Outcomes of Humerus Nonunion Surgery in Patients With Initial Operative Fracture Fixation.

OBJECTIVES: To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population. DESIGN: Retrospective case series. SETTING: Eight, academic, level 1 trauma centers. PATIENTS SELECTION CRITERIA: Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019. OUTCOME MEASURES AND COMPARISONS: Success rate of nonunion surgery. RESULTS: Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate. CONCLUSIONS: This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

High rate of avascular necrosis but excellent patient-reported outcomes after open reduction and internal fixation (ORIF) of proximal humerus fracture dislocations: should ORIF be considered as primary treatment?

BACKGROUND: Proximal humerus fracture dislocations, excluding 2-part greater tuberosity fracture dislocations, are rare injuries. Outcomes after open reduction and internal fixation (ORIF) of these injuries have not been well described in the literature. The purpose of this study was to report the radiographic and functional outcomes of patients who underwent ORIF of a proximal humerus fracture dislocation. METHODS: All skeletally mature patients who underwent ORIF of a proximal humerus fracture dislocation between 2011 and 2020 were identified. Patients with isolated greater tuberosity fracture dislocations were excluded. The primary outcome was American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score at a minimum of 2 years. Secondary outcomes were the development of avascular necrosis (AVN) and reoperation rate. RESULTS: Twenty-six patients met the inclusion criteria. The mean age was 45 years (standard deviation 16), and 77% were men. Median time to reduction and surgery was 1 day (interquartile range [IQR] 1-5). There were 2 (8%) Neer 2-part fractures, 7 (27%) 3-part, and 17 (65%) 4-part fractures. Fifty-four percent (54%) involved the anatomic neck and 31% included a head-split component. Thirty-nine percent (39%) were anterior dislocations. The rate of AVN was 19%. The reoperation rate was 15%. Reoperations included removal of hardware (2), subscapularis repair (1), and manipulation under anesthesia (1). No patients went on to arthroplasty. ASES scores were available for 22 patients (84%) including 4 of 5 patients with AVN. The median ASES score at a mean of 6.0 years postoperatively was 98.3 (IQR 86.7-100, range 63.3-100) and was not different in those with or without AVN (median 98.3 vs. 92.0, P = .175). Only the presence of medial comminution and nonanatomic head shaft alignment on postoperative radiographs were associated with increased risk of AVN. CONCLUSION: Radiographic rates of AVN (19%) and reoperation (15%) were high in this series of patients undergoing ORIF of proximal humerus fracture dislocations. Despite this, none of the patients required arthroplasty, and patient-reported outcome scores at an average of 6 years postinjury were excellent, with a median ASES score of 98.5. ORIF should be considered as primary method of treatment in proximal humerus fracture dislocations not only in young patients but also middle-aged patients.

Understanding risk for early dislocation resulting in reoperation within 90 days of reverse total shoulder arthroplasty: extreme rare event detection through cost-sensitive machine learning.

BACKGROUND: Reliable prediction of postoperative dislocation after reverse total shoulder arthroplasty (RSA) would inform patient counseling as well as surgical and postoperative decision making. Understanding interactions between multiple risk factors is important to identify those patients most at risk of this rare but costly complication. To better understand these interactions, a game theory-based approach was undertaken to develop machine learning models capable of predicting dislocation-related 90-day readmission following RSA. MATERIAL & METHODS: A retrospective review of the Nationwide Readmissions Database was performed to identify patients who underwent RSA between 2016 and 2018 with a subsequent readmission for prosthetic dislocation. Of the 74,697 index procedures included in the data set, 740 (1%) experienced a dislocation resulting in hospital readmission within 90 days. Five machine learning algorithms were evaluated for their ability to predict dislocation leading to hospital readmission within 90 days of RSA. Shapley additive explanation (SHAP) values were calculated for the top-performing models to quantify the importance of features and understand variable interaction effects, with hierarchical clustering used to identify cohorts of patients with similar risk factor combinations. RESULTS: Of the 5 models evaluated, the extreme gradient boosting algorithm was the most reliable in predicting dislocation (C statistic = 0.71, F2 score = 0.07, recall = 0.84, Brier score = 0.21). SHAP value analysis revealed multifactorial explanations for dislocation risk, with presence of a preoperative humerus fracture; disposition involving discharge or transfer to a skilled nursing facility, intermediate care facility, or other nonroutine facility; and Medicaid as the expected primary payer resulting in strong, positive, and unidirectional effects on increasing dislocation risk. In contrast, factors such as comorbidity burden, index procedure complexity and duration, age, sex, and presence or absence of preoperative glenohumeral osteoarthritis displayed bidirectional influences on risk, indicating potential protective effects for these variables and opportunities for risk mitigation. Hierarchical clustering using SHAP values identified patients with similar risk factor combinations. CONCLUSION: Machine learning can reliably predict patients at risk for postoperative dislocation resulting in hospital readmission within 90 days of RSA. Although individual risk for dislocation varies significantly based on unique combinations of patient characteristics, SHAP analysis revealed a particularly at-risk cohort consisting of young, male patients with high comorbidity burdens who are indicated for RSA after a humerus fracture. These patients may require additional modifications in postoperative activity, physical therapy, and counseling on risk-reducing measures to prevent early dislocation after RSA.

Combined Humeral Head and Shaft Fractures: Outcome Following Intramedullary Nailing and Plating.

Background and Objectives: Combined fractures of the humeral head and shaft (FHS) are rare but frequently involve an intermuscular fracture as its characteristic pattern. The aim of this retrospective study was to investigate intramedullary nailed and plated FHS in terms of outcomes and complications. Materials and Methods: The present study included patients with FHS, treated via either intramedullary nailing or plating within a period of 10 years, with a minimum follow-up of 12 months. Functional outcome was assessed using the age- and sex-adapted Constant-Murley Score (CMS-K). Rates of complications and revision surgeries were registered. Results: Twenty-five patients (18 females, 7 males, age 60.1 ± 14.2 years, range 23-76 years) were included in the study. Nailing was performed in 16 patients (12 females, 4 males, age 62.6 ± 12.4 years), whereas plating was executed in nine patients (6 females, 3 males, age 55.8 ± 17.0 years). Follow-up among all patients was 45.1 ± 26.3 months (range 12-97 months). CMS-K was 70.3 ± 32.3 in the nailing group, with reoperation in four cases, and 76.0 ± 31.0 in the plating group, with one reoperation (p = 0.42). Patients with no metaphyseal fragment displacement (n = 19; CMS-K 76.7 ± 17.3) demonstrated significantly better functional outcomes versus those with secondary displacement of the metaphyseal fragments (n = 6; CMS-K 60.0 ± 17.1), p = 0.046. Conclusions: Comparable acceptable clinical outcome is obtained when comparing nailing with additional open cerclage or lag-screw fixation techniques versus plating with open reduction. However, a higher revision rate was observed after nailing. The correct metaphyseal fragment fixation seems to be crucial to avoid loss of reduction and hence the need for revision surgery, as well as a worse outcome.

Functional results and unfavorable events after treatment of proximal humerus fractures using a new locking plate system.

BACKGROUND: Proximal humerus fractures are often treated with a fixed-angle titanium plate osteosynthesis. Recently, plates made of alternative materials such as carbon fibre-reinforced polyetheretherketone (CFR-PEEK) have been introduced. This study presents the postoperative results of patients treated with a CFR-PEEK plate. METHODS: Patients with proximal humerus fractures treated with a CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) were included. In follow-up examination, age and gender adjusted Constant-Murley Score (ACS), Subjective Shoulder Value (SSV), Quick Disabilities of the Arm, Shoulder and Hand Score (QDASH) and pain score (Visual Analog Scale (VAS)) were analyzed. General condition at follow-up was measured by European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L). Range of motion was recorded. In addition, radiographs at follow-up, unfavorable events and revision rate were analyzed. RESULTS: In total, 98 patients (66.0 ± 13.2 years, 74 females, 24 males) were reexamined. Mean follow-up was 27.6 ± 13.2 months. There were 15 2-part, 28 3-part and 55 4-part fractures. The functional scores showed good results: SSV 83.3 ± 15.6%, QDASH 13.1 ± 17.0 and ACS 80.4 ± 16.0. A 4-part-fracture, head split component, nonanatomic head shaft reposition and preoperative radiological signs of osteoarthritis were significant negative predictors for poorer clinical scores. Unfavourable events were observed in 27 patients (27.6%). Revision surgery was performed in 8 (8.2%) patients. Risk factors for an unfavourable event were female gender, age of 50 years and older, diabetes, affected dominant hand, 4-part fracture, head split and preoperative radiological signs of osteoarthritis. CONCLUSION: There are several advantages of the CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) such as the polyaxial screw placement and higher stability of locking screws. In summary, the CFR-PEEK plate osteosynthesis is a good alternative with comparable clinical results and some biomechanical advantages. Proximal humerus fractures show good clinical results after treatment with a CFR-PEEK plate. The revision rate and the risk of unfavorable events are not increased compared to conventional titanium plate osteosynthesis. LEVEL OF EVIDENCE: IV.

Is early mobilization a viable option after intramedullary nailing of 4-parts proximal humerus fractures?

INTRODUCTION: After centromedullary nailing (CMN) of 4-parts (4P) cephalo-tuberositary fractures of the proximal humerus (PH), shoulder immobilization for a few weeks is usual, although no scientific justification does support this attitude, nor the duration of immobilization. The objective of this study was to assess the impact of early mobilization after CMN of PH 4P fractures on clinical, radiological outcomes and complication rates. The hypothesis was that early mobilization would not lead to a deterioration in results or an increase in the complication rate. MATERIALS AND METHODS: All patients operated on for a 4P-PH fracture by CMN in our institution between 2010 and 2018 were included retrospectively. 2 groups were formed according to the duration of post-operative immobilization of the shoulder: 0-2 weeks (group A) and 3-6 weeks (group B). All patients had a clinical examination (Range of motion ROM and Constant score) and X-rays of the shoulder at least 24 months of follow-up. 58 patients (average age 66 years (39-89)) were included, with 25 in group A and 33 in group B. RESULTS: The average follow-up was 38.5 (24-73) months. The active ROM at the last follow-up was: active anterior elevation 149° (80°-180°) in group A versus 134 (60°-180°) in group B (p = 0.099); active external rotation 145° (15°-70°) in group A versus 42° (15-70°) in group B (p = 0.6). The Absolute Mean Constant score was 78.29 for Group A (45-100) versus 68.59 points (45-96) for Group B (p = 0.065). Regarding complications: in group A, we found 2 retractile capsulitis, 2 pseudarthrosis and 2 osteonecrosis of the humeral head. In group B, we found 5 retractile capsulitis, 1 infection of the surgical site, 3 osteonecrosis of the humeral head and 1 pseudarthrosis. CONCLUSION: Early mobilization after CMN of 4P-PH fractures did not lead to an increase in the complications rate and in particular secondary displacements or osteonecrosis. There was a trend toward improved clinical outcomes with early mobilization, although this trend was not statistically significant. EVIDENCE LEVEL: IV, retrospective study.

Short-term Clinical Outcome of Dual Plate Fixation in the Treatment of Proximal Humerus Fractures with Calcar Comminution.

OBJECTIVE: Calcar comminution has been considered to be the main cause of the failure of internal fixation and fracture nonunion in proximal humerus surgery. Anatomical reduction and increasing the strength of internal fixation is the key to success. The purpose of this study was to investigate the short-term clinical effect of dual plate fixation in the treatment of proximal humeral fractures with calcar comminution. METHODS: The data of 37 patients with proximal humeral fractures with calcar comminution, treated in our departments from July 2018 to April 2020, were retrospectively analyzed. These patients were treated with anterior plate and lateral PHILOS plate, and followed up for more than 12 months, including 25 cases in Tianjin Hospital and 12 cases in Shanghai General Hospital. The patients included 12 males and 25 females, their age was 54.89 ± 13.59 years (range from 32-79 years), and 21 patients had dominant hand injury. According to the Neer classification, there were 11 two-part fractures, 22 three-part fractures, and four four-part fractures. The range of motion of the shoulder joint, visual analog scale (VAS), American Shoulder and Elbow Surgeons Shoulder Score (ASES), Constant-Murley shoulder score, neck-shaft angle, anterior-posterior angle, and other complication scores were recorded at the last follow-up. RESULTS: All 37 patients were followed up after operation, and the follow-up time was 21.81 ± 7.35 months (range from 12-36 months). The fractures of all 37 patients had healed at the last follow-up visit. The neck-shaft angle measured immediately after operation was 132.59° ± 8.34°, and the neck-shaft angle measured at the last follow-up visit was 132.38 ± 8.53°. The anterior-posterior angle measured immediately after surgery was 3.45° ± 0.81°, and the anterior-posterior angle at the last follow-up visit was 3.66° ± 0.77°. The range of motion of the shoulder joint was as follows: the shoulder joint could be forward elevated by 158.11° ± 13.09° (range: 140°-180°), rotated externally by 38.38° ± 7.55° (range: 20°-45°), and internally rotated to T4-L4 level. The VAS score was 0.46 ± 0.87 (range: 0-3), the ASES was 86.58 ± 8.79 (range: 56.7-100), and the Constant-Murley score was 88.76 ± 8.25 (range: 60-100). Thirty-three cases were excellent, and four cases were good. No obvious complications occurred. CONCLUSION: The combination of anterior plate and lateral PHILOS plate in the treatment of proximal humeral fractures with calcar comminution can achieve stable fixation, and the postoperative clinical and imaging outcome was satisfactory. Firstly, the anterior plate can provide temporary stability when the Kirschner wires are removed, which can provide space for lateral plate placement during fracture reduction and fixation. Secondly, additional support by the anterior plate can provide higher stability in complex fractures with calcar comminution.

Fixation of humerus shaft fractures in polytrauma patients does not improve short-term outcomes.

BACKGROUND: Surgical fixation of humeral shaft fractures is widely considered a relative indication for polytraumatized patients to improve mobility and expedite care. This study aimed to determine whether operative treatment of humeral shaft fractures improves short term outcomes in polytrauma (PT] patients. METHODS: Using the National Trauma Data Bank, PT patients with humeral shaft fractures were identified from 2010-2015. Three PT groups were analyzed: Group 1 - PT with nonoperative humeral shaft fracture, Group 2 - PT with humeral fixation on Day 1, and Group 3 - PT with humeral fixation on Day 2+. Cox proportional hazards regression models were used to compare discharge timing and days on ventilator and in ICU between the three groups. RESULTS: There were 395 patients in Group 1, 1,346 in Group 2, and 1,318 in Group 3. There were no differences between the three groups when comparing Glasgow Coma Scale (p=0.3]; however, Injury Severity Score and Abbreviated Injury Scale were statistically different (p<0.001]. No differences were found in ICU or ventilator days between the three groups (p=0.2, p=0.5]. For Length of Stay, no difference was observed in Group 1 vs. Group 2 and Group 2 vs. Group 3. However, non-surgical patients were discharged 20% faster than those with Day 1 surgery (p=0.005]. Open fractures were treated one day earlier than closed fractures but discharged one day later (p<0.001]. CONCLUSIONS: This NTDB study demonstrates no differences in length of stay, days in the ICU or on the ventilator in patients with humeral shaft fractures treated non-operatively versus operative fixation. Overall, 44%-58% in all 3 groups had an ISS ≥ 14. Based on these results, we assert that fixation of the humeral shaft provides no short-term benefits in the multiply injured patient.

Treating multifocal humerus fractures: A comparison between the mipo technique and intramedullary nailing.

INTRODUCTION AND OBJECTIVE: Proximal humerus fractures with metaphysodiaphyseal extension represent a challenge for the orthopedic surgeon due to their reduced incidence and the difficulty in the treatment decision. These can be treated with an intramedullary nail or using the MIPO technique, associating different advantages and complications depending on the procedure. The objective of this study was to compare metaphyseal-diaphyseal fractures of the humerus treated with antegrade intramedullary nailing and those operated using the MIPO technique to see if there were significant differences in terms of functional, clinical, and radiological results. MATERIAL AND METHODS: retrospective, analytical and unicentric review of 29 patients with proximal fracture with metaphyseal-diaphyseal extension treated by MIPO technique and 33 patients surgically treated by antegrade intramedullary nailing (IMN) in our hospital from 2014 to 2020. Demographic, functional, radiographic and clinical data were obtained.. RESULTS: No significant differences were observed between both groups in terms of fracture mechanism (p=0.34), fracture type (p=0.13) or Maresca classification (p=0.32). Surgical time was significantly shorter in the IMN group compared to the MIPO technique (p=0.014). No significant difference was observed regarding the need for blood transfusion (p=0.32). The mean consolidation in the MIPO group was 21 weeks compared to 21 weeks in the IMN, with no significant differences between both groups (p= 0.88). No significant differences were observed between CONSTANT test at one year in the MIPO group versus the IMN group (p=0.79), nor in radial nerve palsies (p=0.28). CONCLUSIONS: Proximal fractures with metaphyseal-diaphyseal extension are a challenge for the orthopedic surgeon due to the infrequency, the complexity of these fractures and the fact that there is no established consensus on the ideal treatment for this type of injury. Both the MIPO technique with the Philos plate and the intramedullary nail are valid options for the treatment of these fractures, with no differences observed in terms of fracture consolidation time or in terms of functional results.

Transphyseal Distal Humeral Fractures: A 13-Times-Greater Risk of Non-Accidental Trauma Compared with Supracondylar Humeral Fractures in Children Less Than 3 Years of Age.

BACKGROUND: The transphyseal distal humeral fracture has been well described as a concerning fracture pattern for non-accidental trauma (NAT) in young pediatric patients. Because of the infrequent presentation of this fracture, the association historically has been anecdotal. The purpose of this study was to determine and compare the incidence of NAT among displaced transphyseal distal humeral fractures and displaced supracondylar humeral fractures in children <3 years of age. METHODS: All displaced transphyseal distal humeral fractures and displaced supracondylar humeral fractures in patients <3 years of age admitted because of injury during an 18-year period were reviewed retrospectively for inclusion. Patient demographics, mechanisms of injury, results of child protective services investigations, and medical records were reviewed. A chi-square test was utilized to analyze significance for categorical data; p values of <0.05 were defined as significant. RESULTS: The charts of 23 transphyseal distal humeral and 205 supracondylar humeral fracture cases were reviewed. NAT was the cause for 6 (26%) of the displaced transphyseal distal humeral fractures and 4 (2%) of the displaced supracondylar fractures. The associated risk of NAT was 13 times greater (95% confidence interval [CI], 4.05 to 43.7; p < 0.001) for children admitted for operative management of displaced transphyseal distal humeral fractures compared with those admitted for operative management of displaced supracondylar humeral fractures. CONCLUSIONS: The classic 1980 paper by DeLee et al. sensitized the orthopaedic community to the relationship between transphyseal distal humeral fractures and child abuse. Our study is the first, to our knowledge, to bring statistical weight to this association. We found a 13-times-greater risk of NAT for children <3 years of age who sustain a displaced transphyseal distal humeral fracture compared with a displaced supracondylar fracture. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors and Prognosis for Humeral Fractures in Birds of Prey: A Retrospective Study of 461 Cases from 2000 to 2015.

The objectives of this retrospective study were 1) to characterize humeral fractures in raptors at a rehabilitation program, 2) to determine risk factors for closed and compound humeral fractures in the raptors, and 3) to investigate prognostic factors for humeral fractures in raptors. Of the 6017 birds of prey admitted over 15 years to the Université de Montréal raptor rehabilitation program, 461 birds presented with a humeral fracture. The highest occurrences of humeral fractures were documented in short-eared owls (33%; Asio flammeus), Northern hawk-owls (24%; Surnia ulula), long-eared owls (20%; Asio otus), and Northern harriers (19%; Circus hudsonius). Humeral fractures were more common in males, and species from the intermediate weight group (300 g to 1 kg) were more likely to have compound humeral fractures than birds from the lower and higher weight groups. Humeral fractures of the middle and distal third of the bone were diagnosed as compound more often than fractures of the proximal third. A correlation between the occurrences of humeral fractures and the relative average width of the humerus for each species was observed and suggests that species with slender humeri have an increased likelihood of compound humeral fractures. Following the triage criteria used at this rehabilitation program, surgical (119 birds) or nonsurgical (77 birds) treatments were attempted. Release rate for birds without concomitant conditions in which a treatment was attempted was 39.3% (59/150) and did not significantly differ between closed and compound fractures, which suggests that the triage criteria used for compound fractures in this program were adequate. Our findings emphasize that raptors should not be systematically euthanatized when presented with compound humeral fractures to a rehabilitation facility.

Analysis of feline humeral fracture morphology and a comparison of fracture repair stabilisation methods: 101 cases (2009-2020).

OBJECTIVES: The aims of this study were to describe the type, presentation and prognostic factors of feline humeral fractures over a 10-year period and to compare three stabilisation systems for feline humeral diaphyseal fractures. METHODS: In total, 101 cats with humeral fractures presenting to seven UK referral centres between 2009 and 2020 were reviewed. Data collected included signalment, weight at the time of surgery, fracture aetiology, preoperative presentation, fixation method, surgical details, perioperative management and follow-up examinations. Of these cases, 57 cats with humeral diaphyseal fractures stabilised using three different fixation methods were compared, with outcome parameters including the time to radiographic healing, time to function and complication rate. RESULTS: The majority of the fractures were diaphyseal (71%), with only 10% condylar. Of the known causes of fracture, road traffic accidents (RTAs) were the most common. Neutered males were over-represented in having a fracture caused by an RTA (P = 0.001) and diaphyseal fractures were significantly more likely to result from an RTA (P = 0.01). Body weight had a positive correlation (r = 0.398) with time to radiographic healing and time to acceptable function (r = 0.315), and was significant (P = 0.014 and P = 0.037, respectively). Of the 57 humeral diaphyseal fractures; 16 (28%) were stabilised using a plate-rod construct, 31 (54%) using external skeletal fixation and 10 (18%) using bone plating and screws only. Open diaphyseal fractures were associated with more minor complications (P = 0.048). There was a significant difference between fixation groups in terms of overall complication rate between groups (P = 0.012). There was no significant difference between fixation groups in time to radiographic union (P = 0.145) or time to acceptable function (P = 0.306). CONCLUSIONS AND RELEVANCE: All three fixation systems were successful in healing a wide variety of humeral diaphyseal fractures. There was a significantly higher overall complication rate with external skeletal fixators compared with bone plating; however, the clinical impact of these is likely low.

Minimally invasive plate osteosynthesis with locking plate for metastatic humeral fractures.

BACKGROUND: Limited reports have examined the outcomes and complications of minimally invasive plate osteosynthesis (MIPO) with a locking plate (LP) in metastatic humeral fractures. Therefore, this study aimed to evaluate the effectiveness of MIPO in the treatment of metastatic humeral fractures. METHODS: Patients who underwent MIPO for metastatic humeral fractures were included in this study. Data on patient demographics, new Katagiri score, operative time, amount of blood loss, bone union rate, range of motion (ROM) of the shoulder and elbow, and perioperative complications were obtained. RESULTS: Twelve patients (seven men and five women) with 14 fractures were included in this study. The median operative time was 92.6 ± 28.9 min (range, 57-175 min) and the median amount of intraoperative blood loss was 106.1 ± 109.5 g (range, 10-330 g). No patient required surgery-related transfusion. The median duration of acquisition of active elbow ROM of>100° and active shoulder flexion of >90° were 8.9 ± 6.6 days (range, 1-30 days) and 17.5 ± 13.0 days (range, 6-47 days), respectively. The mean follow-up period was 10.0 ± 9.0 months (range, 1-33 months). There were no complications, and no patient required any further surgery for the affected humerus until death. CONCLUSION: MIPO using an LP provided acceptable functional outcomes in advanced-stage cancer patients with metastatic humeral fractures during their limited lifetime.

Mucinous adenocarcinoma of the lung presenting as pathological humeral fracture: a case report and novel surgical treatment.

We present a 73-year-old woman who presented with a pathological fracture of her right humerus. Further imaging and biopsy indicated a mucinous adenocarcinoma of the lung as the primary neoplasm. This represents the first published case of a mucinous adenocarcinoma of the lung presenting as a metastatic lesion of the humerus. Operative management of pathological fractures of the humerus has typically included either intramedullary nailing or the use of single-plating or double-plating techniques. The authors describe a novel technique using both intramedullary fixation augmented with a locking plate, steel cables and bone cement, with good outcome.

Prediction of Long Bone Fractures in Multiple Myeloma Patients in an Advanced Imaging World.

BACKGROUND: Multiple myeloma (MM) affects the long bones in 25% of patients. The advent of positron-emission tomography/computed tomography (PET/CT) scanners offers the possibility of both metabolic and radiographic information and may help determine fracture risk. To the best of our knowledge, no published study correlates these two factors with long bone fractures. OBJECTIVES: To evaluate the impact of PET/CT on fracture risk assessment in multiple myeloma patients. METHODS: We identified all bone marrow biopsy proven multiple myeloma patients from 1 January 2010 to 31 January 2015 at a single institution. We prospectively followed patients with long bone lesions using PET/CT scan images. RESULTS: We identified 119 patients (59 males/60 females) with 256 long bone lesions. Mean age at diagnosis was 58 years. The majority of lesions were in the femur (n=150, 59%) and humerus (n=84, 33%); 13 lesions in 10 patients (8%) required surgery for impending (n=4) or actual fracture (n=9). Higher median SUVmax was measured for those with cortical involvement (8.05, range 0-50.8) vs. no involvement (5.0, range 2.1-18.1). SUVmax was found to be a predictor of cortical involvement (odds ratio = 1.17, P = 0.026). No significant correlation was found between SUVmax and pain or fracture (P = 0.43). CONCLUSIONS: Improved medical treatment resulted improvement in 8% of patients with an actual or impending fracture. The orthopedic surgeons commonly use the Mirels classification for long bone fracture prediction. Adding PET/CT imaging to study in myeloma long bone lesions did not predict fracture risk directly but suggested it indirectly by cortical erosion.

Proximal Humerus Fracture Following Arthroscopic Biceps Tenodesis.

A 60-year-old woman with chronic atraumatic shoulder pain underwent arthroscopic biceps tenodesis. Upon presenting to the physical therapy clinic 7 days following surgery, she reported constant pain. Following the examination, the physical therapist reviewed the patient's postoperative radiographs and noted a comminuted but minimally displaced fracture of the right proximal humeral metaphysis. J Orthop Sports Phys Ther 2020;50(11):649. doi:10.2519/jospt.2020.9497.

Medial epicondyle avulsion after elbow dislocation in an adolescent non-professional soccer player treated with a cannulated screw: a case report.

BACKGROUND AND AIM OF THE WORK: Medial epicondyle fractures of the humerus account for 11-20% of all elbow injuries in children and in 30-55% of cases they are associated with an elbow dislocation. Undisplaced fractures are usually treated conservatively but literature is controversial regarding the treatment of displaced fractures (≥5mm) in paediatric fractures. In recent years, there is an emerging consensus that such patients may benefit more from open reduction and internal fixation. Authors report a case of a 15 years old nonprofessional soccer player who suffered of an elbow dislocation with an intra-articular fragment derived from avulsion of the medial epicondyle. METHODS: Clinical and instrumental evaluation confirmed elbow dislocation with an intra-articular fragment derived of the medial epicondyle. After the reduction an open reduction and internal fixation with cannulated screw was performed. RESULTS: Clinical evaluation after 90 days showed resolution of pain and almost complete ROM and complete recovery of strength and of functionality of the operated limb. Furthermore, x-rays demonstrated consolidation of the fracture. CONCLUSIONS: this case confirms that a precise evaluation of the fracture and its displacement is at the base of satisfactory outcomes. If fracture is displaced≥5mm and patient is near skeletal maturity open reduction and fixation is indicated.

Impact of breed on canine humeral condylar fracture configuration, surgical management, and outcome.

OBJECTIVE: To report the prevalence, configuration, risk factors, fixation methods and outcomes after repair of humeral condylar fractures (HCF) in dogs. STUDY DESIGN: Retrospective nested cohort study. SAMPLE POPULATION: One hundred twelve dogs. METHODS: Medical records of dogs referred between January 2010 and August 2018 were searched for HCF. Demographics, fracture configuration, repair, and complications were obtained from medical records. Radiographs were assessed for fracture reduction, implant positioning, and bone healing. Short-term radiographic and clinical outcomes, and long-term owner-assessed outcome was determined. Associations between these variables were statistically analyzed. RESULTS: Dogs with HCF represented 112 of 43 325 (0.26%, 95% CI 0.22-0.31) referrals. French bulldogs and spaniel breeds were predisposed to HCF (P < .02). French bulldogs were 6.58 times (95% CI 1.62-26.7) more likely than other breeds to have a medial HCF (P = .008). Epicondylar plate fixation was associated with reduced complications compared with lag screws and Kirschner wires (P = .009). Lameness was scored as 1 of 5 (median) in the 85 dogs with initial follow-up (median 6 weeks) after HCF repair. Outcome was considered excellent in 26 of 31 dogs with long-term follow-up (median 36 months). CONCLUSION: French bulldogs and spaniels were predisposed to HCF, and medial HCF were more common in French bulldogs. Epicondylar plate fixation was associated with reduced complications. CLINICAL SIGNIFICANCE: French bulldogs are predisposed to HCF, including medial HCF. Epicondylar plate fixation is recommended over other epicondylar fixation methods to reduce complications.

Evaluating the reoperation rate and hardware durability of three stabilizing implants for 105 malignant pathologic humerus fractures.

INTRODUCTION: Many patients sustaining a malignant pathologic humerus fracture (MPHF) elect for surgical stabilization. Complications prompting reoperation can occur, leading to additional quality of life and financial cost. One common event preceding reoperation is a broken implant (BI). The purpose of this study was to identify the rate of reoperation following surgical stabilization of MPHF with three techniques - photodynamic bone stabilization (PBS), intramedullary nail (IMN), and cemented plate fixation (CPF) - and estimate to what extent improved implant durability might prevent reoperation. MATERIALS AND METHODS: Retrospective data collection was performed, identifying 105 procedures (100 patients) who underwent non-articular MPHF surgery from 2010-2016: 19 PBS, 65 IMN, 21 CPF. All patients were followed for at least two years or until death. RESULTS: Reoperation rates were similar at one year (10.5%,6.2%,4.8%, p = 737), two years (15.8%,6.2%,9.5%, p = 375), and final evaluation (15.8%,7.7%,14.3%, p = 248). The rate of BI for PBS, IMN, and CPF was 10.5%,0%, and 4.8% (p = 049 PBS/IMN) at one year, 15.8%,0%, and 9.5% (p = 010 PBS/IMN) at two years, and 15.8%,0%, and 14.3% (p = 010 IMN/PBS, p = 013 IMN/CPF) at final evaluation. CONCLUSIONS: Reoperation rate was not significantly different at any time point. However, IMN surgery resulted in the lowest rate of broken implants (zero), statistically significant versus PBS at all time periods and versus CPF at final follow-up. PBS may eventually offer selected advantages for MPHF management, but current data suggests fragility must be thoughtfully considered.