Early outcomes of locked noncemented stems for the management of proximal humeral fractures: a comparative study.

BACKGROUND: Proximal humeral fractures are common and a major concern in public health resources utilization. There is an increase in the use of reverse total shoulder arthroplasty (RTSA) as an option for complex fractures in the elderly. The complexity of the technique in RTSA is increased because of the fracture. To find an advantage of locking stems in RTSA for the treatment of proximal humeral fractures, we designed a comparative study between fracture-dedicated locking stems vs. cemented stems. MATERIALS AND METHODS: We retrospectively studied 58 patients treated with an RTSA after a fracture. We compared how the implant design and the tuberosity consolidation affects patient outcome through measuring range of motion and the Constant score. RESULTS: The groups were similar in age, sex, time to surgery, and Constant score in the uninjured side. Patients treated with a dedicated locking noncemented stem performed better, with an increased Constant score (P > .05) and reached more mobility with no statistical significance. We found that 13 of the 24 fractures (54%) treated with a cemented stem consolidated, and 26 of 34 tuberosities (76%) healed in the noncemented locked stems. Patients with tuberosity consolidation acquired better range of motion and Constant scores (P < .05). CONCLUSIONS: A dedicated stem improves tuberosity healing and increases outcomes seen in Constant scores. Tuberosity consolidation is a main goal when treating proximal humeral fractures with RTSA.

Proposal for a new trajectory for subaxial cervical lateral mass screws.

PURPOSE: Lateral mass screws combined with rods are the standard method for posterior cervical spine subaxial fixation. Several techniques have been described, among which the most used are Roy Camille, Magerl, Anderson and An. All of them are based on tridimensional angles. Reliability of freehand angle estimation remains poorly investigated. We propose a new technique based on on-site spatial references and compare it with previously described ones assessing screw length and neurovascular potential complications. METHODS: Four different lateral mass screw insertion techniques (Magerl, Anderson, An and the new described technique) were performed bilaterally, from C3 to C6, in ten human spine specimens. A drill tip guide wire was inserted as originally described for each trajectory, and screw length was measured. Exit point was examined, and potential vertebral artery or nerve root injury was assessed. RESULTS: Mean screw length was 14.05 mm using Magerl's technique, 13.47 mm using Anderson's, 12.8 mm using An's and 17.03 mm using the new technique. Data analysis showed significantly longer lateral mass screw length using the new technique (p value < 0.00001). Nerve potential injury occurred 37 times using Magerl's technique, 28 using Anderson's, 13 using An's and twice using the new technique. Vertebral artery potential injury occurred once using Magerl's technique, 8 times using Anderson's and none using either An's or the new proposed technique. The risk of neurovascular complication was significantly lower using the new technique (p value < 0.01). CONCLUSION: The new proposed technique allows for longer screws, maximizing purchase and stability, while lowering the complication rate.

Surgical treatment in spine Paget's disease: a systematic review.

Paget's disease of bone (PDB) is a disease characterized by a disorder in the bone metabolism. The spine is the second region affected after the pelvis. Surgical treatment is reserved for cases refractory to medical treatment. We performed a systematic review of patients with Paget disease of bone affecting the spine, treated surgically in the last 30 years. The main objective of the review is to find out indications for surgery, outcomes of these patients and also the standard perioperative management.

Antibodies against 4 Atypical Post-Translational Protein Modifications in Patients with Rheumatoid Arthritis.

Patients with rheumatoid arthritis (RA) show autoantibodies against post-translational protein modifications (PTMs), such as anti-citrullinated protein antibodies. However, the range of recognized PTMs is unknown. Here, we addressed four PTMs: chlorination, non-enzymatic glycation, nitration, and homocysteinylation, identified as targets of atypical RA autoantibodies in studies whose protocols we have followed. The modified antigens included collagen type II, an extract of synovial proteins and a selection of peptides. We interpreted the results according to the optical density (OD) obtained in an enzyme-linked immunosorbent assay ( ELISA) with the modified antigen and the corrected OD obtained after subtracting the reactivity against the unmodified antigen. The results showed evidence of specific antibodies against glycated collagen type II, as the corrected ODs were higher in the 182 patients with RA than in the 164 healthy controls (p = 0.0003). However, the relevance of these antibodies was doubtful because the magnitude of the specific signal was small (median OD = 0.072 vs. 0.027, respectively). There were no specific antibodies against any of the other three PTMs. Therefore, our results showed that the four PTMs are not inducing a significant autoantibody response in patients with RA. These results indicated that the repertoire of PTM autoantigens in RA is restricted.

Cerclage wiring and intramedullary nailing, a helpful and safe option specially in proximal fractures. A multicentric study.

PURPOSE: Antegrade intramedullary nailing is an alternative for humeral shaft fracture treatment. This surgical technique can be especially demanding in some fracture patterns, leading to problems like malunion and non-union. The purpose of our study is to demonstrate that the use of a nail with cerclage wires could be a safe procedure that facilitate reduction, specially in fractures with abduction of the proximal fragment. MATERIALS AND METHODS: Fifty-six patients were included, from January 2007 to March 2016. In this cohort forty-two patients were females and eighteen males; mean age was sixty-seven (32-89). The fractures were reduced using a cerclage wire through a small lateral or anterior approach, then, antegrade intramedullary nailing was performed. Fracture healing was established by clinical and radiographic evaluation. Shoulder function was assessed using the Constant Score. RESULTS: Fifty-three patients healed (94.6%) adequately. Two patients developed a non-union (3.5%). One patient developed an infection (1.8%). Transient radial nerve palsy was observed in two patients (3.5%). The mean Constant Score at the end of the study was 70 points (range from 34 to 98 points). CONCLUSIONS: Surgical treatment of humeral shaft fractures with cerclage wire and intramedullary nailing is a safe technique to improve fracture reduction. The use of cerclage wires leads to better bone contact while minimizing malunions. The rate of non-union in our study is lower than the rate reported in the literature for humeral shaft fractures treated by intramedullary nailing alone.

Commercially available antibiotic-laden PMMA-covered locking nails for the treatment of fracture-related infections - A retrospective case analysis of 10 cases.

Introduction: Fracture-related infections (FRIs) are a devastating complication. FRIs are challenging and should be addressed with a multidisciplinary approach. An FRI should be addressed surgically by non-viable bone debridement, local antibiotic deposition, minimization of dead space and fracture stabilization. Antibiotic-laden PMMA-covered nails are a viable option to face these complications. To demonstrate the safety and utility of commercially available antibiotic-laden PMMA-covered nails, we performed a review of the cases operated in our institution and a cost analysis to compare the cost of a commercial nail to other available alternatives. Material and methods: We designed a retrospective study of consecutive cases to demonstrate the safety and efficacy of antibiotic-laden PMMA-covered commercial nails and designed a cost analysis of commercial coated nails compared to other custom-made alternatives. Results: We treated seven tibias and three femurs. Nine patients fully fit the criteria for FRI. There was one case of reintervention because of persistent drainage. All fractures healed, and in the first year post-intervention, there were no signs or symptoms of infection. There were no complications related to the commercially available nail that was used. There is a small increase in the direct quantifiable cost in commercially available nails, but non-quantifiable cost should be assessed individually. Conclusions: Commercially available antibiotic-laden PMMA-covered nails are a safe and useful treatment option for complicated cases of lower limb long bone reconstruction. The low complication rate and the straightforward technique compensate for the direct cost increase in most situations.