Concurrent upper limb and hip fracture in the elderly.

AIMS: To present a large series of concurrent upper limb and hip fracture in the elderly treated at a United Kingdom major trauma centre. PATIENTS AND METHODS: Prospective data collection was performed for all elderly patients admitted to a single centre with hip fracture between January 2006 and November 2015. Comparative analysis of concurrent upper limb and hip fracture and an isolated hip fracture was performed. RESULTS: Study cohort included 307 patients that had sustained concurrent upper limb and hip fracture and 6887 with an isolated hip fracture. A concurrent upper limb fracture was associated with increased length of stay (21.7 vs. 18.8 days, p = 0.003) and decreased proportion of patients returning to their own home at discharge (39.2% vs. 49.4%, p = 0.001). No differences in age, Abbreviated Mental Test (AMT), Nottingham Hip Fracture Score (NHFS) and mortality were identified. However, concurrent wrist fracture 365-day mortality was lower than that of isolated hip fracture (20.9% vs 29.2%, p = 0.018). Concurrent humerus fracture was associated with increased inpatient death (13.7% vs 6.4%, p = 0.046) and 365-day mortality (34.7% vs 20.9%, p = 0.014) compared to concurrent wrist fracture. Surgical stabilisation of the concurrent upper limb fracture was performed in 90 wrist (52.3%) and 13 humerus (13.7%) cases. Operative management of the concurrent fracture did not yield significant differences in acute hospital length of stay or rehabilitation requirement. Cox regression analysis of 365-day survival data demonstrated that age, NHFS, AMT, gender and presence of a concurrent upper limb fracture independently influence 365-day mortality rate. CONCLUSION: There are increased rehabilitation requirements for elderly patients with concurrent upper limb and hip fractures. There is a marked distinction in survivorship outcomes for patients sustaining concurrent wrist and concurrent humerus fractures. CLINICAL RELEVANCE: Demonstrates increased rehabilitation requirements in concurrent upper limb and hip fracture in the elderly Highlights concurrent humerus fracture as a high risk group.

The Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Open Reduction Internal Fixation for Proximal Humerus Fractures in the Elderly.

Background: Open reduction and internal fixation (ORIF) of proximal humerus fractures in elderly individuals (age >70) carries a relatively high short-term complication and reoperation rate but is generally durable once healed. Reverse total shoulder arthroplasty (RTSA) for fractures may be associated with superior short-term quality of life but carries the lifelong liabilities of joint replacement. The tradeoff between short and long-term risks, coupled with disparities in quality of life and cost, makes this clinical decision amenable to cost-effectiveness analysis. Methods: A Markov state-transition model was constructed with a base case of a 75 year-old patient. Reoperation rates, quality of life values, mortality rates, and costs were based upon published literature. The model was run until all patients had died to simulate the accumulated costs and benefits. Results: RTSA was associated with greater quality of life (7.11 QALYs) than ORIF (6.22 QALYs). RTSA was cost-effective with an incremental cost-effectiveness ratio of $3,945/QALY and $27,299/ QALY from payor and hospital perspectives, respectively. RTSA was favored and cost-effective at any age above 65 and any Charlson Score. The model was sensitive to the utility of both procedures. Conclusion: RTSA resulted in a higher quality of life and was cost-effective in comparison to ORIF for elderly patients.Level of Evidence: III.

Early post-operative outcomes of plate versus nail fixation for humeral shaft fractures.

INTRODUCTION: This study was designed to measure early postoperative outcomes of plate vs. nail fixation for humeral shaft fractures. PATIENTS AND METHODS: Patients ≥18 years who underwent plate or nail fixation for low-energy humeral shaft fractures between 2005-2016 were identified from the National Surgical Quality Improvement Program (NSQIP). Multivariable regression was used to compare postoperative outcomes using propensity score adjustment to account for differences between fixation groups. Variables included in the propensity score were age, American Society of Anesthesiologists (ASA) class, hypertension, steroid use, cancer, functional status, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and sex. RESULTS: Plate fixation was used in 1418 patients (70.6%), while nail fixation was used in 591 (29.4%). Patients undergoing nail fixation were more likely to be older, have a higher American Society of Anesthesiologists (ASA) class, and have comorbidities. Mean operative time was statistically longer in the plate fixation group (130 +/-62 min vs. 102 +/-54 min). After propensity score adjustment, type of fixation was not a significant predictor of major or minor complications, length of stay, or readmission. However, nail fixation was a significant predictor of mortality following propensity score adjustment (OR 3.15, 95% Confidence interval 1.26-7.85). CONCLUSION: Patients undergoing intramedullary nail fixation tended to be older patients with more comorbidities, suggesting that surgeons are selecting nail fixation in patients who may not be ideal surgical candidates. Although LOS, complications, and readmission rates were higher in the nail group, this difference was not statistically significant following propensity score adjustment. However, nail fixation remained an independent predictor of 30-day mortality following adjustment. This suggests that nail fixation may not be a safer surgical option in patients with multiple medical co-morbidities and low-energy humeral shaft fractures.

Mortality Rates of Humerus Fractures in the Elderly: Does Surgical Treatment Matter?

INTRODUCTION: Multiple studies have shown the impact of hip fractures on geriatric mortality. Few evaluate mortality after proximal humerus (PH) or distal humerus (DH) fractures, and fewer determine differences in mortality based on management. We aim to evaluate a statewide cohort of elderly patients with PH or DH fractures to evaluate mortality, length of stay, discharge data, readmission, and differences based on management. METHODS: The New York Statewide Planning and Research Cooperative System database was used to identify patients 60 years and older admitted with a PH or DH fracture. Patient demographics, including age, gender, sex, race, weight, and insurance status, along with comorbid conditions using the Charlson Comorbidity Index, were determined. Seven-day, 30-day, and 1-year mortality was determined for operative and nonoperative cohorts. Logistic regression determined the competing risk of mortality when controlling for patient demographics, comorbid conditions, and treatment. RESULTS: Forty-two thousand five hundred eleven PH and 7654 DH fractures were evaluated. PH fractures had higher mortality than DH. Nonoperative treatment occurred in 76.2% of PH fractures and 53% of DH fractures. There were more comorbid conditions, longer length of stay, and higher mortality at 7 days, 30 days, and 1 year in patients treated nonoperatively. After controlling for patient demographics and comorbid conditions, there was no difference in mortality between PH and DH fractures, but operative treatment for either PH or DH was associated with lower mortality at all time points. DISCUSSION: Fewer PH than DH fractures were treated operatively. Operative treatment was associated with improved survival in patients hospitalized with PH or DH fracture even after controlling for patient demographic and comorbid factors. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Associations between pre-injury racing history and tibial and humeral fractures in Australian Thoroughbred racehorses.

Long bone fractures in racehorses may present as stress fractures which have a good prognosis, or complete fractures, which often result in a fatal outcome. In order to identify differences in modifiable management practices that may contribute to these outcomes, racing histories of horses with humeral or tibial fractures and of matched controls were examined. A retrospective case-control study of Australian Thoroughbred racehorses diagnosed with a fracture of the humerus or tibia by scintigraphy or at post-mortem between 2002 and 2016 was undertaken. Control horses were matched from the same race or trial on age and sex. Statistical analysis was performed using conditional logistic regression, χ2 and Mann-Whitney U tests. More humeral fractures than tibial fractures were fatal (12/47, 26% vs. 3/35, 8.6%, P = 0.049). No differences in pre-injury racing histories were observed between cases and controls for humeral and tibial fractures. Both humeral and tibial fracture case horses were younger than the registered Thoroughbred racing population (P < 0.001), but horses sustaining humeral fractures were older than those with tibial fractures (3.3 ± 0.9 vs. 2.8 ± 0.8 years, P = 0.005) yet raced fewer times prior to the injury (0.5 ± 1.1 vs. 1.3 ± 1.7 races, P = 0.009). Horses with fatal humeral fractures were less likely to have raced than those with non-fatal humeral fractures (16.7% vs. 55.6%, P = 0.02). In conclusion, tibial and humeral fractures occur in young racehorses, and humeral fractures are more likely to be fatal in those with the least exposure to trialling and racing.

Humerus fracture and combined venous injury increases limb loss in axillary or subclavian artery injury.

OBJECTIVE: Axillosubclavian vessel injury is rare, with most cases occurring after penetrating trauma. A prior database (2002-2006) analysis demonstrated an overall limb loss rate of 2.9%, with no difference between isolated arterial axillosubclavian vessel injury and combined artery/vein axillosubclavian vessel injury. Given increases in advanced vascular surgical techniques, as well as improved multidisciplinary care and expeditious diagnosis with computed tomography angiography, we hypothesized the national rate of limb loss in patients with arterial axillosubclavian vessel injury has decreased. In addition, we attempted to identify current predictors for limb loss in arterial axillosubclavian vessel injury. Finally, we hypothesized that combined artery/vein axillosubclavian vessel injury, as well as associated brachial plexus injury will have a higher risk for limb-loss and mortality compared to isolated arterial axillosubclavian vessel injury. METHODS: A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. All patients ≥ 18 years of age with arterial axillosubclavian vessel injury were included. The primary outcome was limb loss. After a univariable logistic regression model identified significant covariates, we performed a multivariable logistic regression for analysis. RESULTS: Of the total 5,494,609 trauma admissions, 3807 patients had arterial axillosubclavian vessel injury (<0.1%). Of these, 3137 (82.4%) had isolated arterial axillosubclavian vessel injury and 670 (17.6%) had combined artery/vein axillosubclavian vessel injury. The overall limb loss rate was 2.4% (from 2.9% in 2006, p = 0.47). After adjusting for covariates, independent risk factors for limb loss included a combined artery/vein axillosubclavian vessel injury (odds ratio = 3.54, confidence interval = 2.06-6.11, p < 0.001), blunt mechanism (odds ratio = 7.81, confidence interval = 4.21-14.48, p < 0.001), open repair (odds ratio = 2.37, confidence interval = 1.47-3.82, p < 0.001), and open proximal humerus fracture (odds ratio = 8.50, confidence interval = 4.97-14.54, p < 0.001). An associated brachial plexus injury was not associated with limb loss ( p = 0.37). Combined artery/vein axillosubclavian vessel injury was associated with higher risk for mortality compared to isolated arterial axillosubclavian vessel injury (odds ratio = 2.17, confidence interval = 1.73-2.71, p < 0.001). CONCLUSIONS: The national rate of limb loss in trauma patients with arterial axillosubclavian vessel injury has not changed in the past decade. A combined artery/vein axillosubclavian vessel injury is an independent risk factor for limb loss, as well as open repair. However, the strongest risk factor is an open proximal humerus fracture. An associated brachial plexus injury is not associated with increased risk of limb loss. Patients with combined artery/vein axillosubclavian vessel injury have a twofold increased risk of death compared to patients with isolated arterial axillosubclavian vessel injury.

High mortality in younger patients with major osteoporotic fractures.

Data were gathered with regard to mortality after fractures in 1006 younger patients. Results revealed that major osteoporotic fractures of the hip and humerus and drinking alcohol to excess were related to an increased risk of mortality. INTRODUCTION: Major osteoporotic fractures are known to be associated with increased mortality in older individuals. It is less clear whether this also applies to younger patients. METHODS: Date were gathered regarding patient demographics, fracture pattern, mechanism of injury, as well as smoking and alcohol intake at the time of injury in consecutive patients aged between 40 and 55 who presented to a UK trauma centre over a 12-month period. Mortality data was taken from the electronic patient records and was cross referenced with data from the General Registrar Office of Scotland. Cox regression analysis was used to identify independent predictors of mortality after adjusting for confounding factors. RESULTS: The study cohort consisted of 1006 patients, of which 53% were male. The commonest mechanism of injury was a fall. We obtained complete data regarding mortality for all patients at a median of 5.4 years (inter-quartile range 5.1 to 5.6). During this period, 46 patients were identified as being deceased. The overall standardised mortality ratio for the cohort was substantially increased relative to the age and sex matched general population with a ratio of 3.89 (95% confidence intervals (CI) 1.59 to 6.19). Alcohol excess and fractures involving the humerus and the neck of femur were independent predictors of mortality. CONCLUSIONS: Young individuals with hip and humerus fractures have a significantly increased mortality risk after their injury relative to the general population. The results of our study suggest that this may be in part due to a high prevalence of alcohol excess.

Third degree open fractures and traumatic sub-/total amputations of the upper extremity: Outcome and relevance of the Mangled Extremity Severity Score.

INTRODUCTION: Third degree open fractures and traumatic sub-/total amputations of the upper extremity represent severe injuries and are associated with a high rate of functional impairment of the affected extremity. More than 20 years ago, the Mangled Extremity Severity Score (MESS) was introduced to predict amputation following severe lower extremity trauma. However, there have been few studies evaluating MESS in connection with the mangled upper limb. MATERIAL AND METHODS: A retrospective medical chart review was performed of all patients diagnosed with the aforementioned fractures of the upper extremity treated at the Department of trauma surgery (level I trauma center) and the Clinical division of plastic and reconstructive surgery at the general hospital of Vienna between 1994 and 2014. RESULTS: Fifty-four out of 606 patients (9%) suffered from a total of 61 third degree open fractures or traumatic sub-/total amputations of the upper extremity (Gustilo-Anderson, type IIIA, n=30; Gustilo-Anderson, type IIIB, n=15; Gustilo-Anderson, type IIIC, n=9; traumatic sub-/total amputations, n=7). Thirty-seven out of 54 patients (69%) suffered fractures of the forearm, 10/54 (19%) patients of the humerus and 7/54 (13%) patients of the forearm and the humerus. The median MESS and Injury Severity Score (ISS) for all patients was 5 (range: 3-10) and 9 (range: 4-50), respectively. Seventeen out of 54 patients (31%) were diagnosed with a MESS≥7. Twenty-one out of 54 patients (39%) suffered severe vascular injuries and 22/54 (41%) patients suffered injuries of neural structures. Throughout the therapy process, 6/54 (11%) patients died. Definite limb salvage was achieved in 45 (94%) of the 48 survivors, of whom 9/45 (20%) subjects had a MESS≥7. DISCUSSION: It became apparent that definite limb salvage could be achieved in the mangled upper extremity regardless of MESS. It should be noted that in the current study, limb functionality was not assessed. However, without a standardized scoring system, there might be significant risk of salving dysfunctional upper limbs. LEVEL OF EVIDENCE: IV: retrospective or historical series.

Increased mortality after upper extremity fracture requiring inpatient care.

BACKGROUND AND PURPOSE: Increased mortality after hip fracture is well documented. The mortality after hospitalization for upper extremity fracture is unknown, even though these are common injuries. Here we determined mortality after hospitalization for upper extremity fracture in patients aged ≥16 years. PATIENTS AND METHODS: We collected data about the diagnosis code (ICD10), procedure code (NOMESCO), and 7 additional characteristics of 5,985 patients admitted to the trauma ward of Central Finland Hospital between 2002 and 2008. During the study, 929 women and 753 men sustained an upper extremity fracture. The patients were followed up until the end of 2012. Mortality rates were calculated using data on the population at risk. RESULTS: By the end of follow-up (mean duration 6 years), 179 women (19%) and 105 men (14%) had died. The standardized mortality ratio (SMR) for all patients was 1.5 (95% CI: 1.4-1.7). The SMR was higher for men (2.1, CI: 1.7-2.5) than for women (1.3, CI: 1.1-1.5) (p < 0.001). The SMR decreased with advancing age, and the mortality rate was highest for men with humerus fractures. INTERPRETATION: In men, the risk of death related to proximal humerus fracture was even higher than that reported previously for hip fracture. Compared to the general population, the SMR was double for humerus fracture patients, whereas wrist fracture had no effect on mortality.

Prognostic factors following pathological fractures.

BACKGROUND: Pathological fractures are a significant and often devastating event in the progression of metastatic bone disease. They are frequently a marker of end-stage cancer and the end of functional independence. Although several studies look into prognosis following the development of metastatic lesions, few look into the prognosis after the fracture itself. This study investigates the variables affecting prognosis in patients suffering pathological fractures. METHOD: Retrospective clinical audit of 72 patients from the Orthopaedic Unit at Fremantle Hospital in Western Australia. The variables of interest include primary cancer, fracture site, method of fixation, use of cement augmentation, appendicular metastatic load, spinal metastatic load, presence of visceral metastases, patient co-morbidities and functional scoring before and after the fracture has occurred. RESULTS: The median time between diagnosis of cancer to pathological fracture was 8.3 months, while the median survival post-fracture was 3.3 months. There is a statistically significant correlation between patient survival and primary cancer type, spinal metastatic burden and functional performance score. CONCLUSION: Overall, the prognosis following pathological fracture is extremely poor. We propose that these variables are scrutinized by the treating orthopaedic team preoperatively to help guide management and provide patients and their families with a realistic expectation of functional outcome and survival time.

Morbimortalidad en fracturas de húmero proximal tratadas quirúrgicamente / Morbidity and mortality of surgically treated proximal humerus fractures

Introducción. El objetivo de este estudio es analizar los factores que se correlacionan con la mortalidad y la capacidad para realizar actividades de la vida diaria (AVD) en las fracturas de húmero proximal tratadas quirúrgicamente. Métodos. Se estudiaron retrospectivamente a 94 pacientes con fractura de húmero proximal intervenidas quirúrgicamente con un seguimiento medio de 8 años (2-12 años). De la muestra, se estudió el tipo de fractura, el tratamiento aplicado y sus comorbilidades. Se correlacionan los parámetros con la mortalidad y el nivel de las actividades de la vida diaria. Resultados. Se localizaron a 72 pacientes, de los cuales el 18,6% habían fallecido. Un 85,4% de los pacientes presentan comorbilidades. El 79,5% de los pacientes eran totalmente independientes para las actividades de la vida diaria. No encontramos correlación entre la mortalidad, el tipo de fractura y el tratamiento aplicado. No se encontró relación significativa entre las AVD y las comorbilidades con el tipo de fractura, pero sí que se encontró una reducción significativa de la función de las actividades de la vida diaria en pacientes tratados con hemiartroplastia y en pacientes con trastornos neurológicos. Conclusiones. Encontramos una mortalidad del 18,6% en los pacientes con fractura de húmero proximal tratada quirúrgicamente. La mayoría de los pacientes intervenidos son totalmente independientes para las actividades de la vida diaria, con un seguimiento a largo plazo (AU)

Background. The aim of the present study is to analyse the factors associated with mortality and the capacity to perform daily life activities (DLA) in patients with surgically treated proximal humeral fractures. Methods. A retrospective study was conducted on 94 patients with a surgically treated proximal humeral fracture, with a mean follow-up of 8 years (2 - 12 years). A correlation analysis was performed to determine the relationship between the type of fracture, surgical technique, comorbidities and mortality and DLA. The Student t test was used for statistical analysis. Results. A total of 72 patients were identified, 18.6% of them died during follow-up, all diagnosed with some comorbidity. There was no correlation between mortality, type of fracture or the technique used. Most of the patients (85.4%) had comorbidities, and 79.5% were completely independent for DLA. Although there was no relationship with the type of fracture, there was a significant reduction in the performing of DLA in patients treated with hemiarthroplasty, and in patients with neurological disorders. Conclusions. There was a mortality of 18.6% among patients with surgically treated proximal humerus fractures. The majority of surgically treated patients were fully independent for DLA at long-term follow-up (AU)

Total elbow arthroplasty in obese patients.

BACKGROUND: The prevalence of obesity in the United States has increased in recent decades. The aim of this study was to evaluate the influence of obesity in patients undergoing primary total elbow arthroplasty. METHODS: From 1987 to 2006, 723 primary semiconstrained, linked total elbow arthroplasties were performed in 654 patients. The average patient age (and standard deviation) at the time of surgery was 62.3 ± 13.7 years, with 550 total elbow arthroplasties (76%) performed in women. Total elbow arthroplasties were used to treat inflammatory conditions in patients undergoing 378 total elbow arthroplasties (52%) and to treat acute traumatic or posttraumatic conditions in patients undergoing 310 total elbow arthroplasties (43%). Patients were classified as non-obese (having a body mass index of <30 kg/m2) in 564 total elbow arthroplasties (78%) and as obese (having a body mass index of ≥30 kg/m2) in 159 total elbow arthroplasties (22%). The median duration of follow-up was 5.8 years (range, zero to twenty-five years). Survivorship of total elbow arthroplasty was estimated with use of the Kaplan-Meier method. The effect of obesity on risk of total elbow arthroplasty revision was estimated with use of Cox regression models, adjusting for age, sex, body mass index, and indication. RESULTS: A total of 118 revisions (16%) were performed. The ten-year survival rate for total elbow arthroplasty revision for any reason was 86% (95% confidence interval, 82% to 89%) in non-obese patients compared with 70% (95% confidence interval, 60% to 79%) in obese patients (p < 0.05). The ten-year survival rate for total elbow arthroplasty revision for mechanical failure was 88% (95% confidence interval, 84% to 91%) in non-obese patients compared with 72% (95% confidence interval, 61% to 81%) in obese patients (p < 0.05). Severely obese patients (those with a body mass index of 35 to <40 kg/m2) had a significantly higher risk of total elbow arthroplasty revision for any reason (hazard ratio, 3.08 [95% confidence interval, 1.61 to 5.45]; p < 0.05) and mechanical failure (hazard ratio, 3.10 [95% confidence interval, 1.47 to 5.89]; p < 0.05) compared with non-obese patients. CONCLUSIONS: Obesity adversely influences the performance of elbow replacement after primary total elbow arthroplasty. Obese patients being considered for elbow replacement surgery should be counseled accordingly.

Humerus fractures at a regional trauma center: an epidemiologic study.

The purpose of this study was to outline the epidemiologic criteria of humerus fractures after traumatic injuries. All patients admitted to the trauma service at the authors' institution between 2005 and 2011 were entered into a prospective database. The authors obtained data on age, sex, injury mechanism, presence and location of humerus fracture, associated injuries, mortality, Injury Severity Score, treatment, and length of stay. Patients were matched to a group of patients with pelvic fractures with similar Injury Severity Scores to investigate whether significant differences existed between the 2 groups. Of the 11,007 trauma patients admitted, 209 (1.9%) had a humerus fracture. Associated fractures occurred in 154 (73.7%) patients. The mortality rate for all trauma patients during this period was 4.5%; it was 12% among those with humerus fractures and 21% among those with humeral shaft injuries. Several significant differences existed between the humerus fracture group and the pelvic fracture group. Visceral injuries were more common in the pelvic group, whereas associated fractures and head injuries were more common in the humerus fractures group. Age, sex, and length of stay were also significantly different between the 2 groups, but mortality was not significantly different. Humerus fractures in polytrauma patients are often associated with multiple injuries and a high mortality rate, especially for patients with humeral shaft fractures. A comprehensive evaluation of the patient is necessary.

Prophylactic stabilization for bone metastases, myeloma, or lymphoma: do we need to protect the entire bone?

BACKGROUND: The current operative standard of care for disseminated malignant bone disease suggests stabilizing the entire bone to avoid the need for subsequent operative intervention but risks of doing so include complications related to embolic phenomena. QUESTIONS/PURPOSES: We questioned whether progression and reoperation occur with enough frequency to justify additional risks of longer intramedullary devices. METHODS: A retrospective chart review was done for 96 patients with metastases, myeloma, or lymphoma who had undergone stabilization or arthroplasty of impending or actual femoral or humeral pathologic fractures using an approach favoring intramedullary fixation devices and long-stem arthroplasty. Incidence of progressive bone disease, reoperation, and complications associated with fixation and arthroplasty devices in instrumented femurs or humeri was determined. RESULTS: At minimum 0 months followup (mean, 11 months; range, 0-72 months), 80% of patients had died. Eleven of 96 patients (12%) experienced local bony disease progression; eight had local progression at the original site, two had progression at originally recognized discretely separate lesions, and one had a new lesion develop in the bone that originally was surgically treated. Six subjects (6.3%) required repeat operative intervention for symptomatic failure. Twelve (12.5%) patients experienced physiologic nonfatal complications potentially attributable to embolic phenomena from long intramedullary implants. CONCLUSIONS: Because most patients in this series were treated with the intent to protect the bone with long intramedullary implants when possible, the reoperation rate may be lower than if the entire bone had not been protected. However, the low incidence of disease progression apart from originally identified lesions (one of 96) was considerably lower than the physiologic complication rate (12 of 96) potentially attributable to long intramedullary implants. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Complications and survival after surgical treatment of 214 metastatic lesions of the humerus.

BACKGROUND: The humerus is the second most common long-bone site of metastatic bone disease. We report complications, risk factors for failure, and survival of a large series of patients operated on for skeletal metastases of the humerus. MATERIALS AND METHODS: This study was based on 208 patients treated surgically for 214 metastatic lesions of the humerus. Reconstructions were achieved by intramedullary nails in 148, endoprostheses in 35, plate fixation in 21, and by other methods in 10. RESULTS: The median age at surgery was 67 years (range, 29-87 years). Breast cancer was the primary tumor in 31%. The overall failure rate of the surgical reconstructions was 9%. The reoperation rate was 7% in the proximal humerus, 8% in the diaphysis, and 33% in the distal part of the bone. Among 36 operations involving an endoprosthesis, 2 were failures (6%) compared with 18 of 178 osteosynthetic devices (10%). In the osteosynthesis group, intramedullary nails failed in 7% and plate fixation failed in 22%. Multivariate Cox regression analysis showed that prostate cancer was associated with an increased risk of failure after surgery (hazard ratio, 7; P < 0.033). The cumulative survival after surgery was 40% (95% confidence interval [CI] 34-47) at 1 year, 21% (95% CI, 15-26) at 2 years, and 16% (95% CI, 12-19) at 3 years. CONCLUSIONS: Our method of choice is the cemented hemiprosthesis for pathologic proximal humeral fractures and interlocked intramedullary nail for lesions in the diaphysis. Pathologic fractures in the distal humerus are uncommon and associated with a very high reoperation rate.

Mortality rates after incident non-traumatic fractures in older men and women.

UNLABELLED: Non-traumatic fractures at typical osteoporotic sites are associated with increased mortality across all age groups, particularly in men. Furthermore, in certain age subgroups of women and men, this rate remained elevated beyond 5 years for fractures of the hip, vertebrae, humerus, and other sites. INTRODUCTION: Increased mortality rates have been documented following non-traumatic hip, vertebral, and shoulder fractures. However, data are lacking as to the duration of excess mortality and whether there is increased mortality following fractures at other sites. We determined mortality up to 15 years following incident fractures at typical osteoporotic sites. METHODS: Using healthcare databases for the Province of Manitoba, Canada, we identified individuals 50 years and older with an incident non-traumatic fracture between 1986 and 2007. Each fracture case was matched to three fracture-free controls. Generalized linear models were used to test for trends in mortality and to estimate the relative risk for cases after adjusting for co-morbidity and living arrangements. RESULTS: During the study period, we identified 21,067 incident fractures in men followed by 10,724 (50.1%) deaths and 49,197 incident fractures in women followed by 22,018 deaths (44.8%). Seventy-six percent of the fractures were at sites other than the hip and vertebrae. After adjustment for age, number of co-morbidities, and level of dependence in living arrangements, the risk of death in cases, relative to controls, was increased in both sexes for hip, vertebral, humerus, wrist (in men only), and other fracture sites. Post-fracture mortality was higher in men than women. Relative mortality was the highest in the younger age groups across the spectrum of fracture sites. CONCLUSIONS: Fractures at typical osteoporotic sites are associated with increased mortality across all age groups, particularly in men. Better understanding of factors associated with increased post-fracture mortality should inform the development of management strategies.

Locked intramedullary nailing of symptomatic metastases in the humerus.

The humerus is a common site for skeletal metastases in the adult. Surgical stabilisation of such lesions is often necessary to relieve pain and restore function. These procedures are essentially palliative and should therefore provide effective relief from pain for the remainder of the patient's life without the need for further surgical intervention. We report a retrospective analysis of 35 patients (37 nails) with symptomatic metastases in the shaft of the humerus which were treated by locked, antegrade nailing. There were 27 true fractures (73.0%) and ten painful deposits (27.0%). Relief from pain was excellent in four (11.4%), good in 29 (82.9%) and fair in two (5.7%) on discharge. Function was improved in all but one patient. One case of palsy of the radial nerve was noted. The mean postoperative survival was 7.1 months (0.2 to 45.5) which emphasises the poor prognosis in this group of patients. There were no failures of fixation and no case in which further surgery was required. Antegrade intramedullary nailing is an effective means of stabilising the humerus for the palliative treatment of metastases. It relieves pain and restores function to the upper limb with low attendant morbidity.

[Surgical treatment of pathologic fractures of the humerus and femur]. / Operative Versorgung von pathologischen Humerus- und Femurfrakturen.

The life expectancy of patients with malignant tumours and the incidence of osseous metastases have increased over the last decades. Operations for skeletal metastases of the extremities represent the most frequent surgery in orthopaedic oncology. The purpose of this study was to evaluate and compare the different operative treatment options for patients with pathologic fractures of the humerus and femur in terms of complications, postoperative recovery, and survival.From 2000 to 2005, 109 patients were surgically treated for pathologic fractures of the humerus (n=19) or femur (n=90). The study group consisted of 60 women and 43 men, with a mean age of 67 years (13-88). Breast carcinoma (36%) was the most common primary tumour, followed by kidney (17%) and bronchial (16%) carcinoma. Of all patients, 75 (73%) had numerous skeletal metastases, and 38 (37%) had visceral metastases.Wide or marginal resection was performed in seven fractures of the humerus and 14 fractures of the femur; intralesional resection was done in seven humeral and 73 femoral fractures; and stabilisation alone was done in five fractures of the humerus and three fractures of the femur. The median survival time for all patients was 6 months (0-102). The survival rate at 1 year was 25% (25% for both humeral and femoral fractures), 15% at 2 years (17% for humeral and 15% for femoral fractures), and 8% at 3 years (16% for humeral and 7% for femoral fractures). The overall complication rate was 11%, and revision surgeries were performed in seven patients (6.4%). The majority of patients (n=65; 60%), especially those with fractures close to the articular joint, were successfully treated with endoprosthetic replacement. Patients with fractures stabilised by intramedullary nails had shorter operating times, a shorter hospital stay, and fewer complications than patients treated with plating systems. Therefore, we recommend intralesional resection of the metastasis and stabilisation with intramedullary devices, supported by bone cement, as the treatment of choice for pathologic fractures of the diaphysis and metaphysis of the humerus and femur. Wide resection should be reserved for selected cases, such as solitary bone metastasis of kidney carcinoma.

A mathematical program to predict survival and to support initial therapeutic decisions for trauma patients with long-bone and pelvic fractures.

AIM: To test a mathematical program to monitor early haemodynamic patterns of patients with fractures, predict survival and support initial therapeutic decisions. METHODS: A mathematical search and display program based on non-invasive haemodynamic monitoring was used to study 430 consecutively monitored patients with fractures during the first 48 h after admission to the emergency department of an inner city public hospital. We studied four types of fractures: simple extremity fractures, long-bone fractures, pelvic fractures and fractures incidental to severe trauma. The program continuously displayed haemodynamic patterns and predicted survival probability (SP), which was evaluated by the actual outcome at hospital discharge. The program also assessed the effectiveness of therapies according to haemodynamic responses. RESULTS: The cardiac index, heart rate, mean arterial pressure, arterial saturation and transcutaneous oxygen tensions at the initial resuscitation were significantly higher in survivors than in non-survivors. After the first 48 h, the haemodynamic patterns were more influenced by fever, sepsis, complications and organ failures. The calculated survival probability averaged 81%+/-18% in the first 48 h for survivors and 72%+/-20% for non-survivors. CONCLUSION: Early continuous non-invasive haemodynamic monitoring using the proposed information system is helpful in predicting outcome and guiding therapy for patients with fractures.

[Osteosynthesis of combined radius head and capitulum humeri fractures with mini-implants]. / Osteosynthese kombinierter Radiusköpfchen- und Capitulum humeri Frakturen mit Miniimplantaten.

INTRODUCTION: Combined injuries of the capitellum humeri and the radial head are rare. Most of them show combined osteocartilaginous lesions and collateral ligament lesions. Recommendations for treatment of these fatal injuries of the elbow are missing. TYPE OF STUDY: Five cases were investigated in an retrospective analysis. The same approach was used for the osteocartilaginous lesion of the capitellum as well as the injury of the radial head. Internal fixation was done with mini-titanimplants, three of them combined with resorbable pins. PATIENTS AND METHODS: Between 1996-1999 five patients (four men, one woman) with combined injury of the radial head and the capitellum were stabilized. The average age was 34 years (31-40 years). All fractures were stabilized by a direct radial approach with 1.5 mm or 2.0 mm lag screws partly with resorbable pins. All patients were evaluated radiologically and clinically according to the Mayo-elbow-performance score. RESULTS: All patients were personally examined after an average period of 12.8 month (8-24 month) by an independent investigator. 4/5 patients were assessed for their satisfaction. No radiological signs of avascular necrosis of the capitellum or arthrosis were found. Three patients showed periarticular calcifications. The range of motion was averagely 124 degrees (extension 5-30 degrees, flexion 110-145 degrees), in three of five cases a secondary intervention for improvement of joint mobility was necessary. The Mayo-elbow-performance score rated for 85 points in average (range 70-100 points). CONCLUSION: Direct screw fixation with mini-implants, eventually combined with resorbable pins allows to use the same approach for anatomic reconstruction and fixation of the capitellum humeri and radial head. Transarticular fragment fixation of the capitellum allows for safe compression. Therefore early functional rehabilitation is possible postoperatively. Secondary interventions for improve joint motion were necessary in three of five cases.