The Translated Proximal Humerus Fracture: A Comparison of Operative and Nonoperative Management

OBJECTIVES

To report on the long-term outcomes of the management of translated proximal humerus fractures.

DESIGN

A prospective cohort study was conducted from January 2010 to December 2018.

SETTING

Academic Level 1 trauma center.

PARTICIPANTS/PATIENTS

A total of 108 patients with a proximal humerus fracture with ≥100% translation, defined as no cortical bony contact between the shaft and humeral head fragments, were included.

INTERVENTION

Patients were managed nonoperatively with sling immobilization or with operative management as determined by the treating surgeon.

MAIN OUTCOME MEASURES

Outcome measures were the Oxford Shoulder Score, EQ-5D-5L, return to work, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, nonunion/malunion, and avascular necrosis.

RESULTS

Of the 108 patients, 76 underwent operative intervention and 32 were managed nonoperatively. The mean (SD) age in the operative group was 54.3 (±20.2) years and in the nonoperative group was 73.3 (±15.3) years ( P < 0.001). There was no association between Oxford Shoulder Score and management options (mean 38.5 [±9.5] operative versus mean 41.3 [±8.5] nonoperative, P = 0.48). Operative management was associated with improved health status outcomes; EQ-5D utility score adjusted mean difference was 0.16 (95% CI, 0.04-0.27; P = 0.008); EQ-5D VAS adjusted mean difference was 19.2 (95% CI, 5.2-33.2; P = 0.008). Operative management was associated with a lower odds of nonunion (adjusted OR 0.30; 95% CI, 0.09-0.97; P = 0.04), malunion (adjusted OR 0.14; 95% CI, 0.04-0.51; P = 0.003), and complications (adjusted OR 0.07; 95% CI, 0.02-0.32; P = 0.001).

CONCLUSION

Translated proximal humerus fractures with ≥100% displacement demonstrate improved health status and radiological outcomes after surgical fixation.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Primary arthrodesis versus open reduction internal fixation for complete Lisfranc fracture dislocations: a retrospective study comparing functional and radiological outcomes

BACKGROUND

The aims of this retrospective study were to compare the functional and radiological outcomes of primary arthrodesis and open reduction internal fixation (ORIF) for the treatment of complete Lisfranc fracture dislocations.

METHODS

A retrospective cohort study of 39 patients treated for a complete Lisfranc fracture dislocation, defined as Myerson types A and C2, over a period of 8 years at a level 1 trauma centre was performed. Of these, 18 underwent primary arthrodesis, and 21 ORIF. The primary outcome measures included the American Orthopaedic Foot and Ankle Society score, the validated Manchester Oxford Foot Questionnaire functional tool, and the secondary outcome was the radiological Wilppula classification of anatomical reduction.

RESULTS

Significantly better functional outcomes were seen in the primary arthrodesis group. These patients had a mean Manchester Oxford Foot Questionnaire score of 30.1 points, compared with 45.1 for the ORIF group (P = 0.017). Similarly, the mean American Orthopaedic Foot and Ankle Society score was 71.8 points in the fusion group versus 62.5 in the ORIF group (P = 0.14). Functional outcome was dependent on the quality of final reduction (P < 0.001). Primary arthrodesis achieved good initial reduction in 83% cases compared to 62% with ORIF (P = 0.138). There was a loss of reduction quality of 47% in the ORIF group over time.

CONCLUSION

Primary arthrodesis for complete Lisfranc fracture dislocations resulted in improved functional outcomes and quality of reduction compared to open reduction and internal fixation.

Keeping your cool - a simple reusable neck cooler in orthopaedic surgery: a pilot randomized controlled trial

BACKGROUND

Infection in orthopaedic surgery can be catastrophic. Increased perspiration from theatre staff has been associated with higher rates of wound contamination. Wearing lead safety gowns, which is often done during surgery to allow the use of image intensifier, may result in heavy perspiration. This study aimed to determine the feasibility of wearing a neck cooling device during surgery and whether it reduced surgeons' subjective discomfort and perspiration levels during orthopaedic procedures requiring the use of lead gowns.

METHODS

A pilot randomized controlled trial was conducted. Surgeons were randomized to either wearing the neck cooling device (intervention) or not wearing the device (control). Procedure duration, theatre temperature, humidity and perceived technical difficulty of operation were recorded. After the procedure, surgeons completed a questionnaire documenting how the temperature and humidity had a negative effect on their comfort and perceived level of perspiration. Multilevel mixed effects linear regression with random effects, adjusting for potential confounders was performed. Alfred Ethics Committee approved the study and the trial was registered (ACTRN12618000976280).

RESULTS

A total of 29 cases (44.6%) were randomized to the intervention group and 36 to the control group. Adjusting for operating room temperature and perceived difficulty of surgery, the neck cooler reduced surgeons' level of discomfort by 1.9 points (95% CI 1.1-2.8, P < 0.001), as well improved on their self-reported perspiration by approximately 1.9 points (95% CI 1.0-2.8, P = 0.04).

CONCLUSIONS

Wearing a neck cooling device during surgery is feasible, reduces perceived levels of perspiration and decreases the negative impact of temperature and humidity on surgeons' comfort levels.

Reverse shoulder arthroplasty vs BIO-RSA: clinical and radiographic outcomes at short term follow-up

Background

Bony increased-offset reverse shoulder arthroplasty (BIO-RSA) may address issues such as inferior scapular notching, prosthetic instability and limited postoperative shoulder rotation; all of which have been reported with the standard RSA and attributed to the medialized design. We hypothesised that this lateralization may increase the rate of scapular stress fractures.

Methods

A retrospective review of prospectively collected data was performed on patients who had undergone a RSA between January 2013 and October 2016. A comparative cohort study was designed to compare patients with a standard Grammont-style RSA to those with a BIO-RSA using the same implant. Functional outcome was measured by the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, the Subjective Shoulder Value (SSV), the Western Ontario Osteoarthritis of the Shoulder (WOOS) index and pain scores. Radiographs were obtained for all patients and examined for the presence of scapular fracture as well as scapular notching and graft incorporation.

Results

A total of forty patients (22 patients in the standard RSA cohort and 18 with BIO-RSA) were included in the study. Patient characteristics (including age, gender, length of follow-up, dominant side and osteoporosis) were similar in both groups (p > 0.05). The average postoperative follow-up was 20 months (range 12–48 months). There was bone graft incorporation in all BIO-RSA patients at the final radiological follow-up, with no evidence of graft resorption. The overall scapular stress fracture rate was 12.5% (9.1% in the standard RSA and 16.7% in the BIO-RSA). The rates were similar in both cohorts (p = 0.64). All fractures were managed conservatively. To determine whether the presence of a scapular stress fracture had an influence on outcomes, the cohort was divided into cases with and without fracture. Patients with a stress fracture had worse ASES (p = 0.028) and WOOS (p = 0.048) scores. Additionally, osteoporosis was present more commonly in the fracture group (80% vs 17%; p = 0.01). A statistically significant difference was identified when comparing the rates of scapular notching between standard RSA and BIO-RSA cohorts (68% vs 33%; p = 0.028). Furthermore, when notching was present, significantly worse outcome scores were present in all outcome measures (p < 0.001).

Conclusion

The BIO-RSA technique was associated with an increase in scapular stress fracture rate when compared to the standard RSA; however, this was not found to be significant. Furthermore, both techniques resulted in similar improvements in the measured functional outcomes. BIO-RSA, however, was associated with a lower scapular notching rate, justifying further evaluation of this technique.

Level of evidence

Retrospective cohort study, level III

Relationship between facet joint distraction during anterior cervical discectomy and fusion for trauma and functional outcome

Aims

The purpose of this retrospective study was to investigate the clinical relevance of increased facet joint distraction as a result of anterior cervical decompression and fusion (ACDF) for trauma.

Patients and Methods

A total of 155 patients (130 men, 25 women. Mean age 42.7 years; 16 to 87) who had undergone ACDF between 1 January 2001 and 1 January 2016 were included in the study. Outcome measures included the Neck Disability Index (NDI) and visual analogue scale (VAS) for pain. Lateral cervical spine radiographs taken in the immediate postoperative period were reviewed to compare the interfacet distance of the operated segment with those of the facet joints above and below.

Results

There was a statistically significant relationship between greater facet distraction and increased NDI and VAS pain scores. This was further confirmed by Spearman correlation, which showed evidence of a moderate correlation between both NDI score and facet joint distraction (Spearman correlation coefficient 0.34; p < 0.001) and VAS score and facet distraction (Spearman correlation coefficient 0.52; p < 0.001). Furthermore, there was a discernible transition point between outcome scores. Significantly worse outcomes, in terms of both NDI scores (17.8 vs 8.2; p < 0.001) and VAS scores (4.5 vs 1.3; p < 0.001), were seen with facet distraction of 3 mm or more. Patients who went on to have a posterior fusion also had increased NDI and VAS scores, independent of facet distraction.

Conclusion

After undergoing ACDF for the treatment of cervical spine injury, patients with facet joint distraction of 3 mm or more have worse NDI and VAS pain scores. Cite this article: Bone Joint J 2018;100-B:1201–7.

Dorsal bridge plating or transarticular screws for Lisfranc fracture dislocations: a retrospective study comparing functional and radiological outcomes

Aims

The aim of this retrospective study was to compare the functional and radiological outcomes of bridge plating, screw fixation, and a combination of both methods for the treatment of Lisfranc fracture dislocations.

Patients and Methods

A total of 108 patients were treated for a Lisfranc fracture dislocation over a period of nine years. Of these, 38 underwent transarticular screw fixation, 45 dorsal bridge plating, and 25 a combination technique. Injuries were assessed preoperatively according to the Myerson classification system. The outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) score, the validated Manchester Oxford Foot Questionnaire (MOXFQ) functional tool, and the radiological Wilppula classification of anatomical reduction.

Results

Significantly better functional outcomes were seen in the bridge plate group. These patients had a mean AOFAS score of 82.5 points, compared with 71.0 for the screw group and 63.3 for the combination group (p < 0.001). Similarly, the mean Manchester Oxford Foot Questionnaire score was 25.6 points in the bridge plate group, 38.1 in the screw group, and 45.5 in the combination group (p < 0.001). Functional outcome was dependent on the quality of reduction (p < 0.001). A trend was noted which indicated that plate fixation is associated with a better anatomical reduction (p = 0.06). Myerson types A and C2 significantly predicted a poorer functional outcome, suggesting that total incongruity in either a homolateral or divergent pattern leads to worse outcomes. The greater the number of columns fixed the worse the outcome (p < 0.001).

Conclusion

Patients treated with dorsal bridge plating have better functional and radiological outcomes than those treated with transarticular screws or a combination technique. Cite this article: Bone Joint J 2018;100-B:468-74.