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Purpose: Recent publications emphasized the role of dorsomedial metaphyseal extension of humeral head as predictor of ischemia after complex proximal humerus fractures (PHFs). We evaluated on preoperative 3D CT scan of PHFs the surface of this metaphyseal extension and its prognostic value on the occurrence of avascular necrosis (AVN). Methods: We followed a series of 25 fixations of complex PHF which had a preoperative 3D CT scan and measured the surface area of the posterior metaphyseal extension (PME) of the head. Using approximations, we calculated the ratio between the PME surface area (PMS) and the articular surface area of the head (HS). The PMS/HS ratio was analyzed against the risk of AVN. Results: The measurement of the PMS/HS ratio emphasizes the significance of PME. The incidence of AVN is correlated with the magnitude of PME. Therefore, we include the PME as a fifth element in the characterization of complex PHFs and we propose a 4-stage prognostic classification based on the number of extensions of the humeral head. The head may have 3 extensions: posteromedial (PME), lesser tuberosity (LTE) and greater tuberosity (GTE). The risk of AVN decreases with the number of extensions of the head. Conclusion: Our study demonstrates a correlation between the occurrence of AVN and the size of PME in complex PHF cases. We propose a four-stage classification system to facilitate treatment decision-making between fixation and prosthesis. [ABSTRACT FROM AUTHOR]

Aims: To develop a reliable and effective radiological score to assess the healing of isolated ulnar shaft fractures (IUSF), the Radiographic Union Score for Ulna fractures (RUSU). Methods: Initially, 20 patients with radiographs six weeks following a non-operatively managed ulnar shaft fracture were selected and scored by three blinded observers. After intraclass correlation (ICC) analysis, a second group of 54 patients with radiographs six weeks after injury (18 who developed a nonunion and 36 who united) were scored by the same observers. Results: In the initial study, interobserver and intraobserver ICC were 0.89 and 0.93, respectively. In the validation study, the interobserver ICC was 0.85. The median score for patients who united was significantly higher than those who developed a nonunion (11 vs. 7, p < 0.001). A ROC curve demonstrated that a RUSU ≤ 8 had a sensitivity of 88.9% and specificity of 86.1% in identifying patients at risk of nonunion. Patients with a RUSU ≤ 8 (n = 21) were more likely to develop a nonunion (n = 16/21) than those with a RUSU ≥ 9 (n = 2/33; OR 49.6, 95% CI 8.6–284.7). Based on a PPV of 76%, if all patients with a RUSU ≤ 8 underwent fixation at 6 weeks, the number of procedures needed to avoid one nonunion would be 1.3. Conclusion: The RUSU shows good interobserver and intraobserver reliability and is effective in identifying patients at risk of nonunion six weeks after fracture. This tool requires external validation but may enhance the management of patients with isolated ulnar shaft fractures. [ABSTRACT FROM AUTHOR]

Purpose: To assess longer-term (> 5 years) function and outcome in patients treated with anatomic locking plates for proximal humerus fractures. Methods: This retrospective cohort study was conducted at an urban, academic level 1 trauma center and an orthopedic specialty hospital. Patients treated operatively for proximal humerus fractures with an anatomic locking plate by three orthopedic trauma surgeons and two shoulder surgeons from 2003 to 2015 were reviewed. Patient demographics and injury characteristics, disabilities of the arm, shoulder, and hand (DASH) scores, complications, secondary surgeries, and shoulder range of motion were compared at 1 year and at latest follow-up. Results: Seventy-five of 173 fractures were eligible for analysis. At a minimum 5 years and a mean of 10.0 ± 3.2 years following surgery, DASH scores did not differ from one-year compared to long-term follow-up (16.3 ± 17.4 vs. 15.1 ± 18.2, p = 0.555). Shoulder motion including: active forward flexion (145.5 vs. 151.5 degrees, p = 0.186), internal rotation (T10 vs. T9, p = 0.204), and external rotation measurements (48.4 vs. 57.9, p = 0.074) also did not differ from one year compared to long-term follow-up. By one year, all fractures had healed. After 1-year post-operatively, four patients underwent reoperation, but none for AVN or screw penetration. Conclusions: Patient-reported functional outcome scores and shoulder range of motion are stable after one year following proximal humerus fracture fixation, and outcomes do not deteriorate thereafter. After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms. [ABSTRACT FROM AUTHOR]

Purpose: Although mortality prediction tools are the subject of significant interest as components of comprehensive hip fracture protocols, few have been applied or validated to prospectively inform ongoing patient management. Five regional hospitals are currently generating real-time mortality risk scores for all adults at the time of admission using available laboratory and comorbidity data (Cowen et al. J Hosp Med 9(11):720–726, 2014). Although results for aggregated conditions have been published, the primary aim of this study is to determine how well prospectively calculated scores predict mortality for hip fracture patients specifically. Methods: Using a five-hospital database, 1376 patients who were prospectively scored on admission were identified from January 2013 to April 2017, cross-referencing ICD9/10 diagnosis and procedure codes for AO/OTA 31A1 through 31B3 fractures. Prospective mortality scores have been previously divided into 5 risk categories to facilitate ease of clinical use. Vital status was determined from hospital data, Social Security and Michigan Death Indices. Results: Prospective scores demonstrated good mortality prediction, with AUCs of 0.80, 0.73, 0.74 and 0.74 for in hospital, 30-, 60- and 90-day mortality, respectively. Patients in the top 2 mortality risk categories represented 30% (410/1376) of the cohort and accounted for 78% (25/32) of the inpatient and 59% (57/97) of the 30 day deaths. Conclusions: Implementation of this real-time mortality risk tool is feasible and valid for the prediction of short- to medium-term mortality risk for hip fracture patients, and potentially offers valuable information to guide ongoing patient management decisions such as admitting service or level of care. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to assess patients with Parkinson's disease (PD) in comparison with patients without PD for the treatment of hip fractures. Therefore, we performed a mono-centre study including 145 patients with PD and 2135 consecutive patients without PD as a concurrent group (C). Methods: For analysis, we used our database, in which any type of hip fracture was enrolled. The study period ranged from 2007 to 2017, and the patient age was ≥ 60 years. Overall, 10 variables were included. The primary measures were operations for any reason, infection, dislocation, failure, and mortality. The secondary outcome was any de novo fracture based on a new fall. The follow-up period for every living patient was 2 years after the operation. Any missing data were retrospectively evaluated via telephone. The hypothesis was no effect between the two groups. Results: No significant differences were observed regarding revision (p = 0.348), infection (p = 0.207), dislocation (p = 0.785), failure of internal fixation (p = 0.368), failure of replacement (p = 0.174), and de novo fractures (p = 0.287). However, patients with PD sustained a contralateral hip fracture significantly more often (p < 0.001). Kaplan–Meier survival analysis demonstrated no effects up to 2 years after the operation (log rank 0.259). Conclusion: Compared to a concurrent group, patients with PD demonstrated no more complications and similar mortality rates within 2 years after surgery. The rate of dislocation after hip replacement was also not increased. A contralateral hip fracture was the most common de novo fracture in PD. Further studies should investigate measures reducing the risk for any new falls in PD. [ABSTRACT FROM AUTHOR]

Introduction: Undisplaced femoral neck fractures (UFNF) are generally treated with in situ internal fixation, and few studies have addressed the impact of closed reduction. The aim of this study was to investigate the clinical outcome of UFNF treated with internal fixation using the Hansson pinloc system after closed reduction.Patients and methods: This was a retrospective study of 40 patients who underwent internal fixation using the Hansson pinloc system after closed reduction between September 2014 and May 2016. In the present study, posterior tilt, presence of complete fracture, interval from injury to surgery, and changes in activities of daily living were statistically analyzed to investigate the association between nonunion and late segmental collapse (LSC).Results: Five cases each of nonunion and LSC were identified. The frequency of LSC was significantly higher in patients with preoperative posterior tilt ≥ 20° (p < 0.05). The risks of nonunion and LSC were lower in patients with incomplete fracture (p < 0.05) and fixation within 48 h (p < 0.05). Of the 40 patients, 34 were categorized in the sufficient reduction group fixed with posterior tilt ≤ 5°. Secondary operation rate was lower in the sufficient reduction group (5/34 cases) than in the insufficient reduction group (3/6 cases).Discussion: The fixation timing < 48 h decrease the risk of fracture healing complications and sufficient reduction may reduce the risk of secondary operation. Preoperative posterior tilt ≥ 20° and complete fractures on CT scans were related to poor prognosis. [ABSTRACT FROM AUTHOR]

Background: Our primary goal was to audit the incidence of erythrocyte blood transfusion (EBT) after hip fracture surgery and study the effects on perioperative complications and early and late mortality. Methods: In a retrospective cohort study all patients 65 years old and above treated operatively for an acute hip fracture were included over a 48-month period with a 2-year follow-up period. Postoperative hemoglobin levels were used to investigate at what threshold EBT was used. The relation between EBT and perioperative complications and survival was analyzed with multivariate regression analysis. A propensity score for predicting the chance of receiving an EBT was calculated and used to differentiate between transfusion being a risk factor for mortality and other related confounding risk factors. Mortality was subdivided as in-hospital, 30-day, 1-year and 2-year mortality.Results: Of the 388 included patients, 41% received a blood transfusion. The postoperative hemoglobin level was the strongest predictor for EBT. Patients who received EBT had a significant longer hospital stay and more postoperative cardiac complications, even after adjustment for confounders. Multivariate analysis for mortality showed that EBT was a significant risk factor for early as well as late mortality, but after adding the propensity score, EBT was no longer associated with increased mortality.Conclusion: There was no effect of EBT on mortality after correction with propensity scoring for predictors of EBT. Transfusion in patients treated operatively for hip fracture should be evenly matched with their cardiovascular risk during the perioperative phase. [ABSTRACT FROM AUTHOR]

Background: Screw-plates disassembly incidence after pertrochanteric fracture (PF) amounts to 1 and 16% among the elderly population. The main occurrence is early cervical screw cut-out. The population at highest risk of disassembly remains difficult to identify. The correlation between femoral offset loss and disassembly occurrence has never been surveyed.Objectives: A radiological prognosis score for screw plate disassembly was defined to reflect trochanteric impaction (TI); it was based on a femoral offset ratio.Study design and methods: Our single-centre retrospective case-control study surveyed patients suffering from Dynamic Hip Screw (DHS, Synthes®) disassembly following osteosynthesis of non-pathological osteoporotic PF between 2004 and 2014. All cases were categorised by age and gender and paired to three patients in the control group. The primary endpoint was TI measurement, corresponding to offset loss on the operated hip compared to healthy hip offset and expressed as a percentage. The measurement was done on an immediate postoperative X-ray. The secondary endpoints were tip apex distance (TAD) measurement, Ender and AO classifications, as well as postoperative weight-bearing prescription.Results: Twenty-three cases and 69 controls were surveyed. The case group’s average age was 87; 70% of the cases were women. The main disassembly occurrence delay was after 27 days. Average TI was 26% within the patients global group and 12% within the control group (p < 10−5). Over a 21% impaction percentage, disassembly occurrence represents a greater risk: OR = 21.95% CI [5.4-104.3], p < 10−5. Ender 3 type fractures were the most frequent indication for surgery within the case group. Average TAD was 20 mm within the case group, and 17 mm within the control group (p = 0.03). The weight-bearing prescription rate was 52% within the control group and 21% within the case group (p = 0.014). 14.5% of the control group had a TI > 21%.Conclusions: Using the offset ratio tool, TI measurement was associated with a greater risk of DHS disassembly when it was higher than 21%. The exclusive use of a DHS device does not seem optimal for a TI > 21%. Weight-bearing may be prescribed for all the patients with a TI < 21%, provided good implant positioning is secured. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study in adult patients with a distal radial fracture was to determine whether socioeconomic status influenced the epidemiology, mechanism of injury, fracture severity, or the outcome according to function, radiographic assessment, and rate of associated complications. Methods: We identified 3983 distal radial fractures over a 7-year period. Socioeconomic status was assigned using the Carstairs score, and the population was divided into quintiles depending on deprivation. Patient demographics, mechanism of injury, fracture severity, and radiographic assessment at time of injury were assessed for epidemiological differences according to social quintile. Functional outcome was assessed using grip strength, Moberg pickup test, return to normal use of the hand, and range of movement. Radiographs were assessed at 1 week, 6 weeks, and 1 year. Complications were defined as malunion, carpal tunnel syndrome, complex regional pain syndrome (CRPS), persistent pain, and subjective cosmetic deformity of the wrist. Results: Socioeconomically deprived patients were significantly younger ( p < 0.001) and more likely to be male ( p = 0.017); after adjusting for confounding factors, deprived patients were 3.1 (95% CI 1.4-4.7) years younger than the most affluent patients ( p < 0.001). Deprived patients were more likely to sustain their fracture by a high-energy mechanism ( p = 0.004). There were no significant differences between quintiles in outcome. There was a significantly greater prevalence of CRPS in more affluent patients ( p = 0.004). Conclusions: Socioeconomically deprived patients sustaining a distal radial fracture are more likely to be younger and male. Outcome is not influenced by socioeconomic status, but the prevalence of CRPS is greater in more affluent patients. [ABSTRACT FROM AUTHOR]

Background: Intramedullary fixation of midclavicular fractures has been described as a minimally invasive operation with few complications. The purpose of this study was to assess the effectiveness of the threaded elastic intramedullary nail (TEIN, made in Kang Li Min Medical Devices Co. Ltd., Tianjin, China) in the treatment of midclavicular fractures. Methods: Between 2010 and 2013, 45 patients with midclavicular fractures, who received closed reduction and intramedullary fixation, were treated with the TEIN in our department. Clinical outcomes were evaluated after a follow-up of 14 (3-42) months. We used the Constant score and the disabilities of the arm, shoulder and hand (DASH) scale to determine the outcomes. Results: The mean time of the operation was 22.4 (13-40) min. The rate of the closed reduction was 64 %. The mean time of the follow-up was 14 (3-42) months. With regard to complications, there was no occurrence of neurovascular impairment, pulmonary injuries, infection, shortening, refracture or nonunion. All of the patients displayed excellent shoulder function, with a mean Constant shoulder score of 96.5 (64-100) and a mean DASH score of 1.4 (range 0-100) at the latest follow-up. Conclusion: Closed reduction and intramedullary fixation of midclavicular fractures with the TEIN present a safe and minimally invasive surgical technique, achieving excellent aesthetic and early recovery after surgery. Level of evidence: Treatment Study, Level II. [ABSTRACT FROM AUTHOR]