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AO 11-A3 fractures before and after ORIF by locking plate. (A)+(B): fracture of a 69 years old female with postoperative anatomical fracture reduction = Inclusion criteria. (C)+(D): fracture of a 72 years old female with postoperative varus malreduction of the humeral head = Exclusion criteria. https://doi.org/10.1371/journal.pone.0207044.g001
Source publication
Introduction
To evaluate outcomes following open reduction and internal fixation of displaced proximal humeral fractures with regards to the surgeon’s experience.
Material and methods
Patients were included undergoing ORIF by use of locking plates for displaced two-part surgical neck type proximal humeral fractures. Reduction and functional outcom...
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Citations
... A crucial surgical step remains in the positioning of the central glenoidal guide wire for correct placement of the anatomic glenoid component or baseplate component. Variation of guide wire positioning depends on estimation and experience of the surgeon and shows significant variation [13]. Particularly differentiating between precision (variance in hitting a target repeatedly) and accuracy (deviation from the target) has become relevant in evaluating the outcome of surgical navigation devices and might play a crucial regarding the learning curve of surgeons with a lower volume of shoulder arthroplasty [14]. ...
... An experimental study was conducted to assess the precision of guide wire placement into three different glenoid models with a standard guide in group (I) compared to a patient-specific aiming device in group (II). Three experienced surgeons (> 50 shoulder arthroplasties per year) [13] inserted 2.5 mm K-wires, which is the most common guide wire size for pegged glenoid component, in predefined corrections angles for version and inclination into 30 glenoid models of each glenoid type. Therefore, 90 guide wires were placed in each group (Fig. 1). ...
... Three experienced shoulder surgeons, performing > 50 shoulder arthroplasties/ year [13], inserted 30 guide wires each in a standardized fashion into glenoid cast models. They have never worked with the used patient-specific aiming device before and therefore had no experience in the application of the guide. ...
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.
... The incidence of avascular necrosis (AVN) after conservative treatment is low, but the incidence of humeral head necrosis after surgical treatment is approximately 13-34% [6]. IF is the most frequently performed operative method for its advantage of providing anatomical reduction [7,8]. Osteonecrosis of the humeral head (ONHH) is one of the severe complications after IF due to increased intraosseous pressure and disruption of vascular ZiXuan Ou and QiYuan Feng Co-first author. ...
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.
... Guo et al. 10.3389/fsurg.2022.978798 Frontiers in Surgery of the procedure and the plates have been evolving over time (32)(33)(34). This implies that the results of earlier human research need to be viewed with greater objectivity because improved surgical procedures and plates may have reduced the incidence of negative events like reoperation rates for LP-treated proximal humeral fractures. ...
... The different percentages of three-and four-part fractures in different trials, the reliability of the fracture classification, the technical variability of the surgeons in different studies(32), the subjective variability of constant score scores and the lack of uniform standards for postoperative functional exercise may have influenced the judgment of outcome indicators to some extent.(3) Due to the small number of included trials and the differences in reporting indicators of outcome among different trials, we ...
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.
... Surgeon experience is an important factor affecting the quality of fixation and thereby influencing the final outcome. Helfen et al. in their study involving 278 displaced proximal humerus fractures concluded that quality of reduction and functional outcomes are related to surgeon experience [10]. They also added that complications and revision rates were less frequent with experienced surgeons. ...
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.
... While functional scoring system might represent a wide variety of daily activities, they might mask certain limitations of movement. The outcome (radiation time, duration of surgery, complications, etc.) might be associated with the surgeon's experience [41]. To minimize this bias, this study only includes cases, where the senior surgeon (FA) acted as the leading and supervising surgeon. ...
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.
... Further studies are needed to get to know the two implant types and their strengths and weaknesses. Evaluations of the relationship between poor reduced fractures and functional outcome, the relationship between poor reduced fractures and complication rates as well as the influence of surgeon's experience in the implants would be helpful [40] . ...
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.
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.
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.
With the increasing popularity of sports, the incidence of sports injuries is rising. The merger of the specialist in orthopedics and the specialist in trauma surgery has been a significant step towards optimal patient care, especially for treatment of sports injuries. Not all sports injuries require a high degree of specialization by the surgeon, nevertheless specialization is useful for a large proportion of sports injuries and may even be relevant for the outcome. In this article, common sports injuries are described using examples, which serve to increase awareness for these injuries and also illustrate that an adequate approach to sports injuries during the initial treatment leads to high-quality and economical patient care.
