Treatment Reality of Proximal Humeral Fractures in the Elderly—Trending Variants of Locking Plate Fixation in Germany

Background: The surgical treatment of proximal humeral fractures (PHFs) with locking plate fixation (LPF) in the elderly is associated with high complication rates, especially in osteoporotic bone. Variants of LPF such as additional cerclages, double plating, bone grafting and cement augmentation can be applied. The objective of the study was to describe the extent of their actual use and how this changed over time. Methods: Retrospective analysis of health claims data of the Federal Association of the Local Health Insurance Funds was performed, covering all patients aged 65 years and older, who had a coded diagnosis of PHF and were treated with LPF between 2010 and 2018. Differences between treatment variants were analyzed (explorative) via chi-squared or Kruskal–Wallis tests. Results: Of the 41,216 treated patients, 32,952 (80%) were treated with LPF only, 5572 (14%) received additional screws or plates, 1983 (5%) received additional augmentations and 709 (2%) received a combination of both. During the study period, relative changes were observed as follows: −35% for LPF only, +58% for LPF with additional fracture fixation and +25% for LPF with additional augmentation. Overall, the intra-hospital complication rate was 15% with differences between the treatment variants (LPF only 15%, LPF with additional fracture fixation 14%, LPF with additional augmentation 19%; p < 0.001), and a 30-day mortality of 2%. Conclusions: Within an overall decrease of LPF by approximately one-third, there is both an absolute and relative increase of treatment variants. Collectively, they account for 20% of all coded LPFs, which might indicate more personalized treatment pathways. The leading variant was additional fracture fixation using cerclages

Treatment Reality of Proximal Humeral Fractures in the Elderly—Trending Variants of Locking Plate Fixation in Germany

Background: The surgical treatment of proximal humeral fractures (PHFs) with locking plate fixation (LPF) in the elderly is associated with high complication rates, especially in osteoporotic bone. Variants of LPF such as additional cerclages, double plating, bone grafting and cement augmentation can be applied. The objective of the study was to describe the extent of their actual use and how this changed over time. Methods: Retrospective analysis of health claims data of the Federal Association of the Local Health Insurance Funds was performed, covering all patients aged 65 years and older, who had a coded diagnosis of PHF and were treated with LPF between 2010 and 2018. Differences between treatment variants were analyzed (explorative) via chi-squared or Kruskal–Wallis tests. Results: Of the 41,216 treated patients, 32,952 (80%) were treated with LPF only, 5572 (14%) received additional screws or plates, 1983 (5%) received additional augmentations and 709 (2%) received a combination of both. During the study period, relative changes were observed as follows: −35% for LPF only, +58% for LPF with additional fracture fixation and +25% for LPF with additional augmentation. Overall, the intra-hospital complication rate was 15% with differences between the treatment variants (LPF only 15%, LPF with additional fracture fixation 14%, LPF with additional augmentation 19%; p < 0.001), and a 30-day mortality of 2%. Conclusions: Within an overall decrease of LPF by approximately one-third, there is both an absolute and relative increase of treatment variants. Collectively, they account for 20% of all coded LPFs, which might indicate more personalized treatment pathways. The leading variant was additional fracture fixation using cerclages

Male Sex Is Associated with Higher Mortality and Increased Risk for Complications after Surgical Treatment of Proximal Humeral Fractures

Aims: The best surgical treatment of multi-fragmentary proximal humeral fractures in the elderly is a highly controversial topic. The aim of this study is to assess for sex-related differences regarding mortality and complications after reverse total shoulder arthroplasty (RTSA) and locking plate fixation (LPF). Patients and Methods: All patients from the largest German healthcare insurance (26.5 million policy holders) above the age of 65 years that were treated with LPF or RTSA after a multi-fragmentary proximal humerus fracture between January 2010 and September 2018 were included. Multivariable Cox regression models were used to assess the association of sex with overall survival, major adverse events and surgical complications. Results: A total of 8264 (15%) men and 45,707 (85%) women were followed up for a median time of 52 months. After 8 years, male patients showed significantly higher rates for death (65.8%; 95% CI 63.9–67.5% vs. 51.1%; 95% CI 50.3–51.9%; p &lt; 0.001) and major adverse events (75.5%; 95% CI 73.8–77.1% vs. 61.7%; 95% CI 60.9–62.5%; p &lt; 0.001). With regard to surgical complications, after adjustment of patient risk profiles, there were no differences between females and males after LPF (p &gt; 0.05), whereas men showed a significantly increased risk after RTSA (HR 1.86; 95% CI 1.56–2.22; p &lt; 0.001) with more revision surgeries performed (HR 1.76, 95% CI 1.46–2.12; p &lt; 0.001) compared to women. Conclusion: The male sex is an independent risk factor for death and major adverse events after both LPF and RTSA. An increased risk for surgical complications after RTSA suggests that male patients benefit more from LPF. Sex should be considered before making treatment decisions

Medical imaging training with eye movement modeling examples: A randomized controlled study

To determine whether ultrasound training in which the expert’s eye movements are superimposed to the underlying ultrasound video (eye movement modeling examples; EMMEs) leads to better learner outcomes than traditional eye movement-free instructions. 106 undergraduate medical students were randomized in two groups; 51 students in the EMME group watched 5-min ultrasound examination videos combined with the eye movements of an expert performing the task. The identical videos without the eye movements were shown to 55 students in the control group. Performance and behavioral parameters were compared prepost interventional using ANOVAs. Additionally, cognitive load, and prior knowledge in anatomy were surveyed. After training, the EMME group identified more sonoanatomical structures correctly, and completed the tasks faster than the control group. This effect was partly mediated by a reduction of extraneous cognitive load. Participants with greater prior anatomical knowledge benefited the most from the EMME training. Displaying experts’ eye movements in medical imaging training appears to be an effective way to foster medical interpretation skills of undergraduate medical students. One underlying mechanism might be that practicing with eye movements reduces cognitive load and helps learners activate their prior knowledge.</p

Male Sex Is Associated with Higher Mortality and Increased Risk for Complications after Surgical Treatment of Proximal Humeral Fractures

Aims: The best surgical treatment of multi-fragmentary proximal humeral fractures in the elderly is a highly controversial topic. The aim of this study is to assess for sex-related differences regarding mortality and complications after reverse total shoulder arthroplasty (RTSA) and locking plate fixation (LPF). Patients and Methods: All patients from the largest German healthcare insurance (26.5 million policy holders) above the age of 65 years that were treated with LPF or RTSA after a multi-fragmentary proximal humerus fracture between January 2010 and September 2018 were included. Multivariable Cox regression models were used to assess the association of sex with overall survival, major adverse events and surgical complications. Results: A total of 8264 (15%) men and 45,707 (85%) women were followed up for a median time of 52 months. After 8 years, male patients showed significantly higher rates for death (65.8%; 95% CI 63.9–67.5% vs. 51.1%; 95% CI 50.3–51.9%; p 0.05), whereas men showed a significantly increased risk after RTSA (HR 1.86; 95% CI 1.56–2.22; p < 0.001) with more revision surgeries performed (HR 1.76, 95% CI 1.46–2.12; p < 0.001) compared to women. Conclusion: The male sex is an independent risk factor for death and major adverse events after both LPF and RTSA. An increased risk for surgical complications after RTSA suggests that male patients benefit more from LPF. Sex should be considered before making treatment decisions

Complex Bone Tumors of the Trunk—The Role of 3D Printing and Navigation in Tumor Orthopedics: A Case Series and Review of the Literature

The combination of 3D printing and navigation promises improvements in surgical procedures and outcomes for complex bone tumor resection of the trunk, but its features have rarely been described in the literature. Five patients with trunk tumors were surgically treated in our institution using a combination of 3D printing and navigation. The main process includes segmentation, virtual modeling and build preparation, as well as quality assessment. Tumor resection was performed with navigated instruments. Preoperative planning supported clear margin multiplanar resections with intraoperatively adaptable real-time visualization of navigated instruments. The follow-up ranged from 2–15 months with a good functional result. The present results and the review of the current literature reflect the trend and the diverse applications of 3D printing in the medical field. 3D printing at hospital sites is often not standardized, but regulatory aspects may serve as disincentives. However, 3D printing has an increasing impact on precision medicine, and we are convinced that our process represents a valuable contribution in the context of patient-centered individual care