Michael Dietrich

The PHILOS plate for proximal humeral fractures--risk factors for complications at one year.

BACKGROUND: Since 2003, we have used the Proximal Humerus Interlocking System plate for treatment of proximal humeral fractures. Although many patients have good and excellent results, the reported rate of complications varies. We have focused on the complication rate and risk factors for complications 1 year after surgery. METHODS: From 2003 until 2008, a total of 294 (223 women; 71 men; median age, 72.9) patients were included. General data were collected at the time of injury (Charlson Index, smoking, and steroid therapy). Fractures were classified (AO/OTA) retrospectively. The follow-up of 1 year included radiographs and Constant-Murley score for functionality. Complications and revision surgeries were analyzed specifically. RESULTS: We found 83 (28.2%) patients with a total of 105 complications, requiring a total of 72 (24.5%) revision surgeries. The most frequent complication was screw cutout (33 of 294, 11.2%), because of secondary fracture displacement or avascular necrosis (AVN). AVN (20 of 294, 6.8%) was the main reason for secondary arthroplasty. Smoking more than 20 pack years had a significant impact on the complication rate. Fractures classified 11-A3 showed more implant failures. Fracture dislocations predisposed to secondary screw cutout and AVN. Patients without complications (211, 71.8%) achieved a median Constant-Murley score of 89 (40–100) points. CONCLUSION: This study points out several predisposing factors for negative outcome after open reduction and internal fixation with the Proximal Humerus Interlocking System plate (fracture type: 11-A3, fracture dislocations, and smoking). Accounting for these, patients risk for complications can be evaluated more individually and taken into consideration for the concept of treatment. Altering the surgical technique was associated with a significant reduction in the incidence of secondary screw cutout.

Comparison of 2 Surgical Approaches for Volar Locking Plate Osteosynthesis of the Distal Radius

PURPOSEnTo determine whether a volar radial (Henry) exposure to the distal radius is associated with less median nerve dysfunction than a direct volar exposure of the distal radius through the carpal tunnel that has been abandoned due to median nerve problems.nnnMETHODSnOver an 18-month period, all patients with distal radius fractures treated with volar locking plate osteosynthesis were consecutively integrated into this therapeutic study. A direct volar midline approach ulnar to the flexor tendons and median nerve including prophylactic carpal tunnel release (CTR) was routinely performed from July 2003 to December 2004 (CTR group). Due to median nerve problems, this approach was abandoned and a distal part of the classical Henry approach (HRY) through the flexor carpi radialis (FCR) tendon sheath was performed for volar locking plate osteosynthesis in a second period from April 2005 to May 2006 (HRY group). In this group, the carpal tunnel was released only in selected cases. Data were collected prospectively for both groups. Analysis included clinical examination, the Patient-Rated Wrist Evaluation, and radiological follow-up up to 1 year after surgery.nnnRESULTSnEighty-three patients entered the CTR group during the initial series. Thirty-one patients showed median nerve dysfunction 6 weeks after surgery. In the second period of observation, 91 patients entered the HRY group. The carpal tunnel was therapeutically decompressed in 18 patients, leaving the carpal tunnel untouched in 91 patients. Temporary median nerve paraesthesia was seen in 4 patients without CTR in the HRY group 6 weeks after surgery. After 1 year, persistent median nerve irritation was observed in 4 patients of the CTR group and none of the HRY group. Grip strength, range of motion, and Patient-Rated Wrist Evaluation were similar after 1 year.nnnCONCLUSIONSnThe direct volar approach to the distal radius with routine CTR should be abandoned because it was associated with an increased rate of temporary and persistent median nerve irritation compared to the distal part of the classic Henry approach in our series.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnTherapeutic III.

Surgical Treatment of Neer Group VI Proximal Humeral Fractures: Retrospective Comparison of PHILOS® and Hemiarthroplasty

BackgroundNeer Group VI proximal humeral fractures often are related to persistent disability despite surgical treatment. We retrospectively compared the outcome after open reduction and internal fixation with the PHILOS® plate or primary hemiarthroplasty in patients with Neer Group VI fractures focusing on complications, shoulder function, health-related quality of life (SF-36), and potential risk factors for complications.Questions/purposesThe aim of this study was to compare the PHILOS® plate with primary hemiarthroplasty for treatment of specific Neer Group VI fractures. We asked whether (1) both procedures have comparable clinical and radiologic complication rates; (2) one procedure is superior in terms of revision rate; (3) objective and subjective shoulder function (Constant-Murley score) and health-related quality of life (SF-36) were comparable in both groups at final followup; and (4) there are clinical or radiologic predictors for complications in any group?MethodsBetween 2002 and 2007, 44 consecutive patients (mean, 75.2xa0years) with a Neer Group VI proximal humeral fracture were included. Twenty-two patients treated with a PHILOS® plate were compared with 22 patients treated by primary hemiarthroplasty. Both groups were similar in all criteria. At minimum followup of 12xa0months (mean, 30xa0months; range, 12-83xa0months), radiographic control, Constant-Murley score, and SF-36 were performed.ResultsFourteen patients with complications (63.6%) were counted in the PHILOS® plate group, of which 10 (45.4%) needed revision surgery, mostly as a result of avascular necrosis and screw cut-outs. In the primary hemiarthroplasty group, only one patient needed revision surgery (4.5%). Smoking and steroid therapy were substantially associated with complications in the PHILOS® plate group. There were no differences between the two groups regarding Constant-Murley or SF-36 scores.ConclusionsAngular stable open reduction and internal fixation was associated with high complication and revision rates, especially in patients who smoked and those receiving steroid therapy. Primary hemiarthroplasty provides limited function, which had little influence on the quality of life in this elderly collective. There are predictive factors for complications after the treatment of Neer Group VI proximal humeral fractures with the PHILOS® plate. Primary hemiarthroplasty remains a good option, especially when treating elderly patients.Level of EvidenceLevel III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Results of volar locking plate osteosynthesis for distal radial fractures.

BACKGROUNDnTo evaluate functional, radiologic, and subjective outcome after volar locking plate osteosynthesis (VLPO) for unstable distal radius fractures (DRF).nnnMETHODSnIn this study, patients treated with VLPO for isolated DRF between March 2005 and December 2007 were prospectively evaluated. Patients with multiple injuries or those unavailable for follow-up were excluded from further evaluation. Range of motion, grip strength, and the subjective Patient-Rated Wrist Evaluation score were monitored for 6 weeks, 3 months, 6 months, and finally 1 year after surgery. The uninjured contralateral wrist served as control. The radiologic outcome after 1 year was scored using the Lidstrom score.nnnRESULTSnIn total, 245 patients were included in the study with a mean age of 62 years ± 18 years. At the final follow-up, 1 year after surgery, 228 patients (93%) could be controlled. Range of motion significantly increased during follow-up. One year after surgery, mean flexion was 64° ± 15°, and mean extension reached 64 ° ± 15 ° corresponding with >90% of the uninjured contralateral wrist function. Grip strength increased from 14 kg ± 8 kg (54%) 6 weeks after surgery to 25 kg ± 11 kg (91%) at the final follow-up. Patient-Rated Wrist Evaluation score resulted in mean 8 points ± 16 points after 1 year. Lidstrom score reached a mean of 1.3 points ± 0.6 points, demonstrating a good initial fracture reduction and stable fixation. A complication rate of 15% could be seen in our series, among secondary fracture displacement in two patients (1%).nnnCONCLUSIONSnVLPO for the treatment of unstable DRF is a reliable technique with excellent subjective, objective, and radiologic outcome.

A Mobile App to Stabilize Daily Functional Activity of Breast Cancer Patients in Collaboration With the Physician: A Randomized Controlled Clinical Trial

Background The well-being of breast cancer patients and reporting of adverse events require close monitoring. Mobile apps allow continuous recording of disease- and medication-related symptoms in patients undergoing chemotherapy. Objective The aim of the study was to evaluate the effects of a mobile app on patient-reported daily functional activity in a supervised and unsupervised setting. Methods We conducted a randomized controlled study of 139 breast cancer patients undergoing chemotherapy. Patient status was self-measured using Eastern Cooperative Oncology Group scoring and Common Terminology Criteria for Adverse Events. Participants were randomly assigned to a control group, an unsupervised group that used a mobile app to record data, or a supervised group that used the app and reviewed data with a physician. Primary outcome variables were change in daily functional activity and symptoms over three outpatient visits. Results Functional activity scores declined in all groups from the first to second visit. However, from the second to third visit, only the supervised group improved, whereas the others continued to decline. Overall, the supervised group showed no significant difference from the first (median 90.85, IQR 30.67) to third visit (median 84.76, IQR 18.29, P=.72). Both app-using groups reported more distinct adverse events in the app than in the questionnaire (supervised: n=1033 vs n=656; unsupervised: n=852 vs n=823), although the unsupervised group reported more symptoms overall (n=4808) in the app than the supervised group (n=4463). Conclusions The mobile app was associated with stabilized daily functional activity when used under collaborative review. App-using participants could more frequently report adverse events, and those under supervision made fewer and more precise entries than unsupervised participants. Our findings suggest that patient well-being and awareness of chemotherapy adverse effects can be improved by using a mobile app in collaboration with the treating physician. ClinicalTrial ClinicalTrials.gov NCT02004496; https://clinicaltrials.gov/ct2/show/NCT02004496 (Archived by WebCite at http://www.webcitation.org/6k68FZHo2)

Quality of life after osteosynthesis of fractures of the proximal humerus.

Objective: Most clinical evaluations after fracture treatment focus on pure functional and radiological outcome. However, this may not appreciate the impact on quality of life (QoL). The aim of this study was to assess QoL and its improvement during the first year of postoperative recovery after fracture treatment. Design: Prospective single-centre observational study. Setting: Trauma unit. City hospital. Patients: From March 2003 to June 2008 inclusion of 269 consecutive patients (72 years, 77% female) was possible. All were treated by open reduction and internal fixation (ORIF) with PHILOS because of isolated traumatic fractures of the proximal humerus. Intervention: Clinical follow-up examinations were performed at 6 weeks and 3, 6, and 12 months, postoperatively. Main Outcome Measurements: Constant–Murley score (CMS) and the QoL (SF-36 questionnaire) were used to assess outcome. All results were stratified according to length of follow-up, age, and fracture type. Results: CMS and SF-36, including the corresponding subgroups Physical Component Summary and Mental Component Summary, demonstrated continuing improvement during the period of observation. US norm values for the SF-36 were achieved after 6 months. However, speed of progress varied greatly between the scores and age groups. The fracture type significantly impacted CMS. Increasing age and complexity of fracture influenced the results negatively and cumulatively. Conclusion: This study highlights and defines subjective improvements and changes of QoL up to 1 year after ORIF of these fractures. Increasing age and a more complex fracture type is correlated with a deceleration of functional improvement. The CMS shows a definite positive correlation with the unassisted self-evaluation of SF-36, but exchangeability could not be demonstrated. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Validation of a transparent decision model to rate drug interactions

BackgroundMultiple databases provide ratings of drug-drug interactions. The ratings are often based on different criteria and lack background information on the decision making process. User acceptance of rating systems could be improved by providing a transparent decision path for each category.MethodsWe rated 200 randomly selected potential drug-drug interactions by a transparent decision model developed by our team. The cases were generated from ward round observations and physicians’ queries from an outpatient setting. We compared our ratings to those assigned by a senior clinical pharmacologist and by a standard interaction database, and thus validated the model.ResultsThe decision model rated consistently with the standard database and the pharmacologist in 94 and 156 cases, respectively. In two cases the model decision required correction. Following removal of systematic model construction differences, the DM was fully consistent with other rating systems.ConclusionThe decision model reproducibly rates interactions and elucidates systematic differences. We propose to supply validated decision paths alongside the interaction rating to improve comprehensibility and to enable physicians to interpret the ratings in a clinical context.

Reverse shoulder arthroplasty for complex fractures of the proximal humerus in elderly patients: impact on the level of independency, early function, and pain medication

BACKGROUNDnThis study investigated early functional outcome, quality of life, and the level of independency in elderly patients after primary reverse shoulder arthroplasty (RSA) for complex fractures of the proximal humerus.nnnMETHODSnThis was a prospective case series that included 33 patients, aged ≥70 years, with a high level of independency who received RSA for complex fractures of the humerus (Orthopaedic Trauma Association B2/C) from January 2012 to April 2014.nnnRESULTSnLevel of independency, quality of life (Short Form 36 Health Survey score), early functional outcome (Constant-Murley score, Disabilities of the Arm, Shoulder and Hand Outcome Measure), and pain medication (World Health Organization grading) were obtained at the 6-month follow-up and 1 year after surgery. The Constant-Murley score was 64u2009±u200914 after 6 months and 71u2009±u200912 at 1 year (Pu2009<u2009.001), reaching 87% compared with the contralateral shoulder. The Disabilities of the Arm, Shoulder and Hand score reached 29u2009±u200920 at 6 months and 30u2009±u200921 at 1 year. The Short Form 36 score was comparable to normative data. After 6 months, 84% of our study group were back at their previous level of independency. Within 1 year, this rate increased to 91%. At the 1-year follow-up, analgesia intake was back at the level before the injury in 97% of the patients.nnnCONCLUSIONSnPrimary RSA provides good early functional results, reliable pain control, and excellent restoration of an independent life style in elderly patients. Thus, RSA may be considered for active patients with a high demand on shoulder function.

Perioperative Fractures in Cementless Total Hip Arthroplasty Using the Direct Anterior Minimally Invasive Approach: Reduced Risk With Short Stems

BACKGROUNDnThe direct minimally invasive anterior approach (DMIAA) and the use of uncemented stems demonstrated an increase in intraoperative fractures in recent literature. Whether the different design of the stems additionally influences the incidence of perioperative local complications, was the goal of this study.nnnMETHODSnFrom January 2008 until June 2010, all patients undergoing primary cementless total hip arthroplasty, using a DMIAA, were consecutively included. The choice of the implant was defined by the day of operation. Age, gender, body mass index, type of prosthesis, and the practical experience of the performing surgeon were retrospectively analyzed. Of main interest were intraoperative fractures, postoperative hematoma, and wound healing.nnnRESULTSnSix hundred forty consecutive patients (64 years [18-94], 339 female, 53%, body mass index 26) have been included. A Quadra-H stem (Medacta) was used in 457 patients (71%). In 183 (29%) patients, a short stem designed for the DMIAA (130 Fitmore, Zimmer and 53 AMIStem, Medacta) was used. We counted 34 (5.3%) intraoperative fractures (16 at the greater trochanter, 18 proximal shaft fractures), 20 (4%) hematomas, and 8 (2%) wound healing problems. The standard length stem showed more local complications (11.8% vs 4.4%) (Pxa0= .014, odds ratio 1.63, confidence interval 1.1-2.4) and significantly more (6.8% vs 1.6%) intraoperative fractures (Pxa0= .027, odds ratio 1.98, confidence interval 1.1-3.6).nnnCONCLUSIONnThe standard length stem showed more perioperative complications, especially periprosthetic fractures. It seems that these implants not only put more stress to proximal osseous structures, but there might also be more traction and irritation to the soft tissue while preparing, resulting in more hematomas and wound healing problems.

Intraoperative Imaging of the Distal Radioulnar Joint Using a Modified Skyline View

PURPOSEnNonanatomic reduction of the sigmoid notch in distal radius fractures may lead to limited motion, instability, or pain with pronation and supination. Standard radiological projections only poorly capture the sigmoid notch contours in the axial plane. The purpose of this study was to find an intraoperatively feasible radiological projection that will facilitate an axial view of the distal radioulnar joint.nnnMETHODSnWe modified a previously described radiographic projection termed the skyline view for evaluating the distal radius axially. We created intra-articular steps at the sigmoid notch in solid foam forearm models to identify the best of 12 projections using an image intensifier. Four observers scored each projection based on the clarity of the sigmoid notch contour and indicated the presence and location of an intra-articular stepoff.nnnRESULTSnThe sigmoid notch was best visualized in the modified skyline view with the wrist in extension and 10° to 15° of dorsal forearm angulation relative to the x-ray path. All observers correctly recognized the presence and location of intra-articular steps at the sigmoid notch with this view. The same forearm angulation with the wrist in flexion did not reach equally good visibility of the sigmoid notch. Arm position (wrist flexion, forearm rotation, or forearm angulation) and intra-articular stepoff (none, palmar, or dorsal) were dependent determinates. Elimination of the variable forearm rotation had minimal effect, indicating that forearm rotation is not important for visualization of the sigmoid notch.nnnCONCLUSIONSnThe modified skyline view for visualization of the distal radioulnar joint in an axial plane allows good visibility of the sigmoid notch and reliable identification of stepoffs. Further cadaver and in vivo studies are required to verify the validity of this method.