Reliability of a visual analog version of the QuickDASH

The value of ultrasound and magnetic resonance imaging scoring systems in explaining handgrip strength and functional impairment in rheumatoid arthritis patients: a pilot study

Purpose

The goal of this study is to investigate the relationship between joint inflammation and damage of the wrists and hands, measured by semiquantitative ultrasound and magnetic resonance imaging scoring systems, with functional disability and handgrip strength (HGs).

Materials and methods

Consecutive adult RA patients with active disease, as defined by a Disease Activity Score 28 joints C-reactive protein (DAS28-CRP) > 3.2, underwent a cross-sectional evaluation comprehensive of a clinimetric assessment, an HGs evaluation, an ultrasound assessment aimed at calculating the UltraSound-CLinical ARthritis Activity (US-CLARA), and a magnetic resonance imaging scored according to the modified Simplified Rheumatoid Arthritis Magnetic Resonance Imaging Score (mod SAMIS). The Spearman’s rho correlation coefficient was used to test the correlations.

Results

Sixty-six patients with RA were investigated (age 55.6 ± 12.2 years). The mod SAMIS total score and the US-CLARA had a weak but significant correlation (rho = 0.377, p = 0.0018). Among the mod SAMIS sub-scores, there was a significant relationship between mod SAMIS bone edema (SAMIS-BME) and US-CLARA (rho = 0.799, p < 0.001) and mod SAMIS synovitis (SAMIS synovitis) and US-CLARA (rho = 0.539, p < 0.001). There were also significant negative relationships between the HGs score and the mod SAMIS total score and US-CLARA (rho = − 0.309, p = 0.011 and rho = − 0.775, p < 0.0001, respectively).

Conclusions

BME and synovitis have an influence on the function of the upper extremities. The US-CLARA and the mod SAMIS total score are intriguing options for semiquantitative assessment of joint inflammation and damage in RA.

Nonoperative treatment of distal humerus fractures in the elderly yields satisfactory functional outcomes and low conversion to delayed surgery: a systematic review

Background

Distal humerus fractures (DHFs) pose a treatment challenge in elderly patients. We sought to systematically review and report the clinical outcomes of the nonoperative approach (eg, "bag of bones") for the treatment of these injuries and the rate of conversion to delayed surgery.

Methods

A comprehensive review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted. Studies involving outcomes after nonoperative treatment of DHF in patients >65 years of age were included from 1985 to present. Data regarding patient age, DHF type, nonoperative treatment method, complications, conversion to delayed surgery, range of motion, union rate, and surgeon- and patient-reported outcome measures were extracted.

Results

A total of five studies met inclusion criteria (all level IV evidence), yielding a total of 143 patients (mean age: 73.5 years to 87.4 years) with 7.1 months to 55 months of follow-up. The mean Mayo Elbow Performance Index scores were good to excellent across several studies (range 83-93.1). Multiple studies reported good range of motion (mean arc of motion: 81 to 106 degrees) and low levels of upper extremity disability (mean Quick Disability of the Arm-Shoulder-Hand scores: 31.3 to 38.5) at the final follow-up. The rate of conversion to total elbow arthroplasty and operative fixation ranged from 0% to 7.5% and 0% to 5%, respectively.

Conclusion

Nonoperative management of distal humerus fractures in the elderly seems to be associated with acceptable functional outcomes and low rates of delayed surgery. This information is important for patient counseling and treatment decision-making.

Robotic first rib resection for thoracic outlet syndrome

Robotic resection of the “offending portion” of the first rib in patients with thoracic outlet syndrome (TOS) has been associated with excellent results. The results have been due to (I) a better understanding of the pathogenesis of TOS, and (II) the technical advantages of the robotic platform. This article outlines the recent understanding of the pathogenesis of TOS, and reports the experience with robotic resection of the “offending portion” of the first rib in patients with neurogenic and venous TOS. Patients diagnosed with TOS underwent robotic first rib resection. Diagnosis of TOS was made by magnetic resonance angiography (MRA). On a thoracoscopic platform, the robot was used to dissect the “offending portion” of the first rib. A total of 162 patients underwent robotic first rib resection. Eighty-three patients underwent robotic first rib resection for Paget-Schroetter syndrome (PSS) (venous TOS). There were 49 men and 34 women. Mean age was 24±8.5 years. Operative time was 127.6±20.8 minutes. Median hospitalization was 4 days. There were no surgical complications, neurovascular injuries, or mortality. At a median follow-up of 24 months, all patients had an open subclavian vein (SV) for a patency rate of 100%. Seventy-nine patients underwent robotic first rib resection for neurologic symptoms of the upper extremity (neurogenic TOS). There were 29 men and 50 women. Mean age was 34±9.5 years. Operative time was 87.6±10.8 minutes. There were no intraoperative complications. Hospital stay ranged from 2–4 days with a median hospitalization of 3 days. There were no neurovascular complications. There was no mortality. In patients with neurogenic symptoms, Quick DASH Scores (mean ± SEM) decreased from 60.3±2.1 preoperatively to 5±2.3 in the immediate postoperative period, and 3.5±1.1 at 6 months (P<0.0001). Immediate relief of symptoms was seen in 71/79 (91%) patients. Persistent paresthesia was seen in 9/79 (9%) immediately postop and 3/79 (3.8%) patients at 6 months. Following the appropriate identification of the “offending portion” of the first rib which results in compression of the SV at its junction with the innominate vein by MRA, robotic resection of the “offending portion” of the first rib allows is associated with excellent results.

The minimal clinically important difference of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and upper extremity computer adaptive tests and QuickDASH in the setting of elbow trauma

Background

Minimal clinically important difference (MCID) estimates are useful for gauging clinical relevance when interpreting changes or differences in patient-reported outcomes scores. These values are lacking in the setting of elbow trauma. Our primary purpose was to estimate the MCID of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) computer adaptive test (CAT), the PROMIS upper extremity (UE) CAT, and the QuickDASH using an anchor-based approach for patients recovering from elbow trauma and related surgeries. Secondarily, we aimed to estimate the MCID using the 1/2 standard deviation method.

Materials & methods

Adult patients undergoing treatment for isolated elbow injuries between July 2014 and April 2020 were identified at a single tertiary academic medical center. Outcomes, including the PROMIS PF CAT v1.2/2.0, PROMIS UE CAT v1.2, and QuickDASH, were collected via a tablet computer. For inclusion, baseline (6 months before injury up to 11 days postoperatively or after injury) and follow-up (11 to 150 days postoperative or after injury) PF or UE CAT scores were required, as well as a response to an anchor question querying improvement in physical function. The MCID was calculated using (1) an anchor-based approach using the difference in mean score change between anchor groups reporting “No change” and “Slightly Improved/Improved” and (2) the 1/2 standard deviation method.

Results

Of the 146 included patients, the mean age was 46 ± 18 years and 67 (46%) were women. Most patients (129 of 146 or 88%) were recovering from surgery, and the remaining 12% were recovering from nonoperatively managed fractures and/or dislocations. The mean follow-up was 157 ± 192 days. Scores for each instrument improved significantly between baseline and follow-up. Anchor-based MCID values were calculated as follows: 5.7, 4.6, and 5.3 for the PROMIS PF CAT, PROMIS UE CAT, and QuickDASH, respectively. MCID values estimated using the 1/2 standard deviation method were 4.3, 4.8, and 11.7 for the PROMIS PF CAT, PROMIS UE CAT, and QuickDASH, respectively.

Conclusions

In the setting of elbow trauma, we propose MCID ranges of 4.3 to 5.7 for the PROMIS PF CAT, 4.6 to 4.8 for the PROMIS UE CAT, and 5.3 to 11.7 for the QuickDASH. These values will provide a framework for clinical relevance when interpreting clinical outcomes studies, or powering clinical trials, for populations recovering from trauma.

Injection of Bone Marrow Aspirate for Glenohumeral Joint Osteoarthritis: A Pilot Randomized Control Trial

Purpose

To compare the efficacy of a single, intra-articular, nonconcentrated bone marrow aspirate (BMA) injection in comparison to cortisone for the treatment of glenohumeral joint osteoarthritis (GHJ OA).

Methods

Inclusion criteria were patients between the ages of 18 and 75 with a diagnosis of GHJ OA on radiograph. Patients were randomized to receive an ultrasound-guided, intra-articular cortisone injection or BMA injection (without concentration). The primary outcome measure was the Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 12 months. Secondary outcome measures were the QuickDASH, EuroQOL 5-dimensions 5-level questionnaire (EQ-5D-5L) and visual analogue scale.

Results

The study included 25 shoulders of 22 patients who completed baseline and 12 months’ patient-reported outcome measures (12 shoulders received cortisone, 13 shoulders received BMA) after the study was terminated early by changes in Health Canada regulations. Baseline characteristics demonstrated a significant difference in the ages of the 2 groups, with the BMA group being older (61.6 vs 53.8 mean years, P = 0.021). For the BMA group, a significant improvement was seen in the WOOS index (P = 0.002), the QuickDASH (P < 0.001), and the EQ-5D-5L pain dimension (P = 0.004) between baseline and 12 months. No significant difference was seen for any outcome in the cortisone group between baseline and 12 months. No significant difference was demonstrated between changes in the WOOS scores from baseline to 12 months when compared between groups (P = 0.07). However, a significant difference in changes in scores was seen in the QuickDASH (P = 0.006) and the EQ-5D-5L pain scores (P = 0.003) and the EQ-5D-5L health scores (P = 0.032) in favor of BMA.

Conclusions

The results of this study demonstrate that patients with GHJ OA treated with BMA have superior changes in the QuickDASH and EQ-5D-5L pain and health scores but not in the WOOS outcomes measures at 12 months post injection when compared to patients treated with cortisone. However, because of the limited number of patients as a result of the early termination of the study, larger randomized studies are required to confirm these findings.

Level of Evidence

Level II, randomized controlled trial.

Outcomes following total elbow arthroplasty for rheumatoid arthritis versus post-traumatic conditions: a systematic review and meta-analysis

AIMS

The aim of this meta-analysis was to compare the outcome of total elbow arthroplasty (TEA) undertaken for rheumatoid arthritis (RA) with TEA performed for post-traumatic conditions with regard to implant failure, functional outcome, and perioperative complications.

MATERIALS AND METHODS

We completed a comprehensive literature search on PubMed, Web of Science, Embase, and the Cochrane Library and conducted a systematic review and meta-analysis. Nine cohort studies investigated the outcome of TEA between RA and post-traumatic conditions. The preferred reporting items for systematic reviews and meta-analysis (Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)) guidelines and Newcastle-Ottawa scale were applied to assess the quality of the included studies. We assessed three major outcome domains: implant failures (including aseptic loosening, septic loosening, bushing wear, axle failure, component disassembly, or component fracture); functional outcomes (including arc of range of movement, Mayo Elbow Performance Score (MEPS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), and perioperative complications (including deep infection, intraoperative fracture, postoperative fracture, and ulnar neuropathy).

RESULTS

This study included a total of 679 TEAs for RA (n = 482) or post-traumatic conditions (n = 197). After exclusion, all of the TEAs included in this meta-analysis were cemented with linked components. Our analysis demonstrated that the RA group was associated with a higher risk of septic loosening after TEA (odds ratio (OR) 3.96, 95% confidence interval (CI) 1.11 to 14.12), while there was an increased risk of bushing wear, axle failure, component disassembly, or component fracture in the post-traumatic group (OR 4.72, 95% CI 2.37 to 9.35). A higher MEPS (standardized mean difference 0.634, 95% CI 0.379 to 0.890) was found in the RA group. There were no significant differences in arc of range of movement, DASH questionnaire, and risk of aseptic loosening, deep infection, perioperative fracture, or ulnar neuropathy.

CONCLUSION

The aetiology of TEA surgery appears to have an impact on the outcome in terms of specific modes of implant failures. RA patients might have a better functional outcome after TEA surgery. Cite this article: Bone Joint J 2019;101-B:1489-1497.

Clinical EFT (Emotional Freedom Techniques) Improves Multiple Physiological Markers of Health

Emotional Freedom Technique (EFT) is an evidence-based self-help therapeutic method and over 100 studies demonstrate its efficacy. However, information about the physiological effects of EFT is limited. The current study sought to elucidate EFTs mechanisms of action across the central nervous system (CNS) by measuring heart rate variability (HRV) and heart coherence (HC); the circulatory system using resting heart rate (RHR) and blood pressure (BP); the endocrine system using cortisol, and the immune system using salivary immunoglobulin A (SigA). The second aim was to measure psychological symptoms. Participants (N = 203) were enrolled in a 4-day training workshop held in different locations. At one workshop (n = 31), participants also received comprehensive physiological testing. Posttest, significant declines were found in anxiety (-40%), depression (-35%), posttraumatic stress disorder (-32%), pain (-57%), and cravings (-74%), all P < .000. Happiness increased (+31%, P = .000) as did SigA (+113%, P = .017). Significant improvements were found in RHR (-8%, P = .001), cortisol (-37%, P < .000), systolic BP (-6%, P = .001), and diastolic BP (-8%, P < .000). Positive trends were observed for HRV and HC and gains were maintained on follow-up, indicating EFT results in positive health effects as well as increased mental well-being.

Validity and interpretability of the QuickDASH in the assessment of hand disability in rheumatoid arthritis

Objective of this study is to evaluate the construct validity and the interpretability of the shortened Disability of Arm, Shoulder and Hand Questionnaire (QuickDASH) in the assessment of rheumatoid arthritis (RA) hand disability. Consecutive RA patients were assessed through the QuickDASH and other function and disease activity indices, respectively, the Health Assessment Questionnaire-Disability Index (HAQ-DI) and the Recent-Onset Arthritis Disability questionnaire (ROAD). For each patient were evaluated the tender and swollen 28-joints counts. Interpretability was defined determining cut-off points of impairment in accordance to the Simplified Disease Activity Index (SDAI) definition of disease activity states. A total of 440 patients (89 men and 351 women, mean age of 57.0 ± 12.7 years) were enrolled. Following the SDAI definition, 98 patients (22.3%) resulted in REM, 115 subjects (26.1%) in LDA, 74 patients (16.8%) in MDA, and 153 subjects (34.8%) in HDA. Mean QuickDASH differed significantly between patients classified as remission (REM), low disease activity (LDA), moderate disease activity (MDA), or high disease activity (HDA) (p < 0.001). High correlations were found comparing QuickDASH to composite indices of disease activity and of physical health function: of special interest are the correlations between the comparable dimension of the QuickDASH and the ROAD Upper Extremity Function (rho = 0.876; p < 0.001). The cut-off points for functional categories (SDAI categories as external criterion) resulted: no impairment ≤ 13, 13 < low impairment ≤ 18.5, 18.5 < moderate impairment ≤ 31.5, and high impairment > 31.5. QuickDASH is useful in clinical practice, for its ease of administration, and positively correlates with the disease activity. It may be a surrogate for evaluating upper extremity impairment, disability index and disease control in RA patients.

Use of a verbal electronic audio reminder with a patient hand hygiene bundle to increase independent patient hand hygiene practices of older adults in an acute care setting

BACKGROUND

We hypothesized that the addition of a novel verbal electronic audio reminder to an educational patient hand hygiene bundle would increase performance of self-managed patient hand hygiene.

METHODS

We conducted a 2-group comparative effectiveness study randomly assigning participants to patient hand hygiene bundle 1 (n = 41), which included a video, a handout, and a personalized verbal electronic audio reminder (EAR) that prompted hand cleansing at 3 meal times, or patient hand hygiene bundle 2 (n = 34), which included the identical video and handout, but not the EAR. The primary outcome was alcohol-based hand sanitizer use based on weighing bottles of hand sanitizer.

RESULTS

Participants that received the EAR averaged significantly more use of hand sanitizer product over the 3 days of the study (mean ± SD, 29.97 ± 17.13 g) than participants with no EAR (mean ± SD, 10.88 ± 9.27 g; t₇₃ = 5.822; P ≤ .001).

CONCLUSIONS

The addition of a novel verbal EAR to a patient hand hygiene bundle resulted in a significant increase in patient hand hygiene performance. Our results suggest that simple audio technology can be used to improve patient self-management of hand hygiene. Future research is needed to determine if the technology can be used to promote other healthy behaviors, reduce infections, and improve patient-centered care without increasing the workload of health care workers.

Coonrad-Morrey total elbow arthroplasty for patients with rheumatoid arthritis: 54 prostheses reviewed at 7 years' average follow-up (maximum, 16 years)

BACKGROUND

Total elbow arthroplasty is a therapeutic option for severe rheumatoid arthritis. We hypothesized that the semiconstrained characteristics of the Coonrad-Morrey prosthesis do not compromise the survival rate of the implant in a rheumatoid elbow.

METHODS

Between 1997 and 2012, there were 54 Coonrad-Morrey total elbow prostheses performed for rheumatoid arthritis in 46 patients. Minimum follow-up was 2 years. There were 35 women and 11 men with a mean age of 60 years (29-83 years). According to the Mayo classification for rheumatoid elbow, there were 30 type IIIA, 21 type IIIB, and 3 type IV. The surgical procedure was the same for all patients. Survivorship was assessed with use of the Kaplan-Meier method, with revision surgery as the end point.

RESULTS

The survival rate was 97% (95% confidence interval, 83.6-99.6) at 5 years and 85% (95% confidence interval, 68.3-93.7) at 10 years. At an average of 7 years of follow-up (2-16 years), the mean Mayo Elbow Performance Score was 91 points (55-100 points), and the shortened version of the Disabilities of the Arm, Shoulder, and Hand score was 34 points (0-75 points). There was a significant improvement in Mayo Elbow Performance Score and in all range of motion at latest follow-up in comparison to preoperative values (P < .0001). Radiolucencies were observed in 6 cases around the humeral component and in 6 cases around the ulnar component. Bushing wear was observed in 16 cases (29%). There were 14 complications (26%). Revisions were performed in 6 of them (11%).

CONCLUSION

The Coonrad-Morrey prosthesis provides satisfactory results with follow-up. The rate of complications remains high even if the rate of implant revision stayed low.

Intercarpal fusions: indications, treatment options and techniques

Partial wrist fusion is a useful technique for the treatment of such specific carpal disorders as arthritis, Kienböck's disease, midcarpal instability, scaphoid nonunion, etc.Many techniques have been described by removing arthritic joint surfaces and transfering load, using, for bone fixation, K-wires, screws, staples, and more recently dedicated plates.The goal of this procedure is to maximise wrist motion and strength while minimizing or eliminating pain.The purpose of this article is to discuss the most commonly used combination of intercarpal arthrodeses, to clarify the indications for each fusion, to describe the appropriate surgical technique for each fusion, and to provide an overview of results and current concepts. Cite this article: Houvet, P. Intercarpal fusions: indications, treatment options and techniques. EFORT Open Rev 2016;1:45-51. DOI: 10.1302/2058-5241.1.000019.

Psychophysical and Patient Factors as Determinants of Pain, Function and Health Status in Shoulder Disorders

Objective:

To estimate the extent to which psychophysical quantitative sensory test (QST) and patient factors (gender, age and comorbidity) predict pain, function and health status in people with shoulder disorders. To determine if there are gender differences for QST measures in current perception threshold (CPT), vibration threshold (VT) and pressure pain (PP) threshold and tolerance.

Design:

A cross-sectional study design.

Setting:

MacHAND Clinical Research Lab at McMaster University.

Subjects:

34 surgical and 10 nonsurgical participants with shoulder pain were recruited.

Method:

Participants completed the following patient reported outcomes: pain (Numeric Pain Rating, Pain Catastrophizing Scale, Shoulder Pain and Disability Index) and health status (Short Form-12). Participants completed QST at 4 standardized locations and then an upper extremity performance-based endurance test (FIT-HaNSA). Pearson r’s were computed to determine the relationships between QST variables and patient factors with either pain, function or health status. Eight regression models were built to analysis QST’s and patient factors separately as predictors of either pain, function or health status. An independent sample t-test was done to evaluate the gender effect on QST.

Results:

Greater PP threshold and PP tolerance was significantly correlated with higher shoulder functional performance on the FIT-HANSA (r =0.31-0.44) and lower self-reported shoulder disability (r = -0.32 to -0.36). Higher comorbidity was consistently correlated (r =0.31-0.46) with more pain, and less function and health status. Older age was correlated to more pain intensity and less function (r =0.31-0.57). In multivariate models, patient factors contributed significantly to pain, function or health status models (r² =0.19-0.36); whereas QST did not. QST was significantly different between males and females [in PP threshold (3.9 vs. 6.2, p < .001) and PP tolerance (7.6 vs. 2.6, p < .001) and CPT (1.6 vs. 2.3, p =.02)].

Conclusion:

Psychophysical dimensions and patient factors (gender, age and comorbidity) affect self-reported and performance-based outcome measures in people with shoulder disorders.

Hemiarthroplasty versus reverse shoulder arthroplasty in 4-part displaced fractures of the proximal humerus: Multicenter retrospective study

INTRODUCTION

Complex 4-part fractures of the proximal humerus are one of the most difficult fractures to manage. For several years, reverse total arthroplasty (RSA) has been proposed as an alternative to hemiarthroplasty (HA) when internal fixation is insufficient. The goal of this study was to compare the short and intermediate term results of these 2 different types of arthroplasty.

MATERIALS AND METHODS

In a retrospective, multicenter study, 57 HA and 41 RSA were reviewed after a follow-up of at least 2 years. The clinical evaluation was based on the absolute and adjusted Constant scores, Simple shoulder value (SSV) and the quick-DASH scores. The radiological assessment included standard radiological tests.

RESULTS

After a mean follow-up of 39 months, the RSA group had a significantly higher adjusted Constant score than the HA group (83% vs 73%, respectively P=0.02). However, there was no significant difference in the absolute Constant score, the quick-DASH or the SSV scores. Active anterior elevation was better in the RSA group, while internal rotation was better in the HA group (130° vs 112°, P=0.01; sacrum vs L3, P=0.03). There was no significant difference in external rotation (28° vs 23°, P=0.31). The rate of complications was higher in the HA group than in the RSA group (24% vs 10%, P=0.01). The radiological rate of union of the greater tuberosity was similar in both groups (70%) and scapular notching was found in 23% of the RSA group.

CONCLUSION

The short and intermediate term clinical outcomes are better with RSA than with HA. The complication rate is higher with HA. Nevertheless, scapular notching occurred in more than 20% of patients with RSA, suggesting that care should be taken when using this prosthesis in young, active patients.

A case series of auricular acupuncture in a veteran's population using a revised auricular mapping-diagnostic paradigm (RAMP-uP)

OBJECTIVES

To evaluate clinical effects of auricular acupuncture treatments for pain based on a revised auricular mapping and diagnostic paradigm (RAMP-uP).

DESIGN

Retrospective chart review.

SETTING

A major US Veterans Affairs Medical Centre located in the Southeaster United States.

MAIN OUTCOME MEASURES

Pain and efficacy rating scores based on visual analogue scales during each clinical visit. Duration of acupuncture treatment effects based on clinic notes documentation.

RESULTS

Patients' average pain score decreased by almost 60% (p<0.0001). The treatment effects lasted 1-3 months (47%). The overall efficacy reported by most patients was helpful (83.6%).

CONCLUSION

The observed clinical effects of auricular acupuncture based on RAMP-uP are promising. Further research is needed to assess its feasibility to generalize and generate clinical effects in randomized controlled clinical trials.

Which Are the Most Relevant Questions in the Assessment of Outcome after Distal Radial Fractures?

A study was designed to determine which wrist scoring system best correlates with patient satisfaction and which individual variables predict a satisfactory outcome. We looked at forty-five females and 5 males with wrist fractures at 12 weeks after injury and compared their level of satisfaction with various respected outcome measures. The mean age was 66 years. Multivariate regression analysis was carried out using a statistical software package. Patient satisfaction correlated best with the MacDermid, Watts, and DASH scores. The variables in these scoring systems that predicted satisfaction were pain and ability to perform household chores or usual occupation, open packets, and cut meat. The four most important questions to ask in the clinic following wrist fractures are about severity of pain and ability to open packets, cut meat, and perform household chores or usual occupation. This may provide simple and more concise means of assessing outcome after distal radial fractures. Level of evidence is level 4.

Psychometric properties of self-reported questionnaires for the evaluation of symptoms and functional limitations in individuals with rotator cuff disorders: a systematic review

PURPOSE

To conduct a systematic review of the psychometric properties (reliability, validity and responsiveness) of self-report questionnaires used to assess symptoms and functional limitations of individuals with rotator cuff (RC) disorders.

METHODS

A systematic search in three databases (Cinahl, Medline and Embase) was conducted. Data extraction and critical methodological appraisal were performed independently by three raters using structured tools, and agreement was achieved by consensus. A descriptive synthesis was performed.

RESULTS

One-hundred and twenty articles reporting on 11 questionnaires were included. All questionnaires were highly reliable and responsive to change, and showed construct validity; seven questionnaires also shown known-group validity. The minimal detectable change ranged from 6.4% to 20.8% of total score; only two questionnaires (American Shoulder and Elbow Surgeon questionnaire [ASES] and Upper Limb Functional Index [ULFI]) had a measurement error below 10% of global score. Minimal clinically important differences were established for eight questionnaires, and ranged from 8% to 20% of total score.

CONCLUSION

Overall, included questionnaires showed acceptable psychometric properties for individuals with RC disorders. The ASES and ULFI have the smallest absolute error of measurement, while the Western Ontario RC Index is one of the most responsive questionnaires for individuals suffering from RC disorders.

IMPLICATIONS FOR REHABILITATION

All included questionnaires are reliable, valid and responsive for the evaluation of individuals with RC disorders. As all included questionnaires showed good psychometric properties for the targeted population, the choice should be made according to the purpose of the evaluation and to the construct being evaluated by the questionnaire. The WORC, a RC-specific questionnaire, appeared to be more responsive. It should therefore be used to evaluate change in time. If the evaluation is time-limited, shorter questionnaires or short versions should be considered (such as Quick DASH or SST).

Reverse shoulder arthroplasty for malignant tumors of proximal humerus

BACKGROUND

Reverse shoulder arthroplasty (RSA) provides an alternative for shoulder girdle reconstruction after wide transarticular resection of the proximal humerus for malignant tumor. The aim of this study was to evaluate midterm outcomes of this therapeutic option.

METHODS

Ten patients with RSA were included and reviewed with 24 months of minimum follow-up. Proximal resection of malignant tumor included the "V" deltoid insertion in 4 patients. The humeral stem was coated (with an allograft in 2 patients and a cement mantel in 3) or left uncoated (5 patients).

RESULTS

At a mean follow-up of 42 months, among 8 prosthesis available for evaluation (2 patients died), the Constant and Murley score averaged 52 points, the 11-item version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score averaged 29.5 points, the Subjective Shoulder Value averaged 58%, and the Musculoskeletal Tumor Society score averaged 20.25 points. Mean forward active elevation reached 122°, external rotation at side was -2°, and internal rotation was to L4. Three prostheses were unstable. The involvement of "V" deltoid insertion at surgery trended to worsen the clinical outcome. Atrophy of the anterior deltoid occurred in most of patients who had a previous transdeltoid biopsy. Radiographic evaluation found 1 stem loosening, 1 stem at risk, and 3 scapular notches without glenoid loosening.

CONCLUSION

Use of RSA after resection of a malignant tumor of the proximal humerus seems to be an acceptable option to preserve function. However, radiographic evolution is worrisome, and long-term study remains necessary to validate this therapeutic option with follow-up.

Distal humerus fracture in the elderly: does conservative treatment still have a role?

INTRODUCTION

Conservative treatment is exceptional in fracture of the distal extremity of the humerus in patients over 65 years of age. In a selected population, however, it may be an attractive option.

MATERIALS AND METHODS

One prospective and one retrospective study included a total of 56 patients, with a mean age of 84.7 years (range, 68-100 yrs). All were managed by 6 to 8 weeks' brachial-antebrachial-palmar immobilization, without fracture reduction. Fractures were AO type A in 18 cases, type B in 8 cases and type C in 30 cases.

RESULTS

At a mean 20.2 months' follow-up in the retrospective and 8.6 months in the prospective series, mean MEPS score was 83 and 86 points with 75% and 83% satisfactory results respectively and mean Quick-DASH 31.3 and 34.4 points respectively. There were 3 non-unions. There was extra-articular malunion in 70% and intra-articular malunion in 65% of cases in the retrospective series, versus 16% intra-articular malunion in the prospective series. The rate of osteoarthritis increased over time, with more than 50% grade 2 or 3 in the retrospective series at end of follow-up. There were 3 complications: 2 hematomas and 1 skin lesion (localized pressure ulcer). There were 3 fracture displacements, not requiring change in management.

DISCUSSION

Conservative treatment for fracture of the distal extremity of the humerus in patients over 65 years of age is exceptional, but conserves patient's independence and provides satisfactory clinical results, with no significant joint stiffness or elbow instability. Non-anatomic results on X-ray, however, have to be accepted.

Total elbow arthroplasty for acute distal humeral fractures in patients over 65 years old - results of a multicenter study in 87 patients

INTRODUCTION

Fractures of the distal humerus represent 5% of osteoporosis fragility fractures in subjects over the age of 60. Osteoporosis, comorbidities and intra-articular comminution make management of this entity difficult.

HYPOTHESIS

The hypothesis was that total elbow arthroplasty could be a reliable treatment option in subjects over the age of 65 presenting with a fracture of the distal humerus.

MATERIALS AND METHODS

Eight-seven patients (80 women and 7 men) mean age 79 years old (65-93) underwent total elbow arthroplasty for the treatment of an AO type A fracture in 9 cases, type B in 8 and type C in 70.

RESULTS

After a mean follow-up of 37.5 months (6-106) the Mayo Elbow Performance Score MEPS was 86±14, the quick-DASH score was 24±19 and the Katz score was 5±1.5 points. The MEPS was better in patients with a high preoperative Katz score and a history of inflammatory arthritis who were living at home. Fifty-five patients (63%) presented with a pain-free elbow, and 20 (24%) with slight pain. The flexion-extension range of motion was 97±22° and 48% presented with a flexion-extension arc of at least 100°. Function was normal in 69 patients. Complications were identified in 20 cases (23%) and revision surgery was necessary in 8 (9%). Two arthroplasties had to be changed, one for a fracture of the humeral stem component and the other for loosening. Only one infection occurred in this series.

CONCLUSION

Total elbow arthroplasties provide fractured patients with immediate satisfactory results and a stable, painless and functional elbow. These results seem to be reliable and durable. The rate of complications is low with revision surgery in approximately 10%.

LEVEL OF EVIDENCE

Level IV.

Experience with the Coonrad-Morrey total elbow arthroplasty: 78 consecutive total elbow arthroplasties reviewed with an average 5 years of follow-up

BACKGROUND

The Coonrad-Morrey total elbow arthroplasty is a linked implant. This study investigated the hypotheses that reliable results can be obtained in rheumatoid patients and in traumatic conditions and that the survival rate is similar to or better than what has been published for nonlinked implants.

METHODS

Surgery was performed on 70 consecutive patients (78 elbows) for an inflammatory arthritis (45 elbows) or a traumatic condition (33 elbows: 18 acute fractures of the distal humerus, 10 nonunions, and 5 post-traumatic arthritis).

RESULTS

At an average of 5 years of follow-up (2 to 11 years), the mean Mayo Elbow Performance Score for the group that had inflammatory arthritis (89 ± 13 points) was significantly higher than that for the group with a traumatic condition (80 ± 17 points). The QuickDASH score was not significantly different according to the etiology. Radiolucencies were observed in 17 cases around the humeral component and in 14 cases around the ulnar component. Bushing wear was observed in 14 cases. There were 27 complications, and 9 of them went to a revision procedure. The survival rate was 97.7% at 5 years and 91.0% at 10 years if we consider revision for aseptic loosening as an endpoint.

CONCLUSIONS

The Coonrad-Morrey total elbow arthroplasty allows treatment of a large spectrum of causes with satisfactory results. Better results have been obtained for rheumatoid patients than for patients with trauma. The rate of complication remains high even if the rate of implant revision stays low. However, the increased incidence of lucent lines around the ulnar component with follow-up and bushing wear are of concern.

Results with a minimum of 10 years follow-up of the Coonrad/Morrey total elbow arthroplasty

INTRODUCTION

Few series have evaluated the long-term results of total elbow arthroplasty (TEA).

MATERIALS AND METHODS

Fifteen patients with a Coonrad/Morrey total elbow implant were reviewed with a minimum follow-up of 10 years. There were nine women and six men with a mean age of 55 years at surgery. The aetiology was rheumatoid arthritis in eight cases, post-traumatic arthritis in five, psoriatic arthritis in one, and sequelae of neonatal septic arthritis in one. The TEA was performed as primary surgery in ten cases and during a revision surgery in four.

RESULTS

At 136 months average follow-up (120-160), MEPS was 82 ± 14 points (range 60-100) with a Quick DASH score of 41 points (range 13-83). Fourteen patients had no or slight pain and six had a functional range of motion. Elbow function was normal in eight of 15 patients. Radiolucent lines were found around the humerus in six cases (all of them incomplete) and around the ulnar component in eight (five of them complete) with loosening and migration of the ulnar stem occurring in two cases. Wear of the bushings was moderate in five cases and severe in two. There were ten complications with a revision needed in three cases. Revision-free survival rate for the implant was 100% at 5 years and 90% at 10 and 13 years.

DISCUSSION

The Coonrad/Morrey total elbow gives long-term satisfactory results. Increased incidence of radiolucent lines around the ulnar stem and bushing wear with longer follow-up is of concern and represents the failure mode for this total elbow arthroplasty implant.

LEVEL OF EVIDENCE

IV.

Scaphocapitate arthrodesis for treatment of scapholunate instability in manual workers

PURPOSE

To assess the long-term efficacy of scaphocapitate arthrodesis for treatment of chronic scapholunate instability in high-demand patients.

METHODS

We retrospectively analyzed the clinical and radiographic results of 20 manual workers who underwent scaphocapitate arthrodesis for chronic scapholunate instability at a mean follow-up of 10 years (range, 1-23 y). We measured range of motion and grip strength; pain on a scale of 0 to 5; Quick Disabilities of the Arm, Shoulder, and Hand score; and ability to return to work. We assessed radiographs for union, carpal height and alignment, signs of ulnar translation or radiocarpal arthritis, and hardware problems.

RESULTS

At most recent follow-up, the arc of motion averaged 87° for flexion-extension and 41° for the radioulnar deviation. The postoperative average maximum grip strength was 21 kg, which was 60% of the opposite, normal wrist. Pain was significantly reduced. The average postoperative Quick Disabilities of the Arm, Shoulder, and Hand score was 19, and the return-to-work rate was 90%. Radiographic analysis showed union in all patients, improvement of carpal height and scaphoid angle, no evidence of ulnar translation, and a 30% rate of radiocarpal osteoarthritis.

CONCLUSIONS

This report of long-term results demonstrates the efficacy of scaphocapitate limited carpal arthrodesis for the treatment of chronic rotatory subluxation of the scaphoid. We conclude that continued use of this procedure is warranted.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Effectiveness of four-corner arthrodesis with use of a locked dorsal circular plate

BACKGROUND

Compared with traditional methods of fixation in four-corner arthrodesis, reviews of results using a dorsal circular plate (DCP) have identified higher complication rates. As the use of circular plate fixation for limited wrist arthrodesis was found to be a valuable concept per se and continued innovation and technical advancement are crucial to improve future treatment, changes in plate design were encouraged.

QUESTIONS/PURPOSES

To further evaluate the use of DCP fixation in four-corner arthrodesis, we report the first results using a radiolucent, nonmetallic (polyetheretherketone), locked DCP for four-corner arthrodesis.

METHODS

We retrospectively analyzed the clinical and radiographic results of 24 patients who underwent four-corner arthrodesis with a locked DCP at a minimum followup of 63 months (mean, 76 months; range, 63-91 months). There were nine women and 15 men, with a mean age of 53 years (range, 37-78 years) at the time of surgery. We evaluated ROM with a goniometer and grip strength with a dynamometer. Function was assessed using QuickDASH. Radiographs were evaluated for union, carpal alignment, and hardware problems.

RESULTS

At latest followup, ROM averaged 66% and 77% of the uninjured side in flexion-extension and radioulnar deviation, respectively. Grip strength averaged 70% of the uninjured side. The average postoperative QuickDASH score was 19.11. Union was achieved by 22 of the 24 patients.

CONCLUSIONS

Our data show four-corner arthrodesis with a radiolucent, nonmetallic, locked DCP is an effective procedure that allows stable primary fixation as a basis for good functional outcome, provided surgical technique and quality of bone graft are adequate.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Pain-related fear and catastrophizing predict pain intensity and disability independently using an induced muscle injury model

Timing of assessment of psychological construct is controversial and results differ based on the model of pain induction. Previous studies have not used an exercise-induced injury model to investigate timing of psychological assessment. Exercise-induced injury models may be appropriate for these investigations because they approximate clinical pain conditions better than other experimental stimuli. In this study we examined the changes of psychological constructs over time and determined whether timing of assessment affected the construct's association with reports of pain intensity and disability. One-hundred twenty-six healthy volunteers completed the Fear of Pain Questionnaire (FPQ-III), Pain Catastrophizing Scale (PCS), and Tampa Scale of Kinesiophobia (TSK) prior to inducing muscle injury to the shoulder. The PCS and TSK were measured again 48 and 96 hours postinjury induction. Pain intensity and disability were collected at 48 and 96 hours and served as dependent variables in separate regression models. Results indicated that the FPQ-III had the strongest prediction of pain intensity from baseline to 96 hours. After baseline the PCS and TSK were stronger predictors of pain intensity and disability, respectively. These data provide support for the use of psychological constructs in predicting outcomes from shoulder pain. However, they deviate from the current theoretical model indicating that fear of pain is a consequence of injury and instead suggests that fear of pain before injury may influence reports of pain intensity.

PERSPECTIVE

The current study provides evidence that fear of pain can be assessed prior to injury. Furthermore, it supports that after injury pain catastrophizing and kinesiophobia are independently associated with pain and disability. Overall these data suggest that timing of psychological assessment may be an important consideration in clinical environments.

Pain management in the emergency department and its relationship to patient satisfaction

Background:

Pain is the most common reason due to which patients come to the emergency department (ED).

Aim:

The purpose of this study was to measure the correlation, if any, between pain reduction and the level of satisfaction in patients who presented to the ED with pain as their chief complaint.

Materials and Methods:

This study used a randomly selected group of patients who presented to the ED with pain of 4 or more on the Visual Analogue Pain Scale (VAS) as their chief complaint to a level one adult and pediatric trauma center. Instruments that were used in this study were the VAS, Brief Pain Inventory (BPI), and the Medical Interview Satisfaction Scale (MISS). They were administered to patients by research fellows in the treatment rooms. Statistical analysis included frequencies, descriptive, and linear regression. This study was approved by the Internal Review Board.

Results:

A total of 159 patients were enrolled in the study. All patients were given some type of treatment for their pain upon arrival to the ED. A logistic regression showed a significant relationship to reduction in pain by 40% or more and customer service questions.

Conclusions:

A reduction in perceived pain levels does directly relate to several indicators of customer service. Patients who experienced pain relief during their stay in the ED had significant increases in distress relief, rapport with their doctor, and intent to comply with given instructions.

Validity and responsiveness of presenteeism scales in chronic work-related upper-extremity disorders

BACKGROUND

The Work Limitations Questionnaire-25 (WLQ-25) and the Work Instability Scale for Rheumatoid Arthritis (RA-WIS) have been used to measure at-work disability related to musculoskeletal disorders. However, a recent systematic review has shown that important psychometric properties still needed to be evaluated.

OBJECTIVE

The purpose of this study was to establish the validity and responsiveness of the WLQ-25 and RA-WIS in people with chronic work-related upper-extremity disorders.

DESIGN

Two-hundred six participants with chronic upper-extremity disorders who attended a specialty clinic operated by the Workplace Safety & Insurance Board of Ontario were evaluated at their initial visit and 6 months later.

METHODS

Questionnaires completed at each evaluation were: the WLQ-25, the RA-WIS, the QuickDASH, the pain subscale of the Shoulder Pain and Disability Questionnaire, and the Chronic Pain Grade Questionnaire. At the 6-month evaluation, participants completed a global rating of change question. Known-group and construct convergent validity were assessed using analysis of variance and Pearson correlations, and standardized response means (SRMs) were used to assess responsiveness. Clinically important differences (CIDs) also were determined.

RESULTS

The WLQ-25 and RA-WIS had low to moderate correlations with pain and disability scales (.28<r<.62) and discriminated among different functional categories (P<.001). For improved participants, the WLQ-25 (SRM=0.65 for summed score, SRM=0.63 for index score) and the RA-WIS (SRM=0.66) demonstrated moderate responsiveness. The CID for improvement was estimated to be 13/100 points for the WLQ-25 summed score, 5/28.6 points for the WLQ-25 index score, and 4/23 points for the RA-WIS.

LIMITATIONS

The external criterion of change was specific to change in upper-extremity condition and not to change in work ability or productivity.

CONCLUSIONS

The WLQ-25 and RA-WIS provide different information from that provided by pain and disability measures. They discriminate among functional outcome subgroups and detect improvement over time in people with chronic work-related upper-extremity disorders.

Performance-integrated self-report measurement of physical ability

BACKGROUND CONTEXT

The technology of self-report measures has advanced rapidly over the past few years. Recently, this technology was used to develop a performance-integrated self-report measure for use with patients with musculoskeletal impairments that may lead to work disability. Psychometric studies of the new measure in patient populations have been successful. A validation study of the measure with adults in good general health is necessary.

PURPOSE

The purpose of this study was to assess the concurrent validity of a new performance-integrated self-report measure, the multidimensional task ability profile (MTAP).

STUDY DESIGN/SETTING

A prospective validation study was conducted in which a self-report measure was administered online, and a physical performance test was administered at various clinics in North America.

PATIENT SAMPLE

One hundred ninety-six (34% male) adult volunteers in good general health participated in this study.

OUTCOME MEASURES

Self-report measure-MTAP. Physiologic measure-EPIC Lift Capacity test.

METHODS

The MTAP was administered online within 1 week of formal testing of lift capacity using a standardized lift capacity test, the EPIC Lift Capacity test. MTAP scores were compared with performance on the EPIC Lift Capacity test. Stepwise regression analysis was used to identify the strength of the relationship between the two measures and the relative explanation of lift capacity variance by the MTAP score, along with gender and age.

RESULTS

The combination of MTAP score, gender, and age demonstrated a regression coefficient of R=0.82, which accounts for 67.3% of the variance in lift capacity.

CONCLUSIONS

The MTAP displayed good concurrent validity compared with actual physical performance as assessed by the EPIC Lift Capacity test. Modern performance-integrated self-report measures, such as the MTAP, have the potential to provide information about functional capacity that is sufficiently useful to confirm status and help guide treatment algorithms.

A modified QuickDASH-9 provides a valid outcome instrument for upper limb function

BACKGROUND

The 30-item Disabilities Arm Shoulder and Hand (DASH) questionnaire was introduced to facilitate assessment of upper limb functional limitations. To improve practicality and eliminate item redundancy a modified instrument was needed. The 11-item QuickDASH was developed to fulfil these requirements and translated into several languages. However, prospective investigations of psychometric and practical characteristics are limited. No published study investigated readability or used concurrent validation with a standardized upper limb criterion measure. The validity of the QuickDASH has been questioned as the results for factor structure are conflicting, and the English-language version has not yet had factor structure reported. A shortened 9-item version, the QuickDASH-9, that addresses these issues is proposed.

METHODS

This two-stage observational study assessed the psychometric and practical characteristics of the QuickDASH and the extracted QuickDASH-9. The Upper Limb Functional Index (ULFI) was the criterion standard in both stages. Stage 1, calibration, reanalyzed extracted QuickDASH and QuickDASH-9 responses from a previous prospective study, by the authors, of the 30-item DASH (n = 137). Stage 2, prospective validation, investigated the QuickDASH through repeated measures in consecutive upper limb musculoskeletal participants' consulting for physical therapy in Australia (n = 67). The QuickDASH and extracted QuickDASH-9 data from both stages was analyzed and compared for psychometric properties, practical characteristics and factor structure.

RESULTS

The proposed QuickDASH-9 had a unidimensional structure, high reliability (ICC 2:1, r = 0.92), internal consistency (alpha = 0.93) and responsiveness (ES = 1.05). It correlated highly with both the DASH (r = 0.97), QuickDASH (r = 0.99) and ULFI criterion (r = 0.85). QuickDASH-9 missing responses reduced to 3.5% from 26% in the QuickDASH. Completion and scoring time was 134 +/- 56 seconds and required a computational aid. The QuickDASH demonstrated a bidimensional structure making it invalid. The QuickDASH-9 summary performance was measured on the 'Measurement of Outcome Measures' at 88% and on the 'Bot' clinimetric scale at 75%.

CONCLUSIONS

The proposed QuickDASH-9 had a unidimensional structure and similar psychometric precision to the full-length DASH with improved practicality and completion time. The QuickDASH was invalid as its bidimensional structure made a single summated score inappropriate. The QuickDASH-9 offers a future direction for ongoing use of the QuickDASH concept.

The effects of deep breathing training on pain management in the emergency department

PURPOSE

The purpose of this study was to measure the impact of deep breathing exercises on the pain levels in patients who presented to the emergency department (ED) with pain as their chief complaint. A secondary purpose was to measure the impact of deep breathing teaching on indicators of patient satisfaction.

METHODS

This was an observational study of patients who presented to the ED with pain as their chief complaint to an urban level one Emergency Department. Patients were randomized into a control group and an experimental group. The control group received the usual treatment for pain. The experimental group received the usual treatment for pain, but also received deep breathing exercises. For the measurement of pain prior to treatment, the brief pain inventory (BPI) was used. The visual analogy system (VAS) was used to measure pain prior to and after treatment and deep breathing were administered. For the measurement of patient satisfaction, the medical interview satisfaction scale (MISS) was used.

RESULTS

There was no significant difference between those who received the deep breathing education and those that did not with regards to postmedication pain levels. There was however, a significant difference in customer service satisfaction within the area of doctor/patient rapport and intention to follow treatment.

CONCLUSION

The usefulness of deep breathing exercises was shown to be ineffective in reducing pain levels; however, the majority of those who received deep breathing education felt it was useful. The exercise was effective in increasing patient's feelings of rapport and intentions to follow their doctor's directives.

Effect of Functional Capacity Evaluation information on the judgment of physicians about physical work ability in the context of disability claims

Purpose

To test whether Functional Capacity Evaluation (FCE) information lead insurance physicians (IPs) to change their judgment about the physical work ability of claimants with musculoskeletal disorders (MSDs).

Methods

Twenty-seven IPs scored twice the physical work ability of two claimants for 12 specified activities, using a visual analogue scale. One claimant performed an FCE, the other served as a control. Outcome measure was the difference between experimental and control group in number of shifts in the physical work ability for the total of 12 specified activities.

Results

The IPs changed their judgment about the work ability 141 times when using FCE information compared to 102 times when not using this information (P-value = 0.001), both in the direction of more and less ability.

Conclusions

The IPs change their judgment of the physical work ability of claimants with MSDs in the context of disability claim procedures more often when FCE information is provided.

Psychometric properties of the shortened disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain

PURPOSE

To examine the psychometric properties of the Shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and the Numeric Pain Rating Scale (NPRS) in patients with shoulder pain.

METHODS

Single-group repeated measures design in which 101 patients presenting to physical therapy completed the QuickDASH and the NPRS at the baseline examination and at a follow-up visit. At the follow-up all patients also completed the Global Rating of Change (GRC), which was used to dichotomize patients as improved or stable. Baseline and follow-up scores were used to determine the test-retest reliability, construct validity and minimal levels of detectable and clinically important change for both the QuickDASH and NPRS.

RESULTS

Test-retest reliability was 0.90 for the QuickDASH and 0.74 for the NPRS. The minimal clinically important difference (MCID) was 8.0 points for the QuickDASH and 1.1 for the NPRS.

CONCLUSION

The NPRS and QuickDASH exhibit good test-retest reliability and responsiveness in patients with shoulder pain.

Operative management of distal radial fractures with 2.4-millimeter locking plates. A multicenter prospective case series

BACKGROUND

In the past decade, there has been a trend toward open reduction and internal fixation of unstable distal radial fractures. There are now more than thirty different implant designs specific for the fixation of distal radial fractures. A multicenter prospective study of a case series was conducted to determine the efficacy of the operative management of distal radial fractures stabilized with 2.4-mm locking plates.

METHODS

One hundred and fifty patients were entered into the study over a two-year period. The mean age of these patients was fifty-one years, and the cohort included eighty-eight women and sixty-two men. Eighty-six patients sustained a low-energy injury. Seventy-one percent of the fractures in the series were intra-articular and were Type C according to the Müller-AO Comprehensive Classification. The follow-up evaluations, which were conducted at six weeks, six months, one year, and two years, included assessments of pain, motion, grip strength, and standard radiographs. Gartland and Werley scores were recorded at six months and one and two years, and Disabilities of the Arm, Shoulder and Hand (DASH) scores were recorded at one and two years.

RESULTS

One hundred and twenty-five patients (83%) had a complete follow-up at six months; 121 (81%), at one year; and 117 (78%), at two years. Significant improvements in motion, grip strength, and patient satisfaction were observed between six months and one year, but further improvements were not seen at the two-year follow-up examination. The mean DASH score changed from a preinjury baseline of 2 points to 8 points at one year and 7 points at two years (p < 0.0001). The mean Gartland and Werley score improved significantly from 4 points at six months to 2 points at two years. Of the 102 intra-articular fractures examined in the immediate postoperative period, twenty had a step-off of < or =2 mm and seven had a step-off of >2 mm. Of the seventy-one intra-articular fractures seen at two years, sixty-one had no step-off, five had a step-off of < or =2 mm, and five had a step-off of >2 mm. Twenty-seven percent of the patients showed an increase of at least one grade in radiographic signs of arthritis at two years. There were twenty-eight complications, twenty of which were considered minor. Tendon inflammation occurred in nine patients. There were two tendon ruptures, one of which was due to a prominent dorsal screw tip placed through a volar plate and one of which was due to a prominent volar plate. Loss of reduction occurred in two patients, and screw loosening occurred in two patients.

CONCLUSION

Internal fixation of displaced distal radial fractures with implants featuring locking screw fixation can result in good-to-excellent outcomes with a limited number of complications.