The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate? PHFs occurring between 1 January 2009 and 31 December 2019 were identified from the Medicare physician service records. Incidence rates were determined, mortality rates were calculated, and semiparametric Cox regression was applied, incorporating 23 demographic, clinical, and socioeconomic covariates, to compare the mortality risk between treatments.Aims
Methods
Aims. Rotator cuff (RC) tears are common musculoskeletal injuries which often require surgical intervention. Noninvasive pulsed electromagnetic field (PEMF) devices have been approved for treatment of long-bone fracture
Aims. To evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus on ultrasound. Methods. Adult patients managed nonoperatively with a displaced mid-shaft clavicle were recruited prospectively. Ultrasound evaluation of the fracture was undertaken to determine if sonographic bridging callus was present. Clinical risk factors at six weeks were used to stratify patients at high risk of
Indocyanine green (ICG) fluorescence angiography is an emerging technique that can provide detailed anatomical information during surgery. The purpose of this study is to determine whether ICG fluorescence angiography can be used to evaluate the blood flow of the rotator cuff tendon in the clinical setting. Twenty-six patients were evaluated from October 2016 to December 2017. The participants were categorized into three groups based on their diagnoses: the rotator cuff tear group; normal rotator cuff group; and adhesive capsulitis group. After establishing a posterior standard viewing portal, intravenous administration of ICG at 0.2 mg/kg body weight was performed, and fluorescence images were recorded. The time from injection of the drug to the beginning of enhancement of the observed area was measured. The hypovascular area in the rotator cuff was evaluated, and the ratio of the hypovascular area to the anterolateral area of the rotator cuff tendon was calculated (hypovascular area ratio).Objectives
Methods
The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes. A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed.Objectives
Methods
Methods. Between 2005 and 2012, 50 patients (23 female, 27 male) with
nonunion of the humeral shaft were included in this retrospective
study. The mean age was 51.3 years (14 to 88). The patients had
a mean of 1.5 prior operations (. sd. 1.2;1 to 8). All patients were assessed according to a specific risk score
in order to devise an optimal and individual therapy plan consistent
with the Diamond Concept. In 32 cases (64%), a change in the osteosynthesis
to an angular stable locking compression plate was performed. According
to the individual risk an additional bone graft and/or bone morphogenetic
protein-7 (BMP-7) were applied. Results. A successful consolidation of the
Most patients with a nightstick fracture of the
ulna are treated conservatively. Various techniques of immobilisation or
early mobilisation have been studied. We performed a systematic
review of all published randomised controlled trials and observational
studies that have assessed the outcome of these fractures following
above- or below-elbow immobilisation, bracing and early mobilisation.
We searched multiple electronic databases, related bibliographies and
other studies. We included 27 studies comprising 1629 fractures
in the final analysis. The data relating to the time to radiological
union and the rates of delayed union and
This study was performed to determine whether
pure cancellous bone graft and Kirschner (K-) wire fixation were sufficient
to achieve bony union and restore alignment in scaphoid
There have been only a few small studies of patients
with an infected shoulder replacement treated with a single-stage
exchange procedure. We retrospectively reviewed 35 patients (19 men
and 16 women) with a peri-prosthetic infection of the shoulder who
were treated in this way. A total of 26 were available for clinical
examination; three had died, two were lost to follow-up and four
patients had undergone revision surgery. The mean follow-up time was
4.7 years (1.1 to 13.25), with an infection-free survival of 94%. The organisms most commonly isolated intra-operatively were Single-stage exchange is a successful and practical treatment
for patients with peri-prosthetic infection of the shoulder. Cite this article:
The Motec cementless modular metal-on-metal ball-and-socket
wrist arthroplasty was implanted in 16 wrists with scaphoid nonunion
advanced collapse (SNAC; grades 3 or 4) and 14 wrists with scapholunate
advanced collapse (SLAC) in 30 patients (20 men) with severe (grades
3 or 4) post-traumatic osteoarthritis of the wrist. The mean age of
the patients was 52 years (31 to 71). All prostheses integrated
well radiologically. At a mean follow-up of 3.2 years (1.1 to 6.1)
no luxation or implant breakage occurred. Two wrists were converted
to an arthrodesis for persistent pain. Loosening occurred in one
further wrist at five years post-operatively. The remainder demonstrated close
bone–implant contact. The clinical results were good, with markedly
decreased Disabilities of the Arm Shoulder and Hand (DASH) and pain
scores, and increased movement and grip strength. No patient used
analgesics and most had returned to work. Good short-term function was achieved using this wrist arthroplasty
in a high-demand group of patients with post-traumatic osteoarthritis.
Bone loss involving articular surface is a challenging
problem faced by the orthopaedic surgeon. In the hand and wrist,
there are articular defects that are amenable to autograft reconstruction
when primary fixation is not possible. In this article, the surgical
techniques and clinical outcomes of articular reconstructions in
the hand and wrist using non-vascularised osteochondral autografts
are reviewed.
There is little information about the management
of peri-prosthetic fracture of the humerus after total shoulder replacement
(TSR). This is a retrospective review of 22 patients who underwent
a revision of their original shoulder replacement for peri-prosthetic
fracture of the humerus with bone loss and/or loose components.
There were 20 women and two men with a mean age of 75 years (61
to 90) and a mean follow-up 42 months (12 to 91): 16 of these had
undergone a previous revision TSR. Of the 22 patients, 12 were treated
with a long-stemmed humeral component that bypassed the fracture.
All their fractures united after a mean of 27 weeks (13 to 94).
Eight patients underwent resection of the proximal humerus with
endoprosthetic replacement to the level of the fracture. Two patients
were managed with a clam-shell prosthesis that retained the original
components. The mean Oxford shoulder score (OSS) of the original
TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean
OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival
using re-intervention for any reason as the endpoint was 91% (95%
confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at
one and five years, respectively. There were two revisions for dislocation of the humeral head,
one open reduction for modular humeral component dissociation, one
internal fixation for
Scapulothoracic fusion (STF) for painful winging
of the scapula in neuromuscular disorders can provide effective pain
relief and functional improvement, but there is little information
comparing outcomes between patients with dystrophic and non-dystrophic
conditions. We performed a retrospective review of 42 STFs in 34
patients with dystrophic and non-dystrophic conditions using a multifilament
trans-scapular, subcostal cable technique supported by a dorsal
one-third semi-tubular plate. There were 16 males and 18 females
with a mean age of 30 years (15 to 75) and a mean follow-up of 5.0
years (2.0 to 10.6). The mean Oxford shoulder score improved from
20 (4 to 39) to 31 (4 to 48). Patients with non-dystrophic conditions
had lower overall functional scores but achieved greater improvements
following STF. The mean active forward elevation increased from
59° (20° to 90°) to 97° (30° to 150°), and abduction from 51° (10°
to 90°) to 83° (30° to 130°) with a greater range of movement achieved
in the dystrophic group. Revision fusion for
Dislocation of the shoulder may occur during
seizures in epileptics and other patients who have convulsions. Following
the initial injury, recurrent instability is common owing to a tendency
to develop large bony abnormalities of the humeral head and glenoid
and a susceptibility to further seizures. Assessment is difficult
and diagnosis may be missed, resulting in chronic locked dislocations
with protracted morbidity. Many patients have medical comorbidities,
and successful treatment requires a multidisciplinary approach addressing
the underlying seizure disorder in addition to the shoulder pathology.
The use of bony augmentation procedures may have improved the outcomes
after surgical intervention, but currently there is no evidence-based
consensus to guide treatment. This review outlines the epidemiology
and pathoanatomy of seizure-related instability, summarising the
currently-favoured options for treatment, and their results.
Radial osteotomy is currently advocated for patients
with Lichtman’s stages II and IIIA of Kienböck’s disease; its place
in the treatment of patients with stage IIIB disease remains controversial.
The purpose of this study was to evaluate the medium-term results
of this procedure and to compare the outcome in patients with stage
IIIB disease and those with earlier stages (II and IIIA). A total
of 18 patients (18 osteotomies) were evaluated both clinically and radiologically
at a mean follow-up of 10.3 years (4 to 18). Range of movement,
grip strength and pain improved significantly in all patients; the
functional score (Nakamura Scoring System (NSSK)) was high and self-reported disability
(Disabilities of Arm, Shoulder and Hand questionnaire) was low at
the final follow-up in all patients evaluated. Patients with stage
IIIB disease, however, had a significantly lower grip strength,
lower NSSK scores and higher disability than those in less advanced
stages. Radiological progression of the disease was not noted in
either group, despite the stage. Radial osteotomy seems effective
in halting the progression of disease and improving symptoms in
stages II, IIIA and IIIB. Patients with less advanced disease should
be expected to have better clinical results.
In light of the growing number of elderly osteopenic
patients with distal humeral fractures, we discuss the history of
their management and current trends. Under most circumstances operative
fixation and early mobilisation is the treatment of choice, as it
gives the best results. The relative indications for and results
of total elbow replacement
This study investigated the anatomical relationship between the clavicle and its adjacent vascular structures, in order to define safe zones, in terms of distance and direction, for drilling of the clavicle during osteosynthesis using a plate and screws following a fracture. We used reconstructed three-dimensional CT arteriograms of the head, neck and shoulder region. The results have enabled us to divide the clavicle into three zones based on the proximity and relationship of the vascular structures adjacent to it. The results show that at the medial end of the clavicle the subclavian vessels are situated behind it, with the vein intimately related to it. In some scans the vein was opposed to the posterior cortex of the clavicle. At the middle one-third of the clavicle the artery and vein are a mean of 17.02 mm (5.4 to 26.8) and 12.45 mm (5 to 26.1) from the clavicle, respectively, and at a mean angle of 50° (12 to 80) and 70° (38 to 100), respectively, to the horizontal. At the lateral end of the clavicle the artery and vein are at mean distances of 63.4 mm (46.8 to 96.5) and 75.67 mm (50 to 109), respectively. An appreciation of the information gathered from this study will help minimise the risk of inadvertent iatrogenic vascular injury during plating of the clavicle.
Radiological changes and differences between cemented and uncemented components of Grammont reverse shoulder arthroplasties (DePuy) were analysed at a mean follow-up of 9.6 years (8 to 12). Of 122 reverse shoulder arthroplasties implanted in five shoulder centres between 1993 and 2000, a total of 68 (65 patients) were available for study. The indications for reversed shoulder arthroplasty were cuff tear arthropathy in 48 shoulders, revision of shoulder prostheses of various types in 11 and massive cuff tear in nine. The development of scapular notching, bony scapular spur formation, heterotopic ossification, glenoid and humeral radiolucencies, stem subsidence, radiological signs of stress shielding and resorption of the tuberosities were assessed on standardised true anteroposterior and axillary radiographs. A scapular notch was observed in 60 shoulders (88%) and was associated with the superolateral approach (p = 0.009). Glenoid radiolucency was present in 11 (16%), bony scapular spur and/or ossifications in 51 (75%), and subsidence of the stem and humeral radiolucency in more than three zones were present in three (8.8%) and in four (11.8%) of 34 cemented components, respectively, and in one (2.9%) and two (5.9%) of 34 uncemented components, respectively. Radiological signs of stress shielding were significantly more frequent with uncemented components (p <
0.001), as was resorption of the greater (p <
0.001) and lesser tuberosities (p = 0.009).
Ununited fractures of the scaphoid with extensive bone resorption are usually treated by bone grafting and internal fixation, using either an open or a minimally invasive technique. We studied the feasibility of percutaneous fixation without bone grafting in a consecutive series of 27 patients with established
A suspected fracture of the scaphoid remains difficult to manage despite advances in knowledge and imaging methods. Immobilisation and restriction of activities in a young and active patient must be balanced against the risks of
