Distal humerus fracture in older patients: ORIF vs. total elbow arthroplasty.

Distal humerus fractures are a contemporary problem because the life expectancy, autonomy and functional demands of older patients continue to grow. This is combined with surgical advances in bone reconstruction, especially in fragile patients. A distal humerus fracture in an older adult is a serious injury with an uncertain prognosis. In fact, damage to the elbow joint in this complex anatomical area overwhelmed by low-quality bone occurs in patients who often have unfavorable characteristics (fragile skin, low physiological reserves, organ failure) combined with pharmaceutical treatments that can be iatrogenic. The treatment indication must not be based solely on the conventional radiographs used for classification purposes; the fracture and bone quality must be analyzed in three dimensions. Also, the surgeon must understand the patient's needs, worries and risks fully to decide between conservative treatment and anatomical locking plate fixation or elbow arthroplasty (hemi or total). In the end, the chosen treatment must allow at least 100̊ and preferably 120̊ of flexion-extension at the elbow. In this age range, the choice between arthroplasty and plate fixation is definitive; the surgical approach must make it possible to carry out either option, with arthroplasty implants available in case the trochlear fracture cannot be plated. The aim of this lecture is to provide a fresh perspective on the anatomy of the distal humerus, its fracture and the best surgical approaches, discuss how to decide on the indication, outline the safest and most reliable ways to reconstruct and stabilize the elbow, and lastly, summarize the expected outcomes and potential complications of each treatment option. Level of evidence: V; expert opinion.

Reproducibility of the Mayo and Schatzker classification systems in proximal ulna fractures.

INTRODUCTION: A fracture classification system should provide a reliable and reproducible means of communication between different parties. It should be logical and understandable, with few categories to memorize. The aim of this study was to determine the intra- and interobserver reliability of the Schatzker and Mayo classification systems for the assessment of proximal ulna fractures. MATERIALS AND METHODS: Intra- and interobserver reliability studies were conducted on 39 X-rays of injured elbows drawn randomly from 74 cases previously used in a series on predictors of ulnohumeral osteoarthritis in proximal ulna fractures. Ten observers independently reviewed these X-rays on 2 separate occasions 3 months apart. The fracture type was assessed according to the Schatzker and Mayo classification systems during each reading session. Cohen's and Fleiss' kappa were used to measure the intra- and interobserver reliability. RESULTS: The Schatzker classification had a fair interobserver reliability for the first (Schatzker R1, Fleiss' κ: 0.394) and second (Schatzker R2, Fleiss' κ: 0.351) readings. The mean intraobserver reliability value between the 10 reviewers for the Schatzker classification was rated as substantial (0.61). The Mayo classification had a fair interobserver reliability for the first (Mayo R1, Fleiss' κ: 0.278) and second (Mayo R2, Fleiss' κ: 0.292) readings. The mean intraobserver reliability value between the 10 reviewers for the Mayo classification was rated as fair (0.52). DISCUSSION: The classification systems for proximal ulna fractures showed poor reproducibility between the different observers since they had low interobserver agreement values. Nevertheless, their use remained reliable since the measured intraobserver agreement value was deemed substantial. LEVEL OF EVIDENCE: IV; retrospective.

Assessment of intraoperative bleeding in reverse shoulder arthroplasty - with or without a stem.

INTRODUCTION: The functional results of stemless reverse shoulder prostheses are similar to those with stems. However, the operative time and the bleeding appear less significant because of the absence of humeral reaming. To date, the data amongst the literature regarding this subject is limited. Thus, we report a retrospective evaluation on these 2 types of prostheses by assessing their respective intraoperative blood loss. HYPOTHESIS: Reverse shoulder arthroplasty without a stem leads to less blood loss, compared to arthroplasty with a stem. MATERIALS AND METHODS: Twenty-three patients underwent an operation for a stemless prosthesis, while 37 patients had a prosthesis with a stem. The hemoglobin was measured preoperatively, as well as postoperatively. Drainage of the operative site was maintained for two to three days. In the stem group, the preoperative hemoglobin was 14g/dL (11.7-16.6), while it was 13.1g/dL (11-15.8) in the stemless group. RESULTS: The intraoperative bleeding reached 223cm3 (80-530), with an operative duration of 81minutes (40-110) in the stemless group, compared to 260cm3 (50-1000) and 92minutes (33-110) in the stem group. On the first day postoperatively, 333cm3 (20-570) of blood had been collected by drainage for the stemless group, compared to 279cm3 (40-550) in the stem group. The amount decreased the second day, with 139cm3 (20-510) and 129cm3 (0-750) respectively. There was no difference between the two groups regarding the postoperative hemoglobin level (11g/dL). DISCUSSION: There is no significant difference concerning the blood loss between reverse shoulder replacements with and without stems. LEVEL OF EVIDENCE: III Retrospective case control study.

Variability of shoulder girdle proprioception in 44 healthy volunteers.

BACKGROUND: Improved knowledge of normal shoulder girdle proprioception should benefit the treatment and rehabilitation of shoulder disorders. Whereas many of the available methods for assessing joint position sense (JPS) are costly and complex, Balke et al. have described a simple test. The primary objective of this study was to use this test to identify factors that influence shoulder-girdle JPS evaluation in healthy individuals. The secondary objective was to determine reference values based on the values obtained and on the factors associated with their variability. HYPOTHESIS: Age and dominant limb influence the results of shoulder girdle JPS evaluation, creating a need for reference values that take these factors in account. PATIENTS AND METHODS: A single-centre prospective study of healthy volunteers was performed between September 2012 and January 2013. In each volunteer, shoulder repositioning accuracy was assessed bilaterally as described by Balke et al. A line was drawn on the floor parallel to and 1 metre away from a wall. A target on the wall showed marks corresponding to three angles of arm elevation: 55°, 90°, and 125°. The volunteer was asked to raise the arm to the three positions, in abduction and in flexion, while memorising the joint positions, then to replicate the same positions with the eyes closed. The absolute differences between the replicated positions and the reference positions, designated angle deviations, were measured in degrees. Age, sex, and dominant upper limb were recorded. RESULTS: The 88 shoulders of 44 healthy volunteers were studied. No significant difference was found between males and females (p>0.05). The only significant difference between sides was better replication by the dominant arm of flexion at 55° (p=0.03). By univariate analysis, age was the only factor significantly associated with repositioning errors (p=0.003); neither dominant limb nor sex were significant (p=0.29 and p=0.59, respectively). In flexion, the angle deviation increased significantly with movement amplitude. The measurements were used to create a chart of expected angle deviations in healthy individuals according to age and to plane and amplitude of movement. DISCUSSION: The test described by Balke et al. is simple and feasible in everyday practice. Age, dominance, and plane of movement should be considered when evaluating abnormal shoulders. Further studies in larger numbers of individuals are needed to better define normal angle deviations related to these factors. LEVEL OF EVIDENCE: IV.

Treatment of distal radius fractures with locking plates: an update.

Internal fixation with volar locking plates has revolutionized the treatment of distal radius fractures. Manufacturers have introduced plate designs that closely follow the anatomy of the distal radius. However, use of volar plates has also led to the emergence of new types of complications. While the use of monoaxial or polyaxial locking screws and of minimally invasive techniques (arthroscopy, preservation of pronator quadratus) increases the cost of the surgical procedure, it results in a tangible benefit for patients, allowing them to move their wrist almost immediately after surgery and to quickly regain their autonomy. We reviewed the literature to analyze the level of proof.

Cementless anatomical prosthesis for the treatment of 3-part and 4-part proximal humerus fractures: cadaver study and prospective clinical study with minimum 2 years followup.

INTRODUCTION: The purpose of this study was to evaluate the functional and radiological outcomes of a cementless, trauma-specific locked stem for 3- and 4-part proximal humeral fractures. MATERIALS AND METHODS: This study consisted of two parts: a cadaver study with 22 shoulders and a multicenter prospective clinical study of 23 fracture patients evaluated at least 2 years after treatment. In the cadaver study, the locked stem (Humelock(TM), FX Solutions) and its instrumentation were evaluated. In the clinical study, five senior surgeons at four different hospitals performed the surgical procedures. An independent surgeon evaluated the patients using clinical (Constant score, QuickDASH) and radiological (X-rays, CT scans) outcome measures. RESULTS: The cadaver study allowed us to validate the height landmarks relative to the pectoralis major tendon. In the clinical study, at the review, abduction was 95° (60-160), forward flexion was 108° (70-160), external rotation (elbow at body) was 34° (0-55), the QuickDASH was 31 (4.5-59), the overall Constant score was 54 (27-75), and the weighted Constant score was 76 (31.5-109). DISCUSSION: This preliminary study of hemiarthroplasty (HA) with a locked stem found results that were at least equivalent to published series. As all patients had at least a 2-year follow-up, integration of the locked stem did not cause any specific complications. These results suggest that it is possible to avoid using cement when hemiarthroplasty is performed for the humeral stem. This implant makes height adjustment and transosseous suturing of the tuberosities more reproducible.

Early postoperative improvements in the QuickDASH score after distal radius fracture are related to the type of surgical treatment.

The goal of this prospective study was to evaluate the real-life experience of 52 patients and their recovery kinetics in the first 6 weeks after surgical treatment of distal radius fractures. The fractures were treated with either a fourth-generation volar locking plate (34 patients, mean age 67 years, range 54-82) or by percutaneous pinning (18 patients, mean age 56 years, range 43-69). These patients were evaluated every week for 6 weeks with the QuickDASH (QD) questionnaire. A lower QD score indicated that the patient's physical function and symptoms had improved. At postoperative week 1, all the patients who had undergone percutaneous pinning had a QD of 80 (out of 100). One-third of patients who had undergone plate fixation had a QD of 80, while the remainder had a QD of 65. Out of all the patients who had a QD of 80 at postoperative week 1, the patients who had undergone plate fixation improved more quickly. After 6 weeks, the patients who had undergone plate fixation had a greater reduction in the QD (50 points) than the ones who had undergone pinning (30 points). Although the direct costs of locking plate fixation are 10 times higher than those of K-wire pinning, evidence suggests that these plates reduce the indirect costs. This study has shown that a patient's recovery rate, day-to-day life and physical function are better over the first 6 weeks postsurgery when the distal radius fracture is fixed with a locking plate.

Plate fixation of distal radius fracture and related complications.

INTRODUCTION: Distal radius fractures are common. In cases where surgical treatment is needed, volar plates can be used to obtain stable, long-lasting fixation. The design of these plates has continually improved over the years, but complications remain a problem. PURPOSE: The goal of this study was to evaluate the types of complications that occur with different types of volar plates with a view towards preventing them. MATERIALS AND METHODS: The emergency department at our hospital saw 524 patients with distal radius fractures between 2006 and 2008. Some of these were treated surgically with a volar plate. All of the post-operative complications were documented. RESULTS: With a minimum follow-up of 6 months, 152 patients who had undergone plate fixation were reviewed: 31 had received plates with non-locking screws or uniaxial locking screws and 121 had received plates with polyaxial locking screws. The complication rate was similar in these two groups (16.1 and 16.5%, respectively). The main complications were tendon ruptures and problems related to the plate itself. DISCUSSION: Plate-related complications have been described in published studies, but few of these studies link them to the plate design or surgical technique. Manufacturers must continue to refine these plates to minimise their thickness while keeping their strength. Surgeons must be sure to use a highly exacting technique.

Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty.

HYPOTHESIS: Reverse shoulder arthroplasty in complex shoulder fractures is now a common practice. Unfortunately, loss of rotation is observed when tuberosity excision is used, impairing function and patient satisfaction. The purpose of this study was to evaluate the advantage of tuberosity repair in terms of the functional result. MATERIALS AND METHODS: We reviewed 41 patients, with a mean age at trauma of 76.9 years, at a mean follow-up of 24 months. Tuberosities were repaired in 27 patients and totally removed in the other 14 cases. RESULTS: Two-thirds of the repaired tuberosities consolidated in anatomic position. We compared a group with tuberosity healing in anatomic position versus a group without repair and with malunion or nonunion of the tuberosities. In the first group, all sectors of motion, especially external rotation (49° vs 10°), were improved and both Constant scores (65 vs 50) and Disabilities of the Arm, Shoulder and Hand scores (30 vs 40) were significantly better. CONCLUSION: Management of complex fractures of the superior extremity of the humerus by reverse shoulder arthroplasty is an accepted approach, but such treatment is restricted to elderly patients. Shoulder rotational ability is improved by systematically repairing the tuberosities around the implant. However, their consolidation should be anatomic; otherwise, the result is impaired by the lack of rotation. Nonunion or malunion does not lead to a functional disaster, as is sometimes the case with hemiarthroplasty without tuberosity healing.