Minimally invasive plate osteosynthesis (MIPO) for scapular fractures

OBJECTIVE

Presentation of a minimally invasive surgical approach for the treatment of scapular fractures and the clinical outcome using this technique.

INDICATIONS

Displaced extra-articular fractures of the scapula body and glenoid neck (AO 14B and 14F) and simple intra-articular fractures of the glenoid.

CONTRAINDICATIONS

Complex intra-articular fractures and isolated fractures of the coracoid base.

SURGICAL TECHNIQUE

Make a straight or slightly curved incision along the lateral margin of the scapula leaving the deltoid fascia intact. Identify the interval between the teres minor muscle and infraspinatus to visualize the lateral column, whilst retracting the deltoid to visualize the glenoid neck. Reduce and align the fracture using direct and indirect reduction tools. A second window on the medial border of the scapula can be made to aid reduction and/or to augment stability. Small (2.0-2.7 mm) plates in a 90° configuration on the lateral border and, if required, on the medial border are used. Intra-operative imaging confirms adequate reduction and extra-articular screw placement.

POSTOPERATIVE MANAGEMENT

Direct postoperative free functional nonweight-bearing rehabilitation limited to 90° abduction for the first 6 weeks. Sling for comfort. Free range of motion and permissive weight-bearing after 6 weeks.

RESULTS

We collected data from 35 patients treated with minimally invasive plate osteosynthesis (MIPO) between 2011 and 2021. Average age was 53 ± 15.1 years (range 21-71 years); 17 had a type B and 18 a type F fracture according the AO classification. All patients suffered concomitant injuries of which thoracic (n = 33) and upper extremity (n = 25) injuries were most common. Double plating of the lateral border (n = 30) was most commonly performed as described in the surgical technique section. One patient underwent an additional osteosynthesis 3 months after initial surgery due to pain and lack of radiological signs of healing of a fracture extension into the spine of the scapula. In the same patient, the plate on the spine of scapula was later removed due to plate irritation. In 2 patients postoperative images showed a screw protruding into the glenohumeral joint requiring revision surgery. After standardisation of intra-operative imaging following these two cases, intra-articular screw placement did not occur anymore. No patient suffered from iatrogenic nerve injury and none developed a wound infection.

Concepts, utilization, and perspectives on the Dutch Nationwide Trauma registry: a position paper

Over the last decades, the Dutch trauma care have seen major improvements. To assess the performance of the Dutch trauma system, in 2007, the Dutch Nationwide Trauma Registry (DNTR) was established, which developed into rich source of information for quality assessment, quality improvement of the trauma system, and for research purposes. The DNTR is one of the most comprehensive trauma registries in the world as it includes 100% of all trauma patients admitted to the hospital through the emergency department. This inclusive trauma registry has shown its benefit over less inclusive systems; however, it comes with a high workload for high-quality data collection and thus more expenses. The comprehensive prospectively collected data in the DNTR allows multiple types of studies to be performed. Recent changes in legislation allow the DNTR to include the citizen service numbers, which enables new possibilities and eases patient follow-up. However, in order to maximally exploit the possibilities of the DNTR, further development is required, for example, regarding data quality improvement and routine incorporation of health-related quality of life questionnaires. This would improve the quality assessment and scientific output from the DNTR. Finally, the DNTR and all other (European) trauma registries should strive to ensure that the trauma registries are eligible for comparisons between countries and healthcare systems, with the goal to improve trauma patient care worldwide.

Long-term follow-up of patients with displaced scapular fractures managed surgically and non-operatively

INTRODUCTION

Controversy remains on which patients with displaced scapula fractures benefit from surgery. This retrospective cohort study aims to compare and describe long-term patient-reported outcomes of patients with displaced scapula fractures treated both surgically and conservatively.

METHODS

This study included patients with intra- and extra-articular scapula fractures, treated between 2010 and 2020 in a Swiss level 1 trauma centre. The decision to operate was based on standardized criteria for fracture displacement. Patients with isolated Bankart lesions (Ideberg 1) and process fractures (AO type 14-A) were excluded. Primary outcomes were functional patient reported measures (DASH score) and quality of life (EQ5D score). Secondary outcomes were complications, radiological union, satisfaction with treatment, pain and range of motion.

RESULTS

Out of 486 cases, 74 patients had displaced scapula fractures. Forty patients were treated surgically and 34 were treated conservatively. Significantly more patients with intra-articular fractures and high-energy trauma were treated surgically. Fifty percent returned the questionnaires after a mean follow-up of 47 months (± SD 36). The mean DASH score of this group was 12 (SD 15.6), with a mean of 14.7 (SD 15.9) in the surgery group and 9.8 (SD 14.6) in the non-operative group (p = 0.7). Multivariate analysis did not show statistically significant correlating factors. No significant differences in quality of life were observed. Patients rated their treatment with a mean of 8.6/10 (SD 1.8). Among surgically treated patients, 19 underwent a deltoid sparing procedure with significant shorter time to union than those that underwent deltoid release (23 vs. 49 weeks, p<0.01). Complications occurred in 3/28 surgically treated patients and all three required a reoperation.

CONCLUSION

In this cohort, functional results after conservative and surgical treatment were similar, despite more complex fractures and more intra-articular fractures being treated surgically. Osteosynthesis of both intra- and extra-articular scapula fractures is safe and leads to good functional results, furthermore, new minimal invasive techniques may lead to faster bone healing and return to work and sports.