Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Anatomic evaluation of the subcoracoid pectoralis major transfer in human cadavers

Subcoracoid transfer of the pectoralis major has recently been described as a reconstruction for subscapularis insufficiency. The purpose of this study was to examine the surgically relevant anatomy of this transfer. The importance of understanding this anatomy was recently highlighted to us following our encounter with musculocutaneous neuropraxia in 2 patients after transfer of the entire pectoralis major, one deep to the musculocutaneous nerve. Dissections were performed on 20 fresh, whole human cadavers in which the entire pectoralis major muscle, medial and lateral pectoral nerves, and musculocutaneous nerve were explored and quantified. The relationship between the pectoralis major and the conjoined tendon was studied in situ and after simulated transfers. The medial and lateral pectoral nerves were located far medial to the pectoralis major tendon insertion and appeared to be safe from injury as long as surgical dissection remained lateral to the pectoris minor and less than 8.5 cm from the humeral insertion. Transfer of the pectoralis major superficial to the musculocutaneous nerve created less tension than transfer deep to the musculocutaneous nerve. Because proximal innervation of the coracobrachialis and short head of the biceps is not an uncommon occurrence, a split pectoralis major transfer, release of the proximal musculocutaneous branches, or debulking of the pectoralis major muscle belly may be required in some instances to prevent tension on the nerve. Because of the variability and location of the musculocutaneous nerve, it should always be visualized operatively. Transfer of the pectoralis major tendon lateral to the biceps tendon appeared to best restore the muscle length-tension relationship.

Dopamine-related tetrahydroisoquinolines: significant urinary excretion by alcoholics after alcohol consumption

Concentrations of dopamine-related tetrahydroisoquinolines (salsolinol and O-methylated salsolinol) were significantly higher in the daily urine samples of alcoholic subjects admitted for alcohol detoxification than in the daily urine samples of nonalcoholic control subjects. Salsolinol concentrations in alcoholic subjects appeared to drop to trace (control) values 2 to 3 days after admission, following the disappearance of ethanol and its reactive metabolite acetaldehyde from the blood. These results indicate that physiologically active tetrahydroisoquinolines increase in humans during long-term alcohol consumption, presumably because of acetaldehyde's direct condensation with catecholamines. The presence of these or similar condensation products in the urine could be useful as clinical indicators of prior blood acetaldehyde concentrations in chronic alcoholics.

Lack of evidence for sustained blood acetaldehyde concentrations during alcohol detoxification

Contrary to a published report, blood acetaldehyde concentrations become undetectable in patients 1--2 days following admission for alcohol detoxification. The persistently elevated blood acetaldehydes reported by others probably were due to artifactual formation during analysis. Nevertheless, our admission blood acetaldehyde concentrations are significant enough to support the contention that acetaldehyde has a cytotoxic role in alcoholic disease.

A total community approach to the treatment of alcoholism

A review of psychopathology and withdrawal in alcoholics is presented. The use of disulfiram, milieu and half-way houses in the treatment of alcoholic patients is described. The role of the Community Mental Health Center is outlined. An extensive description of Palm Beach County's approach to the treatment of alcoholism is then explained. This heterogeneous county offers facilities for all types of patients, from the lowest to highest socioeconomic backgrounds. Detoxification in the Palm Beach Community Mental Health Center is fully described. The half-way houses, Alcoholics Anonymous programs, and other outpatient and inpatient treatment facilities are depicted.