Surgical treatment of complex proximal humeral fractures with a technique of nail and osteosuture: “NOS”

Open reduction and internal fixation of complex proximal humeral fracture represents a surgical challenge. The main objective of this procedure is to anatomically reduce the tuberosities. We propose a standardized and reproducible technique that we apply to all complex displaced 3- and 4-part fractures of patients under 50 years. We use an antero-lateral trans-deltoid approach; the humeral head and the tuberosities are reduced under fluoroscopic control. The tuberosities are stabilized with an inter-tuberosity osteosuture, and we then introduce a thin and straight intra-medullary nail (Telegraph IV FH Orthopedics) at the hinge point of the humeral head. The osteosynthesis of the tuberosities is completed by 3- or 4-self-stable divergent screws in the nail. A dynamic distal locking stabilizes the humeral shaft in rotation and facilitates consolidation thanks to micro movements. The removal of the nail with an arthroscopic shoulder arthrolysis in case of stiffness is possible secondarily.     

Laparoscopic blood-saving liver resection using a new radiofrequency-assisted device: preliminary report of an in vivo study with pig liver

Background

The aim of any device designed for liver resection is to allow blood saving and quick resections. This may be optimized using a minimally invasive approach. A radiofrequency-assisted device is described that combines a cooled blunt-tip electrode with a sharp blade on one side in an in vivo preliminary study using hand-assisted laparoscopy to perform partial hepatectomies.

Methods

Eight partial hepatectomies were performed on pigs with hand-assisted laparoscopy using the radiofrequency-assisted device as the only method for transection and hemostasis. The main outcome measures were transection time, blood loss, transection area, transection speed, blood loss per transection area, and tissue coagulation depth. The risk for biliary leak also was assessed using the methylene blue test.

Results

The transection time was 13 ± 7 min for a mean transected area of 34 ± 11 cm². The mean total blood loss was 26 ± 34 ml. The mean transection speed was 3 ± 1 cm²/min, and the blood loss per transection area was 1 ± 1 ml/cm². Abdominal examination showed no complications in nearby organs. One biliary leak was identified in one case using the methylene blue test. The transection surface was 34 ± 11 cm², and the mean tissue coagulation depth was 9 ± 2 mm. The inviability of the coagulated surface was assessed by adenine dinucleotide (NADH) staining.

Conclusions

The radiofrequency-assisted device has shown with a laparoscopic approach that it can perform liver resections faster and with less blood loss using a single device in a minimally invasive manner without vascular control than other commercial devices. The results show no significant differences with the same device used in an open procedure.     

Reconstruction of Mason type-III and type-IV radial head fractures with a new fixation device: 23 patients followed 1–4 years

Background?Treatment options in radial head fractures of Mason types III and IV range from open reduction and internal fixation (ORIF) to radial head resection with or without prosthetic replacement.

Patients?In a prospective study, the radiographic and clinical outcome was evaluated in 23 patients (age median 51 years) with 23 complex radial head fractures median 2 (1–4) years after ORIF using a new fixation device (FFS; Orthofix). 14 Mason type-III fractures with 2 concomitant olecranon fractures and 1 ulnar nerve lesion, and 11 type-IV fractures with 2 olecranon fractures and 2 fractures of the coronoid process were treated. 2 patients were lost to follow-up. In 7 cases of joint instability, an elbow fixator with motion capacity was applied after ORIF of the radial head.

Results?No radial head resection was necessary. No secondary dislocations or nonunion occurred. The Morrey elbow score was excellent in 8 and good in 4 Mason type-III fractures and excellent in 5, good in 3, and fair in 3 Mason type-IV fractures.

Interpretation?Reconstruction of comminuted radial head fractures can be performed with this device and radial head resection can be avoided.     

The olecranon sled—a new device for fixation of fractures of the olecranon: A mechanical comparison of two fixation methods in cadaver elbows

Background?Tension band wiring is the most common surgical procedure for fixation of fractures of the olecranon, but symptomatic hardware prominence and migration of K-wires can cause a high re-operation rate. The olecranon sled has been designed to minimize some of these problems.

Material and methods?Simulated olecranon fractures were created in 6 matched pairs of cadaver arms. Each pair was fixed with tension band wiring used on the one arm and the olecranon sled being used on the other. Mechanical testing was done with the humerus rigidly fixed in a vertical position while the forearm was held at 1 of 3 angles of elbow fixation, 45°, 90° and 135°, respectively. For each angle, the triceps and the brachialis muscles were sequentially loaded with 5?kg (50?N) for 20 cycles and the amount of fracture displacement measured.

Results?Loading of the brachialis muscle produced no increase in the fracture gap for either of the two fixation techniques. However, an increase in the fracture gap of up to 0.23?mm was found after cyclic loading of the triceps muscle for both techniques. The amount of increase was not significantly different between the two techniques.

Interpretation?The olecranon sled appears to provide as stable fixation as tension band wiring for olecranon fractures.     

Is central skeleton bone quality a predictor of the severity of proximal humeral fractures?

IntroductionThe objectives of this study were to evaluate the correlation between bone attenuation around the shoulder joint assessed on conventional computed tomography (CT) and bone mineral density (BMD) based on dual-energy X-ray absorptiometry (DEXA) of the central skeleton and the correlation between the bone quality around the shoulder joint and the severity of the fracture pattern of the proximal humerus.Materials and methodsA total of 200 patients with proximal humeral fracture who underwent preoperative 3-dimensional shoulder CT as well as DEXA within 3 months of the CT examination were included. Fracture types were divided into simple and comminuted fracture based on the Neer classification. After reliability testing, bone attenuation of the glenoid, three portions of the humeral head, and metaphysis was measured by placing a circular region of interest on the center of each bony region on CT images. Partial correlation analysis was used to assess the correlation between the bone quality around the shoulder joint on CT and the BMD on the central skeleton after adjusting for age and body mass index. Partial correlations between fracture classification and CT/DEXA results were also evaluated.ResultsBone attenuation measurements of the glenoid and humeral head showed good to excellent reliability (intraclass correlation coefficient, 0.623–0.998). Bone attenuation of the central portion of the humeral head on CT showed a significant correlation with the BMD of L1, L4, the femoral neck, and femoral trochanter (correlation coefficient, 0.269–0.431). Bone attenuation of other areas showed a lower correlation with BMD by DEXA. As the level of the Neer classification increased from a 2 to 4-part fracture, bone attenuation of the central humeral head decreased significantly (r = −0.150, p = 0.034). However, the BMD on DEXA was not a predictive factor for comminuted fracture of the proximal humerus.ConclusionsDEXA examination of the central skeleton may not reflect the bone quality of the proximal humerus and severity of proximal humeral fracture. Direct assessment of the bone quality of the proximal humerus is recommended to determine the osteoporotic nature of the fracture.     

Shoulder arthroscopy combined to hardware removal in proximal humeral fractures: a series of 58 cases with a mean follow-up of 2 years

Background

Proximal humerus fractures are common injuries. Locking plates and anterograde medullary nails are the two most common fixation devices used when open reduction and internal fixation (ORIF) is indicated. Complications related to fracture and to hardware are numerous, especially shoulder stiffness. The goal of this study is to report the clinical outcomes of gleno-humeral arthroscopic arthrolysis combined with hardware removal.

Methods

A total of 58 patients (25 men, 33 women) with a mean age of 58 years (24–79) were reviewed retrospectively. Forty of them were active workers (5 heavy workers), and 18 were retired. A total of 24 fractures were reported after sport accident, 26 after domestic accident, and 8 after high energy trauma. Thirty-four patients with 3 or 4 part fractures (fracture through the anatomic neck and tuberosities), 20 patients with two part (displaced surgical neck) fracture and 4 cases of fracture of the tuberosities were operated. We combined a gleno-humeral arthrolysis by arthroscopy and a removal of the hardware using the previous incision for the plate or by arthroscopy for the nail.

Results

The average follow-up was 23 months (range 6–60). Pain in Constant Murley score (CS) increased from 7.3 ± 3.8 points preoperatively to 13 ± 2.76 points post-operatively (p < 0.05). CS increased from 36.8 ± 12.25 points to 68.45 ± 15.24 points. Subjective shoulder value (SSV) score increased from 45.8 ± 16.6 to 78.23 ± 14.74. A gain in all active range of motion was reported (forward flexion: 37.6°, abduction: 39.5°, external rotation: 24.3°, internal rotation: from L5-S1 to T12-L1).

Conclusions

Gleno-humeral arthrolysis by arthroscopy combined with hardware removal after proximal humerus ORIF in one step is safe and beneficial for post-traumatic stiffness of the shoulder. It provides significant pain relief and increase of range of motion and allows to treat associated articular pathology.

     

A propos of 56 humeral fractures treated with elastic “loop” wires: Preliminary report

Summary Elastic osteosynthesis is suitable for the humerus mainly because it is a non-weight-bearing bone. It is subject to muscular compression which shortens the bone's length. This can result in perforation of the proximal extremity by the K wires with subsequent loss of the reduction. To prevent this major drawback the authors report their experience with an original implant. It seems to preserve efficiently the trophic value of a noninvasive treatment but also to provide secure bone length restoration. These original wires are simple to use and check because no stock of different sizes of implant is necessary.     

Displaced proximal humeral fractures: operative versus non-operative treatment—a 2-year extension of a randomized controlled trial

Background

Surgical treatment for displaced proximal humeral fractures is widely used. However, there are very few randomized controlled studies comparing surgical treatment to conservative treatment, and the evidence is debated. The aim of this study was to describe patients with displaced proximal humeral fractures in a 2-years extension of a randomized controlled trial, their functional outcome and quality of life.

Materials and methods

Patients from a single-center randomized controlled study of fifty patients aged 60 or above with displaced proximal humeral fracture (AO/OTA group B2 or C2) were randomized to surgical or conservative treatment. Surgery was performed with an angular stable implant. The main outcome was Constant score at 2-year follow-up. Secondary outcomes were an ASES self-assessment form, the 15D quality of life assessment and radiographs at 2 years.

Results

A marked improvement of shoulder function and health-related quality of life for both surgically and conservatively treated patients occurs between 6 and 12 months. Almost no change was observed between 1 and 2 year. There were no significant differences between the two treatments at 2-year follow-up.

Conclusions

In this randomized controlled trial, surgical treatment proved no better results than conservative treatment for patients with displaced proximal humeral fracture at 2-year follow-up.     

Epidemiology and treatment reality of proximal humeral fractures at a level-1 trauma center

Background

The treatment of proximal humeral fractures (PHF) is challenging. Recently, more restrictive displacement criteria have been introduced and the lack of treatment algorithms in the literature has been emphasized.

Purpose

The primary purpose of this study was to evaluate the epidemiology and treatment reality of PHF at a specialized level-1 trauma center according to current displacement criteria. The secondary aim was to assess whether a standardized treatment algorithm can be adhered to during daily clinical routine.

Methods

In all, 566 patients (71.4?% female; average age, 68.1 ± 15 years) with 569 PHF were included in this retrospective cohort study. All medical records and existing x?rays as well as computed tomography scans were analyzed. Only fractures with ad latus displacement of max 0.5 cm and/or a humeral head angulation of less than 20º were classified as nondisplaced. Patients with displaced fractures were included for evaluation of a standardized treatment algorithm.

Results

The most common fracture type was a three-part fracture (39.9?%, n = 227); 70.9?% of fractures (389/569) were displaced and therefore treated operatively. The accordance between the final operative treatment that patients received and the recommended surgical treatment on the basis of the algorithm was 90.2?% (351/389).

Conclusion

In contrast to the rate of 15?% dislocated fractures reported by Charles Neer in 1970, more than 70?% of fractures were found to be displaced when more restrictive displacement criteria were applied. More than 90?% of displaced fractures were treated as recommended by the treatment algorithm. Fractures that fitted the least into the treatment scheme were more complex fractures of patients aged 60 years and older.

     

Superior pubic ramus fractures fixed with percutaneous screws: what predicts fixation failure?

OBJECTIVE: The purpose of this study is to present the early complications of percutaneous screw fixation of superior pubic ramus fractures and to present a new classification scheme for superior pubic ramus fractures. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS: One hundred and twelve patients with pelvic fracture between the ages of 14 to 89 years underwent percutaneous screw fixation of 145 pubic ramus fractures. Eighty-one patients with 107 surgically repaired fractures were followed to fracture union. Follow-up averaged 9 months (range 2-52 months). One additional patient who sustained fixation failure 4 days after surgery was included to yield a study group of 82 patients with 108 surgically repaired ramus fractures. INTERVENTION: Patients underwent percutaneous screw fixation of a superior pubic ramus fracture. MAIN OUTCOME MEASUREMENTS: Superior pubic ramus fractures were classified according to a new scheme, the Nakatani system, which categorizes superior ramus fractures according to location with respect to the obturator foramen. Patient radiographs were examined for evidence of loss of reduction, defined as any motion at the ramus fracture site or hardware motion, after fracture surgery. RESULTS: Of the 82 patients followed to union or fixation failure, 12 (15%) had loss of reduction on follow-up radiographs. The average age of patients who lost reduction was 55 years. The most common mechanism of reduction loss was a collapse of the pubic ramus over the screw, with recurrence of an internal rotation deformity of the injured hemipelvis. Ten patients who lost reduction were women, and 11 had undergone ramus screw placement in retrograde fashion. No loss of reduction was seen in Zone III ramus fractures (those that involve the bone lateral to the obturator foramen). No patient sustained recognized neurologic, vascular, or urologic injury as a result of percutaneous screw fixation of a superior pubic ramus fracture. CONCLUSIONS: The prevalence of loss of reduction after percutaneous screw fixation of pubic ramus fractures is 15%. Loss of reduction is more common in elderly and female patients and in patients whose ramus screws are placed in a retrograde fashion. Also, loss of reduction appears to be more common in fractures medial to the lateral border of the obturator foramen.     

Fixation of supracondylar femoral fractures following total knee arthroplasty: is there any difference comparing angular stable plate fixation versus rigid interlocking nail fixation?

Introduction

Literature does not provide any reliable comparison between angular stable plate fixation and rigid nail fixation for stabilization of supracondylar periprosthetic femoral fractures. Thus, the purpose of this study was to compare these two implants in clinical practice relating to fracture healing, functional results and treatment-related complications.

Patients and methods

In this retrospective study (level IV), clinical and radiographic records of 86 patients (62 female and 24 male, average age: 75.6) with supracondylar periprosthetic femoral fractures between 1996 and 2010 were analyzed. 48 patients underwent lateral plate fixation by an angular stable plate system (LISS), whereas 38 patients were stabilized by a rigid interlocking nail device.

Results

Sixty-four (76 %) patients returned to their pre-injury activity level and were satisfied with their clinical outcome. We had an overall Oxford outcome score of 2.21, with patients following angular stable plate fixation of 2.22, and patients after rigid nail fixation of 2.20. Successful fracture healing within 6 months was achieved in 74 (88 %) patients. Comparing between plate fixation and nail fixation, statistical analysis did not reveal any significant differences.

Summary

Overall, we had a relatively high rate of fracture healing and a satisfactory functional outcome with both implants. Both methods of fixation showed similar results relating to the functional outcome and individual satisfaction of the patients. However, with regards to fracture healing and treatment-related complications, intramedullary nail fixation showed slight advantages.