Hendrik Frølich Stange Fuglesang

This is a semidouble-blind randomized controlled trial comparing the clinical and radiographic outcomes of fixation of displaced 3- and 4-part proximal humerus fractures with an intramedullary nail versus a locking plate. Seventy-nine patients aged 45 to 81 years (mean 66.5 years) were randomized to open reduction and osteosynthesis with either locking nails or plates. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score at 2 years after surgery. The secondary outcomes were the Constant score (CS), Oxford shoulder score (OSS), visual analog scale for pain at rest and during activity, and complication and reoperation rates. The patients were assessed at 6 weeks, 12 weeks, 6 months, 1 year, and 2 years after inclusion. Physiotherapists who were blinded to the choice of implant performed assessments at 6 months and 2 years. Patients were also blinded to the choice of implant. Three patients were lost to follow-up, leaving data from 38 patients in each group available for analysis. There were no statistically significant differences in the DASH score, CS, OSS, or pain score at any time. The DASH score at 2 years was 12.7 (95% confidence interval [CI] 8.8-17.0) for the nail group and 10.0 (95% CI 5.6-16.1) for the plate group (p = 0.48). Twelve (32%) patients underwent reoperation in the nail group, whereas 2 (5%) patients underwent reoperation in the plate group (p = 0.006). Fourteen (37%) patients in the nail group and 4 (11%) patients in the plate group experienced complications (p = 0.05). There were no statistically significant differences in patient-reported outcomes or function 2 years after surgery for fixation of displaced 3- and 4-part part proximal humerus fractures with nails or plates. However, there were more complications and reoperations in the nail group. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: This is a semidouble-blind randomized controlled trial comparing the clinical and radiographic outcomes of fixation of displaced 3- and 4-part proximal humerus fractures with an intramedullary nail versus a locking plate. Methods: Seventy-nine patients aged 45 to 81 years (mean 66.5 years) were randomized to open reduction and osteosynthesis with either locking nails or plates. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score at 2 years after surgery. The secondary outcomes were the Constant score (CS), Oxford shoulder score (OSS), visual analog scale for pain at rest and during activity, and complication and reoperation rates. The patients were assessed at 6 weeks, 12 weeks, 6 months, 1 year, and 2 years after inclusion. Physiotherapists who were blinded to the choice of implant performed assessments at 6 months and 2 years. Patients were also blinded to the choice of implant. Results: Three patients were lost to follow-up, leaving data from 38 patients in each group available for analysis. There were no statistically significant differences in the DASH score, CS, OSS, or pain score at any time. The DASH score at 2 years was 12.7 (95% confidence interval [CI] 8.8-17.0) for the nail group and 10.0 (95% CI 5.6-16.1) for the plate group (p = 0.48). Twelve (32%) patients underwent reoperation in the nail group, whereas 2 (5%) patients underwent reoperation in the plate group (p = 0.006). Fourteen (37%) patients in the nail group and 4 (11%) patients in the plate group experienced complications (p = 0.05). Conclusions: There were no statistically significant differences in patient-reported outcomes or function 2 years after surgery for fixation of displaced 3- and 4-part part proximal humerus fractures with nails or plates. However, there were more complications and reoperations in the nail group. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: The purpose of the present study was to estimate the cost-effectiveness of treating displaced, intra-articular distal radial fractures with volar locking plate fixation compared with augmented external fixation. Methods: A cost-utility analysis was conducted alongside a randomized, clinical trial comparing 2 surgical interventions for intra-articular distal radial fractures. One hundred and sixty-six patients were allocated to either volar locking plate fixation (84 patients) or external fixation (82 patients) and were followed for 2 years. Health-related quality of life was assessed with the EuroQol-5 Dimensions and was used to calculate patients’ quality-adjusted life-years (QALYs). Resource use was identified prospectively at the patient level at all follow-up intervals. Costs were estimated with use of both a health-care perspective and a societal perspective. Results were expressed in incremental cost-effectiveness ratios, and uncertainty was assessed with use of bootstrapping methods. Results: The average QALY value was equivalent between the groups (1.70463 for the volar locking plate group and 1.70726 for the external fixation group, yielding a nonsignificant difference of −0.00263 QALY). Health-care costs were equal between the groups, with a nonsignificant difference of €52 (p = 0.8) in favor of external fixation. However, the external fixation group had a higher loss of productivity due to absence from work (5.5 weeks in the volar locking plate group compared with 9.2 weeks for the external fixation group; p = 0.02). Consequently, the societal costs were higher for the external fixation group compared with the volar locking plate group (€18,037 compared with €12,567, representing a difference of €5,470; p = 0.04) in favor of the volar locking plate group. Uncertainty analyses showed that there is indifference regarding which method to recommend from a health-care perspective, with volar locking plate treatment and external fixation having a 47% and 53% likelihood of being cost-effective, respectively. From the societal perspective, volar locking plate treatment had a 90% likelihood of being cost-effective. Conclusions: External fixation was less cost-effective than volar locking plate treatment for distal radial fractures from a societal perspective, primarily because patients managed with external fixation had a longer absence from work. Level of Evidence: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Surgical management of completely displaced midshaft fractures of the clavicle is becoming more frequent, although long-term follow-up with Level-I evidence is scarce. Plate fixation (PF) of comminuted fractures provides faster functional recovery than elastic stable intramedullary nailing (ESIN). The 12-month follow-up of this randomized controlled trial, published previously, found no clinical differences at that time on the group level, but subtle differences on the subgroup level indicated that the results after closed ESIN were better than those after open ESIN. The primary aim of the study reported here was to compare the long-term clinical outcomes and sequelae after open reduction with those after closed reduction and to help surgeons develop a treatment strategy of either PF or ESIN for selected patients. Methods: At a median follow-up of 66 months (range, 49 to 89 months), the 123 patients in the original study were invited to an online secure survey. We used the survey results to compare the PF and ESIN treatment arms and to perform predetermined subgroup analyses of closed compared with open ESIN in relation to Disabilities of the Arm, Shoulder and Hand (DASH) score, pain assessment, and implant removal. Results: The questionnaire was completed by 114 (93%) of the 123 patients. There were no differences between the 2 treatment arms with regard to the DASH score (ESIN, 3.1 ± 7.0 and PF, 3.7 ± 7.5; p = 0.9). The 27 patients who had been treated with closed ESIN had a significantly superior DASH score compared with the 27 patients who had been treated with open ESIN (closed, 0.7 ± 1.4 and open, 5.2 ± 8.9; p = 0.015) and compared with the patients who had been treated with PF (closed ESIN, 0.7 ± 1.4 and PF, 3.9 ± 7.5; p = 0.002). Patients who had been treated with closed ESIN also reported fewer sequelae than patients who had been treated with open ESIN or PF. Conclusions: The results of this study, combined with those of our prior 1-year follow-up of the same patients, indicate that it seems to be advantageous to perform closed ESIN. The long-term results after PF were similar to those after open ESIN, but PF resulted in faster functional recovery and fewer patients needing to have the implant removed. Therefore, if open reduction is necessary for a comminuted fracture, it seems that the advantages of the minimally invasive ESIN procedure are lost, and the surgeon should consider conversion to PF. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Fixation of proximal humeral fractures (PHF) with locking plates has gained popularity over conservative treatment, but surgery may be complicated with infection, non-union, avascular necrosis (AVN) of the humeral head and fixation failure. Failure to achieve structural support of the medial column has been suggested to be an important risk factor for fixation failure. The aims of this study were to examine the effect of calcar screws and fracture reduction on the risk of fixation failure and to assess long-term shoulder pain and function. This was a single-centre retrospective study of 190 adult PHF patients treated with a locking plate between 2011 and 2014. Reoperations due to fixation failure were the primary outcome. Risk factors for fixation failure were assessed using the Cox regression analysis. Postoperative shoulder pain and function were assessed by the Oxford Shoulder Score (OSS). Thirty-one of 190 (16%) patients underwent a reoperation: 14 (7%) due to fixation failure, 10 (5%) due to deep infection and 2 (1%) due to AVN. The absence of calcar screws and fixation with residual varus malalignment (head-shaft angle < 120°) both increased the risk of fixation failure with an adjusted hazard ratio (95% CI) of 8.6 (1.9–39.3; p = 0.005) and 4.9 (1.3–17.9; p = 0.02), respectively. The median (interquartile range) OSS was 40 (27–46). The use of calcar screws, as well as the absence of postoperative varus malalignment, significantly reduced the risk of fixation failure. We, therefore, recommend the use of calcar screws and to avoid residual varus malalignment to improve the medial support of proximal humeral fractures treated with a locking plate.

Background: The treatment of completely displaced midshaft clavicle fractures is still controversial, but surgical treatment provides a shorter recovery period and higher union rates than nonoperative treatment with a sling ^1–5 . Even though the literature does not clearly support surgery for these fractures, surgery is becoming more frequent ⁶ . Elastic stable intramedullary nailing (ESIN) with a titanium nail is a well-documented mini-invasive procedure with functional outcomes comparable with those of plate fixation after 1 year but a high rate of implant removal of up to 80% ^6–8 . The ideal injury for ESIN is a fracture without comminution that is available for surgery within a couple of days. ESIN is also a good option for fractures with comminution, but a somewhat slower functional recovery during the first 6 months should be expected. Description: The patient is placed in beach-chair position with the fluoroscope placed on the injured side or cranially in relation to the fracture. The surgeon pushes the skin gently with his/her index finger at the jugular fossa before incising it. This places the skin incision inferior to the implant. A 1 to 2-cm incision down to the bone is then placed about 1 to 2 cm lateral to the sternoclavicular joint. A unicortical entry hole is made at the medial end with a 2.5-mm drill bit and then widened and directed laterally with an awl. Two reduction forceps are placed percutaneously and used by the assistant to align the main fragments. The nail is passed with oscillating movements until it is secured into the lateral fragment. If it is not possible to obtain a closed reduction, an open reduction is performed. The nail is cut short down to the bone, and the myocutaneous layer and skin are closed with sutures. Five to 10 mL of bupivacaine is injected into the fracture area for postoperative pain management. The arm is placed in a simple sling for comfort. A non-weight-bearing active range of motion of 8 .

Objectives It is unclear whether all completely displaced midshaft clavicle fractures require primary surgical intervention. The aim of this study was to elucidate the radiological and clinical outcomes after conservative treatment, and to identify subgroups at risk of an inferior outcome. Design Retrospective case series. Setting Level II trauma center. Patients Between 2005 and 2008, 122 patients were conservatively treated for a completely displaced midshaft clavicle fracture of whom 92 were eligible for inclusion in this study. Of these, 59 completed the study after a median of 2.7 years after the fracture (min–max, 1.1–4.9). Intervention The patients received the standard treatment administered at our institution at the time: nonsurgically with a sling without physiotherapy. Patients with painful nonunions were subsequently offered surgery. Main outcome measurements At follow-up, the patients’ Disabilities of Arm, Shoulder, and Hand (DASH) and the Constant scores were evaluated. Radiographs were taken at follow-up and compared to those taken acutely. Results Nonunion was found in 9 of the 59 (15.3 %) patients. Twenty-four (24 %) patients reported a fair-to-poor DASH score (i.e. >20). Patients with fractures that were vertically displaced by more than 100 % (one bone width) were significantly less satisfied than those with fractures vertically displaced at 100 % (p = 0.04). Initial shortening of more than 15 mm was not associated with a worse outcome or nonunion. The odds ratio of developing a nonunion increased with age (p = 0.04). Conclusions By treating completely displaced midshaft clavicle fractures conservatively with a sling and offering plate fixation for eventual painful nonunions, we found a 24 % risk of a fair or poor clinical result with a DASH score over 20. A vertical displacement of more than 100 % between the main fragments on the initial radiograph was associated with an inferior clinical outcome in this study. Level of evidence IV.