Teardrop Alignment Changes After Volar Locking Plate Fixation of Distal Radius Fractures With Volar Ulnar Fragments.

BACKGROUND: We assessed factors associated with change in radiographic teardrop angle following volar locking plate (VLP) fixation of volarly displaced intra-articular distal radius fractures with volar ulnar fragments (VUF) within the ICUC database. The primary outcome was change in radiographic alignment on follow-up imaging, defined as a change in teardrop angle from intra-operative fluoroscopy greater than 5°. METHODS: Patients with distal radius fractures treated with a VLP within the ICUC database, an international collaborative and publicly available dataset, were identified. The primary outcome was volar rim loss of reduction on follow-up imaging, defined as a change in radiographic alignment from intra-operative fluoroscopy, teardrop angle less than 50°, or loss of normal radiocarpal alignment. Secondary outcomes were final range of motion (ROM) of the affected extremity. Radiographic Soong classification was used to grade plate position. Descriptive statistics were used to assess variables' distributions. A Random Forest supervised machine learning algorithm was used to classify variable importance for predicting the primary outcome. Traditional descriptive statistics were used to compare patient, fracture, and treatment characteristics with volar rim loss of reduction. Volar rim loss of reduction and final ROM in degrees and as compared with contralateral unaffected limb were also assessed. RESULTS: Fifty patients with volarly displaced, intra-articular distal radius fractures treated with a VLP were identified. Six patients were observed to have a volar rim loss of reduction, but none required reoperation. Volar ulnar fragment size, Soong grade 0, and postfixation axial plate position in relation to the sigmoid notch were significantly associated (P < .05) with volar rim loss of reduction. All cases of volar rim loss of reduction occurred when VUF was 10.8 mm or less. CONCLUSIONS: The size of the VUF was the most important variable for predicting volar rim loss of reduction followed by postfixation plate position in an axial position to the sigmoid notch and the number of volar fragments in the Random Forest machine learning algorithm. There were no significant differences in ROM between patients with volar ulnar escape and those without.

The association of ICUC trauma score and quick DASH in a distal radius fracture cohort.

BACKGROUND: This study evaluates the association between ICUC trauma and short-form Disabilities of the Arm, Shoulder, and Hand Questionnaire (Quick DASH) scores among patients who underwent surgery for distal radius fractures. METHODS: This research gathered patient-reported outcomes (PROs) from patients registered in the ICUC database at a single trauma center. The study involved 76 adult patients who underwent surgical treatment for distal radius fractures before 2023. These patients received a volar locking plate for their distal radius fracture. The research utilized two different PROs to evaluate the patients' conditions. The ICUC trauma score measures functional impairment and pain through two 5-point scale questions, allowing patients to self-assess these aspects. The Quick DASH, comprising 11 questions, was used to evaluate symptoms and functionality of the upper extremity. RESULTS: For patients aged 55.9 ± 15.3 years and 4.6 ± 3.9 years post-op follow-up, the ICUC trauma score was 0.70 ± 0.95, and Quick DASH was 6.07 ± 10.35. A strong correlation between ICUC and Quick DASH was identified (r = 0.71, P < 0.01). The interaction between the ICUC trauma score and age at the surgery to Quick DASH revealed a significant unstandardized partial regression coefficient of 0.19 (95% confidence interval 0.08-0.31; P < 0.01). CONCLUSION: This study demonstrated a strong correlation between the ICUC trauma score and the Quick DASH among patients, especially the elderly. It was noted that an elevation in the ICUC trauma score is linked to a more marked increase in the Quick DASH score, particularly in older patients. Given its simplicity and efficacy, the ICUC trauma score may be a viable alternative to the Quick DASH for assessing the patient's clinical outcomes.

Evidence-Based Surgery: What Can Intra-Operative Images Contribute?

Evidence-based medicine integrates results from randomized controlled trials (RCTs) and meta-analyses, combining the best external evidence with individual clinical expertise and patients' preferences. However, RCTs of surgery differ from those of medicine in that surgical performance is often assumed to be consistent. Yet, evaluating whether each surgery is performed to the same standard is quite challenging. As a primary issue, the novelty of this review is to emphasize-with a focus on orthopedic trauma-the advantage of having complete intra-operative image documentation, allowing the direct evaluation of the quality of the intra-operative technical performance. The absence of complete intra-operative image documentation leads to the inhomogeneity of case series, yielding inconsistent results due to the impossibility of a secondary analysis. Thus, comparisons and the reproduction of studies are difficult. Access to complete intra-operative image data in surgical RCTs allows not only secondary analysis but also comparisons with similar cases. Such complete data can be included in electronic papers. Offering these data to peers-in an accessible link-when presenting papers facilitates the selection process and improves publications for readers. Additionally, having access to the full set of image data for all presented cases serves as a rich resource for learning. It enables the reader to sift through the information and pinpoint the details that are most relevant to their individual needs, allowing them to potentially incorporate this knowledge into daily practice. A broad use of the concept of complete intra-operative image documentation is pivotal for bridging the gap between clinical research findings and real-world applications. Enhancing the quality of surgical RCTs would facilitate the equalization of evidence acquisition in both internal medicine and surgery. Joint effort by surgeons, scientific societies, publishers, and healthcare authorities is needed to support the ideas, implement economic requirements, and overcome the mental obstacles to its realization.

Homogeneity in Surgical Series: Image Reporting to Improve Evidence.

Good clinical practice guidelines are based on randomized controlled trials or clinical series; however, technical performance bias among surgical trials is under-assessed. The heterogeneity of technical performance within different treatment groups diminishes the level of evidence. Surgeon variability with different levels of experience-technical performance levels even after certification-influences surgical outcomes, especially in complex procedures. Technical performance quality correlates with the outcomes and costs and should be measured by image or video-photographic documentation of the surgeon's view field during the procedures. Such consecutive, completely documented, unedited observational data-in the form of intra-operative images and a complete set of eventual radiological images-improve the surgical series' homogeneity. Thereby, they might reflect reality and contribute towards making necessary changes for evidence-based surgery.

Complete Intra-Operative Image Data Including 3D X-rays: A New Format for Surgical Papers Needed?

Intra-operative 3D X-rays have been confirmed to decrease revision rates and improve optimal screw placement in complex fractures of the distal radius. Compared with traditional surgical publications, another advantage of whole intraoperative clinical imaging can be presented in electronic databases, e.g., the ICUC working group, through a link without size limitation. The detail of complete intra-operative image dataset includes essential technical details which can be analyzed secondarily for costs and complications, considering the technical performance bias. Furthermore, the new format complies with reading/learning preferences of young surgeons and allows secondary work-up by artificial intelligence. Intra-operative 3D X-ray is a new approach for better surgical outcomes, economic benefit, and educational purposes.

Income protection for self-employed and non-standard workers during the COVID-19 pandemic.

Based on original evidence from the European Social Policy Network (ESPN), the article investigates the extent to which self-employed and non-standard workers, who are less protected by "ordinary" social protection, were included in "extraordinary" income protection and job retention schemes during the COVID-19 pandemic in the European Union (EU) and the United Kingdom. When the crisis hit, countries quickly introduced unprecedented emergency income replacement measures for the self-employed. Nevertheless, most of these schemes provided only basic support through lump sums and were, in some cases, subject to a variety of eligibility conditions. Non-standard workers were in general included in job retention schemes, but substantial gaps remained in some countries. The article discusses how such gaps were addressed in five EU Member States. The article concludes by highlighting some policy pointers for better and more adequate "extraordinary" income protection for the self-employed and non-standard workers in times of crisis.

Sur la base de données inédites du Réseau européen de politique sociale (ESPN), l'article examine dans quelle mesure les travailleurs indépendants et atypiques, qui sont moins protégés par la protection sociale «ordinaire¼, ont été inclus dans des régimes «extraordinaires¼ de protection du revenu et de maintien dans l'emploi pendant la pandémie de COVID­19 dans l'Union européenne (UE) et au Royaume­Uni. Lorsque la crise est survenue, les pays ont rapidement mis en place des mesures d'urgence sans précédent de remplacement du revenu pour les travailleurs indépendants. Cependant, la plupart de ces régimes ne fournissaient qu'une aide de base sous forme de montants forfaitaires et étaient, dans certains cas, soumis à diverses conditions d'ouverture des droits. Les travailleurs atypiques étaient en général inclus dans les programmes de maintien dans l'emploi, mais des lacunes importantes subsistaient dans certains pays. L'article examine comment ces lacunes ont été comblées dans cinq États membres de l'UE. Il conclut en mettant en évidence quelques pistes pour améliorer et rendre plus adéquate la protection des revenus «extraordinaires¼ des travailleurs indépendants et des travailleurs atypiques en temps de crise.

Sobre la base de datos originales de la Red Europea de Política Social (REPS), en el artículo se investiga hasta qué punto se incluyó a los trabajadores por cuenta propia y a los trabajadores atípicos, menos cubiertos por los sistemas de protección social "ordinarios", en los regímenes "extraordinarios" de protección de los ingresos y de mantenimiento del empleo durante la pandemia de COVID­19 en la Unión Europea (UE) y el Reino Unido. Con la llegada de la crisis, los países adoptaron rápidamente medidas de emergencia sin precedentes para garantizar la sustitución de los ingresos de los trabajadores por cuenta propia. No obstante, la mayoría de estos regímenes solo prestaron una ayuda básica en forma de pagos únicos que, en algunos casos, estaban sujetos a diversas condiciones de elegibilidad. En general, los trabajadores atípicos fueron incluidos en los regímenes de mantenimiento del empleo, pero en algunos países siguió habiendo deficiencias importantes. En el artículo se analiza cómo se abordaron esas deficiencias en cinco Estados miembros de la UE, y concluye destacando algunas pautas políticas para que la protección de los ingresos "extraordinaria" en tiempos de crisis sea mejor y más adecuada para los trabajadores por cuenta propia y los trabajadores atípicos.

Com base em evidências originais da Rede europeia em matéria de política social (ESPN, European Social Policy Network), este artigo investiga até que ponto trabalhadores autônomos e trabalhadores não padronizados, que são menos protegidos pela proteção social "comum", foram incluídos em regimes "extraordinários" de proteção de renda e manutenção de emprego durante a pandemia de COVID­19 na União Europeia (UE) e no Reino Unido. Quando a crise chegou, os países rapidamente introduziram medidas emergenciais sem precedentes de reposição de renda para os trabalhadores autônomos. No entanto, a maioria desses regimes proporcionou apenas apoio básico por meio de parcelas únicas e, em alguns casos, estavam sujeitos a uma variedade de condições de elegibilidade. Em geral, os trabalhadores não padronizados foram incluídos em regimes de manutenção de emprego, mas lacunas substanciais se mantiveram em alguns países. Este artigo discute como essas lacunas foram abordadas em cinco Estados­membros da União Europeia. O artigo conclui destacando alguns indicadores políticos para uma proteção de renda "extraordinária" melhor e mais adequada para os trabalhadores autônomos e os trabalhadores não padronizados em tempos de crise.

Peri-Surgical Inflammatory Profile Associated with Mini-Invasive or Standard Open Lumbar Interbody Fusion Approaches.

BACKGROUND: Different surgical approaches are available for lumbar interbody fusion (LIF) to treat disc degeneration. However, a quantification of their invasiveness is lacking, and the definition of minimally invasive surgery (MIS) has not been biochemically detailed. We aimed at characterizing the inflammatory, hematological, and clinical peri-surgical responses to different LIF techniques. METHODS: 68 healthy subjects affected by single-level discopathy (L3 to S1) were addressed to MIS, anterior (ALIF, n = 21) or lateral (LLIF, n = 23), and conventional approaches, transforaminal (TLIF, n = 24), based on the preoperative clinical assessment. Venous blood samples were taken 24 h before the surgery and 24 and 72 h after surgery to assess a wide panel of inflammatory and hematological markers. RESULTS: martial (serum iron and transferrin) and pro-angiogenic profiles (MMP-2, TWEAK) were improved in ALIF and LLIF compared to TLIF, while the acute phase response (C-reactive protein, sCD163) was enhanced in LLIF. CONCLUSIONS: MIS procedures (ALIF and LLIF) associated with a reduced incidence of post-operative anemic status, faster recovery, and enhanced pro-angiogenic stimuli compared with TLIF. LLIF associated with an earlier activation of innate immune mechanisms than ALIF and TLIF. The trend of the inflammation markers confirms that the theoretically defined mini-invasive procedures behave as such.

From creative thinking to scientific principles in clinical practice.

Stephan Perren's contributions to the understanding and application of the principles of bone pathobiology, healing, and fracture fixation to clinical care remain as a lasting legacy of a great creative mind. Less well appreciated perhaps were his important contributions to the dissemination and practical application of those principles through the use of technology as applied to the learning environment. This paper describes and pays tribute to a series of initiatives in which Perren was a leading mentor and collaborator in the development of methods and instruments through which the principles of bone mechano-pathobiology could be translated through active learning environments into the practical world of clinical musculoskeletal traumatology.

Open reduction and internal fixation of OTA type C2-C4 fractures of the calcaneus with a triple-plate technique.

The purpose of this study was to present a surgical technique of open reduction and internal fixation of displaced intra-articular calcaneal fractures with 3 AO mini-fragment plates and to evaluate the clinical and radiological outcome of a consecutive group of patients after a mean follow-up of 41.7 months. A series of 54 patients (16 women and 38 men) with 62 calcaneal fractures were treated over a period of 6.5 years. Forty-five patients with 50 calcaneal fractures were completely clinically and radiologically followed up. Clinical follow-up included assessment of range of motion, pain according to a visual analogue scale, the American Orthopaedic Foot and Ankle Society hindfoot score, and the short-form 36 health survey. Radiological follow-up included plain axial and lateral radiographs and measurement of the Böhler's angle and Gissane's angle. Independent Student's t test and paired Student's t test were used alongside the chi-square test to compare clinical and radiological data and score values between different groups of patients. Eleven patients showed breakage of the osteosynthesis material during the healing process and 2 patients sustained deep wound infection requiring revision surgery. At the final follow-up all fractures had healed. The average range of motion was supination 26.4° (range 0° to 50°; SD 11.6°), pronation 15.4° (range 0° to 30°; SD 6.4°), dorsal extension 14.3° (range -10° to 30°; SD 8.0°), and plantarflexion 39.6° (range 20° to 65°; SD 11.7°). Patients with OTA type C4 fractures achieved significantly lower supination (p < .01) and plantarflexion (p < .01) compared with other fracture types. The mean visual analog scale pain score was 3.6 (range 0 to 8; SD 2.3) points, average American Orthopaedic Foot and Ankle Society hindfoot score was 70.8 (range 33 to 100; SD 17.1) points, and the mean short-form 36 score was 60.98 (range 22.9 to 93.0; SD 18.4) points. The mean postoperative Böhler's angle was 28.9° (range 8° to 38°; SD 7.1°), which decreased to 23.6° (range 4° to 34°; SD 8.7°) at the final follow-up, and the mean postoperative Gissane's angle was 108.6° (range 80° to 140°; SD 11.8°), which finally decreased to 102.4° (range 72° to 126°; SD 12.7°). No statistically significant differences regarding Böhler's and Gissane's angles were found between different OTA fracture types. In conclusion, the presented surgical technique was found to provide comparable and adequate reduction of OTA type C2-C4 injuries based on statistically insignificant differences in radiographic measures of postoperative fracture reduction. Greater limitation in subtalar motion was observed in OTA type C4 fractures in comparison with less severe fractures (p < .01).

Clinical longer-term results after internal fixation of proximal humerus fractures with a locking compression plate (PHILOS).

OBJECTIVES: The aim of this study was to investigate the subjective and objective longer-term outcomes after fracture fixation with the Proximal Humerus InterLocking OSteosynthesis (PHILOS) plate. DESIGN: Minimum 4-year follow-up of a primary prospective cohort study. SETTING: Single university trauma center. PATIENTS/PARTICIPANTS: Sixty-four consecutively collected patients fulfilled the study criteria. Seven patients (11%) were lost to follow-up, resulting in 57 patients (65 ± 14 years). INTERVENTION: Open reduction and internal fixation with the PHILOS® plate. MAIN OUTCOME MEASUREMENTS: Standardized follow-up including functional outcome instruments (eg, Constant Murley score, Disabilities of the Arm, Shoulder and Hand), rate of complications, and secondary surgeries at 6, 12, and no less than 48 months (uni- and multivariate analysis; P < 0.05). RESULTS: At the 4- to 6-year follow-up (median 5 years postinjury), patients on average achieved an 87% range of motion of the injured compared with the uninjured shoulder (eg, 133° ± 40° versus 152° ± 26° abduction). Objective and subjective outcome improved significantly during the overall follow-up, most of all in reoperated and younger patients (65 years and younger) and within the first postinjury year. We observed an overall reoperation rate of 29% and 10 patients (17.5%) demonstrated an insufficient result resulting from pain (greater than 3 visual analog scale) or restricted abduction (less than 90°) at longer-term follow-up. First, the need for revision surgery and, second, increasing age were found to be the most predictive factors for unsatisfactory results. CONCLUSIONS: Fracture fixation with the PHILOS showed good to excellent longer-term results in three fourths of patients with outcome partially still improving after the first postoperative year.

Double-plate fixation in lateral clavicle fractures-a new strategy.

BACKGROUND: Lateral clavicle fractures Neer type II often lead to the dislocation of the medial fragment and an increased rate of nonunion after conservative treatment. Therefore, most authors recommend an open reduction and internal fixation. Double-plate fixation is a common technique in the treatment of complex radius fractures. The authors use it as a routine procedure in the treatment of lateral clavicle fractures Neer type II. In this article, we present our experiences. METHODS: From January 2006 to June 2008, 11 patients with lateral clavicle fractures of Neer type II were treated with an open reduction and internal fixation using the double-plate technique. RESULTS: All patients showed osseous union on radiographs after 10 weeks to 16 weeks. In eight of nine cases, the operated shoulder regained full range of motion. In all patients, we observed immediate postoperative recovery without severe complications. One female patient complained about slight pain and restricted motion in abduction of > 90°. In two patients, we observed the migration of one screw. It was removed under local anesthesia 9 weeks and 26 weeks after surgery. CONCLUSIONS: This study, for the first time, describes the technique of double-plate fixation for the treatment of lateral clavicle fractures. This technique provides a stable fixation even in small and comminuted distal fragments.

Effects of an interdisciplinary nurse-led Delirium Prevention and Management Program (DPMP) on nursing workload: a pilot study.

BACKGROUND: Delirium in elderly hip-fracture patients is common and results in negative patient outcomes and increased nursing workload. DESIGN AND OBJECTIVE: The study was part of an evaluation of the interdisciplinary nurse-led Delirium Prevention and Management Program (DPMP) in a Swiss university hospital. Nursing workload was compared before and after implementing the program, using a quasi-experimental design. PARTICIPANTS: Included were 200 patients who were 65 years of age or older, recovering from hip-fracture surgery on a trauma ward (intervention) or on the other surgery wards. METHODS: Workload was compared before and after implementing the program on the trauma ward and was also compared on other surgery wards. Nursing workload for each patient was evaluated by means of data obtained from the nursing workload management system. Data were collected in a 4-month timeframe in 2004 and 2005 respectively. Differences for workload in total and workload for day, evening, and night shifts on postoperative days 1-5 were calculated, controlled by co-morbidity. Subgroup analysis was performed for patients categorized by nurses as 'confused'. RESULTS: Total workload decreased slightly from Year 1 to 2 by 6.4% and 4.2% for patients on the trauma ward and other surgery wards. However, workload during night shifts on the trauma ward decreased significantly by 22% (p=.004), while there was not a significant change on the other surgery wards. Sub-analyses for 'confused' patients found that the workload at night on the trauma ward decreased significantly by 23% (p=.01), while it did not change significantly on other surgery wards. Higher co-morbidity and nurses' labelling patients as 'confused' were associated with increased workload (p<.001). CONCLUSIONS: After implementing the program, decreased workload at night was found on the trauma ward. Delirium was detected and treated more quickly which led to less care needed at night. The reason for the slight drop in workload on all wards requires further investigation.

Prognostic value of four classifications of calcaneal fractures.

BACKGROUND: The purpose of this study was to assist surgeons treating calcaneal fractures in choosing the most predictive fracture classification and clinical outcome tool. MATERIALS AND METHODS: For 152 patients (189 calcaneal fractures; average followup, 9.9 years), all fractures were classified in accordance with the Essex-Lopresti, OTA, Regazzoni, and Sanders classifications and matched with the following scores: AOFAS score, CNHF, FOA, MFS, Rowe, MFA, SF-36, and VAS. RESULTS: The Essex-Lopresti classification showed no statistically significant relation with any of the clinical scores (p > 0.05). The OTA classification related statistically significant with the MFS (p = 0.006), AOFAS score (p = 0.013), FOA (p = 0.019), Rowe (p = 0.0027), and MFA score (p = 0.03). The Regazzoni classification correlated with the AOFAS score (p = 0.003), MFS (p = 0.002), Rowe (p = 0.002), CNHF (p = 0.0001), FOA (p = 0.003), MFA score (p = 0.002), and VAS (p = 0.005). The Sanders classification corrrelated with the AOFAS score (p = 0.007), MFS (p = 0.001), Rowe (p = 0.001), CNHF (p = 0.024), FOA (p = 0.021), MFA score (p = 0.036), and VAS (p = 0.014). CONCLUSION: Compared to radiological based classifications, the CT based classifications, especially the Regazzoni and Sanders classifications, exhibited higher prognostic value compared to ultimate outcome scores.

Patient-specific three-dimensional composite bone models for teaching and operation planning.

BACKGROUND: Orthopedic trauma care relies on two-dimensional radiograms both before and during the operation. Understanding the three-dimensional nature of complex fractures on plain radiograms is challenging. Modern fluoroscopes can acquire three-dimensional volume datasets even during an operation, but the device limitations constrain the acquired volume to a cube of only 12-cm edge. However, viewing the surrounding intact structures is important to comprehend the fracture in its context. We suggest merging a fluoroscope's volume scan into a generic bone model to form a composite full-length 3D bone model. METHODS: Materials consisted of one cadaver bone and 20 three-dimensional surface models of human femora. Radiograms and computed tomography scans were taken before and after applying a controlled fracture to the bone. A 3D scan of the fracture was acquired using a mobile fluoroscope (Siemens Siremobil). The fracture was fitted into the generic bone models by rigid registration using a modified least-squares algorithm. Registration precision was determined and a clinical appraisal of the composite models obtained. RESULTS: Twenty composite bone models were generated. Average registration precision was 2.0 mm (range 1.6 to 2.6). Average processing time on a laptop computer was 35 s (range 20 to 55). Comparing synthesized radiograms with the actual radiograms of the fractured bone yielded clinically satisfactory results. CONCLUSION: A three-dimensional full-length representation of a fractured bone can reliably be synthesized from a short scan of the patient's fracture and a generic bone model. This patient-specific model can subsequently be used for teaching, surgical operation planning, and intraoperative visualization purposes.

Navigating the fluoroscope's C-arm back into position: an accurate and practicable solution to cut radiation and optimize intraoperative workflow.

OBJECTIVES: During complex image-guided orthopedic trauma procedures, repetitive fluoroscopic scout imaging is performed. A number of preparatory positioning images often must be taken to reproduce a comparable projection. These scout images have no intrinsic clinical relevance but nevertheless expose the patient and the surgical team to considerable radiation, which could be avoided. This study presents and validates a method to decrease intraoperative radiation. METHODS: Precision, time requirements, and number of scout images for repositioning the fluoroscope, with and without navigation aid, were recorded on 20 test-rig and 3 phantom setups. A commercially available image-guided surgical navigation system (Vector Vision, BrainLAB), originally designed for instrument navigation, was employed to register and retrieve the C-arm positions. A newly developed software computed the necessary moves to reposition the C-arm on an intuitive visual display. RESULTS: Retrieving a given C-arm position with the conventional non-navigated technique required an average of 7 scout images (range, 3 to 12 images). In contrast, navigation-assisted repositioning did not necessitate a single scout image. Deviations from the original projection were minimal for both navigated (0.9 degrees, 95% CI 0.8 to 1.1 degrees) and non-navigated repositioning (0.8 degrees, 95% CI 0.7 to 0.9 degrees). Average positioning times were comparable when navigating the C-arm (46 seconds, 95% CI 41 to 51 seconds) and in scout image-based positioning (49 seconds, 95% CI 44 to 53 seconds). CONCLUSIONS: Navigated C-arm positioning avoids multiple scout images and yields sufficient precision for clinical deployment. Radiation exposure can be reduced considerably by a combination of instrument navigation and navigated C-arm positioning.

A CT database for research, development and education: concept and potential.

Both in radiology and in surgery, numerous applications are emerging that enable 3D visualization of data from various imaging modalities. In clinical practice, the patient's images are analyzed on work stations in the Radiology Department. For specific preclinical and educational applications, however, data from single patients are insufficient. Instead, similar scans from a number of individuals within a collective must be compiled. The definition of standardized acquisition procedures and archiving formats are prerequisite for subsequent analysis of multiple data sets. Focusing on bone morphology, we describe our concept of a computer database of 3D human bone models obtained from computed tomography (CT) scans. We further discuss and illustrate deployment areas ranging from prosthesis design, over virtual operation simulation up to 3D anatomy atlases. The database of 3D bone models described in this work, created and maintained by the AO Development Institute, may be accessible to research institutes on request.

Internal fixation of unstable proximal humerus fractures with an anatomically preshaped interlocking plate: a clinical and radiologic evaluation.

BACKGROUND: We evaluated the outcome after internal fixation of unstable or displaced proximal humerus fractures with a new fixed-angle implant. METHODS: Prospective consecutive study with a 1-year clinical follow-up in 119 of 137 patients (87%; mean 68 +/- 15 years; 31 two-, 47 three-, and 41 four-part fractures). RESULTS: One year postoperatively, the range of motion of the injured side demonstrated on average four-fifths of the function of the contralateral side. Ninety-five percentage of patients (n = 114) could dress themselves independently with no or only slight restriction. The mean disabilities of the arm, shoulder, and hand score was 21 (range, 0-62). The absolute and relative Constant score significantly (p < 0.001) improved from 56 +/- 18 (75% +/- 21%) at 6 months postoperatively to up to 65 +/- 18 (82% +/- 18%) at 12 months postoperatively. The initial fracture configuration did not have a significant influence on clinical outcome or complications. Twenty-six patients (22%) underwent a reintervention because of a clinical problem or subjective complaint, which led to total or relevant relief of problems in 23 patients (87%). Radiologic follow-up revealed a significant correction of the mean fragment angles (p < 0.001) postoperatively compared with initial postcrash radiographs. The precision of intraoperative reduction had a significant impact on the patient's disabilities of the arm, shoulder, and hand scoring (p = 0.02). A comparison of the last evaluable radiographs with the intraoperative intensifier images revealed a mean loss of reduction over time of

Unexpected high complication rate following internal fixation of unstable proximal humerus fractures with an angled blade plate.

OBJECTIVES: The increasing number of fractures of the proximal humerus, especially in the elderly, carries with it the unsolved problem of the optimal treatment for the displaced or unstable fractures. The authors' goal was to analyze whether fixation with a bent valgus angled blade plate could improve the outcomes reported in the literature to date. DESIGN: Prospective clinical study. SETTING: Urban level 1 university trauma center. PATIENTS: Over a 27-month period, 42 consecutive patients were treated for an unstable or displaced proximal humerus fracture. INTERVENTION: Open reduction and internal fixation with a 90-degree cannulated angled blade plate prebent to 110 degrees. MAIN OUTCOME MEASUREMENTS: Active follow-up for 1 year with assessment of objective and subjective functional results (ie, motion; strength; Constant score; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and visual analog scale (VAS)) and radiographic assessment (reduction, alignment, necrosis, and nonunion). RESULTS: Follow-up was completed for 86% of the patients, who achieved a mean Constant score of 66 points (82% of the contralateral side) with a mean forward flexion of 125 degrees and an average strength of 72% of the contralateral side. Low disability (mean DASH score 22) and pain values (mean VAS 2) were demonstrated after this type of stabilization. The overall complication rate was 33% (12/36), with protrusion of the blade into the glenohumeral articulation as the most frequent problem (8/36, 22%). The negative impact of an adverse event on subjective and objective outcomes was only significant for forward flexion (P = 0.02). Neither clinical outcome nor complication rate was different when compared to patients with regard to fracture type (3 versus 4 parts) or age (younger or older than 70 years). CONCLUSIONS: Fixation of displaced proximal humeral fractures with an angled blade plate provided sufficient stability. Blade perforation into the humeral joint occurred in every fourth patient and was found to be the major reason for a high complication rate. In view of this major problem, the technique described here cannot be recommended, even though the absence of nonunions in our series seems to support the low invasiveness of this surgical approach.