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International Orthopaedics Jul 2024It is still controversial whether complete displaced mid-shaft clavicle fractures should be treated with internal fixation or conservative therapy. This retrospective... (Comparative Study)
Comparative Study
PURPOSE
It is still controversial whether complete displaced mid-shaft clavicle fractures should be treated with internal fixation or conservative therapy. This retrospective study aims to compare clinical outcomes of two treatment protocols.
MATERIALS AND METHODS
105 patients with displaced and comminuted mid-shaft clavicle fractures were included in this study, among which 55 patients were treated conservatively and 50 patients accepted surgical fixation and were followed up for over 20 months on average. Rate of union, malunion, time taken for union, functional outcome, self-reported satisfaction and complications were compared.
RESULTS
Union rate of operative group (n=49, 98.0%) was higher than the non-operative group (n=48, 87.3%). Time taken for union in operative group (2.37±1.06 months) was shorter than the non-operative group (3.69±1.01 months). Malunion and asymmetric were only seen in the conservative group. Numbness of the shoulder was only reported in the operative group (n=23, 46.0%). Most of patients in the operative group (n=45, 90%) accepted a second operation to remove the implant. No statistically difference was found in self-reported satisfaction, Quick-DASH and Constant-Murley score. The operative group returned to work faster (1.47±0.89 to 3.34±1.37 months), regained full range of motion earlier (1.66±0.78 to 3.83±1.24 months) and regained strength faster (3.86±2.45 to 8.03±2.78 months) than the non-operative group.
CONCLUSION
Complete displaced and comminuted mid-shaft clavicle fractures treated surgically have more reliable union and faster recovery when compared to conservatively treated fractures.
Topics: Humans; Clavicle; Male; Female; Adult; Retrospective Studies; Fractures, Comminuted; Middle Aged; Conservative Treatment; Treatment Outcome; Fracture Fixation, Internal; Young Adult; Fractures, Bone; Fracture Healing; Patient Satisfaction
PubMed: 38713287
DOI: 10.1007/s00264-024-06198-1 -
Cureus Apr 2024This comprehensive review delves into the intricate landscape of proximal humerus fractures (PHFs), exploring their epidemiology, historical evolution, contemporary... (Review)
Review
This comprehensive review delves into the intricate landscape of proximal humerus fractures (PHFs), exploring their epidemiology, historical evolution, contemporary classification systems, treatment strategies, and outcome measures. PHFs present a complex orthopedic challenge, necessitating a nuanced understanding of their multifaceted dimensions. Despite their clinical significance, PHFs remain relatively understudied in population-based epidemiology. This review critically examines existing literature to uncover the incidence, prevalence, and demographic patterns associated with these fractures. A foundational understanding of the epidemiological landscape is crucial for effective preventive strategies and optimized fracture management. Tracing back to historical records, the review explores the evolution of diagnostic and therapeutic approaches for PHFs. From ancient treatment modalities documented on the Edwin Smith papyrus to contemporary X-ray-based classifications such as Neer and AO/OTA, a historical context is provided to understand the journey of managing these fractures. Navigating through a spectrum of treatment strategies, the review contrasts nonoperative approaches with various surgical interventions. The challenges and outcomes associated with conservative management are juxtaposed against methods like open reduction internal fixation and tension band osteosynthesis. Evidence synthesis guides clinicians in making informed decisions based on patient characteristics and fracture complexities. Central to assessing PHF management are patient-reported outcome measures. The review explores the significance of instruments such as the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Constant-Murley score in evaluating treatment success. The shift toward subjective measures is discussed, considering their correlation with patient experiences and the concept of minimal clinically important difference. The impact of demographic factors, including age and gender, on PHFs is scrutinized. The association between these fractures and osteoporosis is highlighted, emphasizing the crucial role of bone health in fracture prevention and management. Through this comprehensive exploration, the review provides a robust foundation for understanding, evaluating, and advancing the management strategies for PHFs. The synthesis of historical perspectives, contemporary classifications, and treatment modalities serves as a valuable resource for the orthopedic community, fostering improved clinical decision-making and patient outcomes.
PubMed: 38711710
DOI: 10.7759/cureus.57691 -
Journal of Shoulder and Elbow Surgery May 2024The primary objective of this study was to compare the clinical outcomes of total elbow arthroplasty as the index procedure in the treatment of traumatic distal humerus...
Outcomes of total elbow arthroplasty in the treatment of distal humeral fractures in the elderly: A retrospective cohort comparison between primary arthroplasty and arthroplasty secondary to failed internal fixation.
BACKGROUND
The primary objective of this study was to compare the clinical outcomes of total elbow arthroplasty as the index procedure in the treatment of traumatic distal humerus fractures, with secondary total elbow arthroplasty following failed internal fixation. The secondary objectives were to compare the complication rates and the radiographic results in the two groups. Our hypothesis was that the clinical results of total elbow arthroplasty performed secondarily to failed internal fixation were comparable to primary total elbow arthroplasty in the treatment of distal humerus fractures in the elderly population.
METHODS
We conducted a retrospective cohort comparison study, including 60 patients with a median age of 80 years (71-85), who either underwent a primary total elbow arthroplasty (group 1; 45 patients), or secondary total elbow arthroplasty following failed internal fixation (group 2; 15 patients), in the treatment of a post-traumatic supra and intercondylar fracture of the distal humerus, between January 2004 and January 2021. The clinical examination, including MEPS score and triceps proficiency test, complication rates and the need for re-operation were noted. The average clinical and radiographic follow-up was 40.8 months (24-120).
RESULTS
The clinical results of the two groups were comparable when looking at the MEPS score (90.00 [85.00, 100.00] p= 0.486). With regards to complications, there were 2 surgical site infections in group 1 and 3 in group 2 (p=0.099), 1 case of mechanical loosening of the humeral component in group 1 and 1 in group 2 (p= 0.448), and 1 patient with triceps insufficiency in group 1.
CONCLUSION
Secondary total elbow arthroplasty following failed internal fixation has shown good functional results, and a complication rate comparable to that of index total elbow arthroplasty in the treatment of articular fractures of the distal humerus in the elderly.
PubMed: 38710364
DOI: 10.1016/j.jse.2024.03.032 -
JSES International May 2024There is substantial evidence that operative treatment reduces the risk of nonunion but offers no long-term functional gains compared with nonoperative treatment.... (Review)
Review
BACKGROUND
There is substantial evidence that operative treatment reduces the risk of nonunion but offers no long-term functional gains compared with nonoperative treatment. Despite some studies citing quicker recovery with surgery, the promise of accelerated functional recovery remains under-investigated. The aim of this meta-analysis of randomized controlled trials was to investigate the possible early functional gains (≤6 months) after operative treatment of displaced midshaft clavicular fractures compared with nonsurgical treatment.
METHODS
A systematic search was performed to identify randomized controlled trials comparing plate osteosynthesis with nonoperative treatment. We evaluated shoulder function outcomes measured by Constant Score or Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Other outcomes of interest were sick leave and return to previous activity (work, leisure).
RESULTS
Ten studies including 1333 patients were included. The mean difference in DASH score after 6 weeks was 9.4 points (95% confidence interval [CI] 13.7-5.1) in favor of operative treatment. At 3 months, the difference was 3.6 points (95% CI 6.9-0.4), and at 6 months, the difference was 3.2 points (95% CI 5.2-1.1), both in favor of operative treatment. Results for Constant Score were similar to that of DASH score.
CONCLUSION
This meta-analysis shows that there is an early functional gain at six weeks following plate fixation of midshaft clavicular fractures compared with nonoperative treatment. At three and six months, the functional gain is lesser and not clinically relevant.
PubMed: 38707583
DOI: 10.1016/j.jseint.2023.12.011 -
JSES International May 2024
Proximal humerus reconstruction in reverse total shoulder arthroplasty with proximal humeral bone loss using a lower trapezius tendon transfer with Achilles tendon-bone allograft: surgical technique and report of 2 cases.
PubMed: 38707582
DOI: 10.1016/j.jseint.2023.12.010 -
JSES International May 2024Proximal humerus fractures are common osteoporotic fractures. Postinjury outcome measures include objective clinician-measured range of motion (ROM) and subjective...
Achieving satisfactory functional outcomes in conservatively treated proximal humerus fractures: relationship between shoulder range of motion and patient-reported clinical outcome scores.
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, = .013, OSS: AC: 0.072, = .002], abduction [QuickDASH: AC: -0.115, = .021, OSS: AC: 0.059, = .005], and extension [QuickDASH: AC: -0.304, = .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.
PubMed: 38707550
DOI: 10.1016/j.jseint.2024.02.003 -
JSES International May 2024Avulsion of the greater tuberosity (GT) due to traumatic anterior shoulder dislocation (ASD) is a commonly observed fracture pattern. After closed reduction of the...
BACKGROUND
Avulsion of the greater tuberosity (GT) due to traumatic anterior shoulder dislocation (ASD) is a commonly observed fracture pattern. After closed reduction of the dislocated humerus, the GT typically reduces itself into its anatomic position enabling the patient to undergo conservative treatment. The aim of this study was to retrospectively review a consecutive series of patients with conservatively treated GT avulsion fractures after closed reduction of an ASD and analyze radiographic outcome, shoulder function and glenohumeral stability and the conversion rate to surgical treatment.
METHODS
All patients who underwent closed reduction of a GT avulsion fracture after ASD with the primary intention of conservative treatment between 2017 and 2022 were included. Complications (i.e. conversion to surgical treatment), shoulder function assessed with the American Shoulder and Elbow Surgeons score and subjective shoulder value, instability assessed with the Western Ontario Shoulder Instability score, radiological impingement (greater tuberosity index = GTI and impingement index = II) and GT fracture pattern were assessed as outcome measurements.
RESULTS
A total of 29 patients (mean age 44 years, 27% female) with a mean follow-up of 32.6 (range, 8-96) months were enrolled. Seven patients (24%) underwent surgery due to secondary displacement (n = 4, 14%) or impingement symptoms (n = 3, 10%). All patients who underwent secondary surgery showed a multifragmentary fracture pattern of the GT. Shoulder stiffness (n = 7) and neuropraxia of the axillary nerve (n = 3) were observed temporarily and resolved during the follow-up period. The American Shoulder and Elbow Surgeons and subjective shoulder value of the conservatively treated patients at the last follow-up was 89.2 ± 19.1 respectively 86 ± 18.2%. No recurrent glenohumeral dislocation was documented. The mean Western Ontario Shoulder Instability score at last follow-up was 8(0-71). The mean GTI decreased from 1.2 ± 0.1 after ASD to 1.1 ± 0.1 at the last follow-up ( = .002). The mean II decreased from 0.6 ± 0.5 after ASD to 0.4 ± 0.3 at the last follow-up ( = .110).
CONCLUSION
The GT avulsion fragment reduces typically into a close to anatomic position after closed reduction and the GTI even improves with further conservative treatment over time. Close radiological follow-up is necessary to rule out secondary displacement which occurs typically in a multifragmentary fracture pattern. Patients without the need for surgery showed good clinical outcomes without recurrence of glenohumeral instability.
PubMed: 38707548
DOI: 10.1016/j.jseint.2023.12.008 -
JSES Reviews, Reports, and Techniques May 2024A clavicle fracture often changes the mechanical axes of the shoulder girdle due to displacement and shortening, potentially leading to scapular protraction and...
Clavicle fractures do not increase the occurrence of later subacromial pain syndrome. A registry-based case-control study with 15-25 years of follow-up of 131.838 persons from the Danish National Patient Register.
BACKGROUND
A clavicle fracture often changes the mechanical axes of the shoulder girdle due to displacement and shortening, potentially leading to scapular protraction and decreased subacromial space. If protraction of the scapula is a major risk factor for developing subacromial pain syndrome (SAPS), a previous clavicle fracture could increase the risk of later SAPS. The purpose of this study was to investigate if a previous clavicle fracture correlates with a higher occurrence or earlier diagnosis of SAPS.
METHODS
In this retrospective case-control study with data from the Danish National Patient Register, all persons aged 18-60 years, with any hospital contact due to a clavicle fracture (DS420) between January 1, 1996, and December 31, 2005, were identified as cases. For each case, five controls, matched on age and sex, were identified. Primary outcome was the first hospital contact with a SAPS diagnosis (DM751-755) registered more than 180 days following the fracture. Follow-up was until November 01, 2021.
RESULTS
21.973 cases and 109.865 controls were included. The incidence of clavicle fractures was 76 fractures per 100.000 persons per year. Twenty-three percent were female. 1.640 (7.46%) cases and 8.072 (7.35%) controls received a SAPS diagnosis within the following 15-25 years, demonstrating no significant difference in the occurrence of SAPS ( = .56). The mean time from fracture to SAPS diagnosis was shorter for cases compared to controls (4040 vs. 4442 days, < .001), and cases were slightly younger when receiving the diagnosis (51.3 vs. 53.6 years, < .001). 1614 cases underwent surgical fixation. This subgroup had a statistically significant higher occurrence of later SAPS diagnosis (205 cases, 13%, < .001).
CONCLUSIONS
Persons with a previous clavicle fracture did not have an increased occurrence of receiving a SAPS diagnosis compared to matched controls. However, the diagnosis was given 1-2 years earlier for people with a previous fracture. Based on these findings, no strong argument for protraction of the scapula as a major risk factor for the development of SAPS was found.
PubMed: 38706675
DOI: 10.1016/j.xrrt.2024.01.008 -
JSES Reviews, Reports, and Techniques May 2024Humeral fractures (HF) are common orthopedic pathologies. Reviewing the content and quality of influential literature over time is important to advance scientific...
BACKGROUND
Humeral fractures (HF) are common orthopedic pathologies. Reviewing the content and quality of influential literature over time is important to advance scientific research regarding a specific topic. This study aims to explore and appraise the fifty most cited HF studies that had been published in orthopedic literature.
METHODS
The Web of Science database was used to conduct a systematic search for articles pertaining to HF. Articles were sorted out in descending order of citations and were included based on their relevance to HF. Data and metrics of the included studies were recorded. The methodological quality of the studies was assessed using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies criteria. Statistical analysis was conducted to explore any significant relationships between the date of publication and other relevant variables.
RESULTS
Included articles (N = 50) were published between 1959 and 2015, with a total of 14,864 accumulated citations. Europe and North America contributed to all but one of the included studies. The contributed to the highest number of included articles with 27 articles (54%). The proximal humerus was the most commonly explored HF location in our study (72%). The average MCMS and Methodological Index for Non-randomized Studies scores were reported to be 64.6 and 10.4, respectively, and the majority of articles (52%) were considered level four case series. Year of publication was found to have a positive correlation with increasing level of evidence(r = -0.301, = .044), citation density (r = 0.734, < .001), and MCMS score (r = 0.41, = .01).
CONCLUSION
The level of evidence, MCMS scores, and citation density of influential HF literature has been increasing with time, reflecting the increasing effort and work being put in that field. While the findings seem encouraging, additional high-quality research is needed to help achieve better treatment strategies and outcomes.
PubMed: 38706674
DOI: 10.1016/j.xrrt.2024.01.014 -
JSES Reviews, Reports, and Techniques May 2024
PubMed: 38706673
DOI: 10.1016/j.xrrt.2024.01.007