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Le TGA, Bui KHT, Do HP, Phan NT, Hoang CM, Pham TT, Dinh MN, Nguyen TV, Diep QM, Le KM, Nguyen TV, Nguyen PD. Factors influencing surgical outcomes of fixation with locking plate for three- and four-part proximal humerus fractures in patients aged 50 Years and older. J Hand Microsurg 2024; 16:100127. [PMID: 39234375 PMCID: PMC11369730 DOI: 10.1016/j.jham.2024.100127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 06/27/2024] [Accepted: 07/05/2024] [Indexed: 07/21/2024] Open
Abstract
Background Treating complex three- and four-part proximal humerus fractures, especially in the elderly, remains contentious, with internal fixation using locking plates and shoulder arthroplasty being primary options. Although proximal humerus locking plates are more commonly used than shoulder replacements, they have a high complication rate. Factors like low bone density, advanced age, multiple fragment fractures, and medial cortical support loss negatively impact treatment outcomes. This study evaluates the functional and radiographic outcomes of using locking plates for treating these fractures in patients aged 50 and older, and the factors influencing outcomes and complication rates at the Ho Chi Minh City Hospital for Trauma and Orthopedics. Method A descriptive case series study was conducted on 58 patients aged 50 and older (15 males, 43 females) with three- and four-part proximal humerus fractures. These patients underwent open reduction and internal fixation with Locking - compression plate (LCP) periarticular proximal humerus plates at the Ho Chi Minh City Hospital for Traumatology and Orthopedics (HTO) from April 2020 to April 2022. The minimum postoperative follow-up period was 12 months. Results The average age of the patients was 62.78 ± 7.73 years, with a mean follow-up of 26.24 ± 5.93 months. Among them, 41 had three-part fractures (70.68 %) and 17 had four-part fractures (29.32 %). At the final follow-up (≥12 months), the mean Constant-Murley score was 70.81 ± 9.15, and the mean QDASH score was 8.33 ± 2.77. Complications occurred in 6 cases (10.34 %). Complex fractures, such as four-part fractures with displacement greater than 2 mm, had lower Constant-Murley scores and higher QDASH scores (p < 0.05). Age, gender, bone density by deltoid tuberosity index (DTI), bone grafting, and rotator cuff sutures showed similar trends, but the differences were not statistically significant. Conclusion Open reduction and internal fixation (ORIF) provides good bone healing and functional outcomes for three- and four-part proximal humerus fractures. Factors such as age, gender, bone density, bone grafting, and rotator cuff sutures do not significantly affect outcomes. Therefore, osteoporosis should not be a contraindication for ORIF with locking plates in these cases. Complex fractures, however, often lead to poorer outcomes and higher complication rates post-surgery.
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Affiliation(s)
- Thy Gia Anh Le
- Hospital for Traumatology and Orthopaedics, Ho Chi Minh City, Viet Nam
| | | | - Hung Phuoc Do
- University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
| | - Nguyen Tri Phan
- University of Medicine and Pharmacy, Ho Chi Minh City, Viet Nam
| | - Cuong Manh Hoang
- Hospital for Traumatology and Orthopaedics, Ho Chi Minh City, Viet Nam
| | - Tan Thanh Pham
- Hospital for Traumatology and Orthopaedics, Ho Chi Minh City, Viet Nam
| | - Minh Ngoc Dinh
- Hospital for Traumatology and Orthopaedics, Ho Chi Minh City, Viet Nam
| | - Tan Viet Nguyen
- Hospital for Traumatology and Orthopaedics, Ho Chi Minh City, Viet Nam
| | - Quan Minh Diep
- Hospital for Traumatology and Orthopaedics, Ho Chi Minh City, Viet Nam
| | - Khoa Minh Le
- Hospital for Traumatology and Orthopaedics, Ho Chi Minh City, Viet Nam
| | - Thai Van Nguyen
- Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Viet Nam
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Akgün D, Paksoy A, Imiolczyk JP, Bahlawane S, Gebauer H, Dey Hazra RO, Stöckle U, Braun KF, Moroder P. Intraoperative Doppler flowmetry evaluation of humeral head perfusion after proximal humerus fracture. JSES Int 2024; 8:990-994. [PMID: 39280151 PMCID: PMC11401537 DOI: 10.1016/j.jseint.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2024] Open
Abstract
Background Understanding vascularity and assessing the risk of post-traumatic avascular necrosis are crucial for predicting outcomes and identifying optimal treatment options in proximal humerus fractures (PHFs). Until now, Hertel et al have been the only researchers to evaluate the intraoperative perfusion of the humeral head after fracture using Doppler flowmetry in a central single drill hole within the head. This pilot study aims to standardize the evaluation of intraoperative perfusion measurements in different areas of the humeral head in patients with PHF. Methods In this prospective pilot study, intraoperative semiquantitative Doppler perfusion measurements were conducted during plate osteosynthesis for PHF treatment in our institution between July 2021 and May 2022. The fracture morphology was classified radiologically according to Resch's criteria. Quality of reduction was determined postoperatively to be either anatomical, minor malreduced, or major malreduced according to Peters et al in conventional and computed tomography examinations. Medial hinge integrity and medial metaphyseal extension were assessed radiographically according to Hertel et al. Intraoperatively, after drilling screw holes through the plate, a Doppler probe was inserted through all nine drill holes on the humeral head and at least one on the humeral shaft to successively measure the presence of a pulse to indicate if perfusion is present. Results A total of ten patients (mean age 59 years, range, 36-83) with a humeral head fracture (2 × 2GL, 3 × 3G, 2 × 4G, 2 × 4GL, 1 × 5aG according to Resch) were included. Nine of the ten patients showed a pulse signal on the humeral shaft. Overall, pulse-synchronous perfusion was detected using Doppler sonography in at least one hole in the humeral head of all patients. In patients with an intact medial hinge (N = 6), pulse-synchronous perfusion could be measured in almost twice as many humeral head holes on average (5.7 vs. 3.0 drill holes) compared to patients with a dislocated medial hinge (N = 4). In patients with metaphyseal extension (N = 3), pulse-synchronous perfusion was measured in an average of 6.7 humeral head holes compared to 3.7 holes in patients without metaphyseal extension (N = 7). Conclusion Semiquantitative, intraoperative Doppler flowmetry offers a noninvasive and rapid assessment of humeral perfusion which allows an understanding of humeral head perfusion, when used in a standardized fashion to measure flow in different areas of the humeral head.
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Affiliation(s)
- Doruk Akgün
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Alp Paksoy
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | | | - Soraya Bahlawane
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Henry Gebauer
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | | | - Ulrich Stöckle
- Charité University Hospital, Center for Musculoskeletal Surgery, Berlin, Germany
| | | | - Philipp Moroder
- Orthopaedic clinic, shoulder and elbow surgery, Schulthess Klinik, Zurich, Switzerland
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O'Driscoll CS, Vukanic D, Daly TG, Molony DC, Jemelik P, Pomeroy E, O'Briain DE, Cleary MS. Trends in the surgical management of proximal humerus fractures in Ireland from 2009 to 2022: An increasing usage of reverse shoulder arthroplasty. Ir J Med Sci 2024; 193:1855-1861. [PMID: 38376642 PMCID: PMC11294391 DOI: 10.1007/s11845-024-03625-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/01/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Proximal humeral fractures are a common injury accounting for a significant workload across orthopaedic departments. Though often managed non-operatively, surgical management is indicated for a proportion of patients. AIMS The aim of this study is to examine the trends in the management of proximal humeral fractures within Ireland over the past 13 years. METHODS A retrospective review of Irish Hospital In-Patient Enquiry (HIPE) data was performed between January 2009 and December 2022. Information regarding demographics including age and gender, along with procedure type were collated after patients with proximal humerus fractures, were identified using relevant ICD 10 codes. RESULTS Demographic details remained stable with females and those within the 55-69 year age bracket accounting for the highest proportion of patients. The mean annual number of procedures performed across the study period was 365 (273-508), with an increase from 288 cases in 2009 to 441 in 2022. Open reduction and internal fixation were the most common procedures accounting for 76.4% of cases. There has been a rising usage of total shoulder arthroplasty for fixation with an increase from < 5 cases in 2016 to 84 in 2022. A decrease in the usage of hemiarthroplasty and closed reduction internal fixation was also observed. CONCLUSIONS There has been an increasing volume of operatively managed proximal humeral fractures in Ireland, which sustained despite the 2015 publication of the highly publicised PROPHER trial. The increasing utilisation of total shoulder arthroplasty in acute trauma management is notable and necessitates appropriate training for trauma theatre personnel.
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Affiliation(s)
- Conor S O'Driscoll
- Department of Trauma and Orthopaedics, University Hospital Waterford, Waterford, Ireland.
- Department of Trauma and Orthopaedics, Royal College of Surgeons, Dublin, Ireland.
| | - Danilo Vukanic
- Department of Trauma and Orthopaedics, University Hospital Waterford, Waterford, Ireland
| | - Tiarnán G Daly
- Department of Trauma and Orthopaedics, University Hospital Waterford, Waterford, Ireland
| | - Diarmuid C Molony
- Department of Trauma and Orthopaedics, Tallaght University Hospital, Dublin, Ireland
| | - Petr Jemelik
- Department of Trauma and Orthopaedics, University Hospital Waterford, Waterford, Ireland
| | - Eoghan Pomeroy
- Department of Trauma and Orthopaedics, University Hospital Waterford, Waterford, Ireland
| | - David E O'Briain
- Department of Trauma and Orthopaedics, University Hospital Waterford, Waterford, Ireland
| | - May S Cleary
- Department of Trauma and Orthopaedics, University Hospital Waterford, Waterford, Ireland
- University College Cork, Cork, Ireland
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Boadi PJ, Da Silva A, Mizels J, Joyce CD, Anakwenze OA, Klifto CS, Chalmers PN. Intramedullary versus locking plate fixation for proximal humerus fractures: indications and technical considerations. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:615-624. [PMID: 39157214 PMCID: PMC11329022 DOI: 10.1016/j.xrrt.2024.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
Background The incidence of proximal humerus fractures (PHFs) continues to increase with an aging population, and intramedullary nailing (IMN) and locking plate fixation are two commonly employed techniques for the surgical management of PHF. However, the optimal fixation method can be a source of ongoing controversy. Some influencing factors include the extent of humeral head involvement, fracture complexity, patient age, and surgeon preference. There are many studies that provide a mix of data either when comparing the two techniques or analyzing them in isolation. The aim of this review is to further elucidate the indications and technical considerations involved specifically in IMN vs. locking plate fixation for PHF to further aid orthopedic surgeons when choosing surgical management. Methods A narrative approach was chosen for this review allowing for a comprehensive review of literature, including recent findings pertaining to the comparison of management options for PHF. A comprehensive literature search was conducted using the PubMed, Embase, and Cochrane Library databases. The inclusion criteria involved studies that discussed "proximal humerus fracture" and either "intramedullary nail" or "locking plate fixation." Results Complications such as avascular necrosis, hardware failure, additional surgical interventions, infection, fracture redisplacement, rotator cuff rupture, and nonunion did not show significant differences between the two groups. Newer generation humeral nails have minimized early complications. As both techniques undergo further refinement and utilization when specifically indicated, functional outcomes, potential complications, and postoperative pain continue to be improved. Conclusion The available evidence suggests that both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method. The choice of technique should be tailored to patient factors such as fracture type, age, bone quality, and functional expectations. Surgeon experience also plays a role. While certain presentations may exhibit trends that favor one fixation, no specific technique can be universally recommended. Both IMN and LP have shown comparable and satisfactory outcomes, and the final fixation method chosen should take into account the unique characteristics of each patient.
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Affiliation(s)
| | - Adrik Da Silva
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Josh Mizels
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Oke A. Anakwenze
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Christopher S. Klifto
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Peter N. Chalmers
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
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Curry M, Tornberg H, Fedorka CJ. Single-stage bilateral uncemented reverse shoulder arthroplasty for traumatic proximal humerus fractures: a case report. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:504-510. [PMID: 39157217 PMCID: PMC11329036 DOI: 10.1016/j.xrrt.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Affiliation(s)
- Michael Curry
- Department of Orthopaedic Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Haley Tornberg
- Department of Orthopaedic Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Catherine J. Fedorka
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA
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Liu J, Zhang Z, Ding J, Zhang J, Sheng Q, Piao C. Morphology and novel classification of proximal humeral fractures. Front Bioeng Biotechnol 2024; 12:1366089. [PMID: 39100622 PMCID: PMC11294115 DOI: 10.3389/fbioe.2024.1366089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 07/09/2024] [Indexed: 08/06/2024] Open
Abstract
Background: The morphology of proximal humeral fractures (PHFs) is complex, and the fixation and selection of implants need to be guided by the fracture type and classification, which requires an accurate understanding of the fracture line. This study had three purposes. 1) Define and analyze the fracture lines and morphological features of all types PHFs by three-dimensional (3D) mapping technology. 2) Determine the osteotomy position of the biomechanical model of the PHFs according to the fracture heat map. 3) Based on the analysis of the pathological morphology and distribution of a large number of consecutive cases of PHFs, propose a novel classification of PHFs. Methods: We retrospectively collected 220 cases of PHFs and generated a 3D fracture map and heat map based on computed tomography (CT) imaging. Through analysis of the fracture morphology of the 220 PHFs, a novel classification was proposed. The primary criterion for staging was the continuity between the humeral head and the greater tuberosity and lesser tuberosity, and the secondary criterion was the relationship between the humeral head segment and the humeral shaft. Results: The fracture line was primarily found around the metaphyseal zone of region of the surgical neck, with the most extensive distribution being below the larger tuberosity and on the posterior medial side of the epiphysis. We suggest that the osteotomy gap should be immediately (approximately 5-10 mm) below the lower edge of the articular surface. The most common type of fracture was type I3 (33 cases, 15.0%), followed by type IV3 fracture (23 cases, 10.4%), and type III2 fracture (22 cases, 10.0%). Interobserver and intraobserver reliability analysis for the fracture classification revealed a k value (95% confidence interval) of 0.639 (0.57-0.71) and 0.841, P < 0.01, respectively. Conclusion: In this study, the fracture line and morphological characteristics of PHFs were clarified in detail by 3D mapping technique. In addition, a new classification method was proposed by analysis of the morphological characteristics of 220 PHFs, A two-part fracture model for PHFs is also proposed.
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Affiliation(s)
- Jichao Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Ziyan Zhang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Jie Ding
- Department of Stomatology, The Affiliated Hospital of Changchun University of Traditional Chinese Medicine, Changchun, Jilin Province, China
| | - Jian Zhang
- Radiology Department, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Qian Sheng
- Medical Insurance Office, The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Chengdong Piao
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, Jilin Province, China
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7
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Watts AC, Jenkins CW, Boyle SP, Crowther MAA, Monga P, Packham IN, Smith CC, Thomas WJ, Walton MJ. Superior functional outcome following reverse shoulder arthroplasty compared to hemiarthroplasty for displaced three- and four-part fractures in patients 65 and older: results from a prospective multicenter randomized controlled trial - The shoulder hemiarthroplasty or reverse polarity arthoplasty (SHeRPA) trial. J Shoulder Elbow Surg 2024:S1058-2746(24)00462-2. [PMID: 38960139 DOI: 10.1016/j.jse.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/30/2024] [Accepted: 05/04/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND Acute unreconstructible 3- or 4-part proximal humerus fractures can be treated with hemiarthroplasty or reverse polarity shoulder arthroplasty. Randomized trials using implants from multiple different companies or uncemented implants have found superior results with reverse polarity arthroplasty. HYPOTHESIS We tested the hypothesis that cemented reverse polarity arthroplasty produces a superior outcome compared to cemented hemiarthroplasty using one implant system in patients aged 65 years and over at 12 months follow-up as measured with the Constant Score. METHODS A prospective patient and assessor blinded multicenter randomized controlled trial was conducted of shoulder hemiarthroplasty or reverse polarity arthroplasty in patients aged 65 years and older with acute 3- and 4-part proximal humerus fracture not amenable to osteosynthesis. The primary outcome was the Constant Score at 12 months with total follow-up to 24 months. Block randomization by site was undertaken using random number generation and sealed envelopes. Power analysis indicated that 17 patients were required in each arm to achieve 80% power with an alpha-value of 5%. Secondary outcome measures were the difference in the mean Constant Score, Quick Disabilities of the Arm Shoulder and Hand Questionnaire (QuickDASH), Oxford Shoulder Score, American Shoulder and Elbow Surgeons Score, and EQ5D-5L up to 2 years; differences in complication rate at 1 and 2 years; differences in revision and implant failure at 1 and 2 years. RESULTS Eighteen patients were randomized to hemiarthroplasty and 18 to reverse polarity arthroplasty across 4 sites. The primary outcome as measured by the Constant Score at 12 months was better in the reverse polarity shoulder arthroplasty group (mean 51.1, s.d. 14.9) compared to the hemiarthroplasty group (mean 35.0, s.d. 13.5) (P = .004). No significant difference was reported at 24 months but this may be due to high rates of attrition (22%). The mean EQ-5D-5 L patient rated health status score was significantly higher in the reverse polarity shoulder arthroplasty group compared to the hemiarthroplasty group at 12 months. One hemiarthroplasty was revised due to implant uncoupling and one reverse polarity shoulder replacement was revised due to instability. No other complications were recorded. DISCUSSION Treatment of unreconstructible 3- or 4-part proximal humerus fractures with reverse polarity shoulder arthroplasty results in a superior outcome compared to shoulder hemiarthroplasty at 12 months measured with the Constant Score with no increased risk of failure up to 24 months in patients age 65 years and over. High attrition rates are observed in this older population due to cognitive decline and death from other causes.
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Affiliation(s)
- Adam C Watts
- Upper Limb Research Department, Wrightington Hospital, Wigan, UK.
| | - Christopher W Jenkins
- Department of Orthopaedics, Manchester University NHS Foundation Trust, Manchester, UK
| | - Simon P Boyle
- Department of Orthopedics, York Teaching Hospital, York, UK
| | - Mark A A Crowther
- Department of Trauma and Orthopedic Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Puneet Monga
- Upper Limb Research Department, Wrightington Hospital, Wigan, UK
| | - Iain N Packham
- Department of Trauma and Orthopedic Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Christopher C Smith
- Department of Shoulder and Elbow Surgery, Princess Elizabeth Orthopedics Centre, Royal Devon and Exeter Hospital, Exeter, UK
| | - William J Thomas
- Department of Shoulder and Elbow Surgery, Princess Elizabeth Orthopedics Centre, Royal Devon and Exeter Hospital, Exeter, UK
| | - Michael J Walton
- Upper Limb Research Department, Wrightington Hospital, Wigan, UK
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Bieling M, Ellwein A, Lill H, Sehmisch S, Reeh FM. Proximal humerus fracture and acromioclavicular joint dislocation. Innov Surg Sci 2024; 9:67-82. [PMID: 39100718 PMCID: PMC11294519 DOI: 10.1515/iss-2023-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 12/12/2023] [Indexed: 08/06/2024] Open
Abstract
Proximal humerus fractures and injuries to the acromioclavicular joint are among the most common traumatic diseases of the upper extremity. Fractures of the proximal humerus occur most frequently in older people and are an indicator fracture of osteoporosis. While a large proportion of only slightly displaced fractures can be treated non-operatively, more complex fractures require surgical treatment. The choice of optimal treatment and the decision between joint-preserving surgery by means of osteosynthesis or endoprosthetic treatment is often a difficult decision in which both fracture morphology factors and individual factors should be taken into account. If endoprosthetic treatment is indicated, satisfactory long-term functional and clinical results have been achieved with a reverse shoulder arthroplasty. Injuries to the acromioclavicular joint occur primarily in young, athletic individuals. The common classification according to Rockwood divides the injury into 6 degrees of severity depending on the dislocation. This classification forms the basis for the decision on non-operative or surgical treatment. The indication for surgical treatment for higher-grade injuries is the subject of controversial debate in the latest literature. In chronic injuries, an autologous tendon transplant is also performed. Whereas in the past, treatment was often carried out using a hook plate, which was associated with complications, the gold standard today is minimally invasive treatment using Endobutton systems. This review provides an overview of the two injury patterns and discusses the various treatment options.
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Affiliation(s)
- Maren Bieling
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Hannover, Germany
| | - Alexander Ellwein
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Hannover, Germany
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Helmut Lill
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Hannover, Germany
| | - Stephan Sehmisch
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Freya Margaretha Reeh
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Hannover, Germany
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Chouhan DK, Gaurav A, Patel S. Three-Part Fracture Dislocation and Four-Part Fracture Dislocation of the Proximal Humerus: How Different are the Glenoid Labrum and Capsular Injuries Between Them? Indian J Orthop 2024; 58:755-761. [PMID: 38812863 PMCID: PMC11130090 DOI: 10.1007/s43465-024-01143-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/23/2024] [Indexed: 05/31/2024]
Abstract
Background Anterior fracture dislocation of the shoulder may have associated injury to the glenoid labrum and/or capsule. There is a need to look at the possible patterns of capsulo-labral injuries intra-operatively and correlate them with pre-operative radiographs and CT scans. It can enable surgeons to predict the patterns of soft-tissue injuries in a specific fracture type. Methods Patients operated for ORIF of 3- and 4-part anterior fracture dislocation between January 2017 and December 2022 were included in the study. The following data were collected: demographic details, fracture morphology and classification on radiograph and CT scan, neurovascular injury, the subtype of anterior dislocation, and intra-operative identifiable injury to glenoid labrum and/or capsule. Results A total of 24 cases (mean age 40 ± 10 years) of anterior fracture dislocation of the shoulder were included in the study and were grouped based on Neer's classification. 12 patients had 3-part anterior fracture dislocation (3-part Group) with a mean age of 34 ± 9 years, while 12 patients had 4-part anterior fracture dislocation (4-part Group) with a mean age of 46 ± 7 years (p = 0.001). 10 out of 12 patients in the 3-part Group had the subcoracoid position of the dislocated head, whereas the head was present in 9 out of 12 patients of the 4-part Group at the preglenoid position (p = 0.003). The head position was at a mean distance of 1.85 cm from the anterior glenoid rim in the 4-part Group, whereas the head was engaged at the anterior rim of the glenoid in the 3-part Group. The medial metaphyseal beak was present in 11 out of 12 patients in the 3-part Group, whereas it was absent in all the cases of the 4-part Group (p = 0.001). 92% of the included patients in our study had capsulo-labral injury. 11 out of 12 patients in the 3-part Group had labral injury compared to 10 out of 12 patients in the 4-part Group with severe capsular stripping (p = 0.001). Conclusion The 3-part fracture dislocation with radiological findings such as the long medial metaphyseal beak and subcoracoid position of the dislocated head had a strong association with a glenoid labral injury, whereas the 4-part fracture dislocation type had a widely displaced preglenoid position of the dislocated head with an absent metaphyseal beak and had a strong association with a capsular type of soft-tissue injury. Level of Evidence III.
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Affiliation(s)
- Devendra Kumar Chouhan
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Ankit Gaurav
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, 249203 India
| | - Sandeep Patel
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012 India
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Delbast L, Koneazny C, Baroan C, Niéto H. Results of transosseous suture fixation in four-part valgus impacted fractures of the proximal humerus. Injury 2024; 55 Suppl 1:111345. [PMID: 39069340 DOI: 10.1016/j.injury.2024.111345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/13/2023] [Accepted: 01/14/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND The osteonecrosis ratio in valgus impacted fractures of the proximal humerus is low (<10 %), giving osteosynthesis all its meaning. However, the optimal fixation technique remains controversial. After recentering the humeral head, osteosuture is stable enough to allow bone healing in an adequate position as well as a good long-term shoulder functionality. METHODS Our cohort included 22 patients with a mean age of 65 (28-83). Patients were placed in a beach-chair position. Surgical exposure was done through an anterolateral, transdeltoid approach. Stay sutures were placed on both tuberosities. Elevation of the humeral head was obtained for 9 patients using iliac crest bone graft, for 7 patients using bone substitutes, for 6 without any graft needed. Both tuberosities were approximated and tied together using two horizontal non-absorbable double-threaded sutures. The whole head was also tied to the humeral metaphysis by cerclage wiring using the same suture. Patients were immobilized in a sling for 4 weeks with no passive or active mobilization; then began rehabilitation starting with passive and active-assisted mobilization. Functional outcome was assessed with the Constant score. Radiographic follow-up was used for fracture healing and osteonecrosis signs. RESULTS All fractures united within the first 3 months. One patient had radiographic signs of osteonecrosis and one had a secondary displaced fracture without osteonecrosis. At an average follow-up of 35 months, the median Constant score was 83.7 % (63-100) in comparison to the uninjured side. DISCUSSION A preserved posteromedial periosteal hinge in a valgus impacted fracture of the proximal humerus is key to the success of osteosuture. This hinge provides mechanical stability to the humeral head once elevated, as well as blood-supply from the branches of the posterior circumflex humeral artery. Computed Tomography with Three-Dimensional reconstructed images allow for a precise analysis of this hinge as well as the vascularity of the humeral head. Osteosuture being a minimally invasive surgical procedure plays a predominant role in sparing the remaining vascularization of the humeral head. CONCLUSION Osteosuture in four-part valgus impacted fractures of the proximal humerus is a minimally invasive procedure as well as a reliable technique yielding good long-term results.
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Affiliation(s)
- Laurent Delbast
- Department A of Orthopaedic Surgery and Traumatology, Niort Hospital, 40 avenue Charles de Gaulle BP 70600, 79021 Niort Cedex, France.
| | - Christopher Koneazny
- Department A of Orthopaedic Surgery and Traumatology, Niort Hospital, 40 avenue Charles de Gaulle BP 70600, 79021 Niort Cedex, France
| | - Célestin Baroan
- Department A of Orthopaedic Surgery and Traumatology, Niort Hospital, 40 avenue Charles de Gaulle BP 70600, 79021 Niort Cedex, France
| | - Hervé Niéto
- Department A of Orthopaedic Surgery and Traumatology, Niort Hospital, 40 avenue Charles de Gaulle BP 70600, 79021 Niort Cedex, France
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11
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Anazor FC, Relwani J, Dhinsa BS. Postoperative outcomes of third-generation shoulder hemiarthroplasties for three-and four-part proximal humeral fractures: A systematic review of published studies from 2012 to 2022. J Clin Orthop Trauma 2024; 53:102435. [PMID: 38983585 PMCID: PMC11228791 DOI: 10.1016/j.jcot.2024.102435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 05/19/2024] [Accepted: 06/05/2024] [Indexed: 07/11/2024] Open
Abstract
Background The aim of this study was to provide up-to-date evidence on the outcomes for hemiarthroplasties (HAs) that were performed using modern third-generation prostheses (post-2004) for isolated (excluding head-splits and fracture-dislocations) three-and four-part proximal humerus fractures (PHFs). Methods PubMed, Medline, Embase and the Cochrane register were searched from January 1, 2012, to November 15, 2022, conforming to the PRISMA guidelines. The outcome measures were the complication rates, revision rates, surgery-related postoperative mortality, post-operative clinical outcome scores and radiological outcomes. Results 432 hemiarthroplasties in 432 patients were performed across the 11 eligible studies (two prospective and 9 retrospective). Three studies compared HA versus reverse shoulder replacement (RSR); one study compared HA with locking plate fixation (LPF) and RSR; one study compared HA with LPF. 61.1 % and 19.4 % of hemiarthroplasties were performed using cemented and uncemented techniques respectively, while cementing data was ill-defined in 19.4 % of shoulders. The results for the outcome measures have been derived directly from the included studies and no statistical pooling was performed, due to heterogeneity in the different study designs and outcomes. Descriptive data synthesis from the included studies showed that third generation HAs have higher overall postoperative complication rates, with similar revision and mortality rates when compared to RSR and LPF for three-and four-part PHFs. RSR and LPF showed better statistically significant improvements than HA for the Constant-Murley score, Quick DASH, forward flexion and abduction. Mixed results were observed for the DASH score, ASES score and internal rotation ROM between RSR/LPF versus HA. Conclusion Low to moderate quality evidence from this review showed that even third-generation HA prostheses provided worse overall outcomes than RSR and LPF for three-and four-part PHFs.
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Affiliation(s)
- Fitzgerald Chukwuemeka Anazor
- Specialty Trainee Registrar (ST3), Trauma and Orthopaedic Surgery, East Midlands North (Nottingham) Orthopaedic Rotation, United Kingdom
| | - Jaikumar Relwani
- Consultant Orthopaedic and Trauma Surgeon, Department of Trauma and Orthopaedics, East Kent Hospitals University NHS Foundation Trust, TN 24 0LZ, United Kingdom
| | - Baljinder Singh Dhinsa
- Consultant Orthopaedic and Trauma Surgeon, Department of Trauma and Orthopaedics, East Kent Hospitals University NHS Foundation Trust, TN 24 0LZ, United Kingdom
- Professor of Regenerative Orthopaedics, Canterbury Christchurch University, United Kingdom
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12
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Agrawal U, K VB, Rao HK, R PK, Narayandas DK. Assessment of Functional Outcome and Postoperative Complications in Proximal Humerus Fracture Patients Managed With Proximal Humerus Internal Locking System (PHILOS) Plating. Cureus 2024; 16:e63250. [PMID: 39070483 PMCID: PMC11281970 DOI: 10.7759/cureus.63250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2024] [Indexed: 07/30/2024] Open
Abstract
BACKGROUND Proximal humerus fractures are primarily common in the old age group. The appropriate approach to managing such displaced and comminuted fracture patterns is often questionable. Hence, this study was conducted to assess the functional outcome of proximal humerus fractures following treatment with a proximal humerus locking plate and to assess the frequency of complications in such patients. METHODOLOGY In this robust study, 33 cases of proximal humerus fractures underwent surgical management at a prestigious teaching hospital from February 2021 to August 2022 utilizing a proximal humerus internal locking system (PHILOS) plate. The NEER classification was employed to categorize the fractures, and the NEER score was used for functional assessment. It's crucial to note that individuals with pathological fractures, associated injuries in the ipsilateral limb, nerve injuries, and cases of open fracture were rigorously excluded from the study. RESULTS The mean age was 47 ± 5.2 years. Based on NEER's classification, the distribution of fractures was as follows: two-part fractures accounted for 18.18% (n = 6) of cases, three-part fractures for 54.54% (n = 18) of cases, and four-part fractures for 27.27% (n = 9) of cases. A history of road traffic accidents and falls was reported in 54.54% (n = 18) and 45.45% (n = 15) of cases, respectively. Functional outcome assessment utilizing NEER's score revealed a minimum score of 48 and a maximum of 96, with an average score of 82.96 ± 12.73. Notably, 39% of patients demonstrated excellent results, 27% exhibited satisfactorily, 21% manifested unsatisfactorily, and 12.12% presented failure outcomes. Of the 33 operated cases, 81.8% (n = 27) exhibited no complications during follow-up. The predominant complication observed was shoulder stiffness (9.09%, n = 3), followed by Varus mal-union (6.06%, n = 2), and superficial surgical site infection (3.03%, n = 1), managed with debridement and antibiotics leading to subsequent resolution. CONCLUSIONS Managing proximal humerus fractures has consistently posed a formidable challenge. Our study indicates that using the PHILOS plate represents a reliable option for addressing such fractures. This plate provides sturdy fixation, facilitates early mobilization, and culminates in exceptional functional outcomes. The insights gained from this study can inform clinical decision-making and guide orthopedic surgeons in selecting the appropriate treatment strategy for proximal humerus fracture patients.
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Affiliation(s)
- Udit Agrawal
- Pediatric Orthopedics, King George's Medical University, Lucknow, IND
| | - Vaibhav B K
- Pediatric Orthopedics, King George's Medical University, Lucknow, IND
| | - Harsh Kirthi Rao
- Orthopedics and Traumatology, Srinivas Institute of Medical Sciences and Research Center, Mangalore, IND
| | - Praseeth K R
- Pediatric Orthopedics, King George's Medical University, Lucknow, IND
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13
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Zhang Z, Li Y, Zhao Y, Lu Y, Zhu Y, Jiang C. What Are the Long-term Outcomes of Locking Plates for Nonosteoporotic Three-part and Four-part Proximal Humeral Fractures With a Minimum 10-year Follow-up Period? Clin Orthop Relat Res 2024; 482:831-840. [PMID: 37874956 PMCID: PMC11008622 DOI: 10.1097/corr.0000000000002895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/19/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Proximal humeral fractures (PHFs) often occur in elderly individuals who experience low-energy falls. Open reduction and internal fixation (ORIF) of the proximal humerus is typically performed in young, active patients because of their good bone quality and high functional demands. Although good short-term results have been reported after ORIF in young patients, few studies have specifically evaluated long-term outcomes. QUESTIONS/PURPOSES (1) What are the long-term clinical outcomes scores and (2) radiologic outcomes of nonosteoporotic three-part and four-part PHFs treated with locking plates? (3) What complications occurred after treatment, and what factors are associated with poor postoperative functional outcomes scores and avascular necrosis (AVN) of the humeral head after ORIF? METHODS Between June 2005 and December 2012, we surgically treated 774 patients for displaced two-, three-, and four-part PHFs. Approximately 75% (581 of 774) underwent ORIF, 10% (77 of 774) underwent hemiarthroplasty, 7% (54 of 774) underwent intramedullary nailing, 5% (39 of 774) underwent reverse shoulder arthroplasty, and the remaining 3% (23 of 774) underwent other surgical treatments. We considered those who had ORIF as potentially eligible. Based on that criterion, 75% (581) were eligible. However, only patients with nonosteoporotic three- and four-part PHFs (cortical thickness of the proximal humeral diaphysis greater than 6 mm on a preoperative AP radiograph of the affected shoulder) and a minimum of 10 years of follow-up were included. Sixty-four percent (498 of 774) of the patients were excluded because of simple or osteoporotic fractures, 1% (7 of 774) were excluded because of ipsilateral limb multiple fractures, 0.3% (2 of 774) were excluded because of pathologic PHFs, and another 2% (13 of 774) were lost before the minimum study follow-up of 10 years, leaving 8% (61 of 774) for analysis here. The mean age at surgery was 45 ± 12 years, with a mean follow-up of 13 years. Fifty-seven percent (35 of 61) of the patients were men. Patient-reported outcomes were evaluated using the University of California Loas Angeles (UCLA) score (range 0 to 35; higher scores represent better shoulder function) and Constant score (range 0 to 100; higher scores represent better shoulder function) at least 10 years postoperatively. Postoperative radiographs were reviewed to assess the cortical bone thickness of the proximal humerus, neck-shaft angle, head-to-tuberosity distance, and radiologically confirmable complications. Logistic regression analysis was performed to evaluate factors associated with poor postoperative functional scores (UCLA score ≤ 27 or Constant score ≤ 70) and AVN of the humeral head; the association between AVN and postoperative functional outcomes was also assessed. RESULTS At the most-recent follow-up, these patients had a mean UCLA score of 31 ± 3 and a Constant score of 88 ± 10. The mean neck-shaft angle was 133° ± 10°, and 23% (14 of 61) of patients experienced AVN of the humeral head during follow-up. Twenty-nine complications in 30% (18 of 61) of patients were reported. After controlling for potentially confounding variables such as age and gender, we found that the presence of greater tuberosity malposition (odds ratio 18 [95% confidence interval 2 to 167]; p = 0.01) and immediate postoperative neck-shaft angle less than 130° (OR 19 [95% CI 3 to 127]; p = 0.002) were associated with poor postoperative functional scores. Four-part PHFs (OR 13 [95% CI 2 to 82]; p = 0.008) and metaphyseal extension less than 8 mm (OR 7 [95% CI 1 to 35]; p = 0.03) were associated with AVN of the humeral head. For patients who met the criteria for anatomic reduction (achievement of all of the following three criteria: neck-shaft angle ≥ 130°, head-shaft displacement < 5 mm, and head-to-tuberosity distance greater than or equal to 3 mm and less than or equal to 20 mm), there were no differences in postoperative functional scores between patients with AVN and those without. CONCLUSION ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up. When encountering complex PHFs in patients with good bone quality, every effort must be made to achieve an anatomic reduction of the fracture as far as possible, which may not reduce the risk of AVN (this occurred in nearly one-fourth of patients). However, good outcomes can usually be expected, even in patients with AVN. Because this was a retrospective study with a high risk of bias owing to sparse data, the factors associated with poor postoperative functional outcomes must be further investigated in large prospective studies. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Zhijun Zhang
- Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Xi Cheng District, Beijing, PR China
| | - Yijun Li
- Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Xi Cheng District, Beijing, PR China
| | - Yang Zhao
- Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Xi Cheng District, Beijing, PR China
| | - Yi Lu
- Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Xi Cheng District, Beijing, PR China
| | - Yiming Zhu
- Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Xi Cheng District, Beijing, PR China
| | - Chunyan Jiang
- Sports Medicine Service, Beijing Jishuitan Hospital, Capital Medical University, Xi Cheng District, Beijing, PR China
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Matheron G, Mahoney M, Domos P. Conservative treatment of 3- and 4-part proximal humeral fractures: Can poor outcomes be predicted? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2031-2040. [PMID: 38517527 DOI: 10.1007/s00590-024-03890-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/28/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE 3- and 4-part proximal humeral fractures are frequently treated conservatively. This study aims to combine radiographic, and patient reported outcome data to identify factors leading to poor outcomes following conservative treatment. METHODS A retrospective local database analysis identified 3- and 4-part fractures. Radiographic and functional outcomes including Oxford Shoulder Score (OSS), QuickDash (QD), Subjective Shoulder Score (SSV) and VAS pain scores were collected. RESULTS 104 patients were included at mean follow-up of 55 months. Analysis highlighted significant OSS differences in 3- versus 4-part (p = 0.027), dominant arm injury (p = 0.046), age > 65 (p = 0.006), varus coronal neck-shaft angle < 115 versus 115-155 degrees (p = 0.008), posterior head tilt > 155 degrees (p = 0.005), greater tuberosity (GT) displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.032). According to QD scores; age > 65 (p = 0.012), varus neck-shaft angle (p = 0.01), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.006). SSV varied significantly with 3- versus 4-part fractures (p = 0.005), age > 65 (p = 0.04), varus neck-shaft angle (p = 0.001), posterior head tilt (p = 0.005), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.003), and medial calcar hinge displacement > 2 mm (p = 0.001). CONCLUSION We highlight risk factors for unfavourable outcomes following conservative management, aiding surgeons in shared decision-making and patient expectation management.
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Affiliation(s)
- George Matheron
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK.
| | - Melissa Mahoney
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK
| | - Peter Domos
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK
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Fares MY, Boufadel P, Koa J, Vadhera AS, Singh J, Abboud JA. Top fifty cited articles on humeral fractures. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:153-160. [PMID: 38706674 PMCID: PMC11065750 DOI: 10.1016/j.xrrt.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Background Humeral fractures (HF) are common orthopedic pathologies. Reviewing the content and quality of influential literature over time is important to advance scientific research regarding a specific topic. This study aims to explore and appraise the fifty most cited HF studies that had been published in orthopedic literature. Methods The Web of Science database was used to conduct a systematic search for articles pertaining to HF. Articles were sorted out in descending order of citations and were included based on their relevance to HF. Data and metrics of the included studies were recorded. The methodological quality of the studies was assessed using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies criteria. Statistical analysis was conducted to explore any significant relationships between the date of publication and other relevant variables. Results Included articles (N = 50) were published between 1959 and 2015, with a total of 14,864 accumulated citations. Europe and North America contributed to all but one of the included studies. The Journal of Bone and Joint Surgery contributed to the highest number of included articles with 27 articles (54%). The proximal humerus was the most commonly explored HF location in our study (72%). The average MCMS and Methodological Index for Non-randomized Studies scores were reported to be 64.6 and 10.4, respectively, and the majority of articles (52%) were considered level four case series. Year of publication was found to have a positive correlation with increasing level of evidence(r = -0.301, P = .044), citation density (r = 0.734, P < .001), and MCMS score (r = 0.41, P = .01). Conclusion The level of evidence, MCMS scores, and citation density of influential HF literature has been increasing with time, reflecting the increasing effort and work being put in that field. While the findings seem encouraging, additional high-quality research is needed to help achieve better treatment strategies and outcomes.
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Affiliation(s)
- Mohamad Y. Fares
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Peter Boufadel
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Jonathan Koa
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Amar S. Vadhera
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Jaspal Singh
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Joseph A. Abboud
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Hameleers A, Boonen B, Most J, Dremmen M, Schotanus MGM, Van Vugt R. Permissive Weight Bearing in Proximal Humeral Fracture Management: A Survey-Based Inquiry in the Netherlands. Cureus 2024; 16:e57670. [PMID: 38707136 PMCID: PMC11070209 DOI: 10.7759/cureus.57670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2024] [Indexed: 05/07/2024] Open
Abstract
Purpose Proximal humeral fractures (PHF) are common, particularly among the elderly due to low-energy trauma. Adequate rehabilitation is essential for functional recovery, whether through conservative or surgical treatment. Permissive weight bearing (PWB) is a relatively new rehabilitation concept, characterized by earlier mobilization of the affected limb/joint after trauma. Multiple studies demonstrated the value of PWB for the lower extremities, but this has not been translated to the upper extremity (i.e. PHF). Therefore, our aim was to investigate the current state and variability of rehabilitation of PHF and the role of implementing PWB principles in aftercare. Materials and methods An online survey, comprising 23 questions about the treatment of PHF, was distributed amongst an estimated 800 Dutch orthopaedic and trauma surgeons via the Dutch Orthopaedic and Dutch Trauma Society newsletter from May 2021 until July 2021. Results Among 88 respondents (n=69 orthopaedic, n=17 trauma surgeons, and n=2 other), most recommended early post-trauma mobilization (<6 weeks). Additionally, 53.4% (n=49) advised starting load bearing after six weeks for conservatively treated patients and 59.8% (n=52) for operative treatment. A wide variation of exercises used after immobilization was found in both groups. The usage of a sling after operative treatment was advised by 86% (n=74) of all 86 respondents. Conclusions The present study found limited consensus about PHF aftercare and the implementation of weight-bearing principles. The majority recommended early mobilization and advised the usage of a sling. A protocol capable of accommodating the diversity in aftercare (e.g. fracture type) is essential for maintaining structured rehabilitation, with PWB emerging as a promising example. More prospective studies are needed to form an evidence-based protocol focusing on the aftercare of PHF.
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Affiliation(s)
- Amber Hameleers
- Department of Orthopedic Surgery, Zuyderland Medical Center, Sittard-Geleen, NLD
- Department of Surgery, Maastricht University Medical Center+, Maastricht, NLD
| | - Bert Boonen
- Department of Orthopedic Surgery, Zuyderland Medical Center, Sittard-Geleen, NLD
| | - Jasper Most
- Department of Orthopedic Surgery, Zuyderland Medical Center, Sittard-Geleen, NLD
| | - Martijn Dremmen
- Department of Rehabilitation Medicine, Zuyderland Medical Center, Heerlen, NLD
| | | | - Raoul Van Vugt
- Department of Surgery, Zuyderland Medical Center, Heerlen, NLD
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Claro R, Barros B, Ferreira C, Ribau A, Barros LH. Comparative analysis of proximal humerus fracture management in elderly patients: complications of open reduction and internal fixation by shoulder surgeons and non-shoulder surgeons-a retrospective study. Clin Shoulder Elb 2024; 27:32-38. [PMID: 38268320 PMCID: PMC10938022 DOI: 10.5397/cise.2023.00626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/12/2023] [Accepted: 09/24/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Open reduction and internal fixation (ORIF) with a locking plate is a popular surgical treatment for proximal humeral fractures (PHF). This study aimed to assess the occurrence of complications in elderly patients with PHF treated surgically using ORIF with a locking plate and to investigate the potential differences between patients treated by shoulder surgeons and non-shoulder surgeons. METHODS A retrospective study was conducted using a single-center database to identify patients aged ≥70 years who underwent ORIF for PHF between January 1, 2011, and December 31, 2021. Data on the Neer classification, follow-up, occurrence of avascular necrosis of the humeral head, implant failure, and revision surgery were also collected. Statistical analyses were performed to calculate the overall frequency of complications according to the Neer classification. RESULTS The rates of implant failure, avascular osteonecrosis, and revision surgery were 15.7%, 4.8%, and 15.7%, respectively. Complications were more common in patients with Neer three- and four-part fractures. Although the difference between surgeries performed by shoulder surgeons and non-shoulder surgeons did not reach statistical significance, the rate of complications and the need for revision surgery were nearly two-fold higher in the latter group. CONCLUSIONS PHF are highly prevalent in the elderly population. However, the ORIF surgical approach, as demonstrated in this study, is associated with a considerable rate of complications. Surgeries performed by non-shoulder surgeons had a higher rate of complications and a more frequent need for revision surgery. Future studies comparing surgical treatments and their respective complication rates are crucial to determine the optimal therapeutic options. Level of evidence: III.
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Affiliation(s)
- Rui Claro
- Department of Orthopaedics, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Shoulder Unit, Department of Orthopaedics, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto, Porto, Portugal
| | - Bianca Barros
- Department of Orthopaedics, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Carlos Ferreira
- Department of Orthopaedics, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Department of Orthopaedics, Centro Hospitalar de Leiria, Hospital de Santo André, Leiria, Portugal
| | - Ana Ribau
- Department of Orthopaedics, Centro Hospitalar do Médio Ave, Famalicão, Portugal
| | - Luis Henrique Barros
- Department of Orthopaedics, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Shoulder Unit, Department of Orthopaedics, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto, Porto, Portugal
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Sapienza M, Pavone V, Muscarà L, Panebianco P, Caldaci A, McCracken KL, Condorelli G, Caruso VF, Costa D, Di Giunta A, Testa G. Proximal humeral multiple fragment fractures in patients over 55: Comparison between Conservative treatment and Plate Fixation. Heliyon 2024; 10:e25898. [PMID: 38375257 PMCID: PMC10875435 DOI: 10.1016/j.heliyon.2024.e25898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/21/2024] Open
Abstract
Proximal humerus fractures account for about 5% of fragility fractures. These involve a significant burden of disability and a reduced quality of life. This study aims to compare functional results and surgical outcomes (closed reduction and internal fixation with the internal closure system of the proximal humerus) and the conservative management of proximal humerus fractures by 2-, 3-, 4-parts, in patients older than 55 years. Between January 2017 and April 2019, 65 patients with 2, 3 or 4-part fractures were retrospectively analyzed: 29 patients (5 males and 24 females) with an average age of 70.8 ± 9.9 years treated non-surgically (conservative group (CG)) and 36 patients (11 males and 25 females) with an average age of 66.2 ± 7.1 years treated surgically with plate fixation (operating group (OG)). Using different evaluation scores, we compared the OG and the CG. Through the DASH score we have seen how at 12 months there is a satisfactory result in patients with conservative treatment (p = 0.0019). Constant-Murley scale shows no difference between the two treatments (p = 0.2300). BARTHEL scale and SST score did not give statistically satisfactory results. Also, after one year of follow-up, patients treated with conservative therapy had a higher improvement in their Range of Motion (ROM) values than patients treated with surgical treatment. The results in terms of pain in NPRS at 3, 6, 12 months are better for conservative groups (p = 0,0000). Our findings suggest that conservative treatment in proximal humeral fractures, particularly in multi-fragmented fractures in patients over 55 years of age, designs an excellent alternative to the surgical option.
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Affiliation(s)
- Marco Sapienza
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Vito Pavone
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Liliana Muscarà
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Pierpaolo Panebianco
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Alessia Caldaci
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | | | - Giuseppe Condorelli
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Vincenzo Fabrizio Caruso
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Danilo Costa
- Orthopaedic Division of Policlinico “G.B. Morgagni”, 95125, Catania, Italy
| | - Angelo Di Giunta
- Orthopaedic Division of Policlinico “G.B. Morgagni”, 95125, Catania, Italy
| | - Gianluca Testa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
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Sandau N, Aagaard TV, Hróbjartsson A, Harris IA, Brorson S. Transitivity, coherence, and reliability of network meta-analyses comparing proximal humerus fracture treatments: a meta-epidemiological study. BMC Musculoskelet Disord 2024; 25:14. [PMID: 38166880 PMCID: PMC10759380 DOI: 10.1186/s12891-023-07119-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 12/14/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Network meta-analyses can be valuable for decision-makers in guiding clinical practice. However, for network meta-analysis results to be reliable, the assumptions of both transitivity and coherence must be met, and the methodology should adhere to current best practices. We aimed to assess whether network meta-analyses of randomized controlled trials (RCTs) comparing interventions for proximal humerus fractures provide reliable estimates of intervention effects. METHODS We searched PubMed, EMBASE, The Cochrane Library, and Web of Science for network meta-analyses comparing interventions for proximal humerus fractures. We critically assessed the methodology regarding the development of a protocol, search strategy, trial inclusion, outcome extraction, and the methods used to conduct the network meta-analyses. We assessed the transitivity and coherence of the network graphs for the Constant score (CS), Disabilities of the Arm, Shoulder, and Hand score (DASH), and additional surgery. Transitivity was assessed by comparing probable effect modifiers (age, gender, fracture morphology, and comorbidities) across intervention comparisons. Coherence was assessed using Separating Indirect from Direct Evidence (SIDE) (Separating Indirect from Direct Evidence) and the design-by-treatment interaction test. We used CINeMA (Confidence in Network Meta-analyses) to assess the confidence in the results. RESULTS None of the three included network meta-analyses had a publicly available protocol or data-analysis plan, and they all had methodological flaws that could threaten the validity of their results. Although we did not detect incoherence for most comparisons, the transitivity assumption was violated for CS, DASH, and additional surgery in all three network meta-analyses. Additionally, the confidence in the results was 'very low' primarily due to within-study bias, reporting bias, intransitivity, imprecision, and heterogeneity. CONCLUSIONS Current network meta-analyses of RCTs comparing interventions for proximal humerus fractures do not provide reliable estimates of intervention effects. We advise caution in using these network meta-analyses to guide clinical practice. To improve the utility of network meta-analyses to guide clinical practice, journal editors should require that network meta-analyses are done according to a predefined analysis plan in a publicly available protocol and that both coherence and transitivity have been adequately assessed and reported.
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Affiliation(s)
- Nicolai Sandau
- Centre for Evidence-Based Orthopedics, Department of Orthopedic Surgery, Zealand University Hospital, Køge, Denmark.
| | - Thomas Vedste Aagaard
- The Research and Implementation Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Naestved-Slagelse-Ringsted Hospitals, Naestved, Denmark
- The Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense (CEBMO), and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales (UNSW Sydney), Liverpool, NSW, Australia
| | - Stig Brorson
- Centre for Evidence-Based Orthopedics, Department of Orthopedic Surgery, Zealand University Hospital, Køge, Denmark
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Ou Z, Feng Q, Peng L, Zhou M, Rai S, Tang X. Risk factors for osteonecrosis of the humeral head after internal fixation of proximal humeral fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2024; 144:31-40. [PMID: 37566131 DOI: 10.1007/s00402-023-05020-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/26/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Osteonecrosis of the humeral head (ONHH) is a severe complication after the internal fixation of proximal humeral fractures (IFPHF). The risk factors remain controversial though many studies have reported. In this research, meta-analysis was used to evaluate which surgeon-level factors can be modified to lower the risk and we hope to provide evidence-based support for preventing ONHH. METHODS Literature was retrieved from PubMed, Cochrane Library, Embase, Web of Science, and Scopus for eligible studies published up to January 2023. The pooled odds ratios (ORs) were calculated with their corresponding 95% confidence intervals (CIs) to evaluate. STATA 15.1 software was applied for data synthesis, sensitivity synthesis, and publication bias. RESULTS 45 articles were published between 2000 and 2022, and 2482 patients were finally included. All articles were observational research, with 7 case-control studies and 38 cohort studies, and the Newcastle Ottawa Scale (NOS) score ranged from 7 to 9. The pooled results suggested that age (OR 0.32, 95% CI 0.14-0.74, P = 0.01), reduction quality (OR 0.08, 95% CI 0.01-0.44, P = 0.00), fracture type (OR 0.44, 95% CI 0.25-0.78, P = 0.01), surgical approach (OR: 4.06, 95% CI 1.21-13.61, P = 0.02) and fixation implant (OR = 0.68, 95% CI = 0.34-1.33, P = 0.02) were risk factors for ONHH after IFPHF. According to sensitivity analysis, Begg (P = 0.42) and Egger (P = 0.68) tests, the results were stable and exhibited no publication bias. CONCLUSIONS The study showed that age, reduction quality, fracture type, surgical approach and fixation implant were risk factors for ONHH after IFPHF, while gender, varus or valgus, timely operation, injured side, and the existence of medial support have little influence on ONHH, as they could not be considered risk factors and still need further investigations.
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Affiliation(s)
- ZiXuan Ou
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - QiYuan Feng
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - LianQi Peng
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - MinQi Zhou
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Orthopaedics, Al Ahalia Hospital, Abu Dhabi, United Arab Emirates
| | - Xin Tang
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Doursounian L, Gregory T, Miquel A. A prognostic classification of proximal humerus fractures: the cephalic extension staging. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:143-153. [PMID: 37378734 DOI: 10.1007/s00590-023-03626-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE Recent publications emphasized the role of dorsomedial metaphyseal extension of humeral head as predictor of ischemia after complex proximal humerus fractures (PHFs). We evaluated on preoperative 3D CT scan of PHFs the surface of this metaphyseal extension and its prognostic value on the occurrence of avascular necrosis (AVN). METHODS We followed a series of 25 fixations of complex PHF which had a preoperative 3D CT scan and measured the surface area of the posterior metaphyseal extension (PME) of the head. Using approximations, we calculated the ratio between the PME surface area (PMS) and the articular surface area of the head (HS). The PMS/HS ratio was analyzed against the risk of AVN. RESULTS The measurement of the PMS/HS ratio emphasizes the significance of PME. The incidence of AVN is correlated with the magnitude of PME. Therefore, we include the PME as a fifth element in the characterization of complex PHFs and we propose a 4-stage prognostic classification based on the number of extensions of the humeral head. The head may have 3 extensions: posteromedial (PME), lesser tuberosity (LTE) and greater tuberosity (GTE). The risk of AVN decreases with the number of extensions of the head. CONCLUSION Our study demonstrates a correlation between the occurrence of AVN and the size of PME in complex PHF cases. We propose a four-stage classification system to facilitate treatment decision-making between fixation and prosthesis.
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Affiliation(s)
- Levon Doursounian
- Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, 75012, Paris, France.
| | - Thomas Gregory
- Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, 93000, Bobigny, France
| | - Anne Miquel
- Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, 75012, Paris, France
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Bekmezci T, Çepni SK, Demir T. Greater tuberosity medial malposition: does it affect shoulder abductor moment? INTERNATIONAL ORTHOPAEDICS 2024; 48:159-167. [PMID: 37670197 DOI: 10.1007/s00264-023-05967-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/30/2023] [Indexed: 09/07/2023]
Abstract
PURPOSE The detrimental effect of greater tuberosity malposition on functional scores is well known. Superior or posterior malpositions exceeding five mm lead to excessive loading on the deltoid strength. However, the significance of situations where greater tuberosity becomes medialized due to the compressive effect of the locking plate fixation, especially in fractures with metaphyseal dead space, has not been emphasized. It is hypothesized that this condition may cause shortening of the rotator cuff moment arm and consequently impact functional scores. METHODS Between 2012 and 2018, 52 patients, aged 65,28 (ranging 40-85) proximal humerus fractures treated with locking plate fixation were included in the study. Cephalodiaphyseal angle, greater tuberosity displacement , patients reported outcome and Constant-Murley scores were evaluated. RESULTS The mean Constant Murley score was determined to be 78.76 (ranging from 38 to 100). According to the patients reported outcome 39 excellent , five good , two fair, six poor results were observed. Avascular necrosis with screw migration was detected in five cases, while one patient experienced implant insufficiency along with varus deformity. Greater tuberosity was found to be positioned between 6 mm posterior-superior and -13 mm medial. Significant medial malposition was observed in three patients, with -9, -12, and -13 mm of medialization, respectively. Cephalodiaphysial angle was determined as 139.30 degrees (ranging from 120 to 150 degrees) and showed weak correlation with the functional score. Greater tuberosity medialization also showed weak correlation with the Constant-Murley score. The values exhibiting deviation were associated with low patient-reported outcome results and functional scores. In the examination of greater tuberosity displacement values, it was observed that Neer type 3 and 4 fractures differed significantly from Neer type 2 fractures regarding to Kruskal-Wallis test. CONCLUSIONS Medial impaction of greater tuberosity may be the reason of decreased functional scores, similar to superior or posterior malposition. The medialization of greater tuberosity should be considered as a potential factor leading to the shortening of the rotator cuff's abductor moment.
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Affiliation(s)
- Taner Bekmezci
- Physiotheraphy and Rehabilitation Department, T.C. Istanbul Yeni Yüzyıl University Faculty of Health Sciences, Maltepe Mahallesi, Yılanlı Ayazma Caddesi, No: 26 P.K. 34010 Cevizlibağ, Zeytinburnu, İstanbul, Turkey.
| | - Serdar Kamil Çepni
- Orthopaedics and Traumatology Department, University of Health Sciences Istanbul Umraniye Training and Research Hospital, Elmalıkent Mahallesi Adem Yavuz Cad. No:1 Ümraniye, İstanbul, Turkey
| | - Tuğcan Demir
- Orthopaedics and Traumatology Department, Giresun University Faculty of Medicine, Gazipaşa Yerleşkesi Debboy Mevkii P.K.:28200 Merkez, Giresun, Turkey
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Opperman FLJ, Blaas LS, Pape M, Buijs N, Sterkenburg MV, Yuan JZ, Lameijer CM, Derksen RJ. Fibula allograft in complex three-part and four-part proximal humeral fractures in active patients, a matched case-control study. JSES Int 2024; 8:21-26. [PMID: 38312278 PMCID: PMC10837717 DOI: 10.1016/j.jseint.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background About 20% of proximal humerus fractures (PHFs) are unstable and/or markedly displaced and therefore require surgery. Locking plate fixation after anatomical reduction has become the current treatment of choice for these fractures in the active population. However, studies have shown complication rates up to 36%, such as loss of reduction and avascular necrosis. To date, data from literature are inconclusive on outcomes following the use of an intramedullary fibula allograft in PHFs, possibly due to the case mix. It is hypothesized that the use of a fibula allograft is beneficial to prevent secondary displacement of the fracture in cases where the medial hinge is markedly displaced and unstable, resulting in better clinical and patient reported outcomes. Methods In this multicenter matched cohort study, patients with an unstable, displaced PHF, including anatomic neck fractures and significantly displaced surgical neck fractures, were included. Patients that were treated with a locking plate augmented with a fibula allograft were matched to patients who had undergone locking plate reconstruction without the allograft. The matches were made based on fracture characteristics, age, and performance status. Functional outcomes, Patient Reported Outcome Measures, complications, and radiographic results were compared. Results Twelve patients with fibula allograft augmented osteosyntheses were included and matched to 12 control patients. The mean age was 58 years in the fibula allograft group compared to 62 years in the control group. Minimum follow-up was 12 months. Disability of the Arm Shoulder and Hand score, Constant Shoulder score, abduction, and external rotation were significantly better in the fibula allograft group (17.4 ± 8.6 vs. 26.1 ± 19.2, P = .048; 16.5 ± 11.5 vs. 19.8 ± 16.5 P = .040; mean 127° ± 38° vs. mean 92° ± 49° P = -.045; 50° ± 21° vs. mean 26° ± 23°, P = .004). There was no statistically significant difference in the Oxford Shoulder score between groups (P = .105). The Visual Analog Scale was not significantly different between groups (3.1 ± 1.8 vs. 1.6 ± 1.9, P = .439). Radiographic union was reached in 11 patients of the fibula allograft group compared to 8 in the control group (P = .317). The complication rate was twice as high in the control group (3 vs. 7). Conclusion Additional support of the medial hinge in unstable PHFs with a locking plate in combination with a fibula allograft appears to create a more stable construct without compromising the viability of the articular surface of the head. The use of a fibula allograft in selected complex cases could therefore result in better clinical outcomes with lower complication rates.
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Affiliation(s)
| | - Leanne S. Blaas
- Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
- Department of Surgery, Zaandam Medical Center, Zaandam, The Netherlands
| | - Merel Pape
- Department of Surgery, Zaandam Medical Center, Zaandam, The Netherlands
| | - Nikki Buijs
- Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | | | - Jian Zhang Yuan
- Department of Surgery, Zaandam Medical Center, Zaandam, The Netherlands
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Klute L, Henssler L, Schliemann B, Königshausen M, Weber N, Alt V, Kerschbaum M. Factors influencing choice of treatment for proximal humeral fractures elaborated in a Delphi consensus process. Arch Orthop Trauma Surg 2023; 143:7053-7061. [PMID: 37658856 PMCID: PMC10635939 DOI: 10.1007/s00402-023-05028-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/09/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION Hitherto, the decision-making process for treatment of proximal humerus fractures (PHF) remains controversial, with no established or commonly used treatment regimens. Identifying fracture- and patient-related factors that influence treatment decisions is crucial for the development of such treatment algorithms. The objective of this study was to define a Delphi consensus of clinically relevant fracture- and patient-related factors of PHF for clinical application and scientific research. METHODS An online survey was conducted among an international panel of preselected experienced shoulder surgeons. An evidence-based list of fracture-related and patient-related factors affecting treatment outcome after PHF was generated and reviewed by the members of the committee through online surveys. The proposed factors were revised for definitions, and suggestions from the first round mentioned in the free text were included as possible factors in the second round of surveys. Consensus was defined as having at least a two-thirds majority agreement. RESULTS The Delphi consensus panel consisted of 18 shoulder surgeons who completed 2 rounds of online surveys. There was an agreement of more than two-thirds of the panel for three fracture-related factors affecting treatment decision in the case of PHF: head-split fracture, dislocated tuberosities, and fracture dislocation. Of all patient-related factors, a two-thirds consensus was reached for two factors: age and rotator cuff tear arthropathy. CONCLUSION This study successfully conducted a Delphi consensus on factors influencing decision-making in the treatment of proximal humeral fractures. The documented factors will be useful for clinical evaluation and scientific validation in future studies.
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Affiliation(s)
- Lisa Klute
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Leopold Henssler
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Benedikt Schliemann
- Department of Trauma, Hand and Reconstructive Surgery, Herz-Jesu Hospital, 48165, Münster, Germany
| | - Matthias Königshausen
- Department of Trauma Surgery and General Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-La-Camp-Platz 1, 44789, Bochum, Germany
| | - Nadine Weber
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
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Jeong HJ, Park JW, Lee YK, Koo KH, Oh JH. Comparison between osteonecrosis of the humeral and femoral heads - epidemiological analysis of the surgical trend using the nationwide claims database of the republic of Korea. BMC Musculoskelet Disord 2023; 24:878. [PMID: 37951880 PMCID: PMC10638789 DOI: 10.1186/s12891-023-07022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUNDS The humeral head is the second most common site of osteonecrosis, after the femoral head. However, compared to osteonecrosis of the femoral head (ONFH), epidemiological information on osteonecrosis of the humeral head (ONHH) is scarce. We hypothesised that different biomechanical properties of the shoulder from the hip joint might present different epidemiological characteristics of ONHH from those of the ONFH. To evaluate epidemiological differences, we compared trends in the surgical treatment of ONHH and ONFH using the nationwide medical claims database of the Republic of Korea (ROK). METHODS We analysed epidemiological data from the Health Insurance Review and Assessment (HIRA) database of the ROK between 2008 and 2018. HIRA database contains almost all medical information in an anonymised form, including demographics, diagnoses, and types of surgical procedures, generated through healthcare practices in ROK. The annual incidence rates of ONHH and ONFH were calculated based on the total number of the general population. Demographics, annual incidence, and the proportion of post-traumatic osteonecrosis and surgical procedures were compared according to the anatomical site and the affected year. RESULTS The total number of patients treated for ONHH and ONFH during the study period was 1,028 and 66,260, respectively. Although the incidence of ONHH increased, it is a relatively rare disease compared to ONFH. ONHH occurred more frequently in females, while ONFH occurred predominantly in male patients (p < 0.001). Surgical treatment for ONHH was most frequently performed in older patients (63.7%), whereas middle-aged patients had the largest proportion of ONFH (48.9%, p < 0.001). The proportion of post-traumatic osteonecrosis was significantly higher in the ONHH (5.1%) than in the ONFH (1.9%, p < 0.001). Arthroplasty was performed more frequently in the ONHH (96.0%) than in the ONFH (92.9%, p < 0.001). CONCLUSION Despite the anatomical similarities between the hip and shoulder joints, the different biomechanical properties, such as weight-bearing functions, might cause epidemiological differences between ONHH and ONFH.
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Affiliation(s)
- Hyeon Jang Jeong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Jung-Wee Park
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Cheil Orthopedic Hospital, Seoul, Republic of Korea
| | - Joo Han Oh
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea.
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Almaghrabi RA, Almousa AM, Almulla A, Salem O, Almana L. Single-Stage Bilateral Reverse Shoulder Arthroplasty for a Bilateral Four-Part Fracture Dislocation of the Proximal Humerus in an Elderly Patient: A Case Report. Cureus 2023; 15:e49002. [PMID: 38111397 PMCID: PMC10726731 DOI: 10.7759/cureus.49002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2023] [Indexed: 12/20/2023] Open
Abstract
Proximal humerus fractures (PHFs) are a common type of fracture in adults. Although PHFs are common, bilateral presentation is extremely rare. Most PHFs are treated conservatively. In this report, we describe a 69-year-old right-hand-dominant male patient who was involved in a high-impact motor vehicle accident (MVA). The patient's upper limbs were in a fully extended position while he was holding the driving wheel, where he sustained a side impaction to the car by a hard object that caused bilateral four-part PHF with dislocation, which was confirmed on radiological investigations. The orthopedic surgery team believed that surgical treatment was necessary and ideal for these bilateral fracture dislocations, specifically bilateral reverse total shoulder arthroplasty (RTSA). This is due to multiple factors, including the risk of humeral head avascular necrosis (AVN), the patient's advanced age, low demand, poor bone stock, osteoporosis, and a non-fixable fracture pattern. The patient underwent a single-stage bilateral RTSA procedure, which was well tolerated. He was optimized postoperatively. The post-operative X-ray showed good and satisfactory implant positions and orientation. Functional assessment using the Constant-Murley Score (CMS) and Disabilities of the Arm, Shoulder and Hand (DASH) score were calculated at three-months follow-up (right-left: 50-60 and 41-14, respectively), at five-months follow-up (right-left: 34-66 and 38-14, respectively), and at eight-months follow-up (right-left: 40-68 and 24-7.5, respectively). Follow-up X-rays revealed good tuberosities healing, and no loosening or scapular notching. In addition, pain was assessed on a numerical rating scale (NRS), which demonstrated fast pain relief. Short-term follow-up with the patient demonstrated that he was satisfied with the surgery, especially the left side with a pain score on the NRS of one. We selected to share our experience of this complex case with our peers in the field of orthopedic surgery worldwide so that such a procedure could be implemented in similar cases to ensure satisfactory outcomes following bilateral four-part PHF with dislocation.
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Affiliation(s)
- Razan A Almaghrabi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Ali M Almousa
- Orthopedic Surgery, King Fahad Specialist Hospital, Dammam, SAU
| | | | - Omar Salem
- Orthopedic Surgery, King Fahad Specialist Hospital, Dammam, SAU
| | - Latifah Almana
- Orthopedic Surgery, King Fahad Specialist Hospital, Dammam, SAU
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Kimmeyer M, Schmalzl J, Rentschler V, Schieffer C, Macken A, Gerhardt C, Lehmann LJ. Correct positioning of the calcar screw leads to superior results in proximal humerus fractures treated with carbon-fibre-reinforced polyetheretherketone plate osteosynthesis with polyaxial locking screws. J Orthop Traumatol 2023; 24:54. [PMID: 37816859 PMCID: PMC10564686 DOI: 10.1186/s10195-023-00733-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/29/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Plate osteosynthesis with implants made of carbon-fibre-reinforced polyetheretherketone (CFR-PEEK) has recently been introduced for the treatment of fractures of the proximal humerus (PHFs). The advantages of the CFR-PEEK plate are considered to be its radiolucency, its favourable modulus of elasticity, and the polyaxial placement of the screws with high variability of the angle. The primary aim of this study is to investigate the influence of calcar screw positioning on the complication and revision rates after CFR-PEEK plating of PHFs. The secondary aim is to assess its influence on functional outcome. MATERIAL AND METHODS Patients were identified retrospectively. Minimum follow-up was 12 months. The cohort was divided into two groups depending on the distance of the calcar screw to the calcar (group I: < 12 mm, group II: ≥ 12 mm). The range of motion (ROM), Subjective Shoulder Value Score (SSV) and Constant-Murley Score (CS) were analysed at follow-up examination. Subjective complaints, complications (e.g. humeral head necrosis, varus dislocation) and the revision rate were evaluated. RESULTS 51 patients (33 female, 18 male) with an average age of 68.6 years were included after a period of 26.6 months (group I: 32 patients, group II: 19 patients). Apart from the gender distribution, no significant differences were seen in the patient characteristics. The outcome scores showed significantly better clinical results in group I: SSV 83.4 vs 71.2, p = 0.007; CS 79.1 vs 67.8, p = 0.013. Complications were seen less frequently in group I (18.8 % vs 47.4 %, p = 0.030). CONCLUSION This study shows that the positioning of the calcar screw is relevant for CFR-PEEK plate osteosynthesis in PHFs with a good reduction of the fracture. Optimal positioning of the calcar screw close to the calcar (< 12 mm) is associated with a lower rate of complications, resulting in significantly superior functional outcomes. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Michael Kimmeyer
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany.
- Alps Surgery Institute, Clinque Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France.
| | - Jonas Schmalzl
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, Oberduerrbacher Str. 6, 97080, Wuerzburg, Germany
| | - Verena Rentschler
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Christian Schieffer
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Arno Macken
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Alps Surgery Institute, Clinque Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
| | - Christian Gerhardt
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Lars-Johannes Lehmann
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
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Misir A, Oguzkaya S, Kizkapan TB, Eken G, Canbaz SB. Fracture line and comminution zone characteristics, and rotator cuff footprint involvement in OTA/AO 11C3-type proximal humeral fractures: complex proximal humerus fracture map. Arch Orthop Trauma Surg 2023; 143:6219-6227. [PMID: 37378893 DOI: 10.1007/s00402-023-04962-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/20/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE To identify fracture characteristics and zones of comminution as well as the relationship with anatomic landmarks and rotator cuff footprint involvement in OTA/AO 11C3-type proximal humerus fractures. METHODS Computed tomography images of 201 OTA/AO 11C3 fractures were included. Fracture lines were superimposed to a 3D proximal humerus template, created from a healthy right humerus, after fracture fragment reduction on 3D reconstruction images. Rotator cuff tendon footprints were marked on the template. Lateral, anterior, posterior, medial, and superior views were captured for the interpretation of fracture line and comminution zone distribution as well as to define the relationship with anatomic landmarks and rotator cuff tendon footprints. RESULTS A total of 106 females and 95 males (mean age = 57.5 ± 17.7 [range 18-101] years) with 103 C3.1-, 45 C3.2-, and 53 C3.3-type fractures were included. On the lateral, medial, and superior humeral surfaces, fracture lines and comminution zones were distributed differently in 3 groups. Tuberculum minus and medial calcar region were significantly less severely affected in C3.1 and C3.2 fractures than C3.3 fractures. The supraspinatus footprint was the most severely affected rotator cuff footprint area. CONCLUSIONS Specifically defining the certain differences for repeatable fracture patterns and comminution zones in OTA/AO 11C3-type fractures and the relationship between the rotator cuff footprint and the joint capsule may contribute to the decision-making process of surgeons.
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Affiliation(s)
- Abdulhamit Misir
- Department of Orthopaedics and Traumatology, Private Safa Hospital, Zafer Mah. Ahmet Yesevi Cad. Gümüş Sk. No: 11A, Bahcelievler, 34194, Istanbul, Turkey.
| | - Sinan Oguzkaya
- Department of Orthopaedics and Traumatology, Bursa Cekirge State Hospital, Bursa, Turkey
| | - Turan Bilge Kizkapan
- Department of Orthopaedics and Traumatology, Basaksehir Pine and Sakura City Hospital, Istanbul, Turkey
| | - Gökay Eken
- Department of Orthopaedics and Traumatology, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Sebati Baser Canbaz
- Department of Orthopaedics and Traumatology, Erciyes University Faculty of Medicine, Kayseri, Turkey
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Roddy E, Kandemir U. High rate of avascular necrosis but excellent patient-reported outcomes after open reduction and internal fixation (ORIF) of proximal humerus fracture dislocations: should ORIF be considered as primary treatment? J Shoulder Elbow Surg 2023; 32:2097-2104. [PMID: 37224914 DOI: 10.1016/j.jse.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 03/23/2023] [Accepted: 04/04/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Proximal humerus fracture dislocations, excluding 2-part greater tuberosity fracture dislocations, are rare injuries. Outcomes after open reduction and internal fixation (ORIF) of these injuries have not been well described in the literature. The purpose of this study was to report the radiographic and functional outcomes of patients who underwent ORIF of a proximal humerus fracture dislocation. METHODS All skeletally mature patients who underwent ORIF of a proximal humerus fracture dislocation between 2011 and 2020 were identified. Patients with isolated greater tuberosity fracture dislocations were excluded. The primary outcome was American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score at a minimum of 2 years. Secondary outcomes were the development of avascular necrosis (AVN) and reoperation rate. RESULTS Twenty-six patients met the inclusion criteria. The mean age was 45 years (standard deviation 16), and 77% were men. Median time to reduction and surgery was 1 day (interquartile range [IQR] 1-5). There were 2 (8%) Neer 2-part fractures, 7 (27%) 3-part, and 17 (65%) 4-part fractures. Fifty-four percent (54%) involved the anatomic neck and 31% included a head-split component. Thirty-nine percent (39%) were anterior dislocations. The rate of AVN was 19%. The reoperation rate was 15%. Reoperations included removal of hardware (2), subscapularis repair (1), and manipulation under anesthesia (1). No patients went on to arthroplasty. ASES scores were available for 22 patients (84%) including 4 of 5 patients with AVN. The median ASES score at a mean of 6.0 years postoperatively was 98.3 (IQR 86.7-100, range 63.3-100) and was not different in those with or without AVN (median 98.3 vs. 92.0, P = .175). Only the presence of medial comminution and nonanatomic head shaft alignment on postoperative radiographs were associated with increased risk of AVN. CONCLUSION Radiographic rates of AVN (19%) and reoperation (15%) were high in this series of patients undergoing ORIF of proximal humerus fracture dislocations. Despite this, none of the patients required arthroplasty, and patient-reported outcome scores at an average of 6 years postinjury were excellent, with a median ASES score of 98.5. ORIF should be considered as primary method of treatment in proximal humerus fracture dislocations not only in young patients but also middle-aged patients.
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Affiliation(s)
- Erika Roddy
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Utku Kandemir
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA.
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Razaeian S, Al Marhi O, Wiese B, Zhang D, Bouklas P, Krettek C, Hawi N. Predicting the deltoid tuberosity index in proximal humerus fractures using fracture characteristics and patient age: development of the LBQ-PHF score. BMC Musculoskelet Disord 2023; 24:754. [PMID: 37749531 PMCID: PMC10519058 DOI: 10.1186/s12891-023-06883-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/14/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate (1) whether fracture pattern and age are associated with local bone quality (LBQ), and (2) whether a scoring system based on these variables is able to predict LBQ in proximal humerus fractures (PHF). MATERIALS AND METHODS A retrospective study was performed of all acute PHF at a Level 2 trauma center with plain radiographs and CT between June 2009 and March 2022. Local bone quality was measured by using the deltoid tuberosity index (DTI). In addition to age and gender, fracture morphology was categorized using the following classification systems: Neer, Resch, AO Foundation/Orthopaedic Trauma Association (AO/OTA), and Hertel/LEGO. Additionally, coronal head alignment was calculated by measuring the head-shaft angle. RESULTS Only the Resch classification system revealed a significant relationship between fracture type and bone quality, as there was a significant association between coronal head alignment and DTI (p = 0.001). Valgus head alignment was observed significantly more frequent in patients with low bone quality (p = 0.002). Multinomial logistic regression analysis revealed a significant relative risk ratio for age (RRR = 0.97, [95% CI, 0.94-1], p = 0.039) and a non-significant trend for DTI (RRR = 1.26, [95% CI, 0.96-1.64], p = 0.092) for occurrence of anatomic relative to valgus head alignment. Using a DTI cut-off value of 1.3 instead of 1.4, age and also varus head alignment were identified as significant predictors of LBQ (OR = 1.12, [95% CI, 1.1-1.15], p < 0.001; OR = 0.54, [95% CI, 0.3-0.96], p = 0.037). A scoring system called the LBQ-PHF score (local bone quality in proximal humerus fractures), developed based on these two variables was able to predict LBQ with a sensitivity of 79.2% and a specificity of 86.7%. CONCLUSION Age and coronal humeral head alignment are independent predictors of LBQ in PHF. A simple scoring system developed based on these variables is able to assess BQ with solid predictive characteristics.
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Affiliation(s)
- Sam Razaeian
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Okba Al Marhi
- Department of Trauma Surgery and Orthopaedic Surgery, Helios St. Marienberg Klinik Helmstedt GmbH, Conringstraße 26, 38350, Helmstedt, Germany
| | - Birgitt Wiese
- Hannover Medical School, MHH Information Technology (MIT), Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Panagiotis Bouklas
- Department of Trauma Surgery and Orthopaedic Surgery, Helios St. Marienberg Klinik Helmstedt GmbH, Conringstraße 26, 38350, Helmstedt, Germany
| | - Christian Krettek
- Hannover Humerus Registry (HHR), Traumastiftung gGmbH Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Nael Hawi
- Hannover Humerus Registry (HHR), Traumastiftung gGmbH Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Orthopaedic and Surgical Clinic Braunschweig (OCP), Mauernstraße 35, 38100, Braunschweig, Germany
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Kotler JA, Zuppke JN, Abraham VM, Sanville JA, Nabet AC, Carofino B, Gardner MJ, Smith CS. Biomechanical Analysis of Combined Medial Calcar and Lateral Locked Plating Versus Isolated Lateral Locked Plating of Proximal Humerus Fractures. J Orthop Trauma 2023; 37:e355-e360. [PMID: 37074819 DOI: 10.1097/bot.0000000000002619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVE Medial calcar buttress plating combined with lateral locked plating is biomechanically tested against isolated lateral locked plating in synthetic humeri models for the treatment of proximal humerus fractures. METHODS Proximal humerus fractures (OTA/AO type 11-A2.1) were manufactured in 10 pairs of Sawbones humeri models (Sawbones, Pacific Research Laboratories, Vashon Island, WA). Specimen were randomly assigned and instrumented with either medial calcar buttress plating combined with lateral locked plating (CP) or isolated lateral locked plating (LP). Nondestructive torsional and axial load tests were performed to evaluate construct stiffness. Large-cycle axial tests were conducted followed by destructive ramp-to-failure tests. Cyclic stiffness was compared in both nondestructive and ultimate failure loads. Failure displacement was recorded and compared between groups. RESULTS The addition of medial calcar buttress plating to lateral locked plating constructs significantly increased the axial ( P < 0.01) and torsional ( P < 0.01) stiffness of the construct compared with isolated lateral locked plating by 95.56% and 37.46%, respectively. All models demonstrated greater axial stiffness ( P < 0.01) after 5000 cycles of axial compression, not dependent on the fixation method. During destructive testing, the CP construct withstood 45.35% larger load ( P < 0.01) and congruently exhibited 58% less humeral head displacement ( P = 0.02) before failure when compared with the LP construct. CONCLUSION This study demonstrates the biomechanical superiority of medial calcar buttress plating when combined with lateral locked plating as compared with isolated lateral locked plating of OTA/AO type 11-A2.1 proximal humerus in synthetic humeri models.
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Affiliation(s)
- Joshua A Kotler
- 3d Medical Battalion, 3D Marine Logistics Group, III Marine Expeditionary Force, Okinawa, Japan
| | - Julia N Zuppke
- Bone and Joint/Sports Medicine Institute, Naval Medical Readiness and Training Center, Portsmouth, VA
| | - Vivek M Abraham
- Bone and Joint/Sports Medicine Institute, Naval Medical Readiness and Training Center, Portsmouth, VA
| | - Jennifer A Sanville
- Bone and Joint/Sports Medicine Institute, Naval Medical Readiness and Training Center, Portsmouth, VA
| | - Austin C Nabet
- Bone and Joint/Sports Medicine Institute, Naval Medical Readiness and Training Center, Portsmouth, VA
| | | | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Christopher S Smith
- Bone and Joint/Sports Medicine Institute, Naval Medical Readiness and Training Center, Portsmouth, VA
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Cosic F, Kirzner N, Edwards E, Page R, Kimmel L, Gabbe B. The Translated Proximal Humerus Fracture: A Comparison of Operative and Nonoperative Management. J Orthop Trauma 2023; 37:e341-e348. [PMID: 37053113 DOI: 10.1097/bot.0000000000002612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 04/14/2023]
Abstract
OBJECTIVES To report on the long-term outcomes of the management of translated proximal humerus fractures. DESIGN A prospective cohort study was conducted from January 2010 to December 2018. SETTING Academic Level 1 trauma center. PARTICIPANTS/PATIENTS A total of 108 patients with a proximal humerus fracture with ≥100% translation, defined as no cortical bony contact between the shaft and humeral head fragments, were included. INTERVENTION Patients were managed nonoperatively with sling immobilization or with operative management as determined by the treating surgeon. MAIN OUTCOME MEASURES Outcome measures were the Oxford Shoulder Score, EQ-5D-5L, return to work, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, nonunion/malunion, and avascular necrosis. RESULTS Of the 108 patients, 76 underwent operative intervention and 32 were managed nonoperatively. The mean (SD) age in the operative group was 54.3 (±20.2) years and in the nonoperative group was 73.3 (±15.3) years ( P < 0.001). There was no association between Oxford Shoulder Score and management options (mean 38.5 [±9.5] operative versus mean 41.3 [±8.5] nonoperative, P = 0.48). Operative management was associated with improved health status outcomes; EQ-5D utility score adjusted mean difference was 0.16 (95% CI, 0.04-0.27; P = 0.008); EQ-5D VAS adjusted mean difference was 19.2 (95% CI, 5.2-33.2; P = 0.008). Operative management was associated with a lower odds of nonunion (adjusted OR 0.30; 95% CI, 0.09-0.97; P = 0.04), malunion (adjusted OR 0.14; 95% CI, 0.04-0.51; P = 0.003), and complications (adjusted OR 0.07; 95% CI, 0.02-0.32; P = 0.001). CONCLUSION Translated proximal humerus fractures with ≥100% displacement demonstrate improved health status and radiological outcomes after surgical fixation. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Filip Cosic
- Department of Orthopaedic Surgery, The Alfred, Melbourne, Australia
| | - Nathan Kirzner
- Department of Orthopaedic Surgery, The Alfred, Melbourne, Australia
| | - Elton Edwards
- Department of Orthopaedic Surgery, The Alfred, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Richard Page
- Department of Orthopaedic Surgery, University Hospital Geelong, Geelong, Australia
- Barwon Centre for Orthopaedic Research and Education (B-CORE), St John of God Hospital and Deakin University, Geelong, Australia
| | - Lara Kimmel
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Physiotherapy, The Alfred, Melbourne, Australia; and
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, Swansea, United Kingdom
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Djebara A, Boulnois I, El Fatayri B, Mertl P, David E. Incidence of secondary displacement after osteosynthesis of proximal humerus fractures: a retrospective study of 185 cases. Acta Orthop Belg 2023; 89:531-538. [PMID: 37935239 DOI: 10.52628/89.3.8939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Proximal humerus fractures are the third most common fracture in patients over 65 years of age. There is no clear consensus regarding their treatment. The objective of this retrospective observational study was to calculate the incidence of secondary displacement after osteosynthesis of these fractures and to identify possible risk factors. 185 cases were reviewed and all osteosynthesized fractures between January 2008 and December 2016 were included. Data collected included age, sex, body mass index, alcohol and tobacco use, bone mineral density of the proximal humerus, fracture type, initial displacement, management time, type of treatment, surgeon's experience and expertise, and postoperative reduction quality. A radiographic follow-up was done at least 3 months following the fracture (until consolidation). The definition of secondary displacement was: varus/valgus displacement >10°, tuberosity translation >5 mm, articular effraction or material breakage. 53 secondary displacements were found, with an incidence of 28.6%. Seventy-two percent were diagnosed at the first follow-up visit, which occurred at an average of 29 days postoperatively. Among all factors studied, only two were statistically significant for secondary displacement: 1) low proximal humeral bone density (defined by a Tingart index <4) appears to be a risk factor, with a calculated relative risk of 2.71 (p = 0.04); and 2) the operator's specialization in the upper limb appears to be a protective factor, with a relative risk of 0.27 (p = 0.01). A similar high incidence of complications after osteosynthesis of the proximal humerus is found in the literature, confirming the difficulty in managing these fractures. More attention should be given to patients with low bone density.
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Helal A, Heimdal T, Lo EY, Montemaggi P, Lund J, Garofalo R, Ouseph A, Krishnan SG. Arthroplasty as Primary Treatment for Metadiaphyseal Proximal Humerus Fractures: A Viable Alternative to Osteosynthesis for the Elderly. J Shoulder Elb Arthroplast 2023; 7:24715492231192055. [PMID: 37547299 PMCID: PMC10399257 DOI: 10.1177/24715492231192055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/18/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction in the elderly patient population, where fracture comminution, osteoporotic fractures, and associated arthritis or rotator cuff pathologies dominate, metadiaphyseal proximal humeral fracture is a challenging subset of fractures to treat. This study reports on cementless long-stem reverse total shoulder arthroplasty (RTSA) as primary treatment of metadiaphyseal proximal humeral fractures in elderly patients. Materials & Methods Between January 2018 and October 2021, 22 consecutive patients sustained proximal humerus fractures with metadiaphyseal extension and underwent surgery with cementless long-stem RTSA. Patients older than 60 years with minimum 1 year of clinical and radiographic follow-up were included. Patient demographics, range of motion, and patient reported outcomes [Visual Analog Scale (VAS) pain scale, Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), and American Shoulder Elbow Surgeon (ASES) scores] were retrospectively collected. Postoperative X-rays were evaluated for fracture and tuberosity union. Results There were 14 eligible patients with a median age of 71 years (range 61-91 years) and a median 13 months follow-up. At final follow-up, the median active elevation was 120° (range 80°-150°), external rotation was 40° (range 0°-50°), and internal rotation was 40° (range 0°-80°). Median VAS was 2 (range 0-8), SST was 71% (range 33%-92%), SSV was 78% (range 20-90%), and ASES was 73 (range 17-90). All patients exhibited radiographic union. There were five minor complications in three patients: postoperative neuropathy, tuberosity nonunion, scapula notching, and proximal humeral stress shielding. Conclusion Cementless long-stem RTSA is a viable alternative to primary fracture fixation in the elderly patient population with metadiaphyseal proximal humerus fractures.
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Affiliation(s)
- Asadullah Helal
- The Shoulder Center Research, Baylor Scott and White Research Institute, Dallas, Texas
- The Shoulder Service, Baylor University Medical Center, Baylor Scott and White Health, Dallas, Texas
| | - Tyler Heimdal
- The Shoulder Center Research, Baylor Scott and White Research Institute, Dallas, Texas
- The Shoulder Service, Baylor University Medical Center, Baylor Scott and White Health, Dallas, Texas
| | - Eddie Y Lo
- The Shoulder Center Research, Baylor Scott and White Research Institute, Dallas, Texas
- The Shoulder Service, Baylor University Medical Center, Baylor Scott and White Health, Dallas, Texas
| | - Paolo Montemaggi
- AOUP- Cisanello Hospital, Department of Orthopaedics and Trauma Surgery, University of Pisa, Pisa
| | - Julia Lund
- The Shoulder Center Research, Baylor Scott and White Research Institute, Dallas, Texas
| | | | - Alvin Ouseph
- The Shoulder Center Research, Baylor Scott and White Research Institute, Dallas, Texas
- The Shoulder Service, Baylor University Medical Center, Baylor Scott and White Health, Dallas, Texas
| | - Sumant G Krishnan
- The Shoulder Center Research, Baylor Scott and White Research Institute, Dallas, Texas
- The Shoulder Service, Baylor University Medical Center, Baylor Scott and White Health, Dallas, Texas
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Sheng N, Wang Q, Xing F, Wang J, Chen Y, Xiang Z. Allografts are not necessary for displaced proximal humeral fractures in patients less than 65 years old, a retrospective cohort study. Injury 2023; 54:110861. [PMID: 37296014 DOI: 10.1016/j.injury.2023.110861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/23/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Displaced proximal humeral fractures (PHF) are frequently treated with locking plates to achieve osteosynthesis. Bone grafts are used as augmentation techniques to improve stability in osteoporotic patients. However, there has been little research into whether bone grafts are necessary for patients younger than 65 years old. This study compared radiographic and clinical outcomes between PHFs augmented with bone grafts or not in a younger population. METHODS Between January 2016 and June 2020, 91 patients treated with a locking plate alone (LP), and 101 patients treated with locking plates augmented with bone grafts (BG) were analyzed. Potential confounding factors for outcomes were adjusted by propensity score-matching analyses. For the retrospective cohort study, 62 patients from each group were evaluated for radiographic outcomes and clinical outcomes and compared. RESULTS Sixth-two patients in each group, both with a mean age of 52 years old, were with a mean follow-up time of 25 months in the LP group and 26 months in the BG group. There was no difference in demographic or surgical characteristics between the two groups after propensity score-matching. With regard to radiographic outcomes, the changes in neck-shaft angle (-5.1 ± 4.9 vs. -3.1 ± 5.3, p = 0.015) and humeral head height (-1.5 ± 2.5 vs. -0.4 ± 2.7, p = 0.002) were more obvious in the BG group. However, regarding functional outcomes, there were no significant differences between the two groups in DASH score, Constant-Murley score, or VAS score. Moreover, the complication rate was not significantly different between two groups. DISCUSSION Allografts only provide minor improvements of stability in radiography for patients less than 65 years old after locking plate fixation of PHFs, but don't improve shoulder function, relieve pain or reduce complications. We concluded that allografts are unnecessary for younger patients with displaced PHFs.
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Affiliation(s)
- Ning Sheng
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Lane 37, Chengdu, 610041, Sichuan Province, China
| | - Qiuke Wang
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200235, China
| | - Fei Xing
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Lane 37, Chengdu, 610041, Sichuan Province, China
| | - Jie Wang
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Lane 37, Chengdu, 610041, Sichuan Province, China
| | - Yunfeng Chen
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200235, China.
| | - Zhou Xiang
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Lane 37, Chengdu, 610041, Sichuan Province, China
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Pandey R, Raval P, Manibanakar N, Nanjayan S, McDonald C, Singh H. Proximal humerus fracture s: A review of current practice. J Clin Orthop Trauma 2023; 43:102233. [PMID: 37636006 PMCID: PMC10457443 DOI: 10.1016/j.jcot.2023.102233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 07/11/2023] [Accepted: 08/03/2023] [Indexed: 08/29/2023] Open
Abstract
The management of proximal humeral fractures (PHF) remains controversial. Its incidence is increasing. Patients should be meticulously assessed clinically for co-morbidities and neuro-vascular injuries. Radiological investigation helps provide information on the fracture configuration and dislocations. Enhanced by 3-dimensional CT scanning, these further help in decision making and operative planning. PHF classifications have been demonstrated to have poor intra-observer and inter-observer reliability. Research has identified some radiographic predictive factors for humeral head ischaemia and likely failure of surgical fixation. The range of management options include non-operative treatment, operative fixation, intramedullary nailing and arthroplasty (hemiarthroplasty, reverse shoulder replacement). The majority of PHFs are stable injuries and non-operative management is usually successful. Some degree of malunion is readily tolerated especially by elderly patients. Surgical management of significantly displaced, unstable proximal humerus fractures should aim to stabilise the fracture adequately and provide satisfactory function for the long term. Management of the greater tuberosity is pivotal for the eventual outcome. When fixation may appear to be compromised by poor bone quality, likely poor function, age related rotator cuff degeneration or likely humeral head ischaemia clinicians may opt for arthroplasty. Successful hemiarthroplasty outcomes are dependent on sufficient healing of the tuberosity and recovery of the rotator cuff integrity. Reverse shoulder replacement can predictably deliver good functional outcomes for the shoulder in elderly patients, where rotator cuff dysfunction is suspected or as a revision procedure following failure of other surgical interventions. As opposed to hemiarthroplasty, which has shown a downward trend, there has been an increasing trend towards the use of reverse shoulder replacement in proximal humeral fractures. The management of PHFs should be patient specific, fracture specific and meet the functional demands and needs of the individual patient. The surgeon's skill set and clinical experience also plays an important role in the options of management available.
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Affiliation(s)
- R. Pandey
- Trauma and Orthopaedic Surgeon, University Hospitals of Leicester, Leicester, United Kingdom
| | - P. Raval
- Trauma and Orthopaedic, University Hospitals of Leicester, Leicester, United Kingdom
| | - N. Manibanakar
- Trauma and Orthopaedic, University Hospitals of Leicester, Leicester, United Kingdom
| | - S. Nanjayan
- Trauma and Orthopaedic Surgeon, University Hospitals of Leicester, Leicester, United Kingdom
| | - C. McDonald
- Trauma and Orthopaedic, University Hospitals of Leicester, Leicester, United Kingdom
| | - Harvinder Singh
- Trauma and Orthopaedic Surgeon, University Hospitals of Leicester, Leicester, United Kingdom
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Fu H, Wu J, Wu X. Intramedullary Nail for Treatment of Proximal Humeral Fracture: A Credible Fixation in Comminuted Calcar. Orthop Surg 2023; 15:2007-2015. [PMID: 36514186 PMCID: PMC10432444 DOI: 10.1111/os.13616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Restoration of the medial support is especially important for the treatment of proximal humeral fractures. The objective of this study was to investigate the radiographic and clinical outcomes of intramedullary nail fixation with a special focus on the presence of calcar comminution. METHODS In this retrospective study of patients with displaced proximal humeral fractures that were treated by intramedullary nail between January 2018 and July 2021, fracture morphology and the calcar integrity were noted on preoperative radiographs. Patients were divided into two groups according to calcar integrity. During follow-up, radiological assessment and functional outcome, including the deltoid tuberosity index (DTI), neck shaft angle (NSA), visual analog scale (VAS), the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST) score, active and passive range of motion, were performed. A Student t-test and univariate logistic regression analysis was used. RESULTS A total of 83 patients (54 female, 29 male) had complete follow-up (average, 12.8 months; range, 10 to 33 months) and functional assessment in our study. The average age was 58.6 years (range, 20 to 89 years). The mean loss of NSA was 4° (range, 0°-12°) and no significant difference was found between two groups (p = 0.27). DTI had an average of 1.50 ± 0.19 (range 1.13-2.04). Patients with intact calcar achieved greater range of forward elevation (129.06 ± 11.91 vs. 121.05 ± 11.97, p = 0.01), and higher SST scores (8.61 ± 1.85 vs. 7.37 ± 2.22, p = 0.02). Two groups showed similar outcomes in VAS, ASES score, and range of abduction. One patient demonstrated a proximal interlocking screw cutting through and osteonecrosis of the humeral head, who underwent a second surgery for screw removal. There were no cases of infection, malunion, nonunion, nerve injury, subacromial impingement, or rotator cuff tear during the study period. CONCLUSION Intramedullary nail can favorably be used to manage proximal humeral fractures with good early radiographic and functional outcomes, even for those with comminuted calcar.
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Affiliation(s)
- Huichao Fu
- Department of Orthopaedic Traumatology, Trauma Center, Shanghai General HospitalShanghaiChina
| | - Jianhong Wu
- Department of Orthopaedic Traumatology, Trauma Center, Shanghai General HospitalShanghaiChina
| | - Xiaoming Wu
- Department of Orthopaedic Traumatology, Trauma Center, Shanghai General HospitalShanghaiChina
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Buscariolo FF, Parron IAC, Costa EF, Santana MVF, Nishimura EM, Dobashi ET. CORRELATION OF OSTEONECROSIS RATES IN THE SURGICAL TREATMENT OF PROXIMAL HUMERAL FRACTURES ACCORDING TO THE NEER AND HERTEL CLASSIFICATIONS. ACTA ORTOPEDICA BRASILEIRA 2023; 31:e268183. [PMID: 37469497 PMCID: PMC10353866 DOI: 10.1590/1413-785220233103e268183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 07/21/2023]
Abstract
Objective To predict the risk of osteonecrosis (ON) according to the Neer and Hertel et al. classification for surgically treated proximal humeral fractures after at least one year of follow-up. Methods This is a retrospective, cross-sectional, and observational cohort study. A total of 44 patients, 16 (36.36%) men and 28 (63.63%) women, with a mean age of 61.36 years, participated in this study. Lesions were categorized according to Neer and Hertel's classifications, considering the preoperative prognosis for ON. After at least a year of follow-up, patients were reassessed. Data were evaluated using IBM SPSS Statistics®. Results A total of three patients (6.8%) developed osteonecrosis. Comparisons showed no statistically significant difference, but we observed a superior association of osteonecrosis for the Hertel classification than that of Neer. Conclusion Both classifications showed a similar ability to identify patients at low risk of developing ON. New studies with a greater number of participants and sample homogeneity may intensify the value of the evaluation of clinical applicability and predictive capacity of the studied classifications with greater significance and correlation. Level of Evidence III, Case Control Study.
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Affiliation(s)
- Fabio Fabian Buscariolo
- Rede D'Or Sao Luiz, Hospital IFOR, Serviço de Ortopedia e Traumatologia, São Bernardo do Campo, SP, Brazil
| | - Igor Arthur Costa Parron
- Rede D'Or Sao Luiz, Hospital IFOR, Serviço de Ortopedia e Traumatologia, São Bernardo do Campo, SP, Brazil
| | - Elzir Finizola Costa
- Rede D'Or Sao Luiz, Hospital IFOR, Serviço de Ortopedia e Traumatologia, São Bernardo do Campo, SP, Brazil
| | | | | | - Eiffel Tsuyoshi Dobashi
- Universidade Federal de Sao Paulo, Escola Paulista de Medicina, Departamento de Ortopedia e Traumatologia, São Paulo, SP, Brazil
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Tong CH, Fang CX. Rehabilitation progress following reverse total shoulder replacement and internal fixation for geriatric three and four-part proximal humerus fractures - a propensity score matched comparison. BMC Musculoskelet Disord 2023; 24:566. [PMID: 37434194 DOI: 10.1186/s12891-023-06669-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 06/26/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Proximal humerus fracture is one of the most common fractures in the elderly population. However, in patients with complex fracture patterns, there is still no general consensus in the best treatment method. This study aims to evaluate the outcomes between those treated with reverse total shoulder arthroplasty (rTSA) and open reduction internal fixation (ORIF). METHODS All geriatric patients (> 60 years of age) with proximal humerus fractures undergoing surgical treatment were analysed. There were 25 patients treated with rTSA and 75 with ORIF. Propensity score matching was used to select 25 matching patients from the ORIF group according to age and gender. All patients underwent surgical intervention within 7 days (mean 3.8 days). All patients followed a protocol-driven rehabilitation programme with outcome assessment at 3, 6, 12 and 24 months. Constant score, qDASH, range of motion, rate of complications and revision surgery were recorded and compared. RESULTS Twenty-five rTSA were age and gender matched with 25 ORIF patients. The average age of patients in rTSA and ORIF groups were 77.0 years and 75.2 years respectively. At 3 months, mean Constant score was 37.7 (rTSA) vs 45.5 (ORIF) (p = 0.099). Mean qDASH score was 50.6 (rTSA) vs 29.4 (ORIF) (p = 0.003). Mean forward flexion range was 72.9° (rTSA) vs 94.4° (ORIF) (p = 0.007). Mean abduction range was 64.0° (rTSA) vs 88.6° (ORIF) (p = 0.001). At 2 years, mean Constant score was 72.8 (rTSA) vs 70.8 (ORIF) (p = 0.472). Mean qDASH score was 4.50 (rTSA) vs 11.0 (ORIF) (p = 0.025). Mean forward flexion range was 143° (rTSA) vs 109° (ORIF) (p < 0.001). Mean abduction range was 135° (rTSA) vs 110° (ORIF) (p = 0.025). There was a higher number of complications observed for ORIF (3) than rTSA (1) (p = 0.297) and a higher number of re-operations for ORIF (3) than rTSA (1) (p = 0.297), which was not statistically significant. CONCLUSION rTSA appears to yield a slower recovery at 3 months but a better outcome at 2 years. It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome.
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Affiliation(s)
- Chi Him Tong
- Department of Orthopaedics & Traumatology, Queen Mary Hospital, Hong Kong, Hong Kong.
| | - Christian Xinshuo Fang
- Department of Orthopaedics & Traumatology, The University of Hong Kong, Hong Kong, Hong Kong
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Shahien A, Likine EF, Soles G, Samborski S, Mehta SK, Ryan SP, Leroy TE, Mullis B, Spitler CA, Tornetta P. Not All Proximal Humerus Fractures Do Well Without Surgery: Anterior Translation Predicts the Need for Surgery. J Orthop Trauma 2023; 37:366-369. [PMID: 37074809 DOI: 10.1097/bot.0000000000002585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVES To evaluate the effect of translation on a large series of low-energy proximal humerus fractures initially treated nonoperatively. DESIGN Retrospective multicenter analysis. SETTING Five level-one trauma centers. PATIENTS/PARTICIPANTS Two hundred ten patients (152 F; 58 M), average age 64, with 112 left- and 98 right-sided low-energy proximal humerus fractures (OTA/AO 11-A-C). INTERVENTION All patients were initially treated nonoperatively and were followed for an average of 231 days. Radiographic translation in the sagittal and coronal planes was measured. Patients with anterior translation were compared with those with posterior or no translation. Patients with ≥80% anterior humeral translation were compared with those with <80% anterior translation, including those with no or posterior translation. MAIN OUTCOMES The primary outcome was failure of nonoperative treatment resulting in surgery and the secondary outcome was symptomatic malunion. RESULTS Nine patients (4%) had surgery, 8 for nonunion and 1 for malunion. All 9 patients (100%) had anterior translation. Anterior translation compared with posterior or no sagittal plane translation was associated with failure of nonoperative management requiring surgery ( P = 0.012). In addition, of those with anterior translation, having ≥80% anterior translation compared with <80% was also associated with surgery ( P = 0.001). Finally, 26 patients were diagnosed with symptomatic malunion, of whom translation was anterior in 24 and posterior in 2 ( P = 0.0001). CONCLUSIONS In a multicenter series of proximal humerus fractures, anterior translation of >80% was associated with failure of nonoperative care resulting in nonunion, symptomatic malunion, and potential surgery. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Amir Shahien
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA
| | - Elive F Likine
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Gillian Soles
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, MN
| | - Steven Samborski
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, MN
| | - Siddhant K Mehta
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, MS; and
| | - Scott Patrick Ryan
- Department of Orthopaedic Surgery, Tufts University Medical Center, Boston, MA
| | - Taryn E Leroy
- Department of Orthopaedic Surgery, Tufts University Medical Center, Boston, MA
| | - Brian Mullis
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, MS; and
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA
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Skedros JG, Smith TR, Cronin JT. Osteomyelitis with abscess associated with acute closed upper humerus fracture in an adult: A case report. Clin Case Rep 2023; 11:e7640. [PMID: 37434954 PMCID: PMC10332134 DOI: 10.1002/ccr3.7640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 07/13/2023] Open
Abstract
A 64-year-old female presented with malaise and fever 11 days after a closed, minimally displaced humerus surgical neck fracture. MR imaging revealed an abscess around the fracture, which is a very rare occurrence in adults. Two open debridements and IV antibiotics eradicated the infection. Reverse total shoulder arthroplasty was eventually performed for fracture nonunion.
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Affiliation(s)
- John G Skedros
- Utah Orthopaedic Specialists Salt Lake City Utah USA
- Saint Marks Medical Center Salt Lake City Utah USA
| | - Tyler R Smith
- Utah Orthopaedic Specialists Salt Lake City Utah USA
- University of Utah School of Medicine Salt Lake City Utah USA
| | - John T Cronin
- Utah Orthopaedic Specialists Salt Lake City Utah USA
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Barreto Rocha DF, Vogel M, Delma SR, Baylor JL, Horwitz DS, Grandizio LC. The Utility of Routine Follow-up Radiographs in the Nonoperative Management of Proximal Humerus Fractures in Patients 65 Years and Older. Orthopedics 2023; 46:e244-e248. [PMID: 36719409 DOI: 10.3928/01477447-20230125-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Whereas prior studies have aimed to define the utility of routine radiographs for the closed treatment of upper extremity fractures, it remains uncertain whether routine radiographs influence management decisions for nonoperative treatment of proximal humerus fractures (PHFs). The purpose of this investigation was to assess the utility of routine radiographic monitoring of closed PHFs in elderly patients initially indicated for nonoperative treatment. We identified all patients 65 years and older who had a PHF from 2016 to 2019. We excluded cases of pathologic fractures or peri-prosthetic fractures, nonunion, malunion, cases with insufficient follow-up, and cases for which surgery was indicated either in the emergency department or at the first orthopedic visit. After applying these exclusion criteria, 402 cases remained. We recorded baseline demographics and fracture descriptions and noted any conversion to operative treatment after the initial office visit. Two-part fractures were most common (56%). Of the 402 fractures indicated for nonoperative treatment, 21 (5%) were converted to operative management during the follow-up period. Nine fractures (2%) were converted to operative management within 30 days of the first office visit. Eight cases (2%) were converted to operative treatment more than 120 days after the initial office visit: 6 due to nonunion and 2 due to posttraumatic arthritis. For patients 65 years and older who undergo initial nonoperative treatment of a PHF, routine follow-up radiographs do not appear to alter management decisions. Given the risk and cost associated with routine radiographs, surgeons should consider forgoing these images in the absence of clinical concern. [Orthopedics. 2023;46(4):e244-e248.].
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Baker HP, Gutbrod J, Cahill M, Shi L. Optimal Treatment of Proximal Humeral Fractures in the Elderly: Risks and Management Challenges. Orthop Res Rev 2023; 15:129-137. [PMID: 37396822 PMCID: PMC10312335 DOI: 10.2147/orr.s340536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/20/2023] [Indexed: 07/04/2023] Open
Abstract
Proximal humeral fractures (PHFs) are a common type of fracture, particularly in older adults, accounting for approximately 5-6% of all fractures. This article provides a comprehensive review of PHFs, focusing on epidemiology, injury mechanism, clinical and radiographic assessment, classification systems, and treatment options. The incidence of PHFs varies across regions, with rates ranging from 45.7 to 60.1 per 100,000 person-years. Females are more susceptible to PHFs than males, and the incidence is highest in women over the age of 85. The injury mechanism of PHFs is typically bimodal, with high-energy injuries predominant in younger individuals and low-energy injuries in the elderly. Clinical assessment of PHFs involves obtaining a thorough history, physical examination, and evaluation of associated injuries, particularly neurovascular injuries. Radiographic imaging helps assess fracture displacement and plan for treatment. The Neer classification system is the most commonly used classification for PHFs, although other systems, such as AO/OTA, Codman-Hertel, and Resch classifications, also exist. The choice of treatment depends on factors such as patient age, activity level, fracture pattern, and surgeon expertise. Nonoperative management is typically preferred for elderly patients with minimal displacement, while operative fixation is considered for more complex fractures. Nonoperative treatment involves sling immobilization followed by physiotherapy, with good outcomes reported for certain fracture patterns. Operative management options include closed reduction and percutaneous pinning (CRPP), open reduction and internal fixation (ORIF), or arthroplasty. CRPP is suitable for specific fracture patterns, but the quality of reduction is crucial for favorable outcomes. ORIF is used when CRPP is not feasible, and various surgical approaches are available, each with its advantages and potential complications. PHFs are a significant clinical challenge due to their prevalence and complexity. Treatment decisions should be patient centered based on patient factors and fracture severity.
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Joseph Gutbrod
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Michael Cahill
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Lewis Shi
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
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Labrum JT, Kuttner NP, Atwan Y, Sanchez-Sotelo J, Barlow JD. Fracture Dislocations of the Glenohumeral Joint. Curr Rev Musculoskelet Med 2023:10.1007/s12178-023-09846-y. [PMID: 37329400 PMCID: PMC10382466 DOI: 10.1007/s12178-023-09846-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE OF REVIEW Proximal humerus fracture dislocations typically result from high-energy mechanisms and carry specific risks, technical challenges, and management considerations. It is vital for treating surgeons to understand the various indications, procedures, and complications involved with their treatment. RECENT FINDINGS While these injuries are relatively rare in comparison with other categories of proximal humerus fractures, fracture dislocations of the proximal humerus require treating surgeons to consider patient age, activity level, injury pattern, and occasionally intra-operative findings to select the ideal treatment strategy for each injury. Proximal humerus fracture dislocations are complex injuries that require special considerations. This review summarizes recent literature regarding the evaluation and management of these injuries as well as the indications and surgical techniques for each treatment strategy. Thorough pre-operative patient evaluation and shared decision-making should be employed in all cases. While nonoperative management is uncommonly considered, open reduction and internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder replacement are at the surgeon's disposal, each with their own indications and complication profile.
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Affiliation(s)
- Joseph T Labrum
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA
| | - Nicolas P Kuttner
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA
| | - Yousif Atwan
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA
| | - Joaquin Sanchez-Sotelo
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA
| | - Jonathan D Barlow
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA.
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Ripoll T, Chelli M, Johnston T, Chaoui J, Gauci MO, Vasseur H, Poltaretskyi S, Boileau P. Three-Dimensional Measurement of Proximal Humerus Fractures Displacement: A Computerized Analysis. J Clin Med 2023; 12:4085. [PMID: 37373779 DOI: 10.3390/jcm12124085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/01/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Neer's classification for proximal humerus fractures (PHFs) uses 10 mm and 45° thresholds to distinguish displaced fragments. While this system was originally developed referencing 2D X-rays, fracture displacements occur in three dimensions. Our work aimed to develop a standardized and reliable computerized method for measuring PHF 3D spatial displacements. CT scans of 77 PHFs were analyzed. A statistical shape model (SSM) was used to generate the pre-fracture humerus. This predicted proximal humerus was then used as a "layer" to manually reduce fragments to their native positions and quantify translation and rotation in three dimensions. 3D computerized measurements could be calculated for 96% of fractures and revealed that 47% of PHFs were displaced according to Neer's criteria. Valgus and varus head rotations in the coronal plane were present in 39% and 45% of cases; these were greater than 45° in 8% of cases and were always associated with axial and sagittal rotations. When compared to 3D measurements, 2D methods underestimated the displacement of tuberosity fragments and did not accurately assess rotational displacements. The use of 3D measurements of fracture displacement is feasible with a computerized method and may help further refine PHF analysis and surgical planning.
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Affiliation(s)
- Thomas Ripoll
- Unité de Recherche Clinique (UR2CA), Université de Nice Côté d'Azur, 06000 Nice, France
- Hôpital Pasteur 2-IULS, 30 Voie Romaine, CÉDEX 1, 06001 Nice, France
| | - Mikaël Chelli
- Institut de Chirurgie Réparatrice-Groupe Kantys, 06004 Nice, France
| | - Tyler Johnston
- Unité de Recherche Clinique (UR2CA), Université de Nice Côté d'Azur, 06000 Nice, France
- Hôpital Pasteur 2-IULS, 30 Voie Romaine, CÉDEX 1, 06001 Nice, France
| | | | - Marc-Olivier Gauci
- Unité de Recherche Clinique (UR2CA), Université de Nice Côté d'Azur, 06000 Nice, France
- Hôpital Pasteur 2-IULS, 30 Voie Romaine, CÉDEX 1, 06001 Nice, France
| | - Heloïse Vasseur
- Hôpital Pasteur 2-IULS, 30 Voie Romaine, CÉDEX 1, 06001 Nice, France
| | | | - Pascal Boileau
- Institut de Chirurgie Réparatrice-Groupe Kantys, 06004 Nice, France
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Damani A, Osmani H, Patel J, Robinson P, Dattani R, Ahmed N. Imaging for patients presenting with a painful shoulder. Br J Hosp Med (Lond) 2023; 84:1-10. [PMID: 37364877 DOI: 10.12968/hmed.2023.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Shoulder pain is a common cause of musculoskeletal presentation in primary care, where both traumatic and atraumatic pathologies can also lead to emergency department attendances. This article discusses common acute and chronic presentations of a painful shoulder, looking at the typical history of patients presenting with a painful shoulder, examination findings and the most appropriate imaging modalities to consider. Strengths and weaknesses of each imaging modality are discussed along with their role in aiding diagnosis, as well as management of the various pathologies encountered in primary and secondary care.
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Affiliation(s)
- Arees Damani
- Department of Radiology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Humza Osmani
- Department of Orthopaedic Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - Jugal Patel
- Department of Radiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Philip Robinson
- Department of Radiology, Chapel Allerton Hospital, Leeds, UK
| | - Rupen Dattani
- Department of Orthopaedic Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Naeem Ahmed
- Department of Radiology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Cehelyk EK, Stull JD, Patel MS, Cox RM, Namdari S. Humeral Head Avascular Necrosis: Pathophysiology, Work-up, and Treatment Options. JBJS Rev 2023; 11:01874474-202306000-00017. [PMID: 37368960 DOI: 10.2106/jbjs.rvw.23.00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
» Avascular necrosis (AVN) of the humeral head is the result of ischemic injury to the epiphyseal bone leading to humeral head collapse and arthritis.» Common causes include trauma, chronic corticosteroid use, or systemic disease processes, such as sickle cell disease, systemic lupus erythematosus, or alcohol abuse.» Nonoperative treatment consists of risk factor management, physical therapy, anti-inflammatory medications, and activity modification.» Surgical treatment options include arthroscopic debridement, core decompression, vascularized bone grafts, and shoulder arthroplasty.
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Affiliation(s)
- Eli K Cehelyk
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Justin D Stull
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Manan S Patel
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ryan M Cox
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Surena Namdari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Sheng N, Shi T, Wang Q, Wang L, Chen Y. Nonanatomic healing of the greater tuberosity after plating in proximal humeral fractures: a case control study. J Orthop Surg Res 2023; 18:374. [PMID: 37208767 DOI: 10.1186/s13018-023-03811-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 04/23/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Open reduction and plate internal fixation (ORIF) is one of the most common treatment methods for proximal humeral fractures. Complications associated with the greater tuberosity (GT) are rarely reported, therefore, the purpose of this study was to analyze the complications associated with the GT and the risk factors after locked-plate internal fixation. METHODS We retrospectively analyzed the medical and radiographic data of patients with proximal humeral fractures involving the GT treated with locking plates between January 2016 and July 2019. We divided all patients into two groups, the anatomic GT healing group and the nonanatomic GT healing group, depending on the radiographic outcomes of the GT. Clinical outcome was assessed by the Constant scoring system. Potential risk factors included preoperative and intraoperative factors. Preoperative factors included sex, age, body mass index, fracture type, fracture-dislocation, proximal humeral bone mineral density, humeral head extension, hinge integrity, comminuted GT, volume and surface area of the main GT fragment, and displacement of the main GT fragment. Intraoperative factors were adequate medial support, residual head-shaft displacement, head-shaft angle and residual GT displacement. Univariate logistic regression and multivariate logistic regression were used to identify risk factors. RESULTS There were 207 patients (130 women and 77 men; mean age, 55 years). GT anatomic healing was observed in 139 (67.1%) patients and nonanatomic healing in 68 (32.9%). Patients with GT nonanatomic healing had significantly inferior Constant scores than those with GT anatomic healing (75.0 ± 13.9 vs. 83.9 ± 11.8, P < 0.001). Patients with high GT malposition had worse Constant scores than patients with low GT malposition (73.3 ± 12.7 vs. 81.1 ± 11.4, P = 0.039). The multivariate logistic model showed that GT fracture characteristics were not risk factors for nonanatomic GT healing, while residual GT displacement was. CONCLUSIONS Nonanatomic healing of the GT is a high-rate complication of proximal humeral fractures, resulting in inferior clinical outcomes, especially for high GT malposition. Fracture characteristics of the GT are not risk factors for GT nonanatomic healing and GT comminution should not be regarded as a contraindication to ORIF for proximal humeral fractures.
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Affiliation(s)
- Ning Sheng
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, People's Republic of China
| | - Tingwang Shi
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, People's Republic of China
| | - Qiuke Wang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, People's Republic of China
| | - Lei Wang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, People's Republic of China.
| | - Yunfeng Chen
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, People's Republic of China.
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Marsalli M, De La Paz J, Córdova C, Fritis D, Errázuriz JDD. Complications of Locked Plating for Proximal Humeral Fractures in Active Patients in a Level One Trauma Center. Shoulder Elbow 2023; 15:181-187. [PMID: 37035615 PMCID: PMC10078815 DOI: 10.1177/17585732221079588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 11/16/2022]
Abstract
Background The incidence of complications associated with locked plating of proximal humerus fractures (PHF) has been reported in up to 40% of surgeries. This study aimed to analyze the incidence and risk factors of complications and re-intervention associated with locked plating of PHF in a an young active working population. Methods This retrospective cohort study included patients indicated for locked plating of displaced PHF at a dedicated workers' accident trauma center. The variables analyzed were patient comorbidities, fracture characteristics, and immediate radiologic surgical outcomes. Postoperative complications and risk factors were determined. Results A total of 127 patients with a median follow-up of 31 months and a median age of 52 years were included. The complication and reintervention rates were 13.4% and 12.6%, respectively. The main cause of reintervention was post-traumatic stiffness. The incidence of other complications was 4% screw protrusion, 1.6% avascular necrosis, 1.6% varus collapse. Complications were not associated with age, comorbidity, fracture classification, bone mineral density, Hertel's risk factors, presence of calcar comminution, reduction quality, and calcar screw position. Discussion The incidence of complications and reintervention was low. The main cause of reintervention was persistent stiffness, and no risk factors for complications were found in this study.
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Affiliation(s)
- Michael Marsalli
- Orthopaedic and Trauma Surgery, Clínica Universidad de los Andes, Chile
| | - Joaquín De La Paz
- Orthopaedic and Trauma Surgery, Hospital del Trabajador de Santiago, Santiago, Chile
| | - Carlos Córdova
- Orthopaedic and Trauma Surgery, Hospital del Trabajador de Santiago, Santiago, Chile
| | - Diego Fritis
- Orthopaedic and Trauma Surgery, Clínica Universidad de los Andes, Chile
- Orthopaedic and Trauma Surgery, Hospital del Trabajador de Santiago, Santiago, Chile
| | - Juan De Dios Errázuriz
- Orthopaedic and Trauma Surgery, Hospital del Trabajador de Santiago, Santiago, Chile
- Orthopaedic and Trauma Surgery, Clínica Dávila, Santiago, Chile
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Sivagurunathan G, Shirodkar K, Hegde G, Shamshuddin S, Proctor R, Naqvi J, Knowles D, Ali I. Musculoskeletal Computed Tomography: How to Add Value When Reporting Adult Upper Limb Trauma. J Comput Assist Tomogr 2023; 47:264-276. [PMID: 36877776 DOI: 10.1097/rct.0000000000001417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
ABSTRACT There is increasing reliance on computed tomography to evaluate fractures and dislocations following routine evaluation with plain radiography, critical in preoperative planning; computed tomography can provide multiplanar reformats and 3-dimensional volume-rendered imaging, providing a better global assessment for the orthopedic surgeon. The radiologist plays a critical role in appropriately reformatting the raw axial images to illustrate best the findings that will help determine further management. In addition, the radiologist must succinctly report the pertinent findings that will have the most significant bearing on treatment, assisting the surgeon in deciding between nonoperative and operative management. The radiologist should also carefully review imaging to look for ancillary findings in the setting of trauma beyond the bones and joints, including the lungs and rib cage when visualized.In this review article, we will systematically describe key features for fractures of the scapula, proximal humerus, distal humerus, radial head and neck, olecranon, coronoid process through a case-based approach, and distal radius. Although there are numerous detailed classification systems for each of these fractures, we aim to focus on the core descriptors that underpin these classification systems. The goal is to provide the radiologist with a checklist of critical structures they must assess and findings that they should mention in their report, emphasizing those descriptors that influence patient management.
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