A man in his mid-80s presented with bilateral posterior fracture dislocations of the humerus after suffering a seizure. He had Parskinson’s disease and lived with his wife at home. His left shoulder was not felt to be reconstructable. The initial treatment plan was to perform reverse total shoulder arthroplasty (rTSA) on the left and non-operatively reduce his right shoulder. A left rTSA was performed, but his right shoulder was unstable due to a glenoid fracture and soft tissue instability. In order to preserve the patient’s quality of life, a right rTSA was performed 4 days later. In the follow-up period, the patient was able to regain enough pain-free range of motion on activities of daily living. The patient died from complications of Parkinson’s disease 10 months postoperatively.
Introduction. Lateral ankle instability represents a common orthopaedic diagnosis. Nonoperative treatment through focused physical therapy provides satisfactory results in most patients. However, some patients experience persistent chronic lateral ankle instability despite appropriate nonoperative treatment. These patients may require stabilization which can include primary lateral ligament reconstruction with a graft to restore ankle stability. Optimal post-operative rehabilitation of lateral ankle ligament reconstruction remains unknown, as surgeons vary in how long they immobilize their patients post-operatively. The aim of this review is to provide insight into early mobilization (EM) versus delayed mobilization (DM) post-operative protocols in patients undergoing primary lateral ankle ligament reconstructions to determine if an optimal evidence-based post-operative rehabilitation protocol exists in the literature. Methods. Following PRIMSA criteria, a systematic review/meta-analysis using the PubMed/Ovid Medline database was performed (10/11/1947-1/28/2020). Manuscripts that were duplicates, non-lateral ligament repair, biomechanical and non-English language were excluded. Protocols were reviewed and divided into two categories; early mobilization (within 3 weeks of surgery) and delayed mobilization (after 3 weeks of surgery). Functional outcome scores (AOFAS, Karlsson scores), radiographic measurements (anterior drawer, talar tilt) and complications evaluated using weighted mean differences (pre- and post-operative scores) and mixed-effect models. Results. After our search, we found 12 out of 1,574 studies that met the criteria for the final analysis, representing 399 patients undergoing lateral ankle reconstruction. Using weighted mean differences the DM group showed superior AOFAS functional scores compared to the EM group; 28.0 (5.5) vs. 26.3 (0.0) respectively, p < 0.001; although sample size was small. Conversely, no significant differences were found for Karlsson functional score (p = 0.246). With regards to radiographic outcome, no significant differences were observed; anterior drawer was p = 0.244 and talar tilt was p = 0.937. A meta-analysis using mixed-effects models confirmed these results, although heterogeneity was high. Conclusions. While there were some conflicting results, findings suggest that EM post-operative protocols for patients undergoing lateral ankle ligament reconstruction may not compromise functional outcomes or post-operative stability. Because heterogeneity was high, future studies are still needed to evaluate these protocols in less diverse patient groups and/or more consistent techniques for lateral ankle ligament reconstruction.
Introduction. The initial treatment for many orthopaedic injuries is splinting. Unfortunately, formal musculoskeletal training is limited in primary care leading to deficiencies in competency and confidence. Suboptimal splints can result in complications such as skin breakdown, worsening of deformity, and increased pain. Our orthopaedic surgery clinic often cares for patients who initially present to an emergency department or primary care clinic for their orthopaedic injury. Previous studies have shown that a high number of splints are applied improperly in the primary care setting, which could result in in avoidable skin complications and fracture instability. Methods. Orthopaedic surgery residents held a splinting workshop for family medicine residents. The workshop involved didactic and skills portions. Pre- and post-surveys were administered using a 10-point scale to assess confidence in applying three common splints. The data were analyzed using student’s t-test and qualitative feedback. Results. Confidence in applying and molding each splint type improved significantly (p < 0.05). Knowledge in splint construction improved significantly as well (p < 0.05). Subjective feedback was positive. Conclusion. These results showed inter-residency education can increase residents’ confidence in skill-based medical care significantly. The results are encouraging and should facilitate further collaboration between multispecialty residency programs to improve patient care. Further investigation is needed to determine how well skills gained in workshop are retained.
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