FRCS orth course Important papers in Orthopaedics

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1 FRCS orth course Important papers in Orthopaedics Scaphoid, Distal radius

2 Scaphoid fracture

3 JBJS Am 2005 oct Should acute scaphoid fractures be fixed? A randomized controlled trial. Dias JJ, Wildin CJ, Bhowal B, Thompson JR. Leicester UK Level 1 evidence N= in each group early internal fixation with use of a Herbert screw without a cast avg 9days post injury vs nonop treatment for eight weeks with immobilization in a below-the-elbow plaster cast with the thumb left free Regular f/u the severity of pain; tenderness; swelling; wrist movement; grip strength; and symptoms and disability+ x-rays Patients returned to work at five to six weeks after the injury in both groups At twelve weeks, grip strength was better in patients who had had surgery. No significant difference was detected between the two groups with respect to any other outcome measure at any other time. 10/44 nonop had not healed radiographically at twelve weeks, and, as a consequence, the treatment was altered. 9/44 operative gp minor complications no clear benefit of early fixation of acute scaphoid fractures over non op Rx. aggressive conservative treatment, carefully assess fracture-healing with plain radiographs, and computed tomography scans, after six to eight weeks of cast immobilization and recommend surgical fixation with or without bone-grafting at that time if a gap is identified at the fracture site. Such an approach should result in fracture union in over 95% of such patients.

4 Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean follow-up of 93 months Prof JJ Dias 2008 JBJS N=71 Non op=36 Op=35 f/u 7 ½ years no statistical difference in symptoms and disability FOR ROM, grip strength, pinch strength or patient rated scores. X-rays: n= 59 patients. OA changes scaphotrapezial (ST)and radioscaphoid (RS)joints no statistical difference. 3/35 patients had asymptomatic lucency surrounding the screw. 1/36 non-operatively treated patient developed nonunion with avascular necrosis. 5/36 scapholunate angle ( > 60 ), 4/5 asymptomatic. No medium-term difference in function or radiological outcome was identified between the two treatment groups.

5 Scaphoid fracture Ix J Bone Joint Surg Br Sep Early magnetic resonance imaging compared with bone scintigraphy in suspected scaphoid fractures. Beeres FJ, Rhemrev SJ, Netherlands N=100 with a suspected scaphoid fracture but without evidence of a fracture on plain radiographs using MRI within 24 hours of injury, and bone scintigraphy three to five days after injury. The reference standard for a true radiologically-occult scaphoid fracture was either a diagnosis of fracture on both MRI and bone scan, or, in the case of discrepancy, clinical and/or radiological evidence of a fracture. MRI false negative in four patients and bone scan in eight. MRI sensitivity 80% and a specificity of 100%. Bone scintigraphy had a sensitivity of 100% and a specificity of 90%.

6 CORR 2009 Sep Diagnosing Suspected Scaphoid Fractures: A Systematic Review and Meta-analysis. Level III Yin ZG, China Imaging protocols for suspected scaphoid fractures are inconsistent. bone scan, MRI, and CT for diagnosing suspected scaphoid fractures. 26 studies. The pooled sensitivity, specificity, natural logarithm of the diagnostic odds ratio, and PPV & NPV were, respectively, 97%, 89%, 4.78, 8.82, and 0.03 for bone scan; 96%, 99%, 6.60, 96, and 0.04 for MRI; and 93%, 99%, 6.11, 93, and 0.07 for CT. MRI is more specific and better for confirming scaphoid fracture.

7 Treatment Injury 2009 Mar Operative versus nonoperative treatment of acute undisplaced and minimally displaced scaphoid waist fractures--a systematic review. Modi CS, Nancoo T, Powers D, Ho K, Boer R, Turner SM. United Kingdom. CORR2007 Jul Treatment of acute scaphoid fractures: systematic review and metaanalysis. Yin ZG, China Included studies were critically appraised using levels of evidence and RCTs were further appraised using a scoring tool. 112 studies, 12 included. Three level 1 RCTs, three level 2 RCTs, two meta-analyses, one economic analysis, and three retrospective studies Percutaneous fixation may result in faster union rates by approximately 5 weeks and an earlier return to sport and work by approximately 7 weeks over cast treatment. This difference is not seen when comparing ORIF with cast treatment. cast treatment results in a higher nonunion rate than ORIF, this needs to be balanced with the 30% minor complication rate. Manual workers require significantly longer time off work than non-manual workers regardless of the method of treatment, ( return to work sooner after ORIF than after cast treatment) Operative treatment should be reserved for patients unable to work in a cast and considered for most manual workers and high-level athletes Jul Treatment of acute scaphoid fractures: systematic review and meta-analysis. Yin ZG, China Operative treatment of acute nondisplaced or minimally displaced fractures of the scaphoid waist does not provide greater benefits regarding nonunion rate, return to work, grip strength, range of wrist motion, or patient satisfaction than cast immobilization Operative treatment of acute nondisplaced or minimally displaced fractures of the scaphoid waist DOES NOT provide greater benefits regarding nonunion rate, return to work, grip strength, range of wrist motion, or patient satisfaction than cast immobilization; however, it causes more complications and, perhaps, a higher risk of scaphotrapezial osteoarthritis. There is no evidence from randomized trials to determine whether operative treatment is superior to nonoperative treatment for an acute proximal pole fracture of scaphoid bones. There is insufficient evidence to determine which type of cast should be used in nonoperative treatment of nondisplaced scaphoid fractures.

8 Conservative treatment of scaphoid nonunion in children and adolescents. Prolonged treatment with cast immobilisation resulted in union of the fracture and an excellent Modified Wrist Score in all patients. D. M. Weber JBJS Br Sep

9 Proximal row carpectomy vs four corner fusion for scapholunate (Slac) or scaphoid nonunion advanced collapse (Snac) wrists: a systematic review of outcomes. Mulford JS, Ceulemans LJ, Nam D, Axelrod TS. J Hand Surg Eur Vol Apr motion-preserving, salvage procedures for scaphoid nonunion (SNAC) or scapholunate advanced collapse (SLAC). 52 articles SNAC or SLAC for PRC or 4CF. both procedures give improvements in pain and subjective outcome measures for patients with symptomatic and appropriately staged SLAC or SNAC wrists. PRC better postoperative range of movement and 4CF :nonunion, hardware issues and dorsal impingement. PRC:risk of subsequent OA significantly higher Grip strength, pain relief and subjective outcomes similar in both treatment groups.

10 SNAC: scaphoid and triquetral excision combined with capitolunate arthrodesis versus 4-corner (capitate, hamate, lunate, triquetrum) fusion Hand Surg Am sept Clinical Outcomes of Scaphoid and Triquetral Excision With Capitolunate Arthrodesis Versus Scaphoid Excision and Four-Corner Arthrodesis. Gaston RG, USA retrospective n=50 patients radiographs, wrist range of motion grip strength; VAS; and DASH questionnaire. Out come same at 3 years f/u. CLA: a lessened need for bone graft harvesting low nonunion rate easier reduction of the lunate following triquetral excision, avoiding subsequent symptomatic pisotriquetral arthritis Screw migration, however, remains a concern with this technique Level of evidence:iii.

11 Degenerative arthritis of the wrist: proximal row carpectomy versus scaphoid excision and four-corner arthrodesis. Cohen MS, USA J Hand Surg Am Both PRC and scaphoid excision and 4-corner arthrodesis are motion-preserving options for the treatment of scapholunate advanced collapse arthritis with minimal subjective or objective differences in short-term follow-up evaluations

12 Scapholunate advanced collapse wrist: proximal row carpectomy or limited wrist arthrodesis with scaphoid excision? Tomaino MM USA J Hand Surg Am for wrists without capitolunate arthritis, PRC avoids the technical demands, lengthy postoperative immobilization, and risk of nonunion associated with LWF (limited intercarpal arthrodesis with scaphoid excision), but for stage III disease (capitolunate arthritis) pain relief may be unsatisfactory, and LWF is recommended. N=24 Retrospective

13 Distal Radial Fracture

14 REDISPLACED UNSTABLE FRACTURES OF THE DISTAL RADIUS A PROSPECTIVE RANDOMISED COMPARISON OF FOUR METHODS OF TREATMENT M. M. MCQUEEN, C. HAJDUCKA, C. M. COURT-BROWN Edinburgh, Scotland JBJS Br May 1996 Level 1 A PROSPECTIVE RANDOMISED COMPARISON OF FOUR METHODS OF TREATMENT N=120 ( 30 in each group) 1) remanipulation + forearm cast 6/52 2) open reduction and bone grafting (McBirnie et al 1995) 3) closed re-reduction and application of a Pennig external fixator removed at 6/52 4) closed re-reduction and application of a Pennig external fixator as in group 3 but early mobilisation at 3/52 Radiological results better improvement in angulation of the distal radius Functional results:6/52, 3-6 and 12 months no difference Carpal malalignment :statistically ve effect on functional results.

15 Do young patients with malunited fractures of the distal radius inevitably develop symptomatic posttraumatic osteoarthritis? D. P. Forward, T. R. C. Davis, Nottingham JBJS May years f/u N=106 adults fracture of the distal radius between and who were below the age of 40 years at the time of injury. Clinical and radiological assessment at a mean follow-up of 38 years (33 to 42). No patient required a salvage procedure. there was radiological evidence of post-traumatic osteoarthritis after an intra-articular fracture in 68% of patients (27 of 40), (DASH) scores were not different from population norms, and function, significant relationship between narrowing of the joint space and extra-articular malunion (dorsal angulation and radial shortening) as well as intra-articular injury. grip strength had fallen to 89% of that of the uninjured side in the presence of dorsal malunion imperfect reduction of these fractures may not result in symptomatic arthritis in the long term

16 Functional Outcomes for Unstable Distal Radial Fractures Treated with Open Reduction and Internal Fixation or Closed Reduction and Percutaneous Fixation A Prospective Randomized Trial JBJS Am 2009 Tamara D. Rozental USA level 1 N=45 22 CR+ k wire 23 volar plate Both closed reduction with percutaneous pin fixation and open reduction with internal fixation with use of a volar plate are effective methods for the treatment of dorsally displaced, unstable, extra-articular or simple intra-articular fractures of the distal part of the radius. Better functional results can be expected in the early postoperative period in association with open reduction and internal fixation, and this form of treatment should be considered for patients requiring a faster return to function after the injury.

17 Locking plates A revolution in the management of fractures of the distal radius? N. D. Downing, JBJS 2008 A number of clinical and biomechanicalstudies have demonstrated the advantages of restoring normal anatomy, but the number of studies which have used validated patient-derived outcome measures has been few and there are no long-term prospective comparative studies of alternative methods of treatment to guide our management. A comparison between subjective outcome score and moderate radial shortening following a fractured distal radius in patients of mean age 69 years. J Hand Surg Eur Vol 2007 Barton found no correlation between moderate shortening (up to 8mm) and outcome, as assessed by the Patient Related Wrist Evaluation at a mean follow-up of 29 months

18 Distal radius# Cochrane database2007 Jul 2009 Jul Prospective randomised study of intraarticular fractures of the distal radius: comparison between external fixation and plate fixation. Xu GG, Chan SP, Puhaindran ME, Chew WY. compare the outcomes of external fixation (EF) with open reduction internal fixation (ORIF) with plates and screw fixation in the treatment of intra-articular fractures of the distal radius. Percutaneous pinning for treating distal radial fractures in adults. Handoll HH, Vaghela MV, Madhok R. Edinburg Adult fracture of the distal radius,compared percutaneous pinning with conservative treatment, or different aspects of percutaneous pinning. CONCLUSIONS: Though there is some evidence to support its use, the precise role and methods of percutaneous pinning are not established. The higher rates of complications with Kapandji pinning and biodegradable materials casts some doubt on their general use. N=35, after a failure of initial conservative treatment. The patients were randomised.patients were followed-up at 1 week, 3, 6, 12 and 24 months. Of the 35 patients, 5 were excluded. Out come not significantly different. Complication rates similar. CONCLUSION: There is no significant difference in the outcome of intra-articular distal radius fractures treated with either EF or ORIF. External fixation versus conservative treatment for distal radial fractures in adults. Handoll HH, Huntley JS, Madhok R. Edinburgh There is some evidence to support the use of external fixation for dorsally displaced fractures of the distal radius in adults. Though there is insufficient evidence to confirm a better functional outcome, external fixation reduces redisplacement, gives improved anatomical results and most of the excess surgically-related complications are minor.

19 Distal radius fracture JBJS am 2007 Management of Distal Radial Fractures Neal C Chen, J Jupiter Prediction of Instability in Distal Radial Fractures M.M. McQueen JBJS AM distal radial fractures were prospectively recorded over a 5.5- year period. The database was validated by re-examining a sample of it. Complex but fairly accurate in predicting instability