Mortality After Complex Displaced Proximal Humerus Fractures in Elderly Patients: Conservative Versus Operative Treatment With Reverse Total Shoulder Arthroplasty.

INTRODUCTION: Proximal humerus fractures (PHFs) are a common fragility fracture and have been shown to increase mortality in elderly patients. In the last decade, reverse total shoulder arthroplasty (RTSA) was introduced as a reliable operative treatment option for this indication. In other fragility fractures, most notably hip fractures, urgent surgical treatment can reduce mortality. The purpose of this study is to evaluate whether treatment with RTSA can reduce 1-year mortality in elderly patients with complex displaced PHFs. MATERIALS AND METHODS: A retrospective study was performed to compare 1-year mortality between 2 groups of elderly patients (>75 years old) who presented to a level 1 trauma center emergency department with complex displaced PHFs. The conservative treatment group (n = 83; mean age, 83.7 years) presented from 2008 to 2010 when RTSA was not yet available, and treatment was nonoperative. The surgical treatment group (n = 62; mean age, 82.2 years) presented from 2012 to 2015 and underwent RTSA. RESULTS: One-year mortality was 8.1% (male 7.1%; female 8.3%) in the surgical treatment group and 10.8% (male 18.8%; female 9.0%) in the conservative treatment group. The reduction in mortality in the surgical treatment group was not significant (entire cohort P = .56; males P = .35; females P = .59). DISCUSSION: Recent studies failed to show better functional results after surgical treatment with RTSA when compared to conservative treatment. This study suggests that a benefit of surgical treatment with RTSA that was not examined until now might exist-a reduction in the increased mortality risk associated with PHFs. CONCLUSIONS: There was no significant difference in 1-year mortality between the groups, although there was a trend showing lower mortality with RTSA, mostly in men. Further studies with larger populations and longer follow-up times are needed to determine whether this trend is of clinical significance.

Pathological fracture risk assessment in patients with femoral metastases using CT-based finite element methods. A retrospective clinical study.

Physician recommendation for prophylactic surgical fixation of a femur with metastatic bone disease (MBD) is usually based on Mirels' criteria and clinical experience, both of which suffer from poor specificity. This may result in a significant number of these health compromised patients undergoing unnecessary surgery. CT-based finite element analyses (CTFEA) have been shown to accurately predict strength in femurs with metastatic tumors in an ex-vivo study. In order to assess the utility of CTFEA as a clinical tool to determine the need for fixation of patients with MBD of the femur, an ad hoc CTFEA was performed on a retrospective cohort of fifty patients. Patients with CT scans appropriate for CTFEA analysis were analyzed. Group 1 was composed of 5 MBD patients who presented with a pathologic femoral fracture and had a scan of their femurs just prior to fracture. Group 2 was composed of 45 MBD patients who were scheduled for a prophylactic surgery because of an impending femoral fracture. CTFEA models were constructed for both femurs for all patients, loaded with a hip contact force representing stance position loading accounting for the patient's weight and femur anatomy. CTFEA analysis of Group 1 patients revealed that they all had higher tumor associated strains compared to typical non-diseased femur bone strains at the same region (>45%). Based on analysis of the 5 patients in Group 1, the ratio between the absolute maximum principal strain in the vicinity of the tumor and the typical median strain in the region of the tumor of healthy bones (typical strain fold ratio) was found to be the 1.48. This was considered to be the predictive threshold for a pathological femoral fracture. Based on this typical strain fold ratio, twenty patients (44.4%) in Group 2 were at low risk of fracture and twenty-five patients (55.5%) high risk of fracture. Eleven patients in Group 2 choose not to have surgery and none fractured in the 5month follow-up period. CTFEA predicted that seven of these patients were below the pathological fracture threshold and four above, for a specificity of 63% Based on CTFEA, 39% of the patients with femoral MBD who were referred and underwent prophylactic stabilization may not have needed surgery. These results indicate that a prospective randomized clinical trial evaluating CTFEA as a criterion for determining the need for surgical stabilization in patients with MBD of the femur may be warranted.

Head trauma is the major risk factor for cerebral sinus-vein thrombosis.

BACKGROUND: Cerebral sinus vein thrombosis (CSVT) is a rare disease with significant neurological sequelae and high mortality rate. Incidence of CSVT diagnosis in the western world has increased despite the reduced occurrence of infections. AIM: To identify risk factors that may explain the predisposition to site specific thrombosis. METHODS: Ninety consecutive patients diagnosed with acute CSVT in tertiary hospital. As a control group we used the data extracted from the National Trauma Registry and Healthcare Services. RESULTS: Trauma history up to one month prior to diagnosis of CVST was found in 13 (14%) patients. Six patients had skull fractures, the others had blunt trauma. The overall SMR was 941 (p<0.0001); the separate results for men and women were 1206 and 543, respectively. Infections confined to the head and neck in 7% of the cases and brain tumor were observed in 8%. At the time of CVST, 23 of 50 (46%) women had a hormonal risk factor. The SMR for OC use was 1.63 (p=0.0298). Prothrombotic polymorphisms were detected in 16 of 63 (25.4%) patients who were tested for factor V Leiden and prothrombin G20210A mutation (OR=3.47, p=0.002) in comparison to 49% in DVT patients (OR=9.95, p<0.0001). CONCLUSIONS: Assessment for CVST in patients with recent trauma and headache even after intact head CT is required. The other risk factors, such as hormone related and prothrombotic polymorphisms, were not specific just for CVST and the latter play a lesser role in CVST than in DVT.