Trends in the surgical treatment of proximal humeral fractures - a nationwide 23-year study in Finland

Trends in the surgical management of proximal humerus fractures over the last 20 years from Australian registry databases

BACKGROUND

Proximal humerus fractures (PHF) are common with approximately 30% requiring surgical intervention. This ranges from open reduction internal fixation (ORIF) to shoulder arthroplasty (including hemiarthroplasty, total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RTSA)). The aim of this study was to assess trends in operative interventions for PHF in an Australian population.

METHODS

Data was retrospectively collected for private patients with a PHF and requiring surgical intervention (2001-2020). Data for patients undergoing ORIF were extracted from the Medicare database, while those receiving arthroplasty for PHF were obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR).

RESULTS

Across the study period, ORIF was the most common surgical procedure for management of PHFs. While the number of RTSA procedures for PHF has increased, shoulder hemiarthroplasty has significantly reduced since 2008 (p < 0.001). Patients aged < 65 years were more likely to receive ORIF. Patients aged ≥ 65 years were more likely to receive RTSA or hemiarthroplasty compared to patients aged < 65 years.

CONCLUSIONS

While the number of ORIF procedures has increased during the period of interest, it has diminished slightly as a proportion of overall procedure volume. RTSA is becoming increasingly popular, with decreasing utilization of hemiarthroplasty, and TSA for fracture remaining uncommon.

LEVEL OF EVIDENCE

Level III.

Regional variation in low-value musculoskeletal surgery: a nationwide study from the Finnish Care Register

BACKGROUND AND PURPOSE

Healthcare systems globally are grappling with resource constraints and rising costs. Concerns have been raised about "low-value" care, which consumes healthcare resources without benefiting patients. We aimed to examine regional differences in common low-value musculoskeletal surgeries in Finland and explore explanatory factors behind the variation.

METHODS

Using data from the Finnish Care Register for Health Care, surgeries conducted from 2006-2007 compared with 2020-2021 were analyzed across 20 hospital districts. Selected surgeries (acromioplasty, rotator cuff repair, partial meniscectomy, wrist arthroscopy, ankle arthroscopy, and distal radius fracture fixation) were categorized based on NOMESCO procedure codes, and incidence rates in older populations were calculated based on population size derived from Statistics Finland.

RESULTS

We found substantial regional disparities in low-value surgeries. The incidence rates were higher in hospitals with high historical incidence rates and smaller population sizes, suggesting that the uptake of evidence is slower in small non-academic hospitals.

CONCLUSION

The incidence of low-value surgery is declining but regional differences remain large. It is unlikely that regional variation in disease incidence explains such large variation in low-value surgery. Instead, local treatment culture seems to be the driving force behind low-value surgery, and the practices seem to be more entrenched in small hospitals.

Comparison of the varus displacement effect of calcar screw in proximal humerus fractures

The aim of this study is to investigate whether not using the calcar screw in proximal humerus fractures affects functional and radiological outcomes. Thirty patients (21 females and 9 males) who presented with proximal humerus fractures and were treated with plate- screw fixation were evaluated. The patients were divided into two groups: group 1 included patients with the use of the calcar screw, and group 2 included patients without the calcar screw. Radiological evaluation was performed by measuring the neck-shaft angle on postoperative day 1 and at 1 year in true anteroposterior radiographs. The groups were compared regarding demographic characteristics, functional outcomes, radiological scores, and complications. The mean age was 60 (27-92) years. In group 1, a mean decrease of 5.2° in the neck-shaft angle was observed (136.1° on postoperative day 1 and 130.6° at 1 year; p<0.05). In group 2, a mean decrease of 3.1° was observed (133.5° on postoperative day 1 and 130.0° at 1 year; p>0.05). There was no significant difference in the change of the humerus neck- shaft angle between the two groups (p>0.05). The mean Constant score was 70.8 in group 1 and 76.7 in group 2, (p>0.05). There was no significant difference in varus displacement and functional outcomes between the groups using and not using the calcar screw in proximal humerus fractures. Good reduction, stable fixation with locking plates, and preservation of soft tissue integrity are crucial to avoid complications and promote healing in proximal humerus fractures.

Trends in the surgical management of proximal humerus fractures in Ireland from 2009 to 2022: An increasing usage of reverse shoulder arthroplasty

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.

Time trends in proximal humeral fractures from 1944 to 2020 - A cohort study in Malmö, Sweden

BACKGROUND

Most studies infer increasing incidence of proximal humeral fractures (PHF) from the 1950´s until the 1990´s. Recent time trends are less clear.

OBJECTIVES

Our primary objective was to identify time trends in the age- and sex-adjusted adult incidence of PHF in Malmö, Sweden, from year 1944 until 2020. Our secondary objectives were to describe the variation in incidence according to age, the monthly distribution, and to compare data from the two most recent decades with earlier.

STUDY DESIGN AND METHODS

Malmö has one emergency hospital where acute fractures are treated. We identified PHF in adult patients (≥ 18 years) by reviewing relevant radiology examinations during 17 sample years from year 1944 to 2020. We used jointpoint analyses to estimate time trends.

RESULTS

We identified 3 031 PHF during the study period (3 231 161 person years), 73% were sustained by women with mean age of 69 years (mean age in men 59). Joinpoint analyses indicated an increase in the age- and sex-adjusted incidence of PHF from year 1944 (52 per 100 000 person years) until 1977 (120 per 100 000) and thereafter a decrease until 2020 (85 per 100 000). A seasonal variation with more fractures during winter months, was apparent in earlier but not recent decades.

CONCLUSIONS

The age- and sex-adjusted incidence of PHF increased in Malmö, Sweden, from the 1940´s until year 1977 and thereafter decreased until 2020. More fractures were seen during winter months in earlier but not recent decades.

Permissive Weight Bearing in Proximal Humeral Fracture Management: A Survey-Based Inquiry in the Netherlands

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.

Greater tuberosity medial malposition: does it affect shoulder abductor moment?

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.

Dual plate fixation of proximal humerus fractures: Retrospective review and surgical technique

Introduction

Recent interest has been directed towards dual plate fixation for comminuted proximal humerus fractures, with an aim to improve construct stability and thus improve patient outcomes while decreasing the risk of fracture-associated complications. We present our experience with this technique in a case series of patients with proximal humerus fractures and describe our surgical technique.

Methodology

This was a single-center retrospective case series of patients presenting with an acute (<6 weeks) proximal humerus fracture who underwent ORIF with dual plating fixation. Patient, fracture, and surgical data were collected. All patient outcomes were evaluated using Constant-Murley shoulder score and Single Assessment Numeric Evaluation.

Results

Our series included nine patients with a mean age of 46.2 years (range: 27-70 years old). All fractures healed within 4 months and no complications were encountered. At 1 year follow-up, the mean SANE score was 69.4% and the mean Constant Murley shoulder score was 78.9 (range: 70-96).

Conclusion

Our current series shows that applying the dual plating technique in severely comminuted proximal humerus fractures provides adequate fixation and thus good patient outcomes. Further research is required before this technique can be strongly recommended for management of these complex fractures.

Level of Evidence

Level 5.

How do surgeons decide when to treat proximal humerus fractures with operative versus nonoperative management?

PURPOSE

The objective of this study was to determine the underlying factors that drive the decision for surgeons to pursue operative versus nonoperative management for proximal humerus fractures (PHF) and if fellowship training had an impact on these decisions.

METHODS

An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons Society to assess differences in patient selection for operative versus nonoperative management of PHF. Descriptive statistics were reported for all respondents.

RESULTS

A total of 250 fellowship trained Orthopaedic Surgeons responded to the online survey. A greater proportion of trauma surgeons preferred nonoperative management for displaced PHF fractures in patients over the age of 70. Operative management was preferred for older patients with fracture dislocations (98%), limited humeral head bone subchondral bone (78%), and intraarticular head split (79%). Similar proportions of trauma surgeons and shoulder surgeons cited that acquiring a CT was crucial to distinguish between operative and nonoperative management.

CONCLUSION

We found that surgeons base their decisions on when to operate primarily on patient's comorbidities, age, and the amount of fracture displacement when treating younger patients. Further, we found a greater proportion of trauma surgeons elected to proceed with nonoperative management in patients older than the age of 70 years old as compared to shoulder surgeons.

Two-year clinical and radiographic outcomes following uncemented reverse shoulder replacements for proximal humerus fractures

BACKGROUND

Uncertainty remains regarding the role and long-term outcomes following uncemented reverse shoulder replacements (RSRs) in managing displaced proximal humeral fractures (PHFs). Although RSRs for trauma have traditionally undergone cemented fixation of the humeral component, there is increasing interest in uncemented RSRs. Our primary aim was to evaluate 2-year outcomes following uncemented RSR fixation for 3- and 4-part PHFs in the elderly. A secondary aim was to evaluate if timing of surgery affected outcomes.

METHODS

This cohort series evaluated 2-year outcomes for 42 patients with Neer 3- and 4-part PHFs treated with uncemented RSRs between October 2016 and December 2019. Thirty-eight patients (90%) had clinical and radiologic follow-up at a minimum of 2 years. The primary outcomes compared postoperative range of movement, radiographic outcomes, and patient-reported outcome measures (PROMs). The PROMs collected included Oxford Shoulder Scores (OSSs), satisfaction scores, and the Friends and Family Test. The secondary outcome involved a subanalysis to see if outcomes were affected by treatment timing-within 2 weeks, 2-12 weeks, and >12 weeks.

RESULTS

The mean age of patients was 74.1 years (range 58-89). There were 11 males and 31 females. No intraoperative fractures were sustained. There was 1 transient axillary neurapraxia, which fully resolved by 4 months. Three patients required postoperative transfusions. During the study follow-up period, no patients developed either deep infections requiring a washout or dislocation, and none underwent further surgery. At 2-year follow-up, radiologic follow-up demonstrated tuberosity union in 29 of 38 cases (76%). Eight of 38 patients (21%) demonstrated some glenoid notching (Sirveaux 1 or 2 only) on radiographic follow-up. There was no evidence of loosening. The mean OSS was 38 (range 15-48). Mean range of movement achieved at 2 years was as follows: forward flexion 122° (50°-180°), abduction 116° (46°-180°), and external rotation 25° (range 5°-60°). Eighteen patients (47%) described their result as excellent, 17 (45%) as good, and 3 (8%) as poor. When comparing the time from injury to treatment, there was no statistically significant difference in complications or radiographic outcomes between the groups. Patients had a reduced forward flexion when treated between 2 and 12 weeks compared with the other groups (P = .019).

CONCLUSION

Uncemented RSR is a safe treatment option for the management of complex PHFs in the elderly. We report low complication rates, high patient satisfaction, and good outcomes at 2-year follow-up.

Management of Proximal Humeral Fractures in Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

Differences in function, pain, and reoperation rates were compared between the following treatment options: (1) operative vs. nonoperative treatment and (2) various surgical treatments including open reduction internal fixation, intramedullary nail, hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA).

DATA SOURCES

MEDLINE, Embase, and Cochrane were searched through February 1, 2022. All English-language randomized trials comparing operative and nonoperative treatment of proximal humeral fractures with a control group in patients 18 years or older were included.

DATA EXTRACTION

Demographic data, functional and pain scores and re-operation rates were extracted. Study quality was determined with the Cochran risk of bias tool and the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE). Heterogeneity was determined with the I-squared statistic.

DATA SYNTHESIS

Meta-analysis of included studies using mean difference and odds ratios where appropriate.

CONCLUSIONS

Surgical treatment with either locked plates or HA results in similar functional scores and pain outcomes as nonoperative treatment, although plates were associated with higher reoperation rates in 3-part and 4-part fractures. In 3-part and 4-part fractures, RSA results in higher function and pain scores compared with HA. Further high-quality trials should focus on RSA, and further study is required to better define the role of open reduction internal fixation in the younger patient population.

LEVEL OF EVIDENCE

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

Clinical and Radiological Outcome of Dual Plating for Proximal Humerus Fractures

Introduction Proximal humerus fractures account for approximately 4%-5% of all fractures. It accounts for approximately 45% of all humeral fractures. Proximal humerus fractures which are mostly stable or minimally displaced fractures are usually managed non-operatively with good outcomes. Displaced or unstable fractures may require reduction and stabilization. For proximal humerus fractures, conservative treatments often result in stiffness and malunion of the shoulder. In comminuted proximal humerus fractures the use of a proximal humeral internal locking system (PHILOS) only does not provide the required stable fixation which usually leads to complications such as varus collapse, malunion, anterior-posterior angulation, screw cutout, metal failure and nonunion and thus open reduction and internal fixation with dual plating are recommended for proximal humerus fractures. Material and methods The Institutional Ethics Committee of Dr. D. Y. Patil Vidyapeeth in Pune approved this prospective study. We included a sample size of 52 patients and conducted a study on these patients who were admitted under the Orthopedics department at Dr. D. Y. Patil Medical College and Hospital, Pune. Results In this study, 52 patients were treated with dual plating for proximal humerus fracture, an additional plate is used along with PHILOS. In our study, the majority of the study population belonged to > 50 years (34.6%), followed by 41-50 years (26.9%), 31-40 years (23.1%), and 21-30 years (15.4%). The mean age of the patient was 53.7 years including 33 male and 19 female patients. The majority of the patient in the study included was with RTA 40 patients and 12 patients with a history of falls from height. The fracture was classified using Neers classification, Neer type 2 fracture (23.1%), Neer type 3 fracture (46.2%), and Neer type 4 fracture (30.7%). In the current study, the mean DASH score at Baseline was 58.88±6.29, at three months was 36.23±5.05 and at six months was 31.85±4.16. The mean DASH score decreased significantly from baseline to three months to 6 months. As per the Paavolainen method, it was good among 40 (76.9%) and fair among 10 (19.2%), and poor among two (3.8%) cases. Out of 52 patients, we found varus collapse in immediate postop x-ray in two patient and screw protrusion in the glenohumeral joint in one patient. Conclusion Satisfactory clinical and radiological outcomes were noted. This dual mechanism prevents varus displacement of the proximal fragment, and as a result, it provides a good functional outcome with dual plates in proximal humerus fractures.

Is arthroplasty necessary for three and four-part proximal humerus fractures in elderly?

Background/Aim: Proximal humerus fractures are common in elderly patients. Treatment of three and four-part fractures is especially controversial in these patients. In recent years, surgical options have been widely used, especially among shoulder surgeons. The purpose of this study was to compare clinical results of conservative and arthroplasty methods. Methods: Between 2016 and 2020, 30 patients who were treated for Neer type 3 and type 4 proximal humeral fractures were included in the study. Patient data were evaluated retrospectively and then divided into three groups. Group 1 was treated conservatively, group 2 underwent hemiarthroplasty; and group 3 underwent reverse total shoulder arthroplasty. CONSTANT and visual analog scale (VAS) scores and radiological results at six months were evaluated retrospectively from patient records. At the last control they have been evaluated with CONSTANT, University of California/Los Angeles. (UCLA), and VAS scores. Results: Twenty-three (76.7%) of the patients included in the study were females. The mean age was 73.5 (5.7) years. The mean follow-up period was 33 (2.5) months. The mean follow-up periods in groups 1–3 were 33.3 (2.9), 32.8 (2), and 32.2 (2.9) months, respectively. When the CONSTANT scores of the patients were compared at the sixth month, they were observed to be better in the reverse total shoulder arthroplasty group (P = 0.001). Final control CONSTANT scores in the hemiarthroplasty group were lower than in the other groups (P = 0.001) and similar in the reverse shoulder prosthesis and conservative treatment group (P = 1). When the UCLA scores of all groups were compared, the mean UCLA scores were found to be significantly higher in groups 1 and 3 compared to group 2 (P = 0.001). When the VAS scores of the patients were compared, a significant difference between all groups was detected (P < 0.05). The highest VAS scores were observed in group 2, the second highest in group 1, and the lowest in group 3. Conclusion: For treatment of proximal humerus fractures in the elderly, patients should be evaluated according to activity levels and expectations, and surgical treatment should be suggested rather than ordered.

Trends in Surgical Treatment of Proximal Humeral Fractures and Analysis of Postoperative Complications Over a Decade in 384,158 Patients

Surgical treatment options for proximal humeral fractures include hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), and open reduction and internal fixation (ORIF). The objectives of this study were to analyze the trends in surgical treatment of proximal humeral fractures across a decade and to compare complications, reoperation rates, and readmission rates between ORIF and RSA.

METHODS

The PearlDiver MUExtr Database was used to identify patients with proximal humeral fractures who were treated with ORIF, HA, or RSA between 2010 and 2019 and analyze yearly trends. Complications, revision procedures, demographic characteristics, comorbidities, and emergency room visits and hospital readmissions within 90 days of the surgical procedure were compared between ORIF and RSA cohorts for patients who had at least 2-year follow-up data.

RESULTS

In this study, 384,158 patients with proximal humeral fractures were identified in the 10-year period between 2010 and 2019. There was a significant increase in the frequency of RSA and a decrease in the frequency of ORIF and HA over time (p < 0.0001). Compared with patients who underwent ORIF or HA, patients who underwent RSA were more likely to be older (p < 0.0001), to be female, and to have a higher Charlson Comorbidity Index. Patients who underwent ORIF had higher complication rates (23.03% compared with 18.62%; p < 0.0001) and higher reoperation rates (20.3% compared with 10.3%; p < 0.0001) than patients who underwent RSA. Patients who underwent RSA had higher emergency room visit rates (20.0% compared with 16.7%; p < 0.001) and hospital readmission rates (12.9% compared with 7.3%; p < 0.0001) within 90 days of the surgical procedure compared with patients who underwent ORIF.

CONCLUSIONS

There has been an increasing trend in RSA utilization for the surgical treatment of proximal humeral fractures, along with a decreasing trend in HA and ORIF, over time. Patients who underwent ORIF for a proximal humeral fracture had higher complication and reoperation rates compared with patients who underwent RSA. Patients who underwent RSA had higher emergency room visit and hospital readmission rates within 90 days of the surgical procedure compared with patients who underwent ORIF, which may be attributable to the RSA cohort being older and having more comorbidities.

LEVEL OF EVIDENCE

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

Epidemiology and trends in management of acute proximal humeral fractures in adults: an observational study of 137,436 cases from the Danish National Patient Register, 1996-2018

BACKGROUND AND PURPOSE

Proximal humeral fractures (PHF) can be managed surgically or non-surgically. Locking plates have been the preferred head-preserving surgical technique while hemiarthroplasty (HA) or reverse shoulder arthroplasty (RSA) have been used in joint replacement surgery. We describe the epidemiology and trends in management of acute PHF in Denmark with a focus on (i) changes in the incidence of PHF; (ii) changes in the proportion of surgical cases; and (iii) changes in preferred surgical techniques.

PATIENTS AND METHODS

Data on diagnoses and interventions was retrieved from the Danish National Patient Register. Patients aged 18 years and above were included. Surgical treatment was defined as the diagnosis of PHF combined with a predefined surgical procedure code within 3 weeks of injury. Data on plate osteosynthesis, HA, RSA, and "other techniques" was retrieved. Non-surgical treatment was defined as no relevant surgical procedure code within 3 weeks.

RESULTS

We identified 137,436 PHF (72% women) in the Danish National Patient Register. The overall mean incidence was 138/100,000/year (500 for women 60 years or above). Non-surgical treatment accounted for 119,966 (87%). The 17,470 surgical procedures included 42% locking plates, 34% arthroplasties, and 25% other techniques. The rate of surgery declined from 17% in 2013 to 11% in 2018.

INTERPRETATION

The overall incidence of PHF remained stable between 1996 and 2018 but the absolute number increased. The approach to PHF remains predominantly non-surgical. The number of surgeries in Denmark have decreased since 2013, especially for locking plates and HA, while RSA is increasingly used.

Proximal humeral fractures in Finland : trends in the incidence and methods of treatment between 1997 and 2019

AIMS

Proximal humeral fractures (PHFs) are common. There is increasing evidence that most of these fractures should be treated conservatively. However, recent studies have shown an increase in use of operative treatment. The aim of this study was to identify the trends in the incidence and methods of treatment of PHFs in Finland.

METHODS

The study included all Finnish inhabitants aged ≥ 16 years between 1997 and 2019. All records, including diagnostic codes for PHFs and all surgical procedure codes for these fractures, were identified from two national registers. Data exclusion criteria were implemented in order to identify only acute PHFs, and the operations performed to treat them.

RESULTS

During the 23-year study period, 79,676 PHFs were identified, and 14,941 operations were performed to treat them. The incidence of PHFs steadily increased. In 2019, the overall incidence was 105 per 100,000 person-years (10⁵). The sex-adjusted incidence for females was 147.1 per 10⁵, and the age-adjusted incidence for patients aged ≥ 80 years was 407.1 per 10⁵. The incidence of operative treatment for PHFs rose during the first half of the study period and decreased during the second half. The use of plate osteosynthesis in particular decreased. In 2019, the incidence of operative treatment for PHFs was 13.2 per 10⁵, with 604 operations.

CONCLUSION

Although the incidence of PHFs is steadily increasing, particularly in elderly females, the incidence of operative treatment is now decreasing, which is in line with current literature regarding their treatment. Cite this article: Bone Joint J 2022;104-B(1):150-156.

In-hospital Complications Are More Likely to Occur After Reverse Shoulder Arthroplasty Than After Locked Plating for Proximal Humeral Fractures

BACKGROUND

Currently, there seems to be a paradigm change in the surgical treatment of proximal humeral fractures in patients aged 65 years and older, with a considerable increase in the use of reverse total shoulder arthroplasty (RTSA) compared with angular stable internal fixation (locking plate fixation). However, even among shoulder specialists there is controversy regarding the best treatment strategy.

QUESTIONS/PURPOSES

To evaluate for (1) a greater risk of in-hospital major adverse events, (2) a greater risk for in-hospital surgical complications, and (3) a greater risk of 30-day mortality, locking plate fixation and RTSA were compared for the treatment of proximal humerus fractures of patients aged 65 years and older after controlling for potentially confounding variables in a large-database analysis.

METHODS

Health claims data of the largest German insurance company including approximately one-third of the population (26.5 million policyholders) between 2010 and 2018 were analyzed. This database was chosen because of its size, nationwide distribution, and high quality/completeness. In total, 55,070 patients (≥ 65 years of age) treated with locking plate fixation (75% [41,216]) or RTSA (25% [13,854]) for proximal humeral fracture were compared. As primary endpoints, major adverse events (including acute myocardial infarction, stroke, organ failure, resuscitation, and death) and surgical complications (infection, hematoma, loss of reduction, dislocation, and revision surgery) were analyzed. The risk of all endpoints was analyzed with multivariable logistic regression models in the context of comorbidities to address existing group differences.

RESULTS

After controlling for potentially confounding variables such as age, sex, and risk profile, RTSA was associated with a higher risk for major adverse events (OR 1.40 [95% CI 1.29 to 1.53]; p < 0.001) and surgical complications (OR 1.13 [95% CI 1.05 to 1.21]; p < 0.01) compared with locking plate fixation. There was no evidence for an increase in mortality (OR 0.98 [95% CI 0.86 to 1.12]; p = 0.81).

CONCLUSION

The increased in-hospital risk for major adverse events and surgical complications may moderate the enthusiasm associated with RTSA for proximal humeral fractures in patients 65 years and older. Treatment decisions should be based on individual risk estimation to avoid potential harmful events. Future studies must include long-term outcomes and quality of life to enlighten these findings in a broader context.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Trending a decade of proximal humerus fracture management in older adults

Background

Proximal humerus fractures are the third most common fracture in older adults. Because of the aging population, the incidence of these fractures and their impact will continue to grow. With advancement in treatment options for proximal humeral fractures, the aim of this study was to evaluate the trends in acute management of proximal humerus fractures to determine how definitive treatment has changed over the past decade in patients older than 65 years.

Methods

Using a commercially available database, patient records were queried from 2010 to 2019 for the incidence of proximal humerus fractures. For each individual year, data were queried to identify the incidence of closed reduction percutaneous pinning (CRPP), hemiarthroplasty (HA), intramedullary nailing (IMN), open reduction internal fixation (ORIF), total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RSA), or nonoperative treatment for acute proximal humeral fractures. A Cochran-Armitage trend test was used to determine significant changes in the trends of proximal humerus fracture management. Logistic regression analyses were performed to generate odds ratios (OR) with associated 95% confidence intervals comparing each individual procedure performed in 2019 to 2010.

Results

A total of 160,836 patients at least 65 years of age and older were diagnosed with a proximal humerus fracture. Of this total, 28,503 (17.72%) patients received operative treatment and 132,333 (82.28%) received nonoperative treatment. From 2010 to 2019, operative treatment trends of proximal humerus fractures changed such that CRPP decreased by 60.0%, HA decreased by 81.4%, IMN decreased by 81.9%, ORIF decreased by 25.7%, TSA decreased by 80.5%, and RSA increased by 1841.4% (all P < .0001). Overall, nonsurgical management increased from 80% to 85% during the examined study period (P < .0001). Patients in 2019 were significantly more likely to receive an RSA (OR 22.65) and were significantly less likely to receive CRPP (OR 0.45), HA (OR 0.20), IMN (OR 0.20), ORIF (OR 0.82), and TSA (OR 0.22) than patients in 2010. In addition, patients in 2019 were significantly more likely to receive nonoperative treatment than patients in 2010 (OR 1.10).

Conclusion

Over the past decade, most of older adults who sustain proximal humerus fractures continue to receive nonoperative treatment. Although CRPP, IMN, HA, ORIF, and TSA have decreased, RSA has recently become more widely utilized, which is consistent with what has been noted in other countries. Continued examination of the mid- and long-term outcomes of the increasing percentages in RSA should be performed in this population.

Analyzing outcomes after proximal humerus fractures in patients <65 years: a systematic review and meta-analysis

Background

There has been an increasing amount of interest and research examining best practices for the treatment of proximal humerus fractures (PHF). Recent, high-level randomized control trials and many retrospective cohort studies have failed to demonstrate clear benefit of surgical management for these injuries especially in the elderly (generally defined as ≥65 years old). There is a paucity of research available on outcomes after surgical and nonsurgical treatment of proximal humerus fractures in adults younger than 65 years, and comparative data are almost nonexistent. The purpose of our study was to perform a systematic review and meta-analysis on the available data to determine if the literature supports surgical management over conservative treatment for PHFs in adults younger than 65 years.

Materials and methods

Adhering to PRISMA guidelines, a systematic review of proximal humerus fractures was performed using MEDLINE and Google Scholar databases. Studies were included if they reported useable data such as outcome measures for adult patients younger than 65 years. Quality of nonrandomized studies was assessed utilizing the MINORs criteria. Extracted data were analyzed using statistical software with P-value set at 0.05.

Results

Six studies were included in the study for data extraction and statistical analysis. When comparing Constant Scores (CS) and Oxford Shoulder Scores (OSS) of operatively and nonoperatively treated adult patients aged less than 65 years, no statistical differences were found. Furthermore, no statistical differences in CS or OSS were found comparing elderly patients (defined as ≥65 years) and adult patients (defined as 18 to <65 years). Analysis of DASH outcome data did show statistical differences of the three cohorts (nonoperative <65, operative <65, and operative ≥65). Thus, only the limb-specific (not joint specific) outcome score (DASH) was found to be significantly different upon data analysis. Differences in shoulder-specific outcome scores (OSS and CS) failed to meet significance.

Conclusion

The available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management of proximal humeral fractures in adult patients younger than 65 years. These results challenge the widely accepted practice of choosing surgical treatment in adult patients younger than 65 years with PHFs.

Radiographic parameter(s) influencing functional outcomes following angular stable plate fixation of proximal humeral fractures

PURPOSE

Radiographic parameters which correlate with poor clinical outcome after proximal humeral fractures could be helpful indicators to answer the question which patients should be followed up closer. Moreover, during surgery, radiographic parameters correlating with unfavourable outcome should be avoided. The primary aim of the study was to compare radiographic measurements between the injured and the contralateral, uninjured shoulder. The secondary aim was to correlate these radiographic parameters with post-operative shoulder function.

METHODS

Fifty-eight patients (age: 55.6 ± 14.4 years, age at surgery) following angular stable plate fixation of a proximal humeral fracture (2-part fractures according to Neer: 24, 3-part: 25, 4-part: 9) were included in this retrospective cohort study. All patients were followed up at least six years (7.9 ± 1.4 after surgical intervention). During follow-up examination, the Constant score (CS) was assessed, and radiographs of both shoulders were taken. Radiographs were analyzed regarding lateral humeral offset, distance between tuberculum and head apex, head diameter, head height, perpendicular height, perpendicular center, vertical height, and angles between head and humeral shaft (CCD and HSA). These parameters were compared between the injured and uninjured shoulder. The cohort was divided in two groups: patients with a CS category of excellent/good and satisfying/worse. Both groups were tested regarding differences of demographic and radiographic parameters.

RESULTS

The distance between tuberculum and head apex (2.6 ± 3.4 mm vs. 4.3 ± 2.1 mm; p = 0.0017), the CCD (123.1 ± 12.9° vs. 130.1 ± 7.3°; p = 0.0005), and the HSA (33.1 ± 12.8° vs. 40.1 ± 7.3°; p = 0.0066) were significantly smaller on the treated shoulder compared to the uninjured side. Patients reached a Constant score of 80.2 ± 17.4 (95% CI 75.6-84.8) points. Regarding outcome categories of the Constant score, 46 patients had a good to excellent outcome, and 12 patients had a satisfying or bad outcome. The comparison of these groups revealed that patients with inferior outcome in the long-term follow-up were older, female, had a more complex fracture type (AO classification), smaller lateral humeral offset, smaller head diameter and height, lower perpendicular height, and lower CCD and HSA angles.

CONCLUSION

If the abovementioned parameters cannot be restored sufficiently during surgery, (reversed) shoulder arthroplasty might be a better solution to reach good post-operative outcome. Moreover, patients presenting these radiographic characteristics in the follow-up, older patients, and patients with a more complex fracture type should be followed up closer to possibly prevent poor shoulder function.

TRIAL REGISTRATION

83 250/2011BO2.

Preoperative measurement of the thickness of the center of the humeral head predicts screw cutout after locked plating of proximal humeral fractures

HYPOTHESIS AND BACKGROUND

Preoperative computed tomography (CT) scans can be used to measure the thickness of the center of the humeral head to identify patients at a higher risk of screw cutout after open reduction-internal fixation.

METHODS

At an academic medical center, we performed a retrospective review of all patients aged ≥ 18 years who had sustained a proximal humeral fracture that was treated with open reduction-internal fixation between January 1, 2005, and December 31, 2014, and who underwent preoperative shoulder CT. Ninety-four patients were included. Patient charts were reviewed to obtain demographic data, and radiographs were reviewed to assess screw cutout. A standardized method was devised to measure the thickness of the center of the humeral head.

RESULTS

Screw cutout developed in 17 patients (17.7%). The mean humeral head thickness was significantly smaller on the axial (18 mm vs. 21 mm, P = .0031), coronal (18 mm vs. 21 mm, P = .0084), and sagittal (18 mm vs. 21 mm, P = .0033) sections in the patients who experienced screw cutout. When the smallest of the 3 measurements for each patient was analyzed, the risk of cutout was markedly greater when the humeral head thickness was <20 mm (25% vs. 6%). In addition, when the humeral head thickness was >25 mm, the risk of cutout was reduced to 0%. A low-energy injury was associated with a lower risk of cutout whereas age, sex, and fracture classification were not independent predictors of cutout on multivariate logistic regression.

CONCLUSIONS

In a patient with a proximal humeral fracture in whom a preoperative CT scan is available, calculating the thickness of the center of the humeral head may provide valuable information to both the surgeon and the patient for preoperative planning and counseling. A smaller thickness of the center of the humeral head on preoperative CT is predictive of screw cutout following locked plating of proximal humeral fractures. A measurement of >25 mm in any one plane is highly protective against cutout; however, extreme caution and consideration of supplemental fixation methods should be taken when the measurements in all planes are <15 mm. This information may be helpful in counseling patients regarding the possibility of postoperative screw cutout.

Glenohumeral joint lavage does not affect clinical outcomes in open reduction and internal fixation of displaced intracapsular proximal humeral fractures: a prospective, randomized, double-blinded trial

BACKGROUND

This prospective, randomized, and double-blinded trial evaluates the effect of intraoperative glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures.

METHODS

Between January 2016 and April 2018, 86 patients (mean age: 65.2 ± 16.3 years) with a displaced intracapsular proximal humeral fracture were treated by open reduction and internal fixation using locking plates. Patients were randomized to either locked plating followed by intraoperatively performed glenohumeral joint lavage (group L, n = 36) or locked plating without the lavage (group NL, n = 36). Functional outcome assessment included range of shoulder motion, strength, and the Constant score, obtained 6 weeks, 3 months, 6 months, and 12 months postoperatively. A total of 62 shoulders could be reviewed for final investigation (86% follow-up).

RESULTS

One year after open reduction and internal fixation, the mean Constant score was 70 ± 14 (group L, n = 31) compared with 73 ± 14 (group NL, n = 31, P = .272). The mean forward flexion and abduction in group L was 134 ± 33 and 128 ± 33 as compared with 139 ± 32 and 135 ± 32 in group NL, respectively (P = .538, P = .427). The mean external rotation was 40 ± 16 (group L) compared with 44 ± 16 (group NL) (P = .210). The overall complication rate was 9.6% and did not differ significantly between the groups (P = .321). In group L, there were 2 cases of avascular necrosis (6.5%) and 1 case of secondary displacement (3.2%). In group NL, 1 case of avascular necrosis (3.2%) and 1 case of secondary displacement were noted (3.2%, P = .742).

CONCLUSION

The results of this study do not demonstrate a need for glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures with regard to shoulder function at 1-year follow-up.

Indications and results of osteosynthesis for proximal humerus fragility fractures in elderly patients

Proximal humerus fractures (PHF) are common injuries in the elderly population. Conservative treatment is indicated for undisplaced and stable fractures, which account for almost 80% of the cases. More complex fracture patterns might need surgery, with a wide variety of indication criteria and surgical techniques described in the literature. Surgical treatment should be reserved for patients in good clinical conditions, autonomous in daily living activities and able to adhere to postoperative rehabilitation protocols. In the elderly population with severe osteoporosis, cognitive impairment and clinical comorbidities, the risk of surgical failures is high. In these patients, the choice between surgical and conservative treatment, as well as for the type of procedure, is even more difficult, with no general consensus in the literature. Final indication is usually conditioned by surgeon's experience and preference. Two independent reviewers (B.H and G.G) independently extracted studies on proximal humeral fractures. All selected studies were screened independently (B.H and G.G) based on title and abstract. Then the full text of any article that either judged potentially eligible was acquired and reviewed again. Any disagreement was resolved by discussing the full text manuscripts. Aim of the present paper is to review the literature about indications and results of osteosynthesis for proximal humerus fragility fractures in the elderly population.

Incidence of Spine Fracture Hospitalization and Surgery in Finland in 1998-2017

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to assess the incidence and trends of the spine fracture hospitalization and surgery in Finland in 1998-2017.

SUMMARY OF BACKGROUND DATA

Traumatic spine fractures are rare, yet they are known to cause significant long-term disability and therefore social, functional, and financial burden. The incidence of spine fractures and related mortality has been suggested to have declined during recent years. However, there are no population-based studies investigating the incidence of surgical treatment of spine fractures.

METHODS

The data for this study was obtained from the Finnish nationwide National Hospital Discharge Register. The study population covered all patients 20 years of age or over in Finland during a 20-year period from January 1, 1998 to December 31, 2017.

RESULTS

A total of 54,612 patients were hospitalized for a spine fracture in Finland in 1998-2017, and 7138 (13%) of the patients underwent surgery. The annual population-based incidence of spine fracture hospitalization increased 57% during the 20-year period, from 57 per 100,000 person-years to 89 per 100,000 person-years. In addition, the incidence of spine fracture surgery increased 65%, from 5.3 per 100,000 person-years to 8.8 per 100,000 person-years. The incidence of cervical spine fracture surgery tripled, and thoracic spine surgery doubled from 1998 to 2017, while incidence of lumbar fracture surgery declined by 13%. Among patients 60 years of age or older, the incidence of cervical spine fracture surgery increased 400%.

CONCLUSION

Incidences of cervical, thoracic, and lumbar fracture hospitalizations increased constantly in Finland during 1998-2017. Accordingly, incidence of cervical and thoracic spine fracture surgery increased rapidly, whereas the incidence of lumbar fracture surgery even decreased, during this 20-year period.

LEVEL OF EVIDENCE

3.

Comparison of surgical and non-surgical treatments for 3- and 4-part proximal humerus fractures: A network meta-analysis

INTRODUCTION

Common treatment strategies for proximal humerus fractures include non-surgical treatment, open reduction internal fixation, hemiarthroplasty, and reverse total shoulder arthroplasty. There is currently no consensus regarding the superiority of any one surgical strategy. We used network meta-analysis of randomized controlled trials to determine the most successful treatment for proximal humerus fractures.

METHODS

MEDLINE, EMBASE, Web of Science, and Cochrane Central electronic databases were searched for randomized controlled trials comparing 3- and 4-part proximal humerus fracture treatments. Data extraction included the mean and standard deviation of clinical outcomes (Constant, DASH), adverse events, and additional surgery rates. Standard Mean Difference was used to compare clinical outcome scores, and pooled risk ratios were used to compare adverse events and additional surgeries.

RESULTS

Eight randomized controlled trials were included for network meta-analysis. Non-surgical treatment was associated with a lower rate of additional surgery and adverse events compared to open reduction internal fixation. Reverse total shoulder arthroplasty resulted in fewer adverse events and a better clinical outcome score than hemiarthroplasty. Non-surgical treatment produced similar clinical scores, adverse event rates, and additional surgery rates to hemiarthroplasty and reverse total shoulder arthroplasty.

CONCLUSION

Non-surgical treatment results in fewer complications and additional surgeries compared to open reduction internal fixation. Preliminary data supports reverse total shoulder arthroplasty over hemiarthroplasty, but more evidence is needed to strengthen this conclusion.

Reverse Shoulder Arthroplasty Is Superior to Plate Fixation at 2 Years for Displaced Proximal Humeral Fractures in the Elderly: A Multicenter Randomized Controlled Trial

BACKGROUND

Almost one-third of patients with proximal humeral fractures are treated surgically, and the number is increasing. When surgical treatment is chosen, there is sparse evidence on the optimum method. The DelPhi (Delta prosthesis-PHILOS plate) trial is a clinical trial comparing 2 surgical treatments. Our hypothesis was that reverse total shoulder arthroplasty (TSA) yields better clinical results compared with open reduction and internal fixation (ORIF) using an angular stable plate.

METHODS

The DelPhi trial is a randomized controlled trial comparing reverse TSA with ORIF for displaced proximal humeral fractures (OTA/AO types 11-B2 and 11-C2) in elderly patients (65 to 85 years of age). The primary outcome measure was the Constant score at a 2-year follow-up. The secondary outcome measures included the Oxford Shoulder Score and radiographic evaluation. Results were reported as the mean difference with 95% confidence interval (CI). The intention-to-treat principle was applied for crossover patients.

RESULTS

There were 124 patients included in the study. At 2 years, the mean Constant score was 68.0 points (95% CI, 63.7 to 72.4 points) for the reverse TSA group compared with 54.6 points (95% CI, 48.5 to 60.7 points) for the ORIF group, resulting in a significant mean difference of 13.4 points (95% CI, 6.2 to 20.6 points; p < 0.001) in favor of reverse TSA. When stratified for fracture classification, the mean score was 69.3 points (95% CI, 63.9 to 74.7 points) for the reverse TSA group and 50.6 points (95% CI, 41.9 to 59.2 points) for the ORIF group for type-C2 fractures, which yielded a significant mean difference of 18.7 points (95% CI, 9.3 to 28.2 points; p < 0.001). In the type-B2 fracture group, the mean score was 66.2 points (95% CI, 58.6 to 73.8 points) for the reverse TSA group and 58.5 points (95% CI, 49.6 to 67.4 points) for the ORIF group, resulting in a nonsignificant mean difference of 7.6 points (95% CI, -3.8 to 19.1 points; p = 0.19).

CONCLUSIONS

At a 2-year follow-up, the data suggested an advantage of reverse TSA over ORIF in the treatment of displaced OTA/AO type-B2 and C2 proximal humeral fractures in elderly patients.

LEVEL OF EVIDENCE

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

Failed Proximal Humerus Osteosynthesis Using Intramedullary Fibular Strut Allograft Conversion to Reverse Shoulder Arthroplasty

Comminuted proximal humerus fractures are more frequently being treated utilizing an intramedullary fibular strut allograft to assist with open reduction internal fixation. Although this technique has led to improved outcomes, avascular necrosis, rotator cuff failure, and/or prominent hardware may still occur necessitating conversion to reverse shoulder arthroplasty. The presence of an intramedullary strut allograft makes this conversion technically demanding and creates certain potential complications unique to this group. This manuscript details the conversion of a proximal humerus open reduction internal fixation with a fibular strut allograft to reverse shoulder arthroplasty including presurgical workup, surgical techniques, and pitfalls for undertaking this increasingly common scenario.

Mid-term results after proximal humeral fractures following angular stable plate fixation in elderly patients-which scores can be evaluated by a telephone-based assessment?

BACKGROUND

The aim was to evaluate postsurgical outcome in elderly patients (> 70 years) after open reduction and internal fixation (ORIF) of proximal humeral fractures and compare the test-retest agreement of scores which are frequently used to assess the outcome of upper extremity disorders.

METHODS

Ninety patients (78.1 ± 5.2 years) with a minimum follow-up of 2 years (3.7 ± 0.9 years) following angular stable plate fixation of a proximal humeral fracture (2-part: 34, 3-part: 41, 4-part: 12) were enrolled. Two telephone-based interviews assessed Disabilities of the Arm, Shoulder and Hand Score (DASH), Oxford Shoulder Score (OSS), and Constant Score adjusted for interview assessment (CS) by two independent interviewers. Correlations, Bland-Altman analyses, Cross tabulation, and weighted Kappa measure of agreement (k) were calculated to assess differences and the test-retest agreement between the categories of each score.

RESULTS

In the first and second interview, we could state fair outcomes: CS 91 (range 40-100) and 65.5 (23-86), DASH 12.5 (0-64.2) and 18.3 (0-66.7), and OSS 58 (33-60) and 55 (25-60) points. The test-retest correlations were r = 0.67, r = 0.77, and r = 0.71 for CS, DASH, and OSS. Bland-Altman analyses showed absolute mean individual score differences of - 22.3, 4.9, and - 3.0 for CS, DASH, and OSS. Limits of agreement represented possible differences of 21.6%, 15.5%, and 9.0% of CS, DASH, and OSS. The category agreements were medium to high: CS 55.9% (k = 0.08), DASH 87.2% (k = 0.62), and OSS 99.3% (k = 0.74).

CONCLUSION

Patients showed good subjective outcomes. The test-retest agreement of the interview-adjusted CS was low, but telephone-based assessment of OSS and DASH present as an alternative to collect outcomes in elderly patients.

TRIAL REGISTRATION

(250/2011BO2).

Trends in surgical management of proximal humeral fractures in adults: a nationwide study of records in Germany from 2007 to 2016

INTRODUCTION

Proximal humeral fractures (PHF) are among the most common adult fractures. However, valid epidemiologic population-based data, including differentiation of treatment modalities, are lacking.

MATERIALS AND METHODS

Using the ICD codes and associated OPS codes for PHF, a retrospective analysis of 2007-2016 Federal Statistical Office of Germany data was performed. Data were evaluated for total incidence of PHF as well as total use, annual utilization rates, age, and sex distributions of all associated surgical procedures. Simple linear regressions were performed to evaluate trends in treatment modalities.

RESULTS

There were 642,556 cases of PHF. During the study period, incidence changed substantially from 65.2 to 74.2 per 100,000 inhabitants with a significant rise in elderly (> 70 years) patients (P < 0.001). The number of surgical procedures increased by 39%, with locking plate fixation being the most common procedure (48.3%), followed by intramedullary nailing (IMN) (20.0%), hemiarthroplasty (HA) (7.5%), K-wire fixation (6.4%), and reverse shoulder arthroplasty (RSA) (5.6%). The utilization rate increased for locking plates, K-wires, and RSA and decreased for HA and IMN. Particularly, the utilization of RSA exhibited a  > eightfold increase. Significant linear correlation of procedure and time were found for all surgical treatments.

CONCLUSIONS

During this period, the number of inpatient PHFs, especially in the elderly, increased. Although locking plate fixation remained the most common treatment method, RSA had the greatest proportional increase over time, supporting its growing popularity in the light of the current scientific evidence. This incline was offset by a corresponding decrease in HA and IMN, which may be related to a growing knowledge of their application limitations.

LEVEL OF EVIDENCE

Descriptive epidemiology study, large database analysis.

Nationwide trends in management of proximal humeral fractures: an analysis of 77,966 cases from 2008 to 2017

BACKGROUND

There is no consensus as to the treatment of proximal humeral fractures (PHFs), particularly in elderly patients. There is increasing evidence that nonoperative management may have similar functional outcomes to operative management, which is potentially conflicting with increasingly improved surgical techniques and implants. The aim of this study was to investigate the changes in the incidence and management of PHFs across Australia over a 10-year period.

MATERIALS AND METHODS

We retrospectively reviewed all hospitalizations of patients with PHFs from 2 Australian national health care databases from 2008 to 2017. We recorded the incidence of PHFs and annual utilization rates of commonly used treatment options including nonoperative management, hemiarthroplasty (HA), reverse total shoulder arthroplasty (RTSA), and open reduction-internal fixation (ORIF).

RESULTS

The incidence of PHFs increased from 26.8 per 100,000 person-years in 2008 to 45.7 per 100,000 person-years in 2017. There was a decrease in operative management from 2008 to 2017, with 32.5% and 22.8% of all PHFs treated operatively in 2008 and 2017, respectively (P = .001). ORIF use decreased significantly from 76.6% to 72.6% (P = .004). RTSA use increased significantly from 4.1% to 24.5% (P < .001). HA use decreased significantly from 19.3% to 3% (P < .001).

CONCLUSIONS

Whereas the incidence of PHFs increased, the operative management of PHFs decreased significantly from 2008 to 2017, particularly in patients aged 65 years or older. This decrease in operative management was in part due to a significant decrease in ORIF and HA use in patients aged 65 years or older. There was a significant increase in RTSA use.

Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial

BACKGROUND

Although increasingly used, the benefit of surgical treatment of displaced 2-part proximal humerus fractures has not been proven. This trial evaluates the clinical effectiveness of surgery with locking plate compared with non-operative treatment for these fractures.

METHODS AND FINDINGS

The NITEP group conducted a superiority, assessor-blinded, multicenter randomized trial in 6 hospitals in Finland, Estonia, Sweden, and Denmark. Eighty-eight patients aged 60 years or older with displaced (more than 1 cm or 45 degrees) 2-part surgical or anatomical neck proximal humerus fracture were randomly assigned in a 1:1 ratio to undergo either operative treatment with a locking plate or non-operative treatment. The mean age of patients was 72 years in the non-operative group and 73 years in the operative group, with a female sex distribution of 95% and 87%, respectively. Patients were recruited between February 2011 and April 2016. The primary outcome measure was Disabilities of Arm, Shoulder, and Hand (DASH) score at 2-year follow-up. Secondary outcomes included Constant-Murley score, the visual analogue scale for pain, the quality of life questionnaire 15D, EuroQol Group's 5-dimension self-reported questionnaire EQ-5D, the Oxford Shoulder Score, and complications. The mean DASH score (0 best, 100 worst) at 2 years was 18.5 points for the operative treatment group and 17.4 points for the non-operative group (mean difference 1.1 [95% CI -7.8 to 9.4], p = 0.81). At 2 years, there were no statistically or clinically significant between-group differences in any of the outcome measures. All 3 complications resulting in secondary surgery occurred in the operative group. The lack of blinding in patient-reported outcome assessment is a limitation of the study. Our assessor physiotherapists were, however, blinded.

CONCLUSIONS

This trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus. These results suggest that the current practice of performing surgery on the majority of displaced proximal 2-part fractures of the humerus in older adults may not be beneficial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01246167.

Surgical trends in elderly patients with proximal humeral fractures in South Korea: a population-based study

Background

It is known that there are large regional variations in treatment methods for the management of proximal humeral fractures. The objective of this study was to investigate the national surgical trends in elderly patients with proximal humeral fractures in South Korea.

Methods

We analyzed the Korean Health Insurance Review and Assessment Service database from 2008 to 2016. International Classification of Diseases, 10th revision codes and procedure codes were used to identify patients aged ≥65 years with proximal humeral fractures.

Results

A total of 69,120 proximal humeral fractures were identified from 2008 to 2016. The overall operative rate for proximal humeral fractures increased steadily from 24.6% in 2008 to 36.8% in 2016 (p < 0.001). The rate of cases treated with open reduction and internal fixation tended to increase each year, from 71.5% of the overall surgeries in 2008 to 85.6% in 2016; conversely, the rate of cases treated with closed reduction and internal fixation tended to decrease from 19.9% in 2008 to 4.5% in 2016. In terms of type of arthroplasty procedure, the rate of cases treated with reverse shoulder arthroplasty tended to increase significantly each year, from 8.2% of the overall arthroplasty procedures in 2008 to 52.0% in 2016 (p < 0.001). The proportion of reverse shoulder arthroplasty was shown to increase especially in patients aged 80 years or older.

Conclusion

Overall, our findings indicated that surgical treatment of proximal humeral fractures, particularly by open reduction and internal fixation, continues to increase; in terms of type of arthroplasty procedure, the rate of cases treated with reverse shoulder arthroplasty tended to increase.

Nordic Innovative Trials to Evaluate osteoPorotic Fractures (NITEP) Collaboration: The Nordic DeltaCon Trial protocol-non-operative treatment versus reversed total shoulder arthroplasty in patients 65 years of age and older with a displaced proximal humerus fracture: a prospective, randomised controlled trial

INTRODUCTION

The proximal humerus fracture (PHF) is one of the most common fractures in the elderly. The majority of PHFs are treated non-operatively, while 15%-33% of patients undergo surgical treatment. Recent randomised controlled trial (RCT) and meta-analyses have shown that there is no difference in outcome between non-operative treatment and locking plate or hemi-arthroplasty. During the past decade, reverse total shoulder arthroplasty (RTSA) has gained popularity in the treatment of PHF, although there is a lack of RCTs comparing RTSA to non-operative treatment.

METHODS

This is a prospective, single-blinded, randomised, controlled, multicentre and multinational trial comparing RTSA with non-operative treatment in displaced proximal humeral fractures in patients 65-85 years. The primary outcome in this study is QuickDASH-score measured at 2 years. Secondary outcomes include visual analogue scale for pain, grip strength, Oxford shoulder score, Constant score and the number of reoperations and complications.The hypothesis of the trial is that operative treatment with RTSA produces better outcome after 2 and 5 years measured with QuickDASH.

ETHICS AND DISSEMINATION

In this protocol, we describe the design, method and management of the Nordic DeltaCon trial. The ethical approval for the trial has been given by the Regional Committee for Medical and Health Research Ethics, Norway. There have been several examples in orthopaedics of innovations that result in failure after medium-term follow-ups . In order to prevent such failures and to increase our knowledge of RSTA, we feel a large-scale study of the effects of the surgery on the outcome that focuses on the complications and reoperations is warranted. After the trial 2-year follow-up, the results will be disseminated in a major orthopaedic publication.

TRIAL REGISTRATION NUMBER

NCT03531463; Pre-Results.

Comparison of CFR-PEEK and conventional titanium locking plates for proximal humeral fractures: a retrospective controlled study of patient outcomes

BACKGROUND

Metal plates are the fixation devices used most frequently to proximal humeral fractures (PHFs). However, in recent years carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates have become increasingly common. This study compares the clinical and radiographic outcomes of 42 Neer three- and four-part PHFs treated with CFR-PEEK or metal (titanium) plates.

MATERIALS AND METHODS

Forty-two PHF patients were managed with CFR-PEEK plates (n = 21, males/females 9/12; mean age 57.4 years; mean follow-up 30.7 months; CFR-PEEK group) or metal plates (n = 21; males/females 7/14; mean age 55.8 years; mean follow-up 52.7 months; Metal group). Active shoulder mobility (anterior elevation, lateral elevation, external rotation, and internal rotation), the Constant-Murley Score, the Simple Shoulder Test Score, and the pain score were recorded. Preoperative computed tomography scans and X-rays were obtained. Postoperative fracture healing and displacement, tuberosity resorption and/or malposition, hardware position, and cortical thinning (CT) under the plate were assessed radiographically.

RESULTS

Shoulder mobility, clinical, and pain scores were similar in both patient groups. CT was significantly greater in CFR-PEEK patients (mean difference, 1.14 mm; p = 0.0003). In both groups, incomplete or poor calcar reduction was associated to a significantly higher complication rate, especially stiffness and muscle weakness (p = 0.016). The rate of tuberosity resorption was significantly higher in the Metal group (p = 0.040). Two patients required revision to a hemiarthroplasty (CFR-PEEK) and reverse arthroplasty (Metal group).

CONCLUSIONS

CFR-PEEK plates provide a viable alternative to conventional titanium plates in PHFs, ensuring similar clinical outcomes and a lower rate of tuberosity resorption, but they involve higher stress shielding under the plate.

Intraobserver and interobserver reliability of recategorized Neer classification in differentiating 2-part surgical neck fractures from multi-fragmented proximal humeral fractures in 116 patients

BACKGROUND

Optimal fracture classification should be simple and reproducible and should guide treatment. For proximal humeral fractures, the Neer classification is commonly used. However, intraobserver and interobserver reliability of the Neer classification has been shown to be poor. In clinical practice, it is essential to differentiate 2-part surgical neck fractures from multi-fragmented fractures. Thus, the aim of this study was to evaluate whether surgeons can differentiate 2-part surgical neck fractures from multi-fragmented fractures using plain radiographs and/or computed tomography (CT).

METHODS

Three experienced upper limb specialists and trauma surgeons (B.O.S., A.P.L., and V.L.) independently reviewed and classified blinded plain radiographs and CT scans of 116 patients as showing 2-part surgical neck fractures or multi-fragmented fractures. Each imaging modality was reviewed and classified separately by each surgeon, after which each surgeon reviewed both modalities at the same time. This process was repeated by all surgeons after 24 weeks. Intraobserver and interobserver analyses were conducted using Cohen and Fleiss κ values, respectively.

RESULTS

The κ coefficient for interobserver reliability showed substantial correlation (0.61-0.73) and was as follows: 0.73 for radiographs alone, 0.61 for CT scans alone, and 0.72 for radiographs and CT scans viewed together. After 24 weeks, the process was repeated and intraobserver reliability was calculated.The κ coefficient for intraobserver reliability showed substantial correlation (0.62-0.75) and was as follows: 0.62 for radiographs alone, 0.64 for CT scans alone, and 0.75 for radiographs and CT scans viewed together.

CONCLUSION

Clinicians were able to differentiate 2-part surgical neck fractures from multi-fragmented fractures based on plain radiographs reliably.

Open reduction internal fixation vs non-operative management in proximal humerus fractures: a prospective, randomized controlled trial protocol

BACKGROUND

Proximal humerus fractures are the third most common fracture in the elderly population and are expected to increase due to the aging population. Surgical fixation with locking plate technology has increased over the last decade despite a lack of proven superiority in the literature. Three previous randomized controlled trials have not shown a difference in patient-centered outcomes when comparing non-operative treatment with open reduction and internal fixation. Low patient enrollment and other methodological concerns however limit the generalizability of these conclusions and as a result, management of these fractures remains a controversy. By comparing the functional outcomes of locked plate surgical fixation versus non-operative treatment of displaced three and four-part proximal humerus fractures in the elderly population with a large scale, prospective, multi-centered randomized controlled trial, the optimal management strategy for this common injury may be determined.

METHODS

We will conduct a prospective, single blind randomized controlled parallel arm trial to compare non-operative management of proximal humerus fractures with open reduction and internal fixation using locked plating technology. One-hundred and sixty patients > age 60 with acute 3- or 4- part proximal humerus fractures will be randomized to either open reduction and internal fixation with locked plating technology or non-operative management treatment arms. The primary outcome measure is the Constant Score at 24 months post-operative. Secondary outcome measures include the American Shoulder and Elbow Surgeon's Score (ASES), EuroQol EQ-5D-5 L Health Questionnaire Score, short form PROMIS upper extremity score and IPAQ for the elderly score. Further outcome measures include assessment of the initial classification, displacement and angulation and the quality of surgical reduction via a standard computed tomography (CT) scan; rates of non-union, malunion, arthrosis, osteopenia or other complications including infection, nerve injury, intra-articular screw penetration, reoperation rates and hospital re-admission rates.

DISCUSSION

The results of this trial will provide Level 1 evidence to guide decision-making in the treatment of proximal humerus fractures in the elderly population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02362100 . Registered 5 Feb 2015.

Rising incidence of scaphoid fracture surgery in Finland

The aim of the present study was to investigate the incidence of scaphoid fracture surgery by obtaining data from the national discharge register in Finland, a country of 5 million inhabitants, for the period from 1997 to 2014. A total of 1380 patients with scaphoid fracture were treated surgically. Half of the patients were aged under 28 years and 84% were men. The surgical treatment of scaphoid fractures was classified into two groups. There were 640 (46%) primary fracture fixations and 740 (54%) treatments of fracture nonunion. The overall incidence of all scaphoid fixations increased twofold (from 14.8 to 30.1 per 1,000,000 person-years) and threefold in the primary fixation group (from 5.5 to 17.8 per 1,000,000 person-years) during the study period.

LEVEL OF EVIDENCE

III.

National trends in proximal humerus fracture treatment patterns

BACKGROUND

The treatment of proximal humerus fractures (PHF) is largely surgeon dependent with no clear guidelines for selecting the optimal method of treatment.

AIMS

The aim of this study was to evaluate trends and variations in treatment methods of PHF in the United States from 2004 to 2012 and to determine the regional differences in treatment.

METHODS

The National Inpatient Sample was used to identify all patient discharges with diagnosis codes for PHF and the data were classified based on ICD-9 procedure codes. Patient and hospital demographics were also analyzed. Simple linear regression analyses were performed for each treatment modality to evaluate current treatment trends and to extrapolate the future trends of PHF treatment over the next 20 years.

RESULTS

A national estimate of 550,116 PHF discharges was identified over the time period. Significant correlations between change over time and treatment modality were found for reverse shoulder arthroplasty (RSA) (r = 0.903, p < 0.001), open reduction internal fixation (r = 0.876, p = 0.002), and closed reduction internal fixation (r = -0.922, p < 0.001). The RSA regression model showed that by the year 2032, PHF treated with RSA will increase 100% from 2012.

DISCUSSION

There were significant changes in treatment modalities for PHF from 2004 to 2012; The projected number of RSA used to treat PHF will be about 9115 in 2032, compared to 340 in 2004.

CONCLUSION

Overall, there was a growth in proximal humerus fractures treated in an inpatient setting in the United States. RSA had the greatest proportional increase over time, but only accounted for less than 2% of total interventions.

Epidemiology of calcaneal fractures in Finland

BACKGROUND

The purpose of this study was to assess the nationwide incidence (per 100,000 person-years) of operative treatment and hospitalization due to calcaneal fractures (CF) in Finland.

METHODS

The study was based on the Finnish National Hospital Discharge Register. All patients aged 18-years or older admitted to Finnish hospitals for primary treatment of CF in 1987-2012 were included.

RESULTS

During the 26-year study period 5977 patients were hospitalized with main or secondary diagnosis of a CF. The incidence of hospitalization due to CF remained relatively stable: (12.5)/100,000 in men and 3.9/100,000 in women. The men were younger (median 43 years) than the women (median 61 years).

CONCLUSIONS

The incidence of the hospitalization due to CF in Finland has remained at steady level during the past 26 years. The incidence of CF is three times higher in men. In 2012 22% of the fractures were operatively treated.

Proximal humeral fractures in Sweden-a registry-based study

Proximal humeral fracture is the third most common osteoporotic fracture. To our knowledge, this is the first nationwide population-based registry study in adults that includes both inpatient and outpatient visits. Thus, we were able to report the true incidence rates and trends in the treatment of proximal humeral fractures.

INTRODUCTION

Proximal humeral fractures are among the most common osteoporotic fractures. Valid epidemiologic population-based data, including both inpatient and outpatient visits, however, are lacking.

METHODS

To investigate the Swedish national incidence rates and treatment trends of proximal humeral fractures, we obtained data from the Swedish Hospital Discharge Register between 2001 and 2012. All adult patients (≥18 years of age) in the Swedish Hospital Discharge Register were included. Outpatient visits have been included in the register since 2001.

RESULTS

We identified 98,770 patients (women n = 72,063; 73 %) with proximal humeral fractures between 2001 and 2012. In 2001, the sex-specific incidence of proximal humeral fractures was 134.5 per 100,000 person-years for women and 49.2 for men. In 2012, the corresponding values were 174.6 for women and 68.1 for men, increasing 30 % in women and 39 % in men. A total of 17,013 surgical procedures were conducted between 2001 and 2012. Open reduction and internal fixation with a plate was the most common procedure (n = 5050, 30 %), followed by endoprosthetic implantation (n = 3962, 23 %) and intramedullary nailing (n = 3376, 20 %). The proportion of surgically treated patients increased from 12.1 % in 2001 to 16.8 % in 2012 for women and from 15.1 % in 2001 to 17.1 % in 2012 for men.

CONCLUSION

The Swedish national incidence of proximal humeral fractures has been increasing, although it seems to have peaked in the elderly population during 2008-2010. The rate of surgical treatment has increased substantially, particularly open reduction and internal fixation with a plate. To our knowledge, this is the first nationwide epidemiologic study for Sweden reporting the incidence of proximal humeral fractures and including all inpatient and outpatient visits.

The female geriatric proximal humeral fracture: protagonist for straight antegrade nailing?

INTRODUCTION

Straight antegrade humeral nailing (SAHN) has become a standard technique for the surgical fixation of proximal humeral fractures, which predominantly affect elderly females. The nail's proximal anchoring point has been demonstrated to be critical to ensure reliable fixation in osteoporotic bone and to prevent iatrogenic damage to the superior rotator cuff bony insertion. Anatomical variations of the proximal humerus, however, may preclude satisfactory anchoring of the nail's proximal end and may bare the risk of rotator cuff violation, even though the nail is inserted as recommended. The aim of this study was to evaluate the anatomical suitability of proximal humeri of geriatric females aged 75 years and older for SAHN. Specifically, we sought to assess the proportion of humeri not anatomically amenable to SAHN for proximal humeral fracture.

MATERIALS AND METHODS

A total of 303 proximal humeri of 241 females aged 75 years and older (mean age 84.5 ± 5.0 years; range 75-102 years) were analyzed for this study. Multiplanar two-dimensional reformations (true ap, true lateral, and axial) were reconstructed from shoulder computed tomography (CT) data sets. The straight antegrade nail's ideal entry point, "critical point" (CP), and critical distance (CD; distance between ideal entry point and CP) were determined. The rate of proximal humeri not anatomically suitable for SAHN (critical type) was assessed regarding proximal reaming diameters of currently available straight antegrade humeral nails.

RESULTS

Overall, 35.6% (108/303) of all proximal humeri were found to be "critical types" (CD <8 mm) as to the recommended minimal proximal reaming diameter of 10 mm of straight antegrade nails currently in use. Moreover, 43.2% (131/303) of the humeri were considered "critical types" with regard to the alternatively used larger proximal reaming diameter of 11.5 mm. Mean CD was 9.0 ± 1.7 mm (range 3.5-13.5 mm) and did not correlate with age (r = -0.04, P = 0.54). No significant differences in CD and rate of "critical types" were found between left and right humeri as well as between females aged between 75 and 84 years (n = 151) and females aged 85 and older (n = 152).

CONCLUSIONS

More than a third of proximal humeri of geriatric females are "critical types" as to SAHN and may, therefore, be at risk for procedure-related complications, such as rotator cuff violation, fixation failure, and potential malreduction. In view of this finding, we recommend to routinely analyze multiplanar CT reformations of the uninjured contralateral side prior to surgery to improve selection of patients for SAHN and to minimize foreseeable complications. For "critical type" humeri, an alternative surgical procedure should be considered.

Accurate application of a precontoured-locking plate for proximal humeral fractures in Asians: a cadaveric study

OBJECTIVES

The purpose of this study was to identify the optimal position for a precontoured-locking plating (PHILOS(®)) of the proximal humerus in Asians in terms of conformity and to determine the prevalence of screw exits in the position of the highest conformity.

METHODS

Twenty adult humeri and 14 cadaveric shoulders were included in this study. After placing the precontoured plate in the well-fitted position on the humerus, we measured the distance between the upper margin of the plate and the tip of greater tuberosity (GT) (distance A) and the distance between the anterior margin of the plate and lateral border of the bicipital groove (BG) (distance B). The prevalence of K-wire exits was assessed. In the 14 cadaver shoulders, the mutual relation between the most inferior locking sleeve of the optimally positioned plate and the axillary nerve was evaluated to assess the potential for axillary nerve injury.

RESULTS

The precontoured plate was well-fitted and remained in a relatively constant position in all specimens. Distance A was an average of 3.6 mm (range 1.4-5.5 mm), and distance B was an average of 2.5 mm (range 0-4.6 mm). The K wire closest to the BG pierced it in four cases (20 %), and most inferior K wires exited at an average distance of 3.8 mm (range 1.6-9.0 mm) from the inferior articular margin of the humeral head. Regarding involvement of the BG, articular width was the only significant variable in the logistic regression model, with an odds' ratio of 0.610. The axillary nerve was located at an average vertical distance of 59.7 mm (range 51.8-66.9 mm) from the tip of the GT in a vertically neutral position. The results did not differ between the left and right sides (t = 0.326, p = 0.755). Although the axillary nerve was slightly inferior to the most inferior locking holes of the proximal humerus, it was located in the path of their locking sleeves on the deltoid muscle.

CONCLUSION

The optimal position for the highest conformity led to ideal fixation of the proximal humerus and inferomedial support screw in Asians. However, the precontoured plate sometimes had screw exits that involved the BG, and articular width had a large impact on involvement of the BG. If locking sleeves for the most inferior holes were introduced on the deltoid muscle in a neutral position, there was high potential for injury to the axillary nerve in Koreans.

Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus: Findings of a meta-analysis

Objectives

The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes.

Methods

A systematic review of the literature was performed identifying all RCTs that compared surgical and non-surgical management of fractures of the proximal humerus. Meta-analysis of clinical outcomes was performed where possible. Subgroup analysis based on the type of fracture, and a sensitivity analysis based on the type of surgical intervention, were also performed.

Results

Seven studies including 528 patients were included. The overall meta-analysis found that there was no difference in clinical outcomes. However, subgroup and sensitivity analyses found improved patient outcomes for more complex fractures managed surgically. Four-part fractures that underwent surgery had improved long-term health utility scores (mean difference, MD 95% CI 0.04 to 0.28; p = 0.007). They were also less likely to result in osteoarthritis, osteonecrosis and non/malunion (OR 7.38, 95% CI 1.97 to 27.60; p = 0.003). Another significant subgroup finding was that secondary surgery was more common for patients that underwent internal fixation compared with conservative management within the studies with predominantly three-part fractures (OR 0.15, 95% CI 0.04 to 0.63; p = 0.009).

Conclusion

This meta-analysis has demonstrated that differences in the type of fracture and surgical treatment result in outcomes that are distinct from those generated from analysis of all types of fracture and surgical treatments grouped together. This has important implications for clinical decision making and should highlight the need for future trials to adopt more specific inclusion criteria.

Cite this article: S. Sabharwal, N. K. Patel, D. Griffiths, T. Athanasiou, C. M. Gupte, P. Reilly. Trials based on specific fracture configuration and surgical procedures likely to be more relevant for decision making in the management of fractures of the proximal humerus: Findings of a meta-analysisBone Joint Res 2016;5:470–480. DOI: 10.1302/2046-3758.510.2000638.

A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change?

Objectives

The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment.

Methods

A total of ten consecutive patients undergoing surgery for the treatment of a proximal humeral fracture from each of 11 United Kingdom hospitals were retrospectively identified over a 15 month period between January 2014 and March 2015. Data gathered for the 110 patients included patient demographics, injury characteristics, mode of surgical fixation, the grade of operating surgeon and the cost of the surgical implants.

Results

A majority of the patients were female (66%, 73 of 110). The mean patient age was 62 years (range 18 to 89). A majority of patients met the inclusion criteria for the PROFHER trial (75%, 83 of 110). Plate fixation was the most common mode of surgery (68%, 75 patients), followed by intramedullary fixation (12%, 13 patients), reverse shoulder arthroplasty (10%, 11 patients) and hemiarthroplasty (7%, eight patients). The consultant was either the primary operating surgeon or supervising the operating surgeon in a large majority of cases (91%, 100 patients). Implant costs for plate fixation were significantly less than both hemiarthroplasty (p < 0.05) and reverse shoulder arthroplasty (p < 0.0001). Implant costs for intramedullary fixation were significantly less than plate fixation (p < 0.01), hemiarthroplasty (p < 0.0001) and reverse shoulder arthroplasty (p < 0.0001).

Conclusions

Our study has shown that the majority of a representative sample of patients currently undergoing surgical treatment for a proximal humeral fracture in these United Kingdom centres met the inclusion criteria for the PROFHER trial and that a proportion of these patients may, therefore, have been effectively managed non-operatively.

Cite this article: Mr B. J. F. Dean. A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change? Bone Joint Res 2016;5:178–184. DOI: 10.1302/2046-3758.55.2000596.

Trends in surgical management of proximal humeral fractures in the Medicare population: a nationwide study of records from 2009 to 2012

BACKGROUND

Surgical management of proximal humeral fractures has reportedly increased in recent years. Much of this growth relates to a growing elderly population, together with the introduction of modern implants, such as locking plates and, recently, introduction of reverse shoulder arthroplasty (RSA). This study evaluated trends in surgical management of proximal humeral fractures from 2009 to 2012 by analyzing the use of hemiarthroplasty (HA), RSA, and osteosynthesis (open reduction with internal fixation [ORIF]) within the Medicare patient population.

METHODS

We retrospectively reviewed a comprehensive Medicare patient population database within the PearlDiver supercomputer (Warsaw, IN, USA) for proximal humeral fractures treated with HA, RSA, or ORIF. Total use, annual utilization rates, age, and gender were investigated.

RESULTS

Within the study period, 32,150 proximal humeral fractures were treated operatively, with no significant change in annual volume (P = .119). The percentage of fractures treated surgically decreased significantly from 16.2% to 13.9% (P < .001). The utilization rate decreased significantly for HA from 52% to 39% (P < .001), increased significantly for RSA from 11% to 28% (P < .001), and did not change significantly for ORIF (P = .164). The utilization rate of RSA nearly tripled for patients older than 65 years (11% to 29%) and doubled for patients younger than 65 (6% to 12%).

CONCLUSION

From 2009 to 2012, utilization rates of ORIF remained fairly constant. HA remains the most commonly used surgical treatment for proximal humeral fractures in the Medicare population, but its use has declined significantly. This decline has been offset by a corresponding increase in RSA.

Do Treatment Policies for Proximal Humerus Fractures Differ among Three Nordic Countries and Estonia? Results of a Survey Study

BACKGROUND AND PURPOSE

Proximal humerus fractures are common fragility injuries. The incidence of these fractures has been estimated to be 82-105 per 105 person-years. Treatment of this fracture, especially in the elderly, is controversial. Our study group published a systematic review of the available literature and concluded that non-operative methods are favored over operative methods in three- and four-part fractures. The aim of this multinational study was to compare treatment policies for proximal humerus fractures among the Nordic countries and Estonia.

MATERIALS AND METHODS

The study was conducted as a questionnaire-based survey, using the Internet-based program, Webropol(®) (webropol.com). The questionnaire link was sent to the surgeons responsible for treating proximal humerus fractures in major public hospitals in Estonia, Finland, Norway, and Sweden. Questionnaire included questions regarding the responder's hospital, patient characteristics, and examinations taken before decision making. Clinical part included eight example patient cases with treatment options.

RESULTS

Of the 77 recipients of the questionnaire, 59 responded; consequently, the response rate was 77%. Based on the eight presented displaced fracture examples, in both Estonia and Norway and in Finland, 41% and 38%, respectively, preferred surgical treatment with locking plate. In Sweden, the percentage was 28%. The pre- and post-operative protocols showed a similarity in all participant countries.

CONCLUSION

Our survey revealed a remarkable uniformity in the current practice of operative treatments and rehabilitation for proximal humerus fractures in the participant countries.