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Resident Research

Submitted by nworks on Wed, 09/14/2016 - 1:48pm

Marlis Sabo, MD, FRCSC
Director, Resident/Fellow Research
 
 
 
 
 
 
 
 
Resident Research Program Goals

The overall goals of the resident research program are to ensure that upon completion of the orthopaedic residency program, our graduates will demonstrate:

  • The ability to effectively engage with new scientific literature
  • A practical understanding of how to navigate the process of scientific inquiry
  • The ability to apply the research skills learned during residency to critical assessment of personal outcomes, to local QI/QA projects, and to participation in formal faculty research projects if desired.

Resident Research Opportunities

Residents in our program are involved with a variety of research projects, including basic science projects, database studies, clinical outcomes research, and knowledge synthesis projects.  Specific opportunities can be discussed with individual faculty members or through contact of the Research Lead for the subspecialty area of interest.  In addition to individual faculty mentorship on research projects, a more formal circuit of workshops and other learning activities are scheduled during the academic year on topics in research methods, dissemination, and scientific communication.

Each resident in PGY1-4 also presents either a finished project, or a project in progress at our annual Resident Research Day in May.  Samples of past projects are available below.

Specific questions or inquiries may be directed to acortho@ucalgary.ca.

Dr. Jennifer Leighton - Evaluation of the proximal femur in atypical femur fractures – is the AP pelvis radiograph enough?

Title: Evaluation of the proximal femur in atypical femur fractures – is the AP pelvis radiograph enough?
 
Authors: Jennifer Leighton, MD ; Prism Schneider, PhD, MD, FRCSC
 
Introduction:
The anteroposterior (AP) pelvis radiograph is standardly used in the evaluation of both hip and pelvic pathology. Atypical femur fractures (AFF) have recently been identified as a relatively new entity in hip and femur pathology, resulting from atypical bone mineralization due to use of bisphosphonates. No consensus exists regarding use diagnostic imaging tests to effectively identify the changes that precede AFF.  Variability in the location of the AFF has been demonstrated throughout the literature.
 
We hypothesized that simple AP pelvis radiographs are highly variable, and do not reliably capture enough of the proximal femur to safely identify these pathologic changes. At present, there is no literature citing the average length of proximal femur typically seen on an AP pelvis radiograph.  Radiographic criteria cite only that the x-ray must include visualization of the innominate bones, down to a level distal to the lesser trochanter. We thus sought to identify the average length of proximal femur visualized on the AP pelvis x-ray. This was then compared to the literature regarding the location of AFF.
 
Methods:
This was a survey of the primary investigator’s practice and a pilot study for future work. It used standard AP Pelvis x-rays in adult patients with adequately exposed greater and lesser trochanters. The length of proximal femur pictured was measured using a standardized measurement technique. This was the primary outcome. Secondary outcomes were age and gender effects on measurement.
 
Results:
Three reviewers looked at 109 hips in 72 patients (36 male, 36 female). Mean age was 59.2 years (+/- 23.9 years; range 17-91 years).  Mean distance captured on the AP pelvis x-rays, was 148.2mm (+/- 37.4mm; range 73.1-297.0mm). The mean for males was 150.3mm (+/- 30.4mm; range 92.9-297.0mm), while for females it was 144.1mm (+/- 39.9mm; range 73.1-293.7mm). This difference trended towards more femur exposure in male patients, but was not statistically significant (p=0.07). There was no difference between right and left hips (p=0.50). Within subject variability was noted to be large.
 
Discussion:
Significant variability was noted in the length of proximal femur visualized on an AP pelvis x-ray in this pilot study, demonstrating a lack of standardization. In applying this to AFF, the literature has demonstrated significant variability in their location.  Diaphyseal AFF account for 52-64% of all AFF, with both gender and geographic variability noted. This suggests that in applying only an AP pelvis radiograph  - with poor standardization - in AFF screening, a significant number of at risk femora may be missed. As a pilot project, this raises an important question regarding standardization of AP pelvis x-rays, with broad implications. It demonstrates feasibility for a definitive study. Work is now ongoing in this area.
 
Character count: 2872 (spaces included)
Funding sources: n/a
CHREB ID: Pending

Dr. Devin Lemmex - Aging and menopause affect lubricin/PRG4 mRNA levels in knee ligaments

Title: Aging and menopause affect lubricin/PRG4 mRNA levels in knee ligaments
 
Authors: D.B. Lemmex, Y. Ono, D.A. Hart, I.K.Y. Lo, G.M. Thornton
 
Introduction
Lubricin/proteoglycan 4 (PRG4) is a boundary lubricant in synovial joints and both a surface and collagen inter-fascicular lubricant in ligaments. Our objective was to characterize the mRNA levels for lubricin/PRG4 in the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL) in aging and surgically-induced menopausal rabbits. Our hypothesis was that lubricin/PRG4 mRNA levels would be increased in ligaments from aging rabbits and menopausal rabbits compared with ligaments from normal rabbits.
 
Methods
Four knee ligaments (ACL, PCL, MCL, LCL) were isolated from normal (1-year-old rabbits, n=8), aging (3-year-old rabbits, n=6), and menopausal (1-year-old rabbits fourteen weeks after surgical ovariohysterectomy, n=8) female New Zealand White rabbits. RT-qPCR was utilized to determine the mRNA levels for lubricin/PRG4 normalized to the housekeeping gene 18S. Data for normal, aging, and menopausal rabbits for each knee ligament (ACL, PCL, MCL, LCL) were compared using ANOVA with linear contrasts or Kruskal-Wallis test with Conover post-hoc analysis.
 
Results
For ACLs, mRNA levels for lubricin/PRG4 were increased in aging rabbits and menopausal rabbits compared with normal rabbits (p≤0.056). For PCLs, trends for increased lubricin/PRG4 mRNA levels were found when comparing aging rabbits and menopausal rabbits with normal rabbits (p≤0.092). For MCLs, mRNA levels for lubricin/PRG4 were increased in aging rabbits and menopausal rabbits compared with normal rabbits (p≤0.050). For LCLs, there were no differences detected in lubricin/PRG4 mRNA levels comparing the three models. For the four ligaments, there were no differences detected in lubricin/PRG4 mRNA levels comparing ligaments from aging rabbits with ligaments from menopausal rabbits.
 
Discussion
Lubricin/PRG4 has a role in collagen fascicle lubrication in ligaments (1,2). Increased lubricin/PRG4 gene expression was associated with mechanical changes (including decreased modulus and increased failure strain) in the aging rabbit MCL (3). Detection of similar molecular changes in the ACL, and possibly the PCL, suggests that their mechanical properties may also change as a result of increased lubricin/PRG4 gene expression, thereby potentially pre-disposing these ligaments to damage accumulation. Compared to aging ligaments, aging tendons exhibited decreased lubricin/PRG4 gene and protein expression, and increased stiffness (4). Although opposite the changes in aging ligaments, these findings support the relationship between lubricin/PRG4 and modulus/stiffness. The similarities between ligaments in the aging and menopausal models may suggest that surgically-induced menopause results in a form of accelerated aging in the rabbit ACL, MCL and possibly PCL.
 
References
1. Funakoshi T et al. (2008) J Bone Joint Surg (Am) 90:803
2. Lee SY et al. (2008) Tissue Eng 14:1799
3. Thornton GM et al. (2015) J Biomech 48:3306
4. Kostrominova TY and Brooks SV. (2013) Age 35:2203
 
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Dr. Christopher Nielsen - What is the diagnostic value of the pain diagram compared to MRI in the evaluation of sciatica?

Title: What is the diagnostic value of the pain diagram compared to MRI in the evaluation of sciatica?
 
Authors: Christopher J Nielsen, MD, BSc, Herman Johal, MD, MPH, FRCSC, Godefroy Hardy St-Pierre, MD, FRCSC, Kenneth C Thomas, MD, MHSc, FRCSC, Jacques Bouchard, MD, FRCSC
 
Introduction
Sciatica is a common diagnosis largely believed to be due to mechanical nerve root compression first described by Mixter and Barr in 1934.  Pain diagrams have been used for decades by physicians for patient evaluation and have been studied in spine patients to screen for underlying psychological traits as well as their correlation with surgical and MRI findings.
 
Methods
138 consecutive patients were reviewed.  Two staff orthopaedic spine surgeons, and one senior orthopaedic surgery resident rated both the pain diagrams and MRIs.  Pain diagrams were scored using previously described methods by Ransford and Uden, as well as given an overall impression by the raters.  MRIs were rated for the presence and location of nerve root compression.
 
Results
The average Ransford score was 2.70 (2.17-3.21) with an ICC statistic of moderate (0.75).  Modifying the Ransford cutoff from 3 to 2, sensitivity was 49.4% (43.8%-55.0%), specificity 68.1% (57.7%-77.3%), ROC 0.59 (0.53-0.64) and PPV 84.0% (78.0%-89.0%).  Patients rated as organic or possibly organic using the Uden method were 57.2% (52.4%-62.0%) with a moderate kappa statistic (0.41).  The Uden method had a sensitivity of 62.2% (56.6%-67.5%), specificity of 59.6% (49.0%-69.6%), ROC 0.61 (0.55-0.67) and PPV of 84.0% (78.7%-88.4%).  Overall impression rated patients with perceived radiculopathy or claudication in 51.2% (46.4%-56.0%) of patients with a moderate kappa statistic (0.49).  Overall impression sensitivity was 56.9% (51.2%-62.4%), specificity 68.1% (57.7%-77.3%), ROC 0.63 (0.57-0.68) and PPV 85.8% (80.4%-90.2%).  Presence of nerve root compression on MRI was evident 77.3% (72.9%-81.1%) of the time with moderate kappa statistic (0.53).
 
Conclusion
Using pain diagrams for the evaluation of sciatica provide modest correlation with presence of nerve root compression as seen on MRI.  The overall impression of the raters was slightly more effective than previously described methods.  Further research into the utility of pain diagrams should include adjuncts to improve their overall performance.
 
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Dr. Jessica Page - Simple Multidisciplinary Arthroplasty Wound Assessment (SMArt) Tool: Assessment of Validity, Reliability, and Responsiveness

Title: Simple Multidisciplinary Arthroplasty Wound Assessment (SMArt) Tool: Assessment of Validity, Reliability, and Responsiveness
 
Authors:  Jessica Page, Brendan Sheehan, Herman Johal, Sahil Kooner, Dr. Robert Korley (PI)
REB ID: REB15-0853
 
Author disclosures: none
 
Introduction: 
Hip and knee arthroplasty makes up a large proportion of orthopedic procedures, with 5216 total hip replacements and 6114 total knee replacements performed in Alberta in 2012-2013.  Infection is a potentially devastating and costly complication, the effects of which may be mitigated with early detection.  A systematic review of the literature in 2013 failed to identify any validated tools for assessing and grading arthroplasty wounds.  We seek to determine the validity, reliability, and responsiveness of a novel “Simple Multidisciplinary Arthroplasty Wound Assessment (SMArt)” tool for the assessment of primary hip and knee arthroplasty wounds.
 
Methods:
The SMArt tool generates a score out of nine points based on: peri-incisional skin appearance, exudate quality, and blister quantity.  We define the current gold standard for validity analysis as a ten-point visual analogue scale (VAS).  Wound data (clinical picture and video) is collected from primary hip and knee arthroplasty patients 2-3 weeks post-operatively.  A sample size of 187 wounds is required for an expected Intraclass Correlation Coefficient (ICC) of 0.7 with a 95% confidence interval and six interdisciplinary wound assessors (nurses, residents, staff orthopedic surgeons).  Assessors will view the wound data using a computer and assess the health of the incisions using the SMArt tool and the VAS.  Re-scoring will occur six weeks later for analysis of intraobserver reliability.  Phase two of the project will examine post-operative infection and responsiveness of the SMArt tool to predict this.  Infection presence will be determined through a chart review at minimum of one year, assessing need for revision surgery or washout, elevated inflammatory markers attributable to the surgical site, prescription of antibiotics, or presence of positive wound cultures.
 
Status: 
Ethics clearance now re-obtained after hold placed during 2015 due to inadvertent discrepancies identified.  COREF grant previously obtained for tool generation.  Awaiting results of CSRDF grant application for stats funding.
Wound data on 155/187 patients obtained. Prior recruitment issues rectified, with recruitment completion expected by May 2016.  Scoring of wounds by inter-disciplinary panel expected in summer 2016.
 
Requirements:   
Funding for statistical assistance is the current hurdle.  A statistician is required to develop our testing strategy prior to engaging the scoring panel, as well as to analyze the inter and intra-observer reliability data.  We await grant application results.
 
Application: 
If found to be valid and reliable, the SMArt tool has the potential to enhance interprofessional communication and the assessment of post-operative arthroplasty wounds.  As the wounds will be assessed using electronic data, the tool has potential applications for telehealth assessment of patients from rural areas.  This tool may be useful for the early identification of at-risk or infected post-arthroplasty wounds, which could allow for early intervention and treatment.
 
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Dr. Natalie Rollick - Assessing Osteoporosis Management of Fragility Fracture Patients in Cast Clinic

Title: Assessing Osteoporosis Management of Fragility Fracture Patients in Cast Clinic
 
Authors: Rollick, R. Korley, P. Duffy, C.R. Martin, R. Buckley, K. Carcary, P. Schneider
 
Introduction:
Orthopaedic surgeons frequently assess fragility fractures (FF), however osteoporosis (OP) is often managed by primary care physicians (PCP). Up to 48% of FF patients have had a previous fracture (Kanis et al., 2004). Discontinuity between fracture care and OP management is a missed opportunity to reduce repeat fractures. This studied aimed to evaluate current OP management in FF patients presenting to cast clinic.
 
Methods:
A single centre, prospective observational study where seven traumatologists screened for FF in cast clinic. FF was defined as a hip, distal radius (DR), proximal humerus (PH), or ankle fracture due to a ground level fall. Patients completed a self-administered questionnaire for demographics, fracture type and treatment, medical and fracture history, and previous OP care. The primary outcome was number of FF patients who received OP investigation and/or treatment. Secondary outcomes included Fracture Risk Assessment Tool (FRAX) and repeat fracture rate. Descriptive statistics were used for analysis.
 
Results:
Between November 17, 2014 and October 13, 2015, a total of 1,677 patients attended cast clinic for an initial assessment. FF were identified in 120 patients (7.2%). The FF cohort had a mean age of 65.3 (± 14.3) years, mean BMI of 26.1 (± 5.3), and was comprised of 83.3% females. Fracture distribution was 69 (57.5%) DR, 23 (19%) ankle, 20 (16.5%) PH, and seven (5.8%) hip fractures, with 24 of the FF (19.8%) treated operatively. Thirteen (10.8%) were current smokers and 40 (33.3%) formerly smoked. A history of steroid use was present in 13 patients (10.8%). Ninety (75%) patients ambulated independently.
 
Twenty-two patients (18.3%) reported prior diagnosis of OP, most often by a PCP (n = 19; 73.7%) over 5 years previously. Calcium (n = 59; 49.2%) and Vitamin D (n = 70; 58.3%) were common and 26 patients (21.5%) had a prior anti-resorptive therapy, with Alendronate (n = 9) being most common.
 
Forty-seven patients (39.2%) had a prior fracture at a mean age of 61.3 (± 11.9) years, with DR and PH fractures being most common. Eleven patients had two or more prior fractures. A family history of OP was found in 34 patients (28.1%). Mean FRAX score was 20.8% (± 10.8%) 10-year major fracture risk and 5.9% (± 6.6%) 10-year hip fracture risk. Of the 26 patients with a Moderate (10-20%) or High (> 20%) 10-year major fracture risk, only eight (30.8%) reported a diagnosis of OP and only three (11.5%) had seen an OP specialist.
 
Discussion:
Cast clinics provide an opportunity for OP screening, initiation of treatment, and patient education. This cohort demonstrated a high rate of repeat fractures and poor patient reporting of prior OP diagnosis. This study likely underestimated FF and calls for resource allocation for quantifying true burden of disease and outpatient fracture liaison service.
 
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Dr. Ed Schwartzenberger - What are the sleep patterns of residents?

Title:  What are the sleep patterns of residents?
 
Author:  Dr Ed Schwartzenberger
 
Co-Authors: Dr Valerie Kirk, Dr Simon Goldstein
 
Introduction:
Currently, residency programs are being faced with making tough decisions regarding work hours and fatigue management.   Patient safety, resident health, and maintaining education quality and clinical experiences are a few of the aspects to be balanced in such decisions.  Most of the research, to date, on resident sleep is from retrospective sleep logs, a method prone to inaccuracy.  The purpose of this study was to objectively determine the sleep patterns of orthopaedic and paediatric residents through a method known as actigraphy.  We hypothesized that residents are getting less sleep than the Canadian average, sleep is further decreased when on call, sleep is affected by the call scheduling technique (24 hours v.s night float), and sleep patterns are affected by year in the residency program. 
 
Methods:
Participants were recruited from the University of Calgary orthopaedic and paediatric residency programs.  Sleep patterns of the participants were recorded for two weeks using actigraphy monitors, which are devices that can determine sleep patterns through measuring movement and light.  A written sleep log was also collected.  Data was downloaded from the devices, compiled by a trained research technologist and then coded for analysis.  Statistical analysis included T-tests and linear regression.
 
Results:
Participants from the University of Calgary orthopaedic (21) and paediatric (5) residency programs were recruited.  Residents had decreased average sleep (M=4.9hr, SD=3.1hrs) compared to the national age and sex matched norms (M=8.1 hrs, P<0.01).  Residents total sleep on call was 0.89 hr less (p=0.02) than their baseline sleep duration.  Orthopaedic residents get on average 2.3 hrs less sleep than paediatric residents (p<0.01).  Regression demonstrated that paediatric programs  and increased postgraduate year were both correlated with increased sleep, while having children less than two years old was associated with less sleep.  Total sleep while on junior call (M=4.06hrs, SD=2.9) was not statistically difference from senior call (M=5.3 hrs, SD=3.1.4, p=0.06).  Additionally, total sleep when on home call (M=4.3hrs, SD=2.9) was not statistically different from in-hospital call (M=3.4hrs, SD=2.7, p=0.23). 
 
Discussion:
Residents get almost 3.2 hours less sleep per night than the general population.  Further, their sleep duration is reduced by almost another hour when residents are on call.  There is evidence to suggest that surgical residents get less sleep than other programs; orthopaedic residents slept 2.3 hours less per night than paediatric residents.  As residents progress through their program their hours per night of sleep also increases.    However, if they have children less than two years old they will get less sleep.  The use of actigraphy in addition to sleep logs provides greater confidence that this information on resident’s sleep is accurate, and therefore, can more reliably be used to make policy decisions.  Further, future studies could use this study’s methodology to determine the effectiveness of any policy changes.  The limitations of this study are that this was a single center study, only paediatric and orthopaedic residents were used and there was lower recruitment for paediatric residents.  Further, no measures of performance were administered. 
 
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Dr. David Cinats - The effects of wrist denervation in patients undergoing proximal row carpectomy or four-corner fusion

Title: The effects of wrist denervation in patients undergoing proximal row carpectomy or four-corner fusion
 
Author: David Cinats
 
Preceptor: Dr. Gurpreet Dhaliwal
 
Introduction:
Proximal row carpectomy (PRC) and scaphoid excision with four-corner fusion (4CF) are both motion-preserving procedures for the treatment of wrists with scapholunate advanced collapse (SLAC) or degenerative wrist arthritis associated with scaphoid non-union (SNAC). Both procedures provide patients with significant improvements in pain and subjective outcomes and each procedure has it’s own risks and benefits. Wrist denervation, although used on its own to treat SLAC and SNAC, is performed at the discretion of the surgeon in addition to PRC and 4CF. To our knowledge, the effects of wrist denervation in conjunction with PRC and 4CF has not been studied.
 
Rationale:
Wrist denervation, as an isolated procedure, has been shown to decrease pain in patients who are physically inactive or perform light manual work. When performed with either PRC or 4CF, it should act as an adjunct to improving pain symptoms in patients with SNAC or SLAC wrists.
 
Hypothesis:
Wrist denervation results in improved DASH and MMWS
 
Methods:
Prospective randomized controlled trial. Sample will include all patients at the South Health Campus undergoing PRC or 4CF. Patients will be randomized to treatment with or without wrist denervation. These patients will be administered the Modified Mayo Wrist Score (MMWS) as well as the disability of shoulder, arm and hand (DASH) questionnaire.
 
Data & Analysis:
A power calculation will be performed to determine the total number of patients required to be included in the study. Independent variable is wrist denervation. Dependent variables include DASH and MMWS. If normality in the data can be assumed, data will be analyzed using an unpaired 2-sided student’s t test.
 
Requirements:
Resources will include consent forms for patients, questionnaires for patients to complete following the procedure, and assistance from nursing staff completing the consent and questionnaires. Data will be collected and analyzed by the resident and preceptor.
 
Application/Dissemination:
This study will determine if wrist denervation is a beneficial procedure for patients undergoing PRC or 4CF and will help determine if wrist denervation is a useful adjunct to relieving symptoms in patients with wrist arthritis.

Dr. Denis Joly - Mechanical performance of #2 sutures versus tape sutures in suture-tendon constructs with micro-CT analysis

Title: Mechanical performance of #2 sutures versus tape sutures in suture-tendon constructs with micro-CT analysis
 
Authors: Denis A. Joly, MD; Yohei Ono, MD, PhD; Ian K.Y. Lo, MD, FRCSC; Gail M. Thornton, PhD.
 
Introduction:
Arthroscopic rotator cuff repair (RCR) commonly involves fixation utilizing sutures. High strength sutures have been shown to have superior mechanical characteristics when compared to standard sutures. Furthermore, tape sutures are proposed to provide further strength improvements and wider contact area to prevent sutures pulling through tendon. However, how these sutures behave at the suture-tendon interface, the most common location of failure, has not previously been reported. Therefore, the purpose of this study was to evaluate the low-load behaviour of high strength sutures and tapes biomechanically and with micro-CT. We hypothesized that stiffer sutures would lead to improved construct biomechanical characteristics but lead to large suture defects within the tendon.
 
Methods:
ULTRABRAID (UB), FiberWire (FW), ULTRATAPE (UT) and FiberTape (FT) sutures were implanted in sheep tendon and suture-tendon constructs were evaluated mechanically and imaged using micro-CT after mechanical testing (24 of each suture) or imaged without prior mechanical testing (8 of each suture). Also, isolated sutures were evaluated mechanically (10 of each suture).
For mechanical testing, isolated sutures and suture-tendon constructs were loaded to 10N preload and held for 10s. Cyclic testing was 500 cycles between 10N and 30N at approximately 1Hz. Samples were evaluated for displacement from initial hold to peak of the 500th cycle. Following mechanical testing, suture-tendons constructs underwent micro-CT for analysis with measurement of suture hole volume. Suture-tendon constructs without mechanical testing underwent the same micro-CT analysis.  Data were analyzed using analysis of variance.
 
Results:
When evaluating the displacement from initial hold to peak of the 500th cycle, all suture-tendon constructs had mean displacements less than 3mm, where the order was FT<FW<UT<UB (p<0.0005). Isolated sutures had the same order for displacement from initial hold to peak of the 500th cycle: FT<FW<UT<UB (p<0.0005). When evaluating suture hole volume, the order without mechanical testing was FT>UT>FW>UB (p<0.0005), and the order after mechanical testing was FT>FW>UT>UB (p<0.0005).
 
Discussion:
Stiffer sutures (i.e. FT>FW>UT>UB) lead to less displacement (FT<FW<UT<UB) during low-load cyclic testing of both isolated sutures and suture-tendon constructs. However, stiffer sutures or tapes also created larger holes within the tendon following cyclic loading as measured by hole volume and correlated with suture stiffness (FT>FW>UT>UB).
These results suggest that, while stiff sutures can lead to less displacement of the overall suture tendon construct, the mechanical load may be redistributed from the suture to the suture-tendon interface and results in larger suture-tendon holes. This mechanism may explain the most common mechanism of failure of the rotator cuff repair construct (i.e. at the suture tendon interface). Furthermore, this mechanism may be even more dramatic in degenerative human rotator cuff tendon.
 
Disclosure:
Funding provided by Smith and Nephew.
 
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Dr. Pierre Zaharia - Iatrogenic radial nerve palsy in minimally invasive plate ostheosynthesis (MIPO) of midshaft humeral fractures: A Systematic Review

Title: Iatrogenic radial nerve palsy in minimally invasive plate ostheosynthesis (MIPO) of midshaft humeral fractures: A Systematic Review
 
Authors: P Zaharia MDCM, J Woodmass MD, N Romatowski MD, R Martin MD FRCS, R Buckley MD FRCS
 
Purpose:
The preferred method for humeral shaft fracture fixation has traditionally been operative  plate osteosynthesis or intramedullary nailing.Over the past decade, reports of minimally invasive plate osteosynthesis (MIPO) have emerged in the literature as a novel method of fixation for humeral shaft fractures.Iatrogenic radial nerve palsy is the primary concern with this technique given the lack of exposure and protection of the nerve during the procedure. This systematic review aims to assess primarily the rate of iatrogenic radial nerve palsy and secondarily the rate of infections, non-unions and hardware failure following these procedures.
 
Methods:
Two independent reviewers completed a search of Medline, Embase and Pubmed from1946 to January 2015. The terms ”humerus (MeSH)” or “humer*” AND “fractures, bone (MeSH)” or “fractur*” AND “minimal*” or “invasiv*” or “percutaneous*” were used in combinations to conduct the search. Pooled estimates and 95% confidence intervals were calculated assuming a random-effects model. Statistical heterogeneity was quantified using the I2 statistic.
 
Results:
A total of 2876 abstracts met the search criteria. After removal of duplicates and assess­ment of inclusion/exclusion criteria, 16 articles were selected for data extraction. A total of 476 fractures in 474 patients were reviewed. The rate of iatrogenic radial nerve palsy was 2.8% and the rate of infection was 1.7%. The rate of non-union obtained was 3.4% and the rate of hardware failure was 1.9%.
 
Conclusion:
Minimally invasive plate osteosynthesis technique for the fixation of midshaft humeral fractures is both safe and effective. The overall rates of iatrogenic radial nerve palsy and infection are lower than those previously reported for open plating techniques. Low rates of non-union and hardware failure were obtained as well, comparable to those reported for open plating.
 
No conflict of interest to disclose
 

Dr. Sahil Kooner - Bicompartmental Knee Arthroplasty Versus Total Knee Arthroplasty for the Treatment of Medial Compartment and Patellofemoral Osteoarthritis: A Meta-Analysis

Title: Bicompartmental Knee Arthroplasty Versus Total Knee Arthroplasty for the Treatment of Medial Compartment and Patellofemoral Osteoarthritis: A Meta-Analysis
 
Authors: Dr. Sahil Kooner, Dr. Marcia Clark, Dr. Herman Johal
 
No funding sources
No disclosures or COI
  
Introduction
Interest in bicompartmental knee arthroplasty (BKA) for treatment of medial patellofemoral osteoarthritis (MPFOA) has grown in recent years because BKA offers a bone and ligament-preserving alternative to total knee arthroplasty (TKA). BKA only resurfaces the diseased compartments, while preserving both cruciate ligaments and retaining native knee kinematics. Currently two BKA constructs are commercially available, including a uniblock monolithic construct, as well as a modular design. The objective of this study is to assess knee function, perioperative morbidity, and revision rate in patients undergoing BKA vs. TKA for treatment of MPFOA.
 
Methods
The databases MEDLINE, PUBMED, and EMBASE were systematically searched. Randomized controlled trials and non-randomized comparative studies comparing BKA with TKA for treatment of MPFOA were included for further analysis. The primary outcome of interest was knee function, which was measured using validated scoring questionnaires. Secondary outcomes included range of movement (ROM), operation length, intra-operative blood loss, hospital length of stay, post-operative complications, and rate of revision length. The quality of evidence was evaluated using the GRADE approach. Meta-analysis was performed by pooling the results of the selected studies when two or more results were available.
 
Results
Our literature search identified 79 unique studies, six of which were selected for inclusion in our study (four prospective studies, two retrospective cohort studies). In total, 274 patients and 277 knees were included for analysis. A total of 24 subgroup analyses were completed. Our meta-analysis did not show any significant differences between BKA vs. TKA for any of the primary outcomes at any time period, when monolithic BKA designs were controlled for due to their high revision rate. In terms of secondary outcomes, BKA did result in significantly decreased intraoperative blood loss (MD=-9.11 g/L, CI 95% -4.88 to -13.34, p<0.0001), at the expense of increased operative length (MD=16.58 minutes, 95% CI 8.59 to 24.58, p<0.0001). There was no difference in complication or revision rates between both groups, when monolithic BKA designs were controlled for.
 
Conclusion
The use of modular BKA for MPFOA is comparable to TKA in terms of short-term function, complications, and revisions. BKA reduces intra-operative blood losses, but it is also technically demanding, resulting in increased operative length.  The use of modular BKA has acceptable outcomes at two to five years, but more long-term data is needed before it can be recommended for routine use in treatment of MPFOA. The selection of modular BKA should be determined on a patient-specific basis. Currently there is no evidence to recommend the use of monolithic BKA designs due to their high revision rate.
 
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Dr. Jeremy Kubik - Evaluating the Utility of the Lateral Elbow Radiograph in Articular Olecranon Reduction: An Anatomic and Radiographic Study

Title: Evaluating the Utility of the Lateral Elbow Radiograph in Articular Olecranon Reduction: An Anatomic and Radiographic Study
 
Author: Jeremy Kubik*, Prism Schneider~, Ryan Martin'
*PGY-2 Orthopedic Surgery, University of Calgary, Kubik@ualberta.ca
~Orthopedic Trauma Surgeon, Department of Surgery, FMC, prism.schneider@gmail.com
'Orthopedic Trauma and Arthroscopy Surgeon, Department of Surgery, FMC, cryanmartin@gmail.com
 
Introduction:
Surgical reductions of intra-articular olecranon fractures are judged primarily on the lateral elbow radiograph, as orthogonal articular imaging is not obtainable. However, there exists no data on the adequacy of the lateral projection at identifying incongruities of the olecranon joint surface. Since the olecranon is made up of two trochlear facets sloped approximately 45 degrees to each other, the radiographic tangent seen on the lateral image presumably represents a small portion of the olecranon joint surface. If surgeons fail to consistently recognize articular olecranon malreductions on the lateral radiograph, it may question the validity of using radiographic classifications of articular reduction to determine if reduction impacts long-term outcome. Moreover, accessory radiographic views of the trochlear notches may be indicated to improve detection of articular malreductions. We sought to determine surgeon accuracy, inter- and intra-observer reliability in identifying intra-articular olecranon malreductions on the lateral radiograph of cadaveric elbows.
 
Methods:
Three distinct patterns of small intra-articular olecranon malreductions were created in six rigidly-fixed cadaveric elbows using a ruler and a standard bone saw. Perfect lateral elbow radiographs were taken of each malreduction for a total of 36 images. These images were randomized along with 36 x-rays of normal cadaveric olecranons, and the 72-image series was presented to four blinded surgeons to determine if the olecranon was anatomic or malreduced. This sample size estimation is based on a nomogram that includes four raters and an expected intra-class correlation coefficient of 0.6. An inter-rater reliability analysis using the Cohen's Kappa statistic was performed to determine consistency among raters with 95% confidence intervals (CIs).
 
Results:
Fellowship-trained observers correctly identified articular olecranon malreductions on the lateral elbow radiograph only 56% of the time.  Using the Cohen's Kappa statistic, the inter-rater reliability was found to be K = 0.69 (p < 0.001), 95% CI (0.51, 0.87).
 
Discussion:
Small intra-articular olecranon malreductions are inconsistently recognized on the lateral elbow radiograph by trained orthopedic surgeons. As such, articular displacement may still be present after surgical fixation despite obtaining true lateral radiographs intra-operatively. Accessory radiographic views of the articular olecranon that account for the articular trochlear slopes may be indicated to improved detection of these incongruities.
 
Character Count: 2581
 

Dr. Cory Kwong - Can HR-pQCT determine healing times for conservatively treated distal radius fracture?

Title: Can HR-pQCT determine healing times for conservatively treated distal radius fracture?
 
Resident: Cory Kwong PGY-2
 
Preceptor: Prism Schneider MD, PhD
 
Co-Authors: Steven Boyd PhD, Rob Korley MD
 
Introduction:
Distal radius fractures (DRFs) are the most common fracture of the upper extremity. Despite this, there is little agreement regarding time to fracture healing both clinically and radiologically. This results in widely variable periods of wrist immobilization. New methods using high resolution peripheral quantitative CT scans (HR-pQCT) are now available that can quantify the bony architecture and biomechanical properties of normal and fractured bone.
The purpose of this study is to use HR-pQCT to determine a more precise healing time for stable DRFs. Bony microarchitecture determined with HR-pQCT will also be correlated to plain radiographs, and clinical outcomes.
We hypothesize that HR-pQCT will more accurately predict fracture-healing time compared to Xray. 
 
Methods:
This study is a single center (FMC cast clinic) prospective cohort following patients up to 1-year. The microarchitecture between DRFs and the contralateral side will be compared on HR-pQCT using previously standardized methods (80% trabecular thickness) to determine healing time. This will then be correlated to Xray, patient demographics, clinical outcome measures (ROM, grip strength) and functional scores (PRWE, QuickDASH).
 
Status:
Currently the study has been registered on IRISS and the protocol and case report forms are in the review process with the Principal Investigator and Resident. We have been successful in obtaining funding from a COREF Grant and are also awaiting the results of additional funding applications (OTA Grant). Enrolment will begin following ethics approval for the first 20 patients. Preliminary logistical analysis of the experimental design will be performed on this cohort and any necessary changes will be submitted for CHREB review.
 
Requirements:
  • Secure additional funding
  • Recruit a radiologist
  • Submit final ethics application for approval
  • Begin enrolment
 
Application:
The goal of this study is to develop evidence-based clinical guidelines to direct the duration of immobilization in non-surgically treated stable DRFs. By correlating fracture-healing time based on HR-pQCT with clinical and functional outcomes we may prevent inadequate or prolonged immobilization of the wrist. This study offers the opportunity to compare injured and uninjured wrists, males and females and plain radiography with HR-pQCT. It also plans for a much longer follow-up interval than previous studies. This research program will lead to clinical application of our research findings. The results of our study will also provide a framework for future studies to utilize HR-pQCT to quantitatively assess healing at other anatomical fracture sites.
 
Timeline: 2.5 years
 
Character Count: 2,642

Dr. Alexander Meldrum - Olecranon Hardware Removal Rates

Title: Olecranon Hardware Removal Rates- Proposal Abstract
 
Author: Dr. Alexander Meldrum
 
Co-author: Dr. Prism Schneider Preceptor, Dr. Cory Kwong
 
Olecranon fractures and osteotomies are notorious for requiring a second operation to remove implanted hardware. Whether it is a plate construct, or a tension-band wiring (TBW) construct, this hardware often irritates the patient’s elbow, necessitating removal. There have been conflicting studies regarding hardware removal rates. An Italian study, by Tarallo et al, found that TBW were more commonly removed than plates, finding 38% versus 17% for Mayo type IIA fractures and 20% versus 6% for type IIB fractures. An American study, by Edwards et al, found a 63% removal rate for TBW and 62.5% removal rate for plate fixation. The purpose of our study is to provide Canadian data on hardware removal rates for Olecranon fixation. We hypothesize that TBW will have a higher hardware removal rate than plate fixation.
 
This will be a retrospective study involving all hospital in Calgary. Through the Alberta Health Services coding system, we will identify all olecranon fractures over a 3 year period in Calgary. We will manually sort through the Impax images to identify which patients underwent an operation. These patients will then be linked to procedural codes, to identify if the patients underwent a second operation. We will then request to access the charts of these patients to identify the reason for hardware removal, whether it was for irritation, non-union, infection, etc.. We will record the fracture type using the Mayo classification of Olecranon fractures. We will record the type of fixation that was placed. Once we have identified these patients, we will do an analysis to assess our numbers and determine if we need to broaden our search. Broadening our search will involve using additional cities within Alberta, as needed.
The data will be analyzed by the research team for a direct comparison of hardware removal rates, with statistical analysis to identify the significance of the findings. We will also identify why the hardware was removed, and report these results.
 
This study will require ethics approval. There will be a fee charged for accessing patient charts, and a research grant will be applied for to assist in this expense. The two co-authors of the project will be in charge of data collection.
 
There is significant variations in the hardware removal rates in the published literature. This makes it difficult to provide patients with an estimated risk of requiring a second operation. At the completion of this study, we will have a Canadian rate of hardware removal for Olecranon fractures for the various types of fixation. This information will be helpful in counselling and consenting patients for operation, and it may provide insight into which type of hardware may be utilized to reduce the likelihood of removal.
 
Characters: 2864
 

Dr. Spencer Montgomery - Outcomes of Surgical Management of Isolated Chronic Scapholunate Interosseous Ligament Injuries: A Systematic Review

Title: Outcomes of Surgical Management of Isolated Chronic Scapholunate Interosseous Ligament Injuries:  A Systematic Review
 
Resident: Dr. S. Montgomery
Preceptor: Dr. N. White
Co-Authors: Dr. N. Rollick, M. Kieski
 
Introduction:
Injuries to the scapholunate interosseous ligament (SLIL) are common and can be seen as isolated injuries or associated with traumatic or degenerative mechanisms. Despite numerous studies on the injury and biomechanics of the SLIL itself, as well as a growing number of proposed surgical corrections, an evidence based clinical algorithm still does not exist. This is due to multiple issues, however, lack of data regarding the natural history of the injury is a predominating factor. Heterogeneity in surgical techniques and the associated production of small retrospective cohort analyses is a further concern. In addition, the degree of injury and resulting instability, whether statically or dynamically unstable, may also be a significant confounding variable. The purpose of this systematic review is to analyze the existing body of data with respect to instability pattern and perform a subgroup analysis on outcomes based on common surgical techniques. Our primary hypothesis based on instability patterns is that dynamic injuries will have better outcome scores overall compared to static injuries. Our secondary hypothesis, based on surgical techniques, is that tendon-weave procedures will be associated with poorer outcomes in dynamic injuries and improved outcomes in static injuries
 
Methods:
We formulated inclusion and exclusion criteria prior to performing our literature search. Two reviewers independently performed the literature search up to full text inclusion. We performed a literature search of PubMed, EMBase and MedLine databases using the search terms “scapholunate” and “injury” resulting in 631 non-duplicate publications. After title and abstract screening 87 articles were assessed in full text, 27 were accepted and a further 21 papers showed evidence of having collected data that would make their study eligible but did not present data in a usable manner. We attempted to contact authors of each paper in order to obtain the necessary data. Where possible, individual patient data was separated and mean values and standard deviations were calculated separately to provide the most accuracy. We collected outcome data on range of motion, grip strength, pain using visual analogue scale, radiographic parameters as well as any validated patient centred outcome score such as DASH, PRWE, Mayo Wrist.
 
Status/Requirements:
We have completed the literature search and attempted to contact all necessary authors. We have begun collecting data. We are awaiting responses from said authors and translation of 3 papers.
 
Application: 
This study aims to provide direction on a topic that is poorly organized in the literature. By attempting to obtain raw data and compile results based on both surgical technique and instability pattern we hope to provide more robust reference points for comparison in future research and potentially identify positive or concerning trends in existing management strategies.
 
Character Count: 2891
 

Dr. Jon Bourget-Murray - Clinical Outcomes Following Single-level, Two-level and Hybrid Lumbar Total Disc Replacement at a Single Canadian Institution

Title: Clinical Outcomes Following Single-level, Two-level and Hybrid Lumbar Total Disc Replacement at a Single Canadian Institution
 
Authors: Jonathan Bourget-Murray, MD, Godefroy Hardy St-Pierre, MD, FRCSC, Jacques Bouchard, MD, FRCSC
 
Introduction:
Lumbar total disc replacements (TDR) have been used in clinical practice for over 20 years. Despite large American FDA studies having shown their non-inferiority to spinal fusion for the treatment of degenerative disc disease (DDD), there remains limited evidence on long-term functional outcomes and patient satisfaction rates following surgery. With a strict patient selection, TDR may provide successful improvement in patient’s pain profile and function by preserving intervertebral motion. This study aims to evaluate the clinical outcomes of a single surgeon’s patients who have undergone either single-level, two-level or hybrid (TDR and ALIF) lumbar TDR.
 
Hypothesis:
Patients will show improved functional outcomes following lumbar TDR. There will be limited complications and re-operations.
 
Study design:
Retrospective analysis of prospectively collected data.
 
Methods:
All patients had a single- or two-level lumber TDR, or a hybrid construct implanted between 2003-2015 by the senior author at the Foothills Medical Center. Twenty-four variables will be collected: age, sex, level of implant, prostheses type, pre-operative pain duration, narcotic use, medical comorbidities, psychiatric comorbidities, neurological deficit, BMI, lower extremity (LE) radicular pain, back dominant pain, smoking history, prior spine surgery, spinal injections, indications for surgery, work status, disability status, litigation, visual analogue scale (VAS) for low back pain and LE pain, Oswestry Disability Index (ODI), blood loss per-op and length of follow-up. All patients will be contacted by phone for follow-up and evaluated using a VAS to rate their LE and low back pain (10-point scale), ODI, need for re-operation, and overall satisfaction (yes/no-point scale).
 
Data & Analysis:
The primary outcomes to be analyzed are changes in pre- and post-operative VAS (Back and LE), ODI scores and post-operative complications as well as reoperation rate. Secondary outcomes include patient satisfaction and all prior outcomes reported individually. We will conduct a multivariate analysis via the random forest method. Mann-Whitney U test and Fisher exact test will be used to qualify relationship between variables.
 
Requirements:
No financial resources will be required for this study. JBM will conduct all phone follow-ups. JBM and GHS will analyze the data. We hope to have this study completed and manuscript written by June 2016.
 
Application/Dissemination:
In strictly selected patients, lumbar TDR could provide significant pain relief as well as improve function. This implant may be an alternative to spinal fusion.
 
Character Count (Spaces included): 2,512 (367 words)
Funding: None
Author disclosures: None

 

Dr. Eva Gusnowski - Use of CTPE scans in post-operative total joint arthroplasty patients: are they used judiciously in Alberta Health Services?

Title: Use of CTPE scans in post-operative total joint arthroplasty patients: are they used judiciously in Alberta Health Services?
 
Author: Dr. E. Gusnowski
 
Preceptor/CoAuthor: Dr. J. Werle
 
Introduction:
The incidence of venous thromboembolism without thromboprophylaxis is 50% and 84% in total hip and knee arthroplasty, respectively, with rates of pulmonary embolus reaching as high as 20% and 7%. The use of chemical thromboprophylaxis post-operatively is therefore standard of care following total joint arthroplasty (TJA). However, despite the use of thromboprophylaxis, rates of venous thromboembolism still reach as high as 2-12%. The gold standard for diagnosis of PE is a computed tomography (CT) scan of the chest with IV contrast, using a specific PE protocol. Although its sensitivity and specificity for detection of PE is high, it puts patients at risk for radiation-induced neoplasm and contrast induced nephropathy and allergy. The high rate of PE detection at Alberta Health Services (AHS) in patients following TJA implies that this complication is more frequent in this patient population and/or that patients are subjected to CT scans more frequently and with less discretion.
  
Methods:
To assess for PE found in the primary TJA patient population, the Alberta Bone and Joint Health Institute (ABJHI) database will be searched for the performance of a CTPE in patients for up to thirty days following primary TJA from 2010-2015. Radiology reports from CTPE scans will be assessed for the diagnosis of PE. If present, PE will be classified based on location and corresponding morbidity/mortality risk. A limited retrospective chart review will be performed on PE positive (and PE negative as a control) TJA patients at the Rockyview General Hospital in Calgary, AB. The modified Well’s, revised Geneva and pulmonary embolism rule out criteria (PERC) scores will be retrospectively applied to these patients based on chart analysis and patient care flow sheets.
 
Data & Analysis:
Data retrieved from the ABJHI database will allow us to calculate the number of CTPE scans performed on the TJA population, and allow a comparison of positive vs. negative scans. Well’s, Geneva and PERC scores from the chart analysis will be compared to the presence/absence of and risk stratification of PE.
 
Requirements:
This project will be performed in collaboration with the ABJHI. A statistician, constituting the sole financial requirement, will perform the statistical analysis. As the Alberta diagnostic imaging database is expected to available for use in the fall of 2016, this project is anticipated to take until mid 2017 to complete.
 
Application:
This study will address whether CTPE scans are used judiciously in the TJA population in AHS. Comparison of Well’s, Geneva and PERC scores to the presence/absence of PE in a subset of the Calgary TJA population will serve to either validate or exclude these scoring schemes for use in this population. If successful, this study may provide evidence for the standardized use of these rules as a means to prevent unnecessary investigations in TJA patients.
 
CHARACTER COUNT: 2987
 

Dr. Joseph Kendal - Surgical Reconstruction of Unstable Posterior Sternoclavicular Joint Dislocations: A Systematic Review

Title: Surgical Reconstruction of Unstable Posterior Sternoclavicular Joint Dislocations: A Systematic Review
 
Author: Joseph Kendal, PGY-1 Orthopaedic Surgery
Co-Authors: Dr. Kate Thomas and Preceptors Dr. Ian Lo and Dr. Aaron Bois
 
Introduction
Sternoclavicular joint (SCJ) dislocations consist of approximately 3% of shoulder girdle injuries and can be classified as anterior or posterior.1 Posterior SCJ dislocations are less common than anterior, but can have severe complications due to damage of vital mediastinal structures.2 These injuries require a large amount of force due to the significant soft tissue supports that surround the SCJ. In patients with an open medial clavicular physis (up to age 25), a physeal fracture may present in a similar fashion to a true posterior dislocation.2 After evaluation, a closed reduction of a posterior SCJ dislocation can be attempted. With true posterior SCJ dislocations there is significant soft tissue disruption and instability can persist post-reduction leading to one of several complications.3 In such cases, surgical reduction with reconstruction is indicated.3-6
Several reconstruction techniques have been reported without any clinical evidence of one superior method. Historically, fixation with K-wires or Steinmann pins have been used, but were associated with catastrophic complications.1,2 Other techniques include plate fixation, local tenodesis, suture/synthetic reconstruction and allograft reconstruction +/- medial clavicle resection.1-6 A cadaveric study compared three soft tissue reconstruction techniques, suggesting allograft figure-of-8 reconstruction to be the biomechanically superior.7
Overall, there is a general lack of consensus as to whether an optimal method of operative fixation exists. Our systematic review will summarize the current data regarding surgical reconstruction of true posterior SCJ dislocations including outcomes and complications. We hypothesize that soft-tissue reconstruction techniques for posterior SCJ dislocations are safe, effective and with minimal complications.
 
Methods
Medline and Embase was searched using the terms “Sternoclavicular joint” OR “Sternoclavicular joint.mp” AND “posterior.mp”. Inclusion criteria: 1) Unilateral posterior SCJ dislocations, 2) Surgical stabilization required, 3) Soft tissue reconstruction, 4) Reported outcomes and 5) English language. Exclusion criteria: 1) Anterior SCJ dislocations, 2 ) Medial clavicular physeal fractures, 3) K-wire fixation, 4) Plate fixation, 5) Stable injuries post-reduction, 5) SCJ arthritis without instability. Data was abstracted including age, sex, mechanism, acuity, intervention, outcome measures and complications. 
 
Status
Medline and Embase searches are complete. Search will be extended to Cochrane database and grey literature. This process will be repeated. Discrepancies will be resolved by a third party. Plan to follow with data analysis and manuscript preparation.
 
Requirements
A repeat review as well as data analysis with potential requirement for a statistician. Plan to complete rough manuscript by end of PGY-1 year.  
 
Application & Dissemination
This study will provide a comprehensive review of surgical management of posterior SCJ dislocations to help guide future surgical practice and research.
 
Character Count: 2,983
  1. Wirth, M., & Rockwood, C. (1996). Acute and Chronic Traumatic Injuries of the Sternoclavicular Joint. The Journal of the American Academy of Orthopaedic Surgeons, 4(5), 268–278.
  2. Dutta AK, Wirth MA, Rockwood CA (2009) Sternoclavicular Joint Injuries. In: Buchholz RW, Court-Brown CM, Heck- man JD, Tornetta P III (eds) Rockwood and green’s fractures in adults, 7th edn. Lippincott Williams and Wilkins, Philadelphia, pp 1243–1271
  3. Laffosse, J.-M., Espie, A., Bonnevialle, N., Mansat, P., Tricoire, J. L., Bonnevialle, P., et al. (2009). Posterior dislocation of the sternoclavicular joint and epiphyseal disruption of the medial clavicle with posterior displacement in sports participants. The Journal of Bone and Joint Surgery. British Volume, 92-B(1), 103–109. http://doi.org/10.1302/0301-620X.92B1.22186
  4. Lee, J. T., Nasreddine, A. Y., Black, E. M., Bae, D. S., & Kocher, M. S. (2014). Posterior Sternoclavicular Joint Injuries in Skeletally Immature Patients. Journal of Pediatric Orthopaedics, 34(4), 369–375. http://doi.org/10.1097/BPO.0000000000000114
  5. Kirby, J. C., Edwards, E., & Kamali Moaveni, A. (2015). Management and functional outcomes following sternoclavicular joint dislocation. Injury, 46(10), 1906–1913. http://doi.org/10.1016/j.injury.2015.05.050
  6. Ting, B. L., Bae, D. S., & Waters, P. M. (2014). Chronic Posterior Sternoclavicular Joint Fracture Dislocations in Children and Young Adults. Journal of Pediatric Orthopaedics, 34(5), 542–547. http://doi.org/10.1097/BPO.0000000000000148
  7. Spencer, E. E., & Kuhn, J. E. (2004). Biomechanical analysis of reconstructions for sternoclavicular joint instability. The Journal of Bone and Joint Surgery (American), 86-A(1), 98–105.

Dr. Katie Thomas - Outcomes and Complications Following Partial Rotator Cuff Repair vs. RTSA for Massive Rotator Cuff Tears: A Systematic Review

Title:  Outcomes and Complications Following Partial Rotator Cuff Repair vs. RTSA for Massive Rotator Cuff Tears: A Systematic Review
 
Author: Katie Thomas
 
Preceptor and Co-Authors: Dr A Bois/Dr I Lo/Dr J Kendal
 
Introduction:  
Massive rotator cuff tears (MRCTs) can be a source of significant pain and disability. There are many treatment options including full repair, partial repair, reverse total shoulder arthroplasty (RTSA), graft augmentation, and tendon transfer. In comparison to smaller cuff tears, repair is more technically difficult due to poor tendon quality, retraction, adhesions, and fatty infiltration and the recurrence rate is much higher. However, a full repair is not necessarily required to achieve a good outcome. Massive cuff tears often disrupt the balance of forces on the glenohumeral joint (GHJ) and compromise the normal mechanics of the fulcrum. The goal of partial repair is to restore the balance of these forces in order to achieve normal GHJ mechanics and good functional outcome.
A conventional shoulder replacement also relies on the balance of these forces. However, this limitation was overcome with the introduction of RTSA, which compensates by medializing the centre of rotation and tensioning the deltoid. This construct is used routinely in those with cuff tear arthropathy but has also been shown to provide good outcomes and is becoming more frequently used in those with MRCTs without arthropathy as well.
To date there is limited research directly comparing these two treatment modalities. The goal of this review is to aid in treatment decision-making by comparing the outcomes and complications seen with partial repair and RTSA in the treatment of MRCTs without GHJ arthritis.
 
Methods: 
A literature search was performed in Medline and EMBASE using the following terms: “reverse shoulder arthroplasty” OR “RSA” AND “rotator cuff”; “reverse total shoulder arthroplasty” OR “RTSA” AND “rotator cuff”; “massive rotator cuff tear*” OR “irreparable rotator cuff tear*; “rotator cuff” AND “partial repair.” In order to meet inclusion criteria, the study was required to: be written in English, define massive rotator cuff tear as ≥5cm or complete tear of 2 or more tendons and specify that repair was partial. Studies were excluded if data included participants with glenohumeral arthritis, repairs with graft augmentation or tendon transfers, animal or cadaver studies. The following data were extracted: age, gender, mean follow-up, pre and post-operative forward elevation, visual analog scale for pain, ASES, UCLA, constant, and SST scores.
 
Status:
The literature search through medline and EMBASE has been completed and data extracted from included studies. Next steps are to search the grey literature, analyze data, and complete the manuscript.
 
Requirements:
The goal is to have the manuscript written by May 5th.
 
Application:
This study will help to clarify the difference in complications and outcomes between RTSA and partial repair when making a treatment choice for massive rotator cuff tears.
 
No funding sources or other disclosures.
 
Character Count: 2965

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