A randomized controlled trial of nonoperative treatment versus open reduction and internal fixation for stable, displaced, partial articular fractures of the radial head: the RAMBO trial.

BACKGROUND: The choice between operative or nonoperative treatment is questioned for partial articular fractures of the radial head that have at least 2 millimeters of articular step-off on at least one radiograph (defined as displaced), but less than 2 millimeter of gap between the fragments (defined as stable) and that are not associated with an elbow dislocation, interosseous ligament injury, or other fractures. These kinds of fractures are often classified as Mason type-2 fractures. Retrospective comparative studies suggest that operative treatment might be better than nonoperative treatment, but the long-term results of nonoperative treatment are very good. Most experts agree that problems like reduced range of motion, painful crepitation, nonunion or bony ankylosis are infrequent with both nonoperative and operative treatment of an isolated displaced partial articular fracture of the radial head, but determining which patients will have problems is difficult. A prospective, randomized comparison would help minimize bias and determine the balance between operative and nonoperative risks and benefits. METHODS/DESIGN: The RAMBO trial (Radial Head - Amsterdam - Amphia - Boston - Others) is an international prospective, randomized, multicenter trial. The primary objective of this study is to compare patient related outcome defined by the 'Disabilities of Arm, Shoulder and Hand (DASH) score' twelve months after injury between operative and nonoperative treated patients. Adult patients with partial articular fractures of the radial head that comprise at least 1/3rd of the articular surface, have ≥ 2 millimeters of articular step-off but less than 2 millimeter of gap between the fragments will be enrolled. Secondary outcome measures will be the Mayo Elbow Performance Index (MEPI), the Oxford Elbow Score (OES), pain intensity through the 'Numeric Rating Scale', range of motion (flexion arc and rotational arc), radiographic appearance of the fracture (heterotopic ossification, radiocapitellar and ulnohumeral arthrosis, fracture healing, and signs of implant loosening or breakage) and adverse events (infection, nerve injury, secondary interventions) after one year. DISCUSSION: The successful completion of this trial will provide evidence on the best treatment for stable, displaced, partial articular fractures of the radial head. TRIAL REGISTRATION: The trial is registered at the Dutch Trial Register: NTR3413.

Early experience with computer-assisted shoulder hemiarthroplasty for fractures of the proximal humerus: development of a novel technique and an in vitro comparison with traditional methods.

A computer-assisted technique was developed for treatment of 4-part proximal humeral fractures via a hemiarthroplasty and tuberosity fixation. This was compared with a standard traditional method in 7 pairs of cadaveric shoulders. The computer-assisted technique used preoperative computed tomography data and computer simulations of anatomic characteristics of the contralateral humerus. This allowed accurate anatomic reconstruction by use of an electromagnetic tracking system and real-time intraoperative feedback. Various anatomic measurements were used to quantify the accuracy of the reconstruction. The differences between the intact and reconstructed values were improved with the computer-assisted technique for 5 of 7 characteristics. However, this was statistically significant only for humeral head offset (P < .05). With further investigation and refinement, this technique should allow for a more anatomic reconstruction of the proximal humerus, potentially resulting in improved patient outcomes. The technique may also prove to be a valuable resource for the laboratory training of inexperienced surgical trainees.

Reliability and comparison of acromion assessment techniques on X-ray and magnetic resonance imaging (reliability of acromion assessment techniques).

OBJECTIVE: To determine the reliability and correlation of plain radiography and magnetic resonance imaging (MRI) in the assessment of acromion morphology. MATERIALS AND METHODS: Acromion morphology was assessed using the lateral acromion angle (LAA) and the acromion-humeral interval (AHI). Thirty patients who had X-rays and MRI for impingement syndrome were included. Six blinded observers assessed the acromion morphology subjectively and objectively. RESULTS: Neither acromion assessment technique demonstrated a positive correlation (kappa and intraclass coefficient < 0.55) between X-ray and MRI. Both techniques were reliable (kappa and intraclass coefficient > 0.55) when measured objectively by experienced observers. CONCLUSION: The LAA and the AHI are both reliable acromion assessment techniques on X-ray and MRI when measured objectively and by experienced observers.

Functional outcome of AO type C distal humeral fractures.

PURPOSE: To review the functional outcome of AO type C distal humeral fractures (bicondylar fractures) managed with dual orthogonal plate fixation. METHOD: Twenty-three patients were reviewed retrospectively at a mean of 45.1 months. Patient-rated outcomes (Disabilities of the Arm Shoulder and Hand [DASH], Patient Rated Ulnar Nerve Evaluation [PRUNE], American Shoulder and Elbow Surgeons Elbow form [ASES-e], and Short Form-36 [SF-36]), clinical, radiographic, and objective evaluations were used to assess outcomes. RESULTS: Almost 40% of patients required a third plate for adequate fixation. Patients identified minimal subjective deficits (10%) with a mean satisfaction of 93%. The arc of motion was decreased in the flexion-extension plane (122 degrees relative to 138 degrees, p <.01), whereas strength was lower for both elbow flexion-extension and forearm rotation (p <.05). The overall complication rate was 48%, however, most were minor and resolved without further surgery. No ulnar neuropathies were identified at follow-up after routine ulnar nerve transposition. CONCLUSIONS: Outcomes of AO type C distal humeral fractures were good with dual orthogonal plating, ulnar nerve transposition, and early motion. Additional plating may be required with distal fracture patterns or osteopenic bone.