Internal fixation

Right.

I think sometimes, at least at our place, logistics does drive almost decision-making at times just because of availability of surgeons that are gonna be ORIF surgeons versus arthroplasty.

I would say that although we're not fifty-fifty, we're definitely increasing the percent that get arthroplasty, and we're making strategic plans to have our shoulder arthroplasty docs more available and having some, a little bit of slack in their system to absorb some of these patients.

So I-- that was actually a, an important thing.

And it was actually, uh, fairly close to the same.

I mean, their odds ratios were very close to one high p-value, so that this was statistically really similar in terms of op versus non-op between the different low and high ADI groups.

Same thing for the type of surgery, whether it was arthroplasty or ORIF.

Again, very similar and no specific difference seen between high and low ADI groups.

It was.

In the ORIF group, 25% of the patients required a return to the operating

theater.

A 25% re-operation rate for the internal fixation group.

However, the TEA patient typically has a shorter acute hospital length of stay because they achieve immediate joint stability and can commence active rehabilitation on postoperative day one.

So they avoid the prolonged immobilization.

They avoid that, and they avoid the intensive community nursing care often required by an ORIF patient navigating a tenuous fixation or a protracted nonunion.

The economic value of preventing an elderly patient from losing their independence and transitioning into a permanent residential care facility far offsets the initial implant costs.

So just be careful how it's asked.

And then, Dr. Summers, what comments do you have on delayed total elbow after a failed RAF?

Yeah, that's a great question because it's one of those things where if an attempt at fixing it that fails would make their final outcome from total elbow arthroplasty worse overall, you know, that just kind of has to factor into your decision.

But they like to kind of quote this Giffen study from 2014 saying, found that even if you had attempted ORIF and then it failed and they were converted to total elbow, there was no difference in outcomes, reoperation rates, or complication rates compared to patients who had an acute or immediate total elbow arthroplasty for distal humerus fracture.

It's interesting that they'll test that concept as well as the two prior papers that support early total elbow arthroplasty.

But the phrase of the test question differently, as we talked about the vignettes for supporting acute total elbow, this will be more so kind of directly asking you if there's a difference in outcomes, if you fail an ORF and then go on to total elbow.

I mean, I don't remember the last time we tried non-operative care for a C-type distal humerus fracture.

And I think they just want you to know that sort of historic treatment isn't really done anymore.

When you looked at it, it was shocking.

It was in linked datasets where you're looking at the primary and the revision and any possible revision afterwards plus ORIF.

Periprosthetic fracture almost equaled the same number of cases if you added together infection and loosening.

I mean, that was mind-boggling because it was way more than, than we thought, you know.

Of this cohort, the mean age was 66 years, and 77% of them were female.

This study looked at surgical treatment, which was the surgeon's choice of ORIF versus Hemi, versus non-operative treatment being a sling and following up with rehab.

The primary outcome of this study showed that there's no clinically or statistically significant difference in the Oxford Shoulder Score at 6, 12, or 24 months.

And there's also shown to not be any differences with complications, secondary surgery, or mortality as well.

The Delphi trial was a multi-center RCT from Norway, I believe, with 124 patients

patientsThey were within the age range of 65 to 85 who had displaced three and four-part proximal humerus fractures.

The comparison between these two groups was a reverse total shoulder versus ORIF with a locking plate.

And the clinical takeaway here was when the surgery is indicated in these elderly patients with complex, specifically the four-part fractures, the reverse total shoulder provided superior functional outcome as compared to the locking plate fixation.