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Introduction: Fracture reduction and fixation of distal femur fractures are technically demanding. Postoperative malalignment is still commonly reported after minimally invasive plate osteosynthesis (MIPO). We evaluated the postoperative alignment after MIPO using a traction table with a dedicated femoral support. Methods: The study included 32 patients aged 65 years or older with distal femur fractures of all AO/OTA types 32 (c) and 33 (except 33 B3 and C3) and peri-implant fractures with stable implants. Internal fixation was achieved with MIPO using a bridge-plating construct. Bilateral computed tomography (CT) scans of the entire femur were performed postoperatively, and measurements of the uninjured contralateral side defined anatomical alignment. Due to incomplete CT scans or excessively distorted femoral anatomy, seven patients were excluded from analyses. Results: Fracture reduction and fixation on the traction table provided excellent postoperative alignment. Only one of the 25 patients had a rotational malalignment of more than 15° (18°). Conclusions: The surgical setup for MIPO of distal femur fractures on a traction table with a dedicated femoral support facilitated reduction and fixation, resulting in a low rate of postoperative malalignment, despite a high rate of peri-implant fractures, and could be recommended for surgical treatment of distal femur fractures.

Background The outcome of non-surgical treatment is generally good, but the treatment course can be long and painful with approximately a quarter of the patients acquiring a nonunion. Both surgical and non-surgical treatment can have disabling consequences such as nerve injury, infection, and nonunion. The purpose of the study is to compare patient-reported outcomes after surgical and non-surgical treatment for humeral shaft fractures. Methods A pragmatic randomized controlled trial (RCT) is planned with two study groups (SHAFT-Young and SHAFT-Elderly). A total of 287 eligible acute humeral shaft fractures are scheduled to be recruited and randomly allocated to surgical or non-surgical treatment with the option of early crossover due to delayed union. The surgical method within the allocation is decided by the surgeon. The primary outcome is the Disability of Arm, Shoulder, and Hand (DASH) score at 52 weeks, and is assessor blinded. The secondary outcomes are DASH score, EQ-5D-5L, pain assessed by visual analog score, Constant-Murley score including elbow range of motion, and anchor questions collected at all timepoints throughout the trial. All complications will be reported including; infection, nerve or vascular injury, surgical revisions (implant malpositioning, hardware failure, aseptic loosening, and peri-implant fracture), major adverse cardiovascular events, and mortality. Discussion The SHAFT trial is a pragmatic multicenter RCT, that will compare the effectiveness of the main strategies in humeral shaft fracture treatment. This will include a variety of fracture morphologies, while taking the dilemmas within the population into account by splitting the population by age and providing the orthopedic society with an interval for early crossover surgery. Trial registration Clinicaltrials.govNCT04574336. Registered on 5 October 2020.

Background: The outcome of non-surgical treatment is generally good, but the treatment course can be long and painful with approximately a quarter of the patients acquiring a nonunion. Both surgical and non-surgical treatment can have disabling consequences such as nerve injury, infection and nonunion. The purpose of the study is to compare patient reported outcome after surgical and non-surgical treatment for humeral shaft fractures. Methods: A pragmatic randomized controlled trial is planned with two study groups (SHAFT-Y and SHAFT-E). A total of 287 eligible acute humeral shaft fractures are scheduled to be recruited and randomly allocated to surgical or non-surgical treatment with the option of early crossover due to delayed union. The surgical method within the allocation is decided by the surgeon. The primary outcome is the Disability of Arm, Shoulder and Hand (DASH) score at 52 weeks, and is assessor blinded. The secondary outcomes are DASH score, EQ-5D-5L, pain assessed by visual analogue score, Constant-Murley score including elbow range of motion and anchor-questions collected at all timepoints throughout the trial. All complications will be reported including; infection, nerve or vascular injury, surgical revisions (implant malpositioning, hardware failure, aseptic loosening and peri-implant fracture), major adverse cardiovascular events, and mortality. Patients declining randomization will be asked to enroll into an observational cohort with same outcomes and post-treatment regimes. Discussion: SHAFT will provide information on the effectiveness of two standard treatments for humeral shaft fractures, while taking the dilemmas within the population into account. Trial registration: Clinicaltrials.gov, NCT04574336. Registered on 5 October 2020.

Background Distal radial fractures (DRF) are one of the most common fractures with a small peak in incidence among young males and an increasing incidence with age among women. The reliable classification of fractures is important, as classification provides a framework for communicating effectively on clinical cases. Fracture classification is also a prerequisite for data collection in national quality registers and for clinical research. Since its inception in 2011, the Swedish Fracture Register (SFR) has collected data on more than 490,000 fractures. The attending physician classifies the fracture according to the AO/OTA classification upon registration in the SFR. Previous studies regarding the classification of distal radial fractures (DRF) have shown difficulties in inter- and intra-observer agreement. This study aims to assess the accuracy of the registration of DRF in adults in the SFR as it is carried out in clinical practice. Methods A reference group of three experienced orthopaedic trauma surgeons classified 128 DRFs, randomly retrieved from the SFR, at two classification sessions 6 weeks apart. The classification the reference group agreed on was regarded as the gold standard classification for each fracture. The accuracy of the classification in the SFR was defined as the agreement between the gold standard classification and the classification in the SFR. Inter- and intra-observer agreement was evaluated and the degree of agreement was calculated as Cohen’s kappa. Results The accuracy of the classification of DRF in the SFR was kappa = 0.41 (0.31–0.51) for the AO/OTA subgroup/group and kappa = 0.48 (0.36–0.61) for the AO/OTA type. This corresponds to moderate agreement. Inter-observer agreement ranged from kappa 0.22–0.48 for the AO/OTA subgroup/group and kappa 0.48–0.76 for the AO/OTA type. Intra-observer agreement ranged from kappa 0.52–0.70 for the AO/OTA subgroup/group and kappa 0.71–0.76 for the AO/OTA type. Conclusions The study shows moderate accuracy in the classification of DRF in the SFR. Although the degree of accuracy for DRF appears to be lower than for other fracture locations, the accuracy shown in the current study is similar to that in previous studies of DRF.

Purpose Register-based clinical research is important. However, it is essential that the collected data are reliable for the registers to be a valuable source of information. This study evaluated the quality of humeral fracture data in the Swedish Fracture Register (SFR) and in the Swedish National Patient Register (NPR). Furthermore, a model for improved case ascertainment was developed for future validation processes. Materials and Methods Data were obtained from the NPR and SFR for all individuals aged ≥16 years with an acute humeral fracture ICD-code treated at Sahlgrenska University Hospital. The true number of humeral fractures (“gold standard”) was determined by cross-linkage between the two registers and a medical charts review. The completeness of registrations in each register was measured as the proportion of registrations compared with the gold standard, and accuracy was measured as positive predictive values (PPV). Results The NPR demonstrated a high level of completeness (97%) and lower accuracy (PPV 70%) for acute humeral fractures, whereas the SFR had slightly lower completeness (88%) but perfect accuracy (PPV 100%). The most common systematic error was the registration of re-admissions as acute fractures in the NPR (84% of all erroneous registrations). With this knowledge, an adjustment model for NPR data was constructed to increase the accuracy of fracture registrations (PPV 92%) without excluding valid registrations. Conclusion Data from the NPR tend to overestimate the true number of fractures, and proper case selection is needed in order for the data to function as a solid basis for epidemiological research and healthcare planning. In contrast, the SFR constitutes a complete, accurate and efficient source of information., Video abstract Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/eh0mBFzrWBk

The most appropriate treatment for displaced multiple-fragment proximal humeral fractures in elderly patients is currently unclear. Reverse total shoulder arthroplasty (rTSA) is a promising treatment option that is being used increasingly. The purpose of this study was to compare the outcome of rTSA vs. hemiarthroplasty (HA) for the treatment of displaced 3- and 4-part fractures in elderly patients.This was a multicenter randomized controlled trial. We included patients aged ≥ 70 years with displaced 3- or 4-part proximal humeral fractures between September 2013 and May 2016. The minimum follow-up period was 2 years, with outcome measures including the Constant score (primary outcome), Western Ontario Osteoarthritis of the Shoulder index, EQ-5D (EuroQol 5 Dimensions) index, and range of motion, as well as pain and shoulder satisfaction assessed on a visual analog scale.We randomized 99 patients to rTSA (48 patients) or HA (51 patients). Fifteen patients were lost to follow-up, leaving 41 rTSA and 43 HA patients for analysis. The mean age was 79.5 years, and there were 76 women (90%). The rTSA group had a mean Constant score of 58.7 points compared with 47.7 points in the HA group, with a mean difference of 11.1 points (95% CI, 3.0-18.9 points; P = .007). Compared with HA patients, rTSA patients had greater mean satisfaction with the shoulder (79 mm vs. 63 mm, P = .011), flexion (125° vs. 90°, P.001), and abduction (112° vs. 83°, P.001), but there was no difference in Western Ontario Osteoarthritis of the Shoulder index, pain, or EQ-5D index scores. We identified 3 and 4 adverse events in the rTSA and HA groups, respectively. Among patients aged ≥ 80 years (n = 38), there was no difference between rTSA treatment and HA treatment in pain (17 mm vs. 9 mm, P = .17) or shoulder satisfaction (77 mm vs. 74 mm, P = .73).We found that rTSA provides better shoulder function than HA as measured with the Constant score, further emphasized by rTSA patients being more satisfied with their shoulder function. The difference appears to be mainly a result of better range of motion (abduction and flexion) in the rTSA group. The results also indicate that patients aged ≥ 80 years benefit less from rTSA than patients aged 70-79 years.

Background The objective of the present study was to evaluate effectiveness, complications and cost-effectiveness of any surgical or non-surgical treatment for radius or ulna fractures in elderly patients. Secondary objectives were to analyze present treatment traditions of distal radius fractures (DRF) in Sweden and to calculate resource usage for its treatment. Methods and findings The assessment contains a systematic review of clinical and health economic studies comparing treatment options for radius or ulna fractures. The results regarding the effectiveness of the treatments are summarized in meta-analyses. In addition, the assessment contains a cost analysis for different treatment options commonly used for DRF care, and an analysis of registry data on the incidence and treatment of DRF. In total 31 randomized controlled trials were included in meta-analyses. When comparing functional outcome for plate fixation versus non-surgical treatment for DRF, there were no clinically important differences at one-year follow-up (mean difference [MD], -3.29, 95% CI, -7.03; 0.44). Similar results were found when comparing plating and percutaneous methods with respect to functional outcome (standardized mean difference [SMD], -0.07, 95% CI, -0.21; 0.07) and grip strength (MD, -3.47, 95% CI, -11.21; 4.28). There were no differences for minor complications, (risk difference [RD], -0.01, 95% CI, -0.07; 0.05) whereas major complications were less common for the percutaneous group, (RD, 0.02, 95% CI, 0.02; 0.03). Given the low number of studies, the evidence above was rated as moderate certainty. The cost for plate fixation versus plaster cast was estimated to 1698 compared to 137 US dollars. For DRF, plate fixation increased in Sweden between 2005 and 2013, and was the most common surgical method in 2013. Conclusions Surgical treatment of moderately displaced distal radius fractures in elderly patients offers no clear benefit compared to non-surgical treatment. Plating procedures have become more common during the second millennium and involve higher costs and higher risk of major complications than percutaneous options. (Less)

The accuracy and precision of RSA were evaluated in the experimental study of screw cut-out complication after fixation of trochanteric fractures. A plastic bone model of a two-part trochanteric fracture was constructed with a Gamma nail implant incorporating RSA markers. The femoral head fragment was attached to a separate rotational table and the femoral shaft was mounted on the micrometer. Three main motions were simulated: Femoral head translation and rotation along the axis of the lag screw and fracture fragment translation along anatomical axes. Accuracy and precision were determined according to ISO 16,087 and ASTM standard F2385-04. Translations along the lag screw axis were measured with a precision within ±0.14 mm and an accuracy within ±0.03 mm. With simultaneous translations along all three anatomical axes, lowest precision was measured for the x-axis (±0.29, 0.07 mm, respectively), but improved when analyzed as a vector (±0.08, 0.03 mm). The precision and accuracy of femoral head rotations were within 0.5° and 0.18°, respectively. The resolution of the RSA method tested in this model was high, though it varied depending on the type of analyzed motion. This information is valuable when selecting and interpreting outcome parameters evaluating implant migration and osteosynthesis stability in future clinical RSA studies. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:705–711, 2015.

Background: The radiographic appearance of osteochondritis dissecans (OCD) of the humeral capitellum varies according to the stage of the lesion. It is important to evaluate the stage of OCD lesion carefully to guide treatment. We compared the interobserver reliability of currently used classification systems for OCD of the humeral capitellum to identify the most reliable classification system. Methods: Thirty-two musculoskeletal radiologists and orthopaedic surgeons specialized in elbow surgery from several countries evaluated anteroposterior and lateral radiographs and corresponding computed tomography (CT) scans of 22 patients to classify the stage of OCD of the humeral capitellum according to the classification systems developed by (1) Minami, (2) Berndt and Harty, (3) Ferkel and Sgaglione, and (4) Anderson on a Web-based study platform including a Digital Imaging and Communications in Medicine viewer. Magnetic resonance imaging was not evaluated as part of this study. We measured agreement among observers using the Siegel and Castellan multirater kappa. Results: All OCD classification systems, except for Berndt and Harty, which had poor agreement among observers (kappa = 0.20), had fair interobserver agreement: k was 0.27 for the Minami, 0.23 for Anderson, and 0.22 for Ferkel and Sgaglione classifications. The Minami Classification was significantly more reliable than the other classifications (P

Cut-out complication remains a major unsolved problem in the treatment of trochanteric hip fractures. A better understanding of the three-dimensional fracture-implant motions is needed to enable further development of clinical strategies and countermeasures. The aim of this clinical study was to characterise and quantify three-dimensional motions between the implant and the bone and between the lag screw and nail of the Gamma nail. Radiostereometry Analysis (RSA) analysis was applied in 20 patients with trochanteric hip fractures treated with an intramedullary nail. The following three-dimensional motions were measured postoperatively, at 1 week, 3, 6 and 12 months: translations of the tip of the lag screw in the femoral head, motions of the lag screw in the nail, femoral head motions relative to the nail and nail movements in the femoral shaft. Cranial migration of the tip of the lag screw dominated over the other two translation components in the femoral head. In all fractures the lag screw slid laterally in the nail and the femoral head moved both laterally and inferiorly towards the nail. All femoral heads translated posteriorly relative to the nail, and rotations occurred in both directions with median values close to zero. The nail tended to retrovert in the femoral shaft. Adverse fracture-implant motions were detected in stable trochanteric hip fractures treated with intramedullary nails with high resolution. Therefore, RSA method can be used to evaluate new implant designs and clinical strategies, which aim to reduce cut-out complications. Future RSA studies should aim at more unstable fractures as these are more likely to fail with cut-out.

Background The ability to correctly classify fractures is of importance for choosing the appropriate treatment and for providing appropriate data for research and quality registers. In the Swedish Fracture Register (SFR) fractures of all types are registered by the attending physician, often a junior doctor. For the majority of fractures, a modified AO/OTA classification is used. This study aimed to validate the accuracy of classification of humerus fractures in the SFR and also at providing insight into inherent classification uncertainties. Methods One hundred and sixteen humerus fractures (among them 90 proximal) were retrieved by computer randomisation from the SFR and reassessed independently at two occasions, 6 weeks apart, by three senior orthopaedic surgeons blinded to patient information and a consensus “gold standard” classification was established. This was compared with the classifications that had been entered into the register. Results The agreement between gold standard classification and original classification in the SFR was kappa = 0.57 for all humerus fractures. For proximal humerus fractures kappa-coefficient for intra-observer agreement was 0.593, 0.599 and 0.752 for the three observers respectively. Taking into account the similarities between certain fracture groups, a modified calculation of agreement was performed. With this modification the intra-observer agreement was 0.910-0.974 and inter-observer agreement was 0.912. Conclusion The classification of humerus fractures in the Swedish Fracture Register was just as accurate as in previous studies, i.e. moderate as defined by Landis and Koch. However, when we introduced a modified analysis, that takes into account the similarities between certain fractures, the accuracy was “near perfect”.

Item does not contain fulltext PURPOSE: Surgical costs are under scrutiny and surgeons are being held increasingly responsible for cost containment. In some instances, implants are the largest component of total procedure cost, yet previous studies reveal that surgeons' knowledge of implant prices is poor. Our study aims to (1) understand drivers behind implant selection and (2) assess whether educating surgeons about implant costs affects implant selection. METHODS: We surveyed 226 orthopedic surgeons across 6 continents. The survey presented 8 clinical cases of upper extremity fractures with history, radiographs, and implant options. Surgeons were randomized to receive either a version with each implant's average selling price ("price-aware" group), or a version without prices ("price-naive" group). Surgeons selected a surgical implant and ranked factors affecting implant choice. Descriptive statistics and univariate, multivariable, and subgroup analyses were performed. RESULTS: For cases offering implants within the same class (eg, volar locking plates), price-awareness reduced implant cost by 9% to 11%. When offered different models of distal radius volar locking plates, 25% of price-naive surgeons selected the most expensive plate compared with only 7% of price-aware surgeons. For cases offering different classes of implants (eg, plate vs external fixator), there was no difference in implant choice between price-aware and price-naive surgeons. Familiarity with the implant was the most common reason for choosing an implant in both groups (35% vs 46%). Price-aware surgeons were more likely to rank cost as a factor (29% vs 21%). CONCLUSIONS: Price awareness significantly influences surgeons' choice of a specific model within the same implant class. Merely including prices with a list of implants leads surgeons to select less expensive implants. This implies that an untapped opportunity exists to reduce surgical expenditures simply by enhancing surgeons' cost awareness. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analyses I.

Objectives The objective of this Health Technology Assessment was to evaluate effectiveness, complications and cost-effectiveness of surgical or non-surgical treatment for proximal, diaphyseal or distal fractures of the humerus in elderly patients. Secondary objectives were to evaluate the intervention costs per treatment of proximal humerus fractures (PHF) and to investigate treatment traditions of PHF in Sweden. Methods and findings The assessment contains a systematic review of clinical and health economic studies comparing treatment options for humerus fractures in elderly patients. The results regarding the effectiveness of treatments are summarized in meta-analyses. The assessment also includes a cost analysis for treatment options and an analysis of registry data of PHF. For hemiarthroplasty (HA) and non-operative treatment, there was no clinically important difference for moderately displaced PHF at one-year follow-up regarding patient rated outcomes, (standardized mean difference [SMD]) -0.17 (95% CI: -0.56; 0.23). The intervention cost for HA was at least USD 5500 higher than non-surgical treatment. The trend in Sweden is that surgical treatment of PHF is increasing. When functional outcome of percutaneous fixation/ plate fixation/prosthesis surgery and non-surgical treatment was compared for PHF there were no clinically relevant differences, SMD -0.05 (95% CI: -0.26; 0.15). There was not enough data for interpretation of quality of life or complications. Evidence was scarce regarding comparisons of different surgical options for humerus fracture treatment. The cost of plate fixation of a PHF was at least USD 3900 higher than non-surgical treatment, costs for complications excluded. In Sweden the incidence of plate fixation of PHF increased between 2005 and 2011. Conclusions There is moderate/low certainty of evidence that surgical treatment of moderately displaced PHF in elderly patients has not been proven to be superior to less costly non-surgical treatment options. Further research of humerus fractures is likely to have an important impact. (Less)

We treated one patient with a mid-diaphyseal radius fracture and concomitant anteromedial facet fracture of the coronoid. The ulnohumeral joint was severely unstable by complete ligament detachment and interosseous membrane rupture. Despite this gross instability, the radiocapitellar was congruent and stable. The possible mechanism of radiocapitellar stability is discussed and the concept of concavity-compression stability across the radiocapitellar joint is emphasized.

Background Humeral fractures are common, but the association between the patho-anatomical fracture pattern and patient characteristics has been inadequately studied and epidemiological knowledge is scarce. Following the introduction of the Swedish Fracture Register (SFR), risk factors for various fractures can be studied, as well as the outcome of different treatments. The objective of this study was to analyse adult humeral fractures in Gothenburg from a descriptive epidemiological perspective. Methods All humeral fractures registered in the SFR at Sahlgrenska University Hospital in 2011–2013 in patients aged ≥ 16 years were included. The fractures were divided into humeral segments (proximal, shaft and distal humerus) and analysed according to patient characteristics and patho-anatomical pattern. Furthermore, overall and age-specific incidence rates were calculated. Results A total of 2,011 humeral fractures were registered in the SFR, of which 79 % were proximal, 13 % shaft and 8 % distal humeral fractures. The mean age was 66.8 years and women ran a higher risk of humeral fractures than men (female/male ratio 2.4:1). On average, women were older than men at the time of fracture (mean age 70.1 years for women vs. 58.9 years for men). The overall incidence of humeral fractures was 104.7 per 100,000 inhabitants per year, with a segment-specific incidence of 83.0 for proximal fractures, 13.4 for shaft fractures and 8.3 per 100,000 person-years for distal fractures. There was a distinct increase in the age-specific incidence from the fifth decade and onwards, regardless of fracture site. Most fractures occurred in older patients (83 % > 50 years) as a result of a simple or an unspecified fall (79 % > 50 years). Only 1.2 % of all fractures were open injuries and 1.3 % were pathological. Conclusion This population-based study provides updated epidemiological data on humeral fractures in a Western-European setting. Most humeral fractures occur as the result of low-energy falls in the elderly population, indicating the influence of age-related risk factors in these fractures. The SFR will be a useful tool for providing continuous information on fracture epidemiology, risk factors and treatment outcome and these population-based data are essential in the planning of future fracture prevention and management.

Background Although fractures consume large social and financial resources, little is known about their actual numbers, treatment methods or outcomes. The scarcity of data calls for a high-quality, population-based register. No previous registers have prospectively collected data and patient-reported outcome measures (PROMs) on fractures of all types. The Swedish Fracture Register was recently created to fill this gap in knowledge. Its purpose is to provide information on fractures of all types, whether treated by surgery or otherwise. The aim of this article is to describe how the register was developed and its current use. Description The Swedish Fracture Register was developed during a 4-year period, 2007–2010. Data collection started in 2011. The register currently collects data on all extremity, pelvic and spine fractures in adults who have been diagnosed or treated at the affiliated departments. Data entry is fully web based, including date, cause of injury, classification and treatment. It is performed by the attending physician. Patients fill out PROMs – EQ-5D-3L and the Short Musculoskeletal Function Assessment (SMFA) – relating to health status and level of functioning before the fracture and one year later. Surgeon-reported outcome measures are registered as reoperation rates. The Swedish Fracture Register is now functioning effectively and is used in clinical routine. From January 2011 to September 2015, more than 103,000 fractures have been entered at 26 Swedish orthopedic departments. Conclusions The Swedish Fracture Register is already a well-functioning, population-based fracture register that covers fractures of all types, regardless of treatment, and collects both surgeon- and patient-reported outcome measures. In the future the Swedish Fracture Register will be able to present both results of fracture treatment and valuable epidemiological data.

We report our experience of performing an elbow hemiarthroplasty in the treatment of comminuted distal humeral fractures in the elderly patients. A cohort of 42 patients (three men and 39 women, mean age 72; 56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after surgery. Functional outcome was measured with the Mayo Elbow Performance Score (MEPS) and range of movement. The disabilities of the arm, shoulder and hand questionnaire (DASH) was used as a patient rated evaluation. Complications and ulnar nerve function were recorded. Plain radiographs were obtained to assess prosthetic loosening, olecranon wear and heterotopic bone formation. The mean extension deficit was 23.5° (0° to 60°) and mean flexion was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°). The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0 to 63). Four patients had additional surgery for limited range of movement and one for partial instability. One elbow was revised due to loosening, two patients had sensory ulnar nerve symptoms, and radiographic signs of mild olecranon wear was noted in five patients. Elbow hemiarthroplasty for comminuted intra-articular distal humeral fractures produces reliable medium-term results with functional outcome and complication rates, comparable with open reduction and internal fixation and total elbow arthroplasty. Cite this article: Bone Joint J 2015;97-B:1377–84.

Introduction The Swedish Fracture Register (SFR) was started in 2011 and registers fractures of all types, treated either surgically or non-surgically. Twenty-six orthopaedic departments in Sweden are affiliated and a total of 84,000 fractures have been registered. The physician who establishes the diagnosis of the fracture registers and classifies it according to the AO/OTA classification. The accuracy of the classification of fractures is important for the reliability of the data in the SFR. This study aimed to evaluate how accurate the classification of tibia fractures in the register is. Methods Three experienced trauma surgeons (raters) were presented with the radiographs of 114 patients with tibia fractures randomly allocated from the SFR. The raters classified the fractures independently and blinded to clinical patient information in two classification sessions with a time interval of one month. The AO/OTA classification coded by the three expert raters (our predefined gold standard) was compared with the classifications in the SFR. Inter- and intra-observer agreement was evaluated. The degree of agreement was reported using the approach of Landis and Koch. Results The accuracy of the SFR, defined as agreement between the SFR and the gold standard classification, was kappa = 0.75 for the AO/OTA type and 0.56 for the AO/OTA group, corresponding to substantial and moderate agreement, respectively. Inter-observer agreement across the three expert raters was kappa = 0.74 for the AO/OTA type and 0.53 for the AO/OTA group. Intra-observer agreement was kappa = 0.74–0.79 for the AO/OTA type and 0.62–0.64 for the AO/OTA group. Conclusion This study shows that the accuracy of classification of tibia fractures in the SFR was substantial for the AO/OTA type (kappa = 0.75) and moderate for the AO/OTA group (kappa = 0.56) as defined by Landis and Koch. This degree of accuracy is similar to that in previous studies. We interpret this as meaning that the results of this study demonstrate the high reliability of the data in the SFR and enable the SFR to be used for further scientific analysis.

The accuracy and precision of RSA were evaluated in the experimental study of screw cut-out complication after fixation of trochanteric fractures. A plastic bone model of a two-part trochanteric fracture was constructed with a Gamma nail implant incorporating RSA markers. The femoral head fragment was attached to a separate rotational table and the femoral shaft was mounted on the micrometer. Three main motions were simulated: Femoral head translation and rotation along the axis of the lag screw and fracture fragment translation along anatomical axes. Accuracy and precision were determined according to ISO 16,087 and ASTM standard F2385-04. Translations along the lag screw axis were measured with a precision within ±0.14 mm and an accuracy within ±0.03 mm. With simultaneous translations along all three anatomical axes, lowest precision was measured for the x-axis (±0.29, 0.07 mm, respectively), but improved when analyzed as a vector (±0.08, 0.03 mm). The precision and accuracy of femoral head rotations were within 0.5° and 0.18°, respectively. The resolution of the RSA method tested in this model was high, though it varied depending on the type of analyzed motion. This information is valuable when selecting and interpreting outcome parameters evaluating implant migration and osteosynthesis stability in future clinical RSA studies.

Almost 2/3 of all fractures will have an acceptable outcome with plaster treatment if used properly. A prerequisite for a good radiological outcome is the absence of volar comminution, since radial length can be maintained only with contact between the opposing volar cortices of the main fragments. Closed reduction usually employs ligamentotaxis, but distraction alone will not fully reduce the fracture; the concept of multiplanar ligamentotaxis has to be used. The wrist should be immobilised in neutral or slight extension as this preserves finger function and diminishes the risk for redisplacement. Secondary displacement may occur after >2 weeks into treatment and the fracture may need to be monitored for 2–3 weeks. If redisplacement occurs, operative fixation is needed to maintain reduction of the fracture.

Why do we struggle with distal radius fractures as Abraham Colles stated 200 years ago: “… the limb will again enjoy perfect freedom in all its motions, and be completely free of pain”?

Purpose To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck fractures with measured fracture angulation would recommend surgery as often as surgeons shown unmarked radiographs. Methods Members of the Science of Variation Group, an international collaboration of fully trained orthopedic and trauma surgeons, were asked to review 20 little finger metacarpal neck fracture cases, which included a vignette and 3 high-quality radiographs. Members were then randomized to review radiographs with or without measured fracture angulation on the lateral view and select operative or nonoperative management. Results Surgeons shown radiographs with measured angulation were more likely to recommend surgery, and there was less variability among these surgeons, particularly for fractures with less angular deformity. Conclusions Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved

Background In dislocated proximal tibial fractures, the most frequently used treatment is ORIF with screws and plates. Minimally-invasive techniques using external fixation are an alternative. The aim of this study was to analyse the clinical and radiological results using the Ilizarov technique in both uni- and bicondylar tibial fractures. Methods Thirty consecutive patients with isolated fractures of the proximal tibia were treated with the Ilizarov technique, 11 Schatzker I-IV with 2–3 rings and 19 Schatzker V-VI with 3–4 tibial rings and a femoral, hinged, two-ring extension. Unrestricted weight-bearing was allowed. Pre and post-operatively, conventional radiographs, computerized tomography scans, post-operative pain assessments and complications were evaluated. The knee function was evaluated with the EQ-5D, NHP and KOOS scores, as well as self-appraisal. Results All the fractures healed. Twenty-five patients achieved a range of motion better than 10-100º. The type I-IV fractures had a shorter operating time and hospital stay, as well as better knee flexion, and the self-appraisal indicated that they tolerated the treatment better. Pin infections occurred in 4% of the pin sites, but only two patients required debridement. Two patients developed compartment syndrome and underwent fasciotomy. No patient complained of functional knee instability. Two patients underwent a total knee arthroplasty because of residual pain. The overall result was judged as satisfactory in twenty-seven patients. Conclusions The Ilizarov method produces a good clinical outcome and is a valuable treatment alternative in proximal tibial fractures of all types.

Purpose To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. Conclusions Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. Clinical relevance Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.

Publisher Summary This chapter discusses acute stimulatory effects of luteinizing hormone-releasing hormone (LHRH) and LHRH analogues on the preovulatory rat follicle. In a study described in the chapter, immature Sprague–Dawley rats, 26 days old, were treated with 10 IU PMSG. This treatment resulted in the ovulation of 12–18 ova early on the morning of day 29. Ovarian follicles or granulosa cells were isolated on the morning of day 28. The follicles were incubated in Krebs–Ringer bicarbonate buffer with glucose and 1% bovine serum albumin. Granulosa cells were cultured in Eagle's minimal essential medium with Hepes and 10% fetal calf serum. For the in vivo experiments, the rats were hypophysectomized on the morning of day 28. It was found that mammalian oocytes remain arrested in the prophase stage of the first meiotic division until meiosis is resumed in the preovulatory follicle following the LH surge. Oocyte meiosis can also be initiated in vitro by the addition of gonadotrophin to isolated preovulatory rat follicles.

Puromycin has been reported to block the meiosis of cultured mouse oocytes before extrusion of the first polar body, but to allow resumption of meiosis as revealed by germinal vesicle breakdown (GVB) (Schultz and Wassarman, 1977a). The conclusion from this was that GVB occurs independently of protein synthesis. In the present study rat oocytes were treated with puromycin during two successive culture periods. During the first period resumption of meiosis was prevented either by the concomitant presence of dibutyryl-cyclic AMP (dbcAMP) or by incubation of oocytes within their intact preovulatory follicles. Isolated oocytes, with or without cumulus cells, were then transferred to plain medium or medium with puromycin alone for a second culture period. Cumulus-surrounded oocytes matured spontaneously in culture. DbcAMP prevented GVB, if added within 1 h from the start of culture, whereas puromycin did not prevent GVB but blocked polar body formation, thus confirming earlier observations. When oocytes were first cultured for 0.5-4 h in the presence of both puromycin and dbcAMP and then cultured for 4 h with puromycin alone, GVB was prevented in a “time dependent” way: the longer the first culture period the lower the rate of GVB. The inhibition of GVB was, however, fully reversed when no drugs were present during the second culture. The block of GVB produced by puromycin was sustained even when the second culture was continued for 18 h. Cycloheximide, but not puromycin aminonucleoside (PAN), produced the same effects as puromycin. Similar results were obtained when denuded oocytes were used, suggesting that the effects of puromycin were directly on the oocyte and not mediated via the cumulus cells. When follicle-enclosed oocytes were incubated for 3 h with puromycin and the oocytes then isolated and cultured with puromycin, GVB was also inhibited. The rise in oxygen consumption seen in maturing oocytes could be prevented in oocytes maturing in medium containing puromycin. Also this effect of puromycin was reversible, indicating that puromycin did not inflict permanent damage on the oocyte. The interpretation of these data is that resumption of meiosis is dependent on some proteins with high turnover rates existing in the oocyte before the start of meiosis. Polar body formation might also be explained in a similar way.

This study was undertaken in order to analyse the role of cyclic AMP (cAMP) in the stimulatory action of LH on the resumption of oocyte meiosis (oocyte maturation) and follicular glycolysis. Follicular development was induced in immature rats by a single injection of pregnant mares' serum gonadotrophin. Pr-ovulatry follices were extirpated on the day before ovulation and incubated in a chemically defined medium for 4–10 h. The follicle-enclosed oocytes remained in the dictyate stage when incubated in hormone-free medium but in the presence of LH oocyte maturation was induced. When cAMP or butyryl derivatives of cAMP were added to the incubation medium no effect on the oocyte was seen. However, these nucleotides prevented the stimulatory action of LH on the oocytes. The phosphodiesterase inhibitors theophylline and IBMX had similar effects as cAMP on oocyte maturation, causing a reversible blockage of the LH effect. When 8-Br-cAMP and the phosphodiesterase inhibitor ICI 63.197 were tested it was found that both had inherent stimulatory effects on oocyte maturation at certain concentrations. Pre-incubation of the follicles in a high concentration of dibutyryl cAMP followed by transfer to plain medium resulted in oocyte maturation. Follicular lactate production was stimulated by all cyclic nucleotide derivatives tested, except cAMP, and by IBMX and ICI 63.197. There was no reduction by these agents of the stimulatory effect of LH on lactate production. A model to explain the role of cAMP in oocyte maturation is presented.

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LH exerts a biphasic effect on rat follicular steroidogenesis: an initial general stimulation of steroidogenesis later followed by an inhibition of androgen and oestrogen synthesis. It is known that the stimulation by LH of steroidogenesis is mediated by cAMP. The present paper examines the role of cAMP in the late inhibitory phase of steroidogenesis. Pre-ovulatory follicles were isolated from PMSG treated immature rats and incubated in modified bicarbonate buffer for different time periods. The accumulation of progesterone (P), androstenedione (A), testosterone (T) and oestradiol-17β (E2) in the medium was measured. Addition of dibutyryl cAMP (dbcAMP, 1 mm) to the medium caused a prolonged increase in P accumulation for 10 h while A and E2 accumulation was stimulated only for 4–6 h whereafter the levels were sustained. The pattern was identical to that produced by LH (10 μg/ml) in vitro. In a second type of experiments follicles were pre-incubated for 6 h with or without LH or dbcAMP and then transferred for a second 2 h incubation, in the presence or absence of unlabelled 17-hydroxyprogesterone (17-OHP) or T (1 μg/ml). Follicles pre-incubated in plain medium increased their formation of A and T in the presence of 17-OHP, while follicles exposed to LH or dbcAMP did not. Addition of T caused a similar increase in E2 formation in all groups (control, LH and dbcAMP). It is concluded that since dbcAMP mimicked the entire response of follicular steroidogenesis normally elicited by LH, cAMP seems to be the physiologic mediator of LH, both on the early stimulatory and on the late inhibitory phase of pre-ovulatory follicular steroidogenesis.

The effect of an agonistic gonadotropin releasing hormone (GnRH) -analog (D -Ala’ ,desGly’#{176} -NH3 -GnRH -ethylamide, GnRHa) on granulosa cell steroidogenesis in the presence or absence of follicle-stimulating hormone (FSH) or luteinizing hormone (LH) was studied. Granulosa cells, isolated from preovulatory follicles of pregnant mare’s serum gonadotropin (PMSG) -treated immature rats or from the less mature follicles of untreated immature rats, were cultured for a period of 72 h with daily changes of medium, and progesterone and its metabolite, 20a -dihydro progesterone (20o-OHP), were assayed in the medium. In granulosa cells from preovulatory follicles, LH and FSH caused a much greater stimulation of steroidogenesis than did GnRHa. There appeared to be no interaction between GnRHa and FSH during the first 10 h, but at 24 h and later the presence of GnRHa clearly inhibited the steroidogenic response to LH and FSH. Steroidogenesis in granulosa cells from immature rats was considerably lower and the effects of GnRHa and FSH alone less pronounced. In these cells, FSH #{149}stimulated progesterone secretion was inhibited by GnRHa only at 72 h. In contrast, 20o-OHP secretion in the same cultures was potentiated by the combined presence of FSH and GnRHa. In conclusion, it seems as though the effects of GnRHa on granulosa cell steroidogenesis varies with exposure time, the initial response being stimulatory and the later inhibitory. Further more, the response is also to some extent determined by the maturational stage of the granulosa cells.

Previous studies have shown that gonadotrophin-releasing hormone (GnRH) can induce resumption of meiosis in follicle-enclosed rat oocytes. In the present study a GnRH antagonistic analogue ([d-pGlul, d-Phe2,-d-Trp3,6]LRF) was found to effectively abolish the stimulatory effect of a GnRH agonist upon resumption of meiosis and lactate accumulation in isolated pre-ovulatory rat follicles but the have no effect on LH stimulation of these parameters. It is concluded that although LH and GnRH can evoke a similar response they act through separate receptor sites and that it is unlikely that GnRH mediates the effect of LH on meiosis or glycolysis.

The secretion of steroids and the release of cAMP in response to repeated luteinizing hormone (LH) stimulation were examined during superfusion of isolated preovulatory rat follicles. A high dose of ovine LH (1 microgram/ml for 20 min) caused a prolonged increase in the secretion of progesterone (P) and 20 alpha-dihydroprogesterone (20 alpha-OHP) and a transient increase in the secretion of testosterone (T) and estradiol-17 beta (E2), and was accompanied by a peak of cAMP release. A single pulse of LH at a low dose level (10 mg/ml for 20 min) gave a limited increase in T secretion, but no clear change in P, 20 alpha-OHP and E2 secretion or cAMP release. When the follicles were challenged with a second pulse of LH (at 1 microgram/ml), the response varied according to the dose of LH delivered in the preceding pulse. Following exposure to the high dose of LH, the follicles were partially refractory to the second LH challenge in terms of cAMP and P and the secretion of T and E2 remained low. The low dose of LH, however, had a conditioning effect on the follicles since the response to the second LH challenge was amplified in terms of P, 20 alpha-OHP and cAMP. In this case a secondary increase in T and E2 secretion was found. The differential response to varying doses of LH are likely to reflect the physiological control of steroidogenesis during final follicular maturation.

The adenylate cyclase activator forskolin was used to study the role of cAMP for oocyte meiosis and follicular steroid secretion. Follicular and cumulus cAMP production was stimulated dose-dependently by forskolin, as was the follicular secretion of progesterone, testosterone and estradiol. Forskolin induced meiosis in follicle-enclosed oocytes with a maximal effect at 1 microM, with lower and higher concentrations being less effective. The spontaneous resumption of meiosis in isolated cumulus-enclosed oocytes was dose-dependently retarded by forskolin. Meiosis of cumulus-free oocytes was also retarded but only slightly. These data support the earlier hypothesis that a limited increase in follicular cAMP levels triggers meiosis, whereas sustained levels of cAMP in the oocyte itself prevent meiosis.

Resumption of meiosis (oocyte maturation) is normally triggered by the preovulatory LH surge, and the first meiotic division is completed at the time of follicle rupture. The mature follicle has receptors for LH both in the theca and granulosa cells but no specific LH receptors have been demonstrated on the oocyte itself. Therefore, the triggering effect of LH on meiosis is likely to be mediated indirectly by an effect on the somatic cell types, probably the granulosa cells. We have studied the mechanism of LH action on meiosis with particular emphasis on the relation to the cumulus cells. In this review we will summarize some of our previous findings as well as report on some new results. We focus on studies where oocyte and cumulus maturation have been studied in relation to metabolic changes (1) of the whole isolated follicle and (2) of the isolated oocyte-cumulus complex.

The effects of GnRH and a potent GnRH analogue (D-Ala6-des-gly-NH2-GnRH-ethylamide) on steroidogenesis in isolated preovulatory follicles of PMSG-treated immature rats were examined in short-term incubations and compared to the effect of LH. Steroids were analyzed by RIA. GnRH stimulated the accumulation of pregnenolone (2-fold), progesterone (4-fold), 20α-OH-progesterone (38-fold), androstenedione (4-fold), testosterone (3-fold), and oestradiol-17β (2-fold) during a 6 h incubation. The time-course of stimulation was the same for each of the steroids analyzed, with a significant effect at 4 and 6 h, but not at 2 h of incubation. Dose-response curves were similar for each steroid, and the GnRH analogue and GnRH gave parallel curves with minimal effective concentrations being 1 and 10 ng/ml, respectively. The stimulatory effect of LH was more pronounced and rapid (2 h) than that of GnRH. During prolonged incubation (6–8 h) with GnRH or LH there was evidence for an inhibition of testosterone production, probably due to suppression of the C21-side chain cleavage enzyme. Thus, the qualitative response to GnRH on follicular steroidogenesis resembled that of LH in some but not all respects. The differences in time-course and maximal steroid secretion between GnRH and LH are compatible with different mechanisms of action in the follicle.

A potent analogue of gonadotropin releasing hormone [D-Ala6- Des-Gly10-NH2]-GnRH ethylamide (GnRHa) caused oocyte maturation and ovulation when injected in the afternoon of proestrus in immature PMSG-treated female rats, hypophysectomized on the morning of proestrus. This action of GnRHa was accompanied by a marked increase in ovarian PGE levels. Furthermore, the pretreatment of the animals with a prostaglandin synthetase inhibitor (indomethacin) completely inhibited this PGE increase and ovulation. These data suggest a role for prostaglandins in GnRHa induced ovulation.

LH exerts a biphasic effect on rat pre-ovulatory follicular steroidogenesis: an initial (1–4h) overall stimulation followed by a later (4–6 h) occurring inhibition of androgen synthesis. Because exogenous steroids may inhibit androgen formation, we investigated whether the steroids produced initially in response to LH are involved in the late inhibition of androgen synthesis. Isolated pre-ovulatory rat follicles were incubated for 6 h with and without ovine LH and 1 of 3 inhibitors of steroidogenesis (aminoglutethimide, cyanoketone, Su 10603). Accumulation of androstenedione and testosterone in a subsequent 2-h incubation in the presence of exogenous 17-hydroxyprogesterone was measured. LH treatment alone caused inhibition of apparent 17,20-lyase activity. The inhibitors had no effect on basal 17,20-lyase activity but were able to prevent the LH-induced inhibition of this enzymic activity. The results suggest that the physiological decline in pre-ovulatory androgen formation may in part be mediated by local action of follicular steroids.