RESUMEN
OBJECTIVE: To compare the clinical efficacy of the minimally invasive locking plate technique (Philos plate) and interlocking intramedullary nailing technique (TRIGEN intramedullary nail) in the treatment of Neer two-part and three-part proximal humeral fractures. METHODS AND MATERIALS: The clinical data of 60 patients with Neer two-part and three-part proximal humerus fractures admitted to the hospital from April 2017 to April 2021 were retrospectively analyzed. Thirty-two patients were treated with the minimally invasive locking plate technique (minimally invasive plate group), and 28 patients were treated with the interlocking intramedullary nailing technique (intramedullary nail group). The operation time, intraoperative blood loss, incision length, fracture healing time, and postoperative complications were compared between the two groups. The ASES score and Constant-Murley score were used to evaluate the shoulder joint function of the two groups one year after surgery. RESULTS: All 60 patients were followed up for 12 to 24 months, with an average of 16 months. There was no significant difference in operation time, intraoperative blood loss, incision length, or fracture healing time between the two groups (P > 0.05). The incidence of postoperative complications in the intramedullary nail group was significantly lower than that in the minimally invasive steel plate group, and the difference between the groups was statistically significant (P < 0.05). There was no significant difference in the ASES score or Constant-Murley score between the two groups one year after surgery (P > 0.05). CONCLUSION: The use of the minimally invasive locking plate technique and interlocking intramedullary nailing technique in the treatment of Neer two-part and three-part proximal humerus fractures has the advantages of a small incision, less blood loss, and a high fracture healing rate, and both can achieve satisfactory clinical effects. The internal nail technique is more convenient than the minimally invasive locking plate technique in controlling postoperative complications.
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Clavos Ortopédicos , Placas Óseas , Fijación Interna de Fracturas , Fijación Intramedular de Fracturas , Curación de Fractura , Procedimientos Quirúrgicos Mínimamente Invasivos , Tempo Operativo , Fracturas del Hombro , Humanos , Masculino , Femenino , Fijación Intramedular de Fracturas/métodos , Fijación Intramedular de Fracturas/instrumentación , Fijación Intramedular de Fracturas/efectos adversos , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Fracturas del Hombro/cirugía , Fracturas del Hombro/clasificación , Estudios Retrospectivos , Fijación Interna de Fracturas/métodos , Fijación Interna de Fracturas/instrumentación , Fijación Interna de Fracturas/efectos adversos , Anciano , Adulto , Pérdida de Sangre Quirúrgica , Complicaciones Posoperatorias/etiología , Resultado del TratamientoRESUMEN
PURPOSE: Several studies have been carried out, and there is no classification for proximal humeral fractures (PHF) exempted from variability in interpretation and with questioned reliability. In the present study, we investigated the 'absolute diagnostic reliability' of the most currently used classifications for PHFs on a single anterior-posterior X-ray shoulder image. METHODS: Six orthopaedic surgeons, with varying levels of experience in shoulder pathology, evaluated radiographs from 30 proximal humeral fractures, according to the 'absolute reliability' criteria. Each of the observers rated each fracture according to Neer, Müller/AO and Codman-Hertel's classification systems. RESULTS: The overall inter-observer agreement (κ) has been 0.297 (CI95% 0.280 to 0.314) for the Neer's classification system, 0.206 (CI95% 0.193 to 0.218) for the Müller/AO classification system, and 0.315 (CI95% 0.334 to 0.368) for the Codman-Hertel classification system. We found loss of agreement in Neer's classification as the study progressed, low agreement in the AO classification, and stable values in the different evaluations with the best degree of agreement for Codman-Hertel classification, with a moderate agreement in the second evaluation among the six evaluators. CONCLUSION: The Neer, AO, and Hertel-Codman classification systems for PHF with a single radiographic projection have a difficult interpretation for orthopaedic surgeons of varying levels of experience, and therefore substantial agreements are not obtained.
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Fracturas del Hombro/clasificación , Fracturas del Hombro/diagnóstico por imagen , Anciano , Anciano de 80 o más Años , Humanos , Persona de Mediana Edad , Variaciones Dependientes del Observador , Cirujanos Ortopédicos , Estudios Prospectivos , Reproducibilidad de los ResultadosRESUMEN
HYPOTHESIS: The aim was to evaluate risk factors for complications, revision, and mid- to long-term outcomes after reverse shoulder arthroplasty (RSA) implanted for proximal humeral fracture sequelae (PHFS). METHODS: The radiographs of 98 patients (mean age, 68 years) who underwent RSA for the treatment of PHFS were reviewed at a minimum 5-year follow-up. PHFS were divided into 4 types according to the Boileau classification: type 1 (46 cases), type 2 (6 cases), type 3 (12 cases), and type 4 (34 cases). The tuberosities underwent osteotomy in 28 cases and excision in 12 (all type 3 or 4 PHFS). The mean follow-up period was 8.4 years (range, 5-14 years). RESULTS: The functional results and rate of RSA survival without revision (85% vs. 100% at 10 years, P = .007) were significantly lower for types 3 and 4 vs. types 1 and 2. Overall, our findings showed that RSA for PHFS is not the panacea that surgeons once believed: At a mean follow-up of 8.5 years (range, 5-14 years), 59% of the patients in our series had fair or poor results. Patients who underwent tuberosity osteotomy or excision had lower functional results (adjusted Constant score, 69% vs. 88%; P < .001), more postoperative complications (32% vs. 9%, P = .003), and a higher revision rate (15% vs. 2%, P = .017). Patients who underwent tuberosity osteotomy or excision at the time of RSA were at risk of postoperative prosthetic instability and humeral stem loosening. The absence of the greater tuberosity at last radiographic follow-up was predictive of higher rates of complications and revisions, as well as a poorer final outcome. Previous fracture fixation was associated with a higher rate of complete tuberosity resorption (56% vs. 33%, P = .026) and with higher rates of postoperative complications (27% vs. 13%, P = .099) and reinterventions (17% vs. 2%, P = .018). CONCLUSION: The functional results and rates of complications and revision depend on the type of fracture sequelae and tuberosity management. Patients with more severe (type 3 and 4) fracture sequelae who undergo tuberosity osteotomy or excision are at risk of having a poorer functional result and higher rates of complications and revision with lower survival. Previous fracture fixation is also a prejudicial factor.
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Artroplastía de Reemplazo de Hombro , Húmero/cirugía , Osteotomía/efectos adversos , Fracturas del Hombro , Articulación del Hombro , Adulto , Anciano , Anciano de 80 o más Años , Artroplastía de Reemplazo de Hombro/efectos adversos , Artroplastía de Reemplazo de Hombro/métodos , Distinciones y Premios , Europa (Continente) , Femenino , Estudios de Seguimiento , Humanos , Húmero/diagnóstico por imagen , Húmero/lesiones , Masculino , Persona de Mediana Edad , Ortopedia , Falla de Prótesis , Recuperación de la Función , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Fracturas del Hombro/clasificación , Fracturas del Hombro/complicaciones , Fracturas del Hombro/diagnóstico por imagen , Fracturas del Hombro/cirugía , Articulación del Hombro/diagnóstico por imagen , Articulación del Hombro/cirugía , Sociedades Médicas , Resultado del TratamientoRESUMEN
BACKGROUND: Although the Neer classification is widely used for the assessment of proximal humeral fractures, its reproducibility has been challenged. The purpose of this study was to evaluate the reproducibility of the conventional Neer classification and a modified classification that defined fracture displacement with respect to the humeral head fragment. METHODS: The fracture patterns in 80 cases of proximal humeral fractures were independently assessed by 6 observers. The cases were grouped according to the conventional Neer classification using radiographs followed by computed tomography (CT) scans by each examiner twice with a 1-month interval. The fractures were then classified with the modified Neer classification, which defined displacement of the fragment as separation of more than 1 cm or angulation of more than 45° from the humeral head fragment, twice with a 1-month interval. Kappa coefficients of the conventional and modified Neer classifications were compared. RESULTS: The modified classification showed significantly higher intra-observer agreement than the conventional classification, both for radiographs (P = .028) and for CT scans (P = .043). Intra-observer agreement was also significantly higher for the modified classification than for the conventional classification, both for radiographs (P = .001) and for CT scans (P < .001). CONCLUSIONS: The present study showed that agreement for the Neer classification could be improved when fracture displacement was defined as separation or angulation from the humeral head. Considering vascularity to the humeral head, furthermore, the modified method might be more helpful for predicting patients' prognosis than the conventional Neer classification.
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Fracturas del Hombro/clasificación , Fracturas del Hombro/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Cabeza Humeral/irrigación sanguínea , Cabeza Humeral/diagnóstico por imagen , Cabeza Humeral/patología , Masculino , Persona de Mediana Edad , Pronóstico , Reproducibilidad de los Resultados , Fracturas del Hombro/diagnóstico por imagen , Fracturas del Hombro/patología , Factores de Tiempo , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
OBJECTIVE: Based on the morphological characteristics of glenoid and greater tuberosity (GT) fractures and the relationship between them, we explored the injury mechanism of acute anterior shoulder dislocation associated with glenoid and GT fractures. METHODS: From December 2013 to December 2019, we retrospectively reviewed the clinical data of patients who were diagnosed with acute anterior shoulder dislocation associated with glenoid and GT fractures in our hospital. According to the fracture site, a glenoid fracture group and a greater tuberosity fracture (GT) group were established, and the morphological characteristics of both glenoid and GT fractures were measured and statistically analyzed. RESULTS: A total of 41 patients (43 shoulders) met the inclusion criteria (39 unilateral shoulders and 2 bilateral shoulders). The mean age was 50.21 years (range, 22-71 years). A total of 27 shoulder injuries (62.8%) were split GT fractures and 33 shoulder injuries (76.7%) were combined with rotator cuff tears. The mean size of glenoid fragments was 30.16% and the mean displacement was 8.85 mm. The mean size of GT fragments was 28.43 mm. The mean superoinferior and anteroposterior displacements of the GT fragment were 6.77 mm and 4.96 mm, respectively. There was a negative correlation between the size of glenoid and GT fracture fragments (r = -0.64, P < 0.05). The glenoid fragments in the Ideberg type Ia glenoid fracture group were smaller than those in the Ideberg type II glenoid fracture group (28.41% and 40.95%, respectively), while the size of GT fragments in the type Ia group were larger than those in the type II group (29.77 mm and 20.21 mm, respectively) (P < 0.05). The GT fragments in the split GT fracture group were larger than those in the avulsion or depression GT fracture group (33.69 mm, 19.07 mm and 21.12 mm, respectively), while the size of glenoid fragments in the split GT fracture group were smaller than those in the avulsion or depression GT fracture group (23.57%, 41.37%, and 43.42%, respectively) (P < 0.05). As for the displacement direction of GT fragments, depression fractures were mainly inferior displacements, avulsion fractures were mainly anterosuperior displacements, while split fractures were mainly posteroinferior displacements (P < 0.05). Multiple regression analysis suggested that the type and the fragment size of GT fractures have a significant influence on the size of glenoid fragments. CONCLUSION: Acute anterior shoulder dislocations associated with glenoid and GT fractures are often combined with rotator cuff tears. There is a negative correlation between the size of glenoid and GT fragments, and split GT fractures are most common. Such injuries are highly correlated to the relative spatial location between the GT and the glenoid when the shoulder dislocates.
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Escápula/lesiones , Escápula/fisiopatología , Luxación del Hombro/clasificación , Luxación del Hombro/fisiopatología , Fracturas del Hombro/clasificación , Fracturas del Hombro/fisiopatología , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: This study aimed to classify the pathomorphology of impacted proximal humeral fractures according to the control volume theory, with the intention to introduce a severity index to support surgeons in decision making. METHODS: In total, 50 proximal humeral fractures were randomly selected from 200 medical records of adult patients treated from 2009 to 2016. Four nonindependent observers used 2 different imaging modalities (computed tomography scans plus volume rendering; 3D model) to test the classification reliability. A fracture classification system was created according to the control volume theory to provide simple and understandable patterns that would help surgeons make quick assessments. The impacted fractures table was generated based on an evaluation of the calcar condition, determined by the impairment of a defined volumetric area under the cephalic cup and the humeral head malposition. In addition to the main fracture pattern, the comminution degree (low, medium, high), providing important information on fracture severity, could also be evaluated. RESULTS: From 3D imaging, the inter- and intraobserver reliability revealed a k value (95% confidence interval) of 0.55 (0.50-0.60) and 0.91 (0.79-1.00), respectively, for the pattern code, and 0.52 (0.43-0.76) and 0.91 (0.56-0.96), respectively, for the comminution degree. CONCLUSIONS: The new classification provides a useful synoptic framework for identifying complex fracture patterns. It can provide the surgeon with useful information for fracture analysis and may represent a good starting point for an automated system.
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Fracturas Conminutas/diagnóstico por imagen , Cabeza Humeral/diagnóstico por imagen , Fracturas del Hombro/clasificación , Fracturas del Hombro/diagnóstico por imagen , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Imagenología Tridimensional , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Reproducibilidad de los Resultados , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
BACKGROUND: The classification systems for proximal humeral fractures routinely used in clinical practice include the Neer and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 2007 systems. Currently used systems have low inter- and intraobserver reliability. In 2018, AO/OTA introduced a new classification system with the aim of simplifying the coding process, in which the Neer four-part classification was integrated into the fracture description. The aim of the present work is to assess the inter- and intraobserver agreement of the new AO/OTA 2018 compared with the Neer and AO/OTA 2007 classifications. MATERIALS AND METHODS: A total of 116 radiographs of consecutive patients with proximal humeral fracture were selected and classified by three observers with different levels of experience. All three observers independently reviewed and classified the images according to the Neer, AO/OTA 2007, and new AO/OTA 2018 systems. To determine the intraobserver agreement, the observers reviewed the same set of radiographs after an interval of 8 weeks. The inter- and intraobserver agreement were determined through Cohen's kappa coefficient analysis. RESULTS: The new AO/OTA 2018 classification showed substantial mean inter- (k = 0.67) and intraobserver (k = 0.75) agreement. These results are similar to the reliability observed for the Neer classification (interobserver, k = 0.67; intraobserver, k = 0.85) but better than those found for the AO/OTA 2007 system, which showed only moderate inter- (k = 0.57) and intraobserver (k = 0.58) agreement. The two more experienced observers showed better overall agreement, but no statistically significant difference was found. No differences were found between surgical experience and agreement regarding specific fracture types or groups. CONCLUSIONS: The results showed that the Neer system still represents the more reliable and reproducible classification. However, the new AO/OTA 2018 classification improved the agreement among observers compared with the AO/OTA 2007 system, while still maintaining substantial descriptive power and simplifying the coding process. The universal modifiers and qualifications, despite their possible complexity, allowed a more comprehensive fracture definition without negatively affecting the reliability or reproducibility of the classification system. LEVEL OF EVIDENCE: Level III, diagnostic studies.
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Ortopedia , Radiografía/métodos , Fracturas del Hombro/clasificación , Sociedades Médicas , Tomografía Computarizada por Rayos X/métodos , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Reproducibilidad de los Resultados , Fracturas del Hombro/diagnóstico , Estados UnidosRESUMEN
INTRODUCTION: The shoulder terrible triad (STT) is a traumatic anterior shoulder dislocation, associated with rotator cuff (RC) tear and nerve injury from the brachial plexus. This study aimed to describe the functional results and prognostic factors of surgery in patients with STT. METHODS: Thirty consecutive patients with acute STT were included at the same institution. All patients were examined with x-rays, MRI, and electromyography. Surgical treatment in the acute setting was indicated to address an RC injury or a displaced greater tuberosity fracture. Variables registered on the day of surgery were preoperative Constant and Western Ontario Rotator Cuff (WORC) scores and injury pattern. At final discharge, Constant, American Shoulder and Elbow Surgeons (ASES), WORC, and subjective shoulder value scores were recorded by an independent evaluator. RESULTS: Twenty-seven patients underwent a complete follow-up. The dominant arm was affected in 50% of cases. The mean follow-up was 27 (12 to 43) months. The mean WORC and Constant scores improved from 1,543 to 1,093 (P = 0.015) and 31 to 54 (P = 0.003), respectively. The ASES and subjective shoulder value scores at the end of the follow-up were 60 and 56 points, respectively. RC tears and nerve injuries that did not involve the axillary or suprascapular nerves were associated to better results than greater tuberosity fractures and injuries to the axillary or suprascapular nerves, respectively, in WORC (P = 0.028), Constant (P = 0.024), and ASES scores (P = 0.035). Preoperative WORC and Constant scores were independent prognostic factors. CONCLUSIONS: The most frequent patterns include complete RC tears, anterior capsular injuries, and an axillary nerve injury. Patients had improved functional scores at the end of follow-up after surgery. Better functional results were correlated to RC tears, injuries to nerves with innervation distal to the shoulder, and higher preoperative Constant and WORC scores.
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Plexo Braquial/lesiones , Plexo Braquial/cirugía , Lesiones del Manguito de los Rotadores/cirugía , Luxación del Hombro/cirugía , Fracturas del Hombro/cirugía , Adulto , Anciano , Evaluación de la Discapacidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Lesiones del Manguito de los Rotadores/clasificación , Luxación del Hombro/clasificación , Fracturas del Hombro/clasificaciónRESUMEN
BACKGROUND: Proximal humerus fracture treatment varies by surgeon preference and patient factors. This study compares patient and fracture characteristics, with outcomes between current surgical treatment options. METHODS: Between 1999 and 2018, 425 proximal humerus fractures underwent acute surgical management: open reduction internal fixation (ORIF, n = 211), hemiarthroplasty (HA, n = 108), or reverse shoulder arthroplasty (RSA, n = 106). Patient and fracture characteristics included age, American Society of Anesthesiologists physical status classification (ASA), and fracture classification. Postoperative motion at 3, 6, and minimum 12 months (avg 20 ± 21 months), radiographic outcomes, and postoperative falls were analyzed. RESULTS: Average age for treatment groups was 65 ± 13 years (range: 18-93 years). Fractures were classified as 2- (11%), 3- (41%), or 4-part (48%). Age, ASA, and fracture classification were associated with selected surgical management (P < .0001, =.001, <.0001, respectively). Outcomes showed a significant improvement in forward flexion from 3 months to 6 months in all groups (P < .0001). No difference in final motion was seen between groups. Radiographic union was higher in ORIF (89%), and similar between HA (79%) and RSA (77%, P = .005). Rate of reoperation was RSA 6.6%, ORIF 17.5%, and hemiarthroplasty 15.7% (P = .029). Postoperatively, 23% patients had at least 1 fall, of which 73% resulted in fractures. CONCLUSION: Older patients with high ASA were treated with arthroplasty, and younger patients with lower ASA were treated with ORIF. All groups showed improvements in motion. At minimum 1 year of follow-up, there was no difference in motion between groups. ORIF and HA showed significantly more reoperations compared with RSA. Patients should be counseled about reoperation, fall risk, and prevention.
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Artroplastía de Reemplazo de Hombro , Fijación Interna de Fracturas , Hemiartroplastia , Reducción Abierta , Fracturas del Hombro/cirugía , Articulación del Hombro/cirugía , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Artroplastía de Reemplazo de Hombro/métodos , Femenino , Curación de Fractura , Humanos , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Rango del Movimiento Articular , Reoperación , Fracturas del Hombro/clasificación , Fracturas del Hombro/diagnóstico por imagen , Fracturas del Hombro/fisiopatología , Articulación del Hombro/diagnóstico por imagen , Articulación del Hombro/fisiopatología , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND The occurrence of fractures and risks following reverse total shoulder arthroplasty (rTSA) is common due to the variation of scapular spine (SS). Therefore, the consideration of the variable osteological features of SS prior to surgery may prove to be significant for the implementation of rTSA. This study aimed to propose a classification of SS through particular and quantitative parameters. MATERIAL AND METHODS In total, 354 intact dry scapulae were geometrical measured and classified on account of anatomical characteristics and the shapes of SS. RESULTS Type I SS was found, and this was the most frequency was type (27.97%). The least common type was type II. The type of SS had a direct association with bone stock and bone mineral density. Type II represented an association with a much thinner spine and restricted cortical and cancellous bone; types II and V were also associated with a crooked SS, which had a more complex morphology. CONCLUSIONS This study offered a comprehensive classification of SS in the Chinese population. On the whole, this study indicates that knowledge of the morphological variations of SS can prompt the diagnosis of scapular fractures and can promote more successful rTSA procedures, and the relative clinical trial is necessary to support it.
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Artroplastía de Reemplazo de Hombro/métodos , Escápula/anatomía & histología , Fracturas del Hombro/clasificación , Adulto , Variación Anatómica , Pueblo Asiatico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Rango del Movimiento Articular , Reoperación , Fracturas del Hombro/cirugía , Articulación del Hombro/cirugíaRESUMEN
Fractures of the proximal humerus are relatively common injuries in adults accounting for 5% of fractures. Nowadays the most common technique used is open reduction internal fixation with LCP plates. The risks associated with open reduction internal fixation had led us to develop and apply a "hybrid" system, which is based on external fixation and closed surgery principles. This system is capable of stabilize up to 4 fragment fractures on different planes while conferring a strong enough fixation to maintain fracture reduction while allowing the patient to perform passive and active movement since the first day following the surgery. Our study group started on November 2009 until December 2015 and consisted of 118 patients with a mean age of 68.84±10.52 years for females (76) and 65.62±12.56 for males (44). Patients were classified according to the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma association) Classification. In a few patients we performed mini lateral accesses to allow reduction of the humeral head and greater tuberosity. Shoulder mobilization was initiated from the first day following surgery. The external fixator was removed at 5 weeks with successive check-ups at 3, 6, and 12 months. The majority of type B and type C1 fractures had almost a complete functional recovery. Patients also, especially in the elderly, reported a good quality of life without pain during any range of motion. Our group of patients, after removal of the apparatus at 5 weeks following the surgery, had a mean articular range of motion with active abduction of 90 degrees and about 100 degrees with passive abduction. Postoperative CS scores at 12 months follow-up was 75,47±8.02. In addition there was also significant (P<0.05) improvement between preoperative and postoperative visual analog scale measurements (in cm), 7.67±2.70 and 1.71±2.08, respectively. This technique has shown good functional results with reduced surgical risks and complications that are typical of open reduction surgical fixation of proximal humerus fractures, is quick in execution and minimally invasive. Given the very good results of the study of this new external fixation technique has shown to be a viable option for the treatment of proximal humerus fractures.
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Fijadores Externos , Fracturas del Hombro/cirugía , Anciano , Clavos Ortopédicos , Hilos Ortopédicos , Diseño de Equipo , Femenino , Fluoroscopía , Estudios de Seguimiento , Humanos , Masculino , Osteoporosis/complicaciones , Complicaciones Posoperatorias , Rango del Movimiento Articular , Fracturas del Hombro/clasificación , Fracturas del Hombro/diagnóstico por imagenRESUMEN
BACKGROUND: Multiple studies have shown low intrarater and interrater agreement of radiographic classification systems for proximal humerus fractures (PHFs) in adults. There is no standardized method of measuring angulation of pediatric PHFs, nor is there consensus as to the amount of angulation and displacement that require operative fixation of adolescent PHFs. We propose a new standardized method to measure fracture angulation that is similar to the method used to measure the epiphyseal-shaft angle for slipped capital femoral epiphysis. The primary purpose of this study was to evaluate the intraobserver and interobserver reliability of our proposed method compared with a nonstandardized method. The secondary purpose was to evaluate the intrarater and interrater agreement of the Neer and Horowitz (NH), and Salter-Harris (SH) classification systems. METHODS: Seven raters evaluated 26 deidentified anteroposterior shoulder radiographs of patients 10 to 16 years of age with PHFs. Raters classified each fracture using the NH and SH systems, and used their own method to measure fracture angulation. This process was repeated 2 weeks later. During the second round, raters also measured fracture angulation using our proposed standardized method. Two weeks after the second round, raters reevaluated the radiographs using the standardized method. Intraclass correlation coefficients were calculated. RESULTS: Excellent intraobserver and interobserver agreement was achieved for the standardized method of measuring fracture angulation. All of the raters had an intrarater reliability classified as excellent (>0.80) using the standardized method. Good intrarater and excellent interrater agreement was achieved when raters used their own fracture angulation measurement method but wide confidence intervals suggested that the results were less precise. Fair to moderate intrarater and interrater reliability was seen for the NH and SH classifications. CONCLUSIONS: Our standardized method for measuring angulation in adolescent PHFs demonstrated excellent intrarater and interrater reliability. We propose that this technique may be a more precise method of measuring fracture angulation and this method should be used in future studies that evaluate indications for operative management of adolescent PHFs. LEVEL OF EVIDENCE: Level III-diagnostic.
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Radiografía/normas , Fracturas del Hombro/diagnóstico por imagen , Hombro/diagnóstico por imagen , Adolescente , Niño , Consenso , Femenino , Humanos , Masculino , Variaciones Dependientes del Observador , Reproducibilidad de los Resultados , Fracturas del Hombro/clasificación , Epífisis Desprendida de Cabeza Femoral/diagnóstico por imagenRESUMEN
BACKGROUND: The high rates of complications and reoperations observed with the early designs of first-generation (unlocked) and second-generation (bent design) humeral intramedullary nail (IMNs) have discouraged their use by most surgeons. The purpose of this study was to report the results of a third-generation (straight, locking, low-profile, tuberosity-based fixation) IMN, inserted through a percutaneous approach, for the treatment of displaced 2-part surgical neck fractures. METHODS: We performed a retrospective review of 41 patients who underwent placement of a third-generation IMN to treat a displaced 2-part surgical neck fracture (AO/OTA type 11A3). The mean age at surgery was 57 years (range, 17-84 years). After percutaneous insertion through the humeral head, the IMN was used as a reduction tool. Static locking fixation was achieved after axial fracture compression ("back-slap" hammering technique). Patients were reviewed and underwent radiography with a minimum of 1 year of follow-up; the mean follow-up period was 26 months (range, 12-53 months). RESULTS: Preoperatively, 3 types of surgical neck fractures were observed: with valgus head deformity (Type A = 8 cases), shaft translation without head deformity (Type B = 19 cases), or with varus head deformity (Type C = 14 cases). At final follow-up, all fractures went on to union, and the mean humeral neck-shaft angle was 132° ± 5°. We observed 2 malunions and 1 case of partial humeral head avascular necrosis. No cases underwent screw migration or intra-articular penetration. At last review, mean active forward elevation was 146° (range, 90°-180°) and mean external rotation was 50° (range, 20°-80°). The mean Constant-Murley score and Subjective Shoulder Value were 71 (range, 43-95) and 80% (range, 50%-100%), respectively. CONCLUSIONS: Antegrade insertion of a third-generation IMN through a percutaneous approach provides a high rate of fracture healing, excellent clinical outcome scores, and a low rate of complications. No morbidity related to the passage of the nail through the supraspinatus muscle and the cartilage was observed. The proposed A, B, and C classification allows choosing the optimal entry point for intramedullary nailing.
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Clavos Ortopédicos , Fijación Intramedular de Fracturas/instrumentación , Fijación Intramedular de Fracturas/métodos , Fracturas del Hombro/clasificación , Fracturas del Hombro/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Fijación Intramedular de Fracturas/efectos adversos , Curación de Fractura , Humanos , Masculino , Persona de Mediana Edad , Rango del Movimiento Articular , Estudios Retrospectivos , Fracturas del Hombro/diagnóstico por imagen , Fracturas del Hombro/fisiopatología , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Optimal fracture classification should be simple and reproducible and should guide treatment. For proximal humeral fractures, the Neer classification is commonly used. However, intraobserver and interobserver reliability of the Neer classification has been shown to be poor. In clinical practice, it is essential to differentiate 2-part surgical neck fractures from multi-fragmented fractures. Thus, the aim of this study was to evaluate whether surgeons can differentiate 2-part surgical neck fractures from multi-fragmented fractures using plain radiographs and/or computed tomography (CT). METHODS: Three experienced upper limb specialists and trauma surgeons (B.O.S., A.P.L., and V.L.) independently reviewed and classified blinded plain radiographs and CT scans of 116 patients as showing 2-part surgical neck fractures or multi-fragmented fractures. Each imaging modality was reviewed and classified separately by each surgeon, after which each surgeon reviewed both modalities at the same time. This process was repeated by all surgeons after 24 weeks. Intraobserver and interobserver analyses were conducted using Cohen and Fleiss κ values, respectively. RESULTS: The κ coefficient for interobserver reliability showed substantial correlation (0.61-0.73) and was as follows: 0.73 for radiographs alone, 0.61 for CT scans alone, and 0.72 for radiographs and CT scans viewed together. After 24 weeks, the process was repeated and intraobserver reliability was calculated.The κ coefficient for intraobserver reliability showed substantial correlation (0.62-0.75) and was as follows: 0.62 for radiographs alone, 0.64 for CT scans alone, and 0.75 for radiographs and CT scans viewed together. CONCLUSION: Clinicians were able to differentiate 2-part surgical neck fractures from multi-fragmented fractures based on plain radiographs reliably.
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Fracturas Conminutas/clasificación , Fracturas Conminutas/diagnóstico por imagen , Fracturas del Hombro/clasificación , Fracturas del Hombro/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Humanos , Persona de Mediana Edad , Variaciones Dependientes del Observador , Estudios Prospectivos , Radiografía , Reproducibilidad de los ResultadosRESUMEN
Fractures of the scapula are rare and have an incidence of 1% of all fractures. Publications highlight glenoid rim fractures. Classification by Ideberg and Euler and Rüdi are accepted. Euler and Rüdi describe three extra-articular and two intra-articular fracture patterns. The indications for surgery are displaced glenoid fractures, scapula tilt of more than 40° and injuries to the superior shoulder suspensory complex. We describe a case of a 22 year old man, who while cycling collided with a moving car due to wet roads. After his admission to hospital as a polytraumatised patient, the trauma CT-Scan showed haemothorax with several associated rip fractures, displaced humeral shaft fracture and fractures of the acromion and glenoid, classified as type D2c according to Euler and Rüdi. Following damage control principles, drainage of the haemothorax was already performed in the ER and surgical treatment of the displaced humeral shaft fracture was performed on the day of admission. No peripheral neurological deficits were evident. After pulmonary stabilisation, surgery was performed 6 days later on the glenoid and acromion fracture, which in conjunction may be regarded as an injury to the superior shoulder suspensory complex. We performed an arthroscopically-assisted screw fixation of the glenoid fracture (type D2c according to Euler and Rüdi) and an ORIF procedure at the acromion. Postoperative rehabilitation was performed with passive abduction and elevation up to 90° for the first two weeks and active abduction an elevation up to 90° for weeks 3 to 6. Full ROM was allowed at week 7. CONCLUSION: Articular fractures of the glenoid are rare and mainly seen as rim fractures. The indications for surgery are displaced articular fractures and injury to the superior shoulder suspensory complex. As demonstrated by this article, type D2c fractures according to Euler and Rüdi can be treated effectively as an arthroscopically-assisted screw fixation procedure.
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Artroscopía/métodos , Traumatismos en Atletas/cirugía , Ciclismo/lesiones , Fijación Interna de Fracturas/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos , Escápula/lesiones , Fracturas del Hombro/cirugía , Accidentes de Tránsito , Acromion/diagnóstico por imagen , Acromion/lesiones , Acromion/cirugía , Traumatismos en Atletas/clasificación , Traumatismos en Atletas/diagnóstico por imagen , Tornillos Óseos , Fijación Interna de Fracturas/instrumentación , Cavidad Glenoidea/diagnóstico por imagen , Cavidad Glenoidea/lesiones , Cavidad Glenoidea/cirugía , Humanos , Imagenología Tridimensional , Masculino , Traumatismo Múltiple/clasificación , Traumatismo Múltiple/diagnóstico por imagen , Traumatismo Múltiple/cirugía , Escápula/diagnóstico por imagen , Escápula/cirugía , Fracturas del Hombro/clasificación , Fracturas del Hombro/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
Background and purpose - We aimed to evaluate the ability of artificial intelligence (a deep learning algorithm) to detect and classify proximal humerus fractures using plain anteroposterior shoulder radiographs. Patients and methods - 1,891 images (1 image per person) of normal shoulders (n = 515) and 4 proximal humerus fracture types (greater tuberosity, 346; surgical neck, 514; 3-part, 269; 4-part, 247) classified by 3 specialists were evaluated. We trained a deep convolutional neural network (CNN) after augmentation of a training dataset. The ability of the CNN, as measured by top-1 accuracy, area under receiver operating characteristics curve (AUC), sensitivity/specificity, and Youden index, in comparison with humans (28 general physicians, 11 general orthopedists, and 19 orthopedists specialized in the shoulder) to detect and classify proximal humerus fractures was evaluated. Results - The CNN showed a high performance of 96% top-1 accuracy, 1.00 AUC, 0.99/0.97 sensitivity/specificity, and 0.97 Youden index for distinguishing normal shoulders from proximal humerus fractures. In addition, the CNN showed promising results with 65-86% top-1 accuracy, 0.90-0.98 AUC, 0.88/0.83-0.97/0.94 sensitivity/specificity, and 0.71-0.90 Youden index for classifying fracture type. When compared with the human groups, the CNN showed superior performance to that of general physicians and orthopedists, similar performance to orthopedists specialized in the shoulder, and the superior performance of the CNN was more marked in complex 3- and 4-part fractures. Interpretation - The use of artificial intelligence can accurately detect and classify proximal humerus fractures on plain shoulder AP radiographs. Further studies are necessary to determine the feasibility of applying artificial intelligence in the clinic and whether its use could improve care and outcomes compared with current orthopedic assessments.
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Aprendizaje Profundo , Fracturas del Hombro/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Área Bajo la Curva , Artrografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fracturas del Hombro/clasificación , Adulto JovenRESUMEN
In recent years, the understanding of shoulder fractures has changed due to the progress of arthroscopy. In addition to the cosmetic result, the access morbidity, particularly the integrity of the subscapularis muscle in glenoid and scapular fractures, must be mentioned as an advantage of a minimally invasive approach. Furthermore, necessary secondary interventions, e. g. hook plate removal, can be prevented or minimized by modern implants and arthroscopic techniques.However, the available data and publications are almost exclusively limited to technical notes or small case series, so statements about faster recreation or potential reduction of infection risk cannot be made. Whether addressing concomitant injuries has an effect on the clinical and functional outcome is also unclear at the present time.
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Artroscopía/métodos , Fijación Interna de Fracturas/métodos , Fracturas del Hombro/cirugía , Placas Óseas , Clavícula/diagnóstico por imagen , Clavícula/lesiones , Clavícula/cirugía , Cavidad Glenoidea/diagnóstico por imagen , Cavidad Glenoidea/cirugía , Humanos , Ligamentos Articulares/diagnóstico por imagen , Ligamentos Articulares/lesiones , Ligamentos Articulares/cirugía , Cuidados Posoperatorios/métodos , Manguito de los Rotadores/diagnóstico por imagen , Manguito de los Rotadores/cirugía , Luxación del Hombro/clasificación , Luxación del Hombro/diagnóstico por imagen , Luxación del Hombro/cirugía , Fracturas del Hombro/clasificación , Fracturas del Hombro/diagnóstico por imagenRESUMEN
INTRODUCTION: Successful treatment of periprosthetic shoulder fractures depends on the right strategy, starting with a well-structured classification of the fracture. Unfortunately, clinically relevant factors for treatment planning are missing in the pre-existing classifications. Therefore, the aim of the present study was to describe a new specific classification system for periprosthetic shoulder fractures including a structured treatment algorithm for this important fragility fracture issue. METHODS: The classification was established, focussing on five relevant items, naming the prosthesis type, the fracture localisation, the rotator cuff status, the anatomical fracture region and the stability of the implant. After considering each single item, the individual treatment concept can be assessed in one last step. To evaluate the introduced classification, a retrospective analysis of pre- and post-operative data of patients, treated with periprosthetic shoulder fractures, was conducted by two board certified trauma surgery consultants. RESULTS: The data of 19 patients (8 male, 11 female) with a mean age of 74 ± five years have been analysed in our study. The suggested treatment algorithm was proven to be reliable, detected by good clinical outcome in 15 of 16 (94%) cases, where the suggested treatment was maintained. Only one case resulted in poor outcome due to post-operative wound infection and had to be revised. CONCLUSIONS: The newly developed six-step classification is easy to utilise and extends the pre-existing classification systems in terms of clinically-relevant information. This classification should serve as a simple tool for the surgeon to consider the optimal treatment for his patients.
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Fracturas Periprotésicas/clasificación , Fracturas del Hombro/clasificación , Prótesis de Hombro/efectos adversos , Anciano , Anciano de 80 o más Años , Algoritmos , Artroplastia/métodos , Femenino , Fijación Interna de Fracturas/métodos , Humanos , Masculino , Persona de Mediana Edad , Fracturas Periprotésicas/cirugía , Estudios Retrospectivos , Fracturas del Hombro/cirugía , Articulación del Hombro/cirugíaRESUMEN
BACKGROUND: Posterior glenohumeral instability (PGHI) is an often unrecognized or misdiagnosed type of shoulder instability due to its heterogenic clinical and radiological presentation. CLASSIFICATION: The ABC classification for PGHI is based on the different pathomechanisms and recommended treatment standards and is therefore a guide to finding the correct diagnosis and therapy for affected patients. There are different types of PGHI: A (first time), B (dynamic), C (static). These groups are further classified based on pathomechanical principles: A1: subluxation, A2: dislocation; B1: functional, B2: structural; C1: constitutional, C2: acquired. THERAPY: In patients with type 1 PGHI (A1, B1, C1) conservative treatment is recommended while in patients with type 2 PGHI (A2, B2, C2) surgical treatment can be considered based on structural defects, clinical symptoms, chronicity, age, functional demand, and patient-specific health status. In addition it has to be considered, that there is the possibility of coexisting or overlapping subtypes as well as the chance of progression from one category into another over time.