Clinical importance of comorbidity in patients with a proximal humerus fracture

Assessment of therapeutic clinical trials for proximal humeral fractures

Proximal humeral fractures (PHFs) are a common injury among the older population. An ideal therapeutic protocol has yet to be developed, and numerous clinical trials are being conducted to find the best therapeutic approach. The purpose of this study is to evaluate the current body of knowledge available via interventional clinical trials. In December 2022, interventional clinical trials relating to PHFs on Clinicaltrials.gov were screened. Trial characteristics included duration, status, intervention, phase, outcomes, location, and study design. Publications associated with each trial were searched on PubMed/Medline using the ClinicalTrials.gov registry number. The final dataset comprised 64 trials. The most common trial status was completed (36%). The majority did not have a Food and Drug Administration-defined phase (67%), was randomized (81%), involved a single facility (72%), used a parallel assignment intervention model (80%), and used an open-label approach (45%). Eleven trials were associated with a publication, and the publication rate was 17%. Average enrollment was 86 participants, and mean trial duration was 51.4 months. Europe/UK/Russia/Turkey participated in the most trials (70%). Most of the trials were initiated after 2010 (87.5%). Procedure-related interventions (55%) were most common. Disability/function was the most common primary outcome assessed (61%). The low publication rate and the multitude of trials conducted after 2010 highlight the urgency and need for trial results to be published to establish an ideal therapeutic protocol. Since the majority of the trials involved a single institution and an open-label approach, reinforcing blinding and establishing multi-centered trials can improve the validity of the clinical trial results.

Blood transfusion and surgical treatment increase mortality in patient with proximal humeral fractures

INTRODUCTION

Proximal humeral fractures (PHFs) often occur in elderly patients with osteoporosis and associated comorbidities. These patients constitute a special risk group. This study aimed to identify associations between comorbidities, treatment type, and mortality risk.

PATIENTS AND METHODS

We conducted a retrospective chart review of a cohort of 350 patients with a diagnosis of PHF and a mean follow-up of 4.5 years. We analysed the 19 prefracture comorbidities included in the Charlson Comorbidity Index (CCI), haemoglobin (Hb) levels, blood transfusion needs, and treatment administered (surgery versus conservative). The nonparametric Kaplan-Meier method and Cox proportional hazards model were used to estimate the mortality risk.

RESULTS

Over a 4.5-year average follow-up of 350 patients, primarily elderly females, with proximal humerus fractures, several factors were associated with increased mortality. The Charlson Comorbidity Index (CCI) was a significant predictor, with patients having a CCI > 5 facing higher mortality risks, especially if they underwent surgery. Additionally, osteosynthesis was linked to a lower mortality rate compared to arthroplasty. Age, dementia, medical complications, and postfracture Hb level also influenced mortality rates. CONCLUSIóN: These findings emphasize the importance of considering comorbidities, specifically the Charlson Comorbidity Index (CCI), in determining patient outcomes, especially amongst elderly patients with proximal humerus fractures. Factors like age, dementia, and postfracture Hb level also play a crucial role in influencing mortality rates.

TRIAL REGISTRATION

The study received written approval from the regional Ethics Committee for Clinical Research (code 2016/125).

Prognostic factors and prediction model for 1-year mortality after proximal humeral fracture

The goal was to investigate if patient characteristics can be used to predict 1-year post-fracture mortality after proximal humeral fracture (PHF). A clinical prediction model showed that the combination of 6 pre-fracture characteristics demonstrated good predictive properties for mortality within 1 year of PHF.

INTRODUCTION

Proximal humeral fractures (PFH) are the third most common major non-vertebral osteoporotic fractures in older persons and result in an increased mortality risk. The aim of this study was to investigate if patient characteristics can be used to predict 1-year post-fracture mortality.

METHODS

Retrospective study with 261 patients aged 65 and older who were treated for a PHF in University Hospitals Leuven between 2016 and 2018. Baseline variables including demographics, residential status, and comorbidities were collected. The primary outcome was 1-year mortality. A clinical prediction model was developed using LASSO regression and validated using split sample and bootstrapping methods. The discrimination and calibration were evaluated.

RESULTS

Twenty-seven (10.3%) participants died within 1-year post-PHF. Pre-fracture independent ambulation (p < 0.001), living at home at time of fracture (p < 0.001), younger age (p = 0.006), higher BMI (p = 0.012), female gender (p = 0.014), and low number of comorbidities (p < 0.001) were predictors for 1-year survival. LASSO regression identified 6 stable predictors for a prediction model: age, gender, Charlson comorbidity score, BMI, cognitive impairment, and pre-fracture nursing home residency. The discrimination was 0.891 (95% CI, 0.833 to 0.949) in the training sample, 0.878 (0.792 to 0.963) in the validation sample and 0.756 (0.636 to 0.876) in the bootstrapping samples. A similar performance was observed for patients with and without surgery. The developed model demonstrated good calibration.

CONCLUSIONS

The combination of 6 pre-fracture characteristics demonstrated good predictive properties for mortality within 1 year of PHF. These findings can guide PHF treatment decisions.

Impact of Increasing Comorbidity Burden on Resource Utilization in Patients With Proximal Humerus Fractures

INTRODUCTION

Proximal humerus fractures (PHF) are a common upper extremity fracture in the elderly cohort. An aging and more comorbid cohort, along with recent trends of increased operative intervention, suggests that there could be an increase in resource utilization caring for these patients. We sought to quantify these trends and quantify the impact that comorbidity burden has on resource utilization.

METHODS

Data on 83,975 patients with PHFs were included from the Premier Healthcare Claims database (2006 to 2016) and stratified by Deyo-Charlson index. Multivariable models assessed associations between Deyo-Charlson comorbidities and resource utilization (length and cost of hospitalization, and opioid utilization in oral morphine equivalents [OME]) for five treatment modalities: (1) open reduction internal fixation (ORIF), (2) closed reduction internal fixation (CRIF), (3) hemiarthroplasty, (4) reverse total shoulder arthroplasty, and (5) nonsurgical treatment (NST). We report a percentage change in resource utilization associated with an increasing comorbidity burden.

RESULTS

Overall distribution of treatment modalities was (proportion in percent/median length of stay/cost/opioid utilization): ORIF (19.1%/2 days/$11,183/210 OME), CRIF (1.1%/4 days/$11,139/220 OME), hemiarthroplasty (10.7%/3 days/$17,255/275 OME), reverse total shoulder arthroplasty (6.4%/3 days/$21,486/230 OME), and NST (62.7%/0 days/$1,269/30 OME). Patients with an increased comorbidity burden showed a pattern of (1) more pronounced relative increases in length of stay among those treated operatively (65.0% for patients with a Deyo-Charlson index >2), whereas (2) increases in cost of hospitalization (60.1%) and opioid utilization (37.0%) were more pronounced in the NST group.

DISCUSSION

In patients with PHFs, increased comorbidity burden coincides with substantial increases in resource utilization in patients receiving surgical and NSTs. Combined with known increases in operative intervention, trends in increased comorbidity burden may have profound effects on the cohort level and resource utilization for those with PHFs, especially because the use of bundled payment strategies for fractures increases.

LEVEL OF EVIDENCE

Level III.

Modified Use of a Fibular Strut in the Reduction and Stabilization of 2-Part Osteoporotic Proximal Humerus Fractures

PURPOSE

This study introduces a modified use of a fibular strut allograft as an adjunct to lateral locked plating in the treatment of osteoporotic two-part fractures of the proximal humerus.

METHODS

A prospective series of 13 consecutive patients (mean age 68; range, 60 to 88) with displaced two-part fractures of the proximal humerus were included. The main outcome measures included radiographic healing, clinical and radiographic findings of complications, assessment of shoulder function measured with the Shoulder Function Index, and ultrasonography assessment of rotator cuff disruption.

RESULTS

At postoperative month four, every fracture healed as evidenced on radiographic assessment. Clinically, patients achieved an average shoulder forward flexion of 141.5°, external rotation of 37°, and abduction of 98°. The mean Shoulder Function Index score was 73.2 (range, 64 to 77). No patients were included who required a major or a minor revision surgery. The average follow-up was 13.2 months (range, 12 to 15). Ultrasonography demonstrated no tears of the rotator cuff.

DISCUSSION

In a series of 13 patients, our technique facilitated fracture reduction while avoiding additional soft-tissue dissection at the fracture site and enabled supplementary stabilization after application of a lateral locking plate. Using this technique, we had minimal complications, a high rate of osseous healing, and achieved favorable clinical outcomes in a challenging patient population.

Acute surgical management of proximal humerus fractures: ORIF vs. hemiarthroplasty vs. reverse shoulder arthroplasty

BACKGROUND

Proximal humerus fracture treatment varies by surgeon preference and patient factors. This study compares patient and fracture characteristics, with outcomes between current surgical treatment options.

METHODS

Between 1999 and 2018, 425 proximal humerus fractures underwent acute surgical management: open reduction internal fixation (ORIF, n = 211), hemiarthroplasty (HA, n = 108), or reverse shoulder arthroplasty (RSA, n = 106). Patient and fracture characteristics included age, American Society of Anesthesiologists physical status classification (ASA), and fracture classification. Postoperative motion at 3, 6, and minimum 12 months (avg 20 ± 21 months), radiographic outcomes, and postoperative falls were analyzed.

RESULTS

Average age for treatment groups was 65 ± 13 years (range: 18-93 years). Fractures were classified as 2- (11%), 3- (41%), or 4-part (48%). Age, ASA, and fracture classification were associated with selected surgical management (P < .0001, =.001, <.0001, respectively). Outcomes showed a significant improvement in forward flexion from 3 months to 6 months in all groups (P < .0001). No difference in final motion was seen between groups. Radiographic union was higher in ORIF (89%), and similar between HA (79%) and RSA (77%, P = .005). Rate of reoperation was RSA 6.6%, ORIF 17.5%, and hemiarthroplasty 15.7% (P = .029). Postoperatively, 23% patients had at least 1 fall, of which 73% resulted in fractures.

CONCLUSION

Older patients with high ASA were treated with arthroplasty, and younger patients with lower ASA were treated with ORIF. All groups showed improvements in motion. At minimum 1 year of follow-up, there was no difference in motion between groups. ORIF and HA showed significantly more reoperations compared with RSA. Patients should be counseled about reoperation, fall risk, and prevention.

Is the Charlson comorbidity index a good predictor of mortality and adverse effects in proximal humerus fractures?

INTRODUCTION

Proximal humerus fractures (PHF) are frequent in elderly patients. This population also suffers from a series of associated comorbidities, and PHF increases morbidity and mortality. The Charlson Comorbidity Index (CCI) is a tool used for calculating comorbidity and therefore the mortality risk.

HYPOTHESIS

Our hypothesis is that CCI is a good predictor of mortality in patients suffering from PHF, and that there is a relationship between CCI and the development of adverse events.

PATIENTS AND METHODS

A retrospective study with prospective data collection of 354 patients who had been diagnosed and treated for a single PHF between August 1st, 2013 and July 31st, 2015 was carried out at our hospital. The minimum follow-up was 24 months (mean 51.1 months). This study included all patients regardless the severity of the fracture, the treatment performed (surgical or conservative treatment) or whether the patient had been admitted to the hospital or was treated as an outpatient. Adverse effects and mortality data were collected and the CCI was calculated.

RESULTS

Patients with high CCI (>5) had a higher mortality risk 4.6 (95% CI [2.4-9.0]) compared to those with CCI<5. During follow-up, 40 (11%) patients died, being the mean follow-up of the patients overall 4.3 years 95% CI [4.1-4.4]. Patients suffering from systemic complications had a higher CCI average (p=0.001) compared to those who did not present adverse effects (HR=6.6; 95% CI [3.5-12.4]). No statistically significant relationship between the type of fracture (p=0.473) and mortality was found.

CONCLUSION

In our study CCI has proven to be a good predictor of mortality and there is a relationship between CCI and the development of adverse effects in patients suffering from PHF, which maybe should be taken into consideration in our therapeutic decision making.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Acute proximal humeral fractures in adults

STUDY DESIGN

Clinical commentary.

INTRODUCTION

Proximal humeral fractures (PHF) are the third most common fracture in the elderly with an increased incidence expected in the coming years with the aging population, causing an important burden to the healthcare system. The management of PHF is challenging due to its complexity and the wide variety of fractures and treatment options.

PURPOSE

The objective of this clinical commentary is to update the available evidence on clinical presentation, classification, imaging, medical treatment, and rehabilitation of acute PHF.

METHODS/RESULTS/DISCUSSION

N/A for clinical commentary.

CONCLUSIONS

The first step to a successful management of PHF is the clinical and radiographic examination of the shoulder, which enables the physician to classify the fracture and choose the appropriate treatment option. The Neer and OA classifications are commonly used and are based on the identification of the fractured parts of the humerus, as well as the displacement of the fragments. In case of non-displaced or minimally displaced fractures, a conservative treatment, consisting of initial immobilization and a rehabilitation program will be chosen. Displaced or unstable fractures will be managed operatively. Different surgical options exist and will vary according to the fracture type, patient's age, and functional needs, followed by rehabilitation.

LEVEL OF EVIDENCE

5.

Predictors of Mortality in Elder Patients With Proximal Humeral Fracture

Background

Known possible consequences of proximal humerus fractures include impaired shoulder function, decreased independence, and increased risk for mortality. The purpose of this report is to describe the survival and independence of elderly patients with fractures of the proximal humerus, treated in our institution, relative to patient characteristics and treatment method.

Methods

Retrospective cohort study from 2006 to 2012.

Setting

Community-based hospital with level 1 designation.

Patients/Participants

Three hundred nineteen patients ≥60 years who presented to the emergency department with an isolated fracture of the proximal humerus were either admitted to the inpatient ward for the organization and provision of immediate definitive care or discharged with the expectation of coordination of their care as an outpatient. Treatment was nonoperative or operative.

Outcome Measures

One- and 2-year mortality.

Results

Significant predictors of mortality at 1 year included Charlson Comorbidity Index (CCI; continuous, hazard ratio [HR] = 1.40; 95% confidence interval [CI]: 1.06-1.86), body mass index (BMI; <25 vs ≥25; HR = 3.43; 95% CI: 1.45-8.14), and American Society of Anesthesiologists (ASA) disease severity score (3-4 vs 1-2; HR = 4.48; 95% CI: 1.21-16.55). In addition to CCI and BMI, reliance on a cane/walker/wheelchair at the time of fracture predicted mortality at 2 years (vs unassisted ambulation; HR = 3.13; 95% CI: 1.59-5.88). Although the Neer classification of fracture severity significantly correlated with inpatient admission (P < .001), it was not significantly associated with mortality or with loss of living or ambulatory independence. Among admitted patients, 64% were discharged to a facility with a higher level of care than their prefracture living facility. Twenty percent of study patients experienced a loss in ambulatory status by at least 1 level at 1 year postfracture.

Conclusion

In a cohort of elderly patients with fractures of the proximal humerus, patient characteristics including comorbidities, ASA classification, and lower BMI were associated with increased mortality. Specifically, those admitted at the time of fracture and treated nonoperatively had the highest mortality rate and, likely, represent the frailest cohort. Those initially treated as outpatients and later treated operatively had the lowest mortality and, likely, represent the healthiest cohort. These data are inherently biased by prefracture comorbidities but help stratify our patients' mortality risk at the time of injury.

Quality of Reduction Influences Outcome After Locked-Plate Fixation of Proximal Humeral Type-C Fractures

BACKGROUND

The aim of this study was to determine if fracture reduction, fracture pattern, and patient-related factors influence clinical outcome after locked-plate fixation of displaced proximal humeral fractures.

METHODS

Ninety-eight patients (mean age, 61.1 ± 11.2 years) with a proximal humeral fracture involving the anatomical neck (type C according to the OTA/AO classification system) were included. Clinical outcome was determined by age and sex-adjusted Constant score (CS%) and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Fracture reduction was quantitatively determined by 3 parameters (head-shaft displacement, head-shaft alignment, and cranialization of the greater tuberosity), and patients were divided into groups according to anatomical reduction, acceptable reduction, or malreduction. Relative risk (RR) for complications, revision surgery, and inferior clinical outcome (CS of <50%) was determined according to the quality of fracture reduction and fracture pattern (disruption of the medial hinge; type-C3 fracture) and patient-related factors (age; comorbidities).

RESULTS

After a mean of 3.1 ± 1.5 years, the mean CS% and DASH score were 54.8% ± 28.0% and 31.9 ± 24.8, respectively. The complication rate was 32.7% (n = 32), and 27 patients (27.6%) required revision surgery. Anatomical or acceptable fracture reduction was achieved in 40 (40.8%) of the patients. This resulted in a significantly lower complication rate (20.0% compared with 41.4% among the patients with malreduction; p = 0.027), a trend of lower revision rate (20% compared with 32.8%; p = 0.165), and better clinical outcome (mean CS% of 65.4% ± 28.2% compared with 47.6% ± 25.7%; p = 0.002) without a higher risk for osteonecrosis of the humeral head (5% compared with 10.3%). Cranialization of the greater tuberosity of >5 mm (n = 25), head-shaft displacement of >5 mm (n = 50), and valgus head-shaft alignment (n = 12) all increased the RR for inferior clinical outcome by twofold to threefold. Conversely, a patient age of >65 years (n = 31) and an OTA/AO type-C3 fracture pattern (n = 38) were not significantly associated with complications and inferior clinical outcome (RR, 0.9 to 1.8).

CONCLUSIONS

Anatomical fracture reduction with a locked plate significantly improved the clinical outcome of unstable and displaced proximal humeral fractures involving the anatomical neck.

LEVEL OF EVIDENCE

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

Outcomes After Hemiarthroplasty for Proximal Humerus Fracture Are Significantly Affected by Hand Dominance

OBJECTIVES

Hand dominance has been reported to be an important factor affecting outcomes after upper extremity trauma but remains unstudied after hemiarthroplasty for fracture. This study determined whether dominance affected outcomes after hemiarthroplasty for proximal humerus fractures.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care referral center.

PATIENTS

Sixty-one patients, after hemiarthroplasty for proximal humerus fracture, returned for comprehensive assessment and were divided into 2 groups: dominant (DOM) shoulder affected (n = 25) and non-dominant (non-DOM) shoulder affected (n = 36).

INTERVENTION

Fracture-specific proximal humeral hemiarthroplasty for displaced proximal humerus fractures.

MAIN OUTCOME MEASURES

Patients were assessed with self-reported outcomes (visual analog scale pain, American Shoulder and Elbow Surgeons shoulder score, disability of the arm, shoulder, and hand questionnaire, simple shoulder test, and short form 12) and objective (range-of-motion and hand-held dynamometer strength) testing.

RESULTS

At 49 months of mean follow-up, there were no significant differences between groups for gender, age, follow-up time, or visual analog scale pain (P > 0.256). The DOM-affected group had significantly worse scores for American Shoulder and Elbow Surgeons shoulder score (P = 0.043), disability of the arm, shoulder, and hand questionnaire (P = 0.039), and simple shoulder test (P = 0.021). The DOM-affected group also had consistently higher correlations between self-reported and objective outcomes than the non-DOM group.

CONCLUSIONS

Patients who underwent hemiarthroplasty for fracture on their DOM shoulders had significantly poorer outcomes than patients with non-DOM-sided injuries. Although positive outcomes can be expected after hemiarthroplasty, patients should be instructed that they may have less satisfactory function and strength if their injury was on the DOM side.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Racial and insurance disparities in the utilization of supportive care after inpatient admission for proximal humerus fracture

BACKGROUND

Post-discharge supportive services such as home health assistance and rehabilitation or skilled nursing facilities are often utilized after inpatient care for fracture of the proximal humerus. It is unclear whether sociodemographic disparities exist in the utilization of post-hospital supportive care. The present study aimed to evaluate the individual and combined effects of race and insurance status on the utilization of supportive services after hospital admission for fracture of the proximal humerus.

METHODS

Among the more than 40,000 patients with a proximal humerus fracture identified in the Nationwide Inpatient Sample (2008 to 2011), 85% were white, 7.7% were Hispanic and 7.0% were black. More black patients (19%) and Hispanic patients (15%) were uninsured compared to white patients (8.7%). Multivariable logistic regression was performed to determine the effect of race/ethnicity and insurance status on the utilization of post-hospital supportive care.

RESULTS

Sixty-nine percent of patients were discharged home, 13% went to home health care and 15% went to rehabilitation or skilled nursing facilities. Compared to white patients, Hispanic patients [odds ratio (OR) = 0.71; 95% confidence interval (CI) = 0.64 to 0.79] and black patients (OR = 0.79; 95% CI = 0.71 to 0.88) exhibited lower odds for the utilization of specialized post-hospital supportive services. Uninsured patients were significantly less likely to use post-discharge supportive services (OR = 0.38; 95% CI = 0.33 to 0.42) compared to privately insured patients. Even when insured at levels comparable to whites, Hispanic and black patients tended to experience decreased rates of discharge to post-acute supportive care.

CONCLUSIONS

The utilization of post-hospital supportive services varies by race, ethnicity and insurance status after an inpatient admission for proximal humerus fracture.

Does the timing of surgery for proximal humeral fracture affect inpatient outcomes?

BACKGROUND

Delayed surgical treatment of hip fractures is associated with adverse medical outcomes, but it is unclear whether the same is true for proximal humeral fractures. The purpose of this study was to evaluate the relationship between surgical delay for proximal humeral fracture and inpatient adverse events, in-hospital death, prolonged postoperative stay, and nonroutine discharge.

METHODS

Of the more than 70,000 patients with an operatively treated proximal humeral fracture identified in the Nationwide Inpatient Sample between 2008 and 2011, 87% underwent surgery within 2 days of admission and 13% underwent surgery 3 days or more after admission. Multivariable logistic regression analyses were performed to evaluate the effect of surgical delay on inpatient outcomes and to identify risk factors associated with late surgery.

RESULTS

Surgery 3 days or more after admission for fracture of the proximal humerus had no influence on in-hospital death but was independently associated with inpatient adverse events (odds ratio [OR], 2.1; 95% confidence interval [CI], 2.0-2.2), prolonged postoperative stay (OR, 1.7; 95% CI, 1.7-1.9), and increased nonroutine discharge (OR, 2.7; 95% CI, 2.6-2.9). Risk factors for surgery 3 days or more after admission included advanced age, male sex, Elixhauser comorbidity score, polytrauma, Hispanic race or black race, no insurance coverage, low household income, and weekend admission.

CONCLUSIONS

Even when comorbidities and complexity are controlled for, delaying surgery for proximal humeral fracture is likely to increase inpatient morbidity, postoperative length of stay, and nonroutine discharge. It appears that avoiding nonmedical delays is advantageous.

[Morbidity and mortality of surgically treated proximal humerus fractures]

BACKGROUND

The aim of the present study is to analyse the factors associated with mortality and the capacity to perform daily life activities (DLA) in patients with surgically treated proximal humeral fractures.

METHODS

A retrospective study was conducted on 94 patients with a surgically treated proximal humeral fracture, with a mean follow-up of 8 years (2 - 12 years). A correlation analysis was performed to determine the relationship between the type of fracture, surgical technique, comorbidities and mortality and DLA. The Student t test was used for statistical analysis.

RESULTS

A total of 72 patients were identified, 18.6% of them died during follow-up, all diagnosed with some comorbidity. There was no correlation between mortality, type of fracture or the technique used. Most of the patients (85.4%) had comorbidities, and 79.5% were completely independent for DLA. Although there was no relationship with the type of fracture, there was a significant reduction in the performing of DLA in patients treated with hemiarthroplasty, and in patients with neurological disorders.

CONCLUSIONS

There was a mortality of 18.6% among patients with surgically treated proximal humerus fractures. The majority of surgically treated patients were fully independent for DLA at long-term follow-up.

Treatment choice affects inpatient adverse events and mortality in older aged inpatients with an isolated fracture of the proximal humerus

BACKGROUND

This study tests the null hypothesis that, among patients aged 65 and older admitted to a United States hospital with an isolated fracture of the proximal humerus (no other injuries or fractures), there are no differences between operative (fixation or arthroplasty) and nonoperative treatments with respect to inpatient adverse events, inpatient mortality, and discharge to a long-term care facility rates accounting for comorbidities.

METHODS

Using a large national database representing an estimated 132,005 patients aged 65 and older admitted to a US hospital with an isolated proximal humerus fracture between 2003 and 2007. Sixty-one percent did not have surgery, 22% were treated with open reduction and internal fixation (ORIF), and 17% were treated with arthroplasty.

RESULTS

The risk of an in hospital adverse event was 21% overall and was 4.4 times greater with arthroplasty and 2.7 times greater with ORIF compared to nonoperative treatment. The risk of in hospital death was 1.8% overall and was 2.8 times greater with ORIF compared to nonoperative treatment. Patients treated operatively were less likely to be discharged to a long-term facility compared to patients treated nonoperatively.

CONCLUSION

In spite of a tendency to treat the most infirm patients (those that are not discharged to home) nonoperatively, operative treatment (open reduction and internal fixation in particular) is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted to the hospital with an isolated fracture of the proximal humerus and should perhaps be offered more judiciously.

LEVEL OF EVIDENCE

Level III, retrospective cohort study, treatment study.

Risk factors and predictors of mortality for proximal humeral fractures

BACKGROUND

Risk factors for mortality after proximal humeral fracture, including socioeconomic status, are poorly defined. This retrospective review of prospectively collected data defines the epidemiology and predictors of mortality in association with proximal humeral fractures.

METHODS

Patients who sustained proximal humeral fractures were identified from fragility fracture and trauma databases between May 2001 and September 2012.

RESULTS

In total, 1880 patients with a mean age of 69 years and a male to female ratio of 2 : 3 were identified. Socioeconomic distribution is skewed towards the lowest and highest quintiles. Low-energy mechanisms caused 88% of fractures. Men sustain fractures when they are aged 10 years younger and via higher-energy mechanisms. In total, 536 patients (29%) died within the study period with a 1-year mortality of 9.8%, rising to 28.2% at 5 years. Female gender, increasing age, pathological fracture and increased number of co-morbidities were independent variables for increased mortality.

CONCLUSIONS

The present study, which was conducted over an 11-year period, is the first to combine the epidemiology and risk factors for mortality with socioeconomic rank. One-year mortality risk is twice that of the background matched population. Patient counselling with respect to increased mortality should be considered, especially in higher-risk elderly females with multiple co-morbidities.

[Treatment of proximal humeral fractures in Germany: Influence of the level of hospital care and the frequency of treatment]

BACKGROUND

Various treatment options exist for displaced proximal humeral fractures. The impact of the level of hospital care and frequency of treatment on current treatment regimens in Germany was analyzed.

MATERIAL AND METHODS

A total of 576 hospitals were included. The survey covered questions on frequency, diagnostics, classification, therapy, complications, and clinical scenarios.

RESULTS

In all, 48% of the hospitals returned the questionnaire: 73% treat more than 60% of the fractures surgically, mainly with angle-stable implants. The angle-stable plate is the treatment of choice for young patients, but older patients are treated using other treatment options. Problems and complications included malreduction, secondary displacement, screw perforation, avascular necrosis, and impingement. According to treatment indication, implant choice, and common complications, no significant differences between the level of hospital care and frequency of treatment were observed.

CONCLUSION

Independent of the level of hospital care and frequency of treatment, there is a trend for head-preserving angular-stable surgery with a homogenous level of treatment in Germany.

Factors associated with the decision for operative versus non-operative treatment of displaced proximal humerus fractures in the elderly

BACKGROUND

In the management of displaced proximal humerus fractures in the elderly, wide variation has been documented. However, no prior study has investigated the factors that currently lead surgeons to treat patients with surgical fixation, arthroplasty or non-operative management. The purpose of this study was to identify the factors associated with treatment selection in the management of displaced proximal humerus fractures in individuals over the age of 60 years. To this end, we conducted a retrospective review of all such injuries that presented to our two level-I trauma centres between 2006 and 2009.

PATIENTS AND METHODS

From our prospectively collected trauma database, we identified 229 displaced proximal humerus fractures that met all inclusion and exclusion criteria. Data were collected on patient-, fracture- and surgeon-related characteristics that were plausibly related to the decision for treatment. The choice of management was recorded, and logistic regression was used to identify factors associated with the decision for treatment.

RESULTS

In the multivariate analysis, the predictors of operative intervention as opposed to non-operative treatment were younger patient age (p = 0.038), associated orthopaedic injuries requiring surgery (p = 0.012), higher Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification (p = 0.012), translation-type displacement (p = 0.0012) and associated glenohumeral dislocation (p = 0.0006). In addition, shoulder and upper extremity specialists were found to choose operative intervention significantly more frequently than orthopaedic trauma specialists (49.1% vs. 26.1%, adjusted relative risk (RR) 1.96, p = 0.012). Factors associated with the decision for arthroplasty as opposed to fixation were higher Charlson score (p = 0.045), higher Neer classification (p = 0.012), and higher AO classification (p = 0.0097).

CONCLUSIONS

In this study of displaced proximal humerus fractures in the elderly, the decision for surgery was influenced by the patient's age, the presence of associated orthopaedic injuries, the severity of the fracture and the presence of an associated glenohumeral dislocation. In addition, treatment by a shoulder or upper extremity specialist (as opposed to an orthopaedic trauma specialist) was associated with a higher likelihood of operative intervention. Further investigation into the resultant clinical outcomes is required to determine whether the use of these characteristics to select operative candidates is appropriate and beneficial for patients.

Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures

BACKGROUND

Complex acute proximal humeral fractures may require prosthetic replacement of the proximal humerus. Reverse shoulder arthroplasty (RSA) has been suggested as an alternative to hemiarthroplasty in the management of such fractures. This study compared the functional outcomes of RSA with hemiarthroplasty in patients with acute proximal humeral fractures.

MATERIALS AND METHODS

All patients who underwent RSA or shoulder hemiarthroplasty for acute proximal humeral fractures between January 1, 1999, and December 31, 2010 were identified from The New Zealand Joint Registry. Baseline information, operative characteristics, and postoperative outcomes (Oxford Shoulder Score [OSS] at 6 months and 5 years, revision rate, and mortality rate) were examined and compared between the study groups.

RESULTS

During the study period, 55 patients underwent RSA and 313 underwent shoulder hemiarthroplasty for acute proximal humeral fractures. Compared with hemiarthroplasty patients, RSA patients were significantly older (mean age, 79.6 vs 71.9 years; P < .001) and more often women (93% vs 78%, P = .013). The 6-month OSS was 28.1 for RSA and 27.9 for hemiarthroplasty, which was not significantly different (P = .923); however, the RSA group had a significantly better 5-year OSS than the hemiarthroplasty group (41.5 vs 32.3; P = .022). There was no significant difference between the RSA and hemiarthroplasty groups in revision rate per 100 component-years (1.7 vs 1.1; P = .747) or in 1-year mortality (3.5% vs 3.6%; P > .99).

CONCLUSIONS

Patients with acute proximal humeral fractures who undergo RSA appear to achieve superior 5-year functional outcomes compared with patients who undergo hemiarthroplasty.

Is it worth fixing proximal humeral fractures at increased vascular risk?

OBJECTIVE

To evaluate fixation of proximal humeral fractures by anterograde nailing, in terms of fracture reduction, bone healing; osteonecrosis; functional consequences of osteonecrosis and malunion.

DESIGN

Prospective, consecutive, multicenter based.

SETTING

Academic Trauma Centers; approval was received from the ethics committee of the institutions involved in the study.

METHODS

Fifty-one patients were enrolled prospectively, with 31 3-part and 20 4-part displaced fractures (head displacement greater than 45°, tuberosity-head gap greater than 10mm, diaphyseal gap greater than 10mm). A Telegraph™ nail (FH Orthopedics, Heimsbrunn, France) was the fixation device used, introduced through a superolateral transdeltoid approach under fluoroscopic guidance. The assessment included Simple Shoulder Test, absolute Constant score, X-rays every 3 months and CT-scan at final evaluation. Twelve patients died and one was lost to follow-up. Immediate complications included secondary displacement in four patients.

RESULTS

There were no infections, no deltoid muscle or axillary nerve damage, and all the fractures united. After a mean follow-up of 24.1 months, malunion was observed in 29% of the remaining 38 patients and osteonecrosis in 32%. Both complications were more frequent and extensive in patients with 4-part fractures. The osteonecrosis area influenced the Constant score, which was 55.8 points when the area was less than 30%, 50.6 points between 30 and 50%, and 38 points when larger than 50%. Head malunion affected the Simple Shoulder Test and the Constant score.

CONCLUSION

Nailing may thus be recommended for 3-part fractures, because osteonecrosis is less frequent, more focused, and better tolerated in this sub-group. In contrast, antegrade nailing was not more beneficial than other internal fixation techniques for preventing osteonecrosis or head malunion in patients with 4-part fractures.

LEVEL OF EVIDENCE

Level IV: prospective study.

Path analysis of factors for functional outcome at one year in 463 proximal humeral fractures

BACKGROUND

Path analysis methods were used to test the prognostic value of 10 patient-related and treatment-related factors on the 1-year functional outcome of 463 proximal humeral fractures measured using the Constant score. Complex inter-relationships between these factors were also evaluated.

MATERIALS AND METHODS

Data were collected from a prospective cohort study that included 3 operative groups repaired using nail or plate fixation and 1 nonoperative group. From the available information, various factors potentially having a direct influence on the functional Constant score were identified. The process of creating a hypothetical causal path diagram was undertaken to order the factors in a sequence of associations or cause-and-effect relationships.

RESULTS

Our final multivariable regression model for the 1-year Constant score included the 6 factors of age, sex, treatment, occurrence of intraoperative and local post-treatment complications, and anatomic restoration. Being a woman aged older than 40 years, treated with a locking proximal humeral plate (LPHP), having experienced intraoperative and local post-treatment complications, and varus deformity of more than 30° were negative predictors of the Constant score (ie, poor shoulder function 1 year after treatment initiation). Three factors, the dominant side fractured and the Neer and AO fracture type, showed only significant association on intermediate factors. The presence of concomitant disease did not show any significant direct or indirect effect. A final pathway outlines these associations and inter-relationships.

CONCLUSION

Prevention of local complications, in particular those leading to severe varus deviation, appears essential to improve shoulder function after a proximal humeral fracture.

Modern perspectives of open reduction and plate fixation of proximal humerus fractures

Recent innovations have greatly increased the range of proximal humeral fractures that are amenable to open reduction and plate fixation.The optimum technique for some of the more complex fracture patterns is not yet fully refined.This article aims to describe the recent advances in the treatment of complex proximal humeral fractures by open reduction and locking plate fixation, focusing particularly on the indications for surgery, the operative techniques, and the expected outcomes after treatment.

Shoulder arthroplasty for acute proximal humerus fracture

Proximal humerus fracture devascularizing the humeral head may require management by prosthesis. Hemiarthroplasty is a logical attitude in such cases, but analysis of functional results and complications has identified a certain number of risk factors limiting indications. Strict analysis of patient characteristics and of fracture type is an essential prerequisite to deciding against treatment by immobilization or osteosynthesis. Results in hemiarthroplasty are primarily dependent on respecting the rules of the art, which aim at stable anatomic osteosynthesis of the surrounding structures so as to restore normal shoulder function. The critical steps are the adjustment of implant height and retroversion, reduction and fixation of tuberosities and good management of the postoperative course. The recent development of fracture-dedicated shoulder implants should improve results. In elderly patients, when local conditions are unsuitable to hemiarthroplasty, a reverse prosthesis may be used, with an adapted surgical technique. Whatever the type of prosthesis, implantation for proximal humerus fracture is a demanding operation with definitive impact on the functional evolution of the shoulder.

Biomechanical evaluation of 3-part proximal humerus fractures: a cadaveric study

Proximal humerus fractures occur frequently, and treatment remains controversial. This study compares stiffness in axial loading for 3 methods of fixation (locking compression plate, standard (nonlocking) proximal humerus plate, and blade plate) in a 3-part proximal humerus fracture model. Twelve paired proximal humeri were obtained from embalmed human cadavers and separated into 3 groups. Osteotomies of the surgical neck and greater tuberosity were created to simulate a 3-part proximal humerus fracture. After fixation, constructs were axially loaded in 20 degrees of abduction for 200 cycles in an Instron materials testing machine (Norwood, Massachusetts). The blade plate (mean, 146.87+/-28.9 N/mm) demonstrated 29% more mean stiffness than the standard plate (mean, 113.0+/-22.3 N/mm; P=.19). The locking compression plate (mean, 130.71+/-39.2 N/mm) exhibited 15% greater stiffness compared to the standard plate in our 3-part model (P=.58). The blade plate demonstrated 12% greater stiffness than the locking compression plate (P=.64). There was no significant difference in mean stiffness between the fixed-angle devices and the standard plate. Future in vitro and clinical studies of plate devices for proximal humerus fractures would be worthwhile to determine the benefits and limitations of various implants for specific types of fractures, including clinical performance and cost of care.

The impacted varus (A2.2) proximal humeral fracture in elderly patients: is minimal fixation justified? A case control study

BACKGROUND

The purpose of this retrospective case control study was to assess the outcome of K-wire osteosynthesis of a varus displaced proximal humeral fracture in patients over 65 years old, compared to a control group treated nonoperatively.

METHODS

The patient cohort was taken from our database in the period 2003-2007. After data extraction, the patients were re-examined and scored by the Constant score (CS), modified Constant score (MCS), and the QuickDASH score. The control group was carefully selected and matched to the surgical one for age, type of fracture, and degree of displacement. Minimum follow-up was 12 months, with a mean of 30 months in the surgery group, and 27 months in the nonoperative group.

RESULTS

K-wire osteosynthesis in our series yielded consistently good results in older patients who sustained an A2.2 proximal humeral fracture, with an average MCS of 88 points and a QuickDASH score of 15. The surgery group had a statistically significant higher CS and modified Constant score at follow-up than did the conservatively treated group (p = .03).

CONCLUSION

Operative treatment of varus displaced proximal humerus fractures treated with K-wire osteosynthesis yields good results that are superior to those treated nonoperatively.

LEVEL OF EVIDENCE

Level 3; Case control study, treatment study.

Health status as an important outcome factor after hemiarthroplasty

The goal of this study was to determine functional results of hemiarthroplasty for 3- and 4-part proximal humeral fractures in elderly patients and to analyze factors affecting the outcome. Thirty-eight consecutive shoulders were treated with hemiarthroplasty after proximal humeral fracture. Two groups of patients with different health status were classified. Group I consisted of patients with 2 or less comorbidities and a maximum of 2 medications at the time of injury. Patients in group II had 3 or more comorbidities with a minimum of 3 medications at the time of injury. The mean of the absolute Constant score in group I was 41, compared to 27 in group II (P < .05). Furthermore, compliance of the patient and regular physiotherapy proved to be important prognostic factors. If primary hemiarthroplasty is not likely to be successful with a low functional score, this surgical procedure should be reconsidered especially in patients with more than three comorbidities.

Prognostic factors for unstable proximal humeral fractures treated with locking-plate fixation

This study evaluated the functional outcomes of proximal humeral fractures treated with locking plates and determined the prognostic factors for successful clinical outcomes. We included 44 patients with 45 unstable proximal humeral fractures. There were 19 two-part, 22 three-part, and 4 four-part fractures. Outcomes were analyzed by use of multivariate linear regression with several different combinations of 7 independent variables: age, fracture pattern, osteoporosis, calcium sulfate graft, rotator cuff suture loop, head-neck shaft angle, and comorbidity. The mean head-shaft angle was 132.4 degrees after the operation and decreased to 127.7 degrees at final follow-up. Five patients showed considerable loss of fixation. The analysis showed that delay in rehabilitation because of comorbidities and decreased head-neck shaft angle induced by lack of medial support were the primary prognostic factors that led to poor outcomes. The absence of comorbidity and the restoration of the medial metaphysis were the most reliable predictors of successful clinical outcomes.

Current concepts in plate and screw fixation of osteoporotic proximal humerus fractures

Most surgeons feel that angular stable implants have improve the ability to obtain reliable fixation of an osteoporotic fracture of the proximal humerus fracture, but complications such as varus fracture collapse and screw penetration of the articular surface remain problematic. The use of limited drilling, blunt tipped locking bolts and routine incorporation of the rotator cuff into the internal fixation construct may help limit these complications. It may be of benefit to replace the concept of standard screw fixation of the osteoporotic proximal humerus with a concept of an angular stable scaffold support of the subchondral bone combined with fixation that does not rely on bone quality and utilizes the more predictable fixation of sutures through the rotator cuff attachments.

Treatment of proximal humerus fractures

The majority of proximal humerus fractures are treated nonoperatively with good functional results. Multiple options exist for treating displaced fractures, without a clear advantage of any one method for a given fracture type. Goals include an adequate reduction and stable fixation to initiate early motion and rehabilitation. Decision-making should be based on patient and injury specifics and surgeon's experience. Various types of fixation, including plates, nails, or percutaneous pins, can maintain sufficient stability to promote shoulder mobility and function. Any of these methods will have few complications when undertaken with appropriate patient selection and careful surgical technique. Preliminary results of locking plates in the proximal humerus suggest that this is a favorable treatment option for displaced, comminuted proximal humerus fractures, which compares well with established methods. Locked plating may improve fracture stability in some complex patterns and facilitate early rehabilitation. It is possible that some fractures previously treated with hemiarthroplasty may be managed successfully with locking plates. Prospective study to assess the complications, outcomes, and cost effectiveness of nonoperative management compared to various surgical treatment options is warranted.