Correction: The Effect of an App-Based Home Exercise Program on Self-reported Pain Intensity in Unspecific and Degenerative Back Pain: Pragmatic Open-label Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/41899.].

The Effect of an App-Based Home Exercise Program on Self-reported Pain Intensity in Unspecific and Degenerative Back Pain: Pragmatic Open-label Randomized Controlled Trial.

BACKGROUND: The recommended first-line treatment for unspecific and degenerative back pain consists of movement exercises and patient education. OBJECTIVE: Using a pragmatic, randomized controlled trial, we evaluated the effectiveness of a digital home exercise program on self-reported pain intensity compared with the standard of care for physiotherapy. METHODS: Participant recruitment was based on newspaper advertisements and a consecutive on-site assessment for eligibility and enrollment. Participants with unspecific and degenerative back pain aged ≥18 years were randomly assigned in a 1:1 ratio to receive a 12-week stand-alone digital home exercise program or physiotherapy. The digital home exercise program included 4 exercises daily, while physiotherapy included 6 to 12 sessions, depending on the severity of symptoms. The primary outcome was pain, which was assessed using a verbal numerical rating scale. The clinical relevance of pain reduction was assessed using the following thresholds: improvement of at least 1.4 points on the verbal numerical rating scale and a pain reduction of at least 30%. RESULTS: During the study period, 108 participants were assigned to the intervention group and 105 participants to the control group. The mean difference in pain scores between the 2 groups at 12 weeks was -2.44 (95% CI -2.92 to -1.95; P<.01) in favor of the intervention group. The group receiving the digital therapeutic achieved a clinically relevant reduction in pain over the course of the study (baseline vs 12 weeks), with a mean change of -3.35 (SD 2.05) score points or -53.1% (SD 29.5). By contrast, this change did not reach clinical relevance in the control group (mean -0.91, SD 1.5; -14.6%, SD 25.3). Retention rates of 89.9% in the intervention group and 97.3% in the control group were maintained throughout the study. CONCLUSIONS: The use of the app-based home exercise program led to a significant and clinically relevant reduction in pain intensity throughout the 12-week duration of the program. The intervention studied showed superior improvement in self-reported pain intensity when compared with the standard of care. Given the great demand for standard physiotherapy for unspecific and degenerative back pain, digital therapeutics are evolving into a suitable therapeutic option that can overcome the limitations of access and availability of conventional modes of health care delivery into this spectrum of indications. However, further independent evaluations are required to support the growing body of evidence on the effectiveness of digital therapeutics in real-world care settings. TRIAL REGISTRATION: German Clinical Trials Register DRKS00022781; https://tinyurl.com/hpdraa89.

Long-term results using the straight tapered femoral cementless hip stem in total hip arthroplasty: a minimum of twenty-year follow-up.

We report the first long-term results of a prospective cohort study after total hip arthroplasty using the cementless Bicontact hip stem. Between 1987 and 1990, 250 total hip arthroplasties in 236 patients were performed using the cementless Bicontact hip stem. The average follow-up was 22.8 years (20.4-24.8) and average age at index surgery was 58.1 years. Eighty-one patients died and 9 were lost to follow-up. We noted 11 stem revisions revealing an overall Kaplan Meier survival rate of 95.0% (CI 95%: 91.1-97.2%). The average Harris Hip Score revealed 81 points (range 24-93). The Bicontact hip stem demonstrated high survival rates despite high ages and osteopenic changes, which are equivalent to other long-term reports of cementless stem fixation.

Current strategies for the treatment of proximal humeral fractures: an analysis of a survey carried out at 348 hospitals in Germany, Austria, and Switzerland.

BACKGROUND: The therapeutic spectrum for the treatment of displaced proximal humeral fractures ranges from conservative therapy to head-preserving surgical interventions and joint replacement. This study initiated a survey on the current treatment options with regard to diagnostics, choice of therapy, and complications that are encountered at trauma surgeries and orthopedic hospitals in Germany, Austria, and Switzerland. MATERIALS AND METHODS: The survey included 743 hospitals. The questionnaire covered information on demographics, diagnostics, classification, therapy, and complications of proximal humeral fractures. RESULTS: The questionnaire was completed by 348 hospitals. Five of 6 hospitals treat more than 40% of the fractures surgically. The percentage distribution of the available implants is at 63.4% for angular stable plates, 30.9% for intramedullary nails, and 10.1% for fracture prostheses. The 5 complications reported most frequently were nonanatomic reduction (83%), implant perforation (73%), secondary displacement of the fracture (71%), avascular necrosis (67%), and implant-related impingement (59%). CONCLUSIONS: A preference for surgical treatment of proximal humeral fractures was found, with stabilization predominantly being attempted by the use of angle-stable implants. The 2 most common complications were "nonanatomic reduction of fractures" and the more specific problem of "implant perforation" when fixed-angle implants were used for treatment.

The complexity of proximal humeral fractures is age and gender specific.

BACKGROUND: Studies that investigated possible associations between the complexity of proximal humeral fractures and patient characteristics are rare. We hypothesized that the grade of fracture complexity may correlate with age and gender of hospitalized, adult patients. METHODS: Based on the Neer classification, we defined four radiological grades of fracture complexity. The data of adult patients that were treated during a 9-year period at a German hospital serving a town of 80,000 inhabitants was reviewed. RESULTS: Seven hundred and eighty fractures were evaluated [518 female/262 male (66.41/33.59 %), average age 64.2 years (range 17.4-99.2)]. During the study period, the number of fractures increased to 167 %. Almost two-thirds of the patients were females and older than 60 years. Of all fractures, 86 % were displaced fractures. In patients younger than 60 years, 1.99-fold more complex fractures occurred in males (32.4 %) than in females (16.2 %). In contrast, in patients older than 60 years, 1.72-fold more complex fractures occurred in females (54.1 %) than in males (31.5 %). There was a significant association between low-energy trauma and female gender older than 60 years. CONCLUSIONS: Our study demonstrated an overall increase of displaced proximal fractures. The vast majority of patients with more complex fractures consisted of female patients older than 60 years.

Onset of preclinical osteoarthritis: the angular spatial organization permits early diagnosis.

OBJECTIVE: Superficial articular chondrocytes display distinct spatial remodeling processes in response to the onset of distant osteoarthritis (OA). Such processes may be used to diagnose early events before manifest OA results in tissue destruction and clinical symptoms. Using a novel method of spatial quantification by calculating the angles between a chondrocyte and its surrounding neighbors, we compared maturational and degenerative changes of the cellular organizations in rat and human cartilage specimens. METHODS: The nuclei of superficial chondrocytes obtained from intact rat cartilage and from human knee cartilage, as well as from cartilage with focal and severe OA, were digitally recorded in top-down views. Their Cartesian coordinates were used to determine the nearest neighbor for each chondrocyte and the angle between these 2 cells and a reference. These angles, cellularity, nearest neighbor distances, and aggregation were analyzed as a function of location and OA severity. RESULTS: Neighboring rat chondrocytes exhibited intricate angular patterns with 4 dominant angles that were maintained during maturation and during the onset and progression of OA. Within intact cartilage, human chondrocytes demonstrated 1 dominant angle and, thus, a significantly different angular organization. With early OA onset, human chondrocytes that were located within intact cartilage displayed an increased occurrence of 4 angles; the resulting angular patterns were indistinguishable from those observed in rats. The angular remodeling was associated with location- and OA severity-dependent changes in cellularity and aggregation. CONCLUSION: This study is the first to identify the presence of angular characteristics of spatial chondrocyte organization and species-specific remodeling processes correlating with OA onset. The appearance of distinct angular and spatial patterns between neighboring chondrocytes can identify the onset of distant OA prior to microscopically visible tissue damage and possibly before clinical onset. With further development, this novel concept may become suitable for the diagnosis and followup of patients susceptible to OA.

Biomechanical analysis of a new expandable vertebral body replacement combined with a new polyaxial antero-lateral plate and/or pedicle screws and rods.

PURPOSE: Restoration of the anterior spinal profile and regular load-bearing is the main goal treating anterior spinal defects in case of fracture. Over the past years, development and clinical usage of cages for vertebral body replacement have increased rapidly. For an enhanced stabilization of rotationally unstable fractures, additional antero-lateral implants are common. The purpose of this study was the evaluation of the biomechanical behaviour of a recently modified, in situ distractible vertebral body replacement (VBR) combined with a newly developed antero-lateral polyaxial plate and/or pedicle screws and rods using a full corpectomy model as fracture simulation. METHODS: Twelve human spinal specimens (Th12-L4) were tested in a six-degree-of-freedom spine tester applying pure moments of 7.5 Nm to evaluate the stiffness of three different test instrumentations using a total corpectomy L2 model: (1) VBR+antero-lateral plate; (2) VBR, antero-lateral plate+pedicle screws and rods and (3) VBR+pedicle screws and rods. RESULTS: In the presented total corpectomy defect model, only the combined antero-posterior instrumentation (VBR, antero-lateral plate+pedicle screws and rods) could achieve higher stiffness in all three-movement planes than the intact specimen. In axial rotation, neither isolated anterior instrumentation (VBR+antero-lateral plate) nor isolated posterior instrumentation (VBR+pedicle screws and rods) could stabilize the total corpectomy compared to the intact state. CONCLUSIONS: For rotationally unstable vertebral body fractures, only combined antero-posterior instrumentation could significantly decrease the range of motion (ROM) in all motion planes compared to the intact state.

Septic arthritis of the knee: presentation of a novel irrigation-suction system tested in a cadaver study.

BACKGROUND: The established treatment for bacterial arthritis of the knee joint is arthroscopic surgery with irrigation and debridement. The aim of this article is to summarize the relevant data in treating bacterial arthritis of the knee joint, and based on these findings to present a novel irrigation suction system, tested in a cadaver study, as an additional tool in the postoperative treatment phase of arthroscopic surgery for knee joint infections. METHOD: The novel automated irrigation-suction system presented here was compared to conventional continuous suction irrigation in a total of six knee joints. All knee joints were filled with 80 ml methylene blue stain and rinsed by two different methods. Fluid specimens were taken after ten and twenty minutes to be compared by photometric extinction measurement at a wave length of 500 nm. RESULTS: After ten minutes, the average extinction was e(1C) = 0.8 for the continuous suction irrigation and e(1N) = 0.4 for the novel irrigation-suction system. After twenty minutes, we recorded an average extinction of e(2C) = 0.3 for continuous suction irrigation and e(2N) = 0.001 for the novel irrigation-suction system. The students t-test revealed superior results after ten and twenty minutes of washing out the knee joints with a p < 0.001 for the novel irrigation-suction system. CONCLUSION: A novel irrigation-suction system may be an effective tool for postoperative knee joint irrigation in arthroscopic therapy for bacterial arthritis of the knee. Further animal studies are needed to verify the effects in vivo.

Effect of proximal humeral fractures on the age-specific prevalence of rotator cuff tears.

BACKGROUND: This study examined the effect of proximal humeral fractures on the age- and shoulder-specific prevalence of rotator cuff tears (RCTs) as well as the association with fracture severity, patient age, and clinical outcome. METHODS: Sixty-three fractures were treated conservatively; in 114 cases, minimally invasive osteosynthesis, and in 125 cases, open reduction and plate fixation were performed without rotator cuff reconstruction. After 4.4 years, all 302 patients were clinically and sonographically examined. RESULTS: We examined 139 two-part, 95 three-part, and 68 four-part fractures according to Neer and 134 A, 86 B, and 82 C fractures according to the AO classification. There were 52 patients (17%) with a complete rotator tear (RCT) only at the injured shoulder and 11 patients (4%) with a complete RCT only at the contralateral shoulder (p < 0.0001). Independent of the patient's age at follow-up, the prevalence of an RCT in the fractured shoulder was 13% higher than the prevalence in the opposite shoulder. Four-part fractures showed a significant association with a complete RCT (p = 0.047).Of 74 patients with a satisfactory or poor Constant Score, 33 (44.6%) had RCTs. In the remaining 228 patients with a good to excellent result, only 26 (11.4%) had RCTs. We showed that 66% of the RCTs observed at the fractured shoulder were caused by trauma. There was no association between treatment modality and a complete RCT. CONCLUSION: RCTs may need special attention in initial diagnostics, management, and follow-up especially in severe proximal humeral fractures.

Inter- and intraobserver reliability of the vertebral, local and segmental kyphosis in 120 traumatic lumbar and thoracic burst fractures: evaluation in lateral X-rays and sagittal computed tomographies.

Evaluation of the kyphosis angle in thoracic and lumbar burst fractures is often used to indicate surgical procedures. The kyphosis angle could be measured as vertebral, segmental and local kyphosis according to the method of Cobb. The vertebral, segmental and local kyphosis according to the method of Cobb were measured at 120 lateral X-rays and sagittal computed tomographies of 60 thoracic and 60 lumbar burst fractures by 3 independent observers on 2 separate occasions. Osteoporotic fractures were excluded. The intra- and interobserver reliability of these angles in X-ray and computed tomogram, using the intra class correlation coefficient (ICC) were evaluated. Highest reproducibility showed the segmental kyphosis followed by the vertebral kyphosis. For thoracic fractures segmental kyphosis shows in X-ray "excellent" inter- and intraobserver reliabilities (ICC 0.826, 0.802) and for lumbar fractures "good" to "excellent" inter- and intraobserver reliabilities (ICC = 0.790, 0.803). In computed tomography, the segmental kyphosis showed "excellent" inter- and intraobserver reliabilities (ICC = 0.824, 0.801) for thoracic and "excellent" inter- and intraobserver reliabilities (ICC = 0.874, 0.835) for the lumbar fractures. Regarding both diagnostic work ups (X-ray and computed tomography), significant differences were evaluated in interobserver reliabilities for vertebral kyphosis measured in lumbar fracture X-rays (p = 0.035) and interobserver reliabilities for local kyphosis, measured in thoracic fracture X-rays (p = 0.010). Regarding both fracture localizations (thoracic and lumbar fractures), significant differences could only be evaluated in interobserver reliabilities for the local kyphosis measured in computed tomographies (p = 0.045) and in intraobserver reliabilities for the vertebral kyphosis measured in X-rays (p = 0.024). "Good" to "excellent" inter- and intraobserver reliabilities for vertebral, segmental and local kyphosis in X-ray make these angles to a helpful tool, indicating surgical procedures. For the practical use in lateral X-ray, we emphasize the determination of the segmental kyphosis, because of the highest reproducibility of this angle. "Good" to "excellent" inter- and intraobserver reliabilities for these three angles could also be evaluated in computed tomographies. Therefore, also in computed tomography, the use of these three angles seems to be generally possible. For a direct correlation of the results in lateral X-ray and in computed tomography, further studies should be needed.

Histologic analysis of ruptured quadriceps tendons.

Quadriceps tendon ruptures are uncommon injuries. Degenerative changes in the tendon are felt to be an important precondition for rupture. We retrospectively reviewed 45 quadriceps tendon ruptures in 42 patients. Quadriceps tendon ruptures occurred most often in the sixth and seventh decade of life. Men were affected six times as often as women. A tissue sample from the rupture-zone was obtained in 22 cases and histologic analysis was performed. Degenerative changes were present in only 14 (64%) of the 22 samples. We observed an increasing ratio of degenerative to nondegenerative tendons with increasing patient age. Our data suggests that quadriceps tendon rupture, especially in younger patients, can occur in the absence of pathologic tendon degeneration.

Long-term results after non-plate head-preserving fixation of proximal humeral fractures.

A retrospective study was conducted to evaluate displaced proximal humeral fractures treated with a non-plate head-preserving fixation and to detect factors predicting functional outcome. After a median follow-up period of 79.7 months, 105 patients with nine A-fractures, 36 B-fractures and 60 C-fractures (nine two-part-fractures, 41 three-part fractures and 55 four-part fractures) were assessed. Functional outcome was measured based on the Constant and UCLA scores. Of all patients, 70-75% had excellent or good Constant and UCLA scores. In 74% a good or satisfactory quality of initial reduction fracture was achieved. About one-fifth (21%) of the fractures showed a secondary displacement. Twenty-seven percent of the patients had signs of humeral head necrosis and 22% had implant related problems. There were significant correlations between a high final score and young age, low AO fracture severity, good quality of fracture reduction and residual osseous deformity, absence of secondary fracture displacement, implant-related complications, shoulder arthrosis and humeral head necrosis at the time of follow-up. In conclusion, the non-plate head-preserving fixation of proximal humeral fractures is an alternative treatment for displaced proximal humeral fractures. Especially in severely displaced C-fractures in older patients, non-anatomical reduction leads to a high rate of secondary displacement, residual osseous deformity and only a fair shoulder function. For these cases alternative methods such as prosthetic replacement should be chosen.

Clinical and radiological evaluation of minimally displaced proximal humeral fractures.

INTRODUCTION: The purpose of this prospective study was to assess the Constant score and radiographic outcome in 66 patients (mean age 58.7 years/mean follow-up 51 months) with a minimally displaced and/or impacted fracture of the proximal humerus treated with early mobilization. METHOD: Special attention was paid to analyze the specific intrinsic parameters (age, gender, ASA grade and length of physiotherapy), injury-related parameters (classification, osteoporosis) and therapy-related parameters (initial fracture displacement, residual bony-deformity after healing, secondary fracture displacement during healing period, non-union, humeral head necrosis and omarthrosis) that may influence the final score. PATIENTS: There were 31 A (47%), 22 B (33%) and 13 C-fractures (19%). The median Constant score for the fractured shoulder was 89 points. RESULTS: All fractures healed without non-union. The radiological assessment showed in 80% a fracture-displacement with <15 degrees angulation and/or <5-mm displacement of the greater tuberosity. At time of follow-up, the residual bony-deformity was perfect and good in 88% of cases. There was a significant association between the final Constant score and the age, ASA classification, AO (ABC) classification and initial fracture displacement. CONCLUSION: Early physiotherapy, with a short period of immobilization is a sufficient therapy for management of minimally displaced and/or impacted fractures of the proximal humerus.

Inter- and intra-observer reliability of the Cobb angle in the measurement of vertebral, local and segmental kyphosis of traumatic lumbar spine fractures in the lateral X-ray.

INTRODUCTION: Measurement of the vertebral, local and segmental kyphosis according to Cobb is a standard procedure in the assessment of traumatic, idiopathic and degenerative spinal deformities. The purpose of this study was to evaluate the inter- and intra-observer reliability of these three radiological angles on the basis of lateral X-rays in lumbar spine fractures with spinal kyphosis. PATIENTS AND METHODS: A consecutive series of 88 patients with traumatic lumbar spine fractures with kyphotic deformities were included in the study. All patients were younger that 50 years of age and had an adequate trauma leading to the fracture. Three independent observers with different levels of clinical training measured the vertebral, segmental and local kyphosis of these patients on the basis of lateral X-rays. The readings were repeated 4 weeks later to assess intra-observer reliability. RESULTS: The most common injury mechanism was a fall from a height of more than 3 m. The first lumbar vertebra was the most commonly affected. Mean inter- and intra-observer reliabilities were good for the vertebral (mean ICC: 0.6607; mean ICC: 0.6979) and local (mean ICC: 0.7778; mean ICC: 0.7642) kyphosis and excellent (mean ICC: 0.8129; mean ICC: 0.8103) for the segmental kyphosis. CONCLUSION: In this study, the segmental-, vertebral-, and local kyphosis angle according to Cobb showed sufficient inter- and intra-observer reliability for the use in daily practice and scientific studies.

Indications for computed tomography (CT-) diagnostics in proximal humeral fractures: a comparative study of plain radiography and computed tomography.

BACKGROUND: Precise indications for computed tomography (CT) in proximal humeral fractures are not established. The purpose of this study was a comparison of conventional radiographic views with different CT reconstructions with 2 D and 3 D imaging to establish indications for additional CT diagnostics depending on the fractured parts. METHODS: In a prospective diagnostic study in two level 1 trauma centers, 44 patients with proximal humeral fractures were diagnosed with conventional X-rays (22 AP + axillary views, 22 AP + scapular Y-views) and CT (multi-planar reconstruction (MPR) and maximum intensity projection (MIP)) with 2 D and 3 D imaging. 3 observers assessed the technical image quality, the assessment of the relevant anatomical structures (2-sample-t-test) and the percentage of the osseous overlap of the proximal humerus (Welch-test) using a scoring system. The quality of the different diagnostic methods was assessed according to the number of fractured parts (Bonferroni-Holm adjustment). RESULTS: There was significantly more overlap of the fractured region on the scapular Y-views (mean 71.5%, range 45-90%) than on axillary views (mean 56.2%, range 10.5-100%). CT-diagnostics allowed a significantly better assessment of the relevant structures than conventional diagnostics (p < 0.05) independently of the fracture severity (two-, three-, and four-part fractures). CONCLUSION: Conventional X-rays with AP view and a high-quality axillary view are useful for primary diagnostics of the fracture and often but not always show a clear presentation of the relevant bony structures such as both tuberosities, the glenoid and humeral head. CT with thin slices technology and additional 3 D imaging provides always a clear presentation of the fractured region. Clinically, a CT should be performed--independently of the number of fractured parts--when the proximal humerus and the shoulder joint are not presented with sufficient X-ray-quality to establish a treatment plan.

Proximal humeral fractures in children and adolescents.

BACKGROUND: The purpose of the study was to investigate possible reasons for the failure of closed reduction of proximal humerus fractures in children and adolescents. We assessed the rate of soft tissue entrapment, and we also investigated the long-term clinical and radiological results after an age- and deformity-focused treatment regimen according to national guidelines. METHODS: Forty-three patients were included in the study. Ten (mean age, 12.4 years; range, 6-16 years) of the patients were treated conservatively. The remaining 33 patients (mean age, 14 years; range, 6-18 years) were treated surgically (n = 2 Neer grade 2, n = 16 Neer grade 3, and n = 15 Neer grade 4) with either closed (n = 16) or open reduction with internal fixation. In 17 fractures, closed anatomical reduction of the fracture under general anesthesia was not possible. Subsequent open reduction and Kirschner wire or screw fixation (n = 12) or plate fixation (n = 5) was necessary. In 9 of these 17 fractures (5 fractures were totally displaced fractures), closed reduction was impossible because of the entrapment of periost (n = 2) or the biceps tendon with parts of the periost (n = 7). At follow-up, the clinical assessment included a structured interview, a detailed physical examination, and the assessment of overall shoulder function with the Constant score. RESULTS: Operative and postoperative complications did not occur. All surgically treated fractures anatomically reduced and healed without loss of reduction. At a mean follow-up of 39 months (range, 12-118 months), all patients who were evaluated had excellent results according to the Constant score and had a normal range of motion and excellent strength of the shoulder joint. CONCLUSIONS: A failed closed reduction should be interpreted as a possible soft tissue entrapment most likely because of the long biceps tendon. Those cases should be addressed with open reduction and removal of the entrapped structures. If anatomical reduction is achieved and maintained until fracture healing, excellent functional and radiological results can be expected from an age- and deformity-focused treatment regimen for children and adolescents with proximal humeral fractures. LEVEL OF EVIDENCE: Level 4 (Therapeutic study).

Fibula and tibia fusion with cancellous allograft vitalised with autologous bone marrow: first results for infected tibial non-union.

BACKGROUND AND AIMS: Autogenous bone grafting has been used in reconstructing bone defects and in stimulating fracture healing, producing high healing rates in the treatment of infected tibial non-unions. A novel therapeutic alternative is now available known as "vitalised allograft", a cancellous bone graft procured from femoral heads from living human donors and "vitalised" through the injection of autologous bone marrow. The aim of this study is to summarise the initial results of the fibula and tibia fusion using vitalised cancellous allograft in the treatment of infected tibial non-unions. PATIENTS AND METHODS: We initiated a follow-up of 15 prospective non-randomized patients who received a vitalised allograft in the treatment of infected tibial non-unions in order to produce bony union. The patients included 13 men and 2 women with an average age of 48 years. All patients received a multi-stage surgical approach. After establishing an infection-free environment, allogenic cancellous bone grafting was performed, intended as the final surgical procedure in fibula and tibia fusion. Our follow-up included a clinical and radiographic investigation of the calf in four planes. We analysed union-rate and time required for bony consolidation, as well as recurrent infections, re-fractures, potential graft-resorption, and time needed for graft and bone remodelling. RESULTS: With an average follow-up of 17.1 months, infection control was obtained in 14 of 15 patients, producing an infection arrest rate of 93.3%. Radiographs indicated consolidation in 11 out of 15 cases, with a union rate of 73.3%. Bone union was achieved on average in 17.1 weeks. CONCLUSIONS: Fibula and tibia fusion with allogenic cancellous bone grafting, vitalised through autogenic bone marrow, could well become an innovative treatment option for infected tibial non-unions. We need, however, to analyse a higher number of cases over a longer follow-up period in order to assess more accurately recurrent infections and re-fractures.

Does fixed-angle plate osteosynthesis solve the problems of a fractured proximal humerus? A prospective series of 87 patients.

BACKGROUND AND PURPOSE: There is considerable controversy about the treatment of complex, displaced proximal humeral fractures. Various types of head-preserving osteosynthesis have been suggested. This prospective case series was designed to evaluate the perioperative and early postoperative complications associated with fixed-angle implants and to record outcome after bone healing. PATIENTS AND METHODS: Fractures of the proximal humerus were stabilized surgically in 87 patients (mean age 64 (16-93) years) by application of a fixed-angle plate (65 PHILOS, 22 T-LCP). There were 34 2-segment fractures, 42 3-segment fractures, and 11 4-segment fractures, including 7 dislocation fractures. Follow-up assessment after a minimum of 12 months was based on the Constant, UCLA, and DASH scores and on radiographs. RESULTS: Postoperative complications included soft tissue problems (n = 9), humeral head necrosis (n = 9), screw perforation (n = 11), secondary displacements (n = 14), and delayed fracture healing (n = 4). Treatment outcomes recorded on the various scores were very good in 60-82% of the cases. INTERPRETATION: Screw perforation of fixed-angle implants has replaced the complications of secondary displacement and implant loosening after using conventional plates. Even with the use of fixed-angle implants, fractures of the proximal humerus are associated with a high complication rate and sometimes poor outcome.

Inter- and intraobserver reliability of the MTM-classification for proximal humeral fractures: a prospective study.

BACKGROUND: A precise modular topographic-morphological (MTM) classification for proximal humeral fractures may address current classification problems. The classification was developed to evaluate whether a very detailed classification exceeding the analysis of fractured parts may be a valuable tool. METHODS: Three observers classified plain radiographs of 22 fractures using both a simple version (fracture displacement, number of parts) and an extensive version (individual topographic fracture type and morphology) of the MTM classification. Kappa-statistics were used to determine reliability. RESULTS: An acceptable reliability was found for the simple version classifying fracture displacement and fractured main parts. Fair interobserver agreement was found for the extensive version with individual topographic fracture type and morphology. CONCLUSION: Although the MTM-classification covers a wide spectrum of fracture types, our results indicate that the precise topographic and morphological description is not delivering reproducible results. Therefore, simplicity in fracture classification may be more useful than extensive approaches, which are not adequately reliable to address current classification problems.

Incidence and effect of calcifications after open-augmented Achilles tendon repair.

BACKGROUND AND AIMS: The objective of this study was to analyse the incidence and effect on clinical outcome of post-operative Achilles tendon calcifications after open-augmented repair according to the Silfverskjöld technique. PATIENTS/METHODS: This retrospective study presents the results of follow-up examinations on 104 patients with Achilles tendon rupture who were treated according to the Silfverskjöld technique. Post-operative calcifications were identified by means of sonography, and clinical outcome was evaluated using the 100 points Thermann score. The average follow-up examination period was 3.7 years with an average patient age of 42.9 years. Two groups were identified and included those with (Group I) and those without (Group II) calcifications. Clinical outcome was evaluated using the Thermann score for both groups and was compared statistically by means of the two random sample t-test. RESULTS: Fifteen patients (Group I) developed tendon calcifications (14.4%) and 89 none (Group II). Group I scored 88.0 points and Group II 88.1 (good to very good outcome). There were no negative effects on clinical outcome (t = 0.98). CONCLUSIONS: The incidence of tendon calcification after open-augmented repair of Achilles tendon rupture was 14.4% with no negative effects on clinical outcome as measured by the Thermann score.