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Oliver WM, Nicholson JA, Bell KR, Carter TH, White TO, Clement ND, Duckworth AD, Simpson AHRW. Ultrasound assessment of humeral shaft nonunion risk: a feasibility and proof of concept study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:909-918. [PMID: 37773419 PMCID: PMC10858097 DOI: 10.1007/s00590-023-03725-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/04/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE To determine the feasibility and reliability of ultrasound in the assessment of humeral shaft fracture healing and estimate the accuracy of 6wk ultrasound in predicting nonunion. METHODS Twelve adults with a non-operatively managed humeral shaft fracture were prospectively recruited and underwent ultrasound scanning at 6wks and 12wks post-injury. Seven blinded observers evaluated sonographic callus appearance to determine intra- and inter-observer reliability. Nonunion prediction accuracy was estimated by comparing images for patients that united (n = 10/12) with those that developed a nonunion (n = 2/12). RESULTS The mean scan duration was 8 min (5-12) and all patients tolerated the procedure. At 6wks and 12wks, sonographic callus (SC) was present in 11 patients (10 united, one nonunion) and sonographic bridging callus (SBC) in seven (all united). Ultrasound had substantial intra- (weighted kappa: 6wk 0.75; 12wk 0.75) and inter-observer reliability (intraclass correlation coefficient: 6wk 0.60; 12wk 0.76). At 6wks, the absence of SC demonstrated sensitivity 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (overall accuracy 92%). The absence of SBC demonstrated sensitivity 100%, specificity 70%, PPV 40% and NPV 100% in nonunion prediction (overall accuracy 75%). Of three patients at risk of nonunion (Radiographic Union Score for HUmeral fractures < 8), one had SBC on 6wk ultrasound (that subsequently united) and the others had non-bridging/absent SC (both developed nonunion). CONCLUSIONS Ultrasound assessment of humeral shaft fracture healing was feasible, reliable and may predict nonunion. Ultrasound could be useful in defining nonunion risk among patients with reduced radiographic callus formation.
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Affiliation(s)
- William M Oliver
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
| | - Jamie A Nicholson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Katrina R Bell
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Thomas H Carter
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Timothy O White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Nicholas D Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - A Hamish R W Simpson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
- Department of Orthopaedics and Trauma, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
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Karimi D, Qvistgaard SW, Gundtoft PH, Brorson S, Viberg B. Unchanged incidence but change in treatment trends from 1996 to 2018: 23,718 humeral shaft fractures from the Danish National Patient Registry. Acta Orthop 2023; 94:523-529. [PMID: 37831408 PMCID: PMC10574250 DOI: 10.2340/17453674.2023.21125] [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] [Received: 03/15/2023] [Accepted: 09/16/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND AND PURPOSE Humeral shaft fractures (HSF) can be treated surgically or non-surgically. National trends and distributions are sparsely reported. We present the temporal trends in epidemiology of adult HSF in Denmark, with the primary aim of reporting HSF incidences, and the secondary aim of reporting on the primary treatment management. PATIENTS AND METHODS The diagnosis (International Classification of Diseases Version 10 [ICD-10]: S42.3) and surgical procedure codes for HSF were obtained from the Danish National Patient Registry (DNPR) covering 1996-2018. The diagnosis code for HSF is validated in the DNPR with a positive predictive value of 89%. Patients aged 18 years and above were included. Surgical treatment was defined as a diagnosis of HSF combined with a surgical procedure within 3 weeks of injury. Cases without relevant registered procedures within 3 weeks were defined as nonsurgical treatment cases. RESULTS 23,718 HSF (62% female) were identified in the DNPR. The overall mean incidence was 25/100,000/year and was stable over 23 years. The population above 50 years accounted for 78% of all HSF. Non-surgical treatment accounted for 87% of treatments and was stable during the study period. Temporal changes were observed regarding surgical procedures; intramedullary nailing decreased from 57% to 26% and plate osteosynthesis increased from 12% to 69%. CONCLUSION The overall incidence for HSF remained stable from 1996 to 2018. Most cases were females aged 50 years and above. The preferred primary treatment for HSF was non-surgical for all ages. Plate osteosynthesis became more popular than intramedullary nailing over the study period.
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Affiliation(s)
- Dennis Karimi
- Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark.
| | - Søren Wacher Qvistgaard
- Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark
| | - Per Hviid Gundtoft
- Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark; Department of Orthopedic Surgery and Traumatology, Aarhus University Hospital
| | - Stig Brorson
- Centre for Evidence-Based Orthopedics, Zealand University Hospital and Department of Clinical Medicine, University of Copenhagen
| | - Bjarke Viberg
- Department of Orthopedic Surgery and Traumatology, Lillebaelt Hospital, University Hospital of Southern Denmark; Department of Orthopedic Surgery and Traumatology, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Denmark
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Sato K, Takegami Y, Tokutake K, Shimamoto Y, Ueno H, Ando T, Imagama S. Retrospective multicenter (TRON group) study of humeral shaft fragility fractures: Analysis of mortality rates and risk factors. Injury 2023:110855. [PMID: 37296013 DOI: 10.1016/j.injury.2023.110855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
AIMS This study aimed to show the mortality rate following humeral shaft fragility fractures (HSFF) in the elderly. The secondary aim was to examine the predictors associated with mortality in elderly patients who have sustained HSFF. METHODS From 2011 to 2020, all elderly patients aged 65 years and older with HSFF managed at our nine hospitals were retrospectively identified from our TRON database. Patient demographics and surgical characteristics were extracted from medical records and radiographs, and multivariable Cox regression analysis was used to identify factors affecting mortality. RESULTS In total, 153 patients who sustained HSFF were included. The mortality rate for HSFF in the elderly was 15.7% at 1 year and 24.6% at 2 years. Multivariable Cox regression analysis showed significant differences in survival for the following variables: older age (p < 0.001), underweight (p = 0.022), severely ill (p = 0.025), mobility limited to indoors (p = 0.003), dominant-side injury (p = 0.027), and nonoperative treatment (p = 0.013). CONCLUSION The outcome following HSFF in the elderly population appears to be relatively grim. The prognosis of elderly patients with HSFF is closely related to their medical history. In the elderly patients with HSFF, operative treatment should be positively considered while taking into account their medical status.
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Affiliation(s)
- Ken Sato
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Takegami
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Katsuhiro Tokutake
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuya Shimamoto
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Ueno
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshihiro Ando
- Department of Orthopaedic Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Kobayashi EF, Namdari S, Schenker M, Athwal GS, Ahn J. Evaluation and treatment of postoperative periprosthetic humeral fragility fractures. OTA Int 2023; 6:e244. [PMID: 37006451 PMCID: PMC10064642 DOI: 10.1097/oi9.0000000000000244] [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: 12/06/2022] [Accepted: 12/22/2022] [Indexed: 06/19/2023]
Abstract
Postoperative periprosthetic humeral shaft fractures represent a growing and difficult complication to treat given the aging patient population and associated bone loss. Determining the best treatment option is multifactorial, including patient characteristics, fracture pattern, remaining bone stock, and implant stability. Possible treatment options include nonoperative management with bracing or surgical intervention. Nonoperative treatment has been shown to have higher nonunion rates, thus should only be selected for a specific patient population with minimally displaced fractures or those that are unfit for surgery. Surgical management is recommended with prosthetic loosening, fracture nonunion, or failure of nonoperative treatment. Surgical options include open reduction and internal fixation, revision arthroplasty, or hybrid fixation. Careful evaluation, decision making, and planning is required in the treatment of these fractures.
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Affiliation(s)
- Evangeline F. Kobayashi
- Department of Orthopaedic Surgery, University of Michigan, Division of Trauma Surgery, Ann Arbor, MI
| | - Surena Namdari
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Division of Shoulder and Elbow Surgery, Bensalem, PA
| | - Mara Schenker
- Department of Orthopaedic Surgery, Emory University, Division of Trauma Surgery, Atlanta, GA
| | - George S. Athwal
- Department of Orthopaedic Surgery, Roth/McFarlane Hand and Upper Limb Centre, Division of Shoulder and Elbow Surgery, London, ON, Canada; and
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, University of Michigan, Division of Trauma Surgery, Ann Arbor, MI
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Walter N, Szymski D, Kurtz SM, Lowenberg DW, Alt V, Lau E, Rupp M. Proximal humerus fractures - epidemiology, comparison of mortality rates after surgical versus non-surgical treatment, and analysis of risk factors based on Medicare registry data. Bone Joint Res 2023; 12:103-112. [PMID: 36718643 PMCID: PMC9950668 DOI: 10.1302/2046-3758.122.bjr-2022-0275.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
AIMS The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate? METHODS PHFs occurring between 1 January 2009 and 31 December 2019 were identified from the Medicare physician service records. Incidence rates were determined, mortality rates were calculated, and semiparametric Cox regression was applied, incorporating 23 demographic, clinical, and socioeconomic covariates, to compare the mortality risk between treatments. RESULTS From 2009 to 2019, the incidence decreased by 11.85% from 300.4 cases/100,000 enrollees to 266.3 cases/100,000 enrollees, although this was not statistically significant (z = -1.47, p = 0.142). In comparison to matched Medicare patients without a PHF, but of the same five-year age group and sex, a mean survival difference of -17.3% was observed. The one-year mortality rate was higher after nonoperative treatment with 16.4% compared to surgical treatment with 9.3% (hazard ratio (HR) = 1.29, 95% confidence interval (CI) 1.23 to 1.36; p < 0.001) and to shoulder arthroplasty with 7.4% (HR = 1.45, 95% CI 1.33 to 1.58; p < 0.001). Statistically significant mortality risk factors after operative treatment included age older than 75 years, male sex, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, chronic kidney disease, a concomitant fracture, congestive heart failure, and osteoporotic fracture. CONCLUSION Mortality risk factors for distinct treatment modes after PHF in elderly patients could be identified, which may guide clinical decision-making.Cite this article: Bone Joint Res 2023;12(2):103-112.
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Affiliation(s)
- Nike Walter
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Dominik Szymski
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Steven M. Kurtz
- Implant Research Center, Drexel University, Philadelphia, Pennsylvania, USA
| | - David W. Lowenberg
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Edmund Lau
- Exponent Inc, Menlo Park, California, USA
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany, Markus Rupp. E-mail:
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Surgical Versus Nonsurgical Management of Humeral Shaft Fractures: A Systematic Review and Meta-Analysis of Randomized Trials. J Am Acad Orthop Surg 2023; 31:e82-e93. [PMID: 36580054 DOI: 10.5435/jaaos-d-22-00432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 08/06/2022] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION The aim was to compare surgical and nonsurgical management for adults with humeral shaft fractures in terms of patient-reported upper limb function, health-related quality of life, radiographic outcomes, and complications. METHODS MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PubMed, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, International Clinical Trials Registry, and OpenGrey (Repository for Grey Literature in Europe) were searched in September 2021. All published prospective randomized trials comparing surgical and nonsurgical management of humeral shaft fractures in adults were included. Of 715 studies identified, five were included in the systematic review and four in the meta-analysis. Data were extracted by two independent reviewers according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Methodological quality was assessed using the revised Cochrane risk-of-bias tool for randomized trials. Pooled data were analyzed using a random-effects model. RESULTS The meta-analysis comprised 292 patients (mean age 41 [18 to 83] years, 67% male). Surgery was associated with superior Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley scores at 6 months (mean DASH difference 7.6, P = 0.01; mean Constant-Murley difference 8.0, P = 0.003), but there was no difference at 1 year (DASH, P = 0.30; Constant-Murley, P = 0.33). No differences in health-related quality of life or pain scores were found. Surgery was associated with a lower risk of nonunion (0.7% versus 15.7%; odds ratio [OR] 0.13, P = 0.004). The number needed to treat with surgery to avoid one nonunion was 7. Surgery was associated with a higher risk of transient radial nerve palsy (17.4% versus 0.7%; OR 8.23, P = 0.01) but not infection (OR 3.57, P = 0.13). Surgery was also associated with a lower risk of reintervention (1.4% versus 19.3%; OR 0.14, P = 0.04). CONCLUSIONS Surgery may confer an early functional advantage to adults with humeral shaft fractures, but this is not sustained beyond 6 months. The lower risk of nonunion should be balanced against the higher risk of transient radial nerve palsy. LEVEL OF EVIDENCE Level I.
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Quarcoopome J, Adam J, Baljer B, Nagi A, Eardley W, McVie JL. Fixation of Proximal Third Humeral Shaft Fractures in Older Patients. Geriatr Orthop Surg Rehabil 2023; 14:21514593231164246. [PMID: 36968624 PMCID: PMC10034302 DOI: 10.1177/21514593231164246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/13/2023] [Accepted: 03/01/2023] [Indexed: 03/29/2023] Open
Abstract
Background Humeral shaft fractures occur frequently in older patients. The more proximal end of the shaft is prone to non-union when compared with more distal fractures. We provide an overview of several key features of this significant patient group. Method Our institutional fracture database was searched for all cases of proximal third humeral shaft fractures in patients over 60 years of age. Retrospective evaluation of patient demographics, management, length of stay and incidence of non-union was performed. Results 75 patients (61 female) were analysed. 33 patients were 'frail' (Clinical Frailty Scores of >4). Non-union occurred in 19 of 45 non-surgically treated fractures and in 1 of 37 cases treated surgically. Mean length of stay was 5.9 days (non-operative) and 6.6 days (operative). Proximal extension into the humeral head is common. Conclusion Non-surgical management of proximal third humeral shaft fractures is associated with an increased risk of non-union. We detail an operative technique and case example supporting early fixation of displaced proximal third humeral shaft fractures in older patients that can be utilized for both primary and delayed fixation. In view of the significant association of non-union a well-constructed prospective cohort study with outcome assessment would be of value to further characterize this emerging injury population.Level of Evidence: Level IV, retrospective case series.
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Affiliation(s)
- Jared Quarcoopome
- Trauma and Orthopaedic Department,
South Tees
Hospitals NHS Foundation Trust,
Middlesbrough, UK
- Jared Quarcoopome, Trauma and Orthopaedic
Department, South Tees Hospitals NHS Foundation Trust, Marton Road,
Middlesbrough, TS4 3BW, UK.
| | - John Adam
- Trauma and Orthopaedic Department,
South Tees
Hospitals NHS Foundation Trust,
Middlesbrough, UK
| | - Bence Baljer
- Trauma and Orthopaedic Department,
South Tees
Hospitals NHS Foundation Trust,
Middlesbrough, UK
| | - Ahmed Nagi
- Trauma and Orthopaedic Department,
South Tees
Hospitals NHS Foundation Trust,
Middlesbrough, UK
| | - Will Eardley
- Trauma and Orthopaedic Department,
South Tees
Hospitals NHS Foundation Trust,
Middlesbrough, UK
- Department of Health Sciences,
University
of York, York, UK
| | - James L. McVie
- Trauma and Orthopaedic Department,
South Tees
Hospitals NHS Foundation Trust,
Middlesbrough, UK
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Epidemiology of 936 humeral shaft fractures in a large Finnish trauma center. J Shoulder Elbow Surg 2022; 32:e206-e215. [PMID: 36435484 DOI: 10.1016/j.jse.2022.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 10/06/2022] [Accepted: 10/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Humeral shaft fractures are relatively common injuries and are classified according to location and fracture morphology. Epidemiological studies improve understanding of injury patterns and lay foundations for future research. There are only a few published larger epidemiological studies on humeral shaft fractures. METHODS We retrospectively analyzed the medical records of adult patients having sustained a humeral shaft fracture treated in the Helsinki University Hospital between 2006 and 2016. We recorded patient and fracture characteristics, timing and mechanism of injury, associated injuries, and 1-year mortality. RESULTS We identified 914 patients (489 females, median age = 61.4 years; 425 males, median age = 50.4 years) with 936 fractures. Over 60% of these fractures were sustained from simple falls. The patient age distribution was bimodal, with highest fracture rates in elderly females and young males. We divided the fractures into typical traumatic, periprosthetic, and pathological fractures. Of the 872 typical traumatic fractures, 3.0% were open. In addition, there were 24 (2.6%) periprosthetic and 40 (4.3%) pathological fractures. An associated injury was found in 24% of patients, with primary radial nerve palsy (PRNP) being the most common (10%). PRNPs were more common in distal shaft fractures and high energy injuries. The 1-year mortality was 9.2%. CONCLUSIONS In this study, the most common injury mechanism was a simple fall. The most common associated injury was PRNP. The observed bimodal fracture distribution is consistent with previous literature.
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Oliver WM, Molyneux SG, White TO, Clement ND, Duckworth AD. Routine fixation of humeral shaft fractures is cost-effective. Bone Jt Open 2022; 3:566-572. [PMID: 35822554 PMCID: PMC9350699 DOI: 10.1302/2633-1462.37.bjo-2022-0047.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the health economic implications of using a Radiographic Union Score for HUmeral fractures (RUSHU) of < 8 to facilitate selective fixation for patients at risk of nonunion. Methods From 2008 to 2017, 215 patients (mean age 57 yrs (17 to 18), 61% female (n = 130/215)) with a nonoperatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved in 77% (n = 165/215) after initial nonoperative management, with 23% (n = 50/215) uniting after surgery for nonunion. The EuroQol five-dimension three-level health index (EQ-5D-3L) was obtained via postal survey. Multiple regression was used to determine the independent influence of patient, injury, and management factors upon the EQ-5D-3L. An incremental cost-effectiveness ratio (ICER) of < £20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective. Results At a mean of 5.4 yrs (1.2 to 11.0), the mean EQ-5D-3L was 0.736 (95% confidence interval (CI) 0.697 to 0.775). Adjusted analysis demonstrated the EQ-5D-3L was inferior among patients who united after nonunion surgery (β = 0.103; p = 0.032). Offering routine fixation to all patients to reduce the rate of nonunion would be associated with increased treatment costs of £1,542/patient, but would confer a potential EQ-5D-3L benefit of 0.120/patient over the study period. The ICER of routine fixation was £12,850/QALY gained. Selective fixation based on a RUSHU < 8 at six weeks post-injury would be associated with reduced treatment costs (£415/patient), and would confer a potential EQ-5D-3L benefit of 0.335 per ‘at-risk patient’. Conclusion Routine fixation for patients with humeral shaft fractures to reduce the rate of nonunion observed after nonoperative management appears to be a cost-effective intervention at five years post-injury. Selective fixation for patients at risk of nonunion based on their RUSHU may confer even greater cost-effectiveness, given the potential savings and improvement in health-related quality of life. Cite this article: Bone Jt Open 2022;3(7):566–572.
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Affiliation(s)
| | | | - Timothy O. White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nick D. Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew D. Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
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Oliver WM, Searle HKC, Molyneux SG, White TO, Clement ND, Duckworth AD. Factors Associated with Patient-Reported Outcomes Following a Humeral Shaft Fracture: Nonunion Results in a Poorer Outcome Despite Union after Surgical Fixation. J Orthop Trauma 2022; 36:e227-e235. [PMID: 34999623 DOI: 10.1097/bot.0000000000002315] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The primary aim was to assess patient-reported outcomes ≥1 year following a humeral diaphyseal fracture. The secondary aim was to compare outcomes of patients who united after initial management (operative/nonoperative) with those who united after nonunion fixation (NU-ORIF). DESIGN Retrospective. SETTING University teaching hospital. PATIENTS AND INTERVENTION From 2008 to 2017, 291 patients [mean age, 55 years (17-86 years), 58% (n = 168/291) female] were available to complete an outcomes survey. Sixty-four (22%) were initially managed operatively and 227 (78%) nonoperatively. After initial management, 227 (78%) united (n = 62 operative, n = 165 nonoperative), 2 had a delayed union (both nonoperative), and 62 (21%) had a nonunion (n = 2 operative, n = 60 nonoperative). Fifty-two patients (93%, n = 52/56) united after NU-ORIF. MAIN OUTCOME MEASURES QuickDASH, EuroQol-5 Dimension (EQ-5D)/EuroQol-Visual Analogue Scale (EQ-VAS), 12-item Short Form Physical (PCS) and Mental Component Summary (MCS). RESULTS At a mean of 5.5 years (range, 1.2-11.0 years) postinjury, the mean QuickDASH was 20.8, EQ-5D was 0.730, EQ-VAS was 74, PCS was 44.8 and MCS was 50.2. Patients who united after NU-ORIF reported worse function (QuickDASH, 27.9 vs. 17.6; P = 0.003) and health-related quality of life (HRQoL; EQ-5D, 0.639 vs. 0.766; P = 0.008; EQ-VAS, 66 vs. 76; P = 0.036; PCS, 41.8 vs. 46.1; P = 0.036) than those who united primarily. Adjusting for confounders, union after NU-ORIF was independently associated with a poorer QuickDASH (difference, 8.1; P = 0.019) and EQ-5D (difference, -0.102; P = 0.028). CONCLUSIONS Humeral diaphyseal union after NU-ORIF resulted in poorer patient-reported outcomes compared with union after initial management. Targeting early operative intervention to at-risk patients may mitigate the potential impact of nonunion on longer-term outcome. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- William M Oliver
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
| | - Henry K C Searle
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
| | - Samuel G Molyneux
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
| | - Timothy O White
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
| | - Nicholas D Clement
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
| | - Andrew D Duckworth
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom ; and
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
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Abstract
Aims The primary aim of this study was to determine the rates of return to work (RTW) and sport (RTS) following a humeral shaft fracture. The secondary aim was to identify factors independently associated with failure to RTW or RTS. Methods From 2008 to 2017, all patients with a humeral diaphyseal fracture were retrospectively identified. Patient demographics and injury characteristics were recorded. Details of pre-injury employment, sporting participation, and levels of return post-injury were obtained via postal questionnaire. The University of California, Los Angeles (UCLA) Activity Scale was used to quantify physical activity among active patients. Regression was used to determine factors independently associated with failure to RTW or RTS. Results The Work Group comprised 177 patients in employment prior to injury (mean age 47 years (17 to 78); 51% female (n = 90)). Mean follow-up was 5.8 years (1.3 to 11). Overall, 85% (n = 151) returned to work at a mean of 14 weeks post-injury (0 to 104), but only 60% (n = 106) returned full-time to their previous employment. Proximal-third fractures (adjusted odds ratio (aOR) 4.0 (95% confidence interval (CI) 1.2 to 14.2); p = 0.029) were independently associated with failure to RTW. The Sport Group comprised 182 patients involved in sport prior to injury (mean age 52 years (18 to 85); 57% female (n = 104)). Mean follow-up was 5.4 years (1.3 to 11). The mean UCLA score reduced from 6.9 (95% CI 6.6 to 7.2) before injury to 6.1 (95% CI 5.8 to 6.4) post-injury (p < 0.001). There were 89% (n = 162) who returned to sport: 8% (n = 14) within three months, 34% (n = 62) within six months, and 70% (n = 127) within one year. Age ≥ 60 years was independently associated with failure to RTS (aOR 3.0 (95% CI 1.1 to 8.2); p = 0.036). No other factors were independently associated with failure to RTW or RTS. Conclusion Most patients successfully return to work and sport following a humeral shaft fracture, albeit at a lower level of physical activity. Patients aged ≥ 60 yrs and those with proximal-third diaphyseal fractures are at increased risk of failing to return to activity. Cite this article: Bone Jt Open 2022;3(3):236–244.
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Affiliation(s)
| | | | - Timothy O. White
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Nick D. Clement
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew D. Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
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Development and Trial of a Prototype Device for Sensorimotor Therapy in Patients with Distal Radius Fractures. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12041967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study examined the clinical feasibility of a prototype device (development name: Ghost) for facilitating range of motion (RoM) recovery in the acute phase in patients with distal radius fractures (DRF). The Ghost device involves the administration of a combination of vibratory and visual stimuli. We divided the patients into the Ghost (n = 10) and control group (n = 4; tendon vibration only) groups. The experimental interventions were administered between the day after surgery and day 7 postoperatively. Traditional hand therapy was provided to both groups once daily from day 7 until day 84 postoperatively and once a week from day 84 until the end of the intervention period. Because vibratory stimulation makes the patient focus on wrist flexion, the primary outcome was the arc of wrist flexion-extension on the injured side, which was measured on days 7, 14, 28, 42, 56, 70, and 84. Analysis of covariance was applied using a bootstrap method to evaluate changes over time and compare them between the groups. Analyses was performed after stratification by age and body mass index. Both interventions improved RoM over time in patients with DRF. Results showed that Ghost has greater efficacy for improving wrist RoM in DRF patients than vibration alone. Treatment with Ghost can result in good RoM improvement during the acute phase of DRF in young patients and those with and normal or low body mass index. Further study is needed to verify our findings and assess the extent of RoM recovery.
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13
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Oliver WM, Searle HKC, Ng ZH, Molyneux SG, White TO, Clement ND, Duckworth AD. Factors associated with humeral shaft nonunion. J Shoulder Elbow Surg 2021; 30:2283-2295. [PMID: 33636324 DOI: 10.1016/j.jse.2021.01.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/17/2021] [Accepted: 01/24/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after nonoperative management. The secondary aim was to determine the effect of management (operative/nonoperative) on nonunion. METHODS From 2008-2017, a total of 734 humeral shaft fractures (732 consecutive skeletally mature patients) were retrospectively identified from a trauma database. Follow-up was available for 663 fractures (662 patients, 90%) that formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed nonoperatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographs. RESULTS The median age at injury was 57 (range 16-96) years and 54% (n = 359/662) were female. Median follow-up was 5 (1.2-74) months. Nonunion occurred in 22.7% (n = 119/524) of nonoperatively managed injuries. Multivariate analysis demonstrated preinjury nonsteroidal anti-inflammatory drugs (NSAIDs; odds ratio [OR] 20.58, 95% confidence interval [CI] 2.12-199.48; P = .009) and glenohumeral arthritis (OR 2.44, 95% CI 1.03-5.77; P = .043) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n = 4/139) compared with nonoperative management (OR for nonoperative/operative management 9.91, 95% CI 3.25-30.23; P < .001). Based on these findings, 5 patients would need to undergo primary operative fixation in order to avoid 1 nonunion. CONCLUSIONS Preinjury NSAIDs and glenohumeral arthritis were independently associated with nonunion following nonoperative management of a humeral diaphyseal fracture. Operative fixation was the independent factor most strongly associated with a lower risk of nonunion. Targeting early operative fixation to at-risk patients may reduce the rate of nonunion and the morbidity associated with delayed definitive management.
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Affiliation(s)
- William M Oliver
- Edinburgh Orthopaedics - Trauma Royal Infirmary of Edinburgh, Edinburgh, Midlothian, UK.
| | - Henry K C Searle
- Edinburgh Orthopaedics - Trauma Royal Infirmary of Edinburgh, Edinburgh, Midlothian, UK
| | - Zhan Herr Ng
- Edinburgh Orthopaedics - Trauma Royal Infirmary of Edinburgh, Edinburgh, Midlothian, UK
| | - Samuel G Molyneux
- Edinburgh Orthopaedics - Trauma Royal Infirmary of Edinburgh, Edinburgh, Midlothian, UK
| | - Timothy O White
- Edinburgh Orthopaedics - Trauma Royal Infirmary of Edinburgh, Edinburgh, Midlothian, UK
| | - Nicholas D Clement
- Edinburgh Orthopaedics - Trauma Royal Infirmary of Edinburgh, Edinburgh, Midlothian, UK
| | - Andrew D Duckworth
- Edinburgh Orthopaedics - Trauma Royal Infirmary of Edinburgh, Edinburgh, Midlothian, UK; Centre for Population and Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, Midlothian, UK
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