Radiographic parameter(s) influencing functional outcomes following angular stable plate fixation of proximal humeral fractures.

PURPOSE: Radiographic parameters which correlate with poor clinical outcome after proximal humeral fractures could be helpful indicators to answer the question which patients should be followed up closer. Moreover, during surgery, radiographic parameters correlating with unfavourable outcome should be avoided. The primary aim of the study was to compare radiographic measurements between the injured and the contralateral, uninjured shoulder. The secondary aim was to correlate these radiographic parameters with post-operative shoulder function. METHODS: Fifty-eight patients (age: 55.6 ± 14.4 years, age at surgery) following angular stable plate fixation of a proximal humeral fracture (2-part fractures according to Neer: 24, 3-part: 25, 4-part: 9) were included in this retrospective cohort study. All patients were followed up at least six years (7.9 ± 1.4 after surgical intervention). During follow-up examination, the Constant score (CS) was assessed, and radiographs of both shoulders were taken. Radiographs were analyzed regarding lateral humeral offset, distance between tuberculum and head apex, head diameter, head height, perpendicular height, perpendicular center, vertical height, and angles between head and humeral shaft (CCD and HSA). These parameters were compared between the injured and uninjured shoulder. The cohort was divided in two groups: patients with a CS category of excellent/good and satisfying/worse. Both groups were tested regarding differences of demographic and radiographic parameters. RESULTS: The distance between tuberculum and head apex (2.6 ± 3.4 mm vs. 4.3 ± 2.1 mm; p = 0.0017), the CCD (123.1 ± 12.9° vs. 130.1 ± 7.3°; p = 0.0005), and the HSA (33.1 ± 12.8° vs. 40.1 ± 7.3°; p = 0.0066) were significantly smaller on the treated shoulder compared to the uninjured side. Patients reached a Constant score of 80.2 ± 17.4 (95% CI 75.6-84.8) points. Regarding outcome categories of the Constant score, 46 patients had a good to excellent outcome, and 12 patients had a satisfying or bad outcome. The comparison of these groups revealed that patients with inferior outcome in the long-term follow-up were older, female, had a more complex fracture type (AO classification), smaller lateral humeral offset, smaller head diameter and height, lower perpendicular height, and lower CCD and HSA angles. CONCLUSION: If the abovementioned parameters cannot be restored sufficiently during surgery, (reversed) shoulder arthroplasty might be a better solution to reach good post-operative outcome. Moreover, patients presenting these radiographic characteristics in the follow-up, older patients, and patients with a more complex fracture type should be followed up closer to possibly prevent poor shoulder function. TRIAL REGISTRATION: 83 250/2011BO2.

Incidence and risk factors for postoperative Achilles tendon calcifications after percutaneous repair.

INTRODUCTION: Numerous publications are dealing with acute Achilles tendon rupture. To our knowledge, no systematic trial has been published analyzing the incidence, risk factors and the potential clinical impact of postoperative tendon calcifications (PTC) after percutaneous Achilles tendon repair. Therefore, the aim of this study was to analyze these relevant aspects. MATERIALS AND METHODS: Between March 2003 and November 2010, a total of 126 patients with an acute, complete Achilles tendon rupture were treated with a percutaneous technique according to Ma and Griffith at a single university-based trauma department. The follow-up included a detailed clinical and sonographic examination. To assess the functional outcome and possible impact of PTC after percutaneous Achilles tendon repair, the Thermann and AOFAS scores were used. 81 patients (65 men and 16 women) with a median age of 46 years (range 24-76) were available for a follow-up examination. The median time of follow-up was 64 months (range 15-110 months). RESULTS: PTC occurred in nine out of 81 patients (11.1%). All patients with PTC were male with a median age of 52 years (range 26-76 years). In the group of patients with PTC, the median overall Thermann score was 94 (range 68-100) and the median overall AOFAS score was 97 (range 85-100). In the group of patients without PTC, the median overall Thermann score was 88.5 (range 60-100) and the median overall AOFAS score was 97 (range 85-100). No significant differences were detected between the group of patients with PTC and the group of patients without PTC and the clinical outcome according to the Thermann (p = 0.21) and the AOFAS scores (p = 0.37). None of the patients with PTC sustained a re-rupture. The overall re-rupture rate was 4.9%. PTC was no risk factor for wound and neurological complications. CONCLUSION: The incidence of PTC after percutaneous Achilles tendon repair was 11.1%. Male gender and advanced age seem to be risk factors for PTC. In this study, PTC had no negative impact on the postoperative clinical outcome.

The acromial index is not predictive for failed rotator cuff repair.

BACKGROUND: The main objective of this study was to evaluate the association between the acromial index (AI) and the incidence of recurrent tears of the rotator cuff (RC) in a cohort of patients with full thickness tears who underwent arthroscopic primary repair. METHODS: A prognostic study of a prospective case series of 103 patients with full thickness RC tears was undertaken. The average age was 59.5 years (39-74) and follow-up was 30.81 months (12-72). True anterior-posterior X-rays were obtained during the pre-operative evaluation. Pre and post-operative magnetic resonance imaging (MRI) were recorded. RESULTS: Eighteen cases with recurrent tears (17.4%) were seen on post-operative MRI. The average AI for patients with recurrent tears was 0.711 ± 0.065 and for patients without recurrent tears 0.710 ± 0.064 (p < 0.05). A positive association between age and recurrent tears of the RC was noted (average ages: recurrent tears group 63 ± 5.9 years; group without recurrent tears 58.8 ± 7.5 years) (r = -0.216; p = 0.029). We did not find an association between size of the primary tear and recurrent tears (r = -0.075; p < 0.05) or between degrees of retraction of the primary and recurrent tears of the cuff (r = -0.073; p < 0.05). We observed that 38.9% of the recurrent tears cases presented with more than one tendon affected before the arthroscopy. At follow-up, none of these recurrent tears showed more than one tendon affected on MRI evaluation. CONCLUSION: In this study, we found that the AI radiological measurement is not a predictor for recurrent tears of the RC after primary arthroscopic repair.

Predicting failure after surgical fixation of proximal humerus fractures.

BACKGROUND: Several studies reported high failures rates after internal fixation of proximal humerus fractures. Loss of reduction and screw cut-out are the most common reasons for revision surgery. Several risk factors for failure have been described in the literature. The aim of the present study was to assess risk factors for failure after surgical fixation of unstable proximal humerus fractures in a multivariate setup. METHODS: Two different surgical techniques (PHILOS locking plate and Humerusblock) were used. In the PHILOS group, every kind of postoperative relative movement between the implant and the humeral head or shaft was defined as failure. In the Humerusblock group, postoperative movement between the humeral head and the shaft in terms of angulation or translational displacement was defined as failure. The following parameters were assessed: age, gender, cancellous bone mineral density (BMD) of the humeral head, fracture type, medial metaphyseal comminution, medial metaphyseal head extension, initial angulation of the humeral head in the frontal plane, initial anteversion of the humeral head, medial hinge displacement, maximum displacement of the tuberosities with respect to the head, surgical technique, anatomic reconstruction and restoration of the medial cortical support. RESULTS: The following parameters were found to have a significant influence on the failure rate: age, local BMD, anatomic reduction, and restoration of the medial cortical support. The failure rate significantly increased with the number of risk factors. CONCLUSION: Preoperative assessment of the local BMD and the patients' biological age as well as intraoperative anatomic reduction and restoration of the medial cortical support are the essentials for successful surgical fixation of proximal humerus fractures. Multifragmentary fracture patterns in old patients with low local BMD are prone for fixation failure. If the surgeon is not able to achieve anatomic reduction and restoration of the medial cortical support intraoperatively in this situation, adjustments such as augmentation or primary arthroplasty should be considered.