Hemiarthroplasty for Distal Humerus Fracture: A Systematic Review and Meta-analysis for Functional Outcome

BACKGROUND: Treatment of distal humerus fractures in osteoporotic elderly patients is often challenging. For non-reconstructible fractures with open reduction and internal fixation, total elbow arthroplasty (TEA) is an acceptable alternative. However, the relatively high complication rates and lifelong activity restrictions make TEA less ideal for elderly or low-demand patients. Efforts to identify or develop alternate procedures that benefit relatively young, high-demand patients have resulted in increased interest in hemiarthroplasty. This systematic review reports the clinical outcomes of hemiarthroplasty for distal humeral fractures. METHODS: We systematically reviewed the databases of PubMed, Ovid MEDLINE, and Cochrane Library. All English-language studies published before June 2017 were considered for possible inclusion. Search terms included ‘distal humerus fracture’ and ‘hemiarthroplasty’. Studies reporting outcomes (and a minimum of 1 year clinical follow-up) in human subjects after hemiarthroplasty (Latitude system) for distal humeral fractures were assessed for inclusion. Patient demographics, clinical and radiographic outcomes, and complications were recorded, and homogenous outcome measures were analyzed. RESULTS: Nine studies with a total of 115 patients met the inclusion criteria. Among the included studies, the weighted mean follow-up time was 35.4 months. Furthermore, the weighted mean of the postoperative range of motion (107.6° flexion-extension, 157.5° for pronation-supination) and functional outcomes (Mayo elbow performance scores: 85.8, Disabilities of the Arm, Shoulder and Hand score: 19.6) were within the acceptable range. CONCLUSIONS: Our study indicates that hemiarthroplasty is a viable option for comminuted distal humerus fracture. Satisfactory functional outcomes were observed in most patients.

Cubital Tunnel Syndrome / 대한정형외과학회잡지

Cubital tunnel syndrome is compressive neuropathy, entrapment of the ulnar nerve around the medial epicondyle of the elbow joint, and the second most common neuropathy after carpal tunnel syndrome. Patients complain of hypoesthesia or paresthesia in the ulnar half of the ring and small fingers early in the disease. Advanced disease is complicated by irreversible muscle weakness or atrophy and claw hand deformity of the ring and small fingers. Although traditional decompression and anterior transposition of the ulnar nerve is known as standard treatment, according to recent reports only simple decompression has a good outcome. So, variety of surgical treatment options are available. In this paper, we purpose to describe the causes, clinical features and recent surgical treatments of cubital tunnel syndrome.

Musicians' Medicine: Musculoskeletal Problems in String Players

There is increasing attention to medical problems of musicians. Many studies find a high prevalence of work-related musculoskeletal disorders in musicians, ranging from 73.4% to 87.7%, and string players have the highest prevalence of musculoskeletal problems. This paper examines the various positions and movements of the upper extremities in string players: 1) basic postures for holding instruments, 2) movements of left upper extremity: fingering, forearm posture, high position and vibrato, 3) movements of right upper extremity: bowing, bow angles, pizzicato and other bowing techniques. These isotonic and isometric movements can lead to musculoskeletal problems in musicians. We reviewed orthopedic disorders that are specific to string players: overuse syndrome, muscle-tendon syndrome, focal dystonia, hypermobility syndrome, and compressive neuropathy. Symptoms, interrelationships with musical performances, diagnosis and treatment of these problems were then discussed.

Locking Plate for Proximal Humeral Fracture in the Elderly Population: Serial Change of Neck Shaft Angle

BACKGROUND: We conducted this radiographic study in the elderly population with proximal humeral fracture aiming to evaluate 1) the serial changes of neck-shaft angle after locking plate fixation and 2) find relationship between change in neck shaft angle and various factors such as age, fracture pattern, severity of osteoporosis, medial support and initial reduction angle. METHODS: Twenty-five patients who underwent surgical treatment for proximal humeral fracture with locking plate between September 2008 and August 2010 are included. True anteroposterior and axillary lateral radiographs were made postoperatively and at each follow-up visit. Measurement of neck shaft angle was done at immediate postoperative, 3 months postoperative and a final follow-up (average, 11 months; range, 8 to 17 months). Severity of osteoporosis was assessed using cortical thickness suggested by Tingart et al. RESULTS: The mean neck shaft angles were 133.6degrees (range, 100degrees to 116degrees) at immediate postoperative, 129.8degrees (range, 99degrees to 150degrees) at 3 months postoperative and 128.4degrees (range, 97degrees to 145degrees) at final follow-up. The mean loss in the neck-shaft angle in the first 3 months was 3.8degrees as compared to 1.3degrees in the period between 3 months and final follow-up. This was statistically significant (p = 0.002), indicating that most of the fall in neck shaft angle occurs in the first three months after surgery. Relationship between neck shaft angle change and age (p = 0.29), fracture pattern (p = 0.41), cortical thickness (p = 0.21), medial support (p = 0.63) and initial reduction accuracy (p = 0.65) are not statistically significant. CONCLUSIONS: The proximal humerus locking plate maintains reliable radiographic results even in the elderly population with proximal humerus fracture.

Erratum: Arthroplasty for Fractures of the Proximal Part of the Humerus / 대한정형외과학회잡지

The authors would like to correct Figure 1 and 2.

Arthroplasty for Fractures of the Proximal Part of the Humerus / 대한정형외과학회잡지

Comminuted proximal humeral fractures with displaced three- or four-part fragments, fracture-dislocations, and humeral head-splitting fractures are very difficult to treat. In older patients, hemiarthroplasty or reverse shoulder arthroplasty is often the indicated treatment. Arthroplasty in this patient cohort is a very technique-dependent procedure, and relies on preserving deltoid function, proper component placement and fixation, and tuberosity fixation. Although pain relief is predictable, it is often difficult to achieve functional improvement. Results depend on the patient's age, timing of the surgery, tuberosity healing, and adequate rehabilitation.

Follow-up Results in Patient with the Progressive Fatty Degeneration of the Rotator Cuff / 대한정형외과학회잡지

PURPOSE: To evaluate the influence of progressive fatty degeneration of the rotator cuff (shown on MRI after rotator cuff repair) on the clinical outcome. MATERIALS AND METHODS: At one-year postoperatively, 25 patients with progressive fatty degeneration on MRI were evaluated using the American Shoulder and Elbow Surgeon Standardized Assessment Form (ASES) score and the Constant score. RESULTS: Average ASES scores were 57.76+/-17.0 preoperatively, and had significantly increased to 84.8+/-11.9 at 1-year postoperatively, and to 92.7+/-7.7 at final follow up. Average Constant scores were 56.2+/-2 preoperatively, and had increased significantly to 78.2+/-11.7 at 1-year after surgery, and to 83.1+/-7.9 at final follow-up. All cases except 1 showed satisfactory results. Groups that showed re-tears, large tears or fatty degeneration on infraspinatus showed inferior results to those without these developments. CONCLUSION: On average 37.4 months of follow-up, clinical outcomes had improved in 96% of patients with progressive fatty degeneration of the rotator cuff. Therefore, progressive fatty degeneration on MRI at 1 year after rotator cuff repair does not influence final clinical results.

Analysis of the Change in Fatty Degeneration of the Rotator Cuff and Its Influence on the Outcome of Rotator Cuff Repair / 대한정형외과학회잡지

PURPOSE: To analyze the changes in fatty degeneration of the rotator cuff after its repair as well as the effect of fatty degeneration on the functional and anatomical outcomes. MATERIALS AND METHODS: The medical records of 107 patients (mean age=58.7 years), who had undergone a repair of rotator cuff tears, were reviewed. The mean follow-up period was 16 months. The following parameters were evaluated: the functional outcomes, including the American shoulder and elbow surgeons (ASES) score, Constant score and muscle power; preoperative and postoperative fatty degeneration of the rotator cuffs, including supraspinatus, infraspinatus and subscapularis; and the cuff integrity. RESULTS: Both the ASES and Constant scores were improved significantly postoperatively. The re-tear rate was 19.6%. The overall rate of satisfactory results was 88.8%. Fatty degeneration progressed in 25 cases (22.4%) and regressed in three (2.8%). More progression was observed in older (p=0.016) and re-tear (p=0.011) patients. The ASES score had a significant relationship with the preoperative fatty degeneration of the supraspinatus and the infraspinatus, whereas the Constant score was associated with the fatty degeneration of all three muscles. CONCLUSION: Greater progression of fatty degeneration was observed in older and re-tear patients. The functional outcomes were better in the less severe fatty degeneration group.

Apoptotic Cells and the Histopathologic Findings in Rotator Cuff Tears / 대한정형외과학회잡지

PURPOSE: We analyzed the relationship between the size of the torn rotator cuff and the frequency of finding apoptotic cells (apoptotic index) or pathological degeneration in the rotator cuff. MATERIALS AND METHODS: The edges of torn supraspinatus tendons were obtained from patients with rotator cuff tear (n=63). The study group consisted of 2 small, 22 medium, 22 large and 17 massive tears. For the histopathologic evaluation, the H&E stained sections of the torn supraspinatus tendons were examined. Apoptosis was detected with TUNEL assay. We analyzed the relationships between the tear size and the pathologic findings or the apoptotic index. RESULTS: Significant differences could not be found for the fibroblast cellularity, thickening of the synovial lining and proliferation of blood vessels according to the size of the rotator cuff tear. All the specimens had apoptotic cells that were concentrated around the margin of the tear site. The apoptotic indexes according to the tear size were 58.50 for the small tears, 27.25 for the medium tears, 33.29 for the large tears and 31.96 for the massive tears. No significant correlation was found between the tear size and the apoptotic index. CONCLUSION: There were no significant differences in the apoptotic indices, the fibroblast cellularity, the thickening of the synovial lining and the proliferation of blood vessels according to the size of the rotator cuff tear, and there were no correlations between the apoptotic index and the histopathologic findings.

Clinical Outcome and Causative Factor in Patients of Structural Failure after Rotator Cuff Repair

PURPOSE: We wanted to evaluate the relationship between the clinical outcomes and cuff integrity after open rotator cuff repair and we wanted to analyze the causes of rotator cuff retear. MATERIALS AND METHODS: 78 patients who underwent open rotator cuff repair were enrolled from 2004 to 2006. All the patients were observed for a minimum follow-up of 12 months and they were evaluated by magnetic resonance imaging (MRI). The clinical outcomes were accessed by dividing the patients into the retear group and the intact group. The groups were also compared to analyze the cause of rotator cuff retear according to the preoperative tear size, the symptom duration, and so on. RESULTS: The clinical outcome of the retear group (n=22) was improved significantly after operation (p<0.001, p<0.001), but the muscle power was not improved significantly (p=0.099, p=0.243). More retears were found in the patients who had a larger preoperative tear (p<0.001) and the symptom duration of the retear group was longer (p=0.027). CONCLUSION: Although there were retear after rotator cuff repair, the clinical outcomes were improved. Yet the muscle power of the supraspinatus and external rotator were not improved significantly. There were more retears for the cases that had a larger preoperative tear size and a longer duration of symptoms.

Proximal Humerus Fracture in Osteoporotic Bone

No abstract available.

Nonunion of the Humerus Shaft

PURPOSE: To evaluate the cause and treatment results of nonunion of humerus shaft fractures. MATERIALS AND METHODS: 39 cases were treated for humerus shaft nonunion between February 1990 and May 2002. The presence of open wounds, initial treatment modality after injury, treatment method for the nonunion and time to union were studied using medical records. The fracture type and appropriateness and problems of the initial surgical treatment were reviewed. Also, Pain and functional recovery in daily living were evaluated in the outpatient clinic, after surgery for nonunion. RESULTS: Amongst the 30 cases, transverse fracture was the most common with 19cases. Most of 29 cases, initially surgically treated, revealed incorrect selection of the internal fixator or technical errors. For surgical treatment of nonunion, open reduction and internal fixation with cancellous bone graft was performed, most commonly, in 36 cases (92.3%). All cases showed clinical and radiographic union at an average of 13.3 weeks. More than 90% of the patients replied minimal pain and excellent functional recovery of daily living at final follow-up. CONCLUSION: If treated with surgery by correct selection of internal fixation methods and accurate technical skills, nonunion incidence can be reduced.

Prognostic Factors of Hemiarthroplasty for the Proximal Humeral Fractures / 대한정형외과학회잡지

PURPOSE: The purpose of the study was to evaluate the results and analyze various prognostic factors of hemiarthroplasty for proximal humeral fractures. MATERIALS AND METHODS: Thirty-one cases, who underwent hemiarthroplasties for proximal humeral fractures, were evaluated with ASES score at a mean follow-up of 45 months (1-8 years). Global Total Shoulder (Depuy.) (TS Gr) for 21 cases, and Global FX (Depuy.) (FX Gr) for 10 cases were used. Twentysix cases were acute fractures within one month after injury. There were two cases with delayed union and three cases with nonunion. Prognostic values of age, delay of surgery, fracture type, position of the greater tuberosity and design of implant were assessed. RESULTS: The most important prognostic factor was the design of implant. Mean score of FX Gr was significantly higher than that of TS Gr (84.4 and 77.6 respectively, p=0.036). Age, fracture type, delay of surgery and position of the greater tuberosity did not show any prognostic value. CONCLUSION: The clinical results of Hemiarthroplasty specially designed for the proximal humeral fractures has better than that of preexisting implant. Design of the implant was considered to be the most important prognostic factor of hemiarthroplasty for the proximal humeral fractures.

Experimental Osteoporosis in Tail Suspended Rat / 대한정형외과연구학회지

PURPOSE: To clarify whether the bone resorption in femur measured by the expression of OPG & RANK-L was increased in tail suspended rat. MATERIALS AND METHODS: Four-week-old female Sprague Dawley rats were divided into two groups. The experimental group (n=79) was housed and fed with 2 weeks of tail suspension, and reloaded for 8 weeks without tail suspension. The control group (n=46) was housed and fed for 10 weeks without tail suspension. Bone mineral densities, serum levels of ALP and TRAP were measured in both groups. The expressions of the mRNAs of OPG and RANK-L were analyzed by RT-PCR. RESULTS: The ALP and TRAP were increased in the experimental group during both tail suspension and reloading, which reflected the increased bone metabolism in the experimental group. In femur of the experimental group, the expression of the mRNA of RANK-L was increased during tail suspension, and the expression the mRNA of OPG was decreased. With reloading, the expression of the mRNA of RANK-L in femur was decreased, while the expression of the mRNA of OPG was increased.

Retrograde Pin Fixation with Tension Band Wiring for the Proximal Humeral Fractures / 대한정형외과학회잡지

PURPOSE: To introduce a surgical technique of retrograde pin fixation with tension band wiring for the proximal humeral fractures and to evaluate the clinical results. MATERIALS AND METHODS: The clinical results of thirty-two patients who underwent surgical treatment for the proximal humeral fractures, during the period from June 1996 to June 2001, using a retrograde pin fixation with tension band wiring were reviewed. The mean followup was 2.5 years (1-5 years) Twelve patients had a two-part fracture, and twenty patients had a three-part fracture with Neer's classification. We analyzed the clinical results using Neer score and radiological state using Zyto's three-point graded scale. RESULTS: By clinical evaluation, eighteen cases (56%) were excellent, twelve cases (38%) were satisfactory, one case (3%) was unsatisfactory and one case (3%) was failure. By radiological evaluation, twenty-one cases (66%) were good, nine cases (28%) were acceptable and two cases (6%) were poor. Three unsatisfactory cases were a case with pin migration, loss of reduction or avascular necrosis. There was not a case of delayed union, nonunion or infection. CONCLUSION: Retrograde pin fixation with tension band wiring for the proximal humeral fractures was considered to be a useful method, which is easy and induces limited soft tissue injury, and provides enough stability for postoperative rehabilitation in majority cases such as surgical neck or three-part fractures.

Modified Tenson Band Fixation for Unstable Fracture of the Distal Clavicle / 대한정형외과학회잡지

PURPOSE: The aims of this study were to introduce a new surgical technique for unstable fracture of the distal clavicle, and to evaluate the clinical results. MATERIALS AND METHODS: The clinical results of nineteen patients who underwent surgical treatment for unstable fracture of the distal clavicle, during the period from March 1995 to December 1999, using a modified tension band fixation with follow up over one year were reviewed. Outcome was analyzed in terms of pain, function, radiologic result and union time. RESULTS: All cases showed satisfactory results; eighteen cases (95%) were excellent, and one case (5%) was good. Radiologic union was achieved on average at eight weeks (six-tweleve) after operation. No complications such as pin migration, metal breakage and nonunion were seen. CONCLUSION: Modified tension band fixation for unstable fracture of the distal clavicle was found to be a useful method, which is easy and induces no injury of the acromioclavicular joint, and provides enough stability for postoperative rehabilitation.

Anatomical Repair of Massive Rotator Cuff Tear / 대한정형외과학회잡지

PURPOSE: We evaluate the possibility of the anatomical repair of massive rotator cuff tear and review the clinical results. MATERIALS AND METHODS: From March 1995 to June 1999, twenty-six cases of massive rotaor cuff tear were reviewed with minimal followup of one year. The clinical results were evaluated using ASES (American Shoulder and Elbow Surgeons) score. RESULTS: Twenty two cases (85%) showed satisfactory results, 8 excellent results (31%) and 14 good results (54%). There were four cases (15%) of unsatisfactory results, two cases of fair and two cases of poor results. Mean value of the ASES score increased from 41 (14-60) points to 83 (46-98) points. Mean value of the increased score was 42 (20-76) points. There were no cases of functional deterioration or revision surgery. CONCLUSION: Anatomical repair was considered to be practically possible in the majority of cases of massive rotator cuff tear as an initial treatment.

Analysis of West Point View in Anterior Shoulder Instability / 대한정형외과학회잡지

PURPOSE: To evaluate the usefulness of the West point view, we investigated the osseous pathology of the glenoid rim associated with shoulder instability and estimate the inter-observer reliability. MATERIALS AND METHODS: The West point views of sixty-seven patients with labral lesion confirmed by operation were mixed with those of thirty-three normal controls. Six observers independently reviewed the mixed radiographs and checked the lesion by identifying the glenoid erosion, bony defect, ectopic ossification and Hill-Sachs lesion. The incidence of osseous lesions suggesting instability was estimated. Sensitivity in the patient group, specificity in the normal control and inter-observer reliability were calculated to evaluate study susceptibility. RESULTS: The sensitivity of 67 patients group was 81.8% on average (73-94%), the specificity of 33 member control group was 85.2% (82-94%). The most frequent finding was glenoid erosion, with an average of 54.7%, which providing a sensitive clue of shoulder instability. Inter-observer reliability analyzed by using Kappa values showed significant agreement. (alpha=0.1 significant level). CONCLUSION: The West point view is considered to be a reliable diagnostic modality for shoulder instability. The additional sophisticated method is indicated only when a discrepancy between physical examination and radiologic findings exists.

Surgical Treatment of the Acute Acromioclavicular Joint Dislocation Using a Wolter Plate / 대한정형외과학회잡지

PURPOSE: To introduce the surgical technique of acute acromioclavicular joint dislocation using a Wolter plate and to evaluate its efficacy after surgical treatment. MATERIALS AND METHODS: Twenty-six patients who underwent surgical treatment of the acute acromioclavicular joint dislocation using a Wolter plate and who were followed up minimally for one year were reviewed. We analyzed the clinical results of pain, function, range of motion and radiologic reduction state of the acromioclavicular joint. RESULTS: All cases showed satisfactory results. By clinical evaluation, twelve cases (46%) were excellent and fourteen cases (54%) were good. By radiologic evaluation, twenty cases (77%) were excellent and six cases (23%) were good. By postoperative X-ray, vertical displacement of the clavicle was restored in all cases. No complications such as infection, loosening of screws, plate failure or redislocation after removal of the plate occurred. CONCLUSION: Acromioclavicular joint reconstruction using a Wolter plate is believed to be a useful method, which minimizes injury of the joint articular surface and provides enough stability for postoperative rehabilitation.

Cemented Fixation Method of Glenoid Prosthesis in Total Shoulder Arthroplasty in a Pig Model / 대한정형외과학회잡지

PURPOSE: To observe the amount and distribution of overflown cement on the backsurface of the glenoid prosthesis and to determine the amount of cement required for ideal fixation of the glenoid prosthesis. MATERIALS AND METHODS: 48 keeled type glenoid prostheses (Global total shoulder, Depuy Co., U.S.A.) were fixed with four different volumes of cement (fully filled in the slots, and cement removed to depths of 4, 7 and 10 mm) to the scapulae of mature pigs, in which 46 scapulae that could be freed from the prostheses were investigated in terms of the amount and distribution of the leaked cement by gross inspection and evaluation using Arc view GIS 8.1. RESULTS: The cement overflowed in an irregular fashion. The average ratio of the area covered by leaked cement to glenoid surface was 30.7% (12.9-52.2) in 27 cases, in which the slots were completely filled by cement; 19% (13.4-29.9) in 6 cases in which a 4 mm depth of cement was removed from the slots; 1.8% (-7.5~16.8) in 8 cases in which a 7 mm depth of cement was removed from the slots; -10.2% (-15.8~-5.2) in 5 cases in which a 10 mm depth of cement was removed from the slots. CONCLUSION: It is impossible to prevent leakage of cement behind the backsurface of the glenoid prosthesis with the conventional cemented fixation method. This can be prevented by removing the equivalent amount of cement before inserting the prosthesis.