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PURPOSE: We assessed the validity of postsurgery venous thromboembolism (VTE) diagnoses identified from administrative databases and compared Bayesian and multiple imputation (MI) approaches in correcting for outcome misclassification in logistic regression models. METHODS: Sensitivity and specificity of postsurgery VTE among patients undergoing total hip or knee replacement (THR/TKR) were assessed against chart review in six Montreal hospitals in 2009 to 2010. Administrative data on all THR/TKR Quebec patients in 2009 to 2010 were obtained. The performance of Bayesian external, Bayesian internal, and MI approaches to correct the odds ratio (OR) of postsurgery VTE in tertiary versus community hospitals was assessed using simulations. Bayesian external approach used prior information from external sources, while Bayesian internal and MI approaches used chart review. RESULTS: In total, 17 319 patients were included, 2136 in participating hospitals, among whom 75 had VTE in administrative data versus 81 in chart review. VTE sensitivity was 0.59 (95% confidence interval, 0.48-0.69) and specificity was 0.99 (0.98-0.99), overall. The adjusted OR of VTE in tertiary versus community hospitals was 1.35 (1.12-1.64) using administrative data, 1.45 (0.97-2.19) when MI was used for misclassification correction, and 1.53 (0.83-2.87) and 1.57 (0.39-5.24) when Bayesian internal and external approaches were used, respectively. In simulations, all three approaches reduced the OR bias and had appropriate coverage for both nondifferential and differential misclassification. CONCLUSION: VTE identified from administrative data had low sensitivity and high specificity. The Bayesian external approach was useful to reduce outcome misclassification bias in logistic regression; however, it required accurate specification of the misclassification properties and should be used with caution.

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OBJECTIVES: This study seeks to evaluate the effects of a mild traumatic brain injury (mTBI) on pain in patients with an isolated limb fracture (ILF) when compared to a matched cohort group with no mTBI (control group). PATIENTS AND METHODS: All subjects included in this observational study suffered from an ILF. Groups were matched according to the type of injury, sex, age, and time since the accident. Main outcome measurements were: Standardized semi-structured interviews at follow-up of a Level I Trauma Center, and a questionnaire on fracture-related pain symptoms. Factors susceptible to influence the perception of pain, such as age, sex, severity of post-concussive symptoms, and worker compensation were also assessed. RESULTS: A total of 68 subjects (36 females; 45 years old) with an ILF were selected, 34 with a comorbid mTBI and 34 without (24/34 with an upper limb fracture per group, 71% of total sample). Patients with mTBI and an ILF reported significantly higher pain scores at the time of assessment (mean: 49days, SD: 34.9), compared to the control group (p<0.0001; mean difference 2.8, 95% confidence interval 1.8-4.0). Correlational analyses show no significant association between the level of pain and factors such as age, sex, severity of post-concussive symptoms, and worker compensation. CONCLUSIONS: Results suggest that mTBI exacerbate perception of pain in the acute phase when occurring with an ILF, and were not explained by age, sex, post-concussive symptoms, or worker compensation. Rather, it appears possible that neurological sequelae induced by mTBI may interfere with the normal recovery of pain following trauma.

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BACKGROUND: The first part of this series of 2 articles revealed that chronic pain is an important issue post extremity trauma (ET) involving permanent biological transformations. Interventions aimed at preventing chronic pain in ET patients are therefore required. OBJECTIVE: To conduct a comprehensive analysis of literature on risk and protective factors for chronic pain post-ET to guide the development of relevant preventive interventions. METHODS: A narrative review of the literature was undertaken. Databases were searched to identify studies on chronic pain prognostic factors in ET patients. RESULTS: Demographic, injury-related and psychological factors were shown to either contribute to or limit acute to chronic pain transition. High-intensity acute pain hasconsistently been identified as an important chronic pain risk factor. Other significant documented risk factors include: female gender, older age, less than college education, lower limb injury, symptoms of anxiety and depression and pain catastrophizing. Pain self-efficacy and pain acceptance have been shown to protect individuals against chronic pain. CONCLUSIONS: This narrative review highlights factors placing ET patients at higher risk of chronic pain or protecting them against this problem. Determining how these factors could be addressed in preventive interventions is the next step before undertaking their development.

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BACKGROUND: Several studies have been conducted over the last decade that describe the issue of pain and prognostic factors of acute to chronic pain transition post extremity trauma (ET). However, no thorough interventions to prevent chronic pain development in ET patients have yet been proposed. OBJECTIVES: This first part of a series of two articles aimed to provide a comprehensive analysis of literature on the epidemiology of pain post-ET, the impact of persistent pain on ET patients and the relevant biological transformations involved in acute to chronic pain transition. The second article will focus on risk and protective factors relating to chronic pain that could potentially assist in the development of preventive interventions. METHODS: A narrative review of the literature was undertaken. Databases were searched to identify relevant studies and seminal works on the topics of interest. RESULTS: The review revealed that acute pain converts to chronic pain in up to 86% of ET patients. Analysis of study findings also indicated that chronic pain interferes with activities of daily living and capacity to work. Weak associations between chronic pain and anxiety as well as depression have been demonstrated. Anxiety and depression have been identified as important predictors of chronic pain post-ET. Neuro-immunological transformations, genetics and an emotional shift in the brain circuitry involved in nociception have been shown to contribute to the transition towards chronic pain. CONCLUSIONS: This narrative review supports the view that acute to chronic pain transition is a prevalent and significant issue post-ET. It also provides information about patients who present a higher risk of chronic pain and features that should be integrated in preventive interventions as well as methodological considerations pertaining to the evaluation of such interventions.

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BACKGROUND: The purpose of our study was to identify the risk factors associated with the need for inpatient rehabilitation after lower limb injury to develop a predictive scoring tool for early identification of such patients. METHODS: We followed a prospective cohort of patients admitted to a level 1 trauma centre. Data were collected through chart review and a self-administered questionnaire on sociodemographics, patient living environment, pretrauma status, injury and treatment received. We compared patients who were discharged home with those going to rehabilitation after acute care. Analysis consisted of bivariate comparisons and logistic regression. RESULTS: Our study included 160 patients with a mean age of 56 years. A total of 40% were discharged to an inpatient rehabilitation centre. Factors associated with inpatient rehabilitation were low preinjury physical health status, concomitant injury of the upper limbs, bilateral lower limb injury, the use of a walking aid before injury, head injury and femur or pelvic fractures. We created a predictive score using the top 3 risk factors: upper limb injury, bilateral lower limb injury and presence of femoral or pelvic fractures. The chance of needing inpatient rehabilitation rose from 14% with 0 factors to 47% with 1 factor and 96% with 2 factors. CONCLUSION: Rehabilitation planning should begin for patients exhibiting at least of 3 risk factors at the time of admission to acute care. Prospective validation of the tool is needed, but it has the potential to orient the multidisciplinary team's decision on rehabilitation needs postdischarge.

CONTEXTE: Notre étude avait pour but de recenser les facteurs de risque associés à un séjour en établissement de réadaptation pour les patients victimes de traumatismes aux membres inférieurs, afin de concevoir un outil de classification prédictive pour l'identification précoce de ces patients. MÉTHODES: Nous avons suivi une cohorte prospective de patients admis dans un centre de traumatologie de niveau 1. Les données proviennent d'une revue des dossiers et de questionnaires auto-administrés sur les caractéristiques sociodémographiques, le milieu de vie des patients, leur statut prémorbide, le traumatisme subi et le traitement reçu. Nous avons comparé les patients qui ont reçu leur congé pour retourner à la maison à ceux qui devaient faire un séjour en centre de réadaptation après des soins actifs. L'analyse a reposé sur des comparaisons bivariées et la régression logistique. RÉSULTATS: Notre étude a regroupé 160 patients âgés en moyenne de 56 ans. En tout, 40 % ont été transférés dans des centres de réadaptation où ils ont séjourné. Les facteurs associés au transfert dans un centre de réadaptation étaient : piètre état de santé physique avant le traumatisme, traumatisme concomitant aux membres supérieurs, traumatisme aux 2 membres inférieurs, utilisation d'un dispositif d'aide à la marche avant le traumatisme, traumatisme crânien et fractures du fémur ou du bassin. Nous avons créé un score prédictif sur la base des 3 principaux facteurs, soit traumatisme concomitant aux membres supérieurs, traumatisme aux 2 membres inférieurs et fractures du fémur ou du bassin. Le risque de devoir séjourner en centre de réadaptation est passé de 14 % en l'absence de ces facteurs à 47 % en présence de l'un des facteurs et à 96 % en présence de 2 facteurs. CONCLUSION: La planification de la réadaptation devrait commencer dès leur admission en centre de soins actifs pour les patients qui présentent au départ au moins 3 facteurs de risque. Il faudra valider l'outil de façon prospective, mais il pourrait orienter les décisions de l'équipe multidisciplinaire quant aux besoins de réadaptation lorsque le patient reçoit son congé.

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HYPOTHESIS: We hypothesized that the radiocapitellar ratio (RCR) is a valid and reproducible method to assess radial head translation in healthy individuals and that the normal RCR of healthy individuals is 0%. MATERIALS AND METHODS: Lateral radiographs of the elbow were examined in 40 healthy patients. The measurement method of the RCR was the displacement of the radial head (minimal distance between the right bisector of the radial head and the center of the capitellum) divided by the diameter of the capitellum. Intraobserver and interobserver reliability was evaluated using intraclass correlation (ICC). RESULTS: The RCR was 4% ± 4% (range, -7% to 19%). The mean RCR of 4% measured in this cohort represents an anterior displacement of 1 mm in a capitellum of 25 mm. Intraobserver reliability was good (ICC, 0.72) and interobserver reliability was fair (ICC, 0.52). A significant side-to-side correlation was observed (r = 0.4, P = .009). No difference was identified between men and women, and no correlation was identified between age and the RCR. The standard deviation of the centered RCR measurements was 3%, which represented the variability of RCR measurements. CONCLUSIONS: The results of this study confirm the traditional belief that in the normal elbow, the radial head is generally aligned towards the capitellum on lateral radiographs. Accordingly, a RCR observed outside the ranges of 1 mm posterior (-5%) to 3 mm anterior (13%) in a 25 mm capitellum suggests a misalignment at the RC joint of the elbow. The RCR method to assess RC joint translations has demonstrated a normal distribution in healthy individuals and good reliability.

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BACKGROUND: Several complications have been reported with the use of the PLLA (poly-L-Lactide) bioabsorbable screw in orthopedic surgery. The hypothesis was that the use of a bioabsorbable screw in distal biceps tenodesis results in significant osteolysis of the radial bone. The correlation between osteolysis and functional and clinical outcomes was also studied. METHODS: All consecutive patients who underwent anatomic repair of the distal biceps tendon with a bioabsorbable screw were included. From the x-ray taken immediately after the surgery, the ratio between the volume of the bone tunnel and the volume of the radius bone section was measured. This relation was calculated at different follow-up periods to obtain the percentage of tunnel enlargement over time. Complications, as well as functional and clinical outcomes, were also assessed. Mayo Elbow Performance Score (MEPS), the quick-Disability Arm Shoulder Hand (DASH), and the Short-Form 12 (SF-12) were used. RESULTS: Nineteen consecutive patients were available for follow-up. The average initial relative volume occupied by the screw tunnel was 49% of the bone section and increased to 61% at the last follow-up at an average of 22 months (range, 3-62 months). Eight of the 19 patients presented postoperative complications. There was only 1 case of complete bone filling of the tunnel, which was observed at a 5-year and 2-months follow-up. There was no significant correlation between the volume of bone resorption and functional and clinical outcomes. DISCUSSION: No correlation was found between the volume of bone tunnel and the functional outcome. However, the results indicate that the use of a bioabsorbable screw in distal biceps tendon repair results in significant bone osteolysis.

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This cadaveric study sought to evaluate the feasibility of applying a locking proximal humerus plate with a novel minimally invasive technique. A unique pre-contoured locking plate was placed on cadaveric proximal humeri through a described minimally invasive approach. Proximity of the plate and screws to the axillary nerve and their respective surgical tracks were quantified. Safe screw hole placement with respect to the axillary nerve was determined. Risk of entrapment of the nerve beneath the plate was evaluated. Three of the holes near the middle of the locking plate consistently intersected the course of the axillary nerve and were unsafe for percutaneous placement of the screws. The axillary nerve could be palpated during the course of surgery and easily protected from injury. No entrapment of the axillary nerve occurred using this minimally invasive technique. The screw-in locking guide cannot be used with this technique as it caused tenting of the axillary nerve. Placement of a locking proximal humerus plate via a minimally invasive lateral trans-deltoid approach is safe if the locking screws are limited to superior and inferior holes. This can be done safely without entrapment of the axillary beneath the plate. Plate fixation of proximal humerus fractures may now be more desirable with the use of this approach.

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