Preinjury Level Of Function Research Articles

Outcomes After Percutaneous Reduction and Fixation of Low-Energy Lisfranc Injuries.

Lisfranc injuries are often missed initially or not anatomically reduced, leading to midfoot collapse, arthrosis, and pain. Operative management of these injuries is also fraught with complications, particularly with respect to the soft tissues. Wound dehiscence and infection are not uncommon. The goal of this study was to analyze the outcomes of a minimally invasive technique in reduction and percutaneous fixation of low-energy minimally displaced Lisfranc injuries and determine if it is a safe alternative to more traditional, open approaches. A retrospective review was performed for all patients who underwent minimally invasive Lisfranc treatment at a single institution over a 6-year period. Thirty-eight patients were identified in this series. All patients were skeletally mature and had a minimum follow-up of 3 years. Patients were assessed clinically and radiographically, in addition to undertaking patient-centric outcome scoring using the Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL) and sports subscales at a mean follow-up of 66 months (range, 36-100). Patients were also asked to subjectively rate their percentage return to preinjury functional level at the time of final follow-up. There were 20 males and 18 females. Seventeen patients were injured participating in sports-related activities, 19 during falls, and 2 as a result of motor vehicle accidents. The average age at the time of surgery was 34.2 (range, 16-69) years. At final follow-up, 31 patients were available for assessment (81.6%). The mean FAAM-ADL score was 94.2 (range, 40.5-100), and sports score was 90.4 (range, 0-100). Percentage recovery compared to their preinjury functional level averaged 91.4% (range, 40%-100%). There were no complications in this series. Twenty-two patients underwent screw removal electively at an average of 6.9 months following the index procedure. No patients had undergone any additional operative procedures, or had any objective evidence of midfoot collapse or arthritis at the time of final follow-up. Minimally invasive methods of treating low-energy Lisfranc injuries with less soft tissue stripping and disruption, as described in this series, were a valuable tool to optimize outcomes while minimizing the potential morbidity of more traditional, open techniques. Level IV, retrospective case series.

The effect of early psychological symptom severity on long-term functional recovery: A secondary analysis of data from a cohort study of minor injury patients

BackgroundThe mental health consequences of injuries can interfere with recovery to pre-injury levels of function and long term wellbeing. ObjectivesThe purpose of this study was to explore the relationship between psychological symptoms after minor injury and long-term functional recovery and disability. DesignThis exploratory study uses secondary data derived from a longitudinal cohort study of psychological outcomes after minor injury. SettingParticipants were recruited from the Emergency Department of an urban hospital in the United States. ParticipantsA cohort of 275 patients was randomly selected from 1100 consecutive emergency department admissions for minor injury. Potential participants were identified as having sustained minor injury by the combination of three standard criteria including: presentation to the emergency department for medical care within 24h of a physical injury, evidence of anatomical injury defined as minor by an injury severity score between 2 and 8 and normal physiology as defined by a triage-Revised Trauma Score of 12. Patients with central nervous system injuries, injury requiring medical care in the past 2 years and/or resulting from domestic violence, and those diagnosed with major depression or psychotic disorders were excluded. MethodsPsychological symptom severity was assessed within 2 weeks of injury, and outcome measures for functional limitations and disability were collected at 3, 6 and 12 months. A quasi-least squares approach was used to examine the relationship between psychological symptom scores at intake and work performance and requirement for bed rest in the year after injury. ResultsAdjusting for demographic and injury covariates, depression symptoms at the time of injury predicted (p≤0.05) both poorer work performance and increased number of days in bed due to health in the year after injury. Anxiety symptoms predicted (p≤0.05) bed days at 3, 6, and 12 months and work performance at 3 months. ConclusionsDepression and anxiety soon after minor injury may help predict important markers of long-term recovery. With further research, simple assessment tools for psychological symptoms may be useful to screen for patients who are at higher risk for poor long-term recoveries and who may benefit from targeted interventions.

Pectoralis major tendon tears: functional outcomes and return to sport in a consecutive series of 40 athletes

There are limited data on the outcomes of surgically repaired pectoralis major tendon (PMT) tears. The purpose of this study was to report the functional outcomes, return to sport, and second surgery rates in a consecutive series of PMT tears. Forty patients with acutely repaired PMT tears were retrospectively identified. Follow-up was conducted with functional outcome scores and adduction strength testing at final follow-up. Return to sport and incidence of subsequent surgery were also recorded. The average age of the patients was 34.4 years (range, 23-59 years). Average follow-up was 2.5 years (range, 2-7.0 years). Twenty-three injuries (58%) occurred in the nondominant extremity. Bench press (n = 26) and contact sport participation (n = 14) were the most common mechanisms. Postoperative Single Assessment Numeric Evaluation scores averaged 93.6 (range, 62-100), with patient satisfaction of 9.6 of 10 (range, 6-10). All athletes returned to preinjury level of function approximately 5.5 months postoperatively (range, 4.5-6.5 months); 23.1% and 2.6% described mild or moderate difficulties with sport participation. Isokinetic strength evaluation revealed an average decrease of 9.9% (range, -18% to 41%). Application of the Bak criteria revealed 37% excellent, 26% good, and 37% fair outcomes, with most in the fair group reporting cosmetic concerns. Removing cosmesis, 46% scored excellent, 37% good, and only 17% fair. Three athletes required a second surgical procedure (7.5%). Surgical repair of PMT tears resulted in high patient satisfaction, with excellent restoration of function and adduction strength, early return to sport, and few reoperations, albeit with the potential for mild cosmetic concerns.

Twelve-month mortality and functional outcomes in hip fracture patients under 65 years of age

IntroductionThere has been a recent call for improved functional outcome reporting in younger hip fracture patients. Younger hip fracture patients represent a different population with different functional goals to their older counterparts. Therefore, previous research on mortality and functional outcomes in hip fracture patients may not be generalisable to the younger population. The aims of this study were to report 12-month survival and functional outcomes in hip fracture patients aged <65 years and predictors of functional outcome. MethodsHip fracture patients aged <65years (range 17–64) registered by the Victorian Orthopaedic Trauma Outcomes Registry over four years were included and their 12-month survival and functional outcomes (Extended Glasgow Outcome Scale) reported. Ordered multivariable logistic regression was used to identify predictors of higher function. ResultsThere were 507 patients enrolled in the study and of the 447 patients (88%) with 12-month outcomes, 24 (5%) had died. The majority of patients had no comorbidities or pre-injury disability and were injured via road trauma or low falls. 40% of patients sustained additional injuries to their hip fracture. 23% of patients had fully recovered at 12 months and 39% reported ongoing moderate disability. After adjusting for all key variables, odds of better function 12-months post-fracture were reduced for patients with co-morbidities, previous disability or additional injuries, those receiving compensation or injured via low falls. ConclusionsWhile 12-month survival rates were satisfactory in hip fracture patients aged under 65 years, their functional outcomes were poor, with less than one quarter having fully recovered 12 months following injury. This study provides new information about which patients may have difficulty returning to their pre-injury level of function. These patients may require additional or more intensive post-discharge care in order to fulfil their functional goals and continue to contribute productively to society.

Development of a Universal Disease-Specific Outcome Instrument for Spine Trauma Patients – the AOSpine Patient Reported Outcome Spine Trauma (AOSpine PROST)

Introduction In the absence of an outcome instrument specifically designed and validated for traumatic spinal column injury patients, it is difficult to measure the effect size of various treatment options in a variety of traumatic spinal column injuries. In reflection of this dilemma, the AOSpine Knowledge Forum Trauma initiated a project to develop and validate universal disease-specific outcome instruments for adult spine trauma patients that include both the patients' and clinicians' perspective. The International Classification of Functioning, Disability and Health (ICF) is used as the basis for the patient reported part of this outcome instrument, named AOSpine Patient Reported Outcome Spine Trauma (AOSpine PROST). Material and Methods Based on the results of 4 preparatory studies and a consensus conference using the ICF methodology, 25 ICF categories were selected as core categories for patient reported outcome measurement in adult traumatic spinal column injury patients. The response scale for use agreed on was the Numeric Rating Scale 0–100, with 0 indicating no function at all and 100 indicating the pre-injury level of function. These results formed the basis for the development of the AOSpine PROST. The first draft of the Dutch version was pilot tested among a consecutively selected representative sample of 25 traumatic spinal column injury patients from a level-1 trauma center in the Netherlands. The ‘think aloud’ and ‘probing’ methods were used to evaluate the comprehensibility, relevance, acceptability, feasibility, and completeness of the AOSpine PROST. Subsequently, this draft version was cross-culturally translated and adapted into English according to established guidelines. This process consisted of multiple stages, including forward-translations, synthesis, back-translations, and an expert committee meeting to reach consensus on any discrepancies and to develop a final English version of AOSpine PROST. Results Out of the 25 core ICF categories, 9 related to body functions, 14 related to activities and participation, and 2 related to environmental factors. Implementing those 25 core categories into the selected response scale resulted in a draft version of AOSpine PROST, consisting of the following 19 items: household activities, work/study, recreation and leisure, social life, walking, travel, changing posture, maintaining posture, lifting and carrying, personal care, urinating, bowel movement, sexual function, emotional function, energy level, sleep, stiffness, loss of strength, and pain. Very satisfactory results were obtained from the pilot study, and only some minor adaptions were needed. Statistical analysis showed a high level of internal consistency (Cronbach's α = 0.926). Conclusion Using the ICF methodology and based on the results of 4 different preparatory studies and a consensus conference, a disease-specific patient reported outcome instrument for traumatic spinal column injury patients has been developed. Very good results were obtained from a pilot study, and currently the Dutch and English versions of AOSpine PROST are being subjected to further validation in an international multicenter study. Ultimately, the AOSpine PROST will be a helpful tool to compare various treatments and improve the quality of health care.

Arthroscopic Repair of an Isolated Teres Minor Tear: A Case Report.

Isolated avulsion of the teres minor tendon is exceedingly uncommon and, to our knowledge, the presentation and arthroscopic repair of this type of injury have not been described. Known musculotendinous avulsions about the shoulder frequently involve the supraspinatus, long head of the biceps, and pectoralis major. We present the case of a patient with an isolated teres minor avulsion and an otherwise intact rotator cuff. The patient underwent successful arthroscopic repair and rehabilitation, allowing for a return to the pre-injury level of function.

Treatment of Middle Third Humeral Shaft Fractures with Anteromedial Plate Osteosynthesis through an Anterolateral Approach.

Background: Treatment of humeral shaft fractures has been a subject of debate for many decades. Even though a large majority of humeral shaft fractures can be treated by non operative methods, few conditions like open fractures, polytrauma, ipsilateral humeral shaft and forearm fractures require surgical intervention. The goal of treatment of humeral shaft fractures is to establish union with an acceptable humeral alignment and to restore the patient to pre-injury level of function. The objective was to assess the incidence of radial nerve palsy, non-union and mean time required for in anteromedial plate osteosynthesis with anterolateral approach and also to measure the functional outcome of this procedure.Method: A prospective study was conducted in the Department of Orthopaedics, PESIMSR, Kuppam, Andhra Pradesh, from August 2012 to August 2015 with a total of 54 patients who were operated with anteromedial plate osteosynthesis were included in the study. Rodriguez- Merchan criteria was used to grade the functional outcome.Results: Of the 54 patients, 28 (58.85%) were in the age group of 30-40 years. The most common fracture pattern identified was A3 type (48.14%).The mean (± SD) duration of surgery for anteromedial humeral plating was 53 ± 5.00 minutes. The time taken for the fracture to unite was less than 16 weeks in the majority or 50 patients (92.59%). Four (7.40%) patients had delayed union. There was no incidence of iatrogenic radial nerve palsy. Rodriguez – Merchan criteria showed that 37(68.51%) of the patients had good and 12 (22.22%) had excellent functional outcome.

Reliability in Measuring Preinjury Physical Function in Orthopaedic Trauma.

In orthopaedic trauma, patients' functional status scores cannot be collected before injury. Due to the lack of these data, it is difficult to reliably determine if patients have returned to their preinjury level of physical function. The goal of this article is to determine if patients' assessment of preinjury function agrees with that of familiar proxies, to determine whether patient assessment of preinjury function may be regarded as reliable. At first postinjury outpatient follow up, orthopaedic trauma patients and their proxies were asked to independently complete the PROMIS physical function computer adaptive test (PF CAT) based on how they perceived the function of the patient before injury. Intraclass correlation, paired sample t tests, and 95% confidence intervals were used to analyze patient-proxy agreement. Fifty patient-proxy pairs completed the questionnaire at an average of 14.3 (SD = 1.1) days postoperative (average 19.3, SD = 12.1 days postinjury). Patient mean PF CAT score was 57.92 (SD = 10.38) for patients and 56.59 (SD = 11.50) for proxies. Paired samples t test showed that patient's PF CAT scores were not significantly different from proxy scores [mean score difference = 1.33; 95% CI = (-1.28, 3.94); P = 0.311]. Intraclass correlation between patient and proxy scores was 0.79. There was no notable bias. Good agreement in PF CAT preinjury assessment between patients and proxies support patients' ability to report reliable preinjury physical functioning in the early postinjury setting using the PF CAT.

Incidence and Predictors of Second Anterior Cruciate Ligament Injury After Primary Reconstruction and Return to Sport.

An estimated 200 000 anterior cruciate ligament (ACL) injuries occur annually in the United States,1,2 with as many as 90% of patients electing to undergo ACL reconstruction (ACLR).3 Despite the high prevalence of surgery after ACL injury, outcomes vary widely in the literature. Recent evidence suggests that more than 50% of athletes are unable to return to their preinjury level of function after ACLR4 and between 50% and 100% develop knee osteoarthritis within 5 to 10 years of surgery.5,6 Considering the high rate of poor outcomes after primary ACLR, we must be very concerned that a large proportion of athletes who have undergone ACLR ultimately suffer a second ACL injury. Future directions in the management of ACL injury after ACLR must focus on prevention. Prior success using an injury-prevention model7,8 to decrease the rate of primary ACL injury may have important applications in this population.

Erratum to: The effect of local bone mineral density on the rate of mechanical failure after surgical treatment of distal radius fractures: a prospective multicentre cohort study including 249 patients

The aim of this prospective, multicentre study was to evaluate the influence of local bone mineral density (BMD) on the rate of mechanical failure after locking plate fixation of closed distal radius fractures. Between June 2007 and April 2010, 230 women and 19 men with a mean age of 67 years were enrolled. Dual energy X-ray absorptiometry measurements for BMD of the contralateral distal radius were made at 6 weeks post-surgery. Follow-up evaluations at 6 weeks, 3 months and 1 year included wrist mobility and strength as well as standard radiographs. Any local bone/fracture or implant/surgery-related complications were documented. The Disability of the Arm, Shoulder, and Hand (DASH), Patient Rated Wrist Evaluation (PRWE), and EuroQol-5D scores were also recorded at the nominated time points. Nine patients were reported with mechanical failure at an estimated risk of 3.6 %. The BMD measurements were generally low for the study population with no difference between patients with (0.561 g/cm2) and without (0.626 g/cm2) mechanical failure (p = 0.148). None of the patients achieved their pre-injury functional level and quality of life status after 1 year. 1-year DASH and PRWE scores as well as the difference in maximum grip strength of the affected wrist relative to the contralateral side were significantly higher for patients with mechanical failure (p ≤ 0.036). Our study could not identify a clear association between bone mineral density status and the risk of mechanical failure. Although the risk for mechanical failure after treatment of distal radius fractures with palmar locking plates is low, these complications must be avoided to prevent negative impact on long-term patient functional and quality of life outcome.

Arthroscopic Fragment Fixation Using Hydroxyapatite/Poly-L-Lactate Acid Thread Pins for Treating Elbow Osteochondritis Dissecans

Background: Various procedures, such as arthroscopic debridement, osteochondral transplantation, and bone plug fixation, have been described for the treatment of osteochondritis dissecans (OCD) of the humeral capitellum. However, the use of hydroxyapatite/poly-L-lactate acid (HA/PLLA) thread pins to fix the osteochondral fragment in an OCD lesion is a recent development. Hypothesis: Adolescent throwing athletes would return to preinjury levels of function after arthroscopic osteochondral fragment fixation using HA/PLLA thread pins. Study Design: Case series; Level of evidence, 4. Methods: Enrolled in this prospective cohort study were 18 adolescent baseball players (mean age, 14.2 years; range 12-16, years) with elbow OCD who underwent arthroscopic fragment fixation with HA/PLLA thread pins between 2006 and 2009. All patients were affected on their dominant side. Plain radiographs taken before surgery showed an open physis in 13 patients (72%) and a closed physis in 5 patients (28%). During surgery, the condition of the OCD lesion was evaluated by use of the International Cartilage Research Society (ICRS) classification system; there were 5 grade II, 11 grade III, and 2 grade IV cases. Outcomes were assessed after 3 years (mean, 39 months; range, 36-50 months). Elbow function was measured using the Timmerman and Andrews score and the Mayo Elbow Performance Index. Return to sports activity was assessed as higher than preinjury, same level, lower level, or no return to sports. Results: The mean Timmerman and Andrews score improved significantly from 126.6 ± 6.5 to 197.5 ± 1.5, and the mean Mayo Elbow Performance Index improved significantly from 68.0 ± 2.1 to 98.06 ± 0.9 (P = .0001 for both). Mean elbow extension improved significantly from −10° ± 10.4° to −0.8° ± 5.2° (P = .006), and mean flexion improved significantly from 123.1° ± 17.9° to 138.6° ± 6.1° (P = .001). Three patients had a loss of extension greater than 5°. Five patients returned to a higher level of sports activity, 10 patients returned to the same level, and 2 patients returned to a lower level. A remaining patient did not return to baseball. In one patient, the lesion did not heal, resulting in fragmentation at 1 year after surgery. This patient consequently underwent revision arthroscopy to remove the lesion, and he eventually returned to sports at the same level of activity. Conclusion: Arthroscopic fragment fixation using HA/PLLA thread pins provides a beneficial clinical outcome to adolescent baseball players with humeral capitellar OCD.

The effect of local bone mineral density on the rate of mechanical failure after surgical treatment of distal radius fractures: a prospective multicentre cohort study including 249 patients.

The aim of this prospective, multicentre study was to evaluate the influence of local bone mineral density (BMD) on the rate of mechanical failure after locking plate fixation of closed distal radius fractures. Between June 2007 and April 2010, 230 women and 19 men with a mean age of 67years were enrolled. Dual energy X-ray absorptiometry measurements for BMD of the contralateral distal radius were made at 6weeks post-surgery. Follow-up evaluations at 6weeks, 3months and 1year included wrist mobility and strength as well as standard radiographs. Any local bone/fracture or implant/surgery-related complications were documented. The Disability of the Arm, Shoulder, and Hand (DASH), Patient Rated Wrist Evaluation (PRWE), and EuroQol-5D scores were also recorded at the nominated time points. Nine patients were reported with mechanical failure at an estimated risk of 3.6%. The BMD measurements were generally low for the study population with no difference between patients with (0.561g/cm(2)) and without (0.626g/cm(2)) mechanical failure (p=0.148). None of the patients achieved their pre-injury functional level and quality of life status after 1year. 1-year DASH and PRWE scores as well as the difference in maximum grip strength of the affected wrist relative to the contralateral side were significantly higher for patients with mechanical failure (p≤0.036). Our study could not identify a clear association between bone mineral density status and the risk of mechanical failure. Although the risk for mechanical failure after treatment of distal radius fractures with palmar locking plates is low, these complications must be avoided to prevent negative impact on long-term patient functional and quality of life outcome.

Hip arthroscopy in males younger than 40 with femoroacetabular impingement: Short-term outcomes

Introduction and objectivesFemoroacetabular impingement is probably the most common mechanism that leads to the development of early cartilage and labral damage in the non-dysplastic hip. The objective was to evaluate the outcomes of hip arthroscopy as a treatment for femoroacetabular impingement in patients with high level of function. Material and methodsA prospective study was performed on 41 patients younger than 40 years old undergoing hip arthroscopy for femoroacetabular impingement. Modified Harris Hip Score and HOS and IHOT questionnaires were used for clinical assessment. Radiological evaluation was made for joint space and alpha angle. ResultsThe mean age of patients was 32.7 years. Labrum injury was detected in 78%, and acetabular cartilage injury in 56% of cases. The average follow-up was 31.3 months. There was a significantly improvement in the mean score in the clinical questionnaires. Radiologically there was no change in the mean joint space, with significantly reduction to normal values of the alpha angle. All patients returned to sports at their pre-injury level of function. DiscussionHip arthroscopy resulted in improvement in hip functional outcomes with correction of the underlying osseous deformity and treatment of the associated labral and cartilage pathology, with the return of patients to their pre-injury sports. Further follow-up is essential to confirm the stability of the clinical and radiological outcomes.

Flap reconstruction for soft-tissue defects with exposed hardware following deep infection after internal fixation of ankle fractures

The aim of the present study was to determine the outcome for patients treated with flap reconstruction following deep ankle fracture infection with exposed hardware. Out of 3041 consecutive ankle fracture operations in 3030 patients from 2006 to 2011, we identified 56 patients requiring flap reconstruction following deep infection. Thirty-two of these patients could be examined at a follow-up visit. Olerud-Molander Ankle (OMA) score, 15D score, Numeric Rating Scale (NRS), and clinical examination were used to assess the outcome. A total of 58 flap reconstructions were performed in 56 patients with a mean age of 57 years (range 25–93 years) and mean follow-up time of 52 months. The most commonly used reconstruction was a distally based peroneus brevis muscle flap with a split-thickness skin graft. A microvascular free flap was required in only one patient. 22 (39%) patients required subsequent surgical interventions because of a flap-related complication. With flap reconstruction, hardware could eventually be salvaged in 53% of patients with a non-consolidated fracture. The mean OMA score was fair or poor in 53% of the patients, and only 56% had recovered their pre-injury level of function. Half of the patients had shoe wear limitations. The 15D score showed a significantly poorer health-related quality of life compared to an age-standardised sample of the general population. The mean pain NRS was 2.1 (range 0–6), and the mean satisfaction NRS was 6.6 (range 0–10). Our study showed that successful treatment of a soft-tissue defect with exposed hardware following ankle fracture infections can be achieved with local flaps. Despite eventual reconstructive success, complications are common. Patients perceive a poorer health-related quality of life, have shoe wear limitations, and only half of them achieve their pre-injury level of function.

La cirugía artroscópica de cadera en deportistas varones menores de 40 años con choque femoroacetabular: resultado a corto plazo

Introduction and objectivesFemoroacetabular impingement is probably the most common mechanism that leads to the development of early cartilage and labral damage in the non-dysplastic hip. The objective was to evaluate the outcomes of hip arthroscopy as a treatment for femoroacetabular impingement in patients with high level of function. Material and methodsA prospective study was performed on 41 patients younger than 40 years old undergoing hip arthroscopy for femoroacetabular impingement. Modified Harris Hip Score and HOS and IHOT questionnaires were used for clinical assessment. Radiological evaluation was made for joint space and alpha angle. ResultsThe mean age of patients was 32.7 years. Labrum injury was detected in 78%, and acetabular cartilage injury in 56% of cases. The average follow-up was 31.3 months. There was a significantly improvement in the mean score in the clinical questionnaires. Radiologically there was no change in the mean joint space, with significantly reduction to normal values of the alpha angle. All patients returned to sports at their pre-injury level of function. DiscussionHip arthroscopy resulted in improvement in hip functional outcomes with correction of the underlying osseous deformity and treatment of the associated labral and cartilage pathology, with the return of patients to their pre-injury sports. Further follow-up is essential to confirm the stability of the clinical and radiological outcomes.

Long-term followup of surgically treated knee dislocations: stability restored, but arthritis is common.

Surgical treatment of knee dislocations is intended to correct the anatomic injury and restore knee stability and patient function. Several studies have shown successful results with surgical treatment of knee dislocations with up to 10 years of followup, but longer-term studies are uncommon. We evaluated patients treated surgically for knee dislocations at 10-year followup to assess (1) knee stability; (2) return to preinjury level of function; (3) development of arthrosis; and (4) range of motion (ROM) loss. This study was a retrospective review of 127 combined PCL, ACL, and medial and/or lateral side reconstructions performed by a single surgeon (GCF) between 1990 and 2008. Of these, 44 were available for clinical and functional evaluation (35%) at a minimum 5-year followup. Inclusion criteria were combined PCL/ACL plus medial and/or lateral side reconstruction. Evaluation methods included arthrometer measurements, stress radiography, knee ligament rating and activity scales (Lysholm and Tegner), plain radiographs with osteoarthritic assessment, and physical examination. Of the 44 patients, there were nine ACL/PCL medial, 22 ACL/PCL lateral, and 13 ACL/PCL mediolateral reconstructions. Followup was at a minimum of 5 years (mean, 10 years; range, 5-22 years). The mean age at the time of injury was 31 years with a range of 13 to 65 years. The mean arthrometer-measured side-to-side differences were as follows: PCL screen, 1.9 mm; corrected posterior, 2.4 mm; corrected anterior, 0.8 mm; and anterior displacement at 30° of knee flexion, 1.7 mm. Stress radiographic measurements at 90° of knee flexion revealed a mean side-to-side difference of 1.9 mm. Mean Lysholm, and Tegner scores were 84 of 100 and 4.1 of 9, respectively. Ninety-three percent (41 of 44) of patients returned to their preinjury level of activity or one Tegner grade lower. Ten of the 44 knees (23%) developed degenerative joint disease. The mean flexion loss was 12.5°, and flexion contractures were not seen in any of the patients. We found that a high proportion of patients treated for these severe injuries achieved static and functional stability, allowing the return to physically demanding work and recreational activities, but that nearly one-fourth of them will develop arthritis at a mean of 10 years. We cannot extrapolate our results to an elite athlete population, but our results probably apply well to working class populations. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Fragility fractures of the ankle in the frail elderly patient: treatment with a long calcaneotalotibial nail.

Conventional methods of treating ankle fractures in the elderly are associated with high rates of complication. We describe the results of treating these injuries in 48 frail elderly patients with a long calcaneotalotibial nail. The mean age of the group was 82 years (61 to 96) and 41 (85%) were women. All were frail, with multiple medical comorbidities and their mean American Society of Anaesthesiologists score was 3 (3 to 4). None could walk independently before their operation. All the fractures were displaced and unstable; the majority (94%, 45 of 48) were low-energy injuries and 40% (19 of 48) were open. The overall mortality at six months was 35%. Of the surviving patients, 90% returned to their pre-injury level of function. The mean pre- and post-operative Olerud and Molander questionnaire scores were 62 and 57 respectively. Complications included superficial infection (4%, two of 48); deep infection (2%, one of 48); a broken or loose distal locking screw (6%, three of 48); valgus malunion (4%, two of 48); and one below-knee amputation following an unsuccessful vascular operation. There were no cases of nonunion, nail breakage or peri-prosthetic fracture. A calcaneotalotibial nail is an excellent device for treating an unstable fracture of the ankle in the frail elderly patient. It allows the patient to mobilise immediately and minimises the risk of bone or wound problems. A long nail which crosses the isthmus of the tibia avoids the risk of peri-prosthetic fracture associated with shorter devices.

Mid-term results after treatment of intertrochanteric femoral fractures with percutaneous compression plate (PCCP)

BackgroundWith the ageing of the population, intertrochanteric femoral fracture is associated with increased morbidity. There is continuing controversy over the best treatment for the injury, and the choice of internal fixation method has been a focus of dispute. The purpose of this study was to evaluate the results of these fractures being treated with the percutaneous compression plate (PCCP) technique. MethodsFrom March 2009 to May 2012, 154 patients with intertrochanteric femoral fractures were treated using the PCCP method. Forty-one patients were excluded from the study. According to the AO classification, the remaining 113 fractures were classified as 35 cases of 31A1 fractures, 59 cases of 31A2 fractures, and 19 cases of 31A3 fractures. The clinical data and imaging results were retrospectively analysed. ResultsThe mean operation time was 42.0 (range, 25–82) min, the mean intraoperative blood loss was 40.5 (range, 10–100) ml, and the mean hospital stay was 8.6 (range, 3–18) days. One patient died of renal failure in the perioperative period. Twelve patients died during the 12 months after surgery. The remaining 100 patients were followed-up for 12–36 months and healed their fractures except one, whose neck screw cut out from the femoral neck after 1 postoperative month and resulting in a revision to a hemiarthroplasty. The mean time to bone healing was 12.6 (range, 6–23) weeks. Sixteen patients had pain. There were 13 major device-related complications, including 5 cases of coxa vara, 4 cases of fracture collapse, 2 cases of head penetration, and 2 cases of fracture collapse combined with head penetration. At the time of the last follow-up, 81 patients had regained a pre-injury level of function. The median Harris hip score was 89 points. The median Parker-Palmer score was 7 points. Patients with poor quality of reduction and bad positioning of neck screw were more likely to suffer complications (p<0.05). ConclusionThe results suggest that the PCCP is an effective and safe method in the treatment of all types of intertrochanteric femoral fractures, but good fracture reduction and ideal positioning of the neck screw are prerequisites for the success of the device.

A Preliminary Report of Acute and Subacute Arthroscopic Repair of the Radial Ulnohumeral Ligament After Elbow Dislocation in the High-Demand Patient

The purpose of this study was to evaluate functional outcomes, range of motion (ROM), elbow stability, and time to return to full activities after acute and subacute arthroscopic repair of a simple elbow dislocation in high-demand patients. "High-demand patients" were defined as in-season athletes and individuals who required use of both hands for their profession and believed that they could not miss the 6 weeks of work that may be required with conservative treatment in an elbow brace. We retrospectively reviewed 14 consecutive patients with a simple elbow dislocation who underwent arthroscopic repair of the radial ulnohumeral ligament from 2008-2012. Outcomes measures included the Mayo Elbow Performance Score (MEPS), elbow ROM, elbow stability, and time to return to full activities. Each patient was contacted once by telephone to determine the current activity level and presence of any pain or functional limitations. The mean patient age was 25 years, with telephone follow-up at a mean of 30 months and clinical examination after a minimum of 6 months. The postoperative MEPS was excellent (mean, 99.6; range, 95 to 100) for all 14 patients, and all returned to their preinjury level of function with no restrictions or instability. Final ROM averaged -3° of full extension to greater than 130° of flexion. The mean time to return to full activities in and out of a brace was 2.7 weeks and 6.6 weeks, respectively, in the acute group and 4.6 weeks and 8.9 weeks, respectively, in the subacute group. All patients were satisfied with their outcome. Conservative management remains the gold standard for most simple elbow dislocations. We believe that certain high-demand patients may be candidates for acute arthroscopic ligamentous repair. Our preliminary data show that acute arthroscopic repair of the radial ulnohumeral ligament is a safe, effective procedure that restores stability to the elbow and allows patients to quickly return to full activities. Level IV, therapeutic case series.

Isokinetic evaluation after two-stage bicruciate reconstruction

Objective: To assess the functional balance of the knee after bicruciate reconstruction and its correlation with clinical score. Methods: 14 patients (11 men and three women), mean age 29.9±7.65 years, mean BMI 26.2±2.51 kg/m2 underwent surgical reconstruction of the Posterior Cruciate Ligament (PCL) and Anterior Cruciate Ligament (ACL) in two stages, with a mean interval of 3 months between procedures. With a mean follow-up period of 27.33 months, the isokinetic knee analysis was performed at 60°/s and 180°/s and the Lysholm and Tegner scores were applied. Results: The Lysholm score was 86.8±11.1 points and the Tegner score showed a deficit of 30% compared to pre-injury level. In isokinetic evaluation, the deficit of the operated quadriceps average torque was 17.05% at 60°/s and 12.16% at 180°/s, while the average flexor torque deficit was 3.43% at 60°/s and 5.82% at 180°/s. Although it was observed torque deficit between members, there were no statistical differences regarding the functional balance between hamstrings and quadriceps. Conclusion: Although the results of isokinetic evaluation has shown a functional balance of the knee (flexor-extensor), which may have contributed to the good subjective Lysholm score in the bicruciate two-stage reconstruction, two-stage reconstruction did not restore the pre-injury functional level. Level of Evidence IV, Case Series.