Yaiza Lopiz

Proximal humerus nailing: a randomized clinical trial between curvilinear and straight nails

BACKGROUND Intramedullary nailing of displaced proximal humerus fractures is an attractive option in the elderly patient. However, in recent reports, some existing intramedullary nails have shown high rate of complications, so new designs are being developed. The objective of the present study is to report on outcomes and complications when comparing a straight to a curvilinear nail design. METHODS We prospectively include 54 patients with Neers 2- or 3-part proximal humerus fractures. Two were lost to follow-up, 26 were surgically treated with a new straight humeral nail (MultiLoc, Synthes) mean age 69 (range, 47-87 years), and 26 with a curvilinear nail (Polarus, Acumed) mean age 71 (range, 38-89 years). At final follow-up (average 14 months), patients underwent a clinical and radiographic evaluation. Clinical outcome was assessed with the adjusted Constant score. RESULTS All but 1 fracture went on to radiographic union. Mean Constant score in the Polarus nail was 72.7 ± 16.0 and 83.3 ± 16.7 in the MultiLoc (P = .246). Symptoms related with rotator cuff disease were present in 19/26 patients (73%) and in 9/26 (34.6%), respectively (P = .001). The mean neck-shaft angle at final follow-up was 135° in the MultiLoc group and 130° in the Polarus group (P > .05). Reoperation rate was 42% for Polarus and 11.5% for MultiLoc. CONCLUSION Straight intramedullary nails had a comparable union rate to an accepted curvilinear design, with a much lower incidence of complications. Rotator cuff pain and dysfunction can be minimized with the use of newer generation straight nails.

Comminuted fractures of the radial head: resection or prosthesis?

INTRODUCTION At present, surgical treatment of comminuted radial head fractures without associated instability continues to be controversial. When anatomical reconstruction is not possible, radial head excision is performed. However, the appearance of long-term complications with this technique, along with the development of new radial head implants situates arthroplasty as a promising surgical alternative. The purpose of the present study was to compare the mid-term functional outcomes of both techniques. MATERIALS AND METHODS A retrospective study was performed between 2002 and 2011 on 25 Mason type-III fractures, 11 patients treated with primary radial head resection and 14 who received treatment of the fracture with metal prosthesis. At the end of follow-up, patients were contacted and outcomes evaluated according to: Mayo Elbow Performance Score (MEPS), the Disabilities of the Arm, Shoulder and Hand score (DASH) and strength measurement. Radiographic assessment (proximal migration of the radius, osteoarthritic changes, and signs of prosthesis loosening) was also performed. RESULTS The average age of the sample was 53.7 years in the resection group, and 54.4 years in the replacement group, with a mean follow-up of 60.3 and 42 months respectively. According to the MEPS scale, there were 6 excellent cases, 3 good and 2 acceptable in the resection group, and 6 excellent cases, 3 good, 3 acceptable, and 2 poor in the prosthesis group. The mean DASH score were 13.5, and 24.8 for the resection and the replacement group respectively. We found one postoperative complication in the resection group (stiffness and valgus instability) and 6 in the replacement group: 3 of joint stiffness, 1 case of prosthesis breakage, and 2 neurological injuries. CONCLUSIONS Although this is a retrospective study, the high complication rate occurring after radial head replacement in comparison with radial head resection, as well as good functional results obtained with this last technique, leads us to recommend it for comminuted radial head fractures without associated instability.

Management of displaced surgical neck fractures of the humerus: health related quality of life, functional and radiographic results

INTRODUCTION There is no controversy about the need for surgical treatment of the displaced surgical neck fractures of the humerus, but there are few studies comparing the results of the three preferred types of surgical treatment. To expand the knowledge needed in decision making, a patient series is reviewed using health related quality of life (HRQoL), functional and radiographic data from patients treated with percutaneous pinning, locking plates or intramedullary nails. MATERIALS AND METHODS Retrospective observational cohort study of patients who underwent internal fixation of fractures of the surgical neck of the humerus between 2004 and 2009 (mean follow-up 40.67 ± 17.93 months). Fifty patients fulfilled the inclusion criteria (mean age 70.04 ± 13.15 years). Nine had been treated by percutaneous pinning, fifteen with locking plates and twenty-six with intramedullary nails. We compared the results between the three groups of the HRQoL with the EuroQol5D questionnaire; the functional capacity of the operated and non-operated shoulder with the Constant score; and the radiographic result with plain X-rays. RESULTS Forty-eight patients had achieved fracture healing. The plating and nailing groups had a better fracture reduction compared with the pinning group (p <0.05). The EuroQol-5D did not discriminate between groups (mean 0.65 ± 0.26; p >0.05). The mean Constant score of the K-wire group (47.67 ± 22.42) was lower than those of the plating (82.45 ± 17.69) and nailing groups (72.72 ± 15.96) (p = 0.001), with no differences between plates and nails. There was positive correlation between the EuroQol-5D result and the Constant score (r = 0.490; p <0.005). The fractured shoulder was worse in each item of the Constant score than the non-operated one in patients treated with pins and nails. Patients treated with plates achieved similar results between operated and non-operated shoulder in three items: arm positioning, internal and external rotation. Seventeen patients (six re-operated) had some kind of complication during follow-up. CONCLUSION Patients treated with pinning achieved a worse radiographic and Constant score than patients treated with plates or nails. Although we did not find differences between the plating and nailing groups, patients treated with plates got a Constant score more similar to the non-operated shoulder.

Fracturas de estrés de la espina de la escápula asociadas a lesión del manguito rotador: a propósito de 3 casos y revisión de la literatura

Scapular spine stress fractures have been scarcely reported in the literature. Their pathomechanics, clinical course and treatment are not well established. We review 3 cases in 2 patients that were associated with cuff dysfunction. On follow-up, none of these fractures progressed to healing. Two of them needed osteosynthesis and bone grafting, and the third one became a painless non-union. The authors propose the combination of 3 factors as a reason for this lesion: a functionally impaired cuff, a greater activation of the muscles with origin and insertion in the spine-acromion and a fragile bone. As we believe that these fractures are unstable, and non-union would be expected, their surgical management is recommended.

Resultados de la reducción abierta y osteosíntesis de fracturas de húmero distal en mayores de 65 años

INTRODUCTION AND OBJECTIVE Distal humerus fractures in the elderly frequently associated with poor bone quality and comminution, making it harder to achieve proper osteosynthesis. Our aim is to evaluate the radiological and functional results of open reduction and internal fixation of these fractures. MATERIAL AND METHODS Retrospective study of 26 patients treated by open reduction and internal fixation between the years 2005-2010. Mean follow-up was 42 months. At final follow-up, a radiography evaluation (Knirk and Jupiter score) and clinical examination using Mayo Elbow Performance Score and Quick-Disabilities of the Arm, Shoulder and Hand Score was performed. Mean age of the group was 76.8 years (65-89), with 83% of the patients being female. Sixteen patients suffered type C fractures and 8 type A by AO classification. All underwent posterior surgical approach. RESULTS Mean elbow flexion reached 118.86°, with a mean extension deficit of 25°. More than 3-quarters (79.1%) of the patients showed 0-1 grade degenerative changes on the X-ray films at final follow-up. Functional results reached an average 19.87 points on Quick-Disabilities of the Arm, Shoulder and Hand Score, and 85 points on Mayo Elbow Performance Score scores. Non-union occurred in 2 cases: distal humerus in one patient and olecranon osteotomy in another. Ulnar nerve neuropraxia was recorded in 2 cases, and radial nerve in one. All 3 recovered uneventfully. Revision surgery was required, with 2 patients needing hardware removal and one a new fixation. DISCUSSION Treatment by open reduction and internal fixation with plating in elderly people for type A and C distal humerus fractures gives good functional results regarding this population, and thus scarcely disturbs their quality of life.

Midterm outcomes of bone grafting in glenoid defects treated with reverse shoulder arthroplasty

BACKGROUND Large glenoid defects are a difficult reconstructive problem for shoulder surgeons. The purpose of this study was to determine the complications, rate of healing, and functional results of glenoid bone grafting in primary or revision surgery with reverse shoulder arthroplasty. METHODS We retrospectively reviewed 23 patients with glenoid bone loss who underwent primary or revision surgery using a glenoid bone graft with a minimum follow-up of 2 years. Range of motion and the Constant, American Shoulder and Elbow Surgeons, and visual analog scale scores were obtained from preoperative assessment and the latest follow-up visit. Radiographic evaluation included analysis of plain radiographs as well as preoperative and follow-up computed tomography. RESULTS Three patients were excluded from the study. Allografts were used in 13 cases and autografts in 7 cases. The mean Constant score improved from 30.7 ± 9.4 to 51.3 ± 13.4 (P < .001). At a mean follow-up of 26 months, computed tomography imaging revealed that the glenoid bone graft was fully incorporated in 95% of cases. No statistically significant differences were found on analysis of the clinical and radiographic outcomes related to the graft source. There was a 20% postoperative complication rate: 1 case of aseptic glenoid component loosening, 1 surgical wound hematoma, 1 acromial fracture, and a symptomatic grade 3 scapular notching. CONCLUSIONS The use of bone grafts in glenoid defects is a useful technique by which, in the majority of cases, single-stage reconstruction surgery may be performed, even in the presence of severe bone loss. Incorporation rates are high, with satisfactory clinical outcome.

Open reduction and internal fixation of coronal fractures of the capitellum in patients older than 65 years

BACKGROUND The aim of this study was to describe the fracture patterns of capitellum coronal fractures and to evaluate the complications and functional and radiographic outcomes of open reduction and internal fixation in patients older than 65 years. METHODS A retrospective study of 23 patients with a mean follow-up of 48 months (36-105) was performed. Fractures were classified according to the Dubberley classification. All patients were evaluated by the Mayo Elbow Performance Index (MEPI) and the Disabilities of the Arm, Shoulder, and Hand (DASH) scores. RESULTS Three patients were lost to follow-up. There were 16 type 1 and 4 type 2 fractures. The mean age was 71 years (66-79), and 65% were women. The mean MEPI score was 92 (60-100), and the mean DASH score was 9 (0-75). Either a concomitant fracture or an elbow dislocation was present in 50% of the patients. Mean sagittal plane range of motion at last follow-up was 122° ± 8°, with lower extension in type 2 and worse scores on MEPI (91 vs. 97) and DASH (3 vs. 0) scales. Placement of the screws in the posteroanterior direction was associated with better range of motion in flexion (130° vs. 122°) and better outcomes in functional scores (MEPI, 97 vs. 89; QuickDASH, 0 vs. 4). Complications were post-traumatic osteoarthritis in 3 patients, avascular necrosis in 1 patient, and heterotopic ossification in 5 patients. One patient required reoperation. CONCLUSIONS Patients older than 65 years have no substantial risk of complex fracture patterns, but they have a large number of concomitant injuries. Open reduction and internal fixation with cannulated screws allow stable fixation and provide satisfactory functional results with a lower complication rate.

Results after internal fixation of humerus distal fractures in patients over than 65 years old

INTRODUCTION AND OBJECTIVE Distal humerus fractures in the elderly frequently associated with poor bone quality and comminution, making it harder to achieve proper osteosynthesis. Our aim is to evaluate the radiological and functional results of open reduction and internal fixation of these fractures. MATERIAL AND METHODS Retrospective study of 26 patients treated by open reduction and internal fixation between the years 2005-2010. Mean follow-up was 42 months. At final follow-up, a radiography evaluation (Knirk and Jupiter score) and clinical examination using Mayo Elbow Performance Score and Quick-Disabilities of the Arm, Shoulder and Hand Score was performed. Mean age of the group was 76.8 years (65-89), with 83% of the patients being female. Sixteen patients suffered type C fractures and 8 type A by AO classification. All underwent posterior surgical approach. RESULTS Mean elbow flexion reached 118.86°, with a mean extension deficit of 25°. More than 3-quarters (79.1%) of the patients showed 0-1 grade degenerative changes on the X-ray films at final follow-up. Functional results reached an average 19.87 points on Quick-Disabilities of the Arm, Shoulder and Hand Score, and 85 points on Mayo Elbow Performance Score scores. Non-union occurred in 2 cases: distal humerus in one patient and olecranon osteotomy in another. Ulnar nerve neuropraxia was recorded in 2 cases, and radial nerve in one. All 3 recovered uneventfully. Revision surgery was required, with 2 patients needing hardware removal and one a new fixation. DISCUSSION Treatment by open reduction and internal fixation with plating in elderly people for type A and C distal humerus fractures gives good functional results regarding this population, and thus scarcely disturbs their quality of life.

Recurrent total knee arthroplasty dislocation after dorsal meningioma diagnosed.

We report on a 68-year-old woman with gonarthrosis who underwent total knee arthroplasty. Having initially achieved a satisfactory result, she developed at 5 months postoperation an irreducible flexion contracture necessitating revision surgery; but no pathological findings were discovered. In the immediate postoperative period, the patient developed a severe spasm of the hamstring muscles and a paralysis of the external popliteal sciatic nerve with a posterior dislocation of the knee. After reduction, an electromyography study showed an alteration in medullary sensitive conduction; and the magnetic resonance image showed a lesion compatible with meningioma. This complication has not been previously described as a consequence of spinal tumor. Technical considerations are described for this rare complication, which remains a serious challenge for the orthopedic surgeon.

Injury to the axillary and suprascapular nerves in rotator cuff arthropathy and after reverse shoulder arthroplasty: a prospective electromyographic analysis

BACKGROUND Neurologic pre- and postoperative injuries to the axillary and/or suprascapular nerve (SSN) have a higher incidence than expected and may lead to significantly decreased functional outcomes and increased risk of reverse shoulder arthroplasty (RSA) failure. METHODS Patients who underwent a RSA for rotator cuff tear arthropathy (RCTA) were included from December 2014 to December 2015. This study focused on the clinical (Constant score), radiographic, and pre- and postoperative electromyographic evaluations at 3 and 6 months. RESULTS Twenty patients met the inclusion criteria. One was lost to follow-up. Preoperatively, 15 patients showed changes on electromyography (9 SSN and 15 axillary nerve lesions); all of them were chronic and disuse injuries. The mean preoperative relative Constant score (rCS) of all included patients was 39 ± 9 (range, 19-64). At 3 months postsurgery, the prevalence of acute injuries for both nerves was 31.5%. At 6 months postsurgery, 2 axillary nerve injuries and 6 SSN injuries remain unchanged, and the rest improved or normalized. The mean postsurgery rCS of the entire cohort at 6-month follow-up was 78 ± 6.5. Mean postoperative rCS for acute postoperative nerve injury was 71 ± 3 for the axillary nerve and 64 ± 5 for SSN. CONCLUSIONS Axillary and SSN injuries in RCTA have a much higher incidence than expected. Most of these axillary lesions are transient, with an almost complete recovery seen on electromyography at 6 months and with scarce functional impact. However, SSN lesions appear to behave differently, with poor functional results and having a lower potential for a complete recovery.