Ralph Hertel

Initial post-fracture humeral head ischemia does not predict development of necrosis.

We evaluated the functional outcome and the occurrence of avascular necrosis in 51 consecutive patients (26 women) with intracapsular fractures of the proximal humerus treated with open reduction and internal fixation between February 1998 and December 2001. Mean age was 44 years (range, 21-60 years). Forty-one heads were initially perfused (group A), and 10 were ischemic (group B). Seven patients were lost to follow-up. Forty-four were evaluated using the Constant-Murley score and the Subjective Shoulder Value; 40 patients consented to a radiographic evaluation. The mean follow-up was 5 years (range, 3.3-7.3 years). In group A, 20 of 30 heads had no sign of structural alterations, 6 had signs of structural alterations of the cancellous bone, and 4 showed collapse of the subchondral bone plate of varying degrees. In group B, 8 of 10 heads were structurally altered, and 2 had collapsed. The median uncorrected Constant-Murley score was 80 (range, 37-98) for patients without structural alterations, 81 (range, 53-93) for patients with structural alterations, and 68 (range, 48-74) for patients with collapsed heads. The median Subjective Shoulder Value was 95 (range, 50-100), 90 (range, 50-100), and 55 (range, 40-80), respectively. Eight of 10 initially ischemic heads did not develop avascular necrosis, indicating that revascularization may indeed occur. The reason for late necrosis in some of the initially perfused heads remains unclear. Collapse was associated with a significantly worse clinical outcome. We conclude that osteosynthesis with preservation of the humeral head is worth considering when adequate reduction and stable conditions for revascularization can be obtained.

Osteosynthesis and hemiarthroplasty of fractures of the proximal humerus: Outcomes in a consecutive case series

HYPOTHESIS This study addresses the outcome after osteosynthesis or hemiarthroplasty, using a cohort of patients that was enrolled in a previous prospective study on humeral head perfusion and was consequently treated using a common conceptual approach. MATERIALS AND METHODS Between 1998 and 2001, 98 patients with 100 fractures of the proximal humerus were treated surgically by a single surgeon with open reduction and internal fixation (ORIF) (51/100, group A, median age 54 years; range, 21-88) or with hemiarthroplasty (49/100, group B, median age 66 years; range, 38-87). Seventy-six of 98 patients were available for re-evaluation at a mean follow-up of five years (3.3-7.3) using the Constant-Murley score (CMS), the Subjective Shoulder Value (SSV), and conventional radiographs. RESULTS The median total CMS was 77 (range, 37-98) for group A and 70 (range, 39-84) for group B. The median SSV was 92 (range, 40-100) for group A and 90 (range, 40-100) for group B. Avascular necrosis occured in 6/40 fractures treated with ORIF. CONCLUSION Osteosynthesis and hemiarthroplasty yield similar functional results and comparable patient satisfaction following the applied decision making process in this selected patient cohort. Osteosynthesis with preservation of the humeral head is worth considering when adequate reduction and stable conditions for revascularization can be obtained. In patients with osteopenic bone and/or comminuted fractures, hemiarthroplasty is a viable alternative. LEVEL OF EVIDENCE Level 2; Prospective non-randomized comparison study.

Free nerve endings in the ligamentum capitis femoris

We report the presence of free nerve endings (FNE) in the ligamentum capitis femoris (LCF). Qualitative and quantitative measurements on the incidence of FNE, as assessed by immuno-histochemistry for the S-100 protein, were obtained from 18 patients undergoing hip surgery. We found FNE in all LCF, with no association to age. The presence of FNE in the LCF suggests a role in noci-/proprioception of the hip.

Evaluation of intratester and intertester reliability of the Constant-Murley shoulder assessment

This study evaluated the reliability of the Constant-Murley Score. Two testers assessed 63 patients twice on the same day using the original publication by Constant and Murley. The intratester reliability of the total score was high and the differences between the tests were small; 2 of 14 items were unreliable. The intertester reliability was high, but there were significant median differences of the total score; 12 of 14 items were unreliable. We believe that the differences between the testers were due to the brief explanations of test components in the original publication. The reliability of the Constant-Murley Score could possibly be improved by a better standardization of the assessment procedure.

The evolution of indirect reduction techniques for the treatment of fractures

During the last decade, classic AO/ASIF techniques for internal fixation shifted from direct reduction and rigid fixation to biologic internal fixation using indirect reduction techniques. Biologic internal fixation is characterized by the preservation of bone and soft tissue vascularity and relative rather than absolute mechanical stability. Reduction is achieved by using soft tissue traction while obtaining axial and rotational alignment and the correct length. Stabilization is performed when possible by compression plating for load sharing or by bridge plating in comminuted fractures. Advancements of these techniques and the development of newer implants that minimize vascular damage have contributed to the development of biologic internal fixation. By using indirect reduction, by using longer plates to improve the mechanical leverage, and by applying fewer screws to avoid unnecessary damage to the bone, fracture union rates were high. There also was a decreased need for supplemental bone grafting. All of these factors provided stable fixation and allowed early motion.

Plate osteosynthesis of diaphyseal fractures of the radius and ulna

Between January 1980 and December 1989, 133 consecutive patients were treated for a fracture of the shaft of one or both forearm bones (134 forearms in total). All fractures were stabilized with AO/ASIF 3.5 mm stainless-steel dynamic compression plates. The 1 year follow-up rate was 99 per cent; the long-term follow-up rate was 92 per cent (the mean long-term follow-up was 10.2 years (range, 2.7-15.2)) so there were 96 men and 35 women, with an average age of 37.5 years (range, 16-63). Twenty-two per cent of the forearms had open fractures, 26 per cent of patients had sustained multiple injuries and 19 per cent had a head injury. One hundred and twenty-seven of 132 forearms (96.2 per cent) underwent problem-free consolidation before 6 months. Two delayed unions and two non-unions required reoperation. There was one superficial infection in a patient with a closed fracture. Plates were removed from 70 patients (53 per cent) at a mean of 33.1 months (range, 8-122) after the first operation. In this group, there were three refractures (4.3 per cent) occurring at a mean of 8.7 months (range, 0-14) after plate removal. This study confirms the safety and efficacy of plate osteosynthesis in forearm shaft fractures: a high union rate and low complication rate can be anticipated. The data presented form the most reliable information on this subject currently available with the longest and highest rate of follow up of a sufficient number of patients using a single implant system in a single institution.

Transacromial approach to obtain fusion of unstable os acromiale

The purpose of this study was to identify possible causes for the low union rate for surgically stabilized os acromiale. Between February 1990 and November 1995, fusion of an os acromiale was attempted in 15 shoulders in 12 patients at our institution. All patients were men. The mean age was 54 years (range 37 to 63 years). All shoulders had an os mesoacromiale considered too large for simple resection. An associated lesion of the rotator cuff ranging from partial-to full-thickness tear was present in all patients. Eleven had an unfused acromial epiphysis in both shoulders. Two different surgical approaches were used. Seven shoulders were approached through an anterior deltoid-off approach, thus potentially devascularizing the os acromiale. Eight shoulders were approached transacromially, preserving the deltoid origin and hence the terminal branches of the thoracoacromial artery. The technique of internal fixation (tension band wiring) was the same for both groups. The mean follow-up was 44 months (range 13 to 72 months). Union, as demonstrated by axial radiographic views, occurred in 3 out of 7 cases with a devascularized os acromiale and in 7 out of 8 shoulders with a perfused os acromiale (P = .017), respectively. Patients with a united os acromiale had a significantly better functional outcome as measured by the Constant score (P = .0169). In conclusion, aiming at a stable fusion of a sizable and hypermobile os acromiale is probably desirable because it enhances the overall functional result. Obtaining consolidation was possible when the vascularity of the acromial epiphysis was respected.

Operative management of the stiff elbow: Sequential arthrolysis based on a transhumeral approach

Between December 1990 and September 1993, 26 consecutive patients (27 elbows) were treated for elbow contractures. We used a modified transhumeral approach supplemented by a limited lateral approach with or without a limited medial approach according to the correction gained after each step of the procedure. Eleven posttraumatic, 6 degenerative, and 10 miscellaneous contractures were evaluated. The mean follow-up was 30 months. Statistically significant improvement in the range of motion was obtained for all groups of patients; the mean flexion-extension arc of motion increased from 66 degrees to 100 degrees for the posttraumatic contractures, from 79 degrees to 102 degrees for the degenerative contractures, and from 85 degrees to 121 degrees for a miscellaneous group of contractures. Relief of pain was not an issue in the posttraumatic group; it was not significant for the degenerative group but was significant for the miscellaneous group. Flexion and extension force were maintained, and no joint was made unstable. Complications included three transient ulnar neuropathies and one tardy ulnar nerve palsy. The technique presented offers the advantage of virtually unlimited exposure of the joint in a stepwise manner, dictated by the intraoperative assessment of joint motion combined with preservation of the medial and lateral collateral ligament complexes and all relevant muscle insertions and origins. The concept is applicable to contractures of differing cause and can be adapted to the specific needs of the patient.

Path analysis of factors for functional outcome at one year in 463 proximal humeral fractures

BACKGROUND Path analysis methods were used to test the prognostic value of 10 patient-related and treatment-related factors on the 1-year functional outcome of 463 proximal humeral fractures measured using the Constant score. Complex inter-relationships between these factors were also evaluated. MATERIALS AND METHODS Data were collected from a prospective cohort study that included 3 operative groups repaired using nail or plate fixation and 1 nonoperative group. From the available information, various factors potentially having a direct influence on the functional Constant score were identified. The process of creating a hypothetical causal path diagram was undertaken to order the factors in a sequence of associations or cause-and-effect relationships. RESULTS Our final multivariable regression model for the 1-year Constant score included the 6 factors of age, sex, treatment, occurrence of intraoperative and local post-treatment complications, and anatomic restoration. Being a woman aged older than 40 years, treated with a locking proximal humeral plate (LPHP), having experienced intraoperative and local post-treatment complications, and varus deformity of more than 30° were negative predictors of the Constant score (ie, poor shoulder function 1 year after treatment initiation). Three factors, the dominant side fractured and the Neer and AO fracture type, showed only significant association on intermediate factors. The presence of concomitant disease did not show any significant direct or indirect effect. A final pathway outlines these associations and inter-relationships. CONCLUSION Prevention of local complications, in particular those leading to severe varus deviation, appears essential to improve shoulder function after a proximal humeral fracture.

External rotation lag sign revisited: Accuracy for diagnosis of full thickness supraspinatus tear

HYPOTHESIS This study reassessed the sensitivity and the specificity of the external rotator lag sign (ERLS) for diagnosis of supraspinatus tears in a large cohort of patients. MATERIALS AND METHODS The ERLS was used to assess 401 consecutive patients with 406 painful shoulder conditions. The clinical diagnosis was controlled either arthroscopically or by open surgery. RESULTS For isolated full-thickness supraspinatus tears, the ERLS had a sensitivity of 56% and a specificity of 98%. When the lesion involved the infraspinatus and the teres minor the sensitivity improved substantially. There was a strong correlation between the extension of the tear and the amount of the lag. The lag increased from 7 degrees for an isolated rupture of the supraspinatus tendon to 26 degrees in case of extension to the teres minor. CONCLUSION The ERLS is highly specific and acceptably sensitive for diagnosis of full-thickness tears, even in case of an isolated lesion of the supraspinatus tendon. LEVEL OF EVIDENCE Level 2; Prospective cohort treatment study.