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Bains SS, Dubin JA, Remily EA, Gilmor R, Hameed D, Monárrez R, Ingari JV, Delanois RE. Treatment of 2-part, 3-part, and 4-part proximal humerus fractures from 2016 to 2020: A nationally-representative database. J Orthop 2024; 50:162-169. [PMID: 38303906 PMCID: PMC10827678 DOI: 10.1016/j.jor.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 02/03/2024] Open
Abstract
Introduction Complex proximal humerus fractures pose challenges in elderly patients, as this common scenario can lead to unpredictable outcomes, regardless of treatment method. Given the evolving nature of the treatment for 3-and-4-part proximal humerus fractures, an epidemiological analysis offers a way to minimize the gap between appropriate understanding and effective intervention. As such, we aimed to i) evaluate the trends of nonoperative and operative management; and ii) compare the complication rates of ORIF to conversion ORIF (to RTSA). Methods We utilized a national, all-payer database to include patients who underwent open reduction and internal fixation for 2-part (n = 2783), 3-part (n = 2170), 4-part (n = 1087) proximal humerus fractures between April 2016 to December 2022. Patients who failed ORIF to RTSA included n = 108 for 2-part fractures, n = 123 for 3-part fractures, and n = 128 for 4-part fractures. We collected demographic and postoperative medical and surgical complications at 90-days, in addition to time-interval between ORIF and RTSA. Results The malunion and nonunion rates for ORIF between different types of proximal humerus fractures were similar (2-part fractures: 1.8 %, 4.7 %; 3-part fractures: 1.8 %, 3.5 %; 4-part fractures: 2.4 %, 3.7 %). The conversion rates of failed ORIF to RTSA were 1.9 %, 2.8 %, and 5.9 % for 2-part, 3-part, and 4-part fractures, respectively. The time interval from failed ORIF to RTSA was 190 days for 2-part fractures, 169 days for 3-part fractures, and 129 for 4-part fractures. Conclusion An epidemiological analysis of proximal humerus fractures by fracture type demonstrated an increase in RTSA for 2-part, 3-part, and 4-part fractures while nonoperative treatment showed no change from 2016 to 2020. Additional research is needed to determine which fractures are best treated operatively while maximizing outcomes. In the setting of complex proximal humerus fractures, several options seem feasible depending on patient demographic characteristics.
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Affiliation(s)
- Sandeep S. Bains
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Jeremy A. Dubin
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Ethan A. Remily
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Ruby Gilmor
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Daniel Hameed
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Rubén Monárrez
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - John V. Ingari
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Ronald E. Delanois
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
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Burkus M, Bruch A, Bergmann EM, Karahodzic-Franjic M, Zdichavsky M. Valgising angular stable plate fixation in the treatment of multifragmentary proximal humeral fractures in elderly patients. Arch Orthop Trauma Surg 2024; 144:1637-1645. [PMID: 38351348 DOI: 10.1007/s00402-024-05218-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/05/2024] [Indexed: 03/27/2024]
Abstract
INTRODUCTION The frequency of proximal humeral fractures shows an increasing tendency, especially in the elderly, who are frequently affected by osteoporosis. The adequate treatment of complex, displaced fractures poses a serious challenge. Among surgical treatment options, osteosynthesis with an angular stable plate is preferred, however, the implant-related complication rate may be exceptionally high. In our present study, we report the short-term outcomes of our new method of valgising angular stable plate fixation which we use for multifragmentary, displaced proximal humeral fractures in elderly patients. MATERIALS AND METHODS We retrospectively evaluated the clinical and radiological outcomes of 52 patients (46 female and 6 male, age: 71.9 ± 9.6) who suffered dislocated three- or four-part fractures and underwent valgising angular stable plate fixation. RESULTS Mean follow-up time was 17.3 months, while the functional outcomes were as following: excellent in 26, good in 18, moderate in 5 and poor in 3 patients. The mean Constant-Murley Score was 82.5 ± 11.2. Functional outcomes only showed significant correlation (p = 0.031) with age and were proven unrelated to fracture type, BMI and known primary diseases. The cumulative complication rate was 9.6% and revision rate was 5.8%. Neurological deficit, pseudoarthrosis or avascular humeral head necrosis did not occur during the follow-up period. CONCLUSIONS Valgising angular stable plate fixation that we apply for proximal humeral fractures provided favourable functional outcomes and a low postoperative complication rate due to the optimal head and plate placement. The method is especially effective for the treatment of displaced three- and four-part fractures with weakened, osteoporotic bone structure.
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Affiliation(s)
- Máté Burkus
- General, Visceral, Thoracic and Trauma Surgery, Surgical Orthopaedics, Die Filderklinik gGmbH, Im Haberschlai 7, 70794, Filderstadt-Bonlanden, Germany.
| | - A Bruch
- General, Visceral, Thoracic and Trauma Surgery, Surgical Orthopaedics, Die Filderklinik gGmbH, Im Haberschlai 7, 70794, Filderstadt-Bonlanden, Germany
| | - E M Bergmann
- General, Visceral, Thoracic and Trauma Surgery, Surgical Orthopaedics, Die Filderklinik gGmbH, Im Haberschlai 7, 70794, Filderstadt-Bonlanden, Germany
| | - M Karahodzic-Franjic
- General, Visceral, Thoracic and Trauma Surgery, Surgical Orthopaedics, Die Filderklinik gGmbH, Im Haberschlai 7, 70794, Filderstadt-Bonlanden, Germany
| | - M Zdichavsky
- General, Visceral, Thoracic and Trauma Surgery, Surgical Orthopaedics, Die Filderklinik gGmbH, Im Haberschlai 7, 70794, Filderstadt-Bonlanden, Germany
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Klute L, Henssler L, Schliemann B, Königshausen M, Weber N, Alt V, Kerschbaum M. Factors influencing choice of treatment for proximal humeral fractures elaborated in a Delphi consensus process. Arch Orthop Trauma Surg 2023; 143:7053-7061. [PMID: 37658856 PMCID: PMC10635939 DOI: 10.1007/s00402-023-05028-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/09/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION Hitherto, the decision-making process for treatment of proximal humerus fractures (PHF) remains controversial, with no established or commonly used treatment regimens. Identifying fracture- and patient-related factors that influence treatment decisions is crucial for the development of such treatment algorithms. The objective of this study was to define a Delphi consensus of clinically relevant fracture- and patient-related factors of PHF for clinical application and scientific research. METHODS An online survey was conducted among an international panel of preselected experienced shoulder surgeons. An evidence-based list of fracture-related and patient-related factors affecting treatment outcome after PHF was generated and reviewed by the members of the committee through online surveys. The proposed factors were revised for definitions, and suggestions from the first round mentioned in the free text were included as possible factors in the second round of surveys. Consensus was defined as having at least a two-thirds majority agreement. RESULTS The Delphi consensus panel consisted of 18 shoulder surgeons who completed 2 rounds of online surveys. There was an agreement of more than two-thirds of the panel for three fracture-related factors affecting treatment decision in the case of PHF: head-split fracture, dislocated tuberosities, and fracture dislocation. Of all patient-related factors, a two-thirds consensus was reached for two factors: age and rotator cuff tear arthropathy. CONCLUSION This study successfully conducted a Delphi consensus on factors influencing decision-making in the treatment of proximal humeral fractures. The documented factors will be useful for clinical evaluation and scientific validation in future studies.
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Affiliation(s)
- Lisa Klute
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Leopold Henssler
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Benedikt Schliemann
- Department of Trauma, Hand and Reconstructive Surgery, Herz-Jesu Hospital, 48165, Münster, Germany
| | - Matthias Königshausen
- Department of Trauma Surgery and General Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-La-Camp-Platz 1, 44789, Bochum, Germany
| | - Nadine Weber
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
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Almaghrabi RA, Almousa AM, Almulla A, Salem O, Almana L. Single-Stage Bilateral Reverse Shoulder Arthroplasty for a Bilateral Four-Part Fracture Dislocation of the Proximal Humerus in an Elderly Patient: A Case Report. Cureus 2023; 15:e49002. [PMID: 38111397 PMCID: PMC10726731 DOI: 10.7759/cureus.49002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2023] [Indexed: 12/20/2023] Open
Abstract
Proximal humerus fractures (PHFs) are a common type of fracture in adults. Although PHFs are common, bilateral presentation is extremely rare. Most PHFs are treated conservatively. In this report, we describe a 69-year-old right-hand-dominant male patient who was involved in a high-impact motor vehicle accident (MVA). The patient's upper limbs were in a fully extended position while he was holding the driving wheel, where he sustained a side impaction to the car by a hard object that caused bilateral four-part PHF with dislocation, which was confirmed on radiological investigations. The orthopedic surgery team believed that surgical treatment was necessary and ideal for these bilateral fracture dislocations, specifically bilateral reverse total shoulder arthroplasty (RTSA). This is due to multiple factors, including the risk of humeral head avascular necrosis (AVN), the patient's advanced age, low demand, poor bone stock, osteoporosis, and a non-fixable fracture pattern. The patient underwent a single-stage bilateral RTSA procedure, which was well tolerated. He was optimized postoperatively. The post-operative X-ray showed good and satisfactory implant positions and orientation. Functional assessment using the Constant-Murley Score (CMS) and Disabilities of the Arm, Shoulder and Hand (DASH) score were calculated at three-months follow-up (right-left: 50-60 and 41-14, respectively), at five-months follow-up (right-left: 34-66 and 38-14, respectively), and at eight-months follow-up (right-left: 40-68 and 24-7.5, respectively). Follow-up X-rays revealed good tuberosities healing, and no loosening or scapular notching. In addition, pain was assessed on a numerical rating scale (NRS), which demonstrated fast pain relief. Short-term follow-up with the patient demonstrated that he was satisfied with the surgery, especially the left side with a pain score on the NRS of one. We selected to share our experience of this complex case with our peers in the field of orthopedic surgery worldwide so that such a procedure could be implemented in similar cases to ensure satisfactory outcomes following bilateral four-part PHF with dislocation.
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Affiliation(s)
- Razan A Almaghrabi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Ali M Almousa
- Orthopedic Surgery, King Fahad Specialist Hospital, Dammam, SAU
| | | | - Omar Salem
- Orthopedic Surgery, King Fahad Specialist Hospital, Dammam, SAU
| | - Latifah Almana
- Orthopedic Surgery, King Fahad Specialist Hospital, Dammam, SAU
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Walter N, Szymski D, Kurtz SM, Lowenberg DW, Alt V, Lau EC, Rupp M. Epidemiology and treatment of proximal femoral fractures in the elderly U.S. population. Sci Rep 2023; 13:12734. [PMID: 37543668 PMCID: PMC10404231 DOI: 10.1038/s41598-023-40087-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 08/04/2023] [Indexed: 08/07/2023] Open
Abstract
Proximal femoral fractures are a serious complication, especially for elderly patients. Detailed epidemiological analyzes provide a valuable resource for stakeholders in the health care system in order to foresee future development possibly influenceable by adaption of therapeutic procedures and prevention strategies. This work aimed at answering the following research questions: (1) What are the incidence rates of proximal femoral fractures in the elderly U.S. population? (2) What is the preferred treatment procedure for these fractures? Proximal femoral fractures occurred between January 1, 2009 and December 31, 2019 in patients ≥ 65 years were identified from the Medicare Physician Service Records Data Base. The 5% sample of Medicare beneficiaries, equivalent to the records from approximately 2.5 million enrollees formed the basis of this study. Fractures were grouped into head/neck, intertrochanteric, and subtrochanteric fractures. The overall incidence rate, age and sex specific incidence rates as well as incidence rate ratios were calculated. Common Procedural Terminology (CPT) codes were used to identify procedures and operations. In 2019, a total number of 7982 femoral head/neck fractures was recorded. In comparison to 9588 cases in 2009, the incidence substantially decreased by 26.6% from 666.7/100,000 inhabitants to 489.3/100,000 inhabitants (z = - 5.197, p < 0.001). Also, in intertrochanteric fractures, a significant decline in the incidence by 17.3% was evident over the years from 367.7/100,000 inhabitants in 2009 to 304.0 cases per 100,000 inhabitants in 2019 (z = - 2.454, p = 0.014). A similar picture was observable for subtrochanteric fractures, which decreased by 29.6% (51.0 cases per 100,000 to 35.9 cases per 100,000) over the time period (z = - 1.612, p = 0.107). Head/neck fractures were mainly treated with an arthroplasty (n = 36,301, 40.0%). The majority of intertrochanteric fractures and subtrochanteric fractures received treatment with an intramedullary device (n = 34,630, 65.5% and n = 5870, 77.1%, respectively). The analysis indicated that the incidence of all types of proximal femoral neck fractures decreased for the population of elderly patients in the U.S. within the last decade. Treatment of head and neck fractures was mainly conducted through arthroplasty, while intertrochanteric and subtrochanteric fractures predominantly received an intramedullary nailing.
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Affiliation(s)
- Nike Walter
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Dominik Szymski
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Steven M Kurtz
- Implant Research Center, Drexel University, Philadelphia, USA
| | - David W Lowenberg
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | | | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
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