Outcome measures reported for the management of proximal humeral fractures: a systematic review

The role of photobiomodulation in the functional recovery of proximal humerus fractures: a randomized controlled clinical protocol

Pain and joint stiffness contribute to functional limitation in the postoperative period following proximal humeral fractures (PHF). Photobiomodulation (PBM) has demonstrated positive outcomes in fracture repair, analgesia, and functional improvement, as evidenced by randomized controlled trials (RCTs) and experimental animal studies. Clinical studies have shown PBM's efficacy in reducing pain and improving functional outcomes, while preclinical studies have demonstrated enhanced bone regeneration through PBM application. This clinical study is a randomized, double-blind, controlled trial to investigate the effects of PBM on the shoulder functional recovery after proximal humerus fractures. A total of forty-two participants, aged 18-65 years of both genders, will be randomly divided into two groups: the Control group (receiving physiotherapy combined with simulated PBM) and the PBM group (receiving physiotherapy combined with active PBM). The PBM application (10 minutes) will be performed daily by the participants at home, using a device equipped with 318 light-emitting diodes (LEDs), consisting of 159 LEDs at 660 nm (28.5 mW; 12 J/cm²; 17 J per LED) and 159 LEDs at 850 nm (23 mW; 10 J/cm²; 14 J per LED). The PBM sessions, along with physiotherapy sessions (30 minutes, twice weekly), will be conducted over a 12-week period. Participants will be blinded to their group allocation and will be assessed by a single evaluator at 24 hours, 1 week, 2 weeks, 4 weeks, 8 weeks, and 12 weeks post-surgery. The evaluator will also be blinded to the participants' group assignments. The primary outcome will be shoulder functional recovery after proximal humerus fractures, assessed using the Quick-DASH scale at all experimental time points. Secondary outcomes will include range of motion (measured with a digital goniometer), quality of life (evaluated using the SF-6D questionnaire), pain on pressure and the incidence of adverse effects, all assessed at each time point. Spontaneous pain, nocturnal pain and analgesic use will be evaluated over a 12-week period. Fracture consolidation will be assessed through radiography at weeks 4, 8, and 12. Muscle strength will be measured through dumbbell lifting at weeks 8 and 12. If the data are normally distributed, ANOVA will be used, and results will be presented as means ± standard deviation (SD). If the data are not normally distributed, they will be presented as medians and interquartile ranges, with comparisons made using non-parametric tests. A p-value of less than 0.05 will be considered statistically significant.

Medialized vs. Lateralized Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

Reverse shoulder arthroplasty (RSA) is increasingly used in the treatment of proximal humerus fractures (PHFs) with reliable clinical improvement. Lateralized RSA implants have conferred superior outcomes compared with the original Grammont design in patients with nontraumatic indications. However, in the setting of a PHF, lateralized components can place increased tension across the tuberosity fracture site and potentially compromise tuberosity healing and outcomes. This systematic review and meta-analysis sought to determine the effect of implant design on clinical outcomes after RSA for PHFs.

METHODS

A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for clinical studies on RSA performed for PHFs that reported implant manufacturer details. Our primary outcomes included postoperative external rotation (ER), forward elevation (FE), abduction, Constant score, rate of greater tuberosity (GT) healing, and the incidence of complications compared between medialized vs. lateralized global implant design.

RESULTS

Globally lateralized RSA cohorts (478 RSAs total with cumulative lateral offset achieved through humeral or glenoid lateralization or both humeral and glenoid lateralization) were found to have a greater mean postoperative Constant score compared with globally medialized (medialized glenoid and medialized humerus) RSA cohorts with 1,494 total medialized RSAs (66 vs. 59, p = 0.006), but there was no significant difference regarding mean postoperative ER (30° vs. 22°, p = 0.078), FE (117° vs. 119°, p = 0.708), or abduction (103° vs. 107°, p = 0.377). On meta-regression, neither implant design nor tuberosity status significantly influenced postoperative ER, FE, abduction, or Constant score on meta-regression independent of mean follow-up and age at surgery. The rate of GT healing was greater in lateralized compared with medialized RSAs (88% vs. 72%, p < 0.001). On meta-regression, medialized RSA design was associated with a 73% lower odds of GT healing (odds ratio = 0.27, 95% confidence interval = 0.11-0.68, p = 0.007) independent of mean follow-up and age at surgery.

CONCLUSION

Lateralized RSA implants conferred no significant functional benefit over medialized implants when used in patients with PHFs.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Correlation and conversion between the QuickDASH, Constant Score, and Oxford Shoulder Score in patients with conservatively treated proximal humerus fractures

BACKGROUND

There is significant heterogeneity of outcome measures used in the research of proximal humerus fractures (PHFs). Current evidence regarding the correlation and conversion between the various outcome measures is sparse. This study aims to study the correlation and conversion between the QuickDASH, Constant Score (CS), and Oxford Shoulder Score (OSS) in conservatively treated PHFs.

METHODS

A prospective cohort study of patients (n = 136) with conservatively treated PHFs between August 2017 and April 2020 was conducted. Patients had a minimum follow-up period of 1 year. The 3 outcome measures (QuickDASH, CS, and OSS) were collected at 4 time points-6 weeks, 3 months, 6 months, and 1 year after injury. Changes in scores across time and correlation between each pair of outcome measures were calculated. A linear regression model was used to derive conversion equations which were then internally validated.

RESULTS

A significant strong negative correlation was observed between the OSS and QuickDASH (coefficient: -0.746; P < .001), a significant moderate negative correlation was observed between the CS and QuickDASH (coefficient: -0.581; P < .001), and a significant moderate positive correlation was observed between the CS and OSS (coefficient: 0.697; P < .001). The 6 derived regression equations showed low mean differences between predicted and actual values (ranging from -1.21 to 2.51). The correlation between actual and predicted values was moderate to strong, ranging from a coefficient of 0.57 in the conversion from the CS to QuickDASH to 0.74 in the conversion from the CS to OSS and OSS to CS.

CONCLUSION

In a cohort of patients with conservatively managed PHFs, moderate to strong correlations were seen in pairwise comparisons of the OSS, QuickDASH, and CS. With linear regression analyses, 6 regression equations were derived to estimate one score from another. On internal validation, there was good agreement between the means of the predicted and actual scores but high within-individual variability. These formulae can help to compare studies with heterogeneous outcome measures and facilitate meta-analyses. However, these equations should not be used to predict one score from another in an individual due to variability when converting individual scores.

Outcomes following reverse total shoulder arthroplasty vs operative fixation for proximal humerus fractures: a systematic review and meta-analysis

INTRODUCTION

Proximal humerus fractures are common in the older population. A consensus on the optimal management of complex fractures requiring surgery has yet to be reached. A systematic review and meta-analysis was performed to compare clinical outcomes between reverse total shoulder arthroplasty (RTSA) and open reduction and internal fixation (ORIF).

METHODS

A systematic search of the literature was undertaken using the Medline®, PubMed, Embase™ and Cochrane Central Register of Controlled Trials databases. Prospective and retrospective studies comparing clinical and patient reported results as primary outcome measures were included in this review, with secondary outcome measures including complications and revision surgery. A meta-analysis was conducted.

RESULTS

A total of 326 patients from 5 studies were eligible for inclusion in this review. Superior Constant-Murley scores (mean difference [MD]: 13.4, 95% confidence interval [CI]: 6.2-20.6; p<0.001), Oxford shoulder scores (MD: 4.3, 95% CI: 1.2-7.4; p=0.007), simple shoulder test scores (MD: 0.95, 95% CI: 0.01-1.89; p=0.05) and DASH (Disabilities of the Arm, Shoulder and Hand) scores (MD: 5.1 [1 study], 95% CI: 2.1-8.1; p=0.034) were noted in patients receiving RTSA. Range of motion and revision surgery rates were also superior in this group.

CONCLUSIONS

This study suggests that RTSA affords more favourable outcomes and lower revision rates than ORIF following proximal humerus fractures. Definitive conclusions are precluded, however, owing to small sample sizes and risk of bias in retrospective studies.

Locking Plate Fixation with Calcium Phosphate Bone Cement Augmentation for Elderly Proximal Humerus Fractures-A Single-Center Experience and Literature Review

Proximal humerus fractures (PHFs) are among the most common upper-extremity fractures, with a rising incidence linked to the growing elderly population. Treatment options include non-surgical and surgical methods, but the best approach for geriatric PHFs remains debated. Patient selection for treatment must consider clinical and functional outcomes and the potential complications of surgery. Osteoporosis, a key factor in elderly PHFs, meaning those in patients over 65 years old, often results from low-energy trauma and necessitates treatments that enhance bone healing. Bone cement, such as calcium phosphate, is widely used to improve fracture stability and healing. However, the benefits of surgical fixation with bone cement augmentation (BCA) for elderly PHF patients remain controversial. Hence, in this article, we searched databases including MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science to analyze the evidence on locking plate fixation (LPF) with BCA for proximal humeral fractures. We aim to provide readers with updates concerning the above issues.

Trends in reported outcomes and patient reported outcome measures (PROMs) in humeral shaft fracture literature: a systematic review

PURPOSE

With a lack of standardization among outcome measures in fracture literature, cross-study comparisons remain limited. This systematic review aimed to identify trends in outcome measures reported by studies of the treatment of humeral shaft fractures.

METHODS

A systematic review was performed of studies reporting clinical outcomes of humeral shaft fractures indexed in PubMed. Extracted data included demographics, fracture characteristics, treatment modalities, outcomes, patient reported outcome measures (PROMs), and journal characteristics. Cochran-Armitage tests and linear regressions were used to identify data trends. Pearson chi-square and Kruskal-Wallis tests were used for comparisons between studies.

RESULTS

This review included 197 studies with outcomes of 15,445 humeral shaft fractures. 126 studies reported PROMs and 37 different PROMs were used. The Constant Score was most commonly reported (34% of studies), followed by ASES Score (21%), MEPS (21%), and DASH Score (20%). There was a significant increase in PROM usage over time (p = 0.016) and in articles using three or more PROMs (p = 0.005). The number of PROMs were significantly greater in prospective cohort studies and RCTs (p = 0.012) compared to retrospective cohort studies and case series (p = 0.044 for both). Post-treatment shoulder motion was reported in 43% of studies and 34% reported elbow motion. 86% of studies reported complications as an outcome parameter. Time to union and nonunion rate were published in 69% and 88% of studies, respectively.

CONCLUSION

This study identified increasing PROM usage over time and disparities in the reporting of outcomes in humeral shaft fracture literature requiring further validation and standardization of available outcome measures.

Physiotherapist-supervised exercises versus unsupervised home-based exercises after nonsurgically treated proximal humerus fracture: a multicenter randomized controlled trial

BACKGROUND

Proximal humerus fracture (PHF) is a common fragility fracture in older adults and can have a substantial impact on upper limb function. Although most patients with PHF can be treated nonsurgically, it is unknown whether older adults benefit from supervised exercise therapy after PHF. Therefore, the objective of this trial was to investigate whether 10 weeks of physiotherapist-supervised exercises once a week were superior to 10 weeks of unsupervised home-based exercises in older adults with a nonsurgically treated displaced 2-part PHF.

METHODS

This was designed as an assessor-blinded, prospective, randomized controlled trial and took place in 3 Nordic countries. In total, 72 patients (≥60 years) with nonsurgically treated displaced 2-part PHF were randomized to either physiotherapist-supervised exercises once a week for 10 weeks, combined with daily home-based exercises, or to 10 weeks of daily unsupervised home-based exercises. The primary outcome measure was the Disability of the Arm, Shoulder, and Hand (DASH) with a primary endpoint at 3 months. Secondary outcomes were DASH (at 12 months), Constant-Murley Score, the 15D-instrument, Visual Analog Scale, General Self-Efficacy Scale, and Pain Catastrophizing Scale, with follow-up visits after 3 and 12 months. Non-union and patient death within 3 months were counted as complications.

RESULTS

The mean age of the patients in both groups was 72 years. At 3 months follow-up, the mean DASH score in the supervised group was 25.9 (SD 16.0) compared to 22.4 (SD 18.9) in the unsupervised group. The mean between-group difference (3.5, 95% CI -5.0 to 12.5) was not clinically relevant. None of the secondary outcome measures presented any clinically relevant or statistically significant between-group differences at 3 or 12 months follow-up. One patient in the supervised group and 3 in the unsupervised group were diagnosed with non-union. One patient from each group died before 3 months follow-up.

CONCLUSIONS

This trial provides no evidence that supervised exercises are superior to unsupervised home-based exercises in improving functional outcome or health-related quality of life in older patients with a nonsurgically treated 2-part PHF. Further, our results suggest that most older adults with a nonsurgically treated 2-part PHF can perform home-based exercises without the supervision of a physiotherapist.

Factors affecting hospital admission, hospital length of stay and new discharge destination post proximal humeral fracture: a retrospective audit

BACKGROUND

Outcomes following proximal humeral fracture (PHF) may be impacted by a range of clinical, fracture and premorbid factors. The aim of this study was to examine factors impacting hospital admission; length of stay (LOS) and new discharge destination for patients presenting to hospital with PHF.

METHODS

Retrospective audit conducted at a tertiary health service. Data was collected from adult patients presenting to hospital with a PHF over a 54-month period. Fractures that were pathological or sustained during admission were excluded. Univariable and multivariable logistic and negative binomial regression were used to explore factors associated with hospital admission, LOS and new discharge destination.

RESULTS

Data were analyzed from 701 participants (age 70 years (IQR 60, 81); 72.8% female); 276 (39.4%) participants required a hospital admission. New discharge destination was required for 109 (15.5%) participants, of whom 49 (45%) changed from home alone to home with family/friend(s). Greater comorbidities, as indicated by the Charlson Comorbidity Index score, were associated with hospital admission, longer LOS and new discharge destination. Premorbid living situations of home with family/friend(s) or from an external care facility were associated with a decreased likelihood of hospital admission, shorter LOS and reduced risk of a new discharge destination. Surgical treatment was associated with shorter LOS. Older age and dementia diagnosis were associated with a new discharge destination.

CONCLUSIONS

Many factors potentially impact on the likelihood or risk of hospitalization, LOS and new discharge destination post PHF. Patients with greater comorbidities are more likely to have negative outcomes, while patients who had premorbid living situations of home with family/friend(s) or from an external care facility are more likely to have positive outcomes. Early identification of factors that may impact patient outcomes may assist timely decision making in hospital settings. Further research should focus on developing tools to predict hospital outcomes in the PHF population.

Study on proximal humerus evaluation of effective treatment (SPHEER) - what is the effect of rehabilitation compliance on clinical outcomes of proximal humerus fractures

INTRODUCTION

Proximal humeral fractures (PHFs) are 3rd commonest fragility fractures and cause significant functional impairment. This paper sought to determine impact of rehabilitation compliance on the clinical outcomes for non-surgically managed PHFs, while ascertaining reasons for non-compliance which can be addressed to improve compliance.

METHODS

Prospective cohort study of patients undergoing non-surgical treatment for PHFs from August 2017 to April 2020 in a tertiary trauma centre was performed. Data was collected via questionnaire: patient demographic data, PHF injury details, clinical outcome measures, therapist-reported (Sport Injury Rehabilitation Adherence Scale [SIRAS]) and patient-reported (subjective compliance, frequency of exercise) rehabilitation compliance measures. Data was analysed using multiple linear regression model to account for confounding variables.

RESULTS

107 participants attended physical therapy follow-up for mean 137.8 days. 6-week SIRAS strongly predicted 3-month Constant score (p = 0.023; 95%CI = 0.265,3.423), OSS (p = 0.038; 95%CI = 0.049,1.634), flexion ROM (p < 0.001; 95%CI = 2.872,8.982), extension ROM (p = 0.035; 95%CI = 0.097,2.614), abduction ROM (p = 0.002;95%CI = 1.995,8.466) and achievement of functional active ROM at 3-months (p = 0.049; 95%CI = 1.001,1.638). Pain was the top reason impairing rehabilitation compliance from therapist (43.9% at 6-weeks and 20.6% at 3-months) and patient-perspective (33.6% at 6-weeks, 24.3% at 3-months). Author-developed patient-reported compliance measures had good correlation with validated SIRAS score (subjective compliance: p < 0.001 frequency of exercise: p = 0.001).

CONCLUSION

Rehabilitation compliance predicts short-term clinical outcomes up to 3-months and potentially 1-year outcomes. Pain control should be optimised to maximise rehabilitation compliance and improve PHF outcomes. There is lack of consensus definition for rehabilitation compliance measures; patient-reported measures used have good correlation to existing validated measures and could serve as a steppingstone for further research.

LEVEL OF EVIDENCE

II, cohort study.

Why treatment of proximal humeral fractures remains unresolved despite randomized trials

Most proximal humeral fractures can be treated nonoperatively, but there are specific indications to perform surgery for some of these fractures. Optimal treatment remains subject to debate, since no consensus has been reached for the best therapy for these fractures. This review provides an overview of randomized controlled trials (RCTs) comparing treatment for proximal humeral fractures. Fourteen RCTs comparing different operative and nonoperative types of treatment for PHF are included. Different RCTs comparing the same interventions for PHF have drawn different conclusions. It also highlights reasons why consensus has not been reached based on these data, and how this could be addressed in future research. Previous RCTs have included different patient groups and fracture patterns, may have been prone to selection bias, often were underpowered for subgroup analysis, and showed inconsistency in the outcome measures used. Based on this, and appreciating that treatment may be tailored to specific fracture types and patient characteristic like age, a better way to move forward could be to use a (international) multicenter prospective cohort study. Such a registry-type study should use accurate patient selection and enrollment, well-defined fracture patterns, standardized surgical techniques performed according to the preferences of the surgeon, and with a standardized follow-up.

Shoulder-specific Outcome after Proximal Humerus Fracture Influences Medium-term Overall Quality of Life

BACKGROUND

Surgical treatment of proximal humerus fracture is an established procedure. Postoperative complications have been shown to have a significant impact on shoulder-specific outcome. Little is known to date about an influence on injury-independent quality of life.

AIM OF THE WORK

The aim of this retrospective study is to analyse whether patients with a poor functional outcome after surgically treated proximal humerus fracture also show a reduced general quality of life in the medium term. Emphasis is placed on the analysis of patients with poor functional outcome due to postsurgical complications.

MATERIAL AND METHODS

Evaluation of all patients operated at one level 1 trauma centre with a proximal humerus fracture in the period 01.01.2005 to 31.12.2015 and follow-up using validated scores (Constant-Murley Score [CMS], EQ-5D). Two groups, group A with good outcome (∆CMS ≤ 15P.) and group B with poor outcome (∆CMS ≥ 16P.), were defined. Furthermore, descriptive variables including definition of a complication were defined in advance.

RESULTS

138 patients were included in the study (group A: 91, group B: 47). The mean follow-up was 93.86 months ± 37.33 (36-167). Group B had significantly more complications. Furthermore, patients with poor outcome regarding the shoulder (group B) were also found to have significantly lower EQ-VAS (78.9 ± 19.2 [20.0-100] vs. 70.4 ± 19.5 [15.0-98.0]; p = 0.008) and EQ index (0.91 ± 0.14 [0.19-1.00] vs. 0.82 ± 0.17 [0.18-1.00]; p < 0.001).

DISCUSSION

In conclusion, in the present study, the patients with poor outcome of shoulder function in CMS have significantly lower overall quality of life after a mean of more than 6 years of follow-up. The poor outcome was due to a significantly higher postoperative complication rate. This was independent of the fracture morphology present and the surgical procedure used.

A systematic review of the patient reported outcome measures utilized in level 1 randomized controlled trials involving achilles tendon ruptures

BACKGROUND

Patient Reported Outcome Measures (PROMs) are utilized in level 1 randomized controlled trials involving Achilles tendon ruptures. However, the characteristics of these PROMs and current practices has not yet been reported. We hypothesize that there will be heterogeneous PROM usage in this context.

METHODS

A PubMed and Embase systematic review was performed including all dates up to July 27th, 2022, assessing Achilles tendon ruptures in level 1 studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines where applicable. Inclusion criteria were all randomized controlled clinical studies involving Achilles tendon injuries. Studies that: (1) were not level 1 evidence (including editorial, commentary, review, or technique articles), (2) omitted outcome data or PROMs, (3) included injuries aside from Achilles tendon ruptures, (4) involved non-human or cadaveric subjects, (5) were not written in English, and (6) were duplicates were excluded. Demographics and outcome measures were assessed in the studies included for final review.

RESULTS

Out of 18,980 initial results, 46 studies were included for final review. The average number of patients per study was 65.5. Mean follow up was 25 months. The most common study design involved comparing two different rehabilitation interventions (48 %). Twenty different outcome measures were reported including the Achilles tendon rupture score (ATRS) (48 %), followed by the American Orthopedic Foot and Ankle score Ankle-Hindfoot score (AOFAS-AH) (46 %), the Leppilahti score (20 %), and the RAND-36/Short Form (SF) - 36/SF-12 scores (20 %). An average of 1.4 measures were reported per study.

CONCLUSION

Significant heterogeneity exists in PROM usage among level 1 studies involving Achilles tendon ruptures, which prevents meaningful interpretation of these data across multiple studies. We advocate for usage of at least the disease-specific Achilles Tendon Rupture score and a global, quality of life (QOL) survey such as the SF-36/12/RAND-36. Future literature should provide more evidence-based guidelines for PROM usage in this context.

LEVEL OF EVIDENCE

Level IV; Systematic Review.

Avascular Necrosis and Posttraumatic Arthritis After Proximal Humerus Fracture Internal Fixation: Evaluation and Management

PURPOSE OF REVIEW

Avascular necrosis (AVN) and posttraumatic arthritis (PTA) are common complications following both conservative treatment and open reduction and internal fixation (ORIF) of proximal humerus fractures (PHFs). Despite the frequent utilization of ORIF, information regarding these leading causes of failure is limited. This review includes a discussion of incidence, risk factors, and evaluation of AVN and PTA following PHF. The mechanisms of treatment options and associated outcomes are also reviewed.

RECENT FINDINGS

Recent best available evidence demonstrates significant rates of AVN and PTA following ORIF of PHF. This is particularly true of complex fracture patterns. A thorough workup is required in the setting of failure caused by AVN and PTA. This includes a careful patient history, clinical exam, plain film radiographs, and CT scans. EMG and/or aspiration may also be indicated. Special consideration is given to the examination of the deltoid muscle, neurovascular status, rotator cuff function, and the possibility of infection. Biological supplementation, anatomic total shoulder replacement (aTSA), and fusion are rarely employed in the treatment of AVN and/or PTA. Due to satisfactory patient outcomes, reverse total shoulder replacement (rTSA) has increased in popularity for the elderly population, while hemiarthroplasty (HA) may be appropriate for some young, active patients. With careful patient selection and meticulous surgical technique, AVN and PTA can be mitigated. Careful indications for ORIF may decrease the frequency of these complications. For most patients, rTSA is the optimal treatment option. Given the frequent utilization of ORIF and the higher than acceptable complication and failure rates, AVN and PTA warrant our attention.

Patient-reported outcome measures used for shoulder disorders: An overview of systematic reviews

BACKGROUND

The aim of this study was to synthesize the psychometric evidence on different patient reported outcome measures (PROMs) for shoulder disorders.

METHODS

This overview conducted a search of six databases. Included systematic reviews must address at least one psychometric property from a PROM for shoulder disorders. Risk of bias was assessed by A MeaSurement Tool to Assess Systematic Reviews (AMSTAR).

RESULTS

Thirteen systematic reviews were identified that assessed measurement properties of 15 different PROMs. Based on AMSTAR, 1 review had a high risk of bias and 7 reviews had a moderate risk of bias. Excellent test-reliability scores of intraclass correlation coefficients (0.85-0.99) were reported by the Disabilities of the Arm, Shoulder and Hand, Shoulder Pain and Dsiability Index, American Shoulder and Elbow Surgeon score and Western Ontario Rotator Cuff Index. Construct validity was supported (r = 0.5-0.8) for the Disabilities of the Arm, Shoulder and Hand, Shoulder Pain and Dsiability Index, American Shoulder and Elbow Surgeon score and Western Ontario Rotator Cuff Index. Limited evidence of responsiveness was reported across various PROMs.

CONCLUSION

Strong reliability and convergent validity properties have been reported across multiple reviews for the Disabilities of the Arm, Shoulder and Hand, Shoulder Pain and Dsiability Index, American Shoulder and Elbow Surgeon score, Simple Shoulder Test and Western Ontario Rotator Cuff Index, which could be considered for a core clinical outcome set.

Fractures of the posterior malleolus: a systematic review and analysis of patient-reported outcome scale selection

PURPOSE

Despite the extensive use of PROs in ankle fracture research, no study has quantified which PROs are most commonly used for assessing outcomes of patients who sustain fractures of the posterior malleolus. The purpose of this study was therefore to quantify which PROs are most commonly used for outcome research after posterior malleolus fractures.

METHODS

A systematic search was performed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Articles were identified through Pubmed, EMBASE, Web of Science, and cochrane central register of controlled trials through May of 2021. Included articles were analyzed for the primary outcome of the most commonly reported PRO.

RESULTS

The American orthopedic foot and ankle ankle-hindfoot score (AOFAS) was the most commonly used PRO for assessment of posterior malleolus fracture outcomes, used in 37 of 72 studies (51.4%). The second and third most common were the olerud-molander ankle score (OMAS) (22 studies, 30.6%) and the visual analogue score (VAS) (21 studies, 29.2%). Eleven different PROs were used only once. Quality of evidence was graded as low given the percentage of studies that were observational or case series (68 of 72 studies, 94.4%).

CONCLUSION

Investigators have used many different PROs to assess outcomes for posterior malleolus fractures, the most common of which are the AOFAS, OMAS, and VAS. Future investigators should attempt to unify outcome reporting for these injuries.

There are more things in physical function and pain: a systematic review on physical, mental and social health within the orthopedic fracture population using PROMIS

Background

The Patient-Reported Outcomes Information System (PROMIS®) is more and more extensively being used in medical literature in patients with an orthopedic fracture. Yet, many articles studied heterogeneous groups with chronic orthopedic disorders in which fracture patients were included as well. At this moment, there is no systematic overview of the exact use of PROMIS measures in the orthopedic fracture population. Therefore this review aimed to provide an overview of the PROMIS health domains physical health, mental health and social health in patients suffering an orthopedic fracture.

Methods

This systematic review was documented according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. We searched Embase, Medline, Web of Science Core Collection, and Cochrane Central Register of controlled Trials, CINAHL and Google Scholar in December 2020 using a combination of MeSH terms and specific index terms related to orthopedic fractures and PROMIS questionnaires. Inclusion criteria were available full text articles that were describing the use of any PROMIS questionnaires in both the adult and pediatric extremity fracture population.

Results

We included 51 relevant articles of which most were observational studies (n = 47, 92.2%). A single fracture population was included in 47 studies of which 9 involved ankle fractures (9/51; 17.6%), followed by humeral fractures (8/51; 15.7%), tibia fractures (6/51; 11.8%) and radial -or ulnar fractures (5/51; 9.8%). PROMIS Physical Function (n = 32, 32/51 = 62.7%) and PROMIS Pain Interference (n = 21, 21/51 = 41.2%) were most frequently used questionnaires. PROMIS measures concerning social (n = 5/51 = 9.8%) and mental health (10/51 = 19.6%) were much less often used as outcome measures in the fracture population. A gradually increasing use of PROMIS questionnaires in the orthopedic fracture population was seen since 2017.

Conclusion

Many different PROMIS measures on multiple domains are available and used in previous articles with orthopedic fracture patients. With physical function and pain interference as most popular PROMIS measures, it is important to emphasize that other health-domains such as mental and social health can also be essential to fracture patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00440-3.

Current trends in patient-reported outcome measures for clavicle fractures: a focused systematic review of 11 influential orthopaedic journals

BACKGROUND

Many patient-reported outcome measures (PROMs) have been used to follow clavicle fractures, providing an objective means to track outcomes. However, lack of standardization of PROM usage makes cross-study comparison difficult. Therefore, we reviewed articles on clavicle fractures from 11 of the most influential orthopedic journals to assess trends in PROM usage over time and based on geographic location.

METHODS

A focused systematic review of 11 of the most influential orthopedic journals was performed using PubMed. All articles published between 1981 and 2020 with greater than 9 patients reporting clinical outcomes of clavicle fractures were included. For each article, patient demographics, treatment modality, geographic location, and outcome measures used were recorded. Temporal trends were identified using the Cochran-Armitage test for trend and linear regression. Pearson chi-square and Kruskal-Wallis tests were used to compare between journals, geographic location, study type, and fracture classification.

RESULTS

From the initial literature search of 623 articles, 151 studies reporting on 15,853 primary clavicle fractures were included. Fractures of the middle one-third of the clavicle were most studied in the included literature (71%). Seventeen different PROMs were used, with an average of 1.6 outcome measures per study, and there was a significant increase in the number of PROMs used per article over time (P < .001). The Constant-Murley score was the most-reported outcome measure (44%) followed by the Disabilities of the Arm, Shoulder, and Hand score (27%), visual analog scale for pain (23%), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES; 14%). There was a significant difference between the measures used based on geography (P = .002), the most notable being that North American authors use the ASES score more frequently.

CONCLUSIONS

The use of PROMs in studies evaluating clavicle fracture treatment outcomes has increased over time, with recent studies reporting more PROMs than older studies, and there are notable differences in usage of the various scores based on geography and journal. Although there is no consensus on the most reliable PROM for assessing clavicle fractures, we recommend the use of at least 2 of the commonly reported PROMs in future studies to facilitate cross-study comparisons.

Editorial Commentary: Delivering the PROMIS for Patients With Shoulder Disorders-Fool's Gold, a Mirage, or an Oasis

Comparative psychometric performance of Patient-Reported Outcome Measurement Information System (PROMIS) instruments to legacy patient-reported outcomes for shoulder disorders is relevant and timely, as numerous stakeholders are engaged in the process of capturing, comparing, and evaluating performance results at the individual and population health levels. Depending on the stakeholder type, patient-reported outcomes could be used for clinical research, reimbursement, point-of-care, or benchmarking for patient comparison with a matched population cohort or comparative surgeon scorecard. Identifying and using the appropriate patient-reported outcome measure may be dependent on the purpose for measurement and stakeholder engagement and, as such, could be considered fool's gold, a mirage, or an oasis. At this time, PROMIS instruments are not a suitable replacement for legacy patient-reported outcomes when orthopaedic surgeons are looking to perform level I and level II clinical studies to develop future clinical practice guidelines grounded in strong evidence.