Original Article
Results after internal fixation of humerus distal fractures in patients aged over 65 years
Resultados de la reducción abierta y osteosíntesis de fracturas de húmero distal en mayores de 65 años
L. Serrano-Mateo
, Y. Lopiz, C. León-Serrano, C. García-Fernández, L. López-Durán-Stern, F. Marco
Corresponding author
Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Clínico San Carlos, Madrid, Spain
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Serrano-Mateo, Y. Lopiz, C. León-Serrano, C. García-Fernández, L. López-Durán-Stern, F. Marco" "autores" => array:6 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Serrano-Mateo" "email" => array:2 [ 0 => "l.serrano.mateo@gmail.com" 1 => "serrano.mateo@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Y." "apellidos" => "Lopiz" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "León-Serrano" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "García-Fernández" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "López-Durán-Stern" ] 5 => array:2 [ "nombre" => "F." "apellidos" => "Marco" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Clínico San Carlos, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resultados de la reducción abierta y osteosíntesis de fracturas de húmero distal en mayores de 65 años" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1384 "Ancho" => 1956 "Tamanyo" => 90800 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Results obtained in the Mayo Elbow Performance Score scale.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fractures of the distal humerus present an incidence of 5.7 per 100,000 people/year distributed in a bimodal form (young people as a result of high-energy traumatisms and a second peak in elderly women, with osteoporotic bone, secondary to low-energy traumatisms). The latest epidemiological data show a considerable increase of this type of fractures in patients aged over 65 years in the last decade.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There is a controversy over what the ideal treatment to follow in this type of fractures in the elderly. Added to the greater complexity from the comminution associated with them is the problem of fixation of osteosynthesis material in a bone with its altered biomechanical and biological characteristics, which encourages implant failure and alters the process of consolidation. In many occasions, this makes it necessary to have a greater period of joint immobilization after fracture fixation, with the functional repercussions that involves. All of this has made the treatment of these fractures the object of debate in the literature, with opposing therapeutic attitudes that vary from conservative treatment to open reduction or elbow arthroplasty.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The objective of this study was to analyze the functional and X-ray results, along with the complications associated, of open reduction and osteosynthesis with internal plating for this type of fractures in patients aged more than 65 years.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study population</span><p id="par0020" class="elsevierStylePara elsevierViewall">We performed a retrospective study on the patients who had suffered distal humerus fracture (supracondylar and supra-intercondylar humerus) in the period 2005–2010 in our center. The criteria for inclusion were: patients aged more than 65 years with this type of fracture treated using internal fixation. There were 26 patients who fulfilled these criteria. Twenty-four of the 26 patients were located by telephone and given appointments to receive an X-ray and functional assessment. The 2 patients lost to follow-up were 2 deaths due to causes unrelated to the fracture. Mean follow-up up to the final interview was 42 months (from 15 months to 7 years). Mean patient age was 76.8 years (65–89) and 83% of the patients were women.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Of the 24 patients included in the study, we found 16 cases of intra-articular fractures (Type 13 C1–C3 using the AO classification) and 8 cases of extra-articular fractures (Type 13 A1–A3).</p><p id="par0030" class="elsevierStylePara elsevierViewall">The lesions were caused by own-height falls in all the cases. In 21 of the cases, the fractures were isolated humerus fractures. In 3 cases, there were associated lesions: fracture of the ipsilateral radial head, the ipsilateral coronoid, and the ipsilateral Galeazzi. All cases were closed fractures.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Surgical technique</span><p id="par0035" class="elsevierStylePara elsevierViewall">The surgery was carried out in all the cases using a posterior approach. Olecranon osteotomy was performed in 14 of the patients (all with a Type C fracture pattern) and with transtriceps approach in 10 (2 of which had nondisplaced intra-articular involvement demonstrated using computed axial tomography (CAT scan); the other 8 cases were Type A). Various types of implant were used. Mayo plates (Acumed<span class="elsevierStyleSup">®</span>, Hillsboro, OR, USA) were the most numerous (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>17, using 2 parallel plates in 58.8% of the cases, orthogonal placement in 23.5%, and a single plate in the remaining 17.6%), followed by LCP type (DePuy Synthes, West Chester, PA, USA) (5 cases, in orthogonal placement) and reconstruction plates (DePuy Synthes, West Chester, PA, USA) (2 cases in parallel). The olecranon osteotomy was fixed with transolecranon stems in 3 cases and tension band cerclage in 11.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The ulnar nerve was exposed routinely and 2 anterior subcutaneous transpositions were performed. No patient received a bone graft. The wounds were closed after abundant lavage, without leaving drainage in any of the cases.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Antibiotic prophylaxis was given in all cases, using cefazolin before surgery (2<span class="elsevierStyleHsp" style=""></span>g i.v.) and postoperatively (2<span class="elsevierStyleHsp" style=""></span>g i.v. in 2 doses).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Postoperative period</span><p id="par0050" class="elsevierStylePara elsevierViewall">The mean hospital stay was 3.5 days. We immobilized the elbow with a brachial splint for 7–10 days, after which the patients began elbow mobilization under doctor's orders. All of the patients, except for 2, received physical therapy rehabilitation in the hospital center after removal of the post-surgical immobilization.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Radiographic and functional assessment</span><p id="par0055" class="elsevierStylePara elsevierViewall">For the radiographic assessment, simple X-rays and/or CAT scans were assessed pre-surgically to analyze the fracture pattern and classification using the AO system.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Likewise, during the postoperative period a control X-ray study was performed during the patient interview. Using 2 elbow projections (anteroposterior and lateral), we assessed radiographic consolidation, state of the osteosynthesis material (migration, breakage), and the degree of osteoarthritis according to the Knirk and Jupiter scale.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Functional assessment was effected by measuring the range of mobility with a manual goniometer, evaluating elbow stability, and using the scales of the Mayo Elbow Performance Score (MEPS)<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> (that assesses the arc of joint mobility, stability and functionality of the elbow and the presence or absence of pain) and the Disabilities of the Arm, Shoulder and Hand (DASH)<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> (that assesses the degree of disability).</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Functional evaluation</span><p id="par0070" class="elsevierStylePara elsevierViewall">Mean joint balance was 118.86° in flexion (70–140°) and 25° in extension deficit (0–40°). There were no final limitations in pronation/supination in any cases, not even in those that presented associated fractures of the radial head, coronoid, or distal ulna. There was no elbow instability after forcing elbow varus/valgus.</p><p id="par0075" class="elsevierStylePara elsevierViewall">At the end of follow-up, the mean DASH score was 19.87 (range, 0–63.63). Mean MEPS scale outcome was 85; there were 8 patients with a mean excellent result (90–100), 14 with good (75–89), and 2 patients with a fair result (60–74) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The score obtained in the various parameters that the scales used measure are shown in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Radiographic assessment</span><p id="par0085" class="elsevierStylePara elsevierViewall">The assessment of the degree of X-ray osteoarthritis at the end of follow-up showed that 79.1% of the patients presented Grade 0 or 1 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">All the fractures consolidated except one, which remained as painless pseudo-osteoarthritis in a patient with scant functional demands. In another case, the osteotomy of the olecranon lacked consolidation as well. The patients did not require reoperation in either of these cases.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Complications</span><p id="par0095" class="elsevierStylePara elsevierViewall">With respect to complications directly related to the osteosynthesis material, we found 1 case in a Type A fracture that required reosteosynthesis 1 month after surgery due to displacement from insufficient initial fixation (single posterior plate). The patient was reoperated after 1 month, removing the first implant and synthesizing the fracture again with 2 parallel Mayo plates. In addition, 1 of the tension bands from an olecranon osteotomy was removed and a stem from a plate was extracted due to migration. The osteotomy was consolidated and, in the case of the stem migration, it was unnecessary to remove the rest of the osteosynthesis material.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In the immediate postoperative period, we found 2 cases of surgical wound infection. These were treated with antibiotic therapy, evolving favorably.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Other complications were 2 ulnar neuroapraxias and 1 radial neuropraxia. These recovered fully during follow-up without any associated sequelae (see the summary in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">Osteoporotic bone differs from healthy bone biologically in that it presents lower mineral density (which mainly affects spongy bone), which makes it biomechanically inferior.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This also gives it less resistance, especially to the axial compression forces, facilitating the presence of complex fracture patterns that affect epiphyseal–metaphyseal areas (Type C fractures) with greater frequency. In osteosynthesis, this translates into vacant areas that make it easier for the implant to fail.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> We defined osteoporotic bone according to the presence or absence of risk factors.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> These features make treating these fractures in the elderly a subject for debate in the literature, with therapeutic attitudes that can range from a conservative treatment, an open reduction plus osteosynthesis, or an elbow arthroplasty.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The appearance of new implants designed specially for osteoporotic bone has been a revolution in this sense, decreasing postoperative immobilization time and preventing the appearance of important joint rigidities. In spite of this, some authors defend the performance of a total elbow arthroplasty as the initial treatment in the elderly. McKee et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> carried out a randomized prospective study with 42 patients aged over 65 years with Type C fractures treated by arthroplasty or osteosynthesis with a mean follow-up of 2 years. Patients in the arthroplasty group showed significant improvement in the MEPS scale results both at the beginning and at 2 years of follow-up. However, the results obtained for the DASH scale were the same for both groups at 1 year after the operation. Although the range of reoperation in the osteosynthesis group was higher (27% against 12%), the differences in this aspect were not statistically significant.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Likewise, Frankle et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> compared the results for both functional and mobility in 2 groups of patients older than 65 years treated using internal fixation or arthroplasty in Type C fractures. They recommend the use of total elbow arthroplasty in elderly patients with significant comminution and in those with underlying pathology (rheumatoid arthritis, chronic steroid use, etc.). However, they maintain the recommendation of internal fixation with plates for patients with good bone reserves.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Although in our series, as in others,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> the complications directly related to failure of osteosynthesis material are not high, there are series gathering figures of up to 29.5%.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> It is precisely these high rates of complications with the osteosynthesis material that encourage some authors to use arthroplasty as the initial treatment for these fractures. In our study we found 3 (12.5%) complications derived directly from problems with the osteosynthesis material (break or migration). Two of these complications were minor (1 removal of a tension band and 1 of a stem) without affecting the course or the natural development of the fracture, while the other complication required a new synthesis because the first one turned out to be insufficient.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Another of the parameters that defenders of arthroplasty as initial treatment for these fractures is the presence of less pain following its implantation than following the performance of an open reduction.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–12</span></a> However, the patients in our series presented a mean of 38.12, the entire set falling among the groups with slight or absent pain according to the MEPS scale. These results coincide with those obtained by other authors, with means of 41.7<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and 41.85.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">It is true that the immediate functional results obtained after the arthroplasty were favorable in these studies. However, we should interpret them with caution and bear in mind the long-term complications of elbow prostheses, above all those related to component removal and periprosthetic fractures.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In the postoperative period, we maintained immobilization in all the cases for less than 10 days and with exclusively analgesic and anti-inflammatory purposes. Just as in other studies,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–19</span></a> we consider this essential for rapid recovery of function in elbow surgery on the elderly patient.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Pseudo-osteoarthritis rates after surgical treatment of fractures of the distal humerus are found in the range of 0–11%.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In our series, in spite of the fact that osteoporotic bone is a bone at greater risk of presenting alterations in consolidating (delay or pseudo-osteoarthritis), all of the humerus fractures except 1 (4.16%) consolidated.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Insofar as infection rates in elbow arthroplasty (a complication that is devastating), they are approximately 7–16%<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–18</span></a>; these are slightly higher than those found for osteosynthesis, which are about 2–13%,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–19</span></a> In our series, we found 2 cases of superficial infection (8.3%), which were solved with antibiotic therapy, and 0 cases of deep infection. We consider that appropriate closure with good coverage of osteosynthesis material and pre- and post-surgery antibiotic prophylaxis is essential for preventing this type of complication. In our center, we use cefazolin pre-surgically (2<span class="elsevierStyleHsp" style=""></span>g) and post-surgically (2<span class="elsevierStyleHsp" style=""></span>g in 2 doses) as the protocol.</p><p id="par0155" class="elsevierStylePara elsevierViewall">The presence of symptoms related to the ulnar nerve is another fact to bear in mind. The incidence of severe ulnar neuropathy after prosthesis implantation is approximately 5%,<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17–20</span></a> although it can vary between 2% and 26%<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> (this variability is probably due to the lack of mention of purely sensitive problems in many of the studies). In osteosynthesis, the percentage of ulnar neuropraxia is considerably lower, oscillating between 0%<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and 6.25%.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In our study, we found 2 cases of ulnar neuropraxia (8.3%), and the nerve was left in situ in both cases; its systematic transposition is controversial, with up to 4 times greater possibility of neuritis being described.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Although there is a consensus in the literature as to the fact that advanced age is not a contraindication per se for carrying out a synthesis, we found few studies about the subject.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,13,16,19,23,24</span></a> Our functional results were excellent or good in 92% of the patients; this is in keeping with those obtained by other authors (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), some of whom managed to obtain up to 100% of good and excellent results in their series.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">With respect to the range of mobility obtained after osteosynthesis, we observed a decrease in the arc of mobility mainly affecting flexion-extension (mean of 118.86° of flexion and 25° of deficit in extension) with slight incidence on pronation–supination. This drop in the arc of mobility (already indicated in previous series,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–24</span></a> as the assessment scale demonstrate) is sufficient for the functional requirements of this type of patients, barely altering the quality of life that they perceive.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Our study has several limitations. It is a retrospective study, it includes articular and extra-articular fractures, and the number of patients is relatively small. However, in spite of these limitations, the results obtained show that the treatment of fractures of the distal humerus with appropriate osteosynthesis in patients aged more than 65 years in whom early mobilization is initiated yield good functional results with few complications and reoperations. That is why we recommend osteosynthesis whenever its performance is possible, reserving total elbow arthroplasty just for elderly patients with scant functional requirements who present fractures on which performing a reconstruction is impossible.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Level of evidence</span><p id="par0175" class="elsevierStylePara elsevierViewall">Level of evidence 4.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Ethical responsibilities</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Protection of persons and animals</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that no experiments on human beings or animals were performed for this research.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Data confidentiality</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Right to privacy and informed consent</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflict of interest</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres310854" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction and objective" 2 => "Material and methods" 3 => "Results" 4 => "Discussion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec294074" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres310855" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción y objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Discusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec294075" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Surgical technique" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Postoperative period" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Radiographic and functional assessment" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Functional evaluation" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Radiographic assessment" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Complications" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Level of evidence" ] 9 => array:3 [ "identificador" => "sec0065" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0070" "titulo" => "Protection of persons and animals" ] 1 => array:2 [ "identificador" => "sec0075" "titulo" => "Data confidentiality" ] 2 => array:2 [ "identificador" => "sec0080" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-12-12" "fechaAceptado" => "2013-09-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec294074" "palabras" => array:5 [ 0 => "Elderly" 1 => "Distal humerus fractures" 2 => "Supracondylar humeral fractures" 3 => "Supra-intercondylar humeral fractures" 4 => "Osteosynthesis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec294075" "palabras" => array:5 [ 0 => "Ancianos" 1 => "Fracturas húmero distal" 2 => "Fracturas supracondíleas húmero" 3 => "Fracturas supraintercondíleas húmero" 4 => "Osteosíntesis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Distal humerus fractures in the elderly frequently associated with poor bone quality and comminution, making it harder to achieve proper osteosynthesis. Our aim is to evaluate the radiological and functional results of open reduction and internal fixation of these fractures.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective study of 26 patients treated by open reduction and internal fixation between the years 2005 and 2010. Mean follow-up was 42 months. At final follow-up, a radiography evaluation (Knirk and Jupiter score) and clinical examination using Mayo Elbow Performance Score and Quick-Disabilities of the Arm, Shoulder and Hand Score was performed. Mean age of the group was 76.8 years (65–89), with 83% of the patients being female. Sixteen patients suffered type C fractures and 8 type A by AO classification. All underwent posterior surgical approach.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Mean elbow flexion reached 118.86°, with a mean extension deficit of 25°. More than 3 quarters (79.1%) of the patients showed 0–1 grade degenerative changes on the <span class="elsevierStyleSmallCaps">X</span>-ray films at final follow-up. Functional results reached an average 19.87 points on Quick-Disabilities of the Arm, Shoulder and Hand Score, and 85 points on Mayo Elbow Performance Score. Non-union occurred in 2 cases: distal humerus in one patient and olecranon osteotomy in another. Ulnar nerve neuropraxia was recorded in 2 cases, and radial nerve in one. All 3 recovered uneventfully. Revision surgery was required, with 2 patients needing hardware removal and one a new fixation.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Treatment by open reduction and internal fixation with plating in elderly people for type A and C distal humerus fractures gives good functional results regarding this population, and thus scarcely disturbs their quality of life.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las fracturas de húmero distal en ancianos asocian mala calidad ósea y gran conminución, lo que teóricamente dificultaría la síntesis de las mismas. Nuestro objetivo es evaluar los resultados radiológicos y funcionales del tratamiento mediante reducción abierta y fijación interna de estas fracturas.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo entre los años 2005-2010 de 26 pacientes tratados mediante reducción abierta y fijación interna. Seguimiento medio de 42 meses. Al finalizar el mismo se realizó una valoración radiográfica (Knirk and Jupiter scale) y funcional mediante las escalas Mayo Elbow Performance Score y Quick-Disabilities of the Arm, Shoulder and Hand Score. La edad media fue de 76,8 años (65-89) siendo el 83% mujeres. Se encontraron 16 pacientes con fractura tipo C y 8 tipo A (según la AO). Todos fueron tratados mediante abordaje posterior.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La flexión media fue de 118,86° con un déficit de extensión medio de 25°. El 79,1% de los pacientes presentaban un grado 0-1 de artrosis. La media obtenida en las escalas funcionales fue: Quick-Disabilities of the Arm, Shoulder and Hand Score: 19,87; Mayo Elbow Performance Score: 85. Encontramos 2 casos de seudoartrosis: una de húmero distal y otra de la osteotomía del olécranon. Hallamos 2 casos de neuroapraxias cubitales y una radial que se recuperaron sin secuelas. Hubo 3 reintervenciones: 2 retiradas de material y un caso de nueva osteosíntesis.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Discusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El tratamiento con reducción abierta y osteosíntesis con placa para las fracturas tipo A y C de húmero distal en ancianos proporciona unos resultados funcionales satisfactorios para las demandas de este tipo de paciente, lo que altera escasamente la calidad de vida percibida por los mismos.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Serrano-Mateo L, Lopiz Y, León-Serrano C, García-Fernández C, López-Durán-Stern L, Marco F. Resultados de la reducción abierta y osteosíntesis de fracturas de húmero distal en mayores de 65 años. Rev Esp Cir Ortop Traumatol. 2014;58:31–37.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1384 "Ancho" => 1956 "Tamanyo" => 90800 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Results obtained in the Mayo Elbow Performance Score scale.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 742 "Ancho" => 1916 "Tamanyo" => 62527 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Score obtained over the maximum attainable based on the parameter evaluated in the MEPS system.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 657 "Ancho" => 1666 "Tamanyo" => 44523 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Degree of radiographic osteoarthritis graded according to the Knirk and Jupiter scale.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of fracture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Plating</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="4" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Radiographic osteoarthritis</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">F/E \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MEPS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DASH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complications \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mayo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">LCP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Recons \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">117°/25.5° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">New osteosynthesisRemoval of materialRadial neuropraxia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">119°/24.7° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Removal of material2 ulnar neuropraxiasHumerus pseudo-osteoarthritisOlecranon pseudo-osteoarthritis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab455484.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Results and complications according to fracture type.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Study \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Type of AO fracture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Flexion/extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mayo Elbow Score (mean and percentage of excellent and good results) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Series presented (2012) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A, C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76.8 (65–89) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">118.86°/25° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85Excellent: 33%Good: 59% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Huang et al. (2005)<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C2, C3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">128.4°/16.8° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94.7Excellent: 79%Good: 21% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liu et al. (2009)<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68.7 (62–79) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">125°/22° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93.58Excellent: 78%Good: 22% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frankle et al. (2003)<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C2, C3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73.6 (65–86) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110°/30° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">87.7Excellent: 33.3%Good: 33.3% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Huang et al. (2011)<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">78.1 (67–88) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">112°/20° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83Excellent: 42.85%Good: 21.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Proust et al. (2007)<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">116°/38° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73.3Excellent: 38.25%Good: 23.53%Fair: 14.7%Poor: 29.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Korner et al. (2005)<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">A, B, C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 (61–92) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">120°/20° \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">83Excellent: 20%Good: 37.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pereles et al. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 3 | 8 |
| 2024 October | 14 | 6 | 20 |
| 2024 September | 17 | 5 | 22 |
| 2024 August | 20 | 4 | 24 |
| 2024 July | 22 | 10 | 32 |
| 2024 June | 28 | 7 | 35 |
| 2024 May | 29 | 11 | 40 |
| 2024 April | 18 | 13 | 31 |
| 2024 March | 32 | 11 | 43 |
| 2024 February | 40 | 8 | 48 |
| 2024 January | 31 | 10 | 41 |
| 2023 December | 16 | 7 | 23 |
| 2023 November | 27 | 5 | 32 |
| 2023 October | 22 | 11 | 33 |
| 2023 September | 18 | 4 | 22 |
| 2023 August | 20 | 4 | 24 |
| 2023 July | 14 | 5 | 19 |
| 2023 June | 23 | 7 | 30 |
| 2023 May | 39 | 2 | 41 |
| 2023 April | 15 | 5 | 20 |
| 2023 March | 26 | 8 | 34 |
| 2023 February | 18 | 5 | 23 |
| 2023 January | 21 | 16 | 37 |
| 2022 December | 24 | 4 | 28 |
| 2022 November | 29 | 8 | 37 |
| 2022 October | 22 | 25 | 47 |
| 2022 September | 61 | 35 | 96 |
| 2022 August | 53 | 17 | 70 |
| 2022 July | 55 | 32 | 87 |
| 2022 June | 26 | 40 | 66 |
| 2022 May | 9 | 48 | 57 |
| 2022 April | 13 | 22 | 35 |
| 2022 March | 14 | 9 | 23 |
| 2022 February | 8 | 17 | 25 |
| 2022 January | 8 | 16 | 24 |
| 2021 December | 7 | 10 | 17 |
| 2021 November | 11 | 13 | 24 |
| 2021 October | 7 | 11 | 18 |
| 2021 September | 14 | 12 | 26 |
| 2021 August | 11 | 5 | 16 |
| 2021 July | 7 | 15 | 22 |
| 2021 June | 22 | 10 | 32 |
| 2021 May | 11 | 6 | 17 |
| 2021 April | 21 | 19 | 40 |
| 2021 March | 14 | 16 | 30 |
| 2021 February | 10 | 8 | 18 |
| 2021 January | 4 | 6 | 10 |
| 2020 December | 1 | 0 | 1 |
| 2020 June | 1 | 0 | 1 |
| 2018 February | 13 | 5 | 18 |
| 2018 January | 8 | 5 | 13 |
| 2017 December | 9 | 6 | 15 |
| 2017 November | 13 | 5 | 18 |
| 2017 October | 17 | 5 | 22 |
| 2017 September | 15 | 5 | 20 |
| 2017 August | 15 | 12 | 27 |
| 2017 July | 18 | 7 | 25 |
| 2017 June | 31 | 3 | 34 |
| 2017 May | 19 | 2 | 21 |
| 2017 April | 14 | 2 | 16 |
| 2017 March | 11 | 32 | 43 |
| 2017 February | 9 | 3 | 12 |
| 2017 January | 14 | 0 | 14 |
| 2016 December | 14 | 2 | 16 |
| 2016 November | 8 | 3 | 11 |
| 2016 October | 18 | 4 | 22 |
| 2016 September | 21 | 6 | 27 |
| 2016 August | 5 | 2 | 7 |
| 2016 July | 4 | 1 | 5 |
| 2016 June | 9 | 5 | 14 |
| 2016 May | 10 | 5 | 15 |
| 2016 April | 4 | 8 | 12 |
| 2016 March | 9 | 2 | 11 |
| 2016 February | 11 | 1 | 12 |
| 2016 January | 5 | 0 | 5 |
| 2015 June | 1 | 1 | 2 |
| 2015 January | 1 | 0 | 1 |
| 2014 November | 0 | 1 | 1 |
| 2014 July | 0 | 1 | 1 |
| 2014 February | 1 | 2 | 3 |
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