Introduction: Optimal management of proximal humeral fractures is still to be defined. The objective of this study is to present the functional and quality of life results of proximal humeral fractures conservatively treated in elderly population

Material and Methods: Prospective study including 74 fractures in patients over 60 and less than 85 years-old. 4 patients lost at final follow-up. Fractures were assessed by X-ray and C.T. exam. There were 14 one-part fractures, 15 two-part greater tuberosity (GT), 17 two-part surgical neck, 10 three-part GT, 6 four-part, 6 two-part GT fracture dislocation, 1 four-part fracture dislocation and 1 impression fracture. Constant Score, EuroQol 5-D and X-Ray study at two-year follow-up. U Mann-Whitney for non parametric and t-student for parametric.

Results: Constant Score: non-displaced fractures mean of 73,58 while displaced fractures 59,41 (p0,003). Significant differences between them in all Constant items except for External rotation (p0,17). Total Constant Score diminished as fracture pattern increased complexity: 2-part GT 72,78, 2-part surgical neck 65,88, 2-part GT fracture dislocation 71, 3-part GT 54,64 and 4-part 33,66. Despite these differences there were no significant differences as far as pain was concerned among all displaced fractures.

Quality of life perception: no significant differences in VAS between displaced and non-displaced fractures (p 0,75). 4 avascular necrosis at final follow-up, 2 in the 4-part group, 1 in 3-part GT and 1 in 4-part fracture dislocation.

Conclusion: Conservative treatment of proximal humeral fractures give reasonable good functional results in 1-part, 2-part GT, 2-part surgical neck and 2-part GT fracture dislocation in specially selected elderly population. 3-part GT and 4-part fractures achieve a limited functional result with conservative treatment. No differences have been observed between non-displaced and displaced fractures conservatively treated as far as quality of life perception is concerned in such elderly population.

Introduction: Pain and disability are two parameters used to indicate and evaluate treatment in lumbar degenerative spine (LDS). Visual Analogue Scales (VAS) and Verbal Rating Scales (VRS) are frequently used to assess pain intensity. Both scales are validated and they have good psychometric properties.

Aim: To evaluate concordance and grade of interchangeability between the two scales.

Design: Retrospective and observational study with dates collected prospectively.

Outcome measures: Pain intensity was evaluated by VAS. As VRS we used pain categoric question of SF 36. Kappa coefficient was used to measure agreement.

Material and Methods: We analysed 50 patients operated by LDS. 28 women and 22 men, mean age was 50 y (17–81 y). All patients filled preoperatively a set of questionnaires (SF 36, Oswestry Disability Index -ODI-, Core set of Deyo and VAS). We evaluated whether VAS follows or not a normal distribution, correlation and concordance between VAS and VRS. Even we study if there are different related to sex, age or study level. Statistically studies were done using SPSS. We considered p=0’05 as statistically significant

Results: VAS not have a normal distribution (Kolmogorov-Smirnov p=0’000). VAS and VRS have a low, but statistically significant, correlation (Rho-Spearman r=0’408 p=0’004), whatever the two scales have low concordance, with large overlap of responses (Kappa=0’345 IC 95% 0’174–0’543). This disagreement dates are aleatory (RV=0’174) and non systematic (RP=−0’093. RC=−0’00005). Making a stratified study, using analogue scale we not found differences by sex (p=0’283) but using VRS we shown more pain intensity in women (p=0’042) and this dates are associated with significative differences in women’s disability (ODI 46’74 vs 57’79 p=0’05)

Conclusions:

VAS data should be analyzed using non paramentrics methods because vas have non-linear properties

Study limitations: Using pain question of SF 36 we are asking about bodily pain and not specifically lumbar pain, but in a patient who are going to be operated by DLS we thing is a good approach.

Number of patients, although we find clinically and statistically significant differences

Introduction: Shoulder hemiarthroplasty is an established treatment for complex proximal humeral fractures but the functional results of these hemiarthroplasties in proximal humeral fractures are often poor and unpredictable. The capacity of restoring proximal humeral anatomy in such these complex fractures is of capital importance to obtain proper placement and secure fixation of the tuberosities to the prosthesis. The purpose of this study was to determine the value of the upper edge of the pectoralis major insertion as a landmark to determine proper height and version of hemiarthroplasties implanted for proximal humeral fractures.

Material and Methods: The upper edge of the pectoralis major insertion was referenced with a metallic device in 20 cadaveric humerus. A Computed Tomography study was performed in all the specimens. Total humeral length was recorded in all the specimens. The distance between the upper pectoralis major insertion and the tangent to the humeral head was also recorded. The anatomical neck of the humeral head was determined in the axial plane of the CT scan and a perpendicular line was drawn to represent the posterior fin of the prosthesis. To that image, the CT scan slice showing the upper insertion of the pectoralis major was superimposed and the distance of the metallic reference to the posterior fin of the prosthesis was recorded as it was the angle formed by the line connecting the upper pectoralis major insertion with the center of the anatomical neck diameter and with the posterior fin of the prosthesis.

Qualitative variables are presented in absolute and percentage values. Quantitative variables are presented with mean values and standard deviation.

Results: Mean total humeral length was 32,13 cm. The mean distance from the upper pectoralis major insertion to the tangent to the humeral head was of 5,64. The mean distance from the upper pectoralis major insertion to the tangent to the humeral head represents the 17,55% of the total humeral length. The mean distance of the upper pectoralis major insertion to the posterior fin of the prosthesis was of 1,06 cm. The angle between the upper pectoralis major insertion and the posterior fin of the prosthesis was of 24,65º.

Conclusions: Mean distance from the upper part of the pectoralis major insertion to the top of the humeral head of 5, 6 cm with a 95% confidence interval.

Placement of the prosthesis in the proper retroversion can be achieved by placing the posterior fin 1,06 cm posterior to the upper insertion of the pectoralis major or by placing the posterior fin at 24,65º with respect to the upper insertion line.

Upper insertion of the pectoralis major constitutes a reliable reference to reproduce anatomy in hemiarthroplasties for proximal humeral fractures.

The objective of this study is to analyze changes in the force needed to raise the arm caused by using a single or a double-row configuration of cuff repair.

Cadaveric study performed using 5 fresh-frozen shoulders. Supraspinatus tear created in all specimens beginning 0.5 cm from biceps tendon. Repair of tear with single and double-row configuration of anchors placed 1cm apart each one. Sutures fixed to digital dynamometer. Continuous traction applied and registered to elevate humerus to 30° and 45°. Experiment repeated 3 times for each configuration and angle of elevation on each specimen. Paired Student t test was used to compare difference between single and double-row configuration at 30° and 45° of anterior elevation.

Significant differences between force needed to raise the arm to 30° with single-row (4,76 kg) configuration and double-row (6,94) (p< 0,001). Significant differences between force needed to raise the arm to 45° with single-row configuration (10,32 kg) and double-row (15,93) (p< 0,008). Significant differences when comparing mean increase of force needed to raise the arm from 30° to 45° between single and double-row configuration (p< 0,012).

The force needed to raise the arm to 30° and 45° is significantly higher for double than for single-row configuration. Quality of tendon margin should be taken into account when choosing between double and single-row configuration. If repair is done to a frayed and degenerated tendon, surgeon has to imbalance benefits of double-row repair with the fact that tendon suture will have to resist an increased force in active movement.

Purpose of study was to determine the value of the upper edge of the pectoralis major (UPM) insertion as landmark to determine proper height and version of hemiarthroplasties implanted for proximal humeral fractures.

UPM insertion was referenced with metallic device in 20 cadaveric humerus. Computed Tomography study was performed in all specimens. Total humeral length and distance between the UPM insertion and the tangent to humeral head was recorded. CT scan slice showing UPM superimposition in humeral head was drawn to determine prosthesis retroversion. Qualitative variables are presented in absolute and percentage values. Quantitative variables are presented with mean values and standard deviation.

Mean total humeral length 32,13 cm. Mean distance from the UPM to the tangent to the humeral head 5,64. Mean distance from UPM insertion to the tangent to the humeral head represents the 17,55 % of total humeral length. Mean distance of UPM insertion to the posterior fin of the prosthesis of 1,06 cm. Angle between UPM insertion and posterior fin of the prosthesis 24,65°.

Mean distance from the UPM insertion to the top of the humeral head of 5, 6 cm with a 95% confidence interval. Placement of the prosthesis in the proper retroversion can be achieved by placing the posterior fin 1,06 cm posterior to the UPM or by placing the posterior fin at 24,65° with respect to the upper insertion line. UPM constitutes a reliable reference to reproduce anatomy in hemiarthroplasties for proximal humeral fractures.

Introduction: Concern remains in loosening of glenoid component reversed prostheses. This study is to analyze glenoid location of stem and 4 screws of glenoid component.

Material and method: 34 reversed prostheses included. Mean age 74,10, 33 females/1 male. Preoperative CT study : glenoid version; measure of anterior-posterior osteophytes. Postoperative CT study: central stem location and superior, inferior, anterior, posterior screws location. Study of influence of glenoid version and presence of osteophytes in location of glenoid implant.

Results: 27 retroverted glenoids (mean 6,5°); 7 ante-verted (mean 5,3°). 17 cases with anterior osteophyte and 12 of posterior. In 52% the central stem was centered inside glenoid, 33% anterior end was outside glenoid and 14% the posterior end. When central stem was anteriorly outside 85% presented retroverted glenoid (mean 8,33°). When the central stem was posteriorly outside 66% presented anteverted glenoid (mean 9,5°). Inferior screw was fully in place in 38%, ¾ part inside in 19%, 2/4 part in 23%, ¼ part in 19%. Superior screw was fully in place in 47%, ¾ part inside in 23%, 2/4 part in 19%, ¼ part in 9%. Anterior screw was fully in place in 66%, ¾ part in 23% and 2/4 part in 9%. Posterior screw was fully in place in 38%, ¾ part in 42%, 2/4 part in 14%, ¼ part in 4%. The correct positioning of superior screw correlates with less coverture of inferior screw. Anterior and posterior osteophytes did not correlated with stem nor screw positioning.

Conclusions: Positoning of central stem correlates with glenoid version. Anteriorly extruded stems correlate with higher retroverted glenoids and posteriorly extruded stems correlate with higher anteversion.

Positioning the inferior screw fully inside the lateral border of the scapula correlates with lower bony coverture of superior screw.

Introduction: Reversed prostheses implantation requires screwing of the glenoid component with prefixed angles. This study is to determine anatomical angles of scapula that take part in reversed prostheses implantation.

Material and method: Seventy-three 3-dimensional computed tomography of the scapula and 108 scapular dry specimens were analyzed. Mean age of the CT-3D serie was of 52.59 years old (ranging from 16 to 84). There were 46 females and 27 males. The following measures were made on each patient: length of the neck of the inferior glenoid, angle between the glenoid surface and the upper posterior column of the scapula, angle between the major craneo-caudal glenoid axis and the base of the coracoid process and angle between the major craneo-caudal glenoid axis and the upper posterior column of the scapula. Measures were performed in the AP view as well as in the posterior view of the scapula.

Results: The length of the neck of the anterior glenoid was classified into two groups named ‘short-neck’ and ‘long-neck’ for both three-dimensional computed tomography and cadaveric scapulas with statistically significant differences between both groups (p< 0,001 for the three-dimensional computed tomography scapulas and p=0,034 for the cadaveric group). The angle between the glenoid surface and the upper posterior column of the scapula was also classified into two different types: type I (52° ranging from 48° to 57°) and type II (64° ranging from 60° to 70°) with statistically significant differences between both groups (p< 0,001 for the three-dimensional computed tomography scapulas and p< 0,001 for the cadaveric group). The angle between the major craneo-caudal glenoid axis and the center of the base of the coracoid process averaged 18,25° (ranging 13° from to 27°). The angle between the major craneo-caudal glenoid axis and the upper posterior column of the scapula averaged 8° (ranging 5° from to 18°).

Conclusions:

- scapulas can be classified into two groups regarding the angle between the glenoid surface and the upper posterior column of the scapula with significant differences between them.

Introduction: Analysis of location of central peg and the fours screws of the glenoid component in inverted shoulder prostheses.

Materials and methods: 34 inverted prostheses. Mean age 74.10. 33 women, 1 man. Preoperative CT: glenoid version, presence and size of bone spurs. Postoperative CT: location of central peg and 4 screws.

Results: 27 retroverted glenoids (mean 6.5°), 7 anteverted glenoids (mean 5.3°); anterior bone spur in 17 cases, posterior in 12. In 52% of the cases the central peg was inside the glenoid; in 33% the anterior part was outside and in 14% the posterior part. If the anterior part of the central peg was outside, 85% was due to retroverted glenoids (mean 8.33°). If the posterior part was outside, 66% of these were due to anteverted glenoids (mean 9.5°). Lower inside screw in the scapula in 38% of cases, 3/4 inside in 19%, 2/4 in 23% and 1/4 in 19%. Upper screw: 47%, 23% 19% and 9%, respectively. Anterior screw: 66%, 23% and 9%, respectively. Posterior screw: 38%, 42%, 14% and 4%, respectively.

Conclusions:

- Lower screw completely within the lateral part of the scapula with less coverage by upper screw.

Introduction: Meniscal extrusion is defined as the situation in which the meniscus is partially or totally luxated from the tibial plateau. The aim of this work is to ascertain the prevalence of meniscal extrusion in non arthritic patients and to define those factors related to it. Special attention was given to the fact of anatomic variations in the menisci attachments.

Methods: The knee MRI of 100 patients that were operated on arthroscopically in our institution was prospectively studied. Seventy-two males and 28 females, average age of 36.6 years (range between 13 and 64), entered in the study. There were 43 right-knees and 57 left-knees. The average weight of the patients was 77 kg (range 44 to 135).

Results: With respect to the medial meniscus 68.9% of the cases showed some degree of extrusion, averaging at 28% of the meniscal size (ranging from 10% to 60%). In the case of the lateral meniscus extrusion averaging 15% (ranging from 10% to 40%) was seen in 18.8% of the cases.

In this series the posterior types of anterior medial meniscus insertion were the most frequently found (69.5%).

Medial meniscal extrusion was significatively correlated to the presence of a chondral lesion (p = 0.008) and to anterior medial meniscus insertion (p = 0.001). No statistical significant relationship to the rest of parameters studied was encountered. None of the parameters studied were related to lateral meniscus extrusion

Discusion: Meniscal extrusion is frequent in our series and, the hypothesis that those patients who have an anterior variant of the anterior horn insertion of the medial meniscus tend to show greater extrusion is confirmed.

Introduction and purpose: The treatment of proximal humerus fractures is still controversial in terms of the surgical approach to be used and even of whether surgery is indeed necessary or not. The purpose of this study is to assess the functional result and the patients’ perception of their general health condition after treatment of displaced humerus fractures by means of transosseous sutures with or without the support of modified Ender nails.

Materials and methods: The study comprised a series of 40 patients (mean age: 66.21 years); 82% females /18% males. The patients had the following fracture types: 27% had two-part fractures, 60% had three-part fractures and 12% had four-part fractures and fracture-dislocations. The mean follow-up was 55.83 months (12.83-97). The final functional evaluation was carried out using the Constant score and the health perception was measured on the EuroQol-5D scale. All patients were submitted to a final radiological exam (AP and profile radiographs on the scapular plane).

Results: The mean value obtained on the Constant Scale was 74.18 in the involved arm and 84.06 in the contralateral one. As regards pain, the mean obtained was 12.57, while the value for forward arm elevation was 8.24. When comparing two age groups (> 70 vis-á-vis < 70 year olds) a significant difference was obtained with respect to Constant Scale’s global value (p 0.022). Furthermore, a significant difference was detected between the result of the EuroQol-5D scale, the global result of the Constant Scale (p 0.061), abduction (p 0.05), internal rotation (p 0.05) and strength (p 0.007). The rate of postop complications was 6% (2 surgical wound haematomas). The final radiological control revealed losses in reduction and necrosis in 9.37% and 3.03% of patients respectively.

Conclusions: (1) Good global functional results on he Constant Scale. (2) Significant differences in functional results based on patients’ age. (3) Difference in quality of life perceptions on the basis of the amount of mobility and strength obtained postoperatively. (4) Low complications rate.