Controlled Trial.

Background: In patients with a high recurrence risk after treatment for Dupuytren contracture (DC) by Collagenase Clostridium histolyticum (CCH), adjuvant medical therapy may improve the outcome. Non-steroidal anti-inflammatory drugs have been used in the treatment of similar fibroproliferative processes. The aim of this study was to investigate if adjuvant anti-inflammatory medication could improve the outcome of CCH treatment for DC. Methods: In a prospective double blinded randomised trial, the effect of adjuvant peroral celecoxib on the outcome of DC treated with CCH was investigated in 32 patients with a high fibrosis diathesis. Primary outcome was the increase in Total Passive Extension Deficit (TPED)/ray. Secondary outcomes were the TPED of the individual finger joints, Tubiana index, Disability of Arm, Shoulder and Hand score (DASH) and visual analogue scale (VAS) for pain and satisfaction. Results: A significantly greater improvement in the celecoxib group for TPED and metacarpophalangeal contracture was found. For the proximal interphalangeal joint, the effect was much less pronounced. The VAS for pain and satisfaction were better at 6 and 12 weeks in the celecoxib group. The other outcome parameters did not significantly differ between both groups. Conclusions: Adjuvant peroral administration of celecoxib might improve the gain in TPED after treatment with CCH in patients with DC and a high fibrosis diathesis, with a beneficial effect up to 24 months. Level of Evidence: Level II (Therapeutic).

Classification of Hamate Fractures: An Analysis of 247 Patients with Hamate Fractures.

Background: We devised a new classification of hamate fractures named the TOUCH classification. Each letter of this acronym depicts a fracture type - Type I (Transverse fracture), Type II (Open and/or complex fracture), Type III (Ulnar/medial tuberosity fracture), Type IV (Coronal fracture) and Type V (Hook fracture). Each fracture type was further divided into two or three subtypes (a, b, and/or c) based on degree of severity. The aim of this study is to classify the hamate fractures treated at our centre using this classification. Methods: A retrospective review of all patients with hamate fractures treated at our hospital between 2003 and 2022 was done. Patient data with regard to age, gender, mechanism of injury, injured limb and any associated injuries was collected. Hamate fractures were classified based on the TOUCH classification. Results: A total of 247 patients with hamate fractures were included. Patients in the age group of 20-40 years accounted for 73.6% of all fractures. Female patients accounted for only 6.9% of all fractures and 76.5% of women with hamate fractures were older than 40 years. The incidence of hamate fracture tended to increase with age in women. The most common mechanism of injury was a fall (69 patients). The injury involved the right upper limb in 195 patients. And 164 patients had associated injuries in the same upper limb. Type III (coronal fracture of the hamate body) accounted for 57.4%, followed by type V (hook of hamate fracture) in 26.7% of patients. Conclusions: The TOUCH classification could cover all kinds of hamate fractures. It is easy to remember and may guide surgeons in considering treatment options. Level of Evidence: Level IV (Diagnostic).

Primary Reconstruction Using Fibular Strut Allograft for Distal Humerus Intra-articular Comminuted Open Fracture (AO/OTA13C2, G-A type IIIA): A Case Report.

Distal humerus intra-articular comminuted open fracture is a challenging injury, with nonunion, infection and stiffness considered as major concerns. We report a 58-year-old woman who was admitted to the emergency department from a car accident, sustaining an open wound with severe comminution of distal humerus and complete articular fracture, classified as AO/OTA 13C2 and Gustillo Anderson type IIIA. Debridement and external fixation was done first, followed by open reduction and internal fixation with fibular strut allograft. The patient showed excellent results in radiological and functional outcomes. Level of Evidence: Level V (Therapeutic).

Post-surgical Rehabilitation Guidelines for Triangular Fibrocartilage Complex Foveal Repair: A Survey of Australian Hand and Wrist Surgeons.

Background: To restore distal radioulnar joint stability following injury to the Triangular Fibrocartilage Complex (TFCC), foveal repair surgery may be necessary. Post-surgery rehabilitation is prescribed to restore wrist and hand function; however, no universally accepted or definitive rehabilitation protocol currently exists. The aim of this study was to survey hand and wrist surgeons regarding their recommended postoperative rehabilitation protocols following TFCC foveal repair surgery. Methods: Australian hand and wrist surgeons were invited to complete a descriptive survey containing 10 questions. Questions included clinical recommendations for wrist and forearm immobilisation, range of motion (ROM) exercise timeframes and surgeon experience of TFCC rupture. Descriptive statistics and between-group (TFCC rupture vs. no-rupture) comparisons (Pearson's Chi2) were calculated. Results: Thirty-one surgeons completed the survey. Recommendations for post-surgery immobilisation ranged from 'not required' to 8 weeks (mode 6 weeks). Wrist and forearm ROM commencement time ranged from 'immediately' to 'later than 8 weeks' (mode 6 weeks). The most recommended orthosis was a 'sugar-tong' (57%). Thirty-seven percent (37%) reported experience of post-surgery re-rupture. Conclusions: While surgeon recommendations varied, the majority recommended 4- to 6-week timeframe for immobilisation and ROM exercise commencement. Additional clinical research is recommended to evaluate whether postoperative rehabilitation decisions influence patient outcomes. Level of Evidence: Level V (Therapeutic).

The Relationship between Structure of the Wrist and Function in a Japanese and Caucasian Population.

Background: Factors such as age and joint structure affect normal wrist motion. The midcarpal joint participates in flexion/extension, radial-ulnar/deviation (RUD), and since lunate/wrist type-2 is likely more stable than a lunate/wrist type-1, we suggest that midcarpal joint structure will affect wrist motion. Our purpose was to compare wrist motion in Caucasian and Japanese populations and to associate motion with midcarpal joint morphology. We hypothesised that radiographic structure would correlate with wrist motion. Methods: A total of 164 patients with normal wrist radiographs were included. Clinical measurements included wrist extension, flexion and RUD. Radiographic measurements included the radiocarpal joint: ulnar variance, radial height, radial inclination, volar inclination and carpal joint measurements: lunate type, capitate circumference and each of its joints contact measured and calculated as a proportion of capitate circumference. Results: The groups differed in wrist motion and in multiple radiographic measurements. When the two populations were analysed together, there were no significant associations between midcarpal joint type and wrist motion. The radiocarpal joint: ulnar variance was correlated with extension and radial deviation. Radial height was directly related to flexion, and both radial height and radial inclination were directly correlated with ulnar deviation. The intracarpal measurements: The main measurement affecting motion was the contact between the capitate and the scaphoid (as a proportion of capitate circumference) with lesser correlations of the contact of the capitate with the trapezoid and hamate. The most significant measurement associated with a lunate type-2 was scaphoid contact with the capitate p = 0.01. Logistic regression demonstrated that the measurements most associated with wrist motion were scaphoid contact with the capitate/capitate circumference and hamate contact with the capitate/capitate. Conclusions: This study supports discrepancies in wrist motion amongst different racial cohorts, and a relationship between bone/joint structure in the wrist and wrist motion. This can help treat wrist pathology. Level of Evidence: Level III (Diagnostic).

Elemental Mercury Poisoning by Self-Injection - A Report of Two Cases.

Injection of mercury into the upper limb is a rare method of self-harm. We report two patients with varied clinical presentations - a 19-year-old male student who injected himself with mercury extracted from a sphygmomanometer bulb and reported to our emergency department 24 hours after the event and a 34-year-old industry worker who presented 2 years after injecting himself with elemental mercury. The management of mercury poisoning is described along with a brief review of literature. Mercury is a toxic element and adequate safety precautions must be taken by the surgical team in the management of such patients. Level of Evidence: Level V (Therapeutic).

Extraskeletal Ewing Sarcoma Disguised as a Vascular Malformation.

Extraskeletal Ewing sarcoma (EES) is a rare entity, accounting for only 3% of lesions encountered in upper extremity. We present two paediatric patients, who were initially diagnosed with a vascular malformation based on clinical assessment and imaging. Final histopathology revealed Ewing sarcoma of soft tissue origin, confirmed by immunohistochemical analysis. Hand surgeons, who are routinely approached for a myriad of hand pathologies, should be wary and consider EES as a differential when treating such lesions. A multidisciplinary approach with an appropriate treatment algorithm can help in a speedy diagnosis, improving the long-term prognosis of the disease. Level of Evidence: Level V (Therapeutic).

Posterolateral Locked Plate and Percutaneous Medial Screw Fixation for Distal Humerus Fractures in Elderly.

Background: A high incidence of ulnar nerve-related complications has been reported in open reduction and internal fixation for distal humerus fractures (DHFs). To minimise ulnar nerve damage, we used a percutaneous medial screw combined with a posterolateral plate in the elderly. The aim of this study was to evaluate the postoperative complications and functional outcomes of this method. Methods: Data from patients aged over 65 who underwent this surgical procedure for DHFs at a single Level I trauma centre from 2013 to 2021 were extracted. Postoperative complications, reoperations, mean range of motion, Mayo Elbow Performance Index (MEPI) scores and Hand20 scores were retrospectively evaluated. All patients in this study received postoperative rehabilitation by hand therapists at our hospital. Results: We identified 28 patients treated with this method. The mean follow-up period was 8.6 ± 3.7 months. The median intraoperative time was 125 minutes (interquartile range: 105-157 minutes). None of the patients developed ulnar nerve neuropathy, but one patient (3.7%) experienced radial nerve dysfunction. Two patients (7.4%) had nonunion. Implant failure occurred in three patients (11.1%) due to migration of the medial screw. One patient (3.7%) amongst them underwent reoperation. The mean flexion to extension arc was 97 ± 18°, 116 ± 19°, and 116 ± 19° at 1-, 3- and 6-month follow-ups, respectively. According to the MEPI, 20 patients achieved excellent results, seven patients achieved good results and one patient achieved a fair result at the last follow-up. The median Hand20 score was 4.3 (interquartile range: 2.1-14.0) at the 6-month follow-up. Conclusions: The posterolateral plate and medial screw method showed good functional outcomes and few nerve-related complications. This modified method might be a better option for DHFs in elderly patients. Level of Evidence: Level IV (Therapeutic).

Pins and Rubber Band Traction System Combined with Internal Fixation for Intra-articular Fractures of the Proximal Interphalangeal Joints.

Background: Intra-articular fractures of the proximal interphalangeal joint (PIPJ) can result in poor outcomes if inadequately treated. Dynamic external fixation and internal fixation with plates and/or screws are two treatment options. The role of combining these two methods is unclear. The aim of this study is to determine the outcomes of patients with intra-articular fractures of the PIPJ treated with a combination of dynamic external fixation with a plate and/or screws. Methods: A retrospective review was conducted on 18 consecutive cases of intra-articular fractures of the PIPJ treated with pins and rubber band traction system (PRTS) combined with dorsal internal fixation with plates and/or screws. The patients' average age was 51 years (range: 20-81 years). The fracture patterns were volar-type (n=2), dorsal-type (n=4) and pilon-type (n=12). Data with regard to time to surgery, interphalangeal joint range of motion, grip strength, VAS for pain, Quick DASH score, complications, duration of follow-up and return to work were collected. Results: The levels of articular involvement were stable (n=1), tenuous (n=5) and unstable (n=12). The average time to surgery was 9 days, and the average follow-up period was 15 months. The fracture was fixed with a dorsal plate and screws in 10 patients and with only screws in eight patients. All patients had PRTS. All patients returned to their original occupation and the fractures united in good alignment. The average grip strength was 86% of that of the unaffected side. The average active PIPJ motion was 85° (range: 50°-106°), and the average active distal interphalangeal joint (DIPJ) motion was 48° (range: 10°-90°). Conclusions: Our results show that a combination of PRTS and open reduction and fixation with plate and/or screws achieved a good range of motion and articular reduction. Level of Evidence: Level IV (Therapeutic).

Complications of Superomedial Versus Inferior Pedicle Reduction Mammaplasty: A Systematic Review and Meta-Analysis.

The superomedial pedicle reduction mammoplasty has gained popularity and is an important alternative approach for reduction mammoplasty, while the inferior pedicle reduction mammaplasty remains by far the most performed as it is considered to provide the best vascularization to the nipple-areola complex, allowing safe removal of large amount of redundant tissue. The authors conducted the first systematic review and meta-analysis in an attempt to declare the differences of the superomedial pedicle versus the inferior pedicle reduction technique by comparing the postoperative complications. PubMed, MEDLINE, and Cochrane Library for clinical studies were queried from inception to January 1, 2024. Review Manager Version 5.4 was used for this meta-analysis. A random effects model was applied to OR, and 95%CI were determined using the Mantel-Haenszel method. The I2 test was used to assess heterogeneity, and the Newcastle-Ottawa scale was used to assess the risk of bias in the nonrandomized studies. Twelve observational comparative studies were included. The superomedial pedicle technique had a statistically lower rate of overall complications (OR 0.59, 95% CI 0.47-0.75; p < 0.0001) and delayed wound healing (OR 0.46, 95% CI 0.33-0.64; p < 0.00001) than the inferior pedicle technique. No significant differences in wound dehiscence, infection, seroma, hematoma, skin necrosis, fat necrosis, NAC necrosis, nipple sensation decrease or loss, asymmetry, hypertrophic scarring, and reoperation were noted. Both two techniques are equally safe and reliable, while the superomedial pedicle technique resulted in a statistically lower rate of overall complications and delayed wound healing. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Cross-linked Sodium Hyaluronate Gel with PLLA-b-PEG Microsphere for Facial Contouring in Chinese: A Retrospective Study.

In Asia, the demand for cosmetic facial treatments has surged due to technological advancements, increased social acceptability, and affordability. Poly-L-lactic acid (PLLA) fillers, known for their biocompatibility and biodegradability, have emerged as a popular choice for facial contouring, yet studies specifically addressing their use in Asian populations are scarce. This retrospective study examined 30 Chinese patients who underwent facial contouring with PLLA fillers, focusing on product composition, injection techniques, and safety measures. A comprehensive clinical evaluation was performed, including the Global Aesthetic Improvement Scale (GAIS) and Global Impression of Change Scale (GICS) for effectiveness and patient satisfaction, respectively. No significant difference in GAIS scores was observed between injectors and blinded evaluators over a 12-month period, indicating consistent effectiveness. Patient satisfaction remained high, with GICS scores reflecting positive outcomes. The safety profile was favorable, with no serious adverse events reported. The study highlighted the importance of anatomical knowledge to avoid complications, particularly in areas prone to blindness. PLLA fillers offer a safe, effective option for facial contour correction in the Asian population, achieving high patient satisfaction and maintaining results over time. The study underscores the need for tailored approaches in cosmetic procedures for Asians, considering their unique facial structures and aesthetic goals. Further research with larger, multicenter cohorts is recommended to validate these findings and explore long-term effects. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Screw Configuration Does Not Significantly Alter Neck Shortening Following Valgus Impacted Femoral Neck Fracture (OTA Type 31B1.1)

OBJECTIVES: To compare three different cancellous screw configurations used for Garden 1 femoral neck fractures (FNF). METHODS: Design: Retrospective review. Setting: A large urban academic medical center. Patient Selection Criteria: All patients with OTA 31B1.1 FNF that underwent in situ fixation with cancellous screws between 2012 and 2021 were included. Patients were divided into three groups: two screws placed in a parallel fashion, three screws placed in an inverted triangle configuration, and three-screw fixation with placement of one “out of plane” (OOP) screw perpendicular to the long axis of the femur. Outcome Measures and Comparisons: Post operative femoral neck shortening (mm) was the primary outcome, which was compared amongst the three groups of different screw configurations. RESULTS: Sixty-one patients with a median follow-up of 1 year (IQR 0.6-1.8 years) and an average age of 72 years (IQR 65.0-83.0 years) were included. All fractures united. Overall, 68.9% of the cohort had ≤ 2 mm of femoral neck shortening. There was no difference between groups in the proportion of patients who experienced greater than 2 mm of shortening (p = 0.839) or in the amount (mm) of femoral neck shortening (Kruskal-Wallis χ2 = 0.517, p = 0.772). CONCLUSIONS: While most patients with valgus impacted femoral neck fractures treated with screw fixation do not experience further femoral neck shortening, some patients demonstrated continued radiographic shortening during the healing process. The development of further femoral neck shortening and the amount of shortening that occurs do not differ based on implant configuration. Multiple different screw configurations appear to be acceptable with regards to achieving healing and minimizing further femoral neck impaction. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Experiences and outcomes in shoulder replacements in a district general hospital over 19 years.

This study aimed to evaluate the changing experiences of shoulder surgeons working in a district general hospital. A consecutive series of 395 shoulders (225 male, 170 female) over a 19-year period (2000-2019) with a minimum follow-up of 2 years were analyzed. Outcome measures were length of stay, operating time, satisfaction visual analog score (VAS), pain VAS, Oxford Shoulder Score (OSS), Constant-Murley score, range of movement, complications, and implant survival. The incidence of a diagnosis of osteoarthritis as the surgical indication increased over time. The number of cases by surgeon per year increased from three cases in 2,000 to a peak of 33 in 2011. Up to seven implant manufacturers were used. The incidence of hemiarthroplasties decreased, and more numerous reverse polarity and anatomic arthroplasties were performed (P<0.001). More glenoid and humeral components were cemented and more short-stem implants were used in later years (P<0.001). Length of stay was a median of 1 day with a trend towards daytime surgery in recent years. Patients were satisfied (VAS 8/10) and OSS improved by 8 points on average throughout the observation period. Despite frequent introductions of new implants, patient outcome, satisfaction, and complication rates remained good. There appears to be a need for large-scale, generalizable studies to understand why technological advancements leading to changes in implants do not influence clinical outcomes. Level of evidence: III.