Complications of Locked Plating for Proximal Humeral Fractures in Active Patients in a Level One Trauma Center.

Background: The incidence of complications associated with locked plating of proximal humerus fractures (PHF) has been reported in up to 40% of surgeries. This study aimed to analyze the incidence and risk factors of complications and re-intervention associated with locked plating of PHF in a an young active working population. Methods: This retrospective cohort study included patients indicated for locked plating of displaced PHF at a dedicated workers' accident trauma center. The variables analyzed were patient comorbidities, fracture characteristics, and immediate radiologic surgical outcomes. Postoperative complications and risk factors were determined. Results: A total of 127 patients with a median follow-up of 31 months and a median age of 52 years were included. The complication and reintervention rates were 13.4% and 12.6%, respectively. The main cause of reintervention was post-traumatic stiffness. The incidence of other complications was 4% screw protrusion, 1.6% avascular necrosis, 1.6% varus collapse. Complications were not associated with age, comorbidity, fracture classification, bone mineral density, Hertel's risk factors, presence of calcar comminution, reduction quality, and calcar screw position. Discussion: The incidence of complications and reintervention was low. The main cause of reintervention was persistent stiffness, and no risk factors for complications were found in this study.

Three-dimensional printing models increase inter-rater agreement for classification and treatment of proximal humerus fractures.

BACKGROUND: Proximal humerus fractures (PHF) are frequent, however, several studies show low inter-rater agreement in the diagnosis and treatment of these injuries. Differences are usually related to the experience of the evaluators and/or the diagnostic methods used. This study was designed to investigate the hypothesis that shoulder surgeons and diagnostic imaging specialists using 3D printing models and shoulder CT scans in assessing proximal humerus fractures. METHODS: We obtained 75 tomographic exams of PHF to print three-dimensional models. After, two shoulder surgeons and two specialists in musculoskeletal imaging diagnostics analyzed CT scans and 3D models according to the Neer and AO/OTA group classification and suggested a treatment recommendation for each fracture based on the two diagnostic methods. RESULTS: The classification agreement for PHF using 3D printing models among the 4 specialists was moderate (global k = 0.470 and 0.544, respectively for AO/OTA and Neer classification) and higher than the CT classification agreement (global k = 0.436 and 0.464, respectively for AO/OTA and Neer). The inter-rater agreement between the two shoulder surgeons were substantial. For the AO/OTA classification, the inter-rater agreement using 3D printing models was higher (k = 0.700) than observed for CT (k = 0.631). For Neer classification,  inter-rater agreement with 3D models was similarly higher (k = 0.784) than CT images (k = 0.620). On the other hand, the inter-rater agreement between the two specialists in diagnostic imaging was moderate. In the AO/OTA classification, the agreement using CT was higher (k = 0.532) than using 3D printing models (k = 0.443), while for Neer classification, the agreement was similar for both 3D models (k = 0.478) and CT images (k = 0.421). Finally, the inter-rater agreement in the treatment of PHF by the 2 surgeons was higher for both classifications using 3D printing models (AO/OTA-k = 0.818 for 3D models and k = 0.537 for CT images). For Neer classification, we saw k = 0.727 for 3D printing models and k = 0.651 for CT images. CONCLUSION: The insights from this diagnostic pilot study imply that for shoulder surgeons, 3D printing models improved the diagnostic agreement, especially the treatment indication for PHF compared to CT for both AO/OTA and Neer classifications On the other hand, for specialists in diagnostic imaging, the use of 3D printing models was similar to CT scans for diagnostic agreement using both classifications. TRIAL REGISTRATION: Brazil Platform under no. CAAE 12273519.7.0000.5505.

Three-dimensional models increase the interobserver agreement for the treatment of proximal humerus fractures.

BACKGROUND: The agreement for the treatment of proximal humerus fractures is low. Interpretation of exams used for diagnosis can be directly associated with this limitation. This study proposes to compare the agreement between experts and residents in orthopedics for treatment indication of proximal humerus fractures, utilizing 3D-models, holography (augmented reality), x-rays, and tomography as diagnostic methods. METHODS: Twenty orthopedists (ten experts in shoulder and elbow surgery and ten experts in traumatology) and thirty resident physicians in orthopedics evaluated nine fractures of the proximal humerus, randomly distributed as x-rays, tomography, 3D-models and holography, using the Neer and AO / OTA Classifications. After, we evaluated the interobserver agreement between treatment options (conservative, osteosynthesis and arthroplasty) and whether the experience of the evaluators interfered with the results. RESULTS: The interobserver agreement analysis showed the following kappa-values: κ = 0.362 and κ = 0.306 for experts and residents (3D-models); κ = 0.240 and κ = 0.221 (X-ray); κ = 0.233 and κ = 0.123 (Tomography) and κ = 0.321 and κ = 0.160 (Holography), for experts and residents respectively. Moreover, residents and specialists were discordant in the treatment indication using Tomography as a diagnostic method (p = 0.003). The same was not seen for the other diagnostic methods (p > 0.05). CONCLUSIONS: Three-dimensional models showed, overall, the highest interobserver agreement (experts versus residents in orthopedics) for the choice of treatment of proximal humerus fractures compared to X-ray, Tomography, and Holography. Agreement in the choice of treatment among experts that used Tomography and Holography as diagnostic methods were two times higher compared to residents. TRIAL REGISTRATION: Registered in Brazil Platform under no. CAAE 12273519.7.0000.5505.

Clasificación de Neer. Variabilidad interobservador / Interobserver Variability Of Neer Classification

Introducción Hacer objetiva la variabilidad interobservador al evaluar una fractura de húmero proximal utilizando la clasificación de Neer y establecer su utilidad diagnóstica y terapéutica. Materiales y Métodos Formulario digital con 20 casos elegidos al azar de fracturas de húmero proximal, de un mismo hospital entre 2010 y 2014. Cada caso incluyó: edad, sexo, lateralidad y dos proyecciones radiográficas. Evaluado de forma anónima por Traumatólogos, con y sin práctica habitual en cirugía del hombro, de hospitales nacionales e internacionales, indicando estadío de Neer y opción terapéutica adecuada. Se estableció la variabilidad interobservador entre grupos y comparando a todos por igual, calculando el índice de Kappa de Fleiss e interpretándolo según los criterios de Landis y Koch. Resultados 40 respuestas de Traumatólogos, 15 con práctica habitual de cirugía de hombro y 25 no. El índice Kappa de Fleiss medio fue 0,173 en el grupo de Traumatólogos con práctica habitual en cirugía de hombro. Siendo 0,176 en el grupo sin práctica habitual. Al evaluarlos conjuntamente, 0,184. Existe gran variabilidad interobservador en la indicación terapéutica y dentro de la indicación quirúrgica. Discusión El grado de acuerdo obtenido, según los criterios de Landis y Koch, ha sido pobre en todos los grupos en lo que a estadío se refiere y débil en lo referente al tratamiento, no influyendo la experiencia del Traumatólogo. Sería necesaria una clasificación más reproducible ya que la clasificación de Neer presenta la suficiente variabilidad interobservador como para aceptarla como único medio en la toma de decisiones.

Background To study inter-observer variability by evaluating a fracture of the proximal humerus using Neer's classification and to establish its diagnostic and therapeutic utility. Methods A computerised form was used with 20 randomly selected cases of fractures of the proximal humerus, from the same hospital between 2010 and 2014. Each case included: age, gender, laterality, and two radiographic projections. They were anonymously evaluated by Traumatologists, for whom shoulder surgery was routine practice or not, from national and international hospitals. They indicated Neer stage and an appropriate therapeutic option. Interobserver variability was established between groups, and comparing all of them equally, calculating Fleap's Kappa index and interpreting it according to the Landis and Koch criteria. Results A total of 40 responses were obtained from the Traumatologists, 15 of them were shoulder surgery was usual practice and 25 where it was not. The mean Fleap Kappa index was 0.173 in the Traumatologists group were shoulder surgery was usual practice, being 0.176 in the group were it was not usual practice. The overall index was 0.184. There is wide interobserver variability in the therapeutic indication, as well as within the surgical indication. Discussion The level of agreement obtained, according to the criteria of Landis and Koch, was poor in all groups in terms of stage, and weak in terms of treatment. The experience of the Traumatologist had no influence. A more reproducible classification may be necessary since Neer's classification has sufficient interobserver variability to accept it as the sole means of decision making.

Estudio comparativo entre clavo endomedular y tratamiento conservador en fracturas de húmero proximal de 2 y 3 fragmentos / Comparative study between intramedullary nailing and conservative treatment in proximal humerus fractures of 2 and 3 fragments

Introducción Hacer objetivas las diferencias relativas a funcionalidad y calidad de vida entre pacientes con fracturas de húmero proximal de 2 y 3 fragmentos tratados de forma conservadora y mediante enclavado endomedular. Materiales y Métodos Estudio descriptivo-retrospectivo realizado en un mismo centro hospitalario entre junio de 2010 y mayo de 2014. Se incluyeron pacientes con fractura de húmero proximal de 2 y 3 fragmentos, excluyendo los menores de 60 años. Se evaluó la movilidad, test de Constant y ASES. El análisis estadístico se realizó con el programa SPSS. Resultados 71 pacientes seleccionados; 43 presentaban fractura de 2 fragmentos y 28 de 3. Mediante enclavado endomedular fueron tratados 15, con una media de edad de 76,7 años, y 38 recibieron tratamiento conservador, con una edad media de 79,8 años; en ambos grupos el número de mujeres fue mayor. Las puntuaciones de los cuestionarios Constant y ASES fueron superiores en el grupo que recibió tratamiento conservador, al igual que su grado de satisfacción y mejor movilidad y funcionalidad. Discusión En las fracturas de 2 y 3 fragmentos el tratamiento conservador es utilizado en gran parte de los casos. La edad no es un factor influyente a la hora de decantarse por una u otra opción terapéutica. La mayoría de los pacientes están satisfechos con el tratamiento recibido. En los test de Constant y ASES obtienen mejor resultado los pacientes tratados de forma conservadora. La abducción y la flexión son ligeramente superiores en pacientes que recibieron tratamiento conservador.

Background To study the differences related to functionality and quality of life between patients with proximal humerus fractures of 2 and 3 fragments treated conservatively and by using intramedullary nailing. Material and Methods Descriptive-retrospective study was conducted in the same hospital between June 2010 and May 2014. Patients with proximal humerus fractures of 2 and 3 fragments were included. Patients under 60 years were excluded. Mobility was evaluated, using the Constant and ASES (American Shoulder and Elbow Surgeons) test. Statistical analysis was performed using the SPSS program. Results Of the 71 selected patients, 43 had a 2 fragments fracture, and 28 had a 3 fragment fracture Intramedullary nailing was used to treat 15 cases (with a mean age of 76.7 years), and 38 (mean age 79.8 years) received conservative treatment. The number of women was higher in both groups. The scores of the Constant and ASES questionnaires were higher in the group that received conservative treatment. They also had a higher level of satisfaction and better mobility and functionality. Discussion In fractures of 2 and 3 fragments conservative treatment is used in a large majority of the cases. Age is not an influential factor when opting for one or another therapeutic option. Most patients are satisfied with the treatment received. Patients treated conservatively obtain better results in the Constant and ASES tests. Abduction and flexion are slightly higher in patients that received conservative treatment.