Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation (original) (raw)
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Functional outcome evaluation of distal humerus fracture fixation
Fracture fixations by K wires and distal one third semi tubular plate have resulted in a high percentage of implant failures, in presence of metaphyseal communition. In osteoporotic bone and in very distal fractures, screw placement becomes difficult because of limited space ABSTRACT Background: Distal humerus fracture are complex, difficult to reduce and fix, cumbersome post-operative mobilization, and yet functional outcome is doubtful. Though various treatment modalities available for past many decades ranging from conservative management, K wire fixation to plate and screws, but still treatment remains difficult. The objective of the study was to assess functional outcome of operative fixation of distal humerus with locking plate and screws. Methods: Prospective study was done in during November 2015 to June 2016 in Vydehi Institute of Medical Sciences and Research Centre, Bengaluru. Patients with distal humerus fractures who were admitted into hospital for operative treatment after fulfilling inclusion and exclusion criteria were included into study. They were followed up to 6 months post-operatively. Functional outcome evaluation was done with Mayo's elbow performance score. Results: 30 patients were included into study with full data. We had excellent, good, fair and poor outcome in 17, 8, 3, 2 patients respectively. Except for infection in one, elbow stiffness in two and non-union in two patients, we had no other complications. Conclusions: Management of distal humerus fractures with preoperative evaluation, pre-operative planning, use of locking plate and screws, early mobilization can result in good functional outcome.
The Journal of Hand Surgery, 2015
Purpose To identify factors associated with reoperation for early loosening or breakage of implants or nonunion after operative treatment of AO type C distal humerus fractures. Methods We retrospectively analyzed 129 adult patients who had operative treatment of an isolated AO type C distal humerus fracture at 1 of 5 hospitals to determine factors associated with reoperation for early loosening or breakage of implants or nonunion. Results Within 6 months of original fixation, 16 of 129 fractures (12%) required reoperation for loosening or breakage of implants (n ¼ 8) or nonunion (n ¼ 8). In bivariate analyses, the Charlson comorbidity index, smoking, a coded diagnosis of obesity, diabetes mellitus, and radiographic osteoarthritis were significantly associated with reoperation for early loosening or breakage of implants or nonunion. Conclusions With the numbers available, patient factors rather than technical factors were associated with reoperation for loosening or breakage of implants and nonunion. Because of the relative infrequency of fixation problems and nonunion, a much larger study is needed to address technical deficiencies.
Interobserver Reliability of Classification and Characterization of Proximal Humeral Fractures
Journal of Bone and Joint Surgery, 2013
Background: Interobserver reliability for the classification of proximal humeral fractures is limited. The aim of this study was to test the null hypothesis that interobserver reliability of the AO classification of proximal humeral fractures, the preferred treatment, and fracture characteristics is the same for two-dimensional (2-D) and three-dimensional (3-D) computed tomography (CT). Methods: Members of the Science of Variation Group-fully trained practicing orthopaedic and trauma surgeons from around the world-were randomized to evaluate radiographs and either 2-D CT or 3-D CT images of fifteen proximal humeral fractures via a web-based survey and respond to the following four questions: (1) Is the greater tuberosity displaced? (2) Is the humeral head split? (3) Is the arterial supply compromised? (4) Is the glenohumeral joint dislocated? They also classified the fracture according to the AO system and indicated their preferred treatment of the fracture (operative or nonoperative). Agreement among observers was assessed with use of the multirater kappa (k) measure. Results: Interobserver reliability of the AO classification, fracture characteristics, and preferred treatment generally ranged from ''slight'' to ''fair.'' A few small but statistically significant differences were found. Observers randomized to the 2-D CT group had slightly but significantly better agreement on displacement of the greater tuberosity (k = 0.35 compared with 0.30, p < 0.001) and on the AO classification (k = 0.18 compared with 0.17, p = 0.018). A subgroup analysis of the AO classification results revealed that shoulder and elbow surgeons, orthopaedic trauma surgeons, and surgeons in the United States had slightly greater reliability on 2-D CT, whereas surgeons in practice for ten years or less and surgeons from other subspecialties had slightly greater reliability on 3-D CT. Conclusions: Proximal humeral fracture classifications may be helpful conceptually, but they have poor interobserver reliability even when 3-D rather than 2-D CT is utilized. This may contribute to the similarly poor interobserver reliability that continued
Decision making in displaced fractures of the proximal humerus: fracture or surgeon based?
International orthopaedics, 2015
The aim of this study was to analyse the factors that influence surgeon decision-making in the treatment of proximal humerus fractures that might be considered for arthroplasty or open reduction and internal fixation. A total of 217 surgeons evaluated radiographs and clinical vignettes of ten patients with fractures of the proximal humerus. In addition to radiographs, we provided patient age, sex, trauma mechanism, activity level (sedentary-vigorously active), and physical status (normal healthy-moribund). Observers were asked to: (1) choose open reduction and internal fixation or hemiarthroplasty (closed question, one option) and (2) to briefly describe the factors that led to their decision (open-ended question). We assessed interobserver reliability using the Fleiss generalized kappa and analysed factors that influenced decision-making according to treatment choice. Internal fixation was the preferred treatment for the majority of fractures. The overall multirater agreement was f...
Indian Journal of Orthopaedics, 2020
Background The purpose of this study was to identify complications after operative treatment of distal humerus fractures with anatomic, pre-contoured, locking distal humeral plates. We hypothesized that these fractures have high complication rates despite the use of these modern implants. Materials and Methods Between 2010 and 2018, 43 adult patients with a distal humerus fracture underwent open reduction and internal fixation (ORIF) at a Level I trauma center. Pre-operative variables, including medical comorbidities, mechanism of injury, open or closed fracture, AO/OTA fracture classification (Type A, B, or C), and nerve palsy, were recorded. Intraoperative variables including surgical approach, ulnar nerve transposition, and plate configuration were recorded. Anatomic, pre-contoured, locking distal humeral plates were used in all patients. Various plating systems were used based on surgeon preference and fracture pattern. Post-operative complications including infection, nonunion, malunion, painful implants, nerve palsy, heterotopic ossification, stiffness, and post-traumatic arthritis were recorded. Results Most fractures were Type C (53%). The posterior olecranon osteotomy approach (51%) and parallel plate configuration (42%) were used in most cases. At a mean follow-up of 15 months, the complication rate was 61% (26/43 patients). Among all patients, 49% (21/43 patients) required a reoperation. Elbow stiffness (19%) was the most common complication followed by nerve palsy (16%). There were four fracture nonunions (9%), deep infections (9%), painful implants (9%), posttraumatic arthritis (9%), and heterotopic ossification (9%). Conclusions Distal humerus fractures treated with ORIF utilizing anatomic, pre-contoured, locking distal humeral plates have a high complication rate, with many requiring reoperation. Level of Evidence Therapeutic Level IV.
Intra- and Inter-Observer Agreement of Proximal Humeral Fractures Classifications in Adults
Acta Ortopédica Brasileira
Objective: Evaluating intra- and inter-observer agreement of the Neer, AO, and AO/OTA proximal humerus fractures classification systems in adults. Methods: In total, 100 X-rays of patients with proximal humerus fractures were selected according to the inclusion and exclusion criteria established in this study. They were evaluated by four evaluators with different levels of expertise. The evaluation was performed at two distinct moments, with an interval of 21 days between each analysis. Images were randomized for the second evaluation by a researcher who did not participate in the image selection process. A Fleiss Kappa test was performed to evaluate intra- and inter-observer agreement. Results: We observed a substantial agreement with k = 0.669, k = 0.715, and k = 0.780 for the Neer, AO, and AO/OTA classification systems, respectively. Conclusion: In the second evaluation, intra-observer agreement improved. In the first evaluation, we obtained values of k = 0.724, k = 0.490, and k ...
Understanding proximal humerus fractures: Image analysis, classification, and treatment
Journal of Shoulder and Elbow Surgery, 2005
Proximal humerus fractures are difficult to define because of their extreme variability and potential for complexity. We designed a study to evaluate further why this is true. Radiographs of 113 proximal humeral fractures were assessed by 3 knowledgeable observers. The observers were asked to answer independently 9 questions about the fracture, to classify the fracture according to the Neer classification, and to recommend treatment. Two months later, a learning session was held to discuss discrepancies among the observers and to develop learning points to improve analysis of the images. Two months later, the radiographs were reassessed. Developing 10 learning points enhanced the ability to interpret images at the second review and provide more consistent fracture classification with statistically significant improvements. The problem is understanding the images of complex fractures-not the classification system. To enhance consistency in understanding these fractures, imaging of complex fractures must be enhanced.
Diagnostic accuracy of 2- and 3-dimensional imaging and modeling of distal humerus fractures
Journal of Shoulder and Elbow Surgery, 2012
Purpose: This investigation used prospectively recorded intraoperative evaluation as the reference standard for distal humerus fracture type and characteristics, in order to measure the diagnostic performance characteristics of computed tomography (CT) and physical models. In secondary analyses, we assessed the reliability of classification. Methods: Thirty-five fractures were evaluated by the treating surgeon and first assistant on radiographs and 2-dimensional CT (2DCT) images first; a second time based on radiographs and 2-and 3dimensional CT (3DCT) images; a third time based on 2-and 3DCT as well as 3D physical models; and a fourth time based on intraoperative visualization of the fracture characteristics. The intraoperative evaluation of the attending surgeon was used as the reference standard. Results: The addition of 3DCT and the 3D models to 2DCT and radiographs led to significant improvements in sensitivity, but not specificity, in the diagnosis and proposed treatment, and improved the interobserver agreement with respect to specific fracture characteristics but not classification. Conclusion: Increasingly sophisticated imaging and modeling leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics.
The factors influencing the decision making of operative treatment for proximal humeral fractures
Journal of Shoulder and Elbow Surgery, 2015
Background: The factors influencing the decision making of operative treatment for fractures of the proximal humerus are debated. We hypothesized that there is no difference in treatment recommendations between surgeons shown radiographs alone and those shown radiographs and patient information. Secondarily, we addressed (1) factors associated with a recommendation for operative treatment, (2) factors associated with recommendation for arthroplasty, (3) concordance with the recommendations of the treating surgeons, and (4) factors affecting the inter-rater reliability of treatment recommendations. Methods: A total of 238 surgeons of the Science of Variation Group rated 40 radiographs of patients with proximal humerus fractures. Participants were randomized to receive information about the patient and mechanism of injury. The response variables included the choice of treatment (operative vs nonoperative) and the percentage of matches with the actual treatment. Results: Participants who received patient information recommended operative treatment less than those who received no information. The patient information that had the greatest influence on treatment recommendations included age (55%) and fracture mechanism (32%). The only other factor associated with a recommendation for operative treatment was region of practice. There was no significant difference between participants who were and were not provided with information regarding agreement with the actual treatment (operative vs nonoperative) provided by the treating surgeon. Conclusion: Patient informationdolder age in particulardis associated with a higher likelihood of recommending nonoperative treatment than radiographs alone. Clinical information did not improve agreement of the Science of Variation Group with the actual treatment or the generally poor interobserver agreement on treatment recommendations.
Singapore Medical Journal, 2014
Proximal humerus fractures account for 5% of all fractures and 10% of all upper limb fractures. (1-3) Surgical treatment, which has acceptable risks, aims to avoid potential complications such as nonunion, malunion and prolonged immobilisation. With advancement in knowledge regarding these fractures and improvements in hardware designs and fixation techniques, fractures are now increasingly being treated surgically. In fact, many different fixation methods have surfaced in the literature over the past ten years, with no large randomised study supporting the use of one method over another. Thus, the primary objective of the present study is to describe the clinical parameters of patients with surgically managed proximal humerus fractures and to identify any evolving trends in such surgeries over the past decade. Any observable predilection for a particular surgery or surgical approach may be used to drive future trials toward studying the indications and outcomes of these surgical techniques and approaches.