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Background: About 20% of proximal humerus fractures (PHFs) are unstable and/or markedly displaced and therefore require surgery. Locking plate fixation after anatomical reduction has become the current treatment of choice for these fractures in the active population. However, studies have shown complication rates up to 36%, such as loss of reduction and avascular necrosis. To date, data from literature are inconclusive on outcomes following the use of an intramedullary fibula allograft in PHFs, possibly due to the case mix. It is hypothesized that the use of a fibula allograft is beneficial to prevent secondary displacement of the fracture in cases where the medial hinge is markedly displaced and unstable, resulting in better clinical and patient reported outcomes. Methods: In this multicenter matched cohort study, patients with an unstable, displaced PHF, including anatomic neck fractures and significantly displaced surgical neck fractures, were included. Patients that were treated with a locking plate augmented with a fibula allograft were matched to patients who had undergone locking plate reconstruction without the allograft. The matches were made based on fracture characteristics, age, and performance status. Functional outcomes, Patient Reported Outcome Measures, complications, and radiographic results were compared. Results: Twelve patients with fibula allograft augmented osteosyntheses were included and matched to 12 control patients. The mean age was 58 years in the fibula allograft group compared to 62 years in the control group. Minimum follow-up was 12 months. Disability of the Arm Shoulder and Hand score, Constant Shoulder score, abduction, and external rotation were significantly better in the fibula allograft group (17.4 ± 8.6 vs. 26.1 ± 19.2, P = .048; 16.5 ± 11.5 vs. 19.8 ± 16.5 P = .040; mean 127° ± 38° vs. mean 92° ± 49° P = -.045; 50° ± 21° vs. mean 26° ± 23°, P = .004). There was no statistically significant difference in the Oxford Shoulder score between groups (P = .105). The Visual Analog Scale was not significantly different between groups (3.1 ± 1.8 vs. 1.6 ± 1.9, P = .439). Radiographic union was reached in 11 patients of the fibula allograft group compared to 8 in the control group (P = .317). The complication rate was twice as high in the control group (3 vs. 7). Conclusion: Additional support of the medial hinge in unstable PHFs with a locking plate in combination with a fibula allograft appears to create a more stable construct without compromising the viability of the articular surface of the head. The use of a fibula allograft in selected complex cases could therefore result in better clinical outcomes with lower complication rates.
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BACKGROUND: Fifth metatarsal fractures are one of the most common foot fractures, and 11% to 25% of such fractures are Dancer's fractures (distal spiral fractures). Conservative therapy while wearing a cast and operative treatment have been used as preferred modes of treatment in the limited literature available. However, we often see healing problems, such as delayed union and nonunion, when Dancer's fractures are treated nonoperatively, resulting in a need for secondary intervention. In our institution, treatment has changed over the years from predominantly conservative treatment to mostly operative treatment. To investigate whether our hypothesis holds true that primary surgical treatment is beneficial, a retrospective study was designed. OBJECTIVE: The objective of the study is to compare differences between outcomes (delayed union and nonunion) of conservative and operative treatments for Dancer's fractures. METHODS: A retrospective comparative cohort study will be conducted in a level II trauma center (Zaandam Medical Center). Patients who experienced a Dancer's fracture in the period of 2012 to 2021 will be included and divided into 2 cohorts-the conservative (2012-2015) and operative (2016-2021) treatment cohorts. The primary outcome will be the differences in percentages of delayed union and nonunion between the two groups. The secondary outcomes will be the percentage of primary conservative treatment failure, the need for secondary operative treatment, complications (infection and hardware failure), and functional outcomes. If 118 patients are included in each group, sufficient power is expected to be reached, depending on the age distribution of patients. The percentages of delayed union and nonunion among the two groups will be calculated and statistically compared via chi-square statistics. A logistic regression analysis will be used to investigate possible associations between patient characteristics and failed conservative treatment. A Mann-Whitney U test will be used to compare functional outcomes between groups. An independent, 2-tailed t test will be used to compare mean 12-Item Short Form Survey scores if they are normally distributed, and a Wilcoxon rank sum test will be used if they are nonnormally distributed. RESULTS: In total, 2134 potentially relevant health insurance codes have been extracted from the hospital's register. We expect to find a total of 236 Dancer's fractures in this data set. CONCLUSIONS: Our study has limitations due to it being a single-center study and data collection being performed retrospectively. However, it covers a large time period and may provide the possibility to show treatment outcome differences (delayed union and nonunion, complications, and functional outcomes) in 2 reasonably large cohorts (conservative and operative treatment cohorts), which has not been done before in literature on Dancer's fractures. If our hypothesis that surgery is beneficial for Dancer's fractures is proven true by our study, we plan to further corroborate it by conducting a prospective randomized controlled trial. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/37171.
RESUMEN
More than a century ago, the first scientific report was published about fracture fixation with plates. During the 1950's, open reduction and plate fixation for fractures were standardized by the founders of Arbeitsgemeinschaft für osteosynthesefragen/Association for the Study of Internal Fixation. Since the introduction of plate fixation for fractures, several plates and screws have been developed, all with their own characteristics. To accomplice more fracture stability, it was thought the bigger the plate, the better. The counter side was a compromised blood supply of the bone, often resulting in bone necrosis and ultimately delayed or non-union. With the search and development of new materials and techniques for fracture fixation, less invasive procedures have become increasingly popular. This resulted in the minimally invasive plate osteosynthesis (MIPO) technique for fracture fixation. With the MIPO technique, procedures could be performed with smaller incisions and thus with less soft tissue damage and a better preserved blood supply. The last 5 years rib fixation has become increasingly popular, rising evidence has become available suggesting that surgical rib fixation improves outcome of patients with a flail chest or isolated rib fractures. Many surgical approaches for rib fixation have been described in the old literature, however, most of these techniques are obscure nowadays. Currently mostly large incisions with considerable surgical insult are used to stabilize rib fractures. We think that MIPO deserves a place in the surgical treatment of rib fractures. We present the aspects of diagnosis, preoperative planning and operative techniques in regard to MIPO rib fixation.
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BACKGROUND: Chronic obstructive pulmonary disease (COPD) is characterised by airflow limitation, and has many components including mucus hypersecretion, oxidative stress, and airway inflammation. We aimed to assess whether carbocisteine, a mucolytic agent with anti-inflammatory and antioxidation activities, could reduce the yearly exacerbation rate in patients with COPD. METHODS: We did a randomised, double-blind, placebo-controlled study of 709 patients from 22 centres in China. Participants were eligible if they were diagnosed as having COPD with a postbronchodilator forced expiratory volume in 1 s (FEV(1)) to forced vital capacity (FVC) ratio (FEV(1)/FVC) of less than 0.7 and an FEV(1) between 25% and 79% of the predicted value, were aged between 40 and 80 years, had a history of at least two COPD exacerbations within the previous 2 years, and had remained clinically stable for over 4 weeks before the study. Patients were randomly assigned to receive 1500 mg carbocisteine or placebo per day for a year. The primary endpoint was exacerbation rate over 1 year, and analysis was by intention to treat. This trial is registered with the Japan Clinical Trials Registry (http://umin.ac.jp/ctr/index/htm) number UMIN-CRT C000000233. FINDINGS: 354 patients were assigned to the carbocisteine group and 355 to the placebo group. Numbers of exacerbations per patient per year declined significantly in the carbocisteine group compared with the placebo group (1.01 [SE 0.06] vs 1.35 [SE 0.06]), risk ratio 0.75 (95% CI 0.62-0.92, p=0.004). Non-significant interactions were found between the preventive effects and COPD severity, smoking, as well as concomitant use of inhaled corticosteroids. Carbocisteine was well tolerated. INTERPRETATION: Mucolytics, such as carbocisteine, should be recognised as a worthwhile treatment for prevention of exacerbations in Chinese patients with COPD.