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Ippolito G, Lanzetti RM, Ferraro S, Pace V, Damo M, Surace MF, Giai Via ADE, Crivellaro M, De Marinis G, Spoliti M. Comparison of Short Uncemented Metaphyseal Stem and Long-Stem Reverse Shoulder Arthroplasty in Proximal Humerus Fractures: Preliminary Study at 2-Year Follow-Up. J Clin Med 2024; 13:4665. [PMID: 39200807 PMCID: PMC11355206 DOI: 10.3390/jcm13164665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 07/29/2024] [Accepted: 07/30/2024] [Indexed: 09/02/2024] Open
Abstract
Introduction: In the last few years, short metaphyseal-socket prosthetic humeral stems have been introduced for reverse shoulder arthroplasty (RSA). A short stem may have advantages in humeral force distribution, reducing shear stress and preserving bone stock, keeping in mind the need for possible future revision surgery. The main objective of our study was to validate the use of a short stem prosthesis in the surgical treatment of humeral fractures by comparing clinical and radiological outcomes of our studied implant with those obtained with the use of traditional long-stem implants. Methods: In this multicentric, controlled prospective study, 125 patients with proximal three- or four-fragment humerus fractures were selected and treated with RSA. A short stem was used in group A (n = 53, mean age: 75.6 ± 5.6 years old), and a long stem was used in group B (n = 72, mean age: 71.76 ± 3). Active range of motion (ROM), Constant score (CS), Quick DASH, American Shoulder and Elbow Surgeons Shoulder (ASES) score, and Visual Analog Scale (VAS) scores were collected and analyzed at 2 years mean follow-up, as well as humeral and glenoid bone resorption (sum Inoue scores and Sirveaux scores were used). Results: No statistically significant differences were observed between group A and B in ROM, Constant score (51.69 ± 15.8 vs. 53.46 ± 15.96, p > 0.05), Quick DASH (31.5 ± 21.81 vs. 28.79 ± 13.72, p = 0.85), ASES (82.53 ± 17.79 vs. 84.34 ± 15.24, p = 0.57), or the VAS (0.53 ± 1 vs. 0.56 ± 1.07, p = 0.14) at the final follow-up. No statistically significant differences were found in the radiographic parameters between the two groups. No statistically significant differences were found for the average degree of humeral and glenoid bone resorption either. Conclusions: The use of a short metaphyseal-socket stem can be considered a safe, effective, and feasible option in reverse shoulder arthroplasty for treating proximal humerus fractures. Our results are encouraging, with no statistically significant differences identified between the proposed treatment and traditional long stems.
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Affiliation(s)
- Giorgio Ippolito
- Trauma & Orthopaedic Department, Icot Hospital “Marco Pasquali”, 04100 Latina, Italy
| | - Riccardo Maria Lanzetti
- Orthopaedics and Traumatology Unit, Department of Emergeny and Acceptance, Azienda Ospedialiera San Camillo-Forlanini, 00152 Rome, Italy (M.S.)
| | | | - Valerio Pace
- Trauma & Orthopaedics Department, AOSP Terni, 05100 Terni, Italy
| | - Marco Damo
- Trauma & Orthopaedic Department, Icot Hospital “Marco Pasquali”, 04100 Latina, Italy
| | - Michele Francesco Surace
- Department of Biotechnology and Sciences for Life, University of Insubria, Cittiglio-Angera, 21100 Varese, Italy
| | - Alessio Davide Enrico Giai Via
- Orthopaedics and Traumatology Unit, Department of Emergeny and Acceptance, Azienda Ospedialiera San Camillo-Forlanini, 00152 Rome, Italy (M.S.)
| | - Michele Crivellaro
- Orthopaedic and Traumatology Department, Orthopaedic and Trauma Center, University of Turin, 10126 Turin, Italy
| | - Giancarlo De Marinis
- Trauma & Orthopaedic Department, Icot Hospital “Marco Pasquali”, 04100 Latina, Italy
| | - Marco Spoliti
- Orthopaedics and Traumatology Unit, Department of Emergeny and Acceptance, Azienda Ospedialiera San Camillo-Forlanini, 00152 Rome, Italy (M.S.)
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Liu J, Zhang Z, Ding J, Zhang J, Sheng Q, Piao C. Morphology and novel classification of proximal humeral fractures. Front Bioeng Biotechnol 2024; 12:1366089. [PMID: 39100622 PMCID: PMC11294115 DOI: 10.3389/fbioe.2024.1366089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 07/09/2024] [Indexed: 08/06/2024] Open
Abstract
Background: The morphology of proximal humeral fractures (PHFs) is complex, and the fixation and selection of implants need to be guided by the fracture type and classification, which requires an accurate understanding of the fracture line. This study had three purposes. 1) Define and analyze the fracture lines and morphological features of all types PHFs by three-dimensional (3D) mapping technology. 2) Determine the osteotomy position of the biomechanical model of the PHFs according to the fracture heat map. 3) Based on the analysis of the pathological morphology and distribution of a large number of consecutive cases of PHFs, propose a novel classification of PHFs. Methods: We retrospectively collected 220 cases of PHFs and generated a 3D fracture map and heat map based on computed tomography (CT) imaging. Through analysis of the fracture morphology of the 220 PHFs, a novel classification was proposed. The primary criterion for staging was the continuity between the humeral head and the greater tuberosity and lesser tuberosity, and the secondary criterion was the relationship between the humeral head segment and the humeral shaft. Results: The fracture line was primarily found around the metaphyseal zone of region of the surgical neck, with the most extensive distribution being below the larger tuberosity and on the posterior medial side of the epiphysis. We suggest that the osteotomy gap should be immediately (approximately 5-10 mm) below the lower edge of the articular surface. The most common type of fracture was type I3 (33 cases, 15.0%), followed by type IV3 fracture (23 cases, 10.4%), and type III2 fracture (22 cases, 10.0%). Interobserver and intraobserver reliability analysis for the fracture classification revealed a k value (95% confidence interval) of 0.639 (0.57-0.71) and 0.841, P < 0.01, respectively. Conclusion: In this study, the fracture line and morphological characteristics of PHFs were clarified in detail by 3D mapping technique. In addition, a new classification method was proposed by analysis of the morphological characteristics of 220 PHFs, A two-part fracture model for PHFs is also proposed.
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Affiliation(s)
- Jichao Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Ziyan Zhang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Jie Ding
- Department of Stomatology, The Affiliated Hospital of Changchun University of Traditional Chinese Medicine, Changchun, Jilin Province, China
| | - Jian Zhang
- Radiology Department, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Qian Sheng
- Medical Insurance Office, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Chengdong Piao
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
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Hameleers A, Boonen B, Most J, Dremmen M, Schotanus MGM, Van Vugt R. Permissive Weight Bearing in Proximal Humeral Fracture Management: A Survey-Based Inquiry in the Netherlands. Cureus 2024; 16:e57670. [PMID: 38707136 PMCID: PMC11070209 DOI: 10.7759/cureus.57670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2024] [Indexed: 05/07/2024] Open
Abstract
Purpose Proximal humeral fractures (PHF) are common, particularly among the elderly due to low-energy trauma. Adequate rehabilitation is essential for functional recovery, whether through conservative or surgical treatment. Permissive weight bearing (PWB) is a relatively new rehabilitation concept, characterized by earlier mobilization of the affected limb/joint after trauma. Multiple studies demonstrated the value of PWB for the lower extremities, but this has not been translated to the upper extremity (i.e. PHF). Therefore, our aim was to investigate the current state and variability of rehabilitation of PHF and the role of implementing PWB principles in aftercare. Materials and methods An online survey, comprising 23 questions about the treatment of PHF, was distributed amongst an estimated 800 Dutch orthopaedic and trauma surgeons via the Dutch Orthopaedic and Dutch Trauma Society newsletter from May 2021 until July 2021. Results Among 88 respondents (n=69 orthopaedic, n=17 trauma surgeons, and n=2 other), most recommended early post-trauma mobilization (<6 weeks). Additionally, 53.4% (n=49) advised starting load bearing after six weeks for conservatively treated patients and 59.8% (n=52) for operative treatment. A wide variation of exercises used after immobilization was found in both groups. The usage of a sling after operative treatment was advised by 86% (n=74) of all 86 respondents. Conclusions The present study found limited consensus about PHF aftercare and the implementation of weight-bearing principles. The majority recommended early mobilization and advised the usage of a sling. A protocol capable of accommodating the diversity in aftercare (e.g. fracture type) is essential for maintaining structured rehabilitation, with PWB emerging as a promising example. More prospective studies are needed to form an evidence-based protocol focusing on the aftercare of PHF.
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Affiliation(s)
- Amber Hameleers
- Department of Orthopedic Surgery, Zuyderland Medical Center, Sittard-Geleen, NLD
- Department of Surgery, Maastricht University Medical Center+, Maastricht, NLD
| | - Bert Boonen
- Department of Orthopedic Surgery, Zuyderland Medical Center, Sittard-Geleen, NLD
| | - Jasper Most
- Department of Orthopedic Surgery, Zuyderland Medical Center, Sittard-Geleen, NLD
| | - Martijn Dremmen
- Department of Rehabilitation Medicine, Zuyderland Medical Center, Heerlen, NLD
| | | | - Raoul Van Vugt
- Department of Surgery, Zuyderland Medical Center, Heerlen, NLD
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Singh R, Ambade R, Landge S, Goyal S, Goel S. Comprehensive Review on Distal Femur Fractures: From Epidemiology to Treatment Strategies. Cureus 2024; 16:e57937. [PMID: 38738010 PMCID: PMC11084923 DOI: 10.7759/cureus.57937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 04/09/2024] [Indexed: 05/14/2024] Open
Abstract
Distal femur fractures present a substantial orthopedic challenge, necessitating a comprehensive exploration spanning epidemiology, anatomy, classification, diagnosis, and treatment strategies. This review thoroughly analyzes the multifaceted aspects surrounding distal femur fractures. It delves into the definition and epidemiology, shedding light on the incidence, age distribution, and associated risk factors. An exhaustive examination of the distal femur's anatomy, encompassing ligaments and tendons, establishes the groundwork for understanding fracture patterns and subsequent classification according to the AO Foundation/Orthopaedic Trauma Association (AO/OTA) system. Diagnostic considerations encompass physical examination and various imaging modalities, emphasizing the critical importance of prompt and accurate assessment. The extensive discussion on treatment options ranges from non-surgical management, including casting and traction, to surgical interventions, such as open reduction and internal fixation, intramedullary nailing, and external fixation. The implications for clinical practice underscore the necessity for tailored approaches based on fracture characteristics to optimize patient outcomes. However, this review also emphasizes areas necessitating further investigation, including exploring predictive biomarkers, advanced surgical techniques, and innovative rehabilitation protocols. Insights from long-term outcomes and quality-of-life assessments in diverse populations offer promising avenues for enhancing the comprehensive management of distal femur fractures. Continuous research in these areas can refine treatment strategies and elevate the standard of care for individuals grappling with this intricate orthopedic condition.
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Affiliation(s)
- Rahul Singh
- Department of Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Ratnakar Ambade
- Department of Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Suhas Landge
- Department of Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Saksham Goyal
- Department of Orthopaedic Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sachin Goel
- Department of Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Huang F, Tan R, Wang MW, Hu LC, Wang Z, Sun SD, Huang JW, Luo YW. Three‑dimensional finite element analysis: Anatomical splint fixation for Colles fractures. Exp Ther Med 2024; 27:98. [PMID: 38356671 PMCID: PMC10865454 DOI: 10.3892/etm.2024.12386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/21/2023] [Indexed: 02/16/2024] Open
Abstract
With the rapid development of digital research in clinical orthopedics, the efficacy and safety of splint fixation can be better evaluated through biomechanical analysis based on a three-dimensional (3D) finite element model. It is essential to address the current gap in understanding the biomechanical implications of anatomical splint fixation for Colles fractures. By employing advanced 3D finite element analysis, the present study aimed to provide a comprehensive evaluation, offering valuable insights that can contribute to enhancing the effectiveness of anatomical splint fixation in the clinical management of Colles fractures. The 3D finite element models of the forearm and hand were constructed using Mimics 15.0 according to data from computed tomography of a patient with a Colles fracture. After the validity of the model was verified, the corresponding material properties of the models were adjusted to simulate a Colles fracture. Subsequently, the reduction functions, such as radial inclination and ulnar deviation, of the simulated fracture were completed and the mechanical changes of the tissues surrounding the fracture were calculated. Anatomical splints were then placed on the surfaces of the 3D finite element models of Colles fractures at various positions to analyze the changes in the stress cloud diagram, such as for the soft tissue and anatomical splints. In the present study, the constructed 3D finite element models were accurate and valid. The maximum stress of the anatomical splints and soft tissues was 2.346 and 0.106 MPa in pronation, 1.780 and 0.069 MPa in median rotation and 3.045 and 0.057 MPa in supination, respectively. Splint stress reached the highest level in supination and soft tissue stress achieved the highest level in pronation. The peak of splint stress occurred during supination, which contrasts to the peak of soft tissue stress observed in pronation, suggesting splint fixation median rotation can effectively avoid compression of the local soft tissue.
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Affiliation(s)
- Fei Huang
- Department of Traumatology, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510000, P.R. China
| | - Rui Tan
- Department of Traumatology, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510000, P.R. China
| | - Meng-Wei Wang
- Department of Traumatology, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510000, P.R. China
| | - Liu-Chao Hu
- Department of Traumatology, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510000, P.R. China
| | - Zhi Wang
- Department of Operating Room, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510000, P.R. China
| | - Shi-Dong Sun
- Department of Traumatology, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510000, P.R. China
| | - Jie-Wen Huang
- Department of Traumatology, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510000, P.R. China
| | - Yi-Wen Luo
- Department of Traumatology, The Third Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510000, P.R. China
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Fidanza A, Caggiari G, Di Petrillo F, Fiori E, Momoli A, Logroscino G. Three-dimensional printed models can reduce costs and surgical time for complex proximal humeral fractures: preoperative planning, patient satisfaction, and improved resident skills. J Orthop Traumatol 2024; 25:11. [PMID: 38418743 PMCID: PMC10902230 DOI: 10.1186/s10195-024-00754-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 02/08/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Proximal humeral fractures (PHFs) are still controversial with regards to treatment and are difficult to classify. The study's objective is to show that preoperative planning performed while handling a three-dimensional (3D) printed anatomical model of the fracture can ensure a better understanding of trauma for both surgeons and patients. MATERIALS AND METHODS Twenty patients (group A, cases) with complex PHF were evaluated preoperatively by reproducing life-size, full-touch 3D anatomical models. Intraoperative blood loss, radiographic controls, duration of surgery, and clinical outcomes of patients in group A were compared with 20 patients (group B, controls) who underwent standard preoperative evaluation. Additionally, senior surgeons and residents, as well as group A patients, answered a questionnaire to evaluate innovative preoperative planning and patient compliance. Cost analysis was evaluated. RESULTS Intraoperative radiography controls and length of operation were significantly shorter in group A. There were no differences in clinical outcomes or blood loss. Patients claim a better understanding of the trauma suffered and the proposed treatment. Surgeons assert that the planning of the definitive operation with 3D models has had a good impact. The development of this tool has been well received by the residents. The surgery was reduced in length by 15%, resulting in savings of about EUR 400 for each intervention. CONCLUSIONS Fewer intraoperative radiography checks, shorter surgeries, and better patient compliance reduce radiation exposure for patients and healthcare staff, enhance surgical outcomes while reducing expenses, and lower the risk of medicolegal claims. LEVEL OF EVIDENCE Level I, prospective randomized case-control study.
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Affiliation(s)
- Andrea Fidanza
- Unit of Orthopaedics, Department of Life, Health and Environmental Sciences, University of L'Aquila (IT), Piazzale S.Tommasi, 1, 67100, L'Aquila, Italy.
| | - Gianfilippo Caggiari
- Orthopaedic and Traumatology Department, Sassari University Hospital, Sassari, Italy
| | - Francesco Di Petrillo
- Unit of Orthopaedics, Department of Life, Health and Environmental Sciences, University of L'Aquila (IT), Piazzale S.Tommasi, 1, 67100, L'Aquila, Italy
| | - Enrico Fiori
- Orthopaedic and Traumatology Department, Sassari University Hospital, Sassari, Italy
| | - Alberto Momoli
- Unit of Trauma and Orthopaedic, San Bortolo Hospital, Vicenza, Italy
| | - Giandomenico Logroscino
- Unit of Orthopaedics, Department of Life, Health and Environmental Sciences, University of L'Aquila (IT), Piazzale S.Tommasi, 1, 67100, L'Aquila, Italy
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Hutaif M, Al-Moaish A, Al-fadliy A. Functional and Radiographic Outcomes of Open Proximal Femoral Fractures Caused by Gunshot Wounds in Yemen: A Prospective Cohort Study. JB JS Open Access 2024; 9:e23.00085. [PMID: 38214007 PMCID: PMC10773698 DOI: 10.2106/jbjs.oa.23.00085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
Background Open proximal femoral fractures caused by gunshot wounds are rare but devastating injuries that pose considerable challenges for prognosis and management. The aim of this study was to evaluate the functional and radiographic outcomes of patients with open proximal femoral fractures caused by gunshot wounds treated at 3 Level-I trauma centers in Yemen and to identify the factors that influence them. Methods We prospectively enrolled 174 patients with open proximal femoral fractures caused by gunshot wounds. The fractures were classified according to the Gustilo-Anderson and OTA/AO systems. The primary outcome measures were fracture union, infection, and functional outcomes. The secondary outcome measures were the Harris hip score (HHS) and the Short Form-36 (SF-36) health survey score. We performed multivariable logistic regression modeling to identify the predictors of complications and poor functional outcomes. Results The overall rate of fracture union was 87%. The complication rates were 18% for infection, 13% for nonunion, 23% for reoperation, 12% for delayed union, 4% for osteonecrosis, 6% for heterotopic ossification, and 2% for amputation. The mean HHS at the final follow-up was 78.4, and the mean SF-36 score was 67.3. Conclusions Open proximal femoral fractures caused by gunshot wounds are associated with high rates of complications and poor functional outcomes in Yemen. Early debridement, appropriate fixation, infection control, and adequate soft-tissue coverage are essential for achieving satisfactory results. The type of wound, the type of fracture, and the type of definitive fixation are significant predictors of the outcomes. Future studies should compare different fixation methods and evaluate the long-term outcomes and complications of these injuries. Level of Evidence Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Yasen Z, Robinson AP, Woffenden H. Advanced Preoperative Planning Techniques in the Management of Complex Proximal Humerus Fractures. Cureus 2024; 16:e51551. [PMID: 38313919 PMCID: PMC10835086 DOI: 10.7759/cureus.51551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 02/06/2024] Open
Abstract
This review evaluates the current literature on the recent advances of preoperative planning in the management of complex proximal humerus fractures (PHF). PHFs can pose a considerable challenge for orthopaedic surgeons due to their diversity in presentation and complexity. Poor preoperative planning can lead to prolonged operations, increased blood loss, higher risk of complications, and increased stress on the surgical team. Recent advances have seen the evolution of preoperative planning from conventional methods to computer-assisted virtual surgical technology (CAVST) and three-dimensional (3D) printing, which have been highlighted as transformative tools for improving preoperative planning and postoperative outcomes. CAVST allows the creation of 3D renderings of patient-specific anatomy, clearly demonstrating fracture patterns and facilitating detailed planning for arthroplasty or surgical fixation. The early studies show promising outcomes however the literature calls for more high-quality randomised controlled trials. Using 3D printing for high-fidelity simulation involving patient-specific physical models offers an immersive experience for surgical planning. Preoperative planning with 3D printing reduces operative time, blood loss and use of fluoroscopy. The technology's potential to produce customisable surgical implants further improves its versatility. There is a need for a cost analysis for the use of these technologies within the orthopaedic field, particularly considering the high expense of 3D printing materials and extended hospital stays until the printed models are available. CAVST and 3D printing also show promising applications within high-fidelity simulation surgical training, with CAVST offering possibilities in virtual reality and haptic-enhanced simulations and 3D printing providing physical models for trainee surgeons to hone their skills. Moving forward, a reduction in the cost of 3D printing and the advancement of CAVST using artificial intelligence would lead to future improvement. In conclusion, preoperative planning supported by these innovative technologies will play a pivotal role in improving surgical outcomes and training for complex PHF cases.
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Affiliation(s)
- Zaid Yasen
- Trauma and Orthopaedics, Royal Free London NHS Foundation Trust, London, GBR
| | - Andrew P Robinson
- Trauma and Orthopaedics, Lewisham and Greenwich NHS Trust, London, GBR
| | - Hugo Woffenden
- General Surgery, HMS Nelson Medical Centre, Ministry of Defence, London, GBR
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Feuerriegel GC, Kronthaler S, Weiss K, Haller B, Leonhardt Y, Neumann J, Pfeiffer D, Hesse N, Erber B, Schwaiger BJ, Makowski MR, Woertler K, Karampinos DC, Wurm M, Gersing AS. Assessment of glenoid bone loss and other osseous shoulder pathologies comparing MR-based CT-like images with conventional CT. Eur Radiol 2023; 33:8617-8626. [PMID: 37453986 PMCID: PMC10667374 DOI: 10.1007/s00330-023-09939-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 04/24/2023] [Accepted: 05/16/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES To evaluate and compare the diagnostic performance of CT-like images based on a 3D T1-weighted spoiled gradient-echo sequence (T1 GRE), an ultra-short echo time sequence (UTE), and a 3D T1-weighted spoiled multi-echo gradient-echo sequence (FRACTURE) with conventional CT in patients with suspected osseous shoulder pathologies. MATERIALS AND METHODS Patients with suspected traumatic dislocation of the shoulder (n = 46, mean age 40 ± 14.5 years, 19 women) were prospectively recruited and received 3-T MR imaging including 3D T1 GRE, UTE, and 3D FRACTURE sequences. CT was performed in patients with acute fractures and served as standard of reference (n = 25). Agreement of morphological features between the modalities was analyzed including the glenoid bone loss, Hill-Sachs interval, glenoid track, and the anterior straight-line length. Agreement between the modalities was assessed using Bland-Altman plots, Student's t-test, and Pearson's correlation coefficient. Inter- and intrareader assessment was evaluated with weighted Cohen's κ and intraclass correlation coefficient. RESULTS All osseous pathologies were detected accurately on all three CT-like sequences (n = 25, κ = 1.00). No significant difference in the percentage of glenoid bone loss was found between CT (mean ± standard deviation, 20.3% ± 8.0) and CT-like MR images (FRACTURE 20.6% ± 7.9, T1 GRE 20.4% ± 7.6, UTE 20.3% ± 7.7, p > 0.05). When comparing the different measurements on CT-like images, measurements performed using the UTE images correlated best with CT. CONCLUSION Assessment of bony Bankart lesions and other osseous pathologies was feasible and accurate using CT-like images based on 3-T MRI compared with conventional CT. Compared to the T1 GRE and FRACTURE sequence, the UTE measurements correlated best with CT. CLINICAL RELEVANCE STATEMENT In an acute trauma setting, CT-like images based on a T1 GRE, UTE, or FRACTURE sequence might be a useful alternative to conventional CT scan sparing associated costs as well as radiation exposure. KEY POINTS • No significant differences were found for the assessment of the glenoid bone loss when comparing measurements of CT-like MR images with measurements of conventional CT images. • Compared to the T1 GRE and FRACTURE sequence, the UTE measurements correlated best with CT whereas the FRACTURE sequence appeared to be the most robust regarding motion artifacts. • The T1 GRE sequence had the highest resolution with high bone contrast and detailed delineation of even small fractures but was more susceptible to motion artifacts.
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Affiliation(s)
- Georg C Feuerriegel
- Department of Radiology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - Sophia Kronthaler
- Department of Radiology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | | | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Yannik Leonhardt
- Department of Radiology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Jan Neumann
- Department of Radiology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
- Musculoskeletal Radiology Section, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Daniela Pfeiffer
- Department of Radiology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Nina Hesse
- Department of Radiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Bernd Erber
- Department of Radiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Benedikt J Schwaiger
- Department of Neuroradiology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Marcus R Makowski
- Department of Radiology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Klaus Woertler
- Department of Radiology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
- Musculoskeletal Radiology Section, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Dimitrios C Karampinos
- Department of Radiology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Markus Wurm
- Department of Trauma Surgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Alexandra S Gersing
- Department of Radiology, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Strasse 22, 81675, Munich, Germany
- Department of Neuroradiology, University Hospital of Munich, LMU Munich, Munich, Germany
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Magnéli M, Ling P, Gislén J, Fagrell J, Demir Y, Arverud ED, Hallberg K, Salomonsson B, Gordon M. Deep learning classification of shoulder fractures on plain radiographs of the humerus, scapula and clavicle. PLoS One 2023; 18:e0289808. [PMID: 37647274 PMCID: PMC10468075 DOI: 10.1371/journal.pone.0289808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/26/2023] [Indexed: 09/01/2023] Open
Abstract
In this study, we present a deep learning model for fracture classification on shoulder radiographs using a convolutional neural network (CNN). The primary aim was to evaluate the classification performance of the CNN for proximal humeral fractures (PHF) based on the AO/OTA classification system. Secondary objectives included evaluating the model's performance for diaphyseal humerus, clavicle, and scapula fractures. The training dataset consisted of 6,172 examinations, including 2-7 radiographs per examination. The overall area under the curve (AUC) for fracture classification was 0.89, indicating good performance. For PHF classification, 12 out of 16 classes achieved an AUC of 0.90 or greater. Additionally, the CNN model had excellent overall AUC for diaphyseal humerus fractures (0.97), clavicle fractures (0.96), and good AUC for scapula fractures (0.87). Despite the limitations of the study, such as the reliance on ground truth labels provided by students with limited radiographic assessment experience, our findings are in concordance with previous studies, further consolidating CNN as potent fracture classifiers in plain radiographs. The inclusion of multiple radiographs with different views from each examination, as well as the generally unselected nature of the sample, contributed to the overall generalizability of the study. This is the fifth study published by our group on AI in orthopaedic radiographs, which has consistently shown promising results. The next challenge for the orthopaedic research community will be to transfer these results from the research setting into clinical practice. External validation of the CNN model should be conducted in the future before it is considered for use in a clinical setting.
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Affiliation(s)
- Martin Magnéli
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Petter Ling
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jacob Gislén
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Johan Fagrell
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Yilmaz Demir
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Erica Domeij Arverud
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Kristofer Hallberg
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Björn Salomonsson
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Max Gordon
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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Shahien A, Likine EF, Soles G, Samborski S, Mehta SK, Ryan SP, Leroy TE, Mullis B, Spitler CA, Tornetta P. Not All Proximal Humerus Fractures Do Well Without Surgery: Anterior Translation Predicts the Need for Surgery. J Orthop Trauma 2023; 37:366-369. [PMID: 37074809 DOI: 10.1097/bot.0000000000002585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVES To evaluate the effect of translation on a large series of low-energy proximal humerus fractures initially treated nonoperatively. DESIGN Retrospective multicenter analysis. SETTING Five level-one trauma centers. PATIENTS/PARTICIPANTS Two hundred ten patients (152 F; 58 M), average age 64, with 112 left- and 98 right-sided low-energy proximal humerus fractures (OTA/AO 11-A-C). INTERVENTION All patients were initially treated nonoperatively and were followed for an average of 231 days. Radiographic translation in the sagittal and coronal planes was measured. Patients with anterior translation were compared with those with posterior or no translation. Patients with ≥80% anterior humeral translation were compared with those with <80% anterior translation, including those with no or posterior translation. MAIN OUTCOMES The primary outcome was failure of nonoperative treatment resulting in surgery and the secondary outcome was symptomatic malunion. RESULTS Nine patients (4%) had surgery, 8 for nonunion and 1 for malunion. All 9 patients (100%) had anterior translation. Anterior translation compared with posterior or no sagittal plane translation was associated with failure of nonoperative management requiring surgery ( P = 0.012). In addition, of those with anterior translation, having ≥80% anterior translation compared with <80% was also associated with surgery ( P = 0.001). Finally, 26 patients were diagnosed with symptomatic malunion, of whom translation was anterior in 24 and posterior in 2 ( P = 0.0001). CONCLUSIONS In a multicenter series of proximal humerus fractures, anterior translation of >80% was associated with failure of nonoperative care resulting in nonunion, symptomatic malunion, and potential surgery. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Amir Shahien
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA
| | - Elive F Likine
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Gillian Soles
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, MN
| | - Steven Samborski
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, MN
| | - Siddhant K Mehta
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, MS; and
| | - Scott Patrick Ryan
- Department of Orthopaedic Surgery, Tufts University Medical Center, Boston, MA
| | - Taryn E Leroy
- Department of Orthopaedic Surgery, Tufts University Medical Center, Boston, MA
| | - Brian Mullis
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, MS; and
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA
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12
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Spek RWA, Kim L. What is the interobserver agreement of displaced humeral surgical neck fracture patterns? Clin Shoulder Elb 2022; 25:304-310. [PMID: 36330721 PMCID: PMC9727487 DOI: 10.5397/cise.2022.01025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/06/2022] [Indexed: 12/04/2022] Open
Abstract
Background: The Boileau classification distinguishes three surgical neck fracture patterns: types A, B, and C. However, the reproducibility of this classification on plain radiographs is unclear. Therefore, we questioned what the interobserver agreement and accuracy of displaced surgical neck fracture patterns is categorized according to the modified Boileau classification. Does the reliability to recognize these fracture patterns differ between orthopedic residents and attending surgeons?Methods: This interobserver study consisted of a randomly retrieved series of 30 plain radiographs representing clinical practice in a level 1 and a level 2 trauma center. Radiographs were included from patients (≥18 years) who sustained an isolated displaced surgical neck fracture if they were taken ≤1 week after initial injury. A ground truth was established by consensus among three senior orthopedic surgeons. All images were assessed by 17 orthopedic residents and 17 attending orthopedic trauma surgeons.Results: Agreement for the modified Boileau classification was fair (κ=0.37; 95% confidence interval [CI], 0.36–0.38) with an accuracy of 62% (95% CI, 57%–66%). Comparison of interobserver variability between residents and attending surgeons revealed a significant but clinically irrelevant difference in favor of attending surgeons (0.34 vs. 0.39, respectively, Δ κ=0.05, 95% CI, 0.02–0.07).Conclusions: The modified Boileau classification yields a low interobserver agreement with an unsatisfactory accuracy in a panel of orthopedic residents and attending surgeons. This supports the hypothesis that surgical neck fractures are challenging to categorize and that this classification should not be used to determine prognosis if only plain radiographs are available.
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Pang B, Li F, Zhong C, Weng X, Xu H, Yang T, Wang X, Wang Y, He L, Zhu Q. Comparative reliability study on classification of femoral intertrochanteric fractures by using Tang and Japanese new typing systems based on 3-D CT and Evans-Jensen and AO/OTA-2018 classical typing systems based on X-ray. JOURNAL OF RADIATION RESEARCH AND APPLIED SCIENCES 2022. [DOI: 10.1016/j.jrras.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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14
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Thelen S, Grassmann JP, Schneider M, Jaekel C, Meier DM, Betsch M, Hakimi M, Wild M. The influence of fracture severity on postoperative outcome and quality of life after locking plate fixation of proximal humeral fractures. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2022; 11:Doc03. [PMID: 35692287 PMCID: PMC9178521 DOI: 10.3205/iprs000164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective: For proximal humeral fractures open reduction und internal fixation (ORIF) with a fixed-angle plate is considered the gold standard for surgical management. However, it can lead to poor functional outcomes and is associated with postoperative complications. Therefore, the purpose of this study was to investigate the influence of fracture severity by applying a new classification (simple versus complex) on clinical outcome and quality of life after ORIF of proximal humerus fractures. Methods: We conducted a prospective clinical study with an average follow-up period of 12 (SD 1) months after ORIF of proximal humeral fractures with a fixed-angle plate. The postoperative function and quality of life was measured using the Oxford Shoulder Score (OSS) and the Constant Score. Data was tested for statistical significance with the Mann-Whitney test and Fisher's exact test. Based on the findings of this study a simplified fracture classification system has been developed. Results: Seventy-two patients with a mean age of 65 years (SD 12) with 69% being males were included. According to the Neer classification, 35% (n=25) non-displaced (“one-part fractures”), 19% (n=14) two-part fractures, 15% (n=11) three-part fractures and 31% (n=22) four-part fractures were detected. Regarding the AO/OTA classification, 18% (n=13) were type A fractures, 43% (n=31) type B and 39% (n=28) type C fractures. From these criteria we derived our own fracture classification, including 50% (n=36) simple and 50% (n=36) severe fractures. Patients with simple fracture types achieved significantly higher total values in the Constant Score as well as the OSS (p=0.008; p=0.013). The cumulative incidence of complications in the entire patient collective was 14% (n=10) with humeral head necrosis (n=5) occurring only in the severe fracture group. Conclusions: The postoperative clinical outcome as well as the incidence of humeral head necrosis after ORIF of proximal humeral fractures with a fixed-angle plate correlates with the fracture type and severity. The newly derived fracture classification into simple and severe fractures is suitable with regard to clinical results and complication rate. However, prospective studies comparing ORIF vs. conservative treatment of proximal humeral fractures of the same severity are required. Level of Evidence: III
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Affiliation(s)
- Simon Thelen
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Jan P. Grassmann
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany,*To whom correspondence should be addressed: Jan P. Grassmann, Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany, Phone: +49 (0) 211-81-04400, Fax: +49 (0) 211-81-04902, E-mail:
| | - Madeleine Schneider
- Department of Orthopedics, Trauma and Hand Surgery, Klinikum Darmstadt, Darmstadt, Germany
| | - Carina Jaekel
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Dana M. Meier
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Marcel Betsch
- Department of Orthopedics and Trauma Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Mohssen Hakimi
- Vivantes Klinikum Am Urban, Department of Orthopedic, Trauma and Hand Surgery, Berlin, Germany
| | - Michael Wild
- Department of Orthopedics, Trauma and Hand Surgery, Klinikum Darmstadt, Darmstadt, Germany
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Lin CC, Karlin E, Boin MA, Dankert JF, Larose G, Zuckerman JD, Virk MS. Operative Treatment of Proximal Humeral Fractures with Reverse Total Shoulder Arthroplasty in Patients ≥65 Years Old: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202205000-00006. [PMID: 35536998 DOI: 10.2106/jbjs.rvw.21.00245] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
» The majority of proximal humeral fractures (PHFs) in patients who are ≥65 years of age are treated nonoperatively, but certain complex fracture patterns benefit from surgical intervention. However, there continues to be debate regarding the indications for surgery and the optimal surgical treatment (repair versus replacement) in this population. » Reverse total shoulder arthroplasty (RTSA) has grown in popularity for surgical treatment of fracture-dislocations and displaced complex PHFs in patients who are ≥65 years of age; it has definite advantages over surgical repair and hemiarthroplasty, but this finding requires additional higher-quality evidence. » RTSA provides early pain relief and return of shoulder function as well as predictable elevation above shoulder level in the forward plane, but the indications for and understanding of the effect of timing on RTSA after a PHF continue to evolve. » RTSA for an acute PHF is indicated in patients who are ≥65 years of age with 3- and 4-part fracture-dislocations, head-split fractures, and severely displaced fractures, and is an option in patients who are not able to tolerate nonoperative treatment of severely displaced 3- and 4-part fractures. » RTSA is also indicated as a salvage operation for PHFs that have failed initial surgical repair (i.e., fixation failure, implant failure, rotator cuff failure, or osteonecrosis) and is an option for symptomatic nonunion or malunion after nonoperative treatment.
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Affiliation(s)
| | - Elan Karlin
- Georgetown University School of Medicine, Washington, DC
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MOLONEY M, KÅREDAL J, PERSSON T, FARNEBO S, ADOLFSSON L. Poor reliability and reproducibility of 3 different radiographical classification systems for distal ulna fractures. Acta Orthop 2022; 93:438-443. [PMID: 35438183 PMCID: PMC9016747 DOI: 10.2340/17453674.2022.2509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Classification of fractures can be valuable for research purposes but also in clinical work. Especially with are fractures, such as distal ulna fractures, a treatment algorithm based on a classification can be helpful. We compared 3 different classification systems of distal ulna fractures and investigated their reliability and reproducibility. PATIENTS AND METHODS patients with 97 fractures of the distal ulna, excluding the ulnar styloid, were included. All fractures were independently classified by 3 observers according to the classification by Biyani, AO/OTA 2007, and AO/OTA 2018. The classification process was repeated after a minimum of 3 weeks. We used Kappa value analysis to determine inter- and intra-rater agreement. RESULTS The inter-rater agreement of the AO/OTA 2007 classification was judged as fair, ĸ 0.40, whereas the agreement of AO/OTA 2018 and Biyani was moderate at ĸ 0.42 and 0.43 respectively. The intra-rater agreement was judged as moderate for all classifications. INTERPRETATION The differences between the classifications were small and the overall impression was that neither of them was good enough to be of substantial clinical value. The Biyani classification, being developed specifically for distal ulna fractures, was the easiest and most fitting for the fracture patterns seen in our material, but lacking options for fractures of the distal diaphysis. Standard radiographs were considered insufficient for an accurate classification. A better radiographic method combined with a revised classification might improve accuracy, reliability, and reproducibility.
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Affiliation(s)
- Maria MOLONEY
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University
| | | | | | - Simon FARNEBO
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University,Department of Clinical and Experimental Medicine, Linköping University, Sweden
| | - Lars ADOLFSSON
- Department of Orthopaedics, Linköping University,Department of Clinical and Experimental Medicine, Linköping University, Sweden
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17
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Foruria AM, Martinez-Catalan N, Pardos B, Larson D, Barlow J, Sanchez-Sotelo J. Classification of Proximal Humerus Fractures According to Pattern Recognition is Associated with High Intraobserver and Interobserver Agreement. JSES Int 2022; 6:563-568. [PMID: 35813132 PMCID: PMC9264021 DOI: 10.1016/j.jseint.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The Mayo-Fundación Jiménez Díaz (FJD) classification for proximal humerus fractures aims to identify specific fracture patterns and apply displacement criteria to each pattern. The classification includes 7 common fracture patterns: isolated fractures of the greater or lesser tuberosity, fractures of the surgical neck, impacted fractures involving head rotation in a varus and posteromedial direction or in valgus, and fractures where the humeral head is dislocated (head dislocation), split (head splitting), or depressed (head impaction). The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Mayo-FJD classification system using plain radiographs (xR) and computed tomography (CT). Methods Three fellowship-trained shoulder surgeons blindly and independently evaluated the xR and CT of 103 consecutive proximal humerus fractures treated at a Level I trauma center. Each surgeon classified all fractures according to the Mayo-FJD classification system on 4 separate sessions at least 6 weeks apart. K values were calculated for intraobserver and interobserver reliability. Results The average intraobserver agreement was 0.9 (almost perfect) for xR and 0.9 (almost perfect) for CT scans. The average interobserver agreement was 0.69 (substantial) for xR and 0.81 (almost perfect) for CT scans at the first round, and 0.66 (substantial) for xR and 0.75 (substantial) for CT scans at the second round. Conclusion The pattern-based Mayo-FJD classification scheme for proximal humerus fractures was associated with adequate intraobserver and interobserver agreement using both xR and CT scan. Interobserver agreement was best when fractures were classified using CT scans.
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Affiliation(s)
- Antonio M. Foruria
- Upper Extremity Reconstruction Unit, Orthopedic Surgery Department. Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Natalia Martinez-Catalan
- Upper Extremity Reconstruction Unit, Orthopedic Surgery Department. Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Belen Pardos
- Upper Extremity Reconstruction Unit, Orthopedic Surgery Department. Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Dirk Larson
- Department of Statistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan Barlow
- Upper Extremity Reconstruction division. Orthopedic Surgery Department, Mayo Clinic, Rochester, Minnesota, USA
| | - Joaquín Sanchez-Sotelo
- Upper Extremity Reconstruction division. Orthopedic Surgery Department, Mayo Clinic, Rochester, Minnesota, USA
- Corresponding author: Joaquín Sanchez-Sotelo, MD, PhD, Gonda 14, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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18
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Cocco LF, Aihara AY, Lopes FPPL, Werner H, Franciozi CE, dos Reis FB, Luzo MVM. Three-dimensional printing models increase inter-rater agreement for classification and treatment of proximal humerus fractures. Patient Saf Surg 2022; 16:5. [PMID: 35057844 PMCID: PMC8772160 DOI: 10.1186/s13037-021-00312-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 12/08/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Proximal humerus fractures (PHF) are frequent, however, several studies show low inter-rater agreement in the diagnosis and treatment of these injuries. Differences are usually related to the experience of the evaluators and/or the diagnostic methods used. This study was designed to investigate the hypothesis that shoulder surgeons and diagnostic imaging specialists using 3D printing models and shoulder CT scans in assessing proximal humerus fractures. METHODS We obtained 75 tomographic exams of PHF to print three-dimensional models. After, two shoulder surgeons and two specialists in musculoskeletal imaging diagnostics analyzed CT scans and 3D models according to the Neer and AO/OTA group classification and suggested a treatment recommendation for each fracture based on the two diagnostic methods. RESULTS The classification agreement for PHF using 3D printing models among the 4 specialists was moderate (global k = 0.470 and 0.544, respectively for AO/OTA and Neer classification) and higher than the CT classification agreement (global k = 0.436 and 0.464, respectively for AO/OTA and Neer). The inter-rater agreement between the two shoulder surgeons were substantial. For the AO/OTA classification, the inter-rater agreement using 3D printing models was higher (k = 0.700) than observed for CT (k = 0.631). For Neer classification, inter-rater agreement with 3D models was similarly higher (k = 0.784) than CT images (k = 0.620). On the other hand, the inter-rater agreement between the two specialists in diagnostic imaging was moderate. In the AO/OTA classification, the agreement using CT was higher (k = 0.532) than using 3D printing models (k = 0.443), while for Neer classification, the agreement was similar for both 3D models (k = 0.478) and CT images (k = 0.421). Finally, the inter-rater agreement in the treatment of PHF by the 2 surgeons was higher for both classifications using 3D printing models (AO/OTA-k = 0.818 for 3D models and k = 0.537 for CT images). For Neer classification, we saw k = 0.727 for 3D printing models and k = 0.651 for CT images. CONCLUSION The insights from this diagnostic pilot study imply that for shoulder surgeons, 3D printing models improved the diagnostic agreement, especially the treatment indication for PHF compared to CT for both AO/OTA and Neer classifications On the other hand, for specialists in diagnostic imaging, the use of 3D printing models was similar to CT scans for diagnostic agreement using both classifications. TRIAL REGISTRATION Brazil Platform under no. CAAE 12273519.7.0000.5505.
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Affiliation(s)
- Luiz Fernando Cocco
- Department of Orthopedic, Escola Paulista de Medicina, Universidade Federal de São Paulo, Hospital Samaritano Higienópolis Américas Serviços Médicos, São Paulo, Brasil
| | - André Yui Aihara
- Department of Diagnostic Imaging, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brasil
| | | | | | - Carlos Eduardo Franciozi
- Department of Orthopedic, Orthopaedic Surgeon, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brasil
| | - Fernando Baldy dos Reis
- Department of Orthopedic, Orthopaedic Surgeon, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brasil
| | - Marcus Vinicius Malheiros Luzo
- Department of Orthopedic, Escola Paulista de Medicina, Universidade Federal de São Paulo, Hospital Samaritano Higienópolis Américas Serviços Médicos, São Paulo, Brasil
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Razaeian S, Askittou S, Wiese B, Zhang D, Harb A, Krettek C, Hawi N. Inter- and intraobserver reliability of morphological Mutch classification for greater tuberosity fractures of the proximal humerus: A comparison of x-ray, two-, and three-dimensional CT imaging. PLoS One 2021; 16:e0259646. [PMID: 34762694 PMCID: PMC8584785 DOI: 10.1371/journal.pone.0259646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/22/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The objective of this study was to investigate inter- and intraobserver reliability of the morphological Mutch classification for greater tuberosity (GT) fragments in consecutive proximal humerus fractures (PHF) regardless of the number of parts according to the Codman classification system for three different imaging modalities (plain radiographs, two-dimensional [2-D] computed tomography [CT], and reformatted, three-dimensional [3-D] CT reconstruction). MATERIALS AND METHODS One hundred thirty-eight consecutive PHF with GT involvement were identified between January 2018 and December 2018 in a supraregional Level 1 trauma center. GT morphology was classified by three blinded observers according to the morphological Mutch classification using the picture archiving and communication software Visage 7.1 (Visage Imaging Inc., San Diego, CA, USA). Fleiss' and Cohens' kappa were assessed for inter- and intraobserver reliability. Strength of agreement for kappa (k) values was interpreted according to the Landis and Koch benchmark scale. RESULTS In cases of isolated GT fractures (n = 24), the morphological Mutch classification achieved consistently substantial values for interobserver reliability (radiograph: k = 0.63; 2-D CT: k = 0.75; 3-D CT: k = 0.77). Moreover, use of advanced imaging (2-D and 3-D CT) tends to increase reliability. Consistently substantial mean values were found for intraobserver agreement (radiograph: Ø k = 0.72; 2-D CT: Ø k = 0.8; 3-D CT: Ø k = 0.76). In cases of multi-part PHF with GT involvement (n = 114), interobserver agreement was only slight to fair regardless of imaging modality (radiograph: k = 0.3; 2-D CT: k = 0.17; 3-D CT: k = 0.05). Intraobserver agreement achieved fair to moderate mean values (radiograph: Ø k = 0.56; 2-D CT: Ø k = 0.61; 3-D CT: Ø k = 0.33). CONCLUSION The morphological Mutch classification remains a reliable classification for isolated GT fractures, even with 2-D or 3-D CT imaging. Usage of these advanced imaging modalities tends to increase interobserver reliability. However, its reliability for multi-part fractures with GT involvement is limited. A simple and reliable classification is missing for this fracture entity.
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Affiliation(s)
- Sam Razaeian
- Trauma Department, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Said Askittou
- Department of Internal Medicine, KRH Klinikum Lehrte, Lehrte, Lower Saxony, Germany
| | - Birgitt Wiese
- Department of General Medicine, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Afif Harb
- Trauma Department, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Christian Krettek
- Trauma Department, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Nael Hawi
- Trauma Department, Hannover Medical School, Hannover, Lower Saxony, Germany
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Management of proximal humeral fractures: a review. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Principles of Locking Plate Fixation of Proximal Humerus Fractures. J Am Acad Orthop Surg 2021; 29:e523-e535. [PMID: 33539058 DOI: 10.5435/jaaos-d-20-00558] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 12/24/2020] [Indexed: 02/01/2023] Open
Abstract
Proximal humerus fractures are common, particularly in elderly patients and those with osteopenia or osteoporosis. Although nonsurgical management results in satisfactory outcomes for most patients, surgical treatment is indicated in select cases. Despite an increasing trend toward arthroplasty, open reduction and internal fixation of proximal humerus fractures can still provide excellent clinical outcomes. Proper technique for internal fixation of the proximal humerus requires an understanding of osseous and neurovascular anatomy. In particular, understanding reliable regions of biomechanically superior bone can help prevent failure of fixation. Biomechanical studies have shown that locked plating of proximal humerus fractures provides stable fixation. Cadaveric and finite element models underscore the importance of screw placement in the posteromedial metaphysis. When medial column support is challenging to obtain, or when bone quality is poor, augmentation with bone autograft, allograft, and/or synthetic composites can improve the biomechanics of internal fixation constructs. The purpose of this review is to outline the anatomic, biologic, and biomechanical principles of plate fixation for proximal humerus fractures to provide evidence-based recommendations for optimizing fixation and preventing fixation failure.
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Three-dimensional models increase the interobserver agreement for the treatment of proximal humerus fractures. Patient Saf Surg 2020; 14:33. [PMID: 32782476 PMCID: PMC7409687 DOI: 10.1186/s13037-020-00258-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/30/2020] [Indexed: 12/16/2022] Open
Abstract
Background The agreement for the treatment of proximal humerus fractures is low. Interpretation of exams used for diagnosis can be directly associated with this limitation. This study proposes to compare the agreement between experts and residents in orthopedics for treatment indication of proximal humerus fractures, utilizing 3D-models, holography (augmented reality), x-rays, and tomography as diagnostic methods. Methods Twenty orthopedists (ten experts in shoulder and elbow surgery and ten experts in traumatology) and thirty resident physicians in orthopedics evaluated nine fractures of the proximal humerus, randomly distributed as x-rays, tomography, 3D-models and holography, using the Neer and AO / OTA Classifications. After, we evaluated the interobserver agreement between treatment options (conservative, osteosynthesis and arthroplasty) and whether the experience of the evaluators interfered with the results. Results The interobserver agreement analysis showed the following kappa-values: κ = 0.362 and κ = 0.306 for experts and residents (3D-models); κ = 0.240 and κ = 0.221 (X-ray); κ = 0.233 and κ = 0.123 (Tomography) and κ = 0.321 and κ = 0.160 (Holography), for experts and residents respectively. Moreover, residents and specialists were discordant in the treatment indication using Tomography as a diagnostic method (p = 0.003). The same was not seen for the other diagnostic methods (p > 0.05). Conclusions Three-dimensional models showed, overall, the highest interobserver agreement (experts versus residents in orthopedics) for the choice of treatment of proximal humerus fractures compared to X-ray, Tomography, and Holography. Agreement in the choice of treatment among experts that used Tomography and Holography as diagnostic methods were two times higher compared to residents. Trial registration Registered in Brazil Platform under no. CAAE 12273519.7.0000.5505.
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