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Jägerhuber L, Siebenbürger G, Fleischhacker E, Gibert F, Böcker W, Helfen T. Patient satisfaction after removal of locking plates in proximal humeral fractures - worth the surgery under functional and cosmetic aspects? JSES Int 2024; 8:921-925. [PMID: 39280154 PMCID: PMC11401535 DOI: 10.1016/j.jseint.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2024] Open
Abstract
Background Locking plates are one of the most frequently used implants in surgical treatment of displaced proximal humeral fractures. In spite of this established implant and a standardized approach, reduced shoulder function might remain a mid-to long-term issue, furthermore scars may influence patient satisfaction as a cosmetic issue. Indications for a second surgery to remove implant and/or scar revision are common questions in this context.The aim of the present study was to assess the benefit of a second surgery, including implant removal and scar revision surgery, on patients' satisfaction under functional and cosmetic aspects. Methods Patients following displaced proximal humeral fractures treated by open reduction and internal fixation with a locking plate osteosynthesis via a delto-pectoral approach following implant removal were included retrospectively. A follow-up took place anamnestically before the incident or the primary surgery [A], before second surgery [B], and after second surgery (scar revision/implant removal) [C]. Functional outcome (Constant Score (CS)) of both shoulders was obtained using a patient-reported outcome measure to evaluate the contralateral side as well as percentage CS (%CS). Furthermore, the cosmetic outcome was evaluated for color, contour, and size. Results The clinical data of n = 81 patients with displaced proximal humeral fractures and the consecutive open reduction and internal fixation with a locking plate (51 women = 63.0% and 30 men = 37.0%; mean age: 53.7 ± 16.6 years) via a standardized deltopectoral approach could be included. The mean CS) before sustaining the humeral fracture or primary surgery [A] was anamnestically 85.8 ± 8.5 points and %CS 99.4 ± 8.4%. After open reduction and internal with a locking plate osteosynthesis [B], the mean CS was 72.2 ± 9.1 points and %CS 84.5 ± 8.7%. Following the scheduled implant removal and scar revision [C], the CS was 80 ± 13.1 points and %CS 92.3 ± 14.1%. After primary surgery, 26 patients (32.1%) complained about the scar because of color, contour, or size before the second surgery, and 23 patients (28.4%) afterwards. Conclusion Implant removal after locking plate osteosynthesis in proximal humeral fractures via a delto-pectoral approach leads to an improved outcome both functionally and cosmetically. CS as well as scar situation and patients' overall satisfaction could be improved with a second surgery. Nevertheless, the need for a second surgery depends on the patients' functional and cosmetic demands.
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Affiliation(s)
- Ludwig Jägerhuber
- Department of Orthopaedics and Trauma Surgery, LMU University Hospital, LMU Munich, Germany
| | - Georg Siebenbürger
- Department of Orthopaedics and Trauma Surgery, LMU University Hospital, LMU Munich, Germany
| | - Evi Fleischhacker
- Department of Orthopaedics and Trauma Surgery, LMU University Hospital, LMU Munich, Germany
| | - Fabian Gibert
- Department of Orthopaedics and Trauma Surgery, LMU University Hospital, LMU Munich, Germany
| | - Wolfgang Böcker
- Department of Orthopaedics and Trauma Surgery, LMU University Hospital, LMU Munich, Germany
| | - Tobias Helfen
- Department of Orthopaedics and Trauma Surgery, LMU University Hospital, LMU Munich, Germany
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Tille E, Lorenz F, Beyer F, Schlüßler A, Biewener A, Nowotny J. Early functional improvements using continuous passive motion therapy after angular-stable plate osteosynthesis of proximal humerus fractures - results of a prospective, randomized trial. J Orthop Surg Res 2024; 19:313. [PMID: 38802866 PMCID: PMC11131183 DOI: 10.1186/s13018-024-04804-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The use of continuous passive motion therapy (CPM) has led to promising results in the early phase of rehabilitation after surgical treatment of rotator cuff tears and arthrolysis of the elbow. However, its use has not been proven in other pathologies of the upper extremity. Therefore, the aim of the underlying study was to evaluate the use of CPM therapy after plate osteosynthesis of proximal humeral fractures. METHODS 95 patients with isolated proximal humerus fractures were enrolled in a prospective, randomized study. Patients were assigned to a treatment group with (n = 48, CPM) or without CPM therapy (n = 47, CG). Four patients (2 of each cohort) violated the study protocol and were excluded. CPM therapy was used for 6 weeks after surgery 2-3 times daily. Functional (range of motion) and patient reported outcomes (PROM, Constant Score [CSS], QuickDASH, subjective shoulder value [SSV], pain on visual analogue scale [VAS]) were evaluated at 6 weeks, 3 and 12months. 60 patients completed the 1-year follow-up. RESULTS The average patient age was 65.3 years (min: 27, max: 88, SD: ± 14.7). Seventy-two patients were female (79%). There was no difference regarding injury severity (2/3/4 part-fracture: 6/32/7 vs. 9/26/11, p = 0.867) and sex (p = 0.08). However, patients in the CPM group were significantly younger (CPM: 67 [min: 34, max: 82], CG: 74 [min: 27, max: 88], p = 0.032). After 6 weeks we observed a better range of motion for forward flexion (CPM: 90° [min: 50°, max: 180°] vs. CG: 80° [min: 20°, max: 170°] p = 0.035) and abduction (CPM: 80° [min: 40°, max: 180°] vs. CG: 70° [min: 20°, max: 180°], p = 0.048) in the CPM group. There was no difference regarding the further planes of motion or the assessed PROMs at 6 weeks. At 3 and 12 months the results between the treatment groups equalized with no further significant differences. CONCLUSION The treatment with CPM increases the range of motion after plate osteosynthesis of proximal humerus fractures in the first 6 weeks after surgery. This effect is not sustained after 3 and 12months. The evaluated PROMs are not being influenced by CPM therapy. Hence the results of this prospective randomized study suggest that CPM can be a beneficial asset in the early period of rehabilitation after proximal humerus plate osteosynthesis. TRIAL REGISTRATION The study protocol was registered in the US National Institutes of Health's database ( http://www. CLINICALTRIALS gov ) registry under NCT05952622.
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Affiliation(s)
- Eric Tille
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany.
| | - Franz Lorenz
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
| | - Franziska Beyer
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
| | - Antonia Schlüßler
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
| | - Achim Biewener
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
| | - Jörg Nowotny
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
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Ong PW, Lim CJ, Pereira MJ, Kwek EB, Tan BY. Achieving satisfactory functional outcomes in conservatively treated proximal humerus fractures: relationship between shoulder range of motion and patient-reported clinical outcome scores. JSES Int 2024; 8:440-445. [PMID: 38707550 PMCID: PMC11064704 DOI: 10.1016/j.jseint.2024.02.003] [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] [Indexed: 05/07/2024] Open
Abstract
Background Proximal humerus fractures are common osteoporotic fractures. Postinjury outcome measures include objective clinician-measured range of motion (ROM) and subjective patient-reported outcome measures (PROMs), but the relationship between both has not been established. This study aimed to determine the relationship between shoulder ROM and PROMs and establish which ROMs correlated most with PROMs. Methods A prospective cohort study was conducted on patients with acute proximal humerus fractures. Surgical intervention, open or pathological fractures, neurovascular compromise, polytrauma, or delayed presentations were excluded. Correlation and regression analyses between active ROM and PROMs (Quick Disabilities of Arm, Shoulder and Hand [QuickDASH] and Oxford Shoulder Score [OSS]) at 1-year postinjury were explored. ROM cutoffs predicting satisfactory PROM scores were established. Results Fifty-five patients were recruited. Moderate correlations were observed between PROMs and flexion, extension, and abduction, but not internal and external rotation. Multivariate analysis showed significant relationships between PROMs and flexion [QuickDASH: adjusted coefficient (AC): -0.135, P = .013, OSS: AC: 0.072, P = .002], abduction [QuickDASH: AC: -0.115, P = .021, OSS: AC: 0.059, P = .005], and extension [QuickDASH: AC: -0.304, P = .020] adjusting for age, gender, Neer classification, injury on dominant side, and employment. Achieving 130° flexion, 59° extension, and 124° abduction were correlated with satisfactory OSS/QuickDASH scores, respectively. Conclusion Overall, holistic assessment of outcomes with both subjective and objective outcomes are necessary, as shoulder flexion, extension, and abduction are only moderately correlated with PROMs. Attaining 130° flexion, 59° extension, and 124° abduction corresponded with satisfactory functional outcomes measured by OSS/QuickDASH and can guide rehabilitation.
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Affiliation(s)
- Pei Wen Ong
- Department of Emergency Medicine, National Healthcare Group, Singapore, Singapore
| | - Chien Joo Lim
- Department of Orthopaedic Surgery, Woodlands Health Campus, Singapore, Singapore
| | - Michelle J. Pereira
- Health Services and Outcomes Research, National Healthcare Group, Singapore, Singapore
| | - Ernest B.K. Kwek
- Department of Orthopaedic Surgery, Woodlands Health Campus, Singapore, Singapore
| | - Bryan Yijia Tan
- Department of Orthopaedic Surgery, Woodlands Health Campus, Singapore, Singapore
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Luk MLM, Chan ACM, Cho JSY, Ng DMT, Lam ICY, Yau ELK, Miller T, Pang MYC. Predictors of chronic pain and disability in patients treated conservatively after distal radius fracture: a prospective cohort study. INTERNATIONAL ORTHOPAEDICS 2023; 47:1535-1543. [PMID: 36973426 DOI: 10.1007/s00264-023-05785-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/16/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE To determine predictors of chronic pain and disability among patients with distal radius fractures (DRF) treated conservatively with closed reduction and cast immobilization. METHODS This was a prospective cohort study. Information on patient characteristics, post-reduction radiographic parameters, finger and wrist range of motion, psychological status (Hospital Anxiety and Depression Scale or HADS), pain (Numeric Rating Scale or NRS), and self-perceived disability (Disabilities of the Arm, Should, and Hand or DASH) were taken at baseline, cast removal, and 24 weeks. Differences in outcomes between time points were determined using analysis of variance. Multiple linear regressions were used to determine predictors of pain and disability at 24 weeks. RESULTS One hundred forty patients with DRF (70% women, age: 67.0 ± 17.9) completed 24 weeks of follow-up and were included in the analysis. NRS (off-cast), range of ulnar deviation (off-cast), and greater occupational demands were significant predictors of pain at week 24 (adjusted R2 = 0.331, p < 0.001). Significant predictors of perceived disability at week 24 were HADS (off cast), sex (female), dominant-hand injury, and range of ulnar deviation (off cast) (adjusted R2 = 0.265, p < 0.001). CONCLUSIONS Off-cast NRS and HADS scores are important modifiable predictors of patient-reported pain and disability at 24 weeks in patients with DRF. These factors should be targeted in the prevention of chronic pain and disability post-DRF.
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Fidanza A, Rossi C, Iarussi S, Necozione S, Indelli PF, Calvisi V. Proximal humeral fractures treated with a low-profile plate with enhanced fixation properties. J Orthop Sci 2022; 27:1298-1303. [PMID: 34625328 DOI: 10.1016/j.jos.2021.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/30/2021] [Accepted: 08/02/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Our purpose was to evaluate the clinical and radiographic outcomes of proximal humeral fractures treated with a new generation plating system and compare results with a meta-analysis of recent literature. METHODS Between 2014 and 2017, 93 patients (18 males, 75 females) with proximal humerus fractures were treated with open reduction and internal fixation (ORIF) using a Pantera® Plate. These low-profile plates are anatomically shaped and include "cross-elements" that form a three-dimensional scaffold in bone to enhance fixation stability. According to Neer classification, there were 24 two-part fractures, 49 three-part fractures and 20 four-part fractures (4 with dislocated heads). X-rays and Constant Shoulder Scores (CSS) were used to evaluate healing, complications, and clinical outcomes. Results were compared with a meta-analysis of similar studies reported in literature over the last 10 years. RESULTS Eighty-three patients with a minimum follow-up of 2 years had a mean CSS of 72 (53-90) graded as excellent for 23 patients (28%), good for 35 (42%), fair for 14 (17%), and poor for 11 (13%). Fractures healed without complication in 75 (91%) patients. Eight (9%) complications were observed, i.e., three avascular necrosis of the humeral head, one case of implant loosening, two cases of subacromial impingement and two superficial infections. There was no significant correlation between Neer fracture stage and patient outcome (p = 0.257). Compared to the literature, this method had a lower complication grade (p = 0.03), though it did not significantly differ in its clinical outcomes (p = 0.08). CONCLUSIONS The investigated plating system includes design features that can potentially increase utility for ORIF of proximal humeral fractures. While the complication profile was signficantly less than reported in the literature for standard proximal humerus plates, clinical outcomes were similar. Further studies will be required to better understand the role of plate design on treatment of these challenging fractures. LEVEL OF EVIDENCE IV, therapeutic study.
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Affiliation(s)
- Andrea Fidanza
- Department of Life Health & Environmental Sciences, University of L'Aquila, Unit of Orthopaedics and Traumatology, Piazzale S.Tommasi, 67100, L'Aquila, Italy.
| | - Costantino Rossi
- S.S. Filippo e Nicola Hospital, Unit of Orthopaedics and Traumatology, Via Di Vittorio, 67051, Avezzano, Italy
| | - Sergio Iarussi
- S.S. Filippo e Nicola Hospital, Unit of Orthopaedics and Traumatology, Via Di Vittorio, 67051, Avezzano, Italy
| | - Stefano Necozione
- Department of Life Health & Environmental Sciences, University of L'Aquila, Unit of Clinical Epidemiology, Piazzale S.Tommasi, 67100, L'Aquila, Italy
| | - Pier Francesco Indelli
- Department of Orthopaedic Surgery, Stanford University, PAVAHCS - Surgical Services, Palo Alto, CA, 94304, USA
| | - Vittorio Calvisi
- Department of Life Health & Environmental Sciences, University of L'Aquila, Unit of Orthopaedics and Traumatology, Piazzale S.Tommasi, 67100, L'Aquila, Italy
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Fleischhacker E, Sprecher CM, Milz S, Saller MM, Gleich J, Siebenbürger G, Helfen T, Böcker W, Ockert B. Functional outcomes before and after implant removal in patients with posttraumatic shoulder stiffness and healed proximal humerus fractures: does implant material (PEEK vs. titanium) have an impact? - a pilot study. BMC Musculoskelet Disord 2022; 23:95. [PMID: 35086539 PMCID: PMC8796509 DOI: 10.1186/s12891-022-05061-x] [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: 07/22/2021] [Accepted: 01/24/2022] [Indexed: 11/25/2022] Open
Abstract
Background Posttraumatic shoulder stiffness remains a problem after proximal humerus fracture (PHF) despite good healing rates. The aim of this pilot study was to determine whether the implant material and overlying soft tissue have an effect on shoulder range of motion (ROM) before and after implant removal (IR). Methods 16 patients (mean age 55.2 ± 15.3 (SD) years; 62.5% female) were included who underwent operative treatment with locking plates of either carbon fiber reinforced Polyetheretherketone (PEEK) (PEEKPower® humeral fracture plate, Arthrex, Naples, Florida, USA, n = 8) or titanium alloy (Ti) (Philos®, DePuy Synthes, Johnson & Johnson Medical, Raynham, Massachusetts, USA, n = 8) for PHF. All patients presented with a limited ROM and persistent pain in everyday life after the fracture had healed, whereupon IR was indicated. ROM before and after IR were compared as well as the Constant Score (CS) and the CS compared to the contralateral shoulder (%CS) 1 year after IR. Results In group PEEK, elevation was 116.3° ± 19.2° pre- and 129.4° ± 23.7° post-IR (p = 0.027). External rotation was 35.0° ± 7.6° pre- and 50.6° ± 21.8° post-IR (p = 0.041). External rotation with the humerus abducted 90° was 38.8° ± 18.1° pre- and 52.5° ± 25.5° post-IR (p = 0.024). In group Ti, elevation was 110.0° ± 34.6° pre- and 133.8° ± 31.1° post-IR (p = 0.011). External rotation with the humerus at rest was 33.8° ± 23.1° pre- and 48.8° ± 18.7° post-IR (p = 0.048). External rotation with the humerus abducted 90° was 40.0° ± 31.6° pre- and 52.5° ± 22.5° post-IR (p = 0.011). Comparison of the two implant materials showed no significant difference. The overall CS was 90.3 ± 8.8, the %CS was 91.8% ± 14.7%. Conclusion There was no significant difference in ROM, CS and %CS with respect to plate materials, although lower cell adhesion is reported for the hydrophobic PEEK. However, all patients showed improved functional outcomes after IR in this pilot study. In patients with shoulder stiffness following locked plating for PHF, implants should be removed and open arthrolysis should be performed, independently from the hardware material. Level of evidence II Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05061-x.
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Affiliation(s)
- E Fleischhacker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | | | - S Milz
- Anatomische Anstalt der Ludwig-Maximilians-Universität, Munich, Germany
| | - M M Saller
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - J Gleich
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - G Siebenbürger
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - T Helfen
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - W Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - B Ockert
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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Rasulić L, Djurašković S, Lakićević N, Lepić M, Savić A, Grujić J, Mićić A, Radojević S, Puzović V, Maletić M, Mandić-Rajčević S. Surgical Treatment of Radial Nerve Injuries Associated With Humeral Shaft Fracture-A Single Center Experience. Front Surg 2022; 8:774411. [PMID: 34977143 PMCID: PMC8716365 DOI: 10.3389/fsurg.2021.774411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/22/2021] [Indexed: 12/05/2022] Open
Abstract
Radial nerve injuries are often associated with humeral shaft fractures. The results of treatment of these injuries, by contemporary surgical approaches, remain diverse. In this paper we presented the outcomes and analyzed the patient, clinical, and surgical procedure related characteristics and factors that may influence the outcome overall, in 77 patients treated at Clinic for Neurosurgery, Clinical Center of Serbia during a 20 years period. The nerve injuries were verified by US and EMNG. The majority of patients were treated by neurolysis or sural nerve grafting, while only few were treated by direct suture. The final recovery was evaluated by muscle strength assessment and classified using MRC. We analyzed extension of the wrist, extension of the fingers including the thumb, and abduction of the thumb. There was a significant statistical difference in MRC grade following the treatment. The total rate of useful functional recovery was achieved in 69 (89.61%) out of all studied patients, out of whom 20 (28.99%) achieved excellent recovery, 26 (37.68%) achieved good recovery and 23 (33.33%) achieved fair recovery. Only 8 (10.39%) out of all studied patients achieved poor recovery. The injured nerves, that were preserved in continuity, acquired by a low-energy trauma, and treated earlier than the 6 months were associated with better functional outcome following the surgery. In addition, there was a trend of better functional improvement with aging, keeping in mind that the old were subjected to lower energy trauma. The expectant management followed by surgery of radial nerve injury associated with humeral shaft fracture should be around 3 months, and the surgical nerve repair should not be performed later than the 6 months after injury. The energy of trauma may be a factor predicting patient's final recovery following the treatment.
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Affiliation(s)
- Lukas Rasulić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Slavko Djurašković
- Clinic for Neurosurgery, Clinical Center of Montenegro, Podgorica, Montenegro
| | - Novak Lakićević
- Clinic for Neurosurgery, Clinical Center of Montenegro, Podgorica, Montenegro
| | - Milan Lepić
- Clinic for Neurosurgery, Military Medical Academy, Belgrade, Serbia
| | - Andrija Savić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Jovan Grujić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Aleksa Mićić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Vladimir Puzović
- College of Higher Vocational Studies "Sports Academy", Belgrade, Serbia
| | - Miloš Maletić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Stefan Mandić-Rajčević
- School of Public Health and Health Management and Institute of Social Medicine, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Privalov M, Euler F, Keil H, Swartman B, Beisemann N, Franke J, Grützner PA, Vetter SY. Influence of reduction quality on functional outcome and quality of life in treatment of tibial plafond fractures: a retrospective cohort study. BMC Musculoskelet Disord 2019; 20:534. [PMID: 31722696 PMCID: PMC6854804 DOI: 10.1186/s12891-019-2932-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/01/2019] [Indexed: 11/21/2022] Open
Abstract
Background The aim of the study was to evaluate the impact of reduction quality, using intraoperative 3D imaging, on quality of life and functional outcome in the operative treatment of tibial plafond fractures. Methods A group of patients with tibial plafond fractures was re-examined. The operative treatment was performed between September 2001 and October 2011. The follow-up examination was at least 2 years after the final surgical procedure. Final reduction result was assessed intraoperatively using a mobile 3D C-arm. A categorization with regard to descriptive parameters as well as type and size of joint surface irregularities was performed. Follow-up results were evaluated using: Olerud and Molander (O & M) score, Short-Form-36 (SF-36) score, movement deficit, Kellgren and Lawrence grade of osteoarthritis, and pain intensity. Results 34 patients with operatively treated tibial plafond fracture could be re-examined. Reduction quality had the greatest influence on functional result measured by the O & M score (p = 0.001) and the PCS domain of the SF-36 score (p = 0.018). Significant differences with regard to O & M score (p = 0.000), SF-36 score (p = 0.001 to p = 0.02; without MCS domain), movement deficit (p = 0.001), grade of osteoarthritis (p = 0.005) and pain (p = 0.001) could be verified under consideration of the reduction quality. The group with the anatomically more accurate reduction also showed a better result for clinical follow-up and quality of life. Furthermore, it is not the type of joint surface irregularity that is always decisive, but rather the size. Conclusions Despite other relevant factors, it appears that reduction quality –which can be analyzed with intraoperative 3D imaging– plays the most important role in postoperative quality of life and functional outcome. Corrections should therefore be performed on joint surface irregularities with a size above 2 mm.
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Affiliation(s)
- Maxim Privalov
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Finn Euler
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Holger Keil
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Benedict Swartman
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Nils Beisemann
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Jochen Franke
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Paul Alfred Grützner
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Sven Y Vetter
- MINTOS - Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.
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Abstract
STUDY DESIGN Clinical commentary. INTRODUCTION Proximal humeral fractures (PHF) are the third most common fracture in the elderly with an increased incidence expected in the coming years with the aging population, causing an important burden to the healthcare system. The management of PHF is challenging due to its complexity and the wide variety of fractures and treatment options. PURPOSE The objective of this clinical commentary is to update the available evidence on clinical presentation, classification, imaging, medical treatment, and rehabilitation of acute PHF. METHODS/RESULTS/DISCUSSION N/A for clinical commentary. CONCLUSIONS The first step to a successful management of PHF is the clinical and radiographic examination of the shoulder, which enables the physician to classify the fracture and choose the appropriate treatment option. The Neer and OA classifications are commonly used and are based on the identification of the fractured parts of the humerus, as well as the displacement of the fragments. In case of non-displaced or minimally displaced fractures, a conservative treatment, consisting of initial immobilization and a rehabilitation program will be chosen. Displaced or unstable fractures will be managed operatively. Different surgical options exist and will vary according to the fracture type, patient's age, and functional needs, followed by rehabilitation. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- Véronique Lowry
- Department of Research, Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, Quebec, Canada
| | - Nathalie J Bureau
- Radiology Department, University of Montreal, Montreal, Quebec, Canada; Department of Research, Research Center, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - François Desmeules
- Department of Research, Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, Quebec, Canada; Department of Rehabilitation, School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Jean-Sébastien Roy
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada; Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec, Canada
| | - Dominique M Rouleau
- Department of Surgery, Hôpital du Sacré-Cœur de Montréal, Montréal PQ, Canada; Department of Surgery, Université de Montréal, Montréal PQ, Canada.
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Spross C, Grueninger P, Gohil S, Dietrich M. Open Reduction and Internal Fixation of Fractures of the Proximal Part of the Humerus. JBJS Essent Surg Tech 2015; 5:e15. [PMID: 30473923 PMCID: PMC6221419 DOI: 10.2106/jbjs.st.n.00106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction We describe the surgical technique for open reduction and internal fixation (ORIF) of proximal humeral fractures with a locking plate. Step 1 Preoperative Planning To choose the right candidate, obtain a full understanding of the patient's fracture pattern, activity level and demands, and bone quality; be aware of predictors of complications and poor outcomes. Step 2 Patient Positioning Place the patient in the beach-chair position with the arm draped free or in a hydraulic device with good access for the image intensifier. Step 3 Approach The deltopectoral approach is generally preferred because of the exposure obtained, the possibility of distal extension, and the minimal risk of nerve injury. Step 4 Reduction and Fixation of the Tuberosities the Key to Obtaining Marionette-Like Control The control, reduction, and fixation of the tuberosities are crucial to restore the anterior-posterior force couple of the shoulder and must therefore be done properly no matter what the fracture pattern looks like. Step 5 Fracture Reduction After carrying out Steps 1 through 4, perform the reduction techniques for the specific fracture type as described below for types that we think suitable for ORIF with a locking plate. Step 6 Fixation Implant-Specific Considerations Plate length and positioning, humeral head screw placement, distal locking, confirming the screw tip position with the image intensifier, and securing the tuberosities. Step 7 Tenotomy or Tenodesis of the Long Biceps Tendon Perform a biceps tenotomy if the biceps is displaced out of the groove by the fracture pattern or if you have to open the rotator interval. Step 8 Wound Closure Do not close the deltopectoral interval. Step 9 Rehabilitation As the failure rate of ORIF of proximal humeral fractures is high, do not force an active rehabilitation protocol. Results In our analysis of 269 fractures followed for twelve months, we found that the Constant-Murley score (CMS) and Short Form-36 (SF-36) score improved continuously during the first six months postoperatively.IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- C Spross
- Department of Orthopaedic Trauma, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch (Western Australia) 6150, Australia. E-mail address:
| | - P Grueninger
- Department of Traumatology and Orthopaedics, Stadtspital Waid, Tieche Strasse 99, 8037 Zurich, Switzerland. E-mail address for M. Dietrich:
| | - S Gohil
- Department of Orthopaedic Trauma, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch (Western Australia) 6150, Australia. E-mail address:
| | - M Dietrich
- Department of Traumatology and Orthopaedics, Stadtspital Waid, Tieche Strasse 99, 8037 Zurich, Switzerland. E-mail address for M. Dietrich:
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