Interobserver reliability of classification and characterization of proximal humeral fractures: a comparison of two and three-dimensional CT

Interobserver reliability for the classification of proximal humeral fractures is limited. The aim of this study was to test the null hypothesis that interobserver reliability of the AO classification of proximal humeral fractures, the preferred treatment, and fracture characteristics is the same for two-dimensional (2-D) and three-dimensional (3-D) computed tomography (CT). Members of the Science of Variation Group--fully trained practicing orthopaedic and trauma surgeons from around the world--were randomized to evaluate radiographs and either 2-D CT or 3-D CT images of fifteen proximal humeral fractures via a web-based survey and respond to the following four questions: (1) Is the greater tuberosity displaced? (2) Is the humeral head split? (3) Is the arterial supply compromised? (4) Is the glenohumeral joint dislocated? They also classified the fracture according to the AO system and indicated their preferred treatment of the fracture (operative or nonoperative). Agreement among observers was assessed with use of the multirater kappa (κ) measure. Interobserver reliability of the AO classification, fracture characteristics, and preferred treatment generally ranged from "slight" to "fair." A few small but statistically significant differences were found. Observers randomized to the 2-D CT group had slightly but significantly better agreement on displacement of the greater tuberosity (κ = 0.35 compared with 0.30, p < 0.001) and on the AO classification (κ = 0.18 compared with 0.17, p = 0.018). A subgroup analysis of the AO classification results revealed that shoulder and elbow surgeons, orthopaedic trauma surgeons, and surgeons in the United States had slightly greater reliability on 2-D CT, whereas surgeons in practice for ten years or less and surgeons from other subspecialties had slightly greater reliability on 3-D CT. Proximal humeral fracture classifications may be helpful conceptually, but they have poor interobserver reliability even when 3-D rather than 2-D CT is utilized. This may contribute to the similarly poor interobserver reliability that was observed for selection of the treatment for proximal humeral fractures. The lack of a reliable classification confounds efforts to compare the outcomes of treatment methods among different clinical trials and reports

Genetic background of osteonecrosis: Associated with thrombophilic mutations?

Intravascular coagulation is considered a major pathogenetic mechanism for nontraumatic osteonecrosis. The aim of our study was to evaluate the association of thrombophilic factor V G1691A mutation (factor V Leiden) and G20210A prothrombin mutation with the disease. Mutation presence was investigated by polymerase chain reaction techniques in a study population of 72 adult Caucasian patients with osteonecrosis of the femoral head and 300 healthy Caucasian control subjects. The disease was considered idiopathic in 23 patients and secondary in 49. The factor V Leiden mutation was present in 18% of patients, compared with 4.6% of control subjects, resulting in a statistically significant odds ratio of 4.5. The prothrombin mutation was not significantly increased in the idiopathic osteonecrosis subgroup (8.7% versus 2.6%) with an odds ratio of 3.5. Overall, either of these coagulation disorders was present in 22.2% of patients and in 7.3% of control subjects resulting in a significant odds ratio of 3.6. Factor V Leiden, a genetic risk factor for venous thrombosis, is associated with nontraumatic osteonecrosis of the femoral head, supporting the hypothesis that intravascular coagulation is a major pathogenetic mechanism of the disease

The 2003 Marshall R. Urist Award Paper - Genetic background of osteonecrosis: Associated with thrombophilic mutations?

Intravascular coagulation is considered a major pathogenetic mechanism for nontraumatic osteonecrosis. The aim of our study was to evaluate the association of thrombophilic factor V G1691A mutation (factor V Leiden) and G20210A prothrombin mutation with the disease. Mutation presence was investigated by polymerase chain reaction techniques in a study population of 72 adult Caucasian patients with osteonecrosis of the femoral head and 300 healthy Caucasian control subjects. The disease was considered idiopathic in 23 patients and secondary in 49. The factor V Leiden mutation was present in 18% of patients, compared with 4.6% of control subjects, resulting in a statistically significant odds ratio of 4.5. The prothrombin mutation was not significantly increased in the idiopathic osteonecrosis subgroup (8.7% versus 2.6%) with an odds ratio of 3.5. Overall, either of these coagulation disorders was present in 22.2% of patients and in 7.3% of control subjects resulting in a significant odds ratio of 3.6. Factor V Leiden, a genetic risk factor for venous thrombosis, is associated with nontraumatic osteonecrosis of the femoral head, supporting the hypothesis that intravascular coagulation disease

Free vascularized fibular grafts for reconstruction of skeletal defects

Nourished by the peroneal vessels, the versatile free vascularized fibular graft can be transferred to reconstruct skeletal defects of the extremities. It may be combined with skin, fascia, muscle, and growth-plate tissue to address the needs of the recipient site. It may be cut transversely and folded to reconstruct the length and width of tibial or femoral defects. The main indications for this graft are defects larger than 5 to 6 cm or with poor vascularity of the surrounding soft tissues. Detailed preoperative planning, experience in microvascular techniques, and careful postoperative follow-up are necessary to minimize complications and improve outcome. The free vascularized fibular graft has been successfully applied as a reconstruction option in patients with traumatic or septic skeletal defect, after tumor resection, and has shown promise in patients with congenital pseudarthrosis

alpha-Lipoic acid supplementation up-regulates antioxidant capacity in adults with G6PD deficiency

The purpose of this study was to examine the effect of alpha-lipoic acid (LA) supplementation on blood redox status in individuals with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Eight adults with G6PD deficiency (D group) and eight controls with normal G6PD levels (N group) participated in this study. Participants received LA (600 mg/day) for 28 days. At baseline, 2 and 4 weeks after supplementation, venous blood was collected for analysis of reduced glutathione (GSH), catalase, protein carbonyls (PC), thiobarbituric acid reactive substances (TBARS), total antioxidant capacity (TAG), bilirubin, uric acid (UA) and hemoglobin (Hb) levels. Baseline GSH was lower (P < 0.05) in D compared to N group whereas LA supplementation for 2 and 4 weeks increased significantly (P < 0.05) GSH levels in both groups. Catalase and TAG increased (P < 0.05) in both groups following 2 and 4 weeks of supplementation. Baseline TBARS values were higher (P < 0.05) in D compared to N group while LA supplementation reduced (P < 0.05) TBARS and PC in both groups. There were no differences for UA at baseline between the two groups but LA supplementation increased significantly UA levels only in the D group. Bilirubin and Hb were unchanged. These results indicate that LA supplementation may modulate redox status regardless G6PD deficiency. (C) 2013 Elsevier Ltd. All rights reserved