Locked Posterior Shoulder Dislocation with Accompanying Fracture: A Debilitating Rare Injury for Athletes?

Shoulder dislocation is undoubtedly one of the most common injuries in traumatology. Posterior dislocation of the shoulder is regarded as comparatively rare compared to anterior dislocation, whilst it is strikingly extraordinary for this type of injury to be accompanied by a concomitant fracture. Accurate diagnosis and appropriate treatment can be considerably demanding, while being vitally important in this exceedingly rare condition. These injuries are broadly considered to be under-reported in the existing literature, especially among high-demand athletes. We present a rare case of a high-demand athlete sustaining a traumatic locked posterior shoulder dislocation with an accompanying fracture treated in our Institution. A detailed clinical examination and plain radiography revealed the peculiar condition, and a CT scan was subsequently performed for more thorough evaluation of the injury. The patient underwent surgery on the day following admission for repair of the extensive shoulder damage, and a deltopectoral approach was utilized. Reduction of the metaphyseal fracture and the dislocation was accomplished with gentle manipulations, and stabilization was obtained with an anatomic plate. A modified McLaughlin procedure was carried out to address the reverse Hill-Sachs lesion. The postoperative period was uneventful, followed by a painstaking physical rehabilitation program, and the patient returned successfully to his sporting activities 6 months postoperatively. By presenting this thought-provoking case, we stress the challenging nature of these immensely infrequent injuries while also highlighting the requirement for more sensitive factor-specific studies regarding their optimal treatment.

Can Early Treatment of Lisfranc Injuries Without Planned Re-Intervention be Safely Performed.

The Lisfranc complex is a unique combination of ligamentous and osseous relationships between the medial cuneiform and second metatarsal base that is often injured by high energy mechanisms. Fixation for these injuries is often operative; however, the optimal timing of surgical treatment has been debated. All patients who underwent operative fixation of a Lisfranc injury at a single urban tertiary care center were reviewed. Patient were split into two groups based on timing to fixation with one group being less than 24 hours from presentation and a second group being greater than 24 hours. There were 58 patients who underwent what was planned as final operative stabilization of their Lisfranc injury in less than 24 hours and 41 patients who underwent fixation after more than 24 hours. The early treatment of Lisfranc injuries did not lead to significant increases in follow up time, infections, time to weight bearing, union rates, or time to union compared patients treated with delayed fixation. There was a higher rate of superficial infection in the early intervention group, but it did not reach statistical significance. We believe our findings demonstrate that delayed fixation is not superior to early treatment of Lisfranc injuries. LEVEL OF EVIDENCE: Level 3 Therapeutic retrospective comparative study.

Complications and morbidity of the extended delto-pectoral approach in treating complex humeral shaft fractures with proximal metaphyseal extension using a long locking plate for internal fixation.

BACKGROUND: Humeral shaft fractures account for up to 3% of all fractures, but complex forms of those fractures (type AO/OTA B or higher) are rare. Plate and screw fixation of the fracture are rated as consolidated from 80 to 97%. Reported complications include non-union, secondary radial nerve palsy and infection. Minimally invasive plate osteosynthesis (MIPO) should provide the same union rate as open reduction and internal fixation (ORIF) but potentially with fewer complications. The aim of our study was to review patients treated for complex humeral fractures with ORIF through an extended delto-pectoral approach using a long pre-contoured locking plate. The morbidity of the open approach, complication rates, union rate and clinical outcomes were assessed. METHODS: We performed a retrospective analysis of 26 consecutive complex humeral shaft fractures (7 males, mean age 59 years; 19 females, mean age 67 years) treated in our institution with a long pre-contoured locking plate between June/2011 and December/2017. Fracture healing was evaluated with standard radiographs. Eventual complications and the morbidity of the approach were assessed through chart review. The final clinical outcome and quality of life were assessed via telephone interview with DASH score and EQ-5D-3 L in 25 of the 26 patients included. RESULTS: There were no complications related to the open approach with uneventful wound healing in all cases without any infections. Mechanical complications occurred in 3 cases (11%): one tuberosity dislocation (revised) and two plate failures (one revised). Postoperative radial nerve palsy was observed in two patients (7%), of which one was transient, the other was persistent. The plate was removed in 4 cases (15%). The average radiological and clinical follow-up was 21 months (range: 12-56). At 12 months follow-up complete fracture healing was confirmed in 22 out of 26 cases and in three more patients after 18 months. After an average of 44 months, the mean DASH score was 35 (SD ± 15.83) points; the EQ-5D-3 L score 0.7 (SD ± 0.31). CONCLUSION: ORIF with a long locking plate though an extended delto-pectoral approach is certainly still a viable option to treat complex humeral shaft fractures with good soft tissue and bone healing as well as good functional recovery. No increased morbidity was attributed to the open surgical approach. In our series, radial nerve palsy could not be completely avoided, accentuating the potential risk of this specific fracture in close proximity to the radial nerve. TRIAL REGISTRATION: Ethics Committee: Ethikkommission Ostschweiz (EKOS), Project ID: 2019-00323.

A Systematic Review of the Optimal Management of Pediatric Distal Radius Displacement Fractures: Open Reduction and Internal Fixation Versus Cast Placement.

Distal radius fractures are among the most common pediatric injuries, affecting thousands of children each year. These fractures often require clinical intervention to reduce displacement and ensure the proper healing of the growth plate and wrist bone. The primary objective of this comprehensive analysis is to compare the effectiveness of open reduction and internal fixation (ORIF) versus cast placement in the treatment of pediatric distal radius fractures, with the aim of identifying the optimal treatment approach. Therefore, a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted on pediatric distal radius displacement fractures using extensive database searches from 2000 to 2024 for specific keywords, ensuring transparency and reproducibility. Our findings indicate that higher displacement necessitates ORIF to minimize long-term complications and ensure better functional outcomes for pediatric patients. Rare studies comparing ORIF and cast placement are analyzed, emphasizing the advantages and limitations of each approach. The document concludes that the choice between ORIF and casting depends on factors such as fracture severity, patient's age, and specific characteristics of the injury to ensure optimal outcomes in pediatric distal radius fracture management. In conclusion, our data suggests that ORIF and cast placement each have pros and cons for pediatric distal radius fractures, with the best treatment depending on fracture specifics and patient factors, but neither method is clearly superior for long-term outcomes.

Readmission within 30-days of open reduction and internal fixation for ankle fractures: NSQIP analysis of 29,905 patients.

BACKGROUND: Historically, ankle fractures have been treated with open reduction and internal fixation (ORIF) procedures, which are considered safe and effective. Patient characteristics may contribute to postoperative difficulties thereby increasing risk of hospital readmission. The objective of this study was to determine the frequency of and reasons for 30-day readmission and postoperative complications following ORIF for ankle fractures. METHODS: A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database from 2015 to 2021 identified patients undergoing ORIF for ankle fractures. Patient demographics, complication incidence, and reasons for unplanned hospital readmission were collected. Multivariable analyses identified patient risk factors for any adverse event (AAE) and readmission within 30-days of surgery. RESULTS: The 29,905 patients queried who underwent ORIF procedures for ankle fractures between 2015 and 2021 were 49.6 ± 18.40 years of age, 30.9 ± 7.10 kg/m2, and 40.81% male. Of this cohort, 981 (3.30%) experienced 30-day postoperative adverse events, with surgical site infections (SSI; 1.25%) the most common. Unplanned readmission was observed in 2.08% of patients after a mean of 14.64 days. Surgical site related readmissions were 20.55% (n = 128) of reported readmissions with the most common being superficial incisional SSI. Notable risk factors for adverse events included ASA class (OR = 1.579, P < .001), COPD (OR = 1.522, P < .001), bleeding disorders (OR = 1.489, P = .001), diabetes (OR = 1.254, P = .008), and current smoking status (OR = 1.295, P = .002). Risk factors for readmission were ASA class (OR = 1.762, P < .001), COPD (OR = 1.599, P < .001), bleeding disorder (OR = 1.711, P < .001), diabetes (OR = 1.494, P < .001), end stage renal disease (OR = 3.304, P < .001), steroid use (OR = 2.144, P < .001), and current smoking status (OR = 1.667, P < .001). CONCLUSION: Despite a low adverse event rate, 2% of patients required unplanned readmission after ORIF for ankle fractures. Surgical site complications account for almost half of reported readmissions. ASA class and various medical comorbidities were found to significantly increase the risk of postoperative adverse events and hospital readmission.

Type of fixation is not associated with range of motion after operative treatment of proximal radius fractures- a systematic review of 519 patients.

Background: The aims of this study are 1) to assess whether open reduction internal fixation (ORIF) techniques for fractures of the proximal radius are associated with the range of motion (ROM), 2) to determine the incidence of hardware-related complications and removal following plate and screw fixation of the proximal radius, and 3) to evaluate whether the safe-zone definition is described in the literature and its relation to the ROM. Methods: A literature search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting ROM in patients undergoing ORIF for radial head or neck fractures were included. Two treatment groups were defined based on ORIF technique: screws only or plates with and without additional screw placement. Results: A total of 13 articles were included with 519 patients, of which 271 belonged to the screw group and 248 to the plate group. At final follow-up, the screw group reported a mean supination of 79 (95% CI: 74-83), pronation of 76 (95% CI: 69-84), flexion of 131 (95% CI: 124-138), and loss of extension of 4 (95% CI: 1-7). The plate group reported a mean supination of 72 (95% CI: 65-80), pronation of 697 (95% CI: 60-75), flexion of 126 (95% CI: 118-133), and loss of extension of 7 (95% CI: 1-14). Conclusion: Predominantly retrospective studies show that the ROM seems similar for screw and plate osteosynthesis of proximal radius fractures. Complication rates are similar as well. The safe-zone definition is rarely reported.

Prospective study on functional outcome of distal femur fracture treated by open reduction and internal fixation using distal femur locking plate in Tibebe Ghion Specialized Hospital, Bahirdar, North West Ethiopia.

BACKGROUND: Distal femur fractures account for 6% of femur fractures. The treatment of distal femur fractures is challenging. Historically, nonoperative management has been the mainstay of management, which has evolved to operative management. There is no single implant used for all types of distal femur fractures. The implant evolves with time. The introduction of a distal femur locking plate (DF LCP) has had a great impact on the treatment. In developing countries like Ethiopia, there is scarcity of studies on functional outcome of operative treatment. So, this study aimed to assess the functional outcome of distal femur fractures treatment using distal femur locking plate. METHODS: This prospective cohort study was carried out among adult patients with distal femur fractures treated using distal femur locking plate at Tibebe Ghion Specialized Hospital from august 2022 to July 2023. A total of 60 patients with AO Type A and Type C fracture were included. All patients were followed for 6 months. Functional outcomes were assessed using Neer's scoring system. Data was entered and analyzed using SPSS 27. Frequency, mean and cross tabulation were used to summarize descriptive statistics. Multinomial logistic regression was used to test the associations. RESULTS: In our study out of 60 patients ,48.3% (29) had excellent functional outcomes, 30% (18) had good functional outcomes, 10% (6) had fair functional outcomes and 11.7% (7) had unsatisfactory functional outcomes according to Neer's scoring system. Patients with closed distal femur fractures had 5 times higher probability of excellent functional outcome than those patients with open distal femur fractures (AOR (2.49(5.8 ,1.07)). Patients who had regular follow up had 7 times higher probability of excellent functional outcome than those who had no regular follow up (AOR 7.16(1.11,46.22)). The average union period was 4.63 months, with only 2 patients experiencing delayed union. CONCLUSION: Closed fracture and regular follow up were determining factors for better functional outcomes. Closed fractures preserve the biological environment, which facilitates early fracture healing. The regular follow up helped patients to assess their rehabilitation status and pick any complication early.

Posterior Cruciate Ligament Avulsion Fracture of Tibia: Fixation with Screw and Augmentation Using Ethibond Suture for Improved Clinical Outcomes.

Introduction: The posterior cruciate ligament (PCL) is a vital structure in knee biomechanics, and its avulsion fractures present a unique challenge. This prospective cohort study was conducted at Grant Government Medical College and JJ Hospital, Mumbai, aimed to assess the clinical outcomes of open reduction and internal fixation (ORIF) utilizing cancellous screws and ethibond suture augmentation for PCL avulsion fractures. PCL avulsion fractures often result from traumatic incidents, such as road traffic accidents, and are associated with complications if left untreated. Materials and Methods: Patients aged 20-45 years with isolated PCL avulsion fractures, confirmed by clinical and radiological assessments, were included. Seven eligible patients underwent ORIF, and outcomes were evaluated through clinical assessments, radiological imaging, and the Lysholm knee scoring system. Follow-ups were conducted for a mean time of 13.2 months, assessing stability, range of motion, and complications. Results: The study demonstrated a mean post-operative Lysholm score of 93.8, significantly improved from the pre-operative score of 49.6. Post-operative knee flexion averaged 125.2°. Fracture healing was observed in all cases, and complications were minimal. The study provides evidence of the effectiveness of ORIF with ethibond suture augmentation for PCL avulsion fractures. Conclusion: The study concludes that the proposed surgical technique yields positive outcomes, including enhanced knee functionality, successful fracture healing, and minimal complications. This approach, combining cancellous screws and ethibond suture augmentation, presents a promising option for the management of PCL avulsion fractures, contributing to the diverse landscape of effective treatment modalities.

Open reduction and internal fixation of zygomatic arch fracture by transbuccal instrumentation - A prospective clinical trial.

Background and Purpose: The zygomatic arch is important to maintain facial projection as well as width. Hence, restitution of its form by open reduction and internal fixation (ORIF) is indicated following its fracture, in certain clinical scenarios. The contemporary surgical approaches are cutaneous with associated complications. This observational clinical trial was designed to evaluate intraoral reduction and transbuccal fixation of zygomatic arch fractures. Materials and Method: Six patients requiring ORIF of the zygomatic arch were recruited for the study. The clinical parameters such as pain, swelling, mouth opening, facial nerve function, and scar were assessed in the pre-operative as well as post-operative period. Radiographic assessment of displacement and inter-fragmentary separation were studied on computed tomography (CT) images. Results: Mean pre-operative mouth opening was increased from 28.33 ± 6.80 to 36.83 ± 1.94 (P value 0.03). Mean pre-operative swelling was decreased from 34.63 ± 5.41 to 29.71 ± 2.73 (P value 0.02). The pain decreased by day 7 in all the patients (P value 0.01). No facial nerve injury (P value 1) or scar formation (P value 0.002) was encountered in our study. The inter-fragmentary separation as assessed by CT analysis revealed satisfactory outcome. Conclusion: Intraoral open reduction and transbuccal fixation is a simple, effective, and less invasive method to address zygomatic arch fractures with no complications.

Phalangeal fractures: A retrospective comparison of open reduction and internal fixation vs. closed reduction and percutaneous pinning.

The treatment of phalangeal fractures is guided by fracture characteristics, patient factors and surgeon judgment. This study retrospectively compares characteristics of phalangeal fractures treated with closed reduction percutaneous pinning (CRPP) with those of fractures treated with open reduction internal fixation (ORIF) to identify risk factors associated with reoperation. A total of 901 phalangeal fractures were included and treated operatively by either CRPP (748 fractures, 83 â€‹%) or ORIF (153 fractures, 17 â€‹%). Demographics, surgical management, and complication data were collected. Statistical analyses were performed to stratify risk associations and identify potential predictors of reoperation. With multivariate analysis and bootstrapped LASSO regression, fractures addressed by means of ORIF (vs. CRPP), work-related fractures, and open fractures were found to be independently associated with reoperation. These findings can be used to guide patient selection, surgical planning and timing of fracture repair. Level of evidence: Level III, Therapeutic.

Factors influencing surgical outcomes of fixation with locking plate for three- and four-part proximal humerus fractures in patients aged 50 ​Years and older.

Background: Treating complex three- and four-part proximal humerus fractures, especially in the elderly, remains contentious, with internal fixation using locking plates and shoulder arthroplasty being primary options. Although proximal humerus locking plates are more commonly used than shoulder replacements, they have a high complication rate. Factors like low bone density, advanced age, multiple fragment fractures, and medial cortical support loss negatively impact treatment outcomes. This study evaluates the functional and radiographic outcomes of using locking plates for treating these fractures in patients aged 50 and older, and the factors influencing outcomes and complication rates at the Ho Chi Minh City Hospital for Trauma and Orthopedics. Method: A descriptive case series study was conducted on 58 patients aged 50 and older (15 males, 43 females) with three- and four-part proximal humerus fractures. These patients underwent open reduction and internal fixation with Locking - compression plate (LCP) periarticular proximal humerus plates at the Ho Chi Minh City Hospital for Traumatology and Orthopedics (HTO) from April 2020 to April 2022. The minimum postoperative follow-up period was 12 months. Results: The average age of the patients was 62.78 â€‹± â€‹7.73 years, with a mean follow-up of 26.24 â€‹± â€‹5.93 months. Among them, 41 had three-part fractures (70.68 â€‹%) and 17 had four-part fractures (29.32 â€‹%). At the final follow-up (≥12 months), the mean Constant-Murley score was 70.81 â€‹± â€‹9.15, and the mean QDASH score was 8.33 â€‹± â€‹2.77. Complications occurred in 6 cases (10.34 â€‹%). Complex fractures, such as four-part fractures with displacement greater than 2 â€‹mm, had lower Constant-Murley scores and higher QDASH scores (p â€‹< â€‹0.05). Age, gender, bone density by deltoid tuberosity index (DTI), bone grafting, and rotator cuff sutures showed similar trends, but the differences were not statistically significant. Conclusion: Open reduction and internal fixation (ORIF) provides good bone healing and functional outcomes for three- and four-part proximal humerus fractures. Factors such as age, gender, bone density, bone grafting, and rotator cuff sutures do not significantly affect outcomes. Therefore, osteoporosis should not be a contraindication for ORIF with locking plates in these cases. Complex fractures, however, often lead to poorer outcomes and higher complication rates post-surgery.

Facial Nerve Paresis After Combined Intraoral and Preauricular Approach to High Condylar Fractures: A Case Report.

Condylar fractures are the most common mandibular fractures, and a variety of open and closed approaches are used for repair, each with its own inherent risks and benefits. A 27-year-old man had a severely displaced and angulated high subcondylar fracture with anterior open bite deformity. The patient underwent open reduction and internal fixation of the condyle via a combined preauricular and intraoral approach as well as maxillomandibular fixation to repair his fracture. This combined approach allows the surgeon to maximize exposure while limiting risks of permanent injury from surgery.

Minimum 10-year Follow-up after Open Reduction and Internal Fixation of Radial Head Fractures Mason Type II and III.

INTRODUCTION: The treatment of complex radial head fractures remains controversial with open reduction and internal fixation (ORIF), radial head arthroplasty, and radial head excision being the most common treatment options. While ORIF is the preferred treatment strategy for Mason type II fractures, the optimal treatment of Mason type III fractures is debated. PURPOSE: To report minimum 10-year outcomes after ORIF of Mason type II and type III radial head fractures. We hypothesized that both Mason Type II and Type III fracture patients would demonstrate satisfactory clinical outcomes at minimum 10-year follow-up. METHODS: All patients with Mason type II or III radial head fractures who were treated with ORIF by a single surgeon between 2005 and 2010 were included. Fractures with significant bone defects were treated with bone grafts and elbow ligament injuries were treated with either primary ligament repair or reconstruction. Patient reported outcome (PRO) questionnaires were administered at the time of last clinical follow-up and at a minimum of 10 years postoperatively. RESULTS: Twenty-four patients, including 13 male and 11 female patients with an average age of 39 (range 19-60) at the time of surgery met inclusion criteria. Thirteen patients suffered from Mason type II and 11 patients from Mason type III fractures. At initial follow-up, 21 out of 24 fractures (88%) demonstrated radiographic union. Three non-unions, 2 of which were Mason type III fractures, were treated with revision ORIF and iliac crest bone grafting. 11 patients developed postoperative elbow stiffness and required capsular release surgery. At last clinical follow-up, average flexion was 139 degrees, average extension was 4 degrees, average supination was 77 degrees, and average pronation was 81 degrees. The median DASH score was 7 (ranging from 0 - 32). Minimum 10-year follow-up (mean: 14.6 years) was collected on 18 of 24 (75%) of the patients. At a minimum of 10 years postoperatively, the median QuickDASH score was 4.5 (range: 0 to 25) and the median SANE score was 96.5 (range: 75-100). Median satisfaction with the surgical outcome was 10/10 (range: 3-10). CONCLUSION: ORIF of Mason type II and III radial head fractures results in high union rates with good functional outcomes at a mean of 14.6 years postoperatively. The study results suggest that ORIF of Mason type II and III radial head fractures leads to long-term positive functional outcomes.

Risk factors for adverse events after clavicle fracture open reduction and internal fixation: A NSQIP study.

BACKGROUND: Midshaft clavicle fractures are often subject to increased complications when treated nonoperatively, so surgical treatment with open reduction and internal fixation (ORIF) is a favored alternative. Despite safer outcomes, adverse events such as surgical site infections may still persist, particularly in the presence of certain patient characteristics. The objective of this study was to determine risk factors for and the frequency of adverse events following ORIF for clavicle fractures. METHODS: A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database from 2012 to 2021 identified patients undergoing isolated ORIF for clavicle fractures. Patient demographics and 30-day complications were collected. Bivariate analyses with a student's t-test or chi-square test were used to identify possible predictor variables for either AAE or SSI, and demographic metrics with P < 0.2 were included in a multivariable regression model. Multivariable analyses identified significant independent patient risk factors for any adverse event (AAE) or SSI within 30-days of surgery. Adjusted odds ratios were reported for each variable included in the model. Statistical significance was set a prior at P < 0.05. RESULTS: The 6,753 selected patients who underwent ORIF for clavicle fractures between 2012 and 2021 were 38.1 ± 15.3 years of age, BMI 26.2 ± 4.9 kg m-12, and 77.3 % male. Of this cohort, 88.4 % received treatment on an outpatient basis. Postoperative adverse events were experienced by 128 (1.9 %) patients within 30 days of surgery, and SSI were prevalent in 0.77 % of patients, followed by wound dehiscence in 0.12 % of patients. After controlling for patient demographics and comorbidities, notable risk factors for adverse events included current smoking status (OR=2.036; P < 0.001) and patient age (OR=1.025; P < 0.001). Outpatient status (OR=0.528; P = 0.004) was protective. CONCLUSION: The present study noted significantly increased risk of postoperative adverse events in older patients, as well as patients who smoke. Outpatient setting was significantly protective for adverse events. These findings help to provide further clinical context to guide surgical decision making and inform surgeons on current risks and outcomes.

Trends in Epidemiology and Treatment of Humerus Fractures in the United States, 2017-2022.

Background Fractures of the humerus are one of the more common fractures in the United States and a cause of fragility fractures in the elderly population. This study aims to understand recent trends in the demographic factors correlated with humeral shaft fractures (HSF) and humeral shaft fracture nonunion (HSFN) following open reduction internal fixation (ORIF) and intramedullary nailing (IMN). Methods The TriNetX database was used to query using International Classification of Diseases-10 (ICD10) diagnosis codes for patients who sustained HSF between 2017 and 2022. Patients were then organized into cohorts based on Current Procedural Terminology (CPT) codes 24515 and 24516 for ORIF and IMN of HSFs, respectively. Subsequent nonunion after operative management was queried. Descriptive and comparative analysis was performed to examine the differences observed between patients based on age, sex, ethnicity, race, and smoking status as well as surgical management across the six-year study period. Results The incidence of HSF increased from 7,108 in 2017 to 8,450 in 2022. The rate of HSF ORIF increased from 12% to 17% while the nonunion rate following ORIF decreased from 4% to 3%. The rate of HSF IMN increased from 4% to 6% and the rate of nonunion following IMN increased from 2% to 4%. The overall rate of HSFN surgery was 1.7% with slight decreasing trend over the past year. Conclusion It is speculated that improved care and surgical indications resulted in a lower rate of nonunion despite an increase in the overall rate of HSF and its operative managements.

Current Role of Reverse Total Shoulder Arthroplasty in the Management of Glenohumeral Osteoarthritis.

Reverse total shoulder arthroplasty (RSA) was historically reserved for the elderly, low-demand patient with rotator cuff arthropathy (RCA) or as a salvage procedure after failed primary arthroplasty. Surgeon expertise and the advancement of implant design has allowed RSA to now become commonplace not only for RCA but also for glenohumeral osteoarthritis. RSA provides a robust glenoid baseplate fixation, which allows for easier and more reliable bone grafting or augmentation when needed. For patients with severe glenoid bone loss, RSA has been shown to have superior or equivalent patient-reported outcomes and shoulder range of motion when compared with total shoulder arthroplasty.

Salvage of failed subtrochanteric fracture fixation in the elderly: revision internal fixation or hip arthroplasty?

PURPOSE: This study aimed to compare reoperation rate and clinical outcomes between revision open reduction and internal fixation and hip arthroplasty following failed subtrochanteric fracture fixation. METHODS: A retrospective review was conducted of patients > 50 years old treated for failed fixation of subtrochanteric fractures with revision ORIF or hip arthroplasty from 2003 to 2023. Primary outcomes included rate of fracture union and reoperations after initial salvage therapy. Secondary outcomes included complications (infection, dislocation, bursitis, implant prominence, implant failure, nonunion), pain, and gait-aid requirements by final follow-up. RESULTS: Forty-four patients were identified: 34 treated with revision ORIF and 10 with hip arthroplasty. The arthroplasty cohort was older (75.4 vs. 66.0 years, p = 0.016) but did not differ from the ORIF cohort in sex, type of initial fixation, or reason for fixation failure. Patients treated with revision ORIF and patients treated with arthroplasty had similar rates of fracture union (85.3% vs. 80.0%, p = 0.772) and reoperation (35.3% vs. 30.0%, p = 0.710). There was no significant difference in rate of additional complications not requiring reoperation (0.0% vs. 40.0%, p = 0.071). The arthroplasty cohort achieved full weightbearing in significantly shorter time than the revision ORIF cohort (3.8 vs. 6.8 weeks, p = 0.005). CONCLUSION: Both revision ORIF and hip arthroplasty are acceptable options for salvage of failed subtrochanteric fracture fixation in patients greater than 50 years old, but patients should be counseled that although the rate of fracture union is high whether revision ORIF or hip arthroplasty is selected, the rate of reoperation can exceed 1-in-4 patients. LEVEL OF EVIDENCE:  : Level III, Retrospective Comparative Study.

Complications after reverse shoulder arthroplasty for proximal humerus nonunion.

BACKGROUND: Proximal humerus nonunion is a challenging complication of fractures that can be treated surgically with either open reduction internal fixation (ORIF) or reverse total shoulder arthroplasty (RTSA). The few studies published on this subject have shown high rates of complications and revision surgery when RTSA has been performed for proximal humerus nonunion. The purpose of this study was to determine the rates of complications and revision of this procedure at our institution, as well as to identify any variables that may impact risks of complications and reoperations. METHODS: A single-institution retrospective review of all patients who underwent RTSA for proximal humerus nonunion between 2005 and 2021 was performed. Nonunion was defined as imaging evidence of lack of union, at least 90 days after the index fracture. Patients with less than 1 year of clinical follow-up were excluded. Fifty patients were included, with the majority being female (78%). The mean age at time of RTSA was 71 (range: 54-86) years and most patients were initially treated nonoperatively (74%). Mean total follow-up was 49 (range: 11-130) months. Demographic and surgical variables were recorded. Primary outcomes were complications and reoperations. Complications were divided into surgical (those directly related to RTSA), or other (those unrelated to RTSA). Secondary outcomes included visual analog scale pain scores and range of motion. RESULTS: A total of 17 shoulders (34%) sustained complications after revision shoulder arthroplasty, with 10 (20%) requiring reoperation. Six patients (12%) sustained dislocations and 5 (10%) had radiographic evidence of humeral loosening. No variables examined, including nonoperative vs. surgical management of the index fracture, prosthesis type, or management of tuberosities, influenced the risk of dislocation. Survivorship free from reoperation at 2 years was 73%. Younger age at time of RTSA and the presence of diabetes mellitus both increased the risk of reoperation significantly (P = .013 and P = .037, respectively). There was a trend towards increased risk of reoperation in patients who were treated with initial ORIF (hazard ratio = 2.95); however, this did not reach statistical significance (P = .088). Three patients (6%) sustained a periprosthetic fracture after a fall. CONCLUSION: RTSA provides improved pain and function for properly selected patients with proximal humerus nonunion. Dislocation, humeral loosening, and reoperation rates remain high when RTSA is performed for nonunion compared to other diagnoses. In this study, younger age and diabetes mellitus increased the odds of reoperation. Every effort must be made to optimize implant stability and humeral component fixation when RTSA is performed for proximal humerus nonunion.