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Matheron G, Mahoney M, Domos P. Conservative treatment of 3- and 4-part proximal humeral fractures: Can poor outcomes be predicted? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2031-2040. [PMID: 38517527 DOI: 10.1007/s00590-024-03890-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/28/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE 3- and 4-part proximal humeral fractures are frequently treated conservatively. This study aims to combine radiographic, and patient reported outcome data to identify factors leading to poor outcomes following conservative treatment. METHODS A retrospective local database analysis identified 3- and 4-part fractures. Radiographic and functional outcomes including Oxford Shoulder Score (OSS), QuickDash (QD), Subjective Shoulder Score (SSV) and VAS pain scores were collected. RESULTS 104 patients were included at mean follow-up of 55 months. Analysis highlighted significant OSS differences in 3- versus 4-part (p = 0.027), dominant arm injury (p = 0.046), age > 65 (p = 0.006), varus coronal neck-shaft angle < 115 versus 115-155 degrees (p = 0.008), posterior head tilt > 155 degrees (p = 0.005), greater tuberosity (GT) displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.032). According to QD scores; age > 65 (p = 0.012), varus neck-shaft angle (p = 0.01), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.006). SSV varied significantly with 3- versus 4-part fractures (p = 0.005), age > 65 (p = 0.04), varus neck-shaft angle (p = 0.001), posterior head tilt (p = 0.005), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.003), and medial calcar hinge displacement > 2 mm (p = 0.001). CONCLUSION We highlight risk factors for unfavourable outcomes following conservative management, aiding surgeons in shared decision-making and patient expectation management.
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Affiliation(s)
- George Matheron
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK.
| | - Melissa Mahoney
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK
| | - Peter Domos
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK
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Floyd SB, Walker JT, Smith JT, Jones PE, Boes N, Lindros S, Carroll M, Brooks JM, Thigpen CA, Pill SG, Kissenberth MJ. ICD-10 diagnosis codes in electronic health records do not adequately capture fracture complexity for proximal humerus fractures. J Shoulder Elbow Surg 2024; 33:417-424. [PMID: 37774829 DOI: 10.1016/j.jse.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/15/2023] [Accepted: 08/27/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The ability to do comparative effectiveness research (CER) for proximal humerus fractures (PHF) using data in electronic health record (EHR) systems and administrative claims databases was enhanced by the 10th revision of the International Classification of Diseases (ICD-10), which expanded the diagnosis codes for PHF to describe fracture complexity including displacement and the number of fracture parts. However, these expanded codes only enhance secondary use of data for research if the codes selected and recorded correctly reflect the fracture complexity. The objective of this project was to assess the accuracy of ICD-10 diagnosis codes documented during routine clinical practice for secondary use of EHR data. METHODS A sample of patients with PHFs treated by orthopedic providers across a large, regional health care system between January 1, 2016, and December 31, 2018, were retrospectively identified from the EHR. Four fellowship-trained orthopedic surgeons reviewed patient radiographs and recorded the Neer Classification characteristics of displacement, number of parts, and fracture location(s). The fracture characteristics were then reviewed by a trained coder, and the most clinically appropriate ICD-10 diagnosis code based on the number of fracture parts was assigned. We assessed congruence between ICD-10 codes documented in the EHR and radiograph-validated codes, and assessed sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for EHR-documented ICD-10 codes. RESULTS There were 761 patients with unilateral, closed PHF who met study inclusion criteria. On average, patients were 67 years of age and 77% were female. Based on radiograph review, 37% were 1-part fractures, 42% were 2-part, 11% were 3-part, and 10% were 4-part fractures. Of the EHR diagnosis codes recorded during clinical practice, 59% were "unspecified" fracture diagnosis codes that did not identify the number of fracture parts. Examination of fracture codes revealed PPV was highest for 1-part (PPV = 0.66, 95% confidence interval [CI] 0.60-0.72) and 4-part fractures (PPV = 0.67, 95% CI 0.13-1.00). CONCLUSIONS Current diagnosis coding practices do not adequately capture the fracture complexity needed to conduct subgroup analysis for PHF. Conclusions drawn from population studies or large databases using ICD-10 codes for PHF classification should be interpreted within this limitation. Future studies are warranted to improve diagnostic coding to support large observational studies using EHR and administrative claims data.
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Affiliation(s)
- Sarah B Floyd
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA; Center for Effectiveness Research in Orthopaedics, Greenville, SC, USA
| | - J Todd Walker
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Justin T Smith
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Patrick E Jones
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Nathan Boes
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Sydney Lindros
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Maile Carroll
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - John M Brooks
- Center for Effectiveness Research in Orthopaedics, Greenville, SC, USA; Department of Health Services Policy & Management, University of South Carolina, Columbia, SC, USA
| | - Charles A Thigpen
- Center for Effectiveness Research in Orthopaedics, Greenville, SC, USA; ATI Physical Therapy, Greenville, SC, USA
| | - Stephan G Pill
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Michael J Kissenberth
- Center for Effectiveness Research in Orthopaedics, Greenville, SC, USA; Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA.
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Descalzo Godoy I, Velasco Alcalde P, Del Olmo Galeano A, Del Río Hortelano J, Martínez Velez D, Fernández González J. Quality of life, functional and radiological outcomes of treatment of three-part and four-part proximal humerus fractures with locking plates and comparison in young versus older than 70 years: a retrospective cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:415-423. [PMID: 37566140 DOI: 10.1007/s00590-023-03675-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE Verify if the use of locking plates in displaced three- and four-part proximal humerus fractures has meant an improvement even in patients over 70 years of age. MATERIAL AND METHODS We performed surgery with locking plate fixation in 56 consecutive patients with three- and four-part proximal humerus fractures according to Neer's classification between 1/1/15 and 12/31/20 at our Hospital. Patient satisfaction, quality of life, functionality and radiological variables, as well as the comparison between patients older and younger than 70 years were the main outcomes. Likewise, factors and complications that may have influenced these variables were analyzed as secondary outcomes. The analysis of all these variables was performed after a minimum follow-up time of 24 months after surgery. RESULTS 51 patients (92%) ended up satisfied or very satisfied according to the SF-36 test and with no disability or mild disability according to the DASH Score questionnaire. 46 patients (82%) obtained a satisfactory or excellent result according to the Neer scale modified by Cofield and 38 (68%) a good or excellent function according to the Constant Murley questionnaire. In 47 cases (84%) good radiological alignment was observed. Complications occurred in 20 patients (36%). The complications and the results of the SF-36, DASH Score, Neer scale modified by Cofield and Constant Murley tests depended on the radiological alignment (p = 0.009, p = 0.006, p = 0.025, p = 0.0008 and p = 0.0004). There were 37 patients younger than 70 years and 19 older than 70 years with no statistically significant differences when comparing the two groups. CONCLUSIONS This study demonstrates that satisfactory results can be obtained with osteosynthesis with locking plates in displaced proximal humerus fractures even in patients older than 70 years of age. LEVEL OF EVIDENCE III Retrospective Cohort, Treatment Study.
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Affiliation(s)
- Ignacio Descalzo Godoy
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, C/Diego de León 62, 28006, Madrid, Spain.
| | - Paula Velasco Alcalde
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, C/Diego de León 62, 28006, Madrid, Spain
| | - Alberto Del Olmo Galeano
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, C/Diego de León 62, 28006, Madrid, Spain
| | - Julián Del Río Hortelano
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, C/Diego de León 62, 28006, Madrid, Spain
| | - David Martínez Velez
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, C/Diego de León 62, 28006, Madrid, Spain
| | - Julián Fernández González
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, C/Diego de León 62, 28006, Madrid, Spain
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Alzobi OZ, Salman LA, Derbas J, Abudalou A, Hantouly AT, Ahmed G. Epidemiology of proximal humerus fractures in Qatar. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3119-3124. [PMID: 37038016 PMCID: PMC10504139 DOI: 10.1007/s00590-023-03539-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 03/27/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE This study aimed to investigate the epidemiological characteristics and treatment options of proximal humerus fractures at a level one trauma center and to compare our data with the current literature. METHODS A retrospective review was conducted on all patients diagnosed and treated for proximal humerus fractures at Hamad General Hospital, a level one trauma center, between January 2018 and December 2019. Age, gender, mechanism of injury, fracture classification, mode of treatment, implant type, length of hospital stay, associated injuries and complications were analyzed. RESULTS A total of 190 patients with a mean age of 52.4 years were included; 56.8% were males. The incidence of proximal humerus fracture was 4.1/100,000 per year. Falling from a standing height was the most common cause of injury (50.5%). Additionally, Neer's two-part fracture was found to be the most common type (n = 132, 69%). Forty-one patients (21.3%) had other associated injuries. Most fractures were treated nonoperatively with an arm sling (n = 138, 72.6%). CONCLUSION In summary, the incidence of proximal humerus fractures during the two-year study period was found to be 4.1 per 100,000 persons per year. Our results showed a lower incidence of proximal humerus fractures with a predominance of males and younger patients in Qatar's population compared to females and older patients in the developed countries. Our results may contribute to the development of effective strategies for preventing and treating proximal humerus fractures, and can provide important data for further high-level clinical research. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Osama Z Alzobi
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Loay A Salman
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Jawad Derbas
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Abedallah Abudalou
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Ashraf T Hantouly
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Ghalib Ahmed
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar.
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Varahra A, MacDermid JC, Szekeres M, Walton D, Faber KJ. Understanding individuals' perspectives and experiences of recovery following a proximal humerus fracture: an interpretive description. Disabil Rehabil 2023; 45:3476-3483. [PMID: 36250673 DOI: 10.1080/09638288.2022.2134469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 09/17/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Proximal humerus fractures are common in older adults and optimizing their outcomes following this injury can be challenging. This study explored recovery from the perspective of individuals who experience proximal humerus fracture. MATERIALS AND METHODS We conducted in-depth semi-structured interviews (n = 14) with participants (aged 45 and over) recruited from a hand clinic in London, Ontario using a purposive sampling technique. The exploratory interviews were audio-recorded, transcribed, and analyzed using interpretive description approach. RESULTS Four themes emerged from the narratives of individuals: challenges of day-to-day activities, coping as you go, recapturing valued life roles, and support matters. CONCLUSIONS Recovery after PHF seems relative to contexts and manifests within numerous scenarios. Based on individuals' narratives, the context produces a mosaic that contributes to unique recovery perception and experience. Awareness of the context emphasizes the complexity inherent in recovery and may guide healthcare professionals' efforts toward care for their patients.IMPLICATIONS FOR REHABILITATIONIndividuals with proximal humerus fracture experience recovery as a personal and dynamic process occurring in their diverse contexts.Healthcare professionals need to recognize the significant impact of context on individuals' physical, emotional, and social life following proximal humerus fracture (PHF).A multidisciplinary treatment plan might be desirable where people with PHF and health care professionals collaborate as a whole.Building a multidisciplinary health team including healthcare professionals, peer support, and case management may remove some barriers and facilitate the transition to recovery.
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Affiliation(s)
- Azar Varahra
- Bruyère Research Institute, Ottawa, Canada
- Health and Rehabilitation Sciences, University of Western Ontario, London, Canada
| | - Joy C MacDermid
- Physical Therapy and Surgery, Western University, London, Canada
- Hand and Upper Limb Centre, St. Joseph's Health Centre, London, Canada
- Rehabilitation Science McMaster University, Hamilton, Canada
| | - Mike Szekeres
- Lawson Health Research Institute, St. Joseph's Health Centre, London, Canada
- Hand Therapy Canada, London, Canada
| | - David Walton
- School of Physical Therapy, Western University, London, Canada
| | - Kenneth J Faber
- Department of Surgery, Western University, Roth ‖ McFarlane Hand & Upper Limb Center, St. Joseph's Health Care, London, Canada
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Foruria AM. Plate Fixation of Proximal Humerus Fractures: How to Get It Right and Future Directions for Improvement. Curr Rev Musculoskelet Med 2023; 16:457-469. [PMID: 37572239 PMCID: PMC10497484 DOI: 10.1007/s12178-023-09853-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE OF REVIEW Open reduction and internal fixation with locking plates (ORIF-LP) has been used for decades for the surgical management of proximal humerus fractures. Despite good outcomes have been widely published in the literature, unacceptably high rates of complications (up to 40%), many of them yielding poor outcomes and requiring reoperation (up to 25%), have also been reported, especially in elderly patients. Most common complications are related to implant failure, with intra-articular screw penetration as the most frequent and devastating. RECENT FINDINGS Advances in patient selection and surgical technique, and implementation of bone or cement augmentation, have been developed to hopefully decrease complication rates. Mayo-FJD Classification offers prognostic information that can aid in the decision-making process for proximal humeral fractures. Displaced valgus impacted fractures seem to be associated with well over a 10% rate of avascular necrosis after ORIF-LP. A principle-based and stepwise surgical technique combining anatomic reduction and a short screw configuration can provide good outcome in most patients, even the elderly, decreasing implant failures to less than 10%. Acrylic cement augmentation has the potential to further decrease implant failure rate to 1%. Reoperation rates are higher partly due to the need to remove hardware for painful subacromial conflict. However, no studies to date definitively demonstrated the superiority of ORIF-LP compared to non-operative treatment, intramedullary nailing, or reverse shoulder arthroplasty. ORIF-LP can provide good results for the surgical management of displaced proximal humerus fractures even in elderly patients provided adequate patient selection and a principle based and stepwise surgical technique, supplemented with bone graft or acrylic cement when needed. Poor outcomes and high complication and reoperation rates should be expected when these recommendations are not followed.
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Affiliation(s)
- Antonio M Foruria
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery, Autónoma University, Fundación Jiménez Díaz University Hospital, Avenida Reyes Católicos 2, Madrid, Spain.
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Patel RS, Bartoletta JJ, Munaretto NF, Tagliero AJ, Rhee PC. Nonoperative Management of Humerus Fractures in Patients With Ispilateral Hemiparesis or Hemiplegia. Hand (N Y) 2023; 18:1027-1036. [PMID: 35189735 PMCID: PMC10470230 DOI: 10.1177/15589447211073835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND Patients with upper limb dysfunction from a brain injury often have different goals of treatment and expectations following a fracture of the upper extremity. This study retrospectively reviewed outcomes of nonoperative management of acute humerus fractures in patients with severe ipsilateral hemiparesis or hemiplegia. METHODS Patients who had sustained an acute humerus fracture managed nonoperatively, greater than 1 year following an upper motor neuron (UMN) injury resulting in ipsilateral severe hemiparesis or hemiplegia at a single tertiary care center from 1988 to 2019, were reviewed. Fractures were classified using the AO-Müller/Orthopaedic Trauma Association and/or Neer classifications. Primary outcome measures included House classification level of function, pain, achievement of and time to radiographic union, and the need for subsequent surgical procedures. RESULTS Ten distinct nonoperatively managed humerus fractures-3 proximal (11A23), 5 mid-shaft (12A2b = 1, 12A2c = 2, 12A3a = 1, 12A2b = 1), and 2 distal (13A2 = 1, 13 C1 = 1)-were identified in 8 patients (6 women and 2 men) with ipsilateral hemiparesis or hemiplegia. The median radiographic follow-up was 20 months (range: 78 days to 12 years). The median clinical follow-up was 33.5 months (range: 100 days to 12 years). All patients presented with severe pain that was absent at final follow-up. Radiographic union was achieved in all patients with a mean time to union of 90.9 ± 39.3 days (range: 35-185 days). No patients required operative management. CONCLUSIONS Nonoperative management of humerus fractures in patients with an ipsilateral UMN injury might result in reliable pain relief and union without the need for further surgical intervention. Management of humerus fractures in this patient population should be individualized toward their goals of care.
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Affiliation(s)
| | | | | | | | - Peter C. Rhee
- Mayo Clinic, Rochester, MN, USA
- Travis Air Force Base, CA, USA
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Chua SKK, Soh QY, Lim CJ, Ring D, Chua ITH, Kwek EBK, Tan BY. Social determinants of outcomes in nonoperatively treated proximal humerus fractures. JSES Int 2023; 7:743-750. [PMID: 37719821 PMCID: PMC10499851 DOI: 10.1016/j.jseint.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background Proximal humerus fractures (PHFs) are common fractures especially in the elderly, with most fractures being managed nonoperatively. Traditional biomedical factors such as radiological alignment have not been able to meaningfully predict comfort and capability after PHFs. Conversely, recent literature has increasingly recognized the role of psychological factors in determining comfort and capability after PHFs. Nonetheless, less is known about the impact of social factors. Additional study of these potentially modifiable social factors as targets for enhancing recovery from injury is merited. Among people recovering from a nonoperatively- treated proximal humerus fracture (PHF) we studied the social factors associated with patient-reported outcomes at 6 months and 1 year. Methods One hundred seventy-one patients who received nonoperative management of a PHF completed baseline measures of sociodemographic characteristics (age, gender, race, employment status, household income, educational level, presence of domestic workers, housing type, and smoking status). Six and 12 months after fracture, participants completed the Oxford Shoulder Score (OSS), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and EuroQol-5-Dimensions (EQ5D) measures of comfort and capability. The relationship between capability and social factors was assessed using linear regression modelling, accounting for potential confounding from age, fracture severity assessed using Neer classification, premorbid comorbidities measured by Charlson Comorbidity Index, and premorbid functional status measured by Parker Mobility Index and Barthel Index. Results Lower capability (higher QuickDASH scores) 6 months and 1 year after fracture were associated with being unemployed (coef: -5.02 [95% CI: -9.96 to -0.07]; P = .047) and having domestic workers at home (coef: 8.63 [95% CI: 1.39 to 15.86]; P = .020), but not with Neer classification. Both greater shoulder discomfort and magnitude of incapability (lower OSS scores) and worse general quality of life (lower EQ5D scores) were associated with having domestic workers (coef: -4.07 [95% CI: -6.62 to -1.53]; P = .002 and coef: -0.18 [95% CI: -0.29 to -0.07]; P = .001 respectively) or living in an assisted care facility (coef: -14.82 [95% CI: -22.24 to -7.39]; P < .001 and coef: -0.59 [95% CI: -0.90 to -0.29] P < .001). Conclusions The finding that people recovering from PHF experience less incapability in proportion to their social independence (employment, absence of a caregiver such as domestic workers at home and living outside care facilities) emphasizes the important associations of social factors to musculoskeletal health, and the utility of accounting for social factors in the development and assessment of care strategies.
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Affiliation(s)
- Shaun Kai Kiat Chua
- Nanyang Technological University, Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Qian Ying Soh
- Nanyang Technological University, Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Chien Joo Lim
- Department of Orthopedic Surgery, Woodlands Health, National Healthcare Group, Singapore, Singapore
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, Austin, TX, USA
| | - Ivan Tjun Huat Chua
- Department of Orthopedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Ernest Beng Kee Kwek
- Department of Orthopedic Surgery, Woodlands Health, National Healthcare Group, Singapore, Singapore
| | - Bryan Yijia Tan
- Department of Orthopedic Surgery, Woodlands Health, National Healthcare Group, Singapore, Singapore
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Lukas J, Menduri H, Christian S, Bernhard J, Matthijs J. Impact of aberrant beam paths on antero-posterior shoulder radiographs in proximal humeral fractures. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04901-2. [PMID: 37169933 DOI: 10.1007/s00402-023-04901-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 04/19/2023] [Indexed: 05/13/2023]
Abstract
INTRODUCTION Accurate radiographic assessment of proximal humeral fractures (PHF) is important as it influences clinical decision-making and predicts clinical outcome. Since aberrant radiographic views might influence the assessment of fracture displacement, it was the goal of this study to investigate the impact of aberrant beam paths on radiographic assessment of PHF. MATERIALS AND METHODS Ten consecutive patients with a displaced PHF, bilateral computed tomography (CT) scan, and a true clinical AP radiograph were included. Digitally reconstructed radiographs (DRRs) were generated and aberrant beam paths were simulated by rotation of ± 30° around the horizontal (flexion and extension) and vertical axis (internal and external rotation) by increments of 10°. Measurement of the neck-shaft-angle (NSA) and eccentric head index (EHI) addressed humeral angulation and offset, respectively. Paired comparisons determined the influence of aberrant beam paths on both measurements between incremental altered views, and between clinical and digital true AP views. Descriptive statistics assessed the change in Neer classification and recommended treatment. RESULTS True AP DRRs approximated the clinical true AP view by a mean difference of 2° for NSA, and a mean difference of 0.12 for EHI. NSA in injured shoulders was most susceptible to malrotation around the vertical axis (p < 0.03), with largest differences seen for internal rotation. Aberrant projections in extension had no influence on NSA (p > 0.70), whereas flexion of ≥ 20° and 30° demonstrated differences in injured and uninjured shoulders, respectively (p < 0.05). EHI was only influenced by malrotation in internal rotation in uninjured shoulders (p < 0.03). Alterations in Neer type occurred at 30° of malrotation in 5 cases, with a change in recommended treatment in 2. CONCLUSIONS Humeral angulation and offset measurements on AP radiographs are more susceptible to aberrant beam paths in fractured humeri. Altered radiographic beam paths around the vertical axis showed the most substantial influence on the assessment of PHF, with angular measurements demonstrating larger differences then offset measurements. Beam path alterations of 30° can influence the Neer classification, and might influence fracture displacement-based decisions.
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Affiliation(s)
- Jud Lukas
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Hoessly Menduri
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Spross Christian
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Jost Bernhard
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Jacxsens Matthijs
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.
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Cognetti DJ, Hughes JD, Sprowls GR, McDonough CM, Sabzevari S, Barrow AE, Lin A. Proximal humerus fracture management and outcomes are distinctly different for individuals 60 years of age or younger: a systematic review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2023; 3:142-149. [PMID: 37588434 PMCID: PMC10426625 DOI: 10.1016/j.xrrt.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Proximal humerus fractures (PHFs) occur most commonly in an elderly and osteoporotic population, but a considerable proportion of these injuries occur in relatively younger individuals. Differences in treatment principles and outcomes in this younger population remain poorly understood. The purpose of this review was to characterize the treatment algorithms and outcomes for patients less than or equal to 60 years of age with PHFs. Methods A comprehensive search of the Medline, Pubmed, Embase, and Cochrane databases for articles published between January 2005 and December 2020 was performed in January 2021. Levels of evidence I-IV analyzing outcomes (patient reported outcomes and/or complications) following PHFs in adult patients less than or equal to 60 years of age were included. The search was carried out in accordance with the preferred reported items for systematic reviews and meta-analyses guidelines. The risk of bias 2 tool and methodological index for nonrandomized studies score were utilized to evaluate included studies. Results Fourteen studies met the inclusion criteria (open reduction internal fixation: 5, intramedullary nail: 4, hemiarthroplasty: 2, nonoperative: 1, and reverse total shoulder arthroplasty (RTSA): 1). Seven studies reported differences in outcomes between younger and older patient populations, with three studies noting separate management algorithms for those 60 years of age or younger. There were no studies comparing different treatments modalities in those less than 60 years of age, and the lone study on RTSA did not include patient-reported outcomes. Conclusion Treatment algorithms and outcomes following PHFs in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population. However, evidence-based treatment recommendations for this younger population are limited by the lack of studies comparing treatment modalities and the absence of patient-reported outcomes for individuals undergoing RTSA.
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Affiliation(s)
| | | | | | | | | | - Aaron E. Barrow
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Albert Lin
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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11
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Risk factors for intra-articular involvement in proximal humeral fractures. Arch Orthop Trauma Surg 2023; 143:1341-1351. [PMID: 35028706 DOI: 10.1007/s00402-021-04293-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 11/27/2021] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Identification of intra-articular involvement in proximal humeral fractures is important for operative decision making. The aim of this study was to identify the risk factors associated with intra-articular involvement in proximal humeral fractures. MATERIALS AND METHODS One hundred consecutive three-dimensional computed tomography reconstructions of proximal humeral fractures were identified. The fracture lines were then accurately transcribed onto a two-dimensional superior view of the humeral head and each fracture was assessed for intra-articular involvement. Statistical analyses were undertaken to identify risk factors for intra-articular involvement and extent of involvement. Furthermore, for each risk factor, common fracture patterns were identified and compared to anatomical landmarks. RESULTS Overall, 58% of the fractures involved the articular surface. High-energy mechanism, female gender, age ≥ 65, and posterior dislocation were risk factors for intra-articular involvement. Low-energy mechanism, female gender, age ≥ 65, varus angulation, and posterior dislocation were risk factors for increased extension of the fracture onto the articular surface. CONCLUSION Intra-articular involvement in proximal humeral fractures is influenced by demographics and fracture characteristics (mechanism of injury, angulation, and dislocation). Patients with identified risk factors should be appropriately evaluated for intra-articular fractures during preoperative planning to assist in operative decision making. LEVEL OF EVIDENCE Basic science; anatomy study.
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12
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Salibi T, Ring D, Van Den Bekerom MP. Comparisons of Routine Initial Operative Fracture Treatment and Later Reconstructive Treatment are not Interesting. THE ARCHIVES OF BONE AND JOINT SURGERY 2023; 11:662-665. [PMID: 37873529 PMCID: PMC10590483 DOI: 10.22038/abjs.2023.74502.3452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 08/28/2023] [Indexed: 10/25/2023]
Abstract
Studies that compare routine immediate operative treatment of fractures with selective later reconstructive surgery for malunion or nonunion may be misleading because it discounts the people who did well with nonoperative treatment. We identified 20 studies comparing routine operative fracture treatment and later reconstruction in the hip, clavicle, proximal humerus, elbow, and distal radius. Fifteen of 20 studies favored immediate operative treatment on the basis of lower reoperation rates, fewer complications, better patient reported outcome scores, and higher satisfaction. Five studies were neutral, and none favored delayed reconstruction for malunion or nonunion. These findings emphasize the potential benefits of routine early surgery and raise questions about the validity of studies comparing different timings of fracture treatment.
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Affiliation(s)
- Tarek Salibi
- The University of Texas at Austin, Austin, Texas, USA
| | - David Ring
- The University of Texas at Austin, Austin, Texas, USA
| | - Michel P.J. Van Den Bekerom
- Shoulder and Elbow Unit, Joint Research, Department of Orthopedic Surgery, OLVG, Amsterdam, The Netherlands
- Shoulder and Elbow Unit, Joint Research, Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands
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13
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Is arthroplasty necessary for three and four-part proximal humerus fractures in elderly? JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.7471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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.
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Russo R, Cozzolino A, Rotonda GD, Guastafierro A, Viglione S, Malfi PF, Minopoli P, Mottola L, Mortellaro M, Pietroluongo LR. Therapeutic and prognostic predictive value of the Control Volume severity grade on proximal humerus fractures due to bone fragility. Orthop Rev (Pavia) 2022; 14:38568. [DOI: 10.52965/001c.38568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background The treatment of proximal humerus fracture complicated by bone fragility is still controversial. The aim of this study is to compare the Neer classification and the Control Volume severity grade for the accuracy in the selection of the type of treatment and for prognostic evaluation. Materials and methods We retrospectively collected the records of all patients admitted at the Emergency Department of our Institute, from 2013 to 2020, for a closed displaced proximal humerus fracture further investigated with a CT scan before treatment decision. We selected all patients with a minimum age of 65 years. The included fractures were retrospectively classified according to Neer, and Control Volume severity grade. The included patients were evaluated with Simple Shoulder Test (SST). A statistical analysis was performed to correlate the type of treatment and the clinical results to the Neer classification and the Control Volume severity grade. Results Sixty-four patients (80%), were available for the telephonically interview at a mean follow up of 4 years and were included. According to the Control Volume model, we identified fracture with a low, medium and high severity grade, in 23 (36%), 13 (20%), and, 28 (44%) cases, respectively. Fifteen patients (23,5%) were conservatively treated, whether fourty-nine patients (76,5%) were operated. We find a statistical correlation between control volume severity grade and type of treatment. No Therapeutic correlation was detected for the Neer classification. A statistical correlation between the severity grade and clinical outcome could be observed only for patients with the same type of treatment. Conclusions The use of Control Volume severity grade is associated with better therapeutic and prognostic informations in confront to the Neer classification.
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Affiliation(s)
| | | | | | | | | | | | | | - Luciano Mottola
- Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
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15
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The Evolution of Reverse Total Shoulder Arthroplasty and Its Current Use in the Treatment of Proximal Humerus Fractures in the Older Population. J Clin Med 2022; 11:jcm11195832. [PMID: 36233699 PMCID: PMC9570675 DOI: 10.3390/jcm11195832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022] Open
Abstract
Proximal humerus fracture (PHF) is a common injury in the older population. While the majority of these fractures are treated non-operatively, a small subset of patients may benefit from surgical treatment. However, there continues to be an ongoing debate regarding the indications and ideal surgical treatment strategy. The use of reverse total shoulder arthroplasty (RTSA) has resulted in a paradigm shift in the treatment of PHFs in the older population. Unique biomechanical principles and design features of RTSA make it a suitable treatment option for PHFs in the older population. RTSA has distinct advantages over hemiarthroplasty and internal fixation and provides good pain relief and a reliable and reproducible improvement in functional outcomes. As a result, there has been an exponential increase in the volume of RTSA in the older population in last decade. The aim of this paper is to review the current concepts, outcomes and controversies regarding the use of RTSA for the treatment of PHFs in the older population.
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Rudran B, Little C, Duff A, Poon H, Tang Q. Proximal humerus fractures: anatomy, diagnosis and management. Br J Hosp Med (Lond) 2022; 83:1-10. [DOI: 10.12968/hmed.2021.0554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Proximal humeral fractures are common with a bimodal distribution and sex discrepancy, affecting younger men and older women. The presentation of a proximal humeral fracture can vary greatly because of this bimodal distribution and the associated differences in mechanism of injury. Initial management should involve assessment of life- and limb-threatening injuries as outlined by the British Orthopaedic Association Standards for Trauma, with particular attention paid to axillary nerve function and vascular status. Initial imaging should involve orthogonal X-rays in three planes to determine fracture characteristics and exclude glenohumeral dislocation. Computed tomography imaging improves interobserver agreement and is the gold standard in determining fracture management. Management depends on fracture pattern, patient functionality and bone stock. Most patients with proximal humeral fractures achieve good functional outcomes via conservative methods (sling support and early, graded mobilisation), although there is a lack of evidence in certain populations, including younger patients. Surgery is required for open fractures and more complex fracture patterns where there is a risk of avascular necrosis of the humeral head, unacceptable impairment of functionality or neurovascular compromise. Surgical techniques can be head-sparing or involve replacement of the humeral head. There are several head-sparing techniques, each with different cost–benefit and complication profiles with no one technique superior to any other. However, improvements in plate technology may render open reduction internal fixation a more suitable technique, particularly in younger patients. Head replacement techniques (hemiarthroplasty and reverse shoulder arthroplasty) are indicated when the risk of avascular necrosis is too high or in older patients with osteoporotic bone. In these patients, reverse shoulder arthroplasty is preferred as it achieves better functional results than hemiarthroplasty. Complication rates vary depending on the fracture configuration and the course of management undertaken.
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Affiliation(s)
- Branavan Rudran
- Department of Specialist Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - Christopher Little
- Oxford University Clinical Academic Graduate School, John Radcliffe Hospital, Oxford, UK
| | - Alexander Duff
- Department of Specialist Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - Henry Poon
- Department of Trauma and Orthopaedics, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Quen Tang
- Department of Trauma and Orthopaedics, Chelsea and Westminster Hospital, London, UK
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Sharrock M, Hagan J, Lee J, Charalambous CP. Greater length of hospital stay for concurrent hip and upper limb fractures compared to isolated hip fractures: a systematic review of 13 studies including 210,289 patients and meta-analysis. Injury 2022; 53:2617-2624. [PMID: 35644643 DOI: 10.1016/j.injury.2022.05.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/22/2022] [Accepted: 05/22/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The impact of concurrent upper limb and fragility hip fractures has not been well defined. A greater understanding of this can guide decision making in the early peri-operative period and subsequent rehabilitation of such patients. AIMS To identify if patients with concurrent upper limb and fragility hip fractures have different outcomes and demographics than those with an isolated hip fracture. METHODS A search of MEDLINE and EMBASE was performed to identify cohort and case-control studies, comparing concurrent hip and upper limb fractures with isolated hip fractures. Meta-analysis was conducted using RevMan 5.4. Subgroup analyses were performed for concurrent distal radius and concurrent proximal humerus fractures. RESULTS 13 studies were included reporting on 196,916 patients with an isolated hip fracture and 13,373 with concurrent hip and upper limb fractures. Patients with concurrent upper limb fractures had a significantly longer length of hospital stay (mean difference: 3.97 days, 95% CI: 1.36, 6.57, P=0.003) as compared to those with isolated hip fractures. Patients with concurrent upper limb fractures were significantly more likely to be female (OR: 0.57, 95% CI: 0.46, 0.70, P<0.00001), reside at home pre-injury (OR: 0.6, 95% CI: 0.37, 0.96, P=0.03) and have no cognitive impairment (OR: 0.54, 95% CI: 0.35, 0.84, P=0.006). Patients with concurrent distal radius fractures had significantly lower 90-day mortality (OR: 0.70, 95% CI: 0.49, 0.99, P=0.04) and 1-year mortality (OR: 0.68, 95% CI: 0.51, 0.90, P=0.008). CONCLUSIONS Concurrent fragility hip and upper limb fractures are associated with increased length of hospital stay. We recommend early, aggressive, individualised rehabilitation to help improve outcomes and early hospital discharge in this highly vulnerable patient group.
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Affiliation(s)
- Martin Sharrock
- School of Surgery, North West Deanery, Manchester, UK; Queen Mary University of London, UK
| | - James Hagan
- The Mater Infirmorum Hospital, Belfast, Northern Ireland
| | - Joshua Lee
- Queen Mary University of London, UK; Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Charalambos P Charalambous
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK; School of Medicine, University of Central Lancashire, Preston, UK.
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Mischler D, Schader JF, Dauwe J, Tenisch L, Gueorguiev B, Windolf M, Varga P. Locking Plates With Computationally Enhanced Screw Trajectories Provide Superior Biomechanical Fixation Stability of Complex Proximal Humerus Fractures. Front Bioeng Biotechnol 2022; 10:919721. [PMID: 35814016 PMCID: PMC9260250 DOI: 10.3389/fbioe.2022.919721] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
Joint-preserving surgical treatment of complex unstable proximal humerus fractures remains challenging, with high failure rates even following state-of-the-art locked plating. Enhancement of implants could help improve outcomes. By overcoming limitations of conventional biomechanical testing, finite element (FE) analysis enables design optimization but requires stringent validation. This study aimed to computationally enhance the design of an existing locking plate to provide superior fixation stability and evaluate the benefit experimentally in a matched-pair fashion. Further aims were the evaluation of instrumentation accuracy and its potential influence on the specimen-specific predictive ability of FE. Screw trajectories of an existing commercial plate were adjusted to reduce the predicted cyclic cut-out failure risk and define the enhanced (EH) implant design based on results of a previous parametric FE study using 19 left proximal humerus models (Set A). Superiority of EH versus the original (OG) design was tested using nine pairs of human proximal humeri (N = 18, Set B). Specimen-specific CT-based virtual preoperative planning defined osteotomies replicating a complex 3-part fracture and fixation with a locking plate using six screws. Bone specimens were prepared, osteotomized and instrumented according to the preoperative plan via a standardized procedure utilizing 3D-printed guides. Cut-out failure of OG and EH implant designs was compared in paired groups with both FE analysis and cyclic biomechanical testing. The computationally enhanced implant configuration achieved significantly more cycles to cut-out failure compared to the standard OG design (p < 0.01), confirming the significantly lower peri-implant bone strain predicted by FE for the EH versus OG groups (p < 0.001). The magnitude of instrumentation inaccuracies was small but had a significant effect on the predicted failure risk (p < 0.01). The sample-specific FE predictions strongly correlated with the experimental results (R2 = 0.70) when incorporating instrumentation inaccuracies. These findings demonstrate the power and validity of FE simulations in improving implant designs towards superior fixation stability of proximal humerus fractures. Computational optimization could be performed involving further implant features and help decrease failure rates. The results underline the importance of accurate surgical execution of implant fixations and the need for high consistency in validation studies.
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Affiliation(s)
| | | | - Jan Dauwe
- AO Research Institute Davos, Davos, Switzerland
- Department of Trauma Surgery, UZ Leuven, Leuven, Belgium
| | | | | | | | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland
- *Correspondence: Peter Varga,
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Handoll HH, Elliott J, Thillemann TM, Aluko P, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2022; 6:CD000434. [PMID: 35727196 PMCID: PMC9211385 DOI: 10.1002/14651858.cd000434.pub5] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely, including in the use of surgery. This is an update of a Cochrane Review first published in 2001 and last updated in 2015. OBJECTIVES To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registries, and bibliographies of trial reports and systematic reviews to September 2020. We updated this search in November 2021, but have not yet incorporated these results. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults. DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. We prepared a brief economic commentary for one comparison. MAIN RESULTS We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. Six comparisons were tested by 2 to 10 trials, the others by small single-centre trials only. Twelve studies evaluated non-surgical treatments, 10 compared surgical with non-surgical treatments, 23 compared two methods of surgery, and two tested timing of mobilisation after surgery. Most trials were at high risk of bias, due mainly to lack of blinding. We summarise the findings for four key comparisons below. Early (usually one week post injury) versus delayed (after three or more weeks) mobilisation for non-surgically-treated fractures Five trials (350 participants) made this comparison; however, the available data are very limited. Due to very low-certainty evidence from single trials, we are uncertain of the findings of better shoulder function at one year in the early mobilisation group, or the findings of little or no between-group difference in function at 3 or 24 months. Likewise, there is very low-certainty evidence of no important between-group difference in quality of life at one year. There was one reported death and five serious shoulder complications (1.9% of 259 participants), spread between the two groups, that would have required substantive treatment. Surgical versus non-surgical treatment Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures). There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants). There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year (EQ-5D (0: dead to 1: best quality): mean difference (MD) 0.01, 95% CI -0.02 to 0.04; 6 studies, 502 participants). There is low-certainty evidence of little between-group difference in mortality: one of the 31 deaths was explicitly linked with surgery (risk ratio (RR) 1.35, 95% CI 0.70 to 2.62; 8 studies, 646 participants). There is low-certainty evidence of a higher risk of additional surgery in the surgery group (RR 2.06, 95% CI 1.21 to 3.51; 9 studies, 667 participants). Based on an illustrative risk of 35 subsequent operations per 1000 non-surgically-treated patients, this indicates an extra 38 subsequent operations per 1000 surgically-treated patients (95% CI 8 to 94 more). Although there was low-certainty evidence of a higher overall risk of adverse events after surgery, the 95% CI also includes a slightly increased risk of adverse events after non-surgical treatment (RR 1.46, 95% CI 0.92 to 2.31; 3 studies, 391 participants). Open reduction and internal fixation with a locking plate versus a locking intramedullary nail Four trials (270 participants) evaluated surgical intervention for displaced fractures (63% were two-part fractures). There is low-certainty evidence of no clinically important between-group difference in shoulder function at one year (SMD 0.15, 95% CI -0.12 to 0.41; 4 studies, 227 participants), six months (Disability of the Arm, Shoulder, and Hand questionnaire (0 to 100: worst disability): MD -0.39, 95% CI -4.14 to 3.36; 3 studies, 174 participants), or two years (American Shoulder and Elbow Surgeons score (ASES) (0 to 100: best outcome): MD 3.06, 95% CI -0.05 to 6.17; 2 studies, 101 participants). There is very low-certainty evidence of no between-group difference in quality of life (1 study), and of little difference in adverse events (4 studies, 250 participants) and additional surgery (3 studies, 193 participants). Reverse total shoulder arthroplasty (RTSA) versus hemiarthroplasty There is very low-certainty evidence from two trials (161 participants with either three- or four-part fractures) of no or minimal between-group differences in self-reported shoulder function at one year (1 study) or at two to three years' follow-up (2 studies); or in quality of life at one year or at two or more years' follow-up (1 study). Function at six months was not reported. Of 10 deaths reported by one trial (99 participants), one appeared to be surgery-related. There is very low-certainty evidence of a lower risk of complications after RTSA (2 studies). Ten people (6.2% of 161 participants) had a reoperation; all eight cases in the hemiarthroplasty group received a RTSA (very low-certainty evidence). AUTHORS' CONCLUSIONS There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery. The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures. There is insufficient evidence from randomised trials to inform the choices between different non-surgical, surgical or rehabilitation interventions for these fractures.
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Affiliation(s)
- Helen Hg Handoll
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, UK
- Department of Orthopaedics and Trauma, The University of Edinburgh, Edinburgh, UK
| | - Joanne Elliott
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, UK
| | - Theis M Thillemann
- Department of Orthopaedics, Shoulder and Elbow Unit, Aarhus University Hospital, Aarhus N, Denmark
| | - Patricia Aluko
- National Institute for Health Research (NIHR) Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Stig Brorson
- Centre for Evidence-Based Orthopaedics, Zealand University Hospital and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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May P, Yeowell G, Connell L, Littlewood C. An analysis of publicly available National Health Service information leaflets for patients following an upper arm break. Musculoskelet Sci Pract 2022; 59:102531. [PMID: 35228112 DOI: 10.1016/j.msksp.2022.102531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/27/2022] [Accepted: 02/16/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recovery following an upper arm break can be prolonged and cause loss of independence. Appropriate information provision to empower and enable active participation in rehabilitation is vital to achieve the best clinical outcomes. OBJECTIVES To identify and analyse, through the lens of health literacy, publicly available information leaflets produced for patients following upper arm breaks in the United Kingdom National Health Service (NHS) to understand their fitness for purpose. METHOD An electronic search of online search engines was undertaken using search terms to identify information leaflets for upper arm breaks. Relevant leaflets were retrieved and a thematic analysis was undertaken from a health literacy perspective. To complement this, each information leaflet was also formally assessed for readability. RESULTS Thirty-five information leaflets were analysed. Two main themes were generated: 'Empowerment' and 'Language Use', with subthemes of promoting recovery, readability and risk of misinterpretation. The information presented in these leaflets was often complicated and sometimes contradictory. Less than half (46%) of the information leaflets were presented at a level that would be understood by the general population. CONCLUSIONS Current information leaflets made available for patients following upper arm breaks are not fit for purpose and are written in a way that the general population would not readily understand. There is an urgent need to understand the information needs of patients and present such information in an accessible way to optimise clinical outcomes following upper arm breaks.
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Affiliation(s)
- Pauline May
- East Lancashire Hospitals NHS Trust, Burnley, UK.
| | - Gillian Yeowell
- Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, UK
| | - Louise Connell
- Allied Health Research Unit, University of Central Lancashire/Rakehead Rehabilitation Centre, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - Chris Littlewood
- Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, UK
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Brorson S. Locking plate osteosynthesis in geriatric shoulder fractures: why do we continue to perform a low-value procedure? Acta Orthop 2022; 93:355-357. [PMID: 35224647 PMCID: PMC8879137 DOI: 10.2340/17453674.2022.2208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Indexed: 01/31/2023] Open
Affiliation(s)
- Stig Brorson
- Centre for Evidence-Based Orthopaedics, Department of Orthopaedic Surgery, Zealand University Hospital, Denmark.
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22
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Schader JF, Mischler D, Dauwe J, Richards RG, Gueorguiev B, Varga P. One size may not fit all: patient-specific computational optimization of locking plates for improved proximal humerus fracture fixation. J Shoulder Elbow Surg 2022; 31:192-200. [PMID: 34298147 DOI: 10.1016/j.jse.2021.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 06/04/2021] [Accepted: 06/12/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Optimal treatment options for proximal humerus fractures (PHFs) are still debated because of persisting high fixation failure rates experienced with locking plates. Optimization of the implants and development of patient-specific designs may help improve the primary fixation stability of PHFs and reduce the rate of mechanical failures. Optimizing the screw orientations in locking plates has shown promising results; however, the potential benefit of subject-specific designs has not been explored yet. The purpose of this study was to evaluate by means of finite element (FE) analyses whether subject-specific optimization of the screw orientations in a fixed-angle locking plate can reduce the predicted cutout failure risk in unstable 3-part fractures. METHODS FE models of 19 low-density proximal humeri were generated from high-resolution computed tomographic images using a previously developed and validated computational osteosynthesis framework. The specimens were virtually osteotomized to simulate unstable malreduced 3-part fractures and fixed with the PHILOS plates using 6 proximal locking screws. The average principal compressive strain in cylindrical bone regions around the screw tips-a biomechanically validated surrogate for the risk of cyclic screw cutout failure-was defined as the main outcome measure. The angles of the 6 proximal locking screws were optimized via parametric analysis for each humerus individually, resulting in subject-specific screw orientations (SSO). The average peri-implant strains of the SSO were statistically compared with the previously reported cohort-specific (CSO) and original PHILOS screw orientations (PSO) for females vs. males. RESULTS The optimized SSO significantly reduced the peri-screw bone strain vs. CSO (6.8% ± 4.0%, P = .006) and PSO (25.24% ± 7.93%, P < .001), indicating lower cutout risk for subject-specific configurations. The benefits of SSO vs. PSO were significantly higher for women than men. CONCLUSION The findings of this study suggest that subject-specific optimization of the locking screw orientations could lead to lower cutout risk and improved PHF fixation. These computer simulation results require biomechanical and clinical corroboration. Further studies are needed to evaluate whether the potential benefit in stability could justify the increased efforts related to implementation of individualized implants. Nevertheless, computational exploration of the biomechanical factors influencing the outcome of fracture fixations could help better understand the fixation failures and reduce their incidence.
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Affiliation(s)
| | | | - Jan Dauwe
- AO Research Institute Davos, Davos, Switzerland; Department of Trauma Surgery, UZ Leuven, Leuven, Belgium
| | | | | | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland.
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23
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Falsafi M, Altini S, Baghianimoghadam B, Bahrami-Freiduni M, Esmaeilnejad-Ganji SMR, Hajiahmadi M, Fallah Y. The outcome measure of proximal humerus fracture treated by open reduction and internal fixation with proximal humerus internal locking system based on oxford shoulder score. Int J Health Sci (Qassim) 2022; 16:49-57. [PMID: 36101849 PMCID: PMC9441643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Objective Proximal humerus fractures became one of the most prevalent upper extremity fractures during recent decades. The use of scoring systems has been taken under consideration to estimate the surveillance, prognosis, and post-operative outcomes. During this study, we investigated the outcome measure of proximal humerus fracture treated by open reduction and internal fixation (ORIF) with plate based on oxford shoulder score (OSS). Furthermore, we tried to propose a new classification system for OSS that could be of prognostic value. Methods Patients with proximal humerus fracture treated by open reduction enrolled in the study. Persian version of the OSS was completed by the patients. Data were analyzed using SPSS-22. Results Forty-four patients including 24 women and 20 men were assessed. The mean age was 54.61 (SD ± 19.371) years. The use of a spoon and fork at the same time had the best score and hanging the clothes up in a wardrobe with the operated hand had the worst score in the questionnaire. Comparison of OSS and number of physiotherapy session showed that patients with best outcome had least number of physiotherapy's session, but it was not statistically significant. Conclusion OSS is useful to evaluate the function of the traumatized shoulder. We suggest classifying the OSS score into three range groups, good (total score 12-28), moderate (total score 29-44), and bad (total scores 45-60).
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Affiliation(s)
- Mani Falsafi
- Department of Orthopedic Surgery, Babol University of Medical Sciences, Babol, Iran
| | - Sara Altini
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
| | - Behnam Baghianimoghadam
- Department of Orthopedic Surgery, Tehran University of Medical Sciences, Tehran, Iran,Address for correspondence: Behnam Baghianimoghadam, Department of Orthopedic Surgery, Sina Hospital, Imam Khomeini Street, Tehran University of Medical Sciences, Tehran, Iran. Phone: +98-2166348500. E-mail:
| | | | | | - Mahmood Hajiahmadi
- Department of Epidemiology, Babol University of Medical Sciences, Babol, Iran
| | - Yousef Fallah
- Department of Orthopedic Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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24
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Leino OK, Lehtimäki KK, Mäkelä K, Äärimaa V, Ekman E. Proximal humeral fractures in Finland : trends in the incidence and methods of treatment between 1997 and 2019. Bone Joint J 2022; 104-B:150-156. [PMID: 34969281 DOI: 10.1302/0301-620x.104b1.bjj-2021-0987.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Oskari K Leino
- Department of Orthopaedics and Traumatology, Turku University Hospital TYKS, Turku, Finland.,Faculty of Medicine, University of Turku, Turku, Finland
| | - Kaisa K Lehtimäki
- Department of Orthopaedics and Traumatology, Turku University Hospital TYKS, Turku, Finland.,Faculty of Medicine, University of Turku, Turku, Finland
| | - Keijo Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital TYKS, Turku, Finland.,Faculty of Medicine, University of Turku, Turku, Finland
| | - Ville Äärimaa
- Department of Orthopaedics and Traumatology, Turku University Hospital TYKS, Turku, Finland.,Faculty of Medicine, University of Turku, Turku, Finland
| | - Elina Ekman
- Department of Orthopaedics and Traumatology, Turku University Hospital TYKS, Turku, Finland.,Faculty of Medicine, University of Turku, Turku, Finland
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25
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Pavone V, Vescio A, Denaro R, Costa D, Condorelli G, Caruso VF, Sessa G, Testa G. Use of different devices for surgical treatment of proximal humerus fractures in adults: a systematic review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021198. [PMID: 34487079 PMCID: PMC8477127 DOI: 10.23750/abm.v92i4.11394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 03/23/2021] [Indexed: 11/23/2022]
Abstract
Background and aim: Proximal humeral fracture is one of the most common osteoporotic fractures in elderly people. The proper treatment choice is controversial. Open reduction and internal fixation (ORIF) with plate and screws is currently the most common treatment for the majority of displaced proximal humeral fractures. The aim of this systematic review is to investigate the surgical treatment outcomes of PHFs, focusing on main used devices and surgical approaches. Methods: From the earliest record up to 21 July 2020, two independent authors conducted a systematic review of two medical electronic database (PubMed and Science Direct). To achieve the maximum sensitivity of the search strategy, the following terms were combined: “(proximal NOT shaft NOT distal) AND humeral AND fracture AND (plate OR locking plate OR osteosynthesis NOT nail NOT arthroplasty)” as either key words or MeSH terms. The risk of bias of the included studies was assessed, agreeing to the Cochrane Handbook guidelines. Results: Thirty-four articles were initially noticed after the term string research in the two electronic databases. Finally, after full-text reading and analyzing the reference list, 8 studies were selected. The mean age recorded was 69.5 years (Range 67-72). All the studies included two-, three-, four-fragments fracture. Seven studies investigated PHILOS (Synthes, Bettlach, Switzerland) implants results, while one investigated CFR-PEEK plate (PEEK Power Humeral Fracture Plate; Arthrex, Naples, Florida, USA) outcomes or other plates. Deltopectoral and Transdeltoid approaches were the more common used. Conclusions: Both deltopectoral and transdeltoid approaches are valid approach in plating after proximal humerus fractures, for these reasons, the surgeon experience is crucial in the choice. The more valid implant is still unclear. The develop of prospective randomized comparative studies is strongly encourages. (www.actabiomedica.it)
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Affiliation(s)
- Vito Pavone
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-San Marco, University of Catania, Catania, Italy.
| | - Andrea Vescio
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-San Marco, University of Catania, Catania, Italy.
| | - Regina Denaro
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-San Marco, University of Catania, Catania, Italy.
| | - Danilo Costa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-San Marco, University of Catania, Catania, Italy.
| | - Giuseppe Condorelli
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-San Marco, University of Catania, Catania, Italy.
| | - Vincenzo Fabrizio Caruso
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-San Marco, University of Catania, Catania, Italy.
| | - Giuseppe Sessa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-San Marco, University of Catania, Catania, Italy.
| | - Gianluca Testa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-San Marco, University of Catania, Catania, Italy.
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26
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Forster M, Brealey S, Chick S, Keding A, Corbacho B, Alban A, Pertile P, Rangan A. Cost-effective clinical trial design: Application of a Bayesian sequential model to the ProFHER pragmatic trial. Clin Trials 2021; 18:647-656. [PMID: 34407641 PMCID: PMC8592107 DOI: 10.1177/17407745211032909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background/Aims: There is growing interest in the use of adaptive designs to improve the efficiency of clinical trials. We apply a Bayesian decision-theoretic model of a sequential experiment using cost and outcome data from the ProFHER pragmatic trial. We assess the model’s potential for delivering value-based research. Methods: Using parameter values estimated from the ProFHER pragmatic trial, including the costs of carrying out the trial, we establish when the trial could have stopped, had the model’s value-based stopping rule been used. We use a bootstrap analysis and simulation study to assess a range of operating characteristics, which we compare with a fixed sample size design which does not allow for early stopping. Results: We estimate that application of the model could have stopped the ProFHER trial early, reducing the sample size by about 14%, saving about 5% of the research budget and resulting in a technology recommendation which was the same as that of the trial. The bootstrap analysis suggests that the expected sample size would have been 38% lower, saving around 13% of the research budget, with a probability of 0.92 of making the same technology recommendation decision. It also shows a large degree of variability in the trial’s sample size. Conclusions: Benefits to trial cost stewardship may be achieved by monitoring trial data as they accumulate and using a stopping rule which balances the benefit of obtaining more information through continued recruitment with the cost of obtaining that information. We present recommendations for further research investigating the application of value-based sequential designs.
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Affiliation(s)
- Martin Forster
- Department of Statistical Sciences 'Paolo Fortunati', University of Bologna, Bologna, Italy.,Department of Economics and Related Studies, University of York, York, UK
| | - Stephen Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Stephen Chick
- Technology & Operations Management Area, INSEAD, Fontainebleau, France
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Belen Corbacho
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Andres Alban
- Technology & Operations Management Area, INSEAD, Fontainebleau, France
| | - Paolo Pertile
- Department of Economics, University of Verona, Verona, Italy
| | - Amar Rangan
- Department of Health Sciences, University of York, York, UK.,Faculty of Medical Sciences & NDORMS, University of Oxford, Oxford, UK.,James Cook University Hospital, Middlesbrough, UK
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27
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Martínez R, Santana F, Pardo A, Torrens C. One Versus 3-Week Immobilization Period for Nonoperatively Treated Proximal Humeral Fractures: A Prospective Randomized Trial. J Bone Joint Surg Am 2021; 103:1491-1498. [PMID: 34101691 DOI: 10.2106/jbjs.20.02137] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is no consensus on the duration of immobilization for nonoperatively treated proximal humeral fractures (PHFs). The main objective of the study was to determine the differences in pain between PHFs that were treated nonoperatively with 3-week immobilization and those treated with 1-week immobilization. METHODS A prospective randomized trial was designed to evaluate whether the immobilization time frame (1-week immobilization [group I] versus 3-week immobilization [group II]) for nonoperatively treated PHFs had any influence on pain and functional outcomes. Pain was assessed using a 10-cm visual analog scale (VAS) that was administrated 1 week after the fracture, at 3 weeks, and then at the 3, 6, 12, and 24-month follow-up. The functional outcome was evaluated using the Constant score. To assess the functional disability of the shoulder, a self-reported shoulder-specific questionnaire, the Simple Shoulder Test (SST), was used. The Constant score and the SST were recorded at the 3, 6, 12, and 24-month follow-up. Complications and secondary displacement were also recorded. RESULTS One hundred and forty-three patients were randomized, and 111 (88 females and 23 males) who had been allocated to group I (55 patients) or group II (56 patients) were included in the final analysis. The mean age of the patients was 70.4 years (range, 42 to 94 years). No significant differences were found between the 2 groups in terms of pain as measured with the VAS at any time point (1 week [5.9 versus 5.6; p = 0.648], 3 weeks [4.8 versus 4.1; p = 0.059], 3 months [1.9 versus 2.4; p = 0.372], 6 months [1.0 versus 1.2; p = 0.605], 1 year [0.65 versus 0.66; p = 0.718], and 2 years [0.63 versus 0.31; p = 0.381]). No significant differences were found in the Constant score or SST score at any time point. No significant differences were noted in the complication rate. CONCLUSIONS Short and long periods of immobilization yield similar results for nonoperatively treated PHFs, independent of the fracture pattern. These fractures can be successfully managed with a short immobilization period of 1 week in order to not compromise patients' independence for an overly extended period. LEVEL OF EVIDENCE Randomized controlled trial Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Raquel Martínez
- Department of Orthopedics, Hospital d'Igualada, Consorci Sanitari de L'Anoia, Barcelona, Spain
| | - Fernando Santana
- Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Albert Pardo
- Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Carlos Torrens
- Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
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28
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Acute versus delayed reverse total shoulder Arthroplasty for the management of Proximal Humerus Fractures. Injury 2021; 52:2272-2278. [PMID: 34140139 DOI: 10.1016/j.injury.2021.05.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 05/10/2021] [Accepted: 05/23/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Proximal humerus fractures (PHF) are common, yet their optimal management remains debated. Reverse total shoulder arthroplasty (rTSA) is an increasingly popular option, particularly for non-reconstructible or osteoporotic fractures. Despite this trend, current literature provides limited guidance with regards to surgical timing and patient selection for rTSA. A trial of non-operative management might be beneficial for many patients who are not clearly indicated for surgery, provided this does not have a major negative impact on results for those who ultimately require rTSA. The purpose of this study was to investigate whether delayed reverse shoulder arthroplasty for fracture (>28 days from injury) is associated with any difference in complication rates or functional outcomes relative to acute surgery. DESIGN Retrospective cohort study PATIENTS/PARTICIPANTS: 114 consecutive patients who underwent rTSA as the primary management of a PHF at two Level 1 trauma centers and one academic community hospital between 2004 and 2016. INTERVENTION rTSA as primary management of proximal humerus fracture MAIN OUTCOME MEASUREMENTS: Complications, range of motion, and patient-reported functional outcomes scores (DASH, PROMIS physical function, and EQ-5D) RESULTS: Eighty-two of 114 patients (72%) underwent early surgery. Complex (4-part, head-split, dislocated) fractures were significantly more common in the acutely treated group. There was no significant difference in complications. Overall complication rate was 11.4%. There was a significant difference in DASH score favoring early surgery, with an average score of 22.4 in acutely treated patients versus 35.1 in delayed patients (p = 0.034). There was a non-statistically significant trend towards better PROMIS physical function scores and ROM in the acutely treated group. CONCLUSION Delay in performing primary rTSA for management of PHF does not lead to an increase in complication rates but it may come at the cost of worse functional outcomes in patients who ultimately require rTSA.
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29
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Abstract
PURPOSE OF REVIEW Fracture fixation aims to provide stability and promote healing, but remains challenging in unstable and osteoporotic fractures with increased risk of construct failure and nonunion. The first part of this article reviews the clinical motivation behind finite element analysis of fracture fixation, its strengths and weaknesses, how models are developed and validated, and how outputs are typically interpreted. The second part reviews recent modeling studies of the femur and proximal humerus, areas with particular relevance to fragility fractures. RECENT FINDINGS There is some consensus in the literature around how certain modeling aspects are pragmatically formulated, including bone and implant geometries, meshing, material properties, interactions, and loads and boundary conditions. Studies most often focus on predicted implant stress, bone strain surrounding screws, or interfragmentary displacements. However, most models are not rigorously validated. With refined modeling methods, improved validation efforts, and large-scale systematic analyses, finite element analysis is poised to advance the understanding of fracture fixation failure, enable optimization of implant designs, and improve surgical guidance.
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Affiliation(s)
- Gregory S Lewis
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, Hershey, PA, USA.
| | | | - Hwabok Wee
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, Hershey, PA, USA
| | - J Spence Reid
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University, Hershey, PA, USA
| | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland
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30
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Management of proximal humeral fractures: a review. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Keskin A, Karslioglu B. Did Covid-19 pandemic narrow the spectrum of surgical indications? JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2021. [DOI: 10.25083/2559.5555/6.1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction. The Covid-19 outbreak has changed orthopedic practices more than expected. We are going through a period in which conservative treatment will become prominent when deciding on fractures with indistinct surgical margins in guidelines. Considering global tendency for surgical interventions in the pre-pandemic period, we tried to find out the answer to the following question: will conservative treatment be the shining star in the post pandemic period? Materials and Methods. 262 patients who were with “gray zone fractures-injuries” like extraarticular distal radius fracture, proximal humerus fracture and Weber type B ankle fracture was treated conservatively during March and August, 2020. Open or pathological fracture, fractures with vascular or neurological injury and fractures involving the articular joint were excluded. Results. 59 patients with proximal humerus fracture followed with arm-sling. Mean ASES scores at 6th was 48.3 and 69.9 12th week. 91 patients with Weber B-type ankle fracture were followed up with below-knee plaster for 6 weeks. American Orthopedic Foot & Ankle Score was 48 in the 6th week and 75 in the 12th week. 90 patients with distal radius fracture were followed up with plaster. Malunion was detected at 5 patients. Mean Quick Dash score at 6th weeks was 52.3 and 29.5 at 12th weeks. Mean wrist flexion was 450, wrist extension was 350, forearm supination 600 and forearm pronation was 700 at final control. Conclusions. The conservative treatment experiences we have gained from pandemic periods probably will change our treatment algorithm.
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32
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Mease SJ, Kraeutler MJ, Gonzales-Luna DC, Gregory JM, Gardner MJ, Choo AM. Current Controversies in the Treatment of Geriatric Proximal Humeral Fractures. J Bone Joint Surg Am 2021; 103:829-836. [PMID: 33617160 DOI: 10.2106/jbjs.20.00665] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes. Factors such as surgeon experience as well as the quality and maintenance of the reduction may influence operative outcomes, and their impact on these findings merits further investigation. ➤ In the treatment of 2 and 3-part fractures involving the surgical neck, intramedullary nailing has demonstrated functional outcomes that are comparable with those of open reduction and internal fixation (ORIF). ➤ In the geriatric population, reverse total shoulder arthroplasty has demonstrated improved functional outcomes, with a decreased rate of reoperation, compared with hemiarthroplasty. Tuberosity repair has been shown to improve functional outcomes and range of motion after both procedures and should be performed at the time of arthroplasty. ➤ Several authors have demonstrated the negative effect of osteopenia on outcomes after ORIF of proximal humeral fractures. Augmentative procedures, including cortical strut augmentation, are being investigated to address this issue; their role in the treatment of these fractures is unclear at this time.
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Affiliation(s)
- Samuel J Mease
- Department of Orthopaedic Surgery, University of Texas Southwestern, Dallas, Texas
| | - Matthew J Kraeutler
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Daniel C Gonzales-Luna
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - James M Gregory
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, California
| | - Andrew M Choo
- Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
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33
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Proximal humerus exposure with the inverted-L anterolateral deltoid flip approach, anterolateral deltoid splitting approach, and deltopectoral approach: A comparative cadaveric study. Injury 2021; 52:738-746. [PMID: 33208271 DOI: 10.1016/j.injury.2020.11.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/05/2020] [Accepted: 11/08/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Reduction of the posterior aspect of proximal humerus fracture, such as far-retracted greater tuberosity or posterior articular head split fracture via a deltopectoral or deltoid splitting approach, is difficult and usually needs extensive dissection. The inverted-L anterolateral deltoid flip approach, which is developed from the deltoid splitting approach, accesses the proximal humerus via lateral deltoid flap lifting. This study compared the area and arc of surgical exposure to the proximal humerus of this proposed approach to existing approaches. METHODS Eleven cadaveric specimens were used. Deltopectoral and deltoid splitting approaches were carried out on the right and left shoulder, respectively. Soft tissue was retracted after completion of a surgical approach to expose the proximal humerus, and dot-to-dot marking pins were placed along the border of exposed area. An additional area with a full shoulder rotation was also marked on the deltopectoral side. An inverted-L deltoid flip approach was further carried out on a deltoid splitting side with a posterior extending incision along the acromion process and the deltoid detachment from the acromion process. The additional area of exposure was subsequently marked. All soft tissue around the proximal humerus was taken down, and the glenohumeral joint was disarticulated. Area of exposure and axial images were taken for further processing and measurement. RESULT An average distance of the axillary nerve from the acromion process of the deltoid splitting and the deltopectoral approaches were 49.15 mm and 57.35 mm, respectively (P < 0.05). The average area of exposure of the inverted-L deltoid flip, deltoid-splitting, deltopectoral, and deltopectoral with full rotation approaches were 2729.81mm2, 1404.39mm2, 1325.41mm2, and 2354.78mm2, respectively (P < 0.05). Mean arc of exposure lateral to bicipital groove of the inverted-L deltoid flip, deltoid splitting, deltopectoral, and deltopectoral with full rotation approaches were 151.75degrees, 105.02degrees, 61.68°, and 110.64°, respectively (P < 0.05). CONCLUSION The inverted-L anterolateral deltoid flip approach provides the most posterior access to the proximal humerus. However, it requires more soft tissue dissection and awareness of tension on the axillary nerve. This approach could be an alternative for displaced posterior head splits or far-retracted greater tuberosity proximal humerus fractures.
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34
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Fleischhacker E, Siebenbürger G, Helfen T, Gleich J, Böcker W, Ockert B. Varus malposition relates to functional outcomes following open reduction and internal fixation for proximal humeral fractures: A retrospective comparative cohort study with minimum 2 years follow-up. Injury 2021; 52:506-510. [PMID: 32917384 DOI: 10.1016/j.injury.2020.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/29/2020] [Accepted: 09/04/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this study was to evaluate functional outcomes in patients with varus malposition following open reduction and internal fixation of displaced proximal humeral fractures. METHODS Data of 685 patients with a mean age of 67±15.8 years (67% female), that were treated by open reduction and internal fixation for a displaced proximal humeral fracture at a level 1 trauma center, were analyzed. On standardized x-ray imaging, the degree of varus displacement was measured over a minimum of two years follow-up and patients were divided into three groups. Group A: anatomic or <10° of varus or valgus malposition, group B: 10-20° of varus malposition and group C: >20° varus malposition, while anatomic head-shaft-angle was defined 135° The groups were compared with regards to functional outcomes by means of the Constant Score (CS). RESULTS In 565 patients with anatomic to minor <10° varus or valgus malposition (Group A), the mean CS was 72.5 ± 18.8 points. The %CS to the uninjured side was 87.2 ± 24.1 and the age and gender normalized nCS was 84.7 ± 21.7. In comparison, in group B (10-20° varus) the mean CS was 64.7 ± 16.9, the mean %CS was 84.5 ± 18.3 and the mean nCS was 76.2 ± 20.6. In group C (>20° varus) the mean CS was 54.1 ± 19.5, the mean was %CS: 72.3 ± 26.4 and the mean nCS was 64.8 ± 23.8 (p = 0.02, p = 0.03, p = 0.01). Overall, the CS, %CS and nCS correlated significantly with the degree of varus position (Pearson correlation, r = 0.23, r = 0.21, r = 0.25). CONCLUSION Varus malposition is related to inferior functional outcomes compared to anatomic healing in patients treated by open reduction and internal fixation for proximal humeral fractures. The data supports suggestions to prevent varus malposition in open reduction and internal fixation. In severe >20° of varus malposition, revision surgery should be considered.
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Affiliation(s)
- E Fleischhacker
- Department of General, Trauma and Reconstructive Surgery, Munich University Hospitals (LMU), Germany.
| | - G Siebenbürger
- Department of General, Trauma and Reconstructive Surgery, Munich University Hospitals (LMU), Germany
| | - T Helfen
- Department of General, Trauma and Reconstructive Surgery, Munich University Hospitals (LMU), Germany
| | - J Gleich
- Department of General, Trauma and Reconstructive Surgery, Munich University Hospitals (LMU), Germany
| | - W Böcker
- Department of General, Trauma and Reconstructive Surgery, Munich University Hospitals (LMU), Germany
| | - B Ockert
- Department of General, Trauma and Reconstructive Surgery, Munich University Hospitals (LMU), Germany
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Quattrini F, Ciatti C, Gattoni S, Burgio V, Puma Pagliarello C, Rivera F, Maniscalco P. DIPHOS® nail for proximal humeral fractures: our experience with more than 190 procedures and surgical tips. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021566. [PMID: 35604258 PMCID: PMC9437691 DOI: 10.23750/abm.v92is3.12565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/03/2022] [Indexed: 11/16/2022]
Abstract
AIM evaluate the outcome of proximal humeral nailing over 5 years follow-up, focusing on possible complications. Secondary endpoint is the description and analysis of some technical notes to simplify surgical procedure. MATERIALS AND METHODS the cohort is composed by 194 fractures fixed with short nail. Neer Classification was used to assess the type of fracture; Deltoid Tuberosity Index (DTI) was applied to verify local bone quality. Follow-up with X-rays and orthopaedic evaluation was conducted on every operated subject. RESULTS mean follow up of the study was 25.4 months. We registered an average CMS score of 84.66 points for 2-parts fractures, 79.05 points for 3-part fractures and 68.62 points for 4-parts fractures. We obtained radiographical healing in 95.9% of patients (186/194) after 2.7 months on average. We recorded "very good" / "good" results in 90.3% of 2-parts fractures, 88.5% of 3-parts fractures and 46.2% of 4-part fractures. Overall complication rate was 10.3% (20/194 nails). Second surgery was performed in 8.2% (16/194) of cases. CONCLUSION intramedullary nailing is an effective treatment for 2 and 3-part fractures with relatively low incidence of complications, small surgical accesses and short surgical time. Future researches are necessary to analyze the results related to nailing in 4-fragment fractures, still uncertain and influenced by multiple factors. The presence of the intramedullary nail reduces the lever arm of the screws making the osteosynthesis more reliable. Modern nails guarantee angular stability for proximal cancellous screws and allows 1 or 2 screws at calcar level to get a valid medial support.
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Affiliation(s)
- Fabrizio Quattrini
- Orthopedics and Traumatology Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Corrado Ciatti
- Orthopedics and Traumatology Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Serena Gattoni
- Orthopedics and Traumatology Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Valeria Burgio
- Orthopedics and Traumatology Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | | | - Fabrizio Rivera
- Orthopedic Surgery Department, SS Annunziata Savigliano Hospital, Azienda Sanitaria Locale CN1, Savigliano, Cuneo, Italy
| | - Pietro Maniscalco
- Orthopedics and Traumatology Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
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Packer T, McMenemy L, Kendrew J, Stapley SA. Military trauma and orthopaedics experience of the UK COVID-19 pandemic: a lesson in versatility and how it can influence our deployed role. BMJ Mil Health 2020; 169:e71-e73. [PMID: 33361437 DOI: 10.1136/bmjmilitary-2020-001663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/17/2020] [Accepted: 11/21/2020] [Indexed: 11/04/2022]
Abstract
The COVID-19 pandemic necessitated unprecedented change within the NHS. Some medical staff have been deployed into unfamiliar roles, while others have been exposed to innovative ways of working. The embedded military Trauma and Orthopaedic (T&O) cadre have been integral to this change. Many of these new skills and ways of working learnt will be transferable to deployed environments. Feedback from the T&O military cadre highlighted key areas of learning as changes in T&O services, use of technology, personal protective equipment, redeployment and training. This paper aims to discuss how these changes were implement and how they could be used within future military roles. The T&O cadre played important roles within their NHS trusts and the skills they learnt will broaden their skills and knowledge for future deployments.
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Affiliation(s)
- Tim Packer
- Academic Deptatment for Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK .,Trauma and Orthopaedics, St Mary's Hospital, London, UK
| | - L McMenemy
- Institute of Naval Medicine, Gosport, UK.,Centre for Blast Injury Studies, Imperial College London, London, UK
| | - J Kendrew
- Trauma and Orthopaedics, Queen Elizabeth Hospital, Birmingham, UK
| | - S A Stapley
- Medical Directorate, RCDM, Birmingham, UK.,Trauma and Orthopaedics, Portsmouth NHS Trust, Portsmouth, Hants, UK
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Rohun J, May P, Littlewood C. Rehabilitation following proximal humeral fracture in the UK National Health Service: A survey of publicly facing information. Musculoskeletal Care 2020; 19:193-198. [PMID: 33085172 DOI: 10.1002/msc.1523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Proximal humeral fractures (PHF) are a common injury in the older population but there is limited research evaluating rehabilitation following PHF. The aim of this study was to understand current National Health Service (NHS) practice for rehabilitation following PHF as a platform for conducting future research. METHODS Two reviewers independently undertook electronic searches for publicly available information sheets (PIS) from websites of NHS Trusts that included detail about rehabilitation following PHF, for example, duration of immobilisation. One reviewer extracted data and a second reviewer verified this. RESULTS Seventeen PIS from 17 different NHS trusts were identified. All provided some information on the method of immobilisation but only six provided guidance on duration of immobilisation with the median time being 2 weeks (range 0-6). The median time to commencement of passive exercise was 2 weeks (range 0-4) and 9 weeks (range 6-12) for active exercise. Only one PIS reported on the time for commencement of resisted exercises and this was reported as 6 weeks. The median time recommended return to work was 7.5 weeks (range 6-12). CONCLUSION This study found limited publicly available information for rehabilitation following PHF in the NHS but offers some insight into current approaches. Our results will facilitate development of relevant information for patients and evaluation of rehabilitation strategies in future research.
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Affiliation(s)
- Jason Rohun
- Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| | - Pauline May
- East Lancashire Hospitals NHS Trust, Lancashire, UK
| | - Chris Littlewood
- Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, UK
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Maurer E, Bahrs C, Kühle L, Ziegler P, Gonser C, Stollhof LE. Comparability of Patient-reported Outcome Measures and Clinical Assessment Tools for Shoulder Function in Patients with Proximal Humeral Fracture. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2020; 159:638-648. [PMID: 32957148 DOI: 10.1055/a-1200-2797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patient-reported outcome measures (PROMs) are gaining increasing importance in the context of quality management. Different PROMs and scoring tools are available to assess shoulder function after proximal humeral fracture (PHFx). In Europe, these include the Constant-Murley Score (CS), Neer Score (NS), Oxford Shoulder Score (OSS), University of California at Los Angeles Score (UCLA) and Disabilities of the Arm, Shoulder and Hands Score (DASH). In addition, the health-related quality of life can be assessed by the PROMs Short Form 36 (SF-36) and EuroQol (EQ-5D). Although all these test instruments assess shoulder function, the components to be answered objectively and subjectively vary and thus the possibility of independent assessment. The aim of the present study is to compare the correlation between the results of the different PROMs and the clinical screening tools in patients with PHFx. METHODS 76 patients who were treated with angular stable plate osteosynthesis for a proximal humeral fracture between 01/2001 and 12/2005 were included in this trial. The outcome was measured with PROMs or clinical scoring tools such as CS, NS, OSS, UCLA, DASH, SF-36 and EQ-5D and a correlation coefficient between those evaluation tools was calculated. In addition, a distinction was made between the two force measurement methods (wrist [HG] vs. deltoid muscle [DM]) for CS. RESULTS The correlation of the results of CS and NS (HG: r = 0.85; p < 0.001/DM: r = 0.93; p < 0.001), CS and UCLA (HG: r = 0.83; p < 0.001/DM: r = 0.86; p < 0.001), NS and UCLA (r = 0.91; p < 0.001) as well as DASH and OSS (r = 0.88; p < 0.001) was strongly expressed. A good comparability of the results was demonstrated between CS and OSS (HG: r = 0.63; p < 0.001/DM: r = 0.66; p < 0.001) and between CS and DASH (HG: r = 0.62; p < 0.001/DM: r = 0.61; p < 0.001). The correlation of CS (HG/DM) and UCLA with the EQ-5D index was also good. Assessment of the physical components of SF-36 with CS, NS, OSS, UCLA and DASH showed a moderate to good association, while the mental components of SF-36 showed a low correlation (p > 0.05). CONCLUSION The assessment of shoulder function after proximal humerus fracture showed a very strong correlation within the clinical questionnaires (CS/NS/UCLA) and the PROMs (OSS/DASH). A strong correlation also exists between the clinical questionnaires and the PROMs. There was only a moderate correlation with the EQ-5D. The moderate to strong correlation between the physical components of SF-36, with almost no correlation between the mental components of SF-36, indicates that the quality of life restriction is based on a physical, but not on a mental impairment.
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Affiliation(s)
- Elke Maurer
- Department for Trauma and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen
| | - Christian Bahrs
- Department for Trauma and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen
| | - Luise Kühle
- Department of Orthopedics and Trauma Surgery, St Josefs Hospital, Wiesbaden
| | - Patrick Ziegler
- Department for Trauma and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen
| | - Christoph Gonser
- Department for Trauma and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen
| | - Laura Emine Stollhof
- Department for Trauma and Reconstructive Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen
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Trends in the Characterization of the Proximal Humerus in Biomechanical Studies: A Review. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10186514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Proximal humerus fractures are becoming more common due to the aging of the population, and more related scientific research is also emerging. Biomechanical studies attempt to optimize treatments, taking into consideration the factors involved, to obtain the best possible treatment scenario. To achieve this, the use of finite element analysis (FEA) is necessary, to experiment with situations that are difficult to replicate, and which are sometimes unethical. Furthermore, low costs and time requirements make FEA the perfect choice for biomechanical studies. Part of the complete process of an FEA involves three-dimensional (3D) bone modeling, mechanical properties assignment, and meshing the bone model to be analyzed. Due to the lack of standardization for bone modeling, properties assignment, and the meshing processes, this article aims to review the most widely used techniques to model the proximal humerus bone, according to its anatomy, for FEA. This study also seeks to understand the knowledge and bias behind mechanical properties assignment for bone, and the similarities/differences in mesh properties used in previous FEA studies of the proximal humerus. The best ways to achieve these processes, according to the evidence, will be analyzed and discussed, seeking to obtain the most accurate results for FEA simulations.
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Wu EJ, Zhang SE, Truntzer JN, Gardner MJ, Kamal RN. Cost-Minimization Analysis and Treatment Trends of Surgical and Nonsurgical Treatment of Proximal Humerus Fractures. J Hand Surg Am 2020; 45:698-706. [PMID: 32482497 DOI: 10.1016/j.jhsa.2020.03.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/20/2019] [Accepted: 03/31/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Recent evidence demonstrated similar outcomes between nonsurgical and surgical management of displaced proximal humerus fractures. We analyzed treatment trends and performed a cost-minimization analysis comparing nonsurgical treatment, open reduction and internal fixation, reverse total shoulder arthroplasty, and hemiarthroplasty. We hypothesized that rates of surgical treatment have increased and that the costs associated with surgery are greater compared with nonsurgical management of proximal humerus fractures. METHODS We used a US private-payer claims database of 22 million patient records from 2007 to 2016 to compare (1) cost for the episode of care from the payer perspective between each surgical group and nonsurgical treatment of proximal humerus fractures, and (2) annual trends and complication rates of each group. Cost data, including facility fees, physician fees, physical therapy, and clinic visits, were used to complete a cost-minimization analysis. RESULTS Nonsurgical treatment was associated with lower average total costs compared with surgical intervention. Facility and physician fees accounted for most of this difference. Physical therapy costs and number of physical therapy visits were higher in each surgical group compared with nonsurgical treatment. Surgical treatment was associated with higher complications, revision rates, and length of stay. There was a small but statistically significant decrease in nonsurgical management of proximal humerus fractures between 2007 and 2016. No change was observed in rates of open reduction and internal fixation, whereas rates of reverse total shoulder arthroplasty increased and rates of hemiarthroplasty decreased. CONCLUSIONS Nonsurgical management of proximal humerus fractures decreased during the study period. In the setting of treatment equipoise, cost-minimization analysis favors nonsurgical management of proximal humerus fractures. Surgical management is associated with higher complication rates, revision rates, and length of stay. TYPE OF STUDY/LEVEL OF EVIDENCE Economic Decision Analysis IV.
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Affiliation(s)
- Edward J Wu
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Steven E Zhang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Jeremy N Truntzer
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Michael J Gardner
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.
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Open reduction and internal fixation of three- and four-part proximal humeral fractures by intrafocal distraction: a clinical and radiographic study of thirty-two cases with five to ten years of follow-up. INTERNATIONAL ORTHOPAEDICS 2020; 44:2101-2112. [PMID: 32564175 DOI: 10.1007/s00264-020-04657-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The disadvantage of ORIF of proximal humerus fracture (PHF) by intrafocal distraction is that once the device is inserted, it cannot be removed. This study was designed to evaluate the tolerance of such a titanium alloy device at five years of minimal follow-up (FU) and secondarily to assess the relevance of the osteosynthesis of these fractures. METHOD Thirty-two patients operated for PHF and implanted with a titanium alloy device between 2009 and 2011 were reviewed: fifteen three-part fracture (3-PF) with mean age 65.2 ± seven years and mean FU at 86 months, and seventeen four-part (4-PF) with mean age 62.9 ± 12 years and mean FU at 88 months. RESULTS There were no signs of clinical or radiological incompatibility to the metal. The lateral cortex of the humeral shaft at the wedge component level of the device was thinner than pre-operatively in half of the cases. For the fifteen 3-PF, the median raw and weighted constant score (CS) were 75 and 100, respectively. Only one case presented avascular necrosis (AVN). For the seventeen 4-PF, the median raw and weighted CS were 64 and 88, respectively. Seven cases presented AVN and none of them seven had initially a dorsomedial metaphyseal extension of the humeral head. Kaplan-Meier survivorship analysis, with 95% confidence interval, was calculated at 89.7% (79.7-100%) survivorship at 7.18 years of follow-up. CONCLUSIONS This study shows no incompatibility of the titanium alloy device, radiological signs of localized stress shielding in half of the cases with no functional impact, excellent clinical and radiological evolution of the 3-PF, and AVN in all 4-PF without dorsomedial metaphyseal extension of the humeral head whereas most of cases without AVN had dorsomedial metaphyseal extension.
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Tischer T, Lenz R, Breinlinger-O’Reilly J, Lutter C. Cost Analysis in Shoulder Surgery: A Systematic Review. Orthop J Sports Med 2020; 8:2325967120917121. [PMID: 32435659 PMCID: PMC7223215 DOI: 10.1177/2325967120917121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cost analysis studies in medicine were uncommon in the past, but with the rising importance of financial considerations, it has become increasingly important to use available resources most efficiently. PURPOSE To analyze the current state of cost-effectiveness analyses in shoulder surgery. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review of the current literature was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All full economic analyses published since January 1, 2010 and including the terms "cost analysis" and "shoulder" were checked for usability. The methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine levels of evidence and established health economic criteria (Quality of Health Economic Studies [QHES] instrument). RESULTS A total of 34 studies fulfilled the inclusion criteria. Compared with older studies, recent studies were of better quality: one level 1 study and eight level 2 studies were included. The mean QHES score was 87 of 100. The thematic focus of most studies (n = 13) was rotator cuff tears, with the main findings as follows: (1) magnetic resonance imaging is a cost-effective imaging strategy, (2) primary (arthroscopic) rotator cuff repair (RCR) with conversion to reverse total shoulder arthroplasty in case of failure is the most cost-effective strategy, (3) the platelet-rich plasma augmentation of RCR seems not to be cost-effective, and (4) the cost-effectiveness of double-row RCR remains unclear. Other studies included shoulder instability (n = 3), glenohumeral osteoarthritis (n = 3), proximal humeral fractures (n = 4), subacromial impingement (n = 4), and other shoulder conditions (n = 7). CONCLUSION Compared with prior studies, the quality of recently available studies has improved significantly. Current studies could help decision makers to appropriately and adequately allocate resources. The optimal use of financial resources will be of increasing importance to improve medical care for patients. However, further studies are still necessary.
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Affiliation(s)
- Thomas Tischer
- Department of Orthopaedic Surgery, University Medicine Rostock, Rostock, Germany
| | - Robert Lenz
- Department of Orthopaedic Surgery, University Medicine Rostock, Rostock, Germany
| | | | - Christoph Lutter
- Department of Orthopaedic Surgery, University Medicine Rostock, Rostock, Germany
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Murena L, Canton G, Ratti C, Hoxhaj B, Giraldi G, Surace MF, Grassi FA. Indications and results of osteosynthesis for proximal humerus fragility fractures in elderly patients. Orthop Rev (Pavia) 2020; 12:8559. [PMID: 32391138 PMCID: PMC7206366 DOI: 10.4081/or.2020.8559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/13/2020] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Luigi Murena
- Orthopedics and Trauma Unit - ASUGI, Department of Medicine, Surgery and Health Sciences, University of Trieste
| | - Gianluca Canton
- Orthopedics and Trauma Unit - ASUGI, Department of Medicine, Surgery and Health Sciences, University of Trieste
| | - Chiara Ratti
- Orthopedics and Trauma Unit - ASUGI, Department of Medicine, Surgery and Health Sciences, University of Trieste
| | - Bramir Hoxhaj
- Orthopedics and Trauma Unit - ASUGI, Department of Medicine, Surgery and Health Sciences, University of Trieste
| | - Gioia Giraldi
- Orthopedics and Trauma Unit - ASUGI, Department of Medicine, Surgery and Health Sciences, University of Trieste
| | - Michele Francesco Surace
- Interdisciplinary Research Centre for Pathology and Surgery of the Musculoskeletal System, Department of Biotechnology and Life Sciences, University of Insubria, Varese
| | - Federico Alberto Grassi
- Orthopedic and Trauma Unit, University Hospital "Maggiore della Carità", Department of Health Sciences, University of East Piedmont, Novara, Italy
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Abstract
PURPOSE OF REVIEW The purpose of this review is to examine trends, outcomes, and principles in treatment of proximal humerus fractures in the elderly with a critical focus on reverse shoulder arthroplasty as a developing treatment option. RECENT FINDINGS Recent literature shows an increase in reverse shoulder arthroplasty and a decrease in hemiarthroplasty performed for proximal humerus fractures. More predictable outcomes and lower revision rates are seen in older individuals treated primarily or secondarily with reverse shoulder arthroplasty compared to those treated with hemiarthroplasty. We report current and historical treatments, outcomes, and principles in reverse shoulder arthroplasty for treatment of complex, displaced proximal humerus fractures in older individuals (≥ 65 years old).
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Affiliation(s)
- Brandon J Kelly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Chad M Myeroff
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA. .,Regions Hospital, Saint Paul, Minnesota, 640 Jackson St, MS 11503L, Saint Paul, MN, 55101, USA. .,TRIA Orthopaedic Center, Woodbury, MN, USA.
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Norman JG, Brealey S, Keding A, Torgerson D, Rangan A. Does time to surgery affect patient-reported outcome in proximal humeral fractures? A subanalysis of the PROFHER randomized clinical trial. Bone Joint J 2020; 102-B:33-41. [PMID: 31888365 DOI: 10.1302/0301-620x.102b1.bjj-2020-0546.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to explore whether time to surgery affects functional outcome in displaced proximal humeral fractures Methods A total of 250 patients presenting within three weeks of sustaining a displaced proximal humeral fracture involving the surgical neck were recruited at 32 acute NHS hospitals in the United Kingdom between September 2008 and April 2011. Of the 125 participants, 109 received surgery (fracture fixation or humeral head replacement) as per randomization. Data were included for 101 and 67 participants at six-month and five-year follow-up, respectively. Oxford Shoulder Scores (OSS) collected at six, 12, and 24 months and at three, four, and five years following randomization was plotted against time to surgery. Long-term recovery was explored by plotting six-month scores against five-year scores and agreement was illustrated with a Bland-Altman plot. Results The mean time from initial trauma to surgery was 10.5 days (1 to 33). Earlier surgical intervention did not improve OSS throughout follow-up, nor when stratified by participant age (< 65 years vs ≥ 65 years) and fracture severity (one- and two-part vs three- and four-part fractures). Participants managed later than reported international averages (three days in the United States and Germany, eight days in the United Kingdom) did not have worse outcomes. At five-year follow-up, 50 participants (76%) had the same or improved OSS compared with six months (six-month mean OSS 35.8 (SD 10.0); five-year mean OSS 40.1 (SD 9.1); r = 0.613). A Bland-Altman plot demonstrated a positive mean difference (3.3 OSS points (SD 7.92)) with wide 95% limits of agreement (-12.2 and 18.8 points). Conclusion Timing of surgery did not affect OSS at any stage of follow-up, irrespective of age or fracture type. Most participants had maximum functional outcome at six months that was maintained at five years. These findings may help guide providers of trauma services on surgical prioritization. Cite this article: Bone Joint J 2020;102-B(1):33–41
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Affiliation(s)
- John G. Norman
- York Teaching Hospital NHS Foundation Trust, York, UK
- Hull York Medical School, University of York, York, UK
| | - Stephen Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Amar Rangan
- York Trials Unit, Department of Health Sciences, University of York, York, UK
- James Cook University Hospital, Middlesbrough, UK
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Iyengar K, Vaish A, Vaishya R. Revisiting conservative orthopaedic management of fractures during COVID-19 pandemic. J Clin Orthop Trauma 2020; 11:718-720. [PMID: 32425429 PMCID: PMC7228883 DOI: 10.1016/j.jcot.2020.05.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 01/08/2023] Open
Abstract
COVID-19 pandemic has brought the need to revisit the conservative management of orthopaedic injuries back into sharp focus. On the advent of COVID-19 pandemic, it has been acknowledged by the British Orthopaedic Association (BOA) emergency COVID-19 and the National Health Service England (NHSE) guidelines to manage urgent orthopaedic and trauma conditions pragmatically balancing optimum treatment of patients against clinical safety with resource utilization .The current Coronavirus outbreak has refocussed orthopaedic minds on managing many injuries conservatively, which would have otherwise been managed with operative fixations. We revisit the role of conservative orthopaedic management of fractures in the context of COVID-19 and current guidelines.
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Affiliation(s)
- Karthikeyan Iyengar
- Southport and Ormskirk NHS Trust, Southport, PR8 6PN, UK
- Corresponding author.
| | - Abhishek Vaish
- Department of Orthopaedics, Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, 110076, New Delhi, India
| | - Raju Vaishya
- Department of Orthopaedics, Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, 110076, New Delhi, India
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Cil A. Proximal Humeral Fractures: "Damned If You Operate, and Damned If You Don't": Commentary on an article by C. Michael Robinson, FRCSEd(Tr&Orth), et al.: "Complications and Long-Term Outcomes of Open Reduction and Plate Fixation of Proximal Humeral Fractures". J Bone Joint Surg Am 2019; 101:e131. [PMID: 31800435 DOI: 10.2106/jbjs.19.01109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Akin Cil
- Department of Orthopaedics, University of Missouri-Kansas City, Kansas City, Missouri
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Robinson CM, Stirling PHC, Goudie EB, MacDonald DJ, Strelzow JA. Complications and Long-Term Outcomes of Open Reduction and Plate Fixation of Proximal Humeral Fractures. J Bone Joint Surg Am 2019; 101:2129-2139. [PMID: 31800426 DOI: 10.2106/jbjs.19.00595] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The optimal treatment of complex proximal humeral fractures in adults remains controversial. We evaluated the risk of complications and the long-term outcomes in patients with a severely displaced fracture or a fracture-dislocation of the proximal part of the humerus treated with open reduction and plate fixation (ORIF). METHODS Between 1995 and 2012, 5,897 consecutive patients with a proximal humeral fracture were referred to a specialist shoulder clinic for surgical assessment. Indications for surgery included anterior or posterior fracture-dislocation, substantial tuberosity involvement with >1 cm of displacement in a Neer 3 or 4-part fracture configuration, disengagement of the head from the shaft, or severe varus or valgus deformity of the head. All patients who met the surgical criteria and had been followed for 2 years were included, and standardized clinical and radiographic assessments of outcomes were performed. At a median of 10.8 years (range, 5 to 22 years) after ORIF, all surviving cognitively intact patients completed a patient-reported questionnaire assessing functional outcomes and satisfaction. RESULTS Three hundred and sixty-eight patients (6.2%) met the inclusion criteria and had the appropriate follow-up. The study population had a high rate of complex fracture configurations; 77.2% had tuberosity involvement, 54.1% had complete head-shaft disengagement, and 44.0% had a dislocated head. Eighty-seven patients (23.6%) had postoperative stiffness, 25 (6.8%) had fixation failure/nonunion, and 16 (4.3%) had late osteonecrosis/posttraumatic osteoarthritis; these complications were the reason for the majority of the reoperations in the cohort. The survivorship until any reoperation was 74% at 10 years, but when reoperations for stiffness were excluded, the survivorship was 90% during the same time period. The patients' mean levels of pain, function, and satisfaction with treatment were good to excellent. CONCLUSIONS Our results support the use of primary ORIF in medically fit patients with a severely displaced fracture or a fracture-dislocation of the proximal part of the humerus in centers where the expertise to carry out such treatment exists. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- C Michael Robinson
- The Edinburgh Shoulder Clinic, New Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Paul H C Stirling
- The Edinburgh Shoulder Clinic, New Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Ewan B Goudie
- The Edinburgh Shoulder Clinic, New Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Deborah J MacDonald
- The Edinburgh Shoulder Clinic, New Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Jason A Strelzow
- The Edinburgh Shoulder Clinic, New Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Klug A, Gramlich Y, Wincheringer D, Schmidt-Horlohé K, Hoffmann R. Trends in surgical management of proximal humeral fractures in adults: a nationwide study of records in Germany from 2007 to 2016. Arch Orthop Trauma Surg 2019; 139:1713-1721. [PMID: 31375915 DOI: 10.1007/s00402-019-03252-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Alexander Klug
- Zentrum für Unfallchirurgie und orthopädische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstrasse 430, 60389, Frankfurt am Main, Germany.
| | - Yves Gramlich
- Zentrum für Unfallchirurgie und orthopädische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstrasse 430, 60389, Frankfurt am Main, Germany
| | - Dennis Wincheringer
- Zentrum für Unfallchirurgie und orthopädische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstrasse 430, 60389, Frankfurt am Main, Germany
| | - Kay Schmidt-Horlohé
- Orthopaedicum Wiesbaden, Praxis für Orthopädie, Unfallchirurgie und Sportmedizin, Zentrum für Ellenbogenchirurgie, Friedrichstrasse 29, 65185, Wiesbaden, Germany
| | - Reinhard Hoffmann
- Zentrum für Unfallchirurgie und orthopädische Chirurgie, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstrasse 430, 60389, Frankfurt am Main, Germany
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Affiliation(s)
- Sally Kerr
- Department of Trauma and Orthopaedics, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - David Warwick
- Department of Orthopaedics, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Fares S Haddad
- The Bone & Joint Journal, University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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