Open reduction and internal fixation of displaced proximal humeral fractures. Does the surgeon's experience have an impact on outcomes?

Shape-matching-based fracture reduction aid concept exemplified on the proximal humerus-a pilot study

PURPOSE

Optimizing fracture reduction quality is key to achieve successful osteosynthesis, especially for epimetaphyseal regions such as the proximal humerus (PH), but can be challenging, partly due to the lack of a clear endpoint. We aimed to develop the prototype for a novel intraoperative C-arm-based aid to facilitate true anatomical reduction of fractures of the PH.

METHODS

The proposed method designates the reduced endpoint position of fragments by superimposing the outer boundary of the premorbid bone shape on intraoperative C-arm images, taking the mirrored intact contralateral PH from the preoperative CT scan as a surrogate. The accuracy of the algorithm was tested on 60 synthetic C-arm images created from the preoperative CT images of 20 complex PH fracture cases (Dataset A) and on 12 real C-arm images of a prefractured human anatomical specimen (Dataset B). The predicted outer boundary shape was compared with the known exact solution by (1) a calculated matching error and (2) two experienced shoulder trauma surgeons.

RESULTS

A prediction accuracy of 88% (with 73% 'good') was achieved according to the calculation method and an 87% accuracy (68% 'good') by surgeon assessment in Dataset A. Accuracy was 100% by both assessments for Dataset B.

CONCLUSION

By seamlessly integrating into the standard perioperative workflow and imaging, the intuitive shape-matching-based aid, once developed as a medical device, has the potential to optimize the accuracy of the reduction of PH fractures while reducing the number of X-rays and surgery time. Further studies are required to demonstrate the applicability and efficacy of this method in optimizing fracture reduction quality.

Surgeon experience in multi-ligament knee injury reconstruction is associated with decreased complications and surgical time

INTRODUCTION

Operative management of multi-ligament knee injuries (MLKI) is technically challenging, with high complication rates. However, the impact of surgeon experience on surgical outcomes remains underreported. This purpose of this study was to examine how surgeon experience impacts operative time and complication rates. It was hypothesized that increased surgeon experience in MLKI correlates with reduced surgical duration and postoperative complications.

METHODS

A retrospective review of MLKI patients who underwent reconstruction from 2011 to 2024 by fellowship-trained sports medicine surgeons at two high-volume level 1 trauma centers was conducted. Patient demographics, surgical procedure characteristics, complications, and surgeon experience (defined by years in practice postfellowship) were analyzed. Correlations were examined using linear regression for continuous variables and binary logistic regression for binary variables.

RESULTS

There were 191 MLKI patients meeting inclusion criteria, with a 25.7% overall complication rate. Arthrofibrosis (16.2%) was most common, followed by recurrent instability (3.7%), infection (3.7%), revision surgery (2.7%), and hardware removal (1.0%). Controlling for age, sex, BMI, and number of ligaments reconstructed, we found a significant negative correlation between surgeon experience and both surgical duration (ß =  - 0.28, p < .001) and complication risk (OR 0.92, p = 0.024).

CONCLUSION

This study demonstrates that increased surgeon experience in operative management of MLKI is associated with decreased complication rates and shorter procedure duration. Additional risk factors for complications included the number of ligaments injured and concomitant knee dislocation.

From the last 100 to the first 100-outcome after a manufacturer change in reverse fracture arthroplasty

PURPOSE

If surgery is indicated for elderly patients suffering a proximal humerus fracture, reverse fracture arthroplasty became the preferred type of treatment due to its good and reliable outcomes over the last decade. Surgeons could choose from a wide range of implants and up to now there was no evaluation, if a change of the manufacturer affects patients` outcome.

METHODS

The last 100 patients before and the first 100 after manufacturer change in reverse fracture arthroplasty were evaluated at a level one trauma center, all treated by only 3 senior shoulder surgeons. Clinical as well as radiographic outcome parameters were assessed, perioperative up to 24 months after surgery.

RESULTS

Mean age in both groups was nearly 80 years with comparable distribution of gender and comorbidities. A trend to shorter duration of surgery was observed after the change, mainly according to an uncemented fixation of the stem. During follow-up no significant differences, beneficial as well as negative, could be observed regarding clinical and radiographic outcome.

CONCLUSION

A manufacturer change on the fly is possible without negative consequences for patients` outcome. Expertise of the whole OR-team as well as standardized training with the new implant seems to be a more important factor than a specific type of implant.

Surgeon-related Factors in the Surgical Treatment of Proximal Humerus Fractures

INTRODUCTION

In this study, we reviewed proximal humeral fractures surgically treated with open reduction and internal fixation (ORIF) to test the null hypothesis that there is no association between fracture characteristics and surgeon characteristics in outcomes after surgical management of displaced proximal humeral fractures with ORIF.

METHODS

A retrospective review of surgically treated proximal humeral fractures was done at a tertiary-level hospital. The data were organized into two categories: fracture characteristics and surgeon characteristics.

RESULTS

There were 314 proximal humeral fractures treated with ORIF. In total, there were 112 failures (36%). Bivariate Pearson correlations demonstrated that the number of proximal humerus fixation surgeries performed by an individual surgeon was associated with adequate calcar reduction (r = 0.995, P < 0.001) and greater tuberosity reduction (r = 0.994, P < 0.001). Years of experience was positively associated with adequate calcar reduction (r = 0.594, P = 0.012) and greater tuberosity reduction (r = 0.589, P = 0.013). Regression analysis of two surgeons versus the rest of the cohort demonstrated significantly lower failure rates (P = 0.001).

DISCUSSION

Complex proximal humeral fractures (3-part and 4-part) have better calcar reduction and tuberosity reduction when treated by surgeons with greater volume of proximal humeral fracture surgery. Among surgeons with high volume, there may be individuals who have the unique ability to provide markedly better results.

Pre-operative virtual three-dimensional planning for proximal humerus fractures: A proof-of-concept study

Purpose

To (1) evaluate surgeon agreement on plating features (position and screw length) in virtual 3D planning software, (2) describe outcomes (fracture reduction, plate position, malpositioning of calcar screws and screw lengths) of plate fixations planned with routine pre-operative assessment (2D- and 3D CT imaging) and those planned with dedicated virtual 3D software of the same proximal humerus fracture.

Methods

Fourteen proximal humerus fractures were retrospectively reduced and fixed with virtual planning software by eight attending orthopaedic surgeons and compared to the true surgical fixation with post-operative computed tomography (CT) scans. Reduction differences were quantified using CT micromotion analysis.

Results

Intraclass correlation for screw lengths was 0.97 (95% CI: 0.96-0.98) and 0.90 (95% CI: 0.79-0.96) for plate position. Mean difference in total fracture rotation of the head between the virtual and conventional group was 22.0°. Plate position in the virtual planning group was 3.2 mm more proximal. There were no differences in inferomedial quadrant calcar screw positioning and, apart from the superior posterior converging screw, no significant differences in screw lengths.

Conclusion

Reproducibility on plate position and screw length with virtual planning software is adequate. Apart from fracture reduction, virtual planning yielded similar plate positions, screw malpositioning rates and lengths compared to routine pre-operative assessment.

Experimental guide wire placement for total shoulder arthroplasty in glenoid models: higher precision for patient-specific aiming guides compared to standard technique without learning curve

BACKGROUND

Patient-specific aiming devices (PSAD) may improve precision and accuracy of glenoid component positioning in total shoulder arthroplasty, especially in degenerative glenoids. The aim of this study was to compare precision and accuracy of guide wire positioning into different glenoid models using a PSAD versus a standard guide.

METHODS

Three experienced shoulder surgeons inserted 2.5 mm K-wires into polyurethane cast glenoid models of type Walch A, B and C (in total 180 models). Every surgeon placed guide wires into 10 glenoids of each type with a standard guide by DePuy Synthes in group (I) and with a PSAD in group (II). Deviation from planned version, inclination and entry point was measured, as well as investigation of a possible learning curve.

RESULTS

Maximal deviation in version in B- and C-glenoids in (I) was 20.3° versus 4.8° in (II) (p < 0.001) and in inclination was 20.0° in (I) versus 3.7° in (II) (p < 0.001). For B-glenoid, more than 50% of the guide wires in (I) had a version deviation between 11.9° and 20.3° compared to ≤ 2.2° in (II) (p < 0.001). 50% of B- and C-glenoids in (I) showed a median inclination deviation of 4.6° (0.0°-20.0°; p < 0.001) versus 1.8° (0.0°-4.0°; p < 0.001) in (II). Deviation from the entry point was always less than 5.0 mm when using PSAD compared to a maximum of 7.7 mm with the standard guide and was most pronounced in type C (p < 0.001).

CONCLUSION

PSAD enhance precision and accuracy of guide wire placement particularly for deformed B and C type glenoids compared to a standard guide in vitro. There was no learning curve for PSAD. However, findings of this study cannot be directly translated to the clinical reality and require further corroboration.

Risk factors for osteonecrosis of the humeral head after internal fixation of proximal humeral fractures: a systematic review and meta-analysis

BACKGROUND

Osteonecrosis of the humeral head (ONHH) is a severe complication after the internal fixation of proximal humeral fractures (IFPHF). The risk factors remain controversial though many studies have reported. In this research, meta-analysis was used to evaluate which surgeon-level factors can be modified to lower the risk and we hope to provide evidence-based support for preventing ONHH.

METHODS

Literature was retrieved from PubMed, Cochrane Library, Embase, Web of Science, and Scopus for eligible studies published up to January 2023. The pooled odds ratios (ORs) were calculated with their corresponding 95% confidence intervals (CIs) to evaluate. STATA 15.1 software was applied for data synthesis, sensitivity synthesis, and publication bias.

RESULTS

45 articles were published between 2000 and 2022, and 2482 patients were finally included. All articles were observational research, with 7 case-control studies and 38 cohort studies, and the Newcastle Ottawa Scale (NOS) score ranged from 7 to 9. The pooled results suggested that age (OR 0.32, 95% CI 0.14-0.74, P = 0.01), reduction quality (OR 0.08, 95% CI 0.01-0.44, P = 0.00), fracture type (OR 0.44, 95% CI 0.25-0.78, P = 0.01), surgical approach (OR: 4.06, 95% CI 1.21-13.61, P = 0.02) and fixation implant (OR = 0.68, 95% CI = 0.34-1.33, P = 0.02) were risk factors for ONHH after IFPHF. According to sensitivity analysis, Begg (P = 0.42) and Egger (P = 0.68) tests, the results were stable and exhibited no publication bias.

CONCLUSIONS

The study showed that age, reduction quality, fracture type, surgical approach and fixation implant were risk factors for ONHH after IFPHF, while gender, varus or valgus, timely operation, injured side, and the existence of medial support have little influence on ONHH, as they could not be considered risk factors and still need further investigations.

Effect of uncertain clinical conditions on the early healing and stability of distal radius fractures

BACKGROUND AND OBJECTIVES

The healing outcomes of distal radius fracture (DRF) treated with the volar locking plate (VLP) depend on surgical strategies and postoperative rehabilitation. However, the accurate prediction of healing outcomes is challenging due to a range of certainties related to the clinical conditions of DRF patients, including fracture geometry, fixation configuration, and physiological loading. The purpose of this study is to investigate the influence of uncertainty and variability in fracture/fixation parameters on the mechano-biology and biomechanical stability of DRF, using a probabilistic numerical approach based on the results from a series of experimental tests performed in this study.

METHODS

Six composite radius sawboneses fitted with titanium VLP (VLP 2.0, Austofix) were loaded to failure at a rate of 2 N/s. The testing results of the elastic and plastic behaviour of the VLP were used as inputs for a probabilistic-based computational model of DRF, which simulated mechano-regulated tissue differentiation and fixation elastic capacity at the fracture site. Finally, the probability of success in early indirect healing and fracture stabilisation was predicted.

RESULTS

The titanium VLP is a strong and ductile fixation whose flexibility and elastic capacity are governed by flexion working length and bone-to-plate distance, respectively. A fixation with optimised designs and configurations is critical to mechanically stabilising the early fracture site. Importantly, the uncertainty and variability in fracture/fixation parameters could compromise early DRF healing. The physiological loading uncertainty is the most adverse factor, followed by the negative impact of uncertainty in fracture geometry.

CONCLUSIONS

The VRP 2.0 fixation made of grade II titanium is a desirable fixation that is strong enough to resist irreparable deformation during early recovery and is also ductile to deform plastically without implant failure at late rehabilitation.

Proximal humerus fractures (PHFs): comparison of functional outcome 1 year after minimally invasive plate osteosynthesis (MIPO) versus open reduction internal fixation (ORIF)

PURPOSE

Osteosynthetic treatment strategies of PHFs include MIPO or ORIF techniques. The aim of this study was to compare the 1 year outcome following either technique in type B PHFs.

METHODS

This study was designed as a retrospective cohort study of patients treated at one academic Level 1 trauma center. Patients from 2009 to 2019 who required surgical treatment of a type B PHF were eligible to be included in this study. Patients with A- or C-type fractures or patients requiring arthroplasty were excluded. All patients were treated with Proximal Humerus Interlocking System (PHILOS) and stratified according the approach into Group MIPO or Group ORIF. Outcome measures include local complications that occurred during hospitalization, nonunion after 12 months, and range of motion after 1 year follow-up.

RESULTS

This study included 149 (75.3%) patients in Group ORIF, and 49 (24.7%) in Group MIPO. The fracture morphology and concomitant injuries were comparable amongst these groups. When compared with Group MIPO, Group ORIF had a 2.6 (95% CI 0.6-11.7) higher risk of suffering from local complications. The rate of postoperative nerve lesions was comparable (OR 0.9, 95% CI 0.1-9.7) as was the rate of soft tissue complications (OR 2.0, 95% CI 0.2-17.2). The risk for nonunion was 4.5 times higher (95% 1.1-19.5) in Group ORIF when compared with Group MIPO. Group MIPO had a higher chance of flexion above 90° (OR 8.2, 95% CI 2.5-27.7).

CONCLUSION

This study provides indications that patients following surgical treatment of PHFs in MIPO technique might have favourable outcome. Large-scale and high-quality studies are warranted to confirm these results.

Different treatments for 3- or 4-part proximal humeral fractures in the elderly patients: A Bayesian network meta-analysis of randomized controlled trials

Background

Proximal humeral fractures are the third most common fracture in the body, and their incidence is rising year by year as the population ages. However, the treatment of the proximal humerus in parts 3 and 4 is still debatable, necessitating a network meta-analysis to determine the best treatment for each treatment modality.

Methods

We searched PubMed, Embase, Cochrane Library for randomized controlled trials on proximal humeral fractures up to June 21, 2022. We performed data extraction and literature quality assessment by two independent authors and extracted constant score and reoperation rate as indicators for evaluation. Stata software, Revman software, JAGS software and the R-based BlandAltmanLeh package, gemtc package and riags package were used to perform this Bayesian network meta-analysis.

Results

Following screening, 11 papers with a total of 648 participants were included in the analysis. The SUCRA values for the constant score were in the following order: RSA, IMN, Conservative, HA, and LP, and the SUCRA values for the reoperation rate were LP, HA, IMN, Conservative, and RSA.

Conclusion

The elderly with 3- or 4-part proximal humeral fractures should consider RSA because it received the best evaluation ranking in terms of constant score and reoperation rate.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022341209, identifier: CRD42022341209.

Operative treatment of 2-part surgical neck type fractures of the proximal humerus in the elderly: Cement augmented locking plate PHILOS™ vs. proximal humerus nail multiloc®

INTRODUCTION

The purpose of this prospective randomized controlled clinical trial was to compare locked plating with intramedullary nailing in the treatment of displaced 2-part surgical neck type proximal humeral fractures in elderly patients.

PATIENTS AND METHODS

Patients ≥60 years of age with a displaced 2-part surgical neck type fracture of the proximal humerus were surgically treated and randomized for either augmented locking plate fixation Group LP or multiplanar intramedullary nailing Group IN. The primary outcome parameter was the Disabilities of the Shoulder, Arm and Hand (DASH) Score after 24 months. Secondary outcome parameters were the age- and gender adjusted Constant Murley Score (CS), the American Shoulder and Elbow Score (ASES), the Oxford Shoulder Score (OSS) and the Short Form 36 (SF-36) after 6 weeks, 3 months, 6 months, 12 and 24 months. Further parameters included the quality of fracture reduction as well as complications and revision surgeries. 60 patients with a mean age of 75±9.8 were included and longitudinally followed over 24 months (follow-up rate: 83.3%).

RESULTS

The mean DASH-Scores at 24 months was 32.6 ± 9.7 points in Group LP versus 37.8 ± 8.3 points in Group IN (p = 0.04). The mean Constant Murley Score at 24 months follow-up was 76.2 ± 7.7 points in Group LP compared to 72 ± 9.1 points in Group IN (p = 0.08). The ASES at 24 months follow-up was 75.1 ± 9 points in Group LP versus to 73.5 ± 8.9 in Group IN (p = 0.51). The OSS at 24 months was 43.7 ± 8.1 in Group LP compared to 38.2 ± 10 in Group IN (p = 0.03). The SF-36 at 24 months was 74.7 ± 12.5 in Group LP versus to 70.9 ± 12.8 in Group IN (p = 0.29). Screw cutting out was observed in n = 2 (6,7%) cases of Group LP, and in none of Group IN (p = 0.49). Revision surgery was necessary in n = 2 (6.7%) cases of Group LP and in two cases of Group IN (6.7%, p = 1).

CONCLUSION

Functional outcomes are similar at 2-years follow-up in locked plating with screw tip augmentation compared to intramedullary nailing. Both implants reached low complication- and revision rates for two-part surgical neck types fractures of the proximal humerus in patients ≥60 years, if anatomic fracture reduction and accurate implant position was obtained.

The role of a trauma review system and development of intra-operative checklists in improving the quality of fracture fixations in a high volume tertiary centre

INTRODUCTION

In high volume centres, audits are essential to ensure good surgical techniques and fracture fixations to avoid complications, revision surgeries and poor outcomes. A method to assess fixations for fractures of different regions employing different implants and surgical demands is a challenge. We present here a simple method of review and follow-up work flow of more than 6000 fixations every year that helped in improving outcomes and also provide training for residents and junior staff.

MATERIALS AND METHODS

The results of 6348 fracture fixations in 2014, led to a trauma review system in January 2015 to classify all fracture fixations by senior consultants into three categories: category A (good fixations); category B (acceptable fixations; need further follow-up); category C (poor/unacceptable fixations needing revision) combined with a teaching program. A strategy was evolved that included the following practices: (1) identifying 'red flag' fractures that led to frequent failures, (2) routine senior surgeons' involvement in such fractures, (3) evolving 'intra-operative checklists', (4) requirement of senior surgeons' intervention if there was a 'fiddle time' of more than 20 min, and (5) approval of post-fixation c-arm image by a senior person before closure. The impact of these rules on the fixations for 2015, 2016 and 2017 were prospectively analysed.

RESULTS

In the years 2015, 2016 and 2017 the number of fracture fixations performed were 6579, 6978 and 7012, respectively. There was a significant increase (p < 0.001) in the number of category A fixations (87.7%, 94.6% and 96.3% in 2015, 2016 and 2017, respectively) and also a decrease in the number of category C fixations (2.23%, 0.7% and 0.2% in 2015, 2016 and 2017, respectively). The quality of fixations of the 'red flag' fractures also improved.

CONCLUSION

We present here a very effective, tested, simple and easily reproducible method of audit and follow-up work flow that can be used in all high turnover trauma centres to improve outcomes and can also serve as a teaching resource for junior staff.

STUDY DESIGN

Prospective study.

LEVEL OF EVIDENCE

Level II.