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Østergaard HK, Launonen AP, Toft M, Fjalestad T, Sumrein BO, Døssing KV, Axelsen MH, Noe SS, Wagle T, Engebretsen KB, Laitinen MK, Mattila VM, Mechlenburg I. Physiotherapist-supervised exercises versus unsupervised home-based exercises after nonsurgically treated proximal humerus fracture: a multicenter randomized controlled trial. J Shoulder Elbow Surg 2024; 33:994-1003. [PMID: 38311103 DOI: 10.1016/j.jse.2023.12.002] [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: 07/13/2023] [Revised: 11/21/2023] [Accepted: 12/04/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Proximal humerus fracture (PHF) is a common fragility fracture in older adults and can have a substantial impact on upper limb function. Although most patients with PHF can be treated nonsurgically, it is unknown whether older adults benefit from supervised exercise therapy after PHF. Therefore, the objective of this trial was to investigate whether 10 weeks of physiotherapist-supervised exercises once a week were superior to 10 weeks of unsupervised home-based exercises in older adults with a nonsurgically treated displaced 2-part PHF. METHODS This was designed as an assessor-blinded, prospective, randomized controlled trial and took place in 3 Nordic countries. In total, 72 patients (≥60 years) with nonsurgically treated displaced 2-part PHF were randomized to either physiotherapist-supervised exercises once a week for 10 weeks, combined with daily home-based exercises, or to 10 weeks of daily unsupervised home-based exercises. The primary outcome measure was the Disability of the Arm, Shoulder, and Hand (DASH) with a primary endpoint at 3 months. Secondary outcomes were DASH (at 12 months), Constant-Murley Score, the 15D-instrument, Visual Analog Scale, General Self-Efficacy Scale, and Pain Catastrophizing Scale, with follow-up visits after 3 and 12 months. Non-union and patient death within 3 months were counted as complications. RESULTS The mean age of the patients in both groups was 72 years. At 3 months follow-up, the mean DASH score in the supervised group was 25.9 (SD 16.0) compared to 22.4 (SD 18.9) in the unsupervised group. The mean between-group difference (3.5, 95% CI -5.0 to 12.5) was not clinically relevant. None of the secondary outcome measures presented any clinically relevant or statistically significant between-group differences at 3 or 12 months follow-up. One patient in the supervised group and 3 in the unsupervised group were diagnosed with non-union. One patient from each group died before 3 months follow-up. CONCLUSIONS This trial provides no evidence that supervised exercises are superior to unsupervised home-based exercises in improving functional outcome or health-related quality of life in older patients with a nonsurgically treated 2-part PHF. Further, our results suggest that most older adults with a nonsurgically treated 2-part PHF can perform home-based exercises without the supervision of a physiotherapist.
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Affiliation(s)
- Helle K Østergaard
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Antti P Launonen
- Department of Orthopaedics, Tampere University Hospital, Tampere, Finland
| | - Marianne Toft
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark
| | - Tore Fjalestad
- Department of Orthopaedics, Oslo University Hospital, Oslo, Norway
| | - Bakir O Sumrein
- Department of Orthopaedics, Tampere University Hospital, Tampere, Finland
| | - Kaj V Døssing
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark
| | - Mette H Axelsen
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark
| | - Sidsel S Noe
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark
| | - Tone Wagle
- Department of Orthopaedics, Oslo University Hospital, Oslo, Norway
| | - Kaia B Engebretsen
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Minna K Laitinen
- Department of Orthopaedics, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Ville M Mattila
- Department of Orthopaedics, Tampere University Hospital, Tampere, Finland
| | - Inger Mechlenburg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Orthopaedics, Aarhus University Hospital, Aarhus, Denmark
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Ong PW, Lim CJ, Pereira MJ, Kwek EB, Tan BY. Achieving satisfactory functional outcomes in conservatively treated proximal humerus fractures: relationship between shoulder range of motion and patient-reported clinical outcome scores. JSES Int 2024; 8:440-445. [PMID: 38707550 PMCID: PMC11064704 DOI: 10.1016/j.jseint.2024.02.003] [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: 05/07/2024] Open
Abstract
Background Proximal humerus fractures are common osteoporotic fractures. Postinjury outcome measures include objective clinician-measured range of motion (ROM) and subjective patient-reported outcome measures (PROMs), but the relationship between both has not been established. This study aimed to determine the relationship between shoulder ROM and PROMs and establish which ROMs correlated most with PROMs. Methods A prospective cohort study was conducted on patients with acute proximal humerus fractures. Surgical intervention, open or pathological fractures, neurovascular compromise, polytrauma, or delayed presentations were excluded. Correlation and regression analyses between active ROM and PROMs (Quick Disabilities of Arm, Shoulder and Hand [QuickDASH] and Oxford Shoulder Score [OSS]) at 1-year postinjury were explored. ROM cutoffs predicting satisfactory PROM scores were established. Results Fifty-five patients were recruited. Moderate correlations were observed between PROMs and flexion, extension, and abduction, but not internal and external rotation. Multivariate analysis showed significant relationships between PROMs and flexion [QuickDASH: adjusted coefficient (AC): -0.135, P = .013, OSS: AC: 0.072, P = .002], abduction [QuickDASH: AC: -0.115, P = .021, OSS: AC: 0.059, P = .005], and extension [QuickDASH: AC: -0.304, P = .020] adjusting for age, gender, Neer classification, injury on dominant side, and employment. Achieving 130° flexion, 59° extension, and 124° abduction were correlated with satisfactory OSS/QuickDASH scores, respectively. Conclusion Overall, holistic assessment of outcomes with both subjective and objective outcomes are necessary, as shoulder flexion, extension, and abduction are only moderately correlated with PROMs. Attaining 130° flexion, 59° extension, and 124° abduction corresponded with satisfactory functional outcomes measured by OSS/QuickDASH and can guide rehabilitation.
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Affiliation(s)
- Pei Wen Ong
- Department of Emergency Medicine, National Healthcare Group, Singapore, Singapore
| | - Chien Joo Lim
- Department of Orthopaedic Surgery, Woodlands Health Campus, Singapore, Singapore
| | - Michelle J. Pereira
- Health Services and Outcomes Research, National Healthcare Group, Singapore, Singapore
| | - Ernest B.K. Kwek
- Department of Orthopaedic Surgery, Woodlands Health Campus, Singapore, Singapore
| | - Bryan Yijia Tan
- Department of Orthopaedic Surgery, Woodlands Health Campus, Singapore, Singapore
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Hameleers A, Boonen B, Most J, Dremmen M, Schotanus MGM, Van Vugt R. Permissive Weight Bearing in Proximal Humeral Fracture Management: A Survey-Based Inquiry in the Netherlands. Cureus 2024; 16:e57670. [PMID: 38707136 PMCID: PMC11070209 DOI: 10.7759/cureus.57670] [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: 04/04/2024] [Indexed: 05/07/2024] Open
Abstract
Purpose Proximal humeral fractures (PHF) are common, particularly among the elderly due to low-energy trauma. Adequate rehabilitation is essential for functional recovery, whether through conservative or surgical treatment. Permissive weight bearing (PWB) is a relatively new rehabilitation concept, characterized by earlier mobilization of the affected limb/joint after trauma. Multiple studies demonstrated the value of PWB for the lower extremities, but this has not been translated to the upper extremity (i.e. PHF). Therefore, our aim was to investigate the current state and variability of rehabilitation of PHF and the role of implementing PWB principles in aftercare. Materials and methods An online survey, comprising 23 questions about the treatment of PHF, was distributed amongst an estimated 800 Dutch orthopaedic and trauma surgeons via the Dutch Orthopaedic and Dutch Trauma Society newsletter from May 2021 until July 2021. Results Among 88 respondents (n=69 orthopaedic, n=17 trauma surgeons, and n=2 other), most recommended early post-trauma mobilization (<6 weeks). Additionally, 53.4% (n=49) advised starting load bearing after six weeks for conservatively treated patients and 59.8% (n=52) for operative treatment. A wide variation of exercises used after immobilization was found in both groups. The usage of a sling after operative treatment was advised by 86% (n=74) of all 86 respondents. Conclusions The present study found limited consensus about PHF aftercare and the implementation of weight-bearing principles. The majority recommended early mobilization and advised the usage of a sling. A protocol capable of accommodating the diversity in aftercare (e.g. fracture type) is essential for maintaining structured rehabilitation, with PWB emerging as a promising example. More prospective studies are needed to form an evidence-based protocol focusing on the aftercare of PHF.
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Affiliation(s)
- Amber Hameleers
- Department of Orthopedic Surgery, Zuyderland Medical Center, Sittard-Geleen, NLD
- Department of Surgery, Maastricht University Medical Center+, Maastricht, NLD
| | - Bert Boonen
- Department of Orthopedic Surgery, Zuyderland Medical Center, Sittard-Geleen, NLD
| | - Jasper Most
- Department of Orthopedic Surgery, Zuyderland Medical Center, Sittard-Geleen, NLD
| | - Martijn Dremmen
- Department of Rehabilitation Medicine, Zuyderland Medical Center, Heerlen, NLD
| | | | - Raoul Van Vugt
- Department of Surgery, Zuyderland Medical Center, Heerlen, NLD
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Kus G, Zengin Alpozgen A, Gungor F, Razak Ozdincler A, Altun S. Clinical outcomes of conservative versus surgical treatment for patients with proximal humeral fracture before physiotherapy. Acta Orthop Belg 2024; 90:96-101. [PMID: 38669657 DOI: 10.52628/90.1.12409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Fear of movement, pain, and loss of shoulder function are the most common problems irrespective of their approach to management after proximal humeral fracture (PHF). However, it has been unclear whether there could be differences between both treatments in early clinical outcomes. It can help physiotherapists to guide in choosing treatment approaches. This study aimed to compare kinesiophobia, pain, range of motion (ROM), shoulder function, and Quality of life (QoL) in patients treated with either conservative (CT) versus surgical (ST) after PHF. In addition, it aimed to determine correlations between fear of movement and seconder outcome measures. This cross-sectional study enrolled the patients having 5-6 weeks (being permitted active movement) after being treated either CT or ST and receiving no physical therapy. Pain, passive and active ROMs, shoulder function, fear of movement, and QoL were evaluated. 42 patients were recruited. Kinesiophobia scores were similar (p=0.55) and moderate in both groups. There was a significant difference in degrees of shoulder active flexion, active and passive abduction in favor of the CT group (p=0.05, p=0.02, p=0.04, respectively). However, there was no difference between groups regarding the remaining clinical outcomes. Furthermore, kinesiophobia showed a moderate negative correlation with energy/fatigue, social functioning, and general health. These findings showed that patients treated surgically did not have more kinesiophobia, less function, and QoL before starting physiotherapy, despite having soft tissue damage and different types of fractures. However, surgically treated patients had significantly less range of motion.
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Dukan R, Juvenspan M, Scheibel M, Moroder P, Teissier P, Werthel JD. Non-operative management of humeral periprosthetic fracture after stemless shoulder arthroplasty. INTERNATIONAL ORTHOPAEDICS 2024; 48:253-259. [PMID: 37857856 DOI: 10.1007/s00264-023-06005-3] [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: 07/27/2023] [Accepted: 10/04/2023] [Indexed: 10/21/2023]
Abstract
PURPOSE Periprosthetic fractures around a stemless implant often involve lesser and greater tuberosities with a well-fixed implant in the metaphysis. This exposes the surgeon to unique questions and challenges as no surgical option (open reduction and internal fixation or revision to a stem) appears satisfactory to address them. Purpose of this study was to evaluate the clinical outcomes after non-operative management of periprosthetic fractures after stemless shoulder arthroplasty. METHODS A retrospective multicenter study was conducted to identify all patients who had sustained non-operative management of a periprosthetic fracture after a stemless shoulder. Exclusion criteria were as follows: (1) intraoperative fractures and (2) implant loosening. Primary outcomes included mean Constant score and mean active range of motion. Secondary outcomes were VAS, radiological analysis, and complications. RESULTS Nine patients were included. One was excluded due to the loss of follow-up at three months. Mean age was 79 years. At the last follow-up, no significant difference was observed between the Constant score, VAS, or the range of motion before fracture and at the last follow-up. Fracture healing did not result in any change in angulation in the frontal plane in seven cases and was responsible for a varus malunion in two cases of anatomic arthroplasty. No change in lateralization or distalization was reported. No cases of implant loosening after fracture have been observed. CONCLUSIONS Conservative management seems to be appropriate in cases of minimally displaced fractures without implant loosening.
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Affiliation(s)
| | - Marc Juvenspan
- Institut Français de Chirurgie de la Main, Paris, France
| | | | | | | | - Jean David Werthel
- Hopital Ambroise Pare, Orthopedic Department, 9 Av. Charles de Gaulle, 92100, Boulogne-Billancourt, France
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Dong W, Lisitano LSJ, Marchand LS, Reider LM, Haller JM. Weight-bearing Guidelines for Common Geriatric Upper and Lower Extremity Fractures. Curr Osteoporos Rep 2023; 21:698-709. [PMID: 37973761 DOI: 10.1007/s11914-023-00834-2] [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] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review paper is to summarize current weight-bearing guidelines for common geriatric fractures, around weight-bearing joints, of the upper and lower extremities. RECENT FINDINGS There is an increasing amount of literature investigating the safety and efficacy of early weight-bearing in geriatric fractures, particularly of the lower extremity. Many recent studies, although limited, suggest that early weight-bearing may be safe for geriatric distal femur and ankle fractures. Given the limited data pertaining to early weight-bearing in geriatric fractures, it is difficult to establish concrete weight-bearing guidelines in this population. However, in the literature available, early weight-bearing appears to be safe and effective across most injuries. The degree and time to weight-bearing vary significantly based on fracture type and treatment method. Future studies investigating postoperative weight-bearing protocols should focus on the growing geriatric population and identify methods to address specific barriers to early weight-bearing in these patients such as cognitive impairment, dependence on caregivers, and variations in post-acute disposition.
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Affiliation(s)
- Willie Dong
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Leonard S J Lisitano
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Lucas S Marchand
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Lisa M Reider
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
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Nah MFK, Pereira MJ, Hemaavathi M, Wong SW, Lim CJ, Tan BY. Study on proximal humerus evaluation of effective treatment (SPHEER) - what is the effect of rehabilitation compliance on clinical outcomes of proximal humerus fractures. BMC Musculoskelet Disord 2023; 24:778. [PMID: 37784126 PMCID: PMC10544385 DOI: 10.1186/s12891-023-06894-w] [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: 04/24/2023] [Accepted: 09/18/2023] [Indexed: 10/04/2023] Open
Abstract
INTRODUCTION Proximal humeral fractures (PHFs) are 3rd commonest fragility fractures and cause significant functional impairment. This paper sought to determine impact of rehabilitation compliance on the clinical outcomes for non-surgically managed PHFs, while ascertaining reasons for non-compliance which can be addressed to improve compliance. METHODS Prospective cohort study of patients undergoing non-surgical treatment for PHFs from August 2017 to April 2020 in a tertiary trauma centre was performed. Data was collected via questionnaire: patient demographic data, PHF injury details, clinical outcome measures, therapist-reported (Sport Injury Rehabilitation Adherence Scale [SIRAS]) and patient-reported (subjective compliance, frequency of exercise) rehabilitation compliance measures. Data was analysed using multiple linear regression model to account for confounding variables. RESULTS 107 participants attended physical therapy follow-up for mean 137.8 days. 6-week SIRAS strongly predicted 3-month Constant score (p = 0.023; 95%CI = 0.265,3.423), OSS (p = 0.038; 95%CI = 0.049,1.634), flexion ROM (p < 0.001; 95%CI = 2.872,8.982), extension ROM (p = 0.035; 95%CI = 0.097,2.614), abduction ROM (p = 0.002;95%CI = 1.995,8.466) and achievement of functional active ROM at 3-months (p = 0.049; 95%CI = 1.001,1.638). Pain was the top reason impairing rehabilitation compliance from therapist (43.9% at 6-weeks and 20.6% at 3-months) and patient-perspective (33.6% at 6-weeks, 24.3% at 3-months). Author-developed patient-reported compliance measures had good correlation with validated SIRAS score (subjective compliance: p < 0.001 frequency of exercise: p = 0.001). CONCLUSION Rehabilitation compliance predicts short-term clinical outcomes up to 3-months and potentially 1-year outcomes. Pain control should be optimised to maximise rehabilitation compliance and improve PHF outcomes. There is lack of consensus definition for rehabilitation compliance measures; patient-reported measures used have good correlation to existing validated measures and could serve as a steppingstone for further research. LEVEL OF EVIDENCE II, cohort study.
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Affiliation(s)
- Ming Foo Kenneth Nah
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore.
| | | | | | - Shiyun Winnie Wong
- Department of Occupational Therapy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chien Joo Lim
- Medical Statistician (Research), Woodlands Health, Singapore, Singapore
| | - Bryan Yijia Tan
- Department of Orthopedic Surgery, Woodlands Health, Singapore, Singapore
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Baldairon F, Antoni M, Le Thai V, Clavert P. Is early mobilization a viable option after intramedullary nailing of 4-parts proximal humerus fractures? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03478-1. [PMID: 36715762 DOI: 10.1007/s00590-023-03478-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/18/2023] [Indexed: 01/31/2023]
Abstract
INTRODUCTION After centromedullary nailing (CMN) of 4-parts (4P) cephalo-tuberositary fractures of the proximal humerus (PH), shoulder immobilization for a few weeks is usual, although no scientific justification does support this attitude, nor the duration of immobilization. The objective of this study was to assess the impact of early mobilization after CMN of PH 4P fractures on clinical, radiological outcomes and complication rates. The hypothesis was that early mobilization would not lead to a deterioration in results or an increase in the complication rate. MATERIALS AND METHODS All patients operated on for a 4P-PH fracture by CMN in our institution between 2010 and 2018 were included retrospectively. 2 groups were formed according to the duration of post-operative immobilization of the shoulder: 0-2 weeks (group A) and 3-6 weeks (group B). All patients had a clinical examination (Range of motion ROM and Constant score) and X-rays of the shoulder at least 24 months of follow-up. 58 patients (average age 66 years (39-89)) were included, with 25 in group A and 33 in group B. RESULTS The average follow-up was 38.5 (24-73) months. The active ROM at the last follow-up was: active anterior elevation 149° (80°-180°) in group A versus 134 (60°-180°) in group B (p = 0.099); active external rotation 145° (15°-70°) in group A versus 42° (15-70°) in group B (p = 0.6). The Absolute Mean Constant score was 78.29 for Group A (45-100) versus 68.59 points (45-96) for Group B (p = 0.065). Regarding complications: in group A, we found 2 retractile capsulitis, 2 pseudarthrosis and 2 osteonecrosis of the humeral head. In group B, we found 5 retractile capsulitis, 1 infection of the surgical site, 3 osteonecrosis of the humeral head and 1 pseudarthrosis. CONCLUSION Early mobilization after CMN of 4P-PH fractures did not lead to an increase in the complications rate and in particular secondary displacements or osteonecrosis. There was a trend toward improved clinical outcomes with early mobilization, although this trend was not statistically significant. EVIDENCE LEVEL IV, retrospective study.
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Affiliation(s)
- Florent Baldairon
- Department of Upper Limb Surgery, CHU de Strasbourg, Avenue Molière, 67200, Strasbourg, France
| | - Maxime Antoni
- Department of Upper Limb Surgery, CHU de Strasbourg, Avenue Molière, 67200, Strasbourg, France.
| | - Vinh Le Thai
- Department of Upper Limb Surgery, CHU de Strasbourg, Avenue Molière, 67200, Strasbourg, France
| | - Philippe Clavert
- Department of Upper Limb Surgery, CHU de Strasbourg, Avenue Molière, 67200, Strasbourg, France
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Martinez-Catalan N. Conservative Treatment of Proximal Humerus Fractures: When, How, and What to Expect. Curr Rev Musculoskelet Med 2022; 16:75-84. [PMID: 36562923 PMCID: PMC9889589 DOI: 10.1007/s12178-022-09817-9] [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] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW The key question to answer during the decision-making process for proximal humerus fractures (PHF) is whether the amount of displacement of a specific fracture pattern will be acceptable taking into account the anticipated demands on the patient. The aim of this review article was to provide some clarity regarding the features that contribute to poor clinical outcomes when PHF are treated non-operatively and to review the reported outcomes of conservative treatment. RECENT FINDINGS Conservative treatment for non-displaced or minimally displaced fractures leads to good outcomes in 80% to 90% of patients. However, with increasing fracture complexity and displacement, functional outcomes tend to diminish. In active patients with significant functional demands, the challenge is to predict which fractures will do poorly when treated non-operatively. A better understanding of fracture patterns and fragment displacement may improve treatment indications. To avoid complications related to conservative treatment, surgery should be considered (1) in fractures in which the humeral head is severely compromised (due to fracture-dislocation, severe impaction, or a split of the head itself), (2) in non-impacted fractures with gross instability between the humeral shaft and humeral head, and (3) in those cases in which displacement of the tuberosities or the final shape of the proximal humerus after healing will lead to symptomatic malunion.
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Affiliation(s)
- Natalia Martinez-Catalan
- Department of Orthopaedics and Traumatology, Hospital Fundación Jimenez Diaz, Avenida de los Reyes Catolicos 2, 28040 Madrid, Spain
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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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11
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Thelen S, Grassmann JP, Schneider M, Jaekel C, Meier DM, Betsch M, Hakimi M, Wild M. The influence of fracture severity on postoperative outcome and quality of life after locking plate fixation of proximal humeral fractures. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2022; 11:Doc03. [PMID: 35692287 PMCID: PMC9178521 DOI: 10.3205/iprs000164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective: For proximal humeral fractures open reduction und internal fixation (ORIF) with a fixed-angle plate is considered the gold standard for surgical management. However, it can lead to poor functional outcomes and is associated with postoperative complications. Therefore, the purpose of this study was to investigate the influence of fracture severity by applying a new classification (simple versus complex) on clinical outcome and quality of life after ORIF of proximal humerus fractures. Methods: We conducted a prospective clinical study with an average follow-up period of 12 (SD 1) months after ORIF of proximal humeral fractures with a fixed-angle plate. The postoperative function and quality of life was measured using the Oxford Shoulder Score (OSS) and the Constant Score. Data was tested for statistical significance with the Mann-Whitney test and Fisher's exact test. Based on the findings of this study a simplified fracture classification system has been developed. Results: Seventy-two patients with a mean age of 65 years (SD 12) with 69% being males were included. According to the Neer classification, 35% (n=25) non-displaced (“one-part fractures”), 19% (n=14) two-part fractures, 15% (n=11) three-part fractures and 31% (n=22) four-part fractures were detected. Regarding the AO/OTA classification, 18% (n=13) were type A fractures, 43% (n=31) type B and 39% (n=28) type C fractures. From these criteria we derived our own fracture classification, including 50% (n=36) simple and 50% (n=36) severe fractures. Patients with simple fracture types achieved significantly higher total values in the Constant Score as well as the OSS (p=0.008; p=0.013). The cumulative incidence of complications in the entire patient collective was 14% (n=10) with humeral head necrosis (n=5) occurring only in the severe fracture group. Conclusions: The postoperative clinical outcome as well as the incidence of humeral head necrosis after ORIF of proximal humeral fractures with a fixed-angle plate correlates with the fracture type and severity. The newly derived fracture classification into simple and severe fractures is suitable with regard to clinical results and complication rate. However, prospective studies comparing ORIF vs. conservative treatment of proximal humeral fractures of the same severity are required. Level of Evidence: III
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Affiliation(s)
- Simon Thelen
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Jan P. Grassmann
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany,*To whom correspondence should be addressed: Jan P. Grassmann, Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany, Phone: +49 (0) 211-81-04400, Fax: +49 (0) 211-81-04902, E-mail:
| | - Madeleine Schneider
- Department of Orthopedics, Trauma and Hand Surgery, Klinikum Darmstadt, Darmstadt, Germany
| | - Carina Jaekel
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Dana M. Meier
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Marcel Betsch
- Department of Orthopedics and Trauma Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Mohssen Hakimi
- Vivantes Klinikum Am Urban, Department of Orthopedic, Trauma and Hand Surgery, Berlin, Germany
| | - Michael Wild
- Department of Orthopedics, Trauma and Hand Surgery, Klinikum Darmstadt, Darmstadt, Germany
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12
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Goudie EB, MacDonald DJ, Robinson CM. Functional Outcome After Nonoperative Treatment of a Proximal Humeral Fracture in Adults. J Bone Joint Surg Am 2022; 104:123-138. [PMID: 34878423 DOI: 10.2106/jbjs.20.02018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The functional outcome following nonoperative treatment of a proximal humeral fracture and the factors that influence it are poorly defined. We aimed to prospectively assess patient-reported outcome measures (PROMs) in a patient cohort at 1 year after the injury. METHODS In this study, 774 adult patients sustaining a proximal humeral fracture completed PROM assessments, including the Oxford Shoulder Score (OSS), the EuroQol-5 Dimensions-3 Levels (EQ-5D-3L), and visual analog scale (VAS) assessments of pain, health, and overall treatment satisfaction at 1 year. The mean patient age was 65.6 years, and 73.8% of patients were female. The influences of demographic and fracture measurements and complications on the OSS and EQ-5D-3L were assessed. RESULTS The 1-year mean scores were 33.2 points (95% confidence interval [CI], 32.1 to 34.2 points) for the OSS and 0.58 (95% CI, 0.55 to 0.61) for the EQ-5D-3L. There was considerable heterogeneity in the reported scores, and the 3 demographic variables of higher levels of dependency, higher levels of social deprivation, and a history of affective (mood) disorder were most consistently associated with poorer outcomes, accounting for between 37% and 43% of the score variation. The initial fracture translation potentially leading to nonunion accounted for 9% to 15% of the variation, and a displaced tuberosity fracture was also predictive of 1% to 4% of the outcome variation. There was evidence of a ceiling effect for the OSS, with 238 patients (30.8%) having a score of ≥47 points but a mean outcome satisfaction of only 72.9 points, and this effect was more pronounced in younger, active individuals. At the other end of the spectrum, 239 patients (30.9%) reported an OSS of ≤24 points, and 120 patients (15.5%) had a "worse-than-death" EQ-5D-3L score. CONCLUSIONS Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year, and a substantial proportion of patients have poor perceived functional outcomes. The outcome for the majority of less-displaced fractures is mainly influenced by preexisting patient-related psychosocial factors, although the fracture-related factors of displacement, nonunion, and tuberosity displacement account for a small but measurable proportion of the variation and the poorer outcomes in the minority with more severe injuries. LEVEL OF EVIDENCE Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ewan B Goudie
- The Edinburgh Shoulder Clinic, New Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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13
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Bahrilli T, Topuz S. Does immobilization of the shoulder in different positions affect gait? Gait Posture 2022; 91:254-259. [PMID: 34775228 DOI: 10.1016/j.gaitpost.2021.10.018] [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: 05/24/2021] [Revised: 09/21/2021] [Accepted: 10/15/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The shoulder joint is immobilized in various positions after injury or reconstructive operative intervention. It is not clear how these immobilization positions in the shoulder joint affect gait. RESEARCH QUESTION Does the immobilized shoulder joint in different positions following shoulder surgery or injury affect gait? METHODS A total of 38 healthy individuals with a mean age of 25.94 years and BMI of 25.66 kg/m2, underwent gait analysis in 4 different immobilized positions and normal gait. Gait parameters were evaluated using the GAITRite electronic walkway, and to determine symmetry, the bilateral spatiotemporal gait parameters were calculated using the Symmetry Index. Repeated-measures one way analysis of variance was used to compare the walking parameters in different positions. RESULTS Velocity, step length and stride length were significantly decreased, and step width and single support time were increased in some immobilized positions (p < 0.05). Differences in asymmetry were determined in the gait parameters of the immobilized positions but not significantly. When the shoulder was immobilized in abduction, step width asymmetry tended to increase but it was not significant. SIGNIFICANCE This cross-sectional simulation study may be important in demonstrating the clinical changes of gait in injuries, pathologies, and postoperative rehabilitation that require the immobilization of the shoulder joint. It could be recommended that arm swing is included in gait rehabilitation, gait and balance training can be provided to patients after shoulder immobilization.
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Affiliation(s)
| | - Semra Topuz
- Faculty of Physical Therapy and Rehabilitation, Hacettepe University, Ankara, Turkey.
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14
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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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15
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The fragility and reverse fragility indices of proximal humerus fracture randomized controlled trials: a systematic review. Eur J Trauma Emerg Surg 2021; 48:4545-4552. [PMID: 34056677 DOI: 10.1007/s00068-021-01684-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/28/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The quality of evidence of the orthopedic literature has been often called into question. The fragility index (FI) has emerged as a means to evaluate the robustness of a significant result. Similarly, reverse fragility index (RFI) can be used for nonsignificant results to evaluate whether one can confidently conclude that there is no difference between groups. The analysis of FI and RFI in proximal humerus fracture (PHF) management is of particular interest, given ongoing controversy regarding optimal management and patient selection. The aim of this study was to report the FI, RFI and quality of the evidence in the proximal humerus fracture literature. METHODS A systematic review was conducted based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, which utilized EMBASE, MEDLINE and Cochrane Library databases. Inclusion criteria included randomized controlled clinical trials related to the management of proximal humerus fractures, published from 2000 to 2020 with dichotomous outcome measures and 1:1 allocation. The FI and RFI were calculated by successively changing one nonevent to an event for each outcome measure until the result was made nonsignificant or significant, respectively. The fragility quotient, (FQ), calculated by dividing the FI by the total sample size, was calculated as well. RESULTS There were 25 studies that met our criteria with 48 outcome measures recorded. A total of 21 studies had at least one fragile result, with ten studies including a fragile result in the conclusion of the abstract. A total of 31 outcome measures had nonsignificant results and the median RFI was found to be 4, with 71% greater than number of patients lost to follow up. Seventeen outcomes had significant results, with a median FI of 1, with 65% greater than or equal to the number patients lost to follow up. A total of 18 of 25 studies (72%) included a power analysis. In particular, ten studies reported a statistical analysis of complication rates, 90% of which were fragile. The median FQ was found to be 0.037. CONCLUSIONS The literature on PHF management is frequently fragile. Outcome measures are often fragile, particularly with regards to comparing complication rates and reoperation rates in treatment arms. Comparing to the studies in other subspecialties PHF RCTs are relatively more fragile and underpowered. Standardized reporting of FI, FQ and RFI can help the reader to reliably draw conclusions based on the fragility of outcome measures.
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16
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The Benefits and Harms of Early Mobilization and Supervised Exercise Therapy after Non-surgically Treated Proximal Humerus or Distal Radius fracture: A systematic Review and Meta-analysis. Curr Rev Musculoskelet Med 2021; 14:107-129. [PMID: 33689149 DOI: 10.1007/s12178-021-09697-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Fractures of the proximal humerus (PHF) and distal radius (DRF) are among the most common upper extremity fractures in the elderly. Recent randomized controlled trials support non-surgical treatment. Evidence behind the best non-surgical treatment strategy has been sparse and raises questions as to when and how to initiate exercises. The purpose of this systematic review and meta-analysis was to assess the benefits and harms of early mobilization versus late mobilization and supervised versus non-supervised exercises therapy after PHF and DRF. RECENT FINDINGS 15 published and 5 unpublished trials were included. Early mobilization after PHF resulted in better function with a mean difference (MD) of 4.55 (95% CI 0.00-9.10) on the Constant Shoulder Score. However, the MD was not found to be clinically relevant. No clear evidence showed that early mobilization after PHF had a positive effect on range of motion or pain. Neither did it lead to more complications. Furthermore, no eligible evidence was found supporting early mobilization to be superior to late mobilization after DRF, or that supervised exercise therapy was superior to non-supervised exercise therapy after PHF and DRF. The quality of evidence on all outcomes was found to be low or very low. Early mobilization after PHF may have a beneficial effect on function. Due to the lack of clear evidence, there is an urgent need for future studies to determine the effect of early mobilization and supervised exercise therapy after PHF and DRF. Prospero ID number: CRD42020167656, date of registration 28.04.2020.
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17
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Some outcomes of patients treated operatively for distal humerus fractures are affected by hand dominance. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1507-1513. [PMID: 33660048 DOI: 10.1007/s00590-021-02915-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE This study sought to compare postoperative outcomes and complications between patients with distal humerus fractures treated with open reduction and internal fixation (ORIF) of their non-dominant versus dominant arm. METHODS A retrospective review of all patients who sustained a distal humerus fracture treated operatively with ORIF at one academic institution between 2011 and 2015 was performed. Measured outcomes included complications, time to fracture union, painful hardware, removal of hardware, Mayo Elbow Performance Index (MEPI), and elbow range of motion. Differences in outcomes between patients who underwent surgery of their dominant upper extremity and those who underwent surgery of their non-dominant extremity were assessed. RESULTS Sixty-nine patients met inclusion criteria. Forty (58.0%) underwent ORIF of a distal humerus fracture on their non-dominant arm and 29 (42.0%) on their dominant arm. Groups did not differ with respect to demographics, injury information, or surgical management. Mean overall follow-up was 14.1 ± 10.5 months, with all patients achieving at least 6 months follow-up. The non-dominant cohort experienced a higher proportion of postoperative complications (P = 0.048), painful hardware (P = 0.018), and removal of hardware (P = 0.002). At latest follow-up, the non-dominant cohort had lower MEPI scores (P = 0.037) but no difference in elbow arc of motion (P = 0.314). CONCLUSION Patients who sustained a distal humerus fracture of their non-dominant arm treated with ORIF experienced more postoperative complications, reported a greater incidence of painful hardware, underwent removal of hardware more often, and had worse functional recovery in this study. Physicians should emphasize the importance of physical therapy and maintaining arm movement especially when the non-dominant arm is involved following distal humerus fracture repair. LEVEL OF EVIDENCE Level III.
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18
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19
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Smith CS, Mollon B, Vannabouathong C, Fu JM, Sales B, Bhandari M, Whelan DB. An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013. J Bone Joint Surg Am 2020; 102:e116. [PMID: 33086352 DOI: 10.2106/jbjs.18.00653] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials. METHODS A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted. RESULTS A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment. CONCLUSIONS The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.
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Affiliation(s)
| | - Brent Mollon
- Soldiers' Memorial Hospital, Orillia, Ontario, Canada
| | | | - Joyce M Fu
- Department of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | | | - Mohit Bhandari
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Daniel B Whelan
- University of Toronto Orthopaedic Sports Medicine, St. Michael's and Women's College Hospitals, Toronto, Ontario, Canada
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20
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Napora JK, Demyanovich H, Mulliken A, Oslin K, Pensy R, Slobogean G, O'Toole RV, O'Hara N. Patients' preferences for occupational therapy after upper extremity fractures: a discrete choice experiment. BMJ Open 2020; 10:e039888. [PMID: 33055120 PMCID: PMC7559050 DOI: 10.1136/bmjopen-2020-039888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Occupational therapy is often prescribed after the acute treatment of upper extremity fractures. However, high out-of-pocket expenses and logistical constraints can reduce access to formal therapy services. We aimed to quantify preferences of patients with upper extremity fracture for attending occupational therapy, when considering possible differences in clinical outcomes. DESIGN Discrete choice experiment. SETTING Level 1 trauma centre in Baltimore, Maryland, USA. PARTICIPANTS 134 adult patients with upper extremity fractures. PRIMARY OUTCOME MEASURES The scenarios were described with five attributes: cost, duration of therapy session, location of therapy, final range of motion and pain. We report the relative importance of each attribute as a proportion of total importance, and the willingness to pay for benefits of the therapy services. RESULTS Of the 134 study participants, the mean age was 47 years and 53% were men. Cost (32%) and range of motion (29%) were the attributes of greatest relative importance. Pain (17%), duration of therapy (13%) and location of therapy (8%) were of lesser importance. Patients were willing to pay $85 more per therapy session for a 40% improvement in their range of motion. Patients were willing to pay $43 more per therapy session to improve from severe pain to mild pain. Patients were indifferent to whether the therapy treatment was home-based or in a clinical environment. CONCLUSIONS When deciding on an upper extremity fracture therapy programme, out-of-pocket costs are a paramount consideration of patients. Improvements in range of motion are of greater importance than residual pain, the duration of therapy sessions and the location of service provision. Patients with upper extremity fracture should be prescribed occupational therapy services that align with these patients' preferences.
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Affiliation(s)
- Joshua Kyle Napora
- Department of Orthopaedics, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | | | - Kimberly Oslin
- Orthopedics, University of Maryland, Baltimore, Maryland, USA
| | - Raymond Pensy
- Orthopedics, University of Maryland, Baltimore, Maryland, USA
| | | | | | - Nathan O'Hara
- Orthopedics, University of Maryland, Baltimore, Maryland, USA
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21
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Yang YY, Qin H, Zheng X, Hu B, Zhang M, Ma T. Administration of Tranexamic Acid in Proximal Humeral Fractures. Indian J Orthop 2020; 54:277-282. [PMID: 33194102 PMCID: PMC7609467 DOI: 10.1007/s43465-020-00128-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/22/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION This study aimed to analyze the efficacy of intravenous administration of tranexamic acid in complex proximal humeral fractures. MATERIALS AND METHODS Sixty-seven patients with displaced 3 and 4 part proximal humerus fractures were randomized into the control (n = 33) and TXA (n = 34) groups. Fifteen minutes before the skin incision, 15 mg/kg body weight of 0.9% sodium chloride solution or TXA was injected intravenously. Open reduction and internal fixation was conducted through a deltoid-pectoral approach with fixed angle locked plating (PHILOS) for all the patients. The patients were followed up 2 months after surgery. Total blood loss, blood test results, blood transfusion rate, and wound complications were analyzed between the two groups. RESULTS Significant differences were observed in intraoperative blood loss and postoperative blood loss during the first 24 h between the two groups. There were no significant differences in postoperative blood loss during the second 24 h, wound complication rates, blood transfusion rate and adverse side effects. And thromboembolic events related with the application of TXA were not noted in the TXA group. CONCLUSION Preoperative administration of tranexamic acid could reduce intraoperative and postoperative blood loss in patients with complex proximal humeral fractures. LEVEL OF EVIDENCE II, prospective comparative study.
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Affiliation(s)
- Ying-ying Yang
- grid.452929.1Department of Orthopedics, The First Affiliated Hospital of Wannan Medical College, No. 2 Zheshan West Road, Jinghu District, Wuhu, 241000 Anhui People’s Republic of China
| | - Hongjiu Qin
- grid.452929.1Department of Orthopedics, The First Affiliated Hospital of Wannan Medical College, No. 2 Zheshan West Road, Jinghu District, Wuhu, 241000 Anhui People’s Republic of China
| | - Xin Zheng
- grid.413389.4Department of Orthopaedics, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, People’s Republic of China
| | - Bin Hu
- grid.452929.1Department of Orthopedics, The First Affiliated Hospital of Wannan Medical College, No. 2 Zheshan West Road, Jinghu District, Wuhu, 241000 Anhui People’s Republic of China
| | - Min Zhang
- grid.452929.1Department of Orthopedics, The First Affiliated Hospital of Wannan Medical College, No. 2 Zheshan West Road, Jinghu District, Wuhu, 241000 Anhui People’s Republic of China
| | - Tao Ma
- grid.452929.1Department of Orthopedics, The First Affiliated Hospital of Wannan Medical College, No. 2 Zheshan West Road, Jinghu District, Wuhu, 241000 Anhui People’s Republic of China
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Ernstbrunner L, Rahm S, Suter A, Imam MA, Catanzaro S, Grubhofer F, Gerber C. Salvage reverse total shoulder arthroplasty for failed operative treatment of proximal humeral fractures in patients younger than 60 years: long-term results. J Shoulder Elbow Surg 2020; 29:561-570. [PMID: 31594724 DOI: 10.1016/j.jse.2019.07.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/18/2019] [Accepted: 07/28/2019] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS Is salvage reverse total shoulder arthroplasty (RTSA) a justifiable treatment for failed operative treatment (open reduction-internal fixation [ORIF] or primary and secondary hemiarthroplasty) of proximal humeral fractures in patients younger than 60 years? METHODS Thirty patients (mean age, 52 years; age range, 30-59 years) were reviewed after a mean follow-up period of 11 years (range, 8-18 years). Of the patients, 7 (23%) underwent RTSA for failed ORIF and 23 (77%) for failed hemiarthroplasty. Clinical and radiographic outcomes were assessed longitudinally. RESULTS At final follow-up, the mean relative Constant score had improved from 25% (±12%) to 58% (±21%, P < .001). Significant improvements were seen in the mean Subjective Shoulder Value (20% to 56%), active elevation (45° to 106°), abduction (42° to 99°), pain scores, and strength (P < .001). Clinical outcomes did not significantly deteriorate over a period of 10 years. Patients with salvage RTSA for failed secondary hemiarthroplasty (n = 8) vs. those for failed ORIF (n = 6) showed significantly inferior active abduction (77° vs. 116°, P = .023). Patients with a healed greater tuberosity (n = 9) showed significantly better external rotation than patients with a resorbed/resected greater tuberosity (n = 13, 21° vs. 3°, P = .025). One or more complications occurred in 18 shoulders (60%), and 6 (20%) resulted in explantation of the RTSA. CONCLUSIONS Salvage RTSA in patients younger than 60 years is associated with a high complication rate. It leads nonetheless to substantial and durable improvement beyond 10 years, provided the complications can be handled with implant retention. Inferior shoulder function is associated with greater tuberosity resorption or resection and inferior overhead elevation with the diagnosis of failed hemiarthroplasty.
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Affiliation(s)
- Lukas Ernstbrunner
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
| | - Stefan Rahm
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Aline Suter
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Mohamed A Imam
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Sabrina Catanzaro
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Florian Grubhofer
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Christian Gerber
- Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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23
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Stelter J, Malik S, Chiampas G. The Emergent Evaluation and Treatment of Shoulder, Clavicle, and Humerus Injuries. Emerg Med Clin North Am 2020; 38:103-124. [DOI: 10.1016/j.emc.2019.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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24
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Nowak LL, Davis AM, Mamdani M, Beaton D, Schemitsch EH. A concept analysis and overview of outcome measures used for evaluating patients with proximal humerus fractures. Disabil Rehabil 2019; 43:1450-1462. [PMID: 31479302 DOI: 10.1080/09638288.2019.1649728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE It is unclear to which degree existing studies evaluate the primary goal of treatment for patients with proximal humerus fractures (restoration of daily activities). Our purpose was to systematically review and analyze the concepts reflected by outcome measures used in studies of patients with proximal humerus fractures. METHODS We reviewed three databases from 2000 to 2018. Two reviewers categorized outcomes in each study into concepts of the International Classification of Functioning, Disability and Health framework. RESULTS The most commonly represented concept across 35 studies was "Body Function/Structure Impairment", followed by aggregate measures that reflect multiple concepts to varying degrees. All patient-reported aggregate measures such as the Disabilities of the Arm, Shoulder, and Hand, American Shoulder and Elbow Surgeon's, and Oxford Shoulder scores better reflected "Activity Limitations", however, these measures were only reported in 34% of studies. CONCLUSION There may be misalignment between what studies measure, and the primary goal of treatment for patients with proximal humerus fractures. The Disabilities of the Arm, Shoulder and Hand, American Shoulder and Elbow Surgeon's, and Oxford Shoulder scores reflect concepts that more adequately address the restoration of daily activities following these injuries, and future studies should include at least one of these measures.Implications for rehabilitationWe have shown that there is a misalignment between what existing studies are measuring (primarily objective measures of impairment) and the primary goal of treatment and rehabilitation (restoring activities of daily living).This suggests that existing studies evaluating different treatment types for proximal humerus fracture patients are providing inadequate information to make evidence-based treatment and rehabilitation decisions following theses injuries.Our results tentatively suggest that the Disabilities of the Arm, Shoulder and Hand, the American Shoulder and Elbow Surgeon's, and Oxford Shoulder scores may better reflect limitations in daily activities following these injuries and should be used in future studies and by clinicians.
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Affiliation(s)
- Lauren L Nowak
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Clinical Orthopaedic Research, St. Michael's Hospital, Toronto, Canada
| | - Aileen M Davis
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Muhammad Mamdani
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Li Ka Shing Centre for Healthcare Analytics Research and Training, St. Michael's Hospital, Toronto, Canada
| | - Dorcas Beaton
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Musculoskeletal Health & Outcomes Research, Institute for Work Health, Toronto, Canada
| | - Emil H Schemitsch
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Clinical Orthopaedic Research, St. Michael's Hospital, Toronto, Canada.,Division of Orthopaedic Surgery, London Health Sciences Centre, London, Canada
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25
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Ziebart C, Nazari G, MacDermid JC. Therapeutic exercise for adults post-distal radius fracture: An overview of systematic reviews of randomized controlled trials. HAND THERAPY 2019. [DOI: 10.1177/1758998319865751] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Christina Ziebart
- Department of Rehabilitation Sciences, Faculty of Health Science, Western University, London, Canada
- School of Physical Therapy, Faculty of Health Science, Western University, London, Canada
| | - Goris Nazari
- School of Physical Therapy, Faculty of Health Science, Western University, London, Canada
- Collaborative Program in Musculoskeletal Health Research, Bone and Joint Institute, Western University, London, Canada
| | - Joy C MacDermid
- School of Physical Therapy, Faculty of Health Science, Western University, London, Canada
- Collaborative Program in Musculoskeletal Health Research, Bone and Joint Institute, Western University, London, Canada
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph’s Hospital, London, Canada
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26
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Jung HS, Nho JH, Ha YC, Jang S, Kim HY, Yoo JI, Park SM, Lee YK. Incidence of Osteoporotic Refractures Following Proximal Humerus Fractures in Adults Aged 50 Years and Older in Korea. J Bone Metab 2019; 26:105-111. [PMID: 31223607 PMCID: PMC6561855 DOI: 10.11005/jbm.2019.26.2.105] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 12/28/2022] Open
Abstract
Background The purpose of this study was to investigate the incidence and characteristics of osteoporotic refractures after proximal humerus fracture in Korean adults aged above 50 years. Methods Patients aged 50 years or older with initial proximal humerus fractures reported in 2012 were enrolled and followed up until 2016 using the Korean National Health Insurance data. Based on the last claim date, the refractures were classified as osteoporotic fractures including spine, hip, distal radius, and humerus 6 months after the index fracture involving the proximal humerus. Each osteoprotic fracture was identified using specific International Classification of Diseases, 10th Revision codes and site-specific physician claims for procedures. Results A total of 5,587 first-time fractures involving proximal humerus were reported in 2012. Among them, a total of 1,018 osteoporotic refractures occured between 2012 and 2016. The total cumulative incidence of osteoporotic refractures was 4.85% (271/5,587) at 1 year, 9.61% (537/5,587) at 2 years, 14.21% (794/5,587) at 3 years, and 18.22% (1,018/5,587) at 4 years. In terms of site by year, the incidence of associated refractures was as follows: spine, 48.62% (495/1,018); hip, 25.83% (263/1,018); wrist 18.57% (189/1,018); and humerus 6.97% (71/1,018) during all the follow-up periods. Conclusions Our study showed that the cumulative incidence of osteoporotic refractures following proximal humerus fractures in the elderly population has been increasing over the years. Given that osteoporotic refractures are associated with an increased mortality risk, a public health strategy to prevent the refracture after proximal humerus fracture in the elderly is imperative.
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Affiliation(s)
- Hyoung-Seok Jung
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jae-Hwi Nho
- Department of Orthopedic Surgery, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sunmee Jang
- College of Pharmacy and Gachon Institute of Pharmaceutical Sciences, Gachon University, Incheon, Korea
| | - Ha-Young Kim
- Division of Endocrinology, Department of Internal Medicine, Wonkwang University Sanbon Hospital, Wonkwang University School of Medicine, Gunpo, Korea
| | - Jun-Il Yoo
- Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Jinju, Korea
| | - Sang-Min Park
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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27
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Singaram S, Naidoo M. The physical, psychological and social impact of long bone fractures on adults: A review. Afr J Prim Health Care Fam Med 2019; 11:e1-e9. [PMID: 31170796 PMCID: PMC6556928 DOI: 10.4102/phcfm.v11i1.1908] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 02/07/2019] [Accepted: 02/07/2019] [Indexed: 01/31/2023] Open
Abstract
Background Long bone fractures are common injuries caused by trauma and are a common cause for referral to hospitals. Little consideration has been given to the impact of long bone fractures in adults despite the World Health Organization’s statement that such injuries cause substantial morbidity in low- and middle-income countries. Aim This review targeted published studies conducted from 1990 to 2017 that examined the impact of long bone fractures on the psychological, social, financial, occupational and physical health of adults. Method This scoping review involved a systematic literature search using key terms in Science Direct, Cochrane Library, BMJ Online, PubMed, Jstor, SpringerLink, Emerald Insight and Ebscohost Research databases and Google Scholar. Results From a total of 297 publications, 19 met the inclusion criteria: four publications focused on the impact of fractures of the humerus, one publication looked at ulna fractures, six publications focused on distal radius fractures, five looked at femur fractures and three focused on tibial fractures. Conclusion Long bone fractures have a considerable impact on many facets of a patient’s life. In some cases, the fracture prevents patients from working and meeting financial obligations. The injury limited previously normal social interactions and pre-injury functioning. Future research should examine the impact of long bone fractures in Africa, as there were very limited studies, which were identified.
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Affiliation(s)
- Sevani Singaram
- Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban.
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28
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Oka K, Tanaka H, Okada K, Sahara W, Myoui A, Yamada T, Yamamoto M, Kurimoto S, Hirata H, Murase T. Three-Dimensional Corrective Osteotomy for Malunited Fractures of the Upper Extremity Using Patient-Matched Instruments: A Prospective, Multicenter, Open-Label, Single-Arm Trial. J Bone Joint Surg Am 2019; 101:710-721. [PMID: 30994589 DOI: 10.2106/jbjs.18.00765] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Medical image processing has facilitated simulation of 3-dimensional (3-D) corrective osteotomy, and 3-D rapid prototyping technology has further enabled the manufacturing of patient-matched surgical guides and implants (patient-matched instruments, or PMIs). However, 3-D corrective osteotomy using these technologies has not been the standard procedure. We aimed to prospectively verify the efficacy and safety of PMIs in corrective osteotomy for deformities of the upper extremity. METHODS We enrolled 16 patients with a total of 17 bone deformities in the upper extremity. Eight patients had distal radial malunion; 5, distal humeral malunion; and 3, forearm diaphyseal malunion. All cases underwent 3-D corrective osteotomy with PMIs. The primary end point was the residual maximum deformity angle (MDA), which was calculated from 2 deformity angles-1 on the anteroposterior and 1 on the lateral postoperative radiograph. Secondary end points included the deformity angle on radiographs, 3-D error between the preoperative planning model and the postoperative result, range of motion, grip strength, pain measured with a visual analog scale (VAS), patient satisfaction, and Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS The average MDA significantly improved from 25.5° preoperatively to 3.3° at the final follow-up (p < 0.001). The angular deformity was within 5° in all cases, except for 1 with distal radial malunion who had a higher angle on the anteroposterior radiograph. The error between the correction seen on the postoperative 3-D bone model and the planned correction was <1° and <1 mm. Flexion and extension of the wrist and pronation of the forearm of the patients treated for distal radial malunion improved significantly, and pronation improved for those treated for forearm diaphyseal malunion. The average VAS score, grip strength, and DASH score significantly improved as well. Of the 16 patients, 15 were very satisfied or satisfied with the outcomes. CONCLUSIONS Corrective osteotomy using PMIs achieved accurate correction and good functional recovery in the upper extremity. Although our study was limited to cases without any deformity on the contralateral side, 3-D corrective osteotomy using PMIs resolved treatment challenges for complex deformities in upper extremities. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kunihiro Oka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan.,Health and Counseling Center, Osaka University, Toyonaka, Japan
| | - Hiroyuki Tanaka
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Kiyoshi Okada
- Data Coordinating Center (T.Y.), Department of Medical Innovation (K. Okada and A.M.), Osaka University Hospital, Suita, Japan
| | - Wataru Sahara
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Akira Myoui
- Data Coordinating Center (T.Y.), Department of Medical Innovation (K. Okada and A.M.), Osaka University Hospital, Suita, Japan
| | - Tomomi Yamada
- Data Coordinating Center (T.Y.), Department of Medical Innovation (K. Okada and A.M.), Osaka University Hospital, Suita, Japan
| | - Michiro Yamamoto
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shigeru Kurimoto
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hitoshi Hirata
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsuyoshi Murase
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
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29
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Aguado HJ, Ariño B, Moreno-Mateo F, Bustinza EY, Simón-Pérez C, Martínez-Zarzuela M, García-Virto V, Ventura PS, Martín-Ferrero MÁ. Does an early mobilization and immediate home-based self-therapy exercise program displace proximal humeral fractures in conservative treatment? Observational study. J Shoulder Elbow Surg 2018; 27:2021-2029. [PMID: 29803503 DOI: 10.1016/j.jse.2018.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/26/2018] [Accepted: 04/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Nonoperative management of proximal humeral fractures (PHFs) is the most common treatment, but its functional outcome may improve with early mobilization. In frail osteoporotic patients, quick recovery of prefracture independency is mandatory. This study assessed fracture displacement in PHFs managed with conservative treatment after early mobilization and a home-based self-exercise program. METHODS We retrospectively analyzed the radiologic displacement of fracture fragments of PHFs treated conservatively with early mobilization and a home-based self-exercise program. RESULTS Included were 99 patients with 26 one-part, 32 two-part, 32 three-part, and 9 four-part PHFs managed conservatively, followed by early mobilization and a home-based self-exercise program. In the x-ray examinations, the head displaced from varus into valgus 55° ± 23° to 42° ± 22°, in the normal range of anatomic values. The medial hinge displaced from medial to the diaphysis (+1 ± 6 mm) to lateral to the head (-0.6 ± 6 mm). The greater tuberosity displaced cranially from -1 ± 7 mm to 2 ± 5 mm. The Constant score at the 1-year follow-up was 79.69 ± 16.3. DISCUSSION AND CONCLUSIONS The home-based self-exercise program for conservative treatment of PHFs displaces the head-diaphysis angle and the medial hinge toward anatomic reduction, but there is a risk of greater tuberosity cranial displacement. Functional results are fairly good, allowing frail patients to keep on with their independency and life style. Because a large number of patients might need further physiotherapy, the quality of the home-based self-exercises should be supervised.
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Affiliation(s)
- Héctor J Aguado
- Orthopedic and Trauma Surgery (Trauma Unit), Hospital Clínico Universitario, Valladolid, Spain; Medical School, University of Valladolid, Valladolid, Spain.
| | - Blanca Ariño
- Orthopedic and Trauma Surgery, Hospital Clínico Universitario, Valladolid, Spain
| | | | - Elías Y Bustinza
- Orthopedic and Trauma Surgery, Hospital Clínico Universitario, Valladolid, Spain
| | - Clarisa Simón-Pérez
- Medical School, University of Valladolid, Valladolid, Spain; Orthopedic and Trauma Surgery (Upper Limb Unit), Hospital Clínico Universitario, Valladolid, Spain
| | | | - Virginia García-Virto
- Orthopedic and Trauma Surgery (Trauma Unit), Hospital Clínico Universitario, Valladolid, Spain
| | | | - Miguel Ángel Martín-Ferrero
- Medical School, University of Valladolid, Valladolid, Spain; Orthopedic and Trauma Surgery, Hospital Clínico Universitario, Valladolid, Spain
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30
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Abstract
STUDY DESIGN Clinical commentary. INTRODUCTION Proximal humeral fractures (PHF) are the third most common fracture in the elderly with an increased incidence expected in the coming years with the aging population, causing an important burden to the healthcare system. The management of PHF is challenging due to its complexity and the wide variety of fractures and treatment options. PURPOSE The objective of this clinical commentary is to update the available evidence on clinical presentation, classification, imaging, medical treatment, and rehabilitation of acute PHF. METHODS/RESULTS/DISCUSSION N/A for clinical commentary. CONCLUSIONS The first step to a successful management of PHF is the clinical and radiographic examination of the shoulder, which enables the physician to classify the fracture and choose the appropriate treatment option. The Neer and OA classifications are commonly used and are based on the identification of the fractured parts of the humerus, as well as the displacement of the fragments. In case of non-displaced or minimally displaced fractures, a conservative treatment, consisting of initial immobilization and a rehabilitation program will be chosen. Displaced or unstable fractures will be managed operatively. Different surgical options exist and will vary according to the fracture type, patient's age, and functional needs, followed by rehabilitation. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- Véronique Lowry
- Department of Research, Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, Quebec, Canada
| | - Nathalie J Bureau
- Radiology Department, University of Montreal, Montreal, Quebec, Canada; Department of Research, Research Center, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - François Desmeules
- Department of Research, Maisonneuve-Rosemont Hospital Research Center, University of Montreal Affiliated Research Center, Montreal, Quebec, Canada; Department of Rehabilitation, School of Rehabilitation, Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Jean-Sébastien Roy
- Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada; Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec, Canada
| | - Dominique M Rouleau
- Department of Surgery, Hôpital du Sacré-Cœur de Montréal, Montréal PQ, Canada; Department of Surgery, Université de Montréal, Montréal PQ, Canada.
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31
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Bruder AM, Shields N, Dodd KJ, Taylor NF. Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation: a systematic review. J Physiother 2017; 63:205-220. [PMID: 28941967 DOI: 10.1016/j.jphys.2017.08.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 08/14/2017] [Accepted: 08/16/2017] [Indexed: 01/09/2023] Open
Abstract
QUESTION What is the effect of exercise on increasing participation and activity levels and reducing impairment in the rehabilitation of people with upper limb fractures? DESIGN Systematic review of controlled trials. PARTICIPANTS Adults following an upper limb fracture. INTERVENTION Any exercise therapy program, including trials where exercise was delivered to both groups provided that the groups received different amounts of exercise. OUTCOME MEASURES Impairments of body structure and function, activity limitations and participation restrictions. RESULTS Twenty-two trials were identified that evaluated 1299 participants with an upper limb fracture. There was insufficient evidence from 13 trials to support or refute the effectiveness of home exercise therapy compared with therapist-supervised exercise or therapy that included exercise following distal radius or proximal humeral fractures. There was insufficient evidence from three trials to support or refute the effectiveness of exercise therapy compared with advice/no exercise intervention following distal radius fracture. There was moderate evidence from five trials (one examining distal radius fracture, one radial head fracture, and three proximal humeral fracture) to support commencing exercise early and reducing immobilisation in improving activity during upper limb rehabilitation compared with delayed exercise and mobilisation. There was preliminary evidence from one trial that exercise to the non-injured arm during immobilisation might lead to short-term benefits on increasing grip strength and range of movement following distal radius fracture. Less than 40% of included trials reported adequate exercise program descriptions to allow replication according to the TIDieR checklist. CONCLUSION There is emerging evidence that current prescribed exercise regimens may not be effective in reducing impairments and improving activity following an upper limb fracture. Starting exercise early combined with a shorter immobilisation period is more effective than starting exercise after a longer immobilisation period. REGISTRATION CRD42016041818. [Bruder AM, Shields N, Dodd KJ, Taylor NF (2017) Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation: a systematic review. Journal of Physiotherapy 63: 205-220].
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Affiliation(s)
| | - Nora Shields
- School of Allied Health, La Trobe University; Department of Allied Health, Northern Health
| | - Karen J Dodd
- School of Allied Health, La Trobe University; Victoria University
| | - Nicholas F Taylor
- School of Allied Health, La Trobe University; Allied Health Clinical Research Office, Eastern Health, Melbourne, Australia
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Carbone S, Razzano C, Albino P, Mezzoprete R. Immediate intensive mobilization compared with immediate conventional mobilization for the impacted osteoporotic conservatively treated proximal humeral fracture: a randomized controlled trial. Musculoskelet Surg 2017; 101:137-143. [PMID: 28770512 DOI: 10.1007/s12306-017-0483-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/05/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE To select in a 2-year survey of proximal humerus fractures accessing the emergency department, a population of osteoporotic stable impacted fractures and to randomize them into two groups, one with an immediate intensive mobilization program and the other with an immediate conventional mobilization program. METHODS In emergency department, patients with clinical signs of shoulder girdle fracture were submitted to standard X-ray examination and CT scan. Patients with stable (absence of metaphyseal comminution or fifth fragment) osteoporotic (cortical bone thickness lower than 6 mm) impacted (Is any part of metaphysis or head impacted into the shaft? YES/NO) proximal humerus fractures were selected for randomization in one of the two groups. Group 1: early intensive mobilization; Group 2: early conventional mobilization. Functional and radiographic assessment was recorded at 3, 6 and 12 months of follow-up. RESULTS In the considered period, 120 patients were affected by a stable impacted osteoporotic proximal humerus fracture. At the final follow-up, 36 patients in group 1 and 39 patients in group 2 were available for statistical analysis. Functional and radiographic scores were comparable, with a trend of significance in favor of group 2. No fracture in any of the group showed significant loss of reduction respect to 6 months of follow-up. 4 (10%) and 1 (2.5%) patients in groups 1 and 2 were not compliant with the rehabilitation program (p = 0.037). CONCLUSIONS This randomized controlled trial showed that impacted osteoporotic proximal humerus fractures can be managed non-operatively with an early conventional rehabilitation program composed by 10 sessions of passive motion twice a week, followed by recovery of active range of motion for further 10 sessions thrice a week, while no advantage is given by a more aggressive rehabilitation regimen. Self-assisted exercises should be explained to patients to maximize the effects of the assisted program. LEVEL OF EVIDENCE Level 1, randomized controlled double-blinded trial.
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Affiliation(s)
- S Carbone
- Orthopaedic and Traumatology Department, Ospedale San Camillo de Lellis, Rieti, Italy.
- FIMAC Onlus, Via Giulio Pittarelli 114, 00166, Rome, Italy.
| | - C Razzano
- Department of Physical Medicine and Rehabilitation, Sapienza University of Rome, P.le Aldo Moro, 5, 00185, Rome, Italy
- Department of Physical Medicine and Rehabilitation, Centro Medico Erre, Via Pennino Traversa Mustilli, Sant'Agata dei Goti, BN, Italy
- MED.IT.A Onlus, Naples, Italy
| | - P Albino
- Casa di Cura Città di Aprilia, Aprilia, Italy
| | - R Mezzoprete
- Orthopaedic and Traumatology Department, Ospedale San Camillo de Lellis, Rieti, Italy
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33
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Gigis I, Nenopoulos A, Giannekas D, Heikenfeld R, Beslikas T, Hatzokos I. Reverse Shoulder Arthroplasty for the Treatment of 3 and 4- Part Fractures of the Humeral Head in the Elderly. Open Orthop J 2017; 11:108-118. [PMID: 28400879 PMCID: PMC5366383 DOI: 10.2174/1874325001711010108] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 04/18/2016] [Accepted: 04/20/2016] [Indexed: 01/30/2023] Open
Abstract
Background: Proximal humeral fractures in elderly patients present with severe comminution and osteoporotic bone quality. Reverse shoulder arthroplasty has lately been proven beneficial in treating patients with complex proximal humeral fractures. The above technique is recommended and has better results in elderly than in younger individuals. Methods: We performed a literature search in the databases Pubmed, Medline, EMBASE and Cochrane Library for published articles between 1970 and 2016 using the terms: proximal humerus fractures and reverse shoulder arthroplasty. Results: Significant benefits with the use of reverse prosthesis, especially in patients older than 70 years with a proximal humeral fracture, include reduced rehabilitation time as well as conservation of a fixed fulcrum for deltoid action in case of rotator cuff failure. Compared with hemiarthroplasty and internal fixation, reverse prosthesis may be particularly useful and give superior outcomes in older patients, due to comminuted fractures in osteopenic bones. However, significant disadvantages of this technique are potential complications and a demanding learning curve.Therefore, trained surgeons should follow specific indications when applying the particular treatment of proximal humeral fractures and be familiar with the surgical technique. Conclusion: Although long-term results and randomized studies for reverse prosthesis are lacking, short and mid- term outcomes have given promising results encouraging more shoulder surgeons to use this type of prosthesis in proximal humeral fractures.
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Affiliation(s)
- Ioannis Gigis
- 2 Orthopedic Department, Aristotle University of Thessaloniki, "G. Gennimatas" General Hospital Thessaloniki, Thessaloniki, Greece
| | - Alexandros Nenopoulos
- 2 Orthopedic Department, Aristotle University of Thessaloniki, "G. Gennimatas" General Hospital Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Giannekas
- 2 Orthopedic Department, Aristotle University of Thessaloniki, "G. Gennimatas" General Hospital Thessaloniki, Thessaloniki, Greece
| | - Roderich Heikenfeld
- Center for Shoulder, Elbow and Hand Surgery, Center for Orthopaedics and Traumatology of the St. Elisabeth Group - Catholic Hospitals Rhein-Ruhr, St. Anna Hospital Herne, Marienhospital Herne University Hopsital, Marienhospital Witten, Germany
| | - Theodoros Beslikas
- 2 Orthopedic Department, Aristotle University of Thessaloniki, "G. Gennimatas" General Hospital Thessaloniki, Thessaloniki, Greece
| | - Ippokratis Hatzokos
- 2 Orthopedic Department, Aristotle University of Thessaloniki, "G. Gennimatas" General Hospital Thessaloniki, Thessaloniki, Greece
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Bruder AM, McClelland JA, Shields N, Dodd KJ, Hau R, van de Water ATM, Taylor NF. Validity and reliability of an activity monitor to quantify arm movements and activity in adults following distal radius fracture. Disabil Rehabil 2017. [PMID: 28637143 DOI: 10.1080/09638288.2017.1288764] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To examine the validity and reliability of an activity monitor to estimate upper limb activity. METHODS Thirty-two adults after distal radial fracture were recruited. 15 adults performed five upper limb activities during two testing sessions, one week apart to investigate criterion validity against the criterion reference of three-dimensional motion analysis, convergent validity, and test-retest reliability. 17 adults in two therapy groups wore monitors for three consecutive days at baseline and six weeks post-intervention. Hypothesis testing (noninferiority) assessed comparison of group differences. RESULTS There were large, significant positive correlations between monitor counts and motion analysis for affected/unaffected wrists during the grocery shelving [r = 0.82, r = 0.73, respectively] and floor sweeping activities [r = 0.54, r = 0.59, respectively]. Large confidence intervals relative to means suggests the monitor could not accurately predict motion analysis distance or acceleration. Relative reliability was excellent in affected/unaffected wrists for crank ergometer [ICC(2,1) = 0.91, ICC(2,1) = 0.88, respectively], grocery shelving [ICC(2,1) = 0.83, ICC(2,1) = 0.89, respectively], and table dusting activities [ICC(2,1) = 0.77, ICC(2,1) = 0.83, respectively]. Correlations and reliability for typing were poor; hypothesis testing of group equivalence was not confirmed. CONCLUSIONS There is preliminary evidence that an activity monitor is a valid and reliable tool to measure gross arm activity after distal radial fracture. Implications for Rehabilitation Distal radius fractures are one of the most common upper limb fractures that cause activity limitations and participation restrictions. After a distal radius fracture patients are often referred to therapy (physiotherapy, occupational therapy, hand therapy) for rehabilitation to return to pre-injury function and activity levels. Activity monitors may be a valid and reliable measurement tool that therapists can use with their patients to quantify gross arm activity to enable monitoring of injury recovery and rehabilitation adherence. Activity monitors may not be sufficiently reliable and valid to monitor fine movements of the wrist and hand after distal radius fracture.
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Affiliation(s)
- Andrea M Bruder
- a School of Allied Health, La Trobe University , Melbourne , Australia
| | | | - Nora Shields
- a School of Allied Health, La Trobe University , Melbourne , Australia.,b Department of Allied Health , Northern Health , Melbourne , Australia
| | - Karen J Dodd
- c College of Science, Health and Engineering, La Trobe University , Melbourne , Australia
| | - Raphael Hau
- d Northern Clinical School, Melbourne Medical School , Melbourne , Australia
| | - Alexander T M van de Water
- a School of Allied Health, La Trobe University , Melbourne , Australia.,e Physiotherapy Department , Saxion University of Applied Science , Enschede , Netherlands
| | - Nicholas F Taylor
- a School of Allied Health, La Trobe University , Melbourne , Australia.,f Allied Health Clinical Research Office, Eastern Health , Melbourne , Australia
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Grubhofer F, Wieser K, Meyer DC, Catanzaro S, Schürholz K, Gerber C. Reverse total shoulder arthroplasty for failed open reduction and internal fixation of fractures of the proximal humerus. J Shoulder Elbow Surg 2017; 26:92-100. [PMID: 27521139 DOI: 10.1016/j.jse.2016.05.020] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/11/2016] [Accepted: 05/26/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open reduction and internal fixation (ORIF) of complex fractures of the proximal humerus may yield unsatisfactory results. This study analyzed the results obtained after revision of failed ORIF of proximal humeral fractures using reverse total shoulder arthroplasty (RTSA). METHODS Fifty-four shoulders of 53 patients with a subjectively unacceptable outcome after ORIF of a complex fracture of the proximal humerus were revised with RTSA. At a minimum follow-up of 2 years (mean follow-up, 46 months; range, 24-108 months), 44 shoulders were clinically and radiographically reviewed for the purpose of this study. Six patients had been lost to follow-up, and 4 patients (7%) were excluded from functional analysis because of revision surgeries. RESULTS The mean absolute Constant score improved from 26 (range, 4-54) to 55 (range, 19-80) points; the mean relative Constant score improved from 32% (range, 4%-85%) to 67% (range, 27%-94%) of an age- and gender-matched, normal shoulder. The mean subjective shoulder value improved from 29% (range, 0%-90%) preoperatively to 67% (range, 5%-95%) at final follow-up. Nineteen patients rated their outcome excellent, 16 good, and 7 fair; 2 patients were dissatisfied. CONCLUSION RTSA is a valuable salvage procedure after failed ORIF of a proximal humeral fracture with relatively low revision rates. Shoulder function, patient satisfaction, and pain levels can be reliably improved.
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Affiliation(s)
- Florian Grubhofer
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Karl Wieser
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Dominik C Meyer
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Sabrina Catanzaro
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Katharina Schürholz
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland
| | - Christian Gerber
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zürich, Switzerland.
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Clinical Effects of the Probing Method with Depth Gauge for Determining the Screw Depth of Locking Proximal Humeral Plate. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5898161. [PMID: 27975055 PMCID: PMC5126400 DOI: 10.1155/2016/5898161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/27/2016] [Indexed: 11/17/2022]
Abstract
Background. The use of locking plates has gained popularity to treat proximal humeral fractures. However, the complication rates remain high. Biomechanical study suggested that subchondral screw-tip abutment significantly increased the stability of plant. We present a simple method to obtain the proper screw length through the depth gauge in elderly patients and compared the clinical effects with traditional measuring method. Methods. 40 patients were separated into two groups according to the two surgical methods: the probing method with depth gauge and the traditional measuring method. The intraoperative indexes and postoperative complications were recorded. The Constant and Murley score was used for the functional assessment in the 12th month. Results. Operative time and intraoperative blood loss indicated no statistical differences. X-ray exposure time and the patients with screw path penetrating the articular cartilage significantly differed. Postoperative complications and Constant and Murley score showed no statistical differences. Conclusions. Probing method with depth gauge is an appropriate alternative to determine the screw length, which can make the screw-tip adjoin the subchondral bone and keep the articular surface of humeral head intact and at the same time effectively avoid frequent X-ray fluoroscopy and adjusting the screws.
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Cabana F, Pagé C, Svotelis A, Langlois-Michaud S, Tousignant M. Is an in-home telerehabilitation program for people with proximal humerus fracture as effective as a conventional face-to face rehabilitation program? A study protocol for a noninferiority randomized clinical trial. BMC Sports Sci Med Rehabil 2016; 8:27. [PMID: 27570627 PMCID: PMC5000429 DOI: 10.1186/s13102-016-0051-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 08/17/2016] [Indexed: 12/22/2022]
Abstract
Background Proximal humerus fractures can be treated surgically (eg: pinning, plate and screws) or conservatively by wearing a splint or a cast. Following both of these approaches, rehabilitation has proven effective to prevent functional limitations and to re-establish normal shoulder function. However, access to these rehabilitation services and compliance tends to be limited in elderly patients due to travelling difficulties caused by their precarious health status and, in some cases, social and marital status. Since the majority of patients with a proximal humerus fracture are elderly, it becomes relevant to find a new way to offer quick, simple and suitable rehabilitation service. Thus, the use of promising alternative approaches, as in-home telerehabilitation, can enhance access to rehabilitation services for such population. The main objective of the study is to compare the clinical effects of the innovative telerehabilitation approach (TELE group) compared to face-to-face visits to a clinic (CLINIC group) for patients treated for a proximal humerus fracture. Methods/Design In this randomized controlled trial, individuals who have had a proximal humerus fracture treated conservatively at the Centre intégré universitaire de santé et de services sociaux de l’Estrie - Centre hospitalier universitaire de Sherbrooke (CIUSSS de l’Estrie CHUS), and who are returning home will be included. Participants will be recruited during their visit to the emergency ward or outpatient clinic by the medical or research team and will then sign the informed consent form if they are interested to participate in the study. We expect to recruit 52 participants (26 per group). Randomization will be done by a random number generator with sealed envelopes. Each patient will be evaluated before the beginning of the rehabilitation (T1), and immediately after the 2-month intervention (T2). The following outcomes will be measured: 1) upper extremity function (Constant Shoulder Score and Disability of the Arm, Shoulder and Hand questionnaire [DASH]); 2) range of motion (conventional goniometer); 3) user satisfaction (Health Care Satisfaction questionnaire); and 4) cost of services to the public healthcare system. The difference between the two groups will be compared using a t-test or a chi-squared test, and through a cost-effectiveness economic analysis. Discussion We hypothesize that in-home telerehabilitation will provide a good alternative to conventional rehabilitation, in terms of its efficacy, simplicity, patient satisfaction, and low associated costs. Trial registration ClinicalTrials.gov: NCT02425267. April 22nd, 2015.
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Affiliation(s)
- François Cabana
- Department of surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, J1H 5N4 QC Canada
| | - Catherine Pagé
- Research Centre on Aging, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie CHUS), 1036 Belvédère Sud, Sherbrooke, J1H 4C4 QC Canada
| | - Amy Svotelis
- Department of surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, J1H 5N4 QC Canada
| | - Samuel Langlois-Michaud
- Department of surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, J1H 5N4 QC Canada
| | - Michel Tousignant
- Research Centre on Aging, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie CHUS), 1036 Belvédère Sud, Sherbrooke, J1H 4C4 QC Canada
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Cvetanovich GL, Frank RM, Chalmers PN, Verma NN, Nicholson GP, Romeo AA. Surgical Management of Proximal Humeral Fractures: The Emerging Role of Reverse Total Shoulder Arthroplasty. Orthopedics 2016; 39:e465-73. [PMID: 27045483 DOI: 10.3928/01477447-20160324-02] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 10/13/2015] [Indexed: 02/03/2023]
Abstract
Acute proximal humeral fractures are common injuries in elderly patients. These fractures can lead to significant pain and functional loss. Nonoperative treatment offers high rates of satisfactory function and pain relief in the majority of fractures, particularly in elderly patients. Open reduction and internal fixation, closed reduction and percutaneous pinning, and hemiarthroplasty are used for treating displaced proximal humeral fractures, depending on patient and fracture characteristics. Recently, reverse total shoulder arthroplasty has gained popularity for treatment of complex proximal humeral fractures due to a rapid recovery of active elevation and activities of daily living function. Although complications remain a concern, early results of reverse total shoulder arthroplasty for proximal humeral fractures have been promising. Future comparative outcome studies are needed to define the indications for reverse total shoulder arthroplasty instead of nonoperative and other operative options. Optimal treatment of proximal humeral fractures requires clinical judgment based on fracture characteristics, bone quality, patient factors, and surgeon experience with the array of available techniques. [Orthopedics. 2016; 39(3):e465-e473.].
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Abstract
BACKGROUND Fracture of the proximal humerus, often termed shoulder fracture, is a common injury in older people. The management of these fractures varies widely. This is an update of a Cochrane Review first published in 2001 and last updated in 2012. 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 Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and other databases, conference proceedings and bibliographies of trial reports. The full search ended in November 2014. SELECTION CRITERIA We considered all randomised controlled trials (RCTs) and quasi-randomised controlled trials pertinent to the management of proximal humeral fractures in adults. DATA COLLECTION AND ANALYSIS Both review authors performed independent study selection, risk of bias assessment and data extraction. Only limited meta-analysis was performed. MAIN RESULTS We included 31 heterogeneous RCTs (1941 participants). Most of the 18 separate treatment comparisons were tested by small single-centre trials. The main exception was the surgical versus non-surgical treatment comparison tested by eight trials. Except for a large multicentre trial, bias in these trials could not be ruled out. The quality of the evidence was either low or very low for all comparisons except the largest comparison.Nine trials evaluated non-surgical treatment in mainly minimally displaced fractures. Four trials compared early (usually one week) versus delayed (three or four weeks) mobilisation after fracture but only limited pooling was possible and most of the data were from one trial (86 participants). This found some evidence that early mobilisation resulted in better recovery and less pain in people with mainly minimally displaced fractures. There was evidence of little difference between the two groups in shoulder complications (2/127 early mobilisation versus 3/132 delayed mobilisation; 4 trials) and fracture displacement and non-union (2/52 versus 1/54; 2 trials).One quasi-randomised trial (28 participants) found the Gilchrist-type sling was generally more comfortable than the Desault-type sling (body bandage). One trial (48 participants) testing pulsed electromagnetic high-frequency energy provided no evidence. Two trials (62 participants) provided evidence indicating little difference in outcome between instruction for home exercises versus supervised physiotherapy. One trial (48 participants) reported, without presentable data, that home exercise alone gave better early and comparable long-term results than supervised exercise in a swimming pool plus home exercise.Eight trials, involving 567 older participants, evaluated surgical intervention for displaced fractures. There was high quality evidence of no clinically important difference in patient-reported shoulder and upper-limb function at one- or two-year follow-up between surgical (primarily locking plate fixation or hemiarthroplasty) and non-surgical treatment (sling immobilisation) for the majority of displaced proximal humeral fractures; and moderate quality evidence of no clinically important difference between the two groups in quality of life at two years (and at interim follow-ups at six and 12 months). There was moderate quality evidence of little difference between groups in mortality in the surgery group (17/248 versus 12/248; risk ratio (RR) 1.40 favouring non-surgical treatment, 95% confidence interval (CI) 0.69 to 2.83; P = 0.35; 6 trials); only one death was explicitly linked with the treatment. There was moderate quality evidence of a higher risk of additional surgery in the surgery group (34/262 versus 16/261; RR 2.06, 95% CI 1.18 to 3.60; P = 0.01; 7 trials). Although there was moderate evidence of a higher risk of adverse events after surgery, the 95% confidence intervals for adverse events also included the potential for a greater risk of adverse events after non-surgical treatment.Different methods of surgical management were tested in 12 trials. One trial (57 participants) comparing two types of locking plate versus a locking nail for treating two-part surgical neck fractures found some evidence of slightly better function after plate fixation but also of a higher rate of surgically-related complications. One trial (61 participants) comparing a locking plate versus minimally invasive fixation with distally inserted intramedullary K-wires found little difference between the two implants at two years. Compared with hemiarthroplasty, one trial (32 participants) found similar results with locking plate fixation in function and re-operation rates, whereas another trial (30 participants) reported all five re-operations occurred in the tension-band fixation group. One trial (62 participants) found better patient-rated (Quick DASH) and composite shoulder function scores at a minimum of two years follow-up and a lower incidence of re-operation and complications after reverse shoulder arthroplasty (RSA) compared with hemiarthroplasty.No important between-group differences were found in one trial (120 participants) comparing the deltoid-split approach versus deltopectoral approach for non-contact bridging plate fixation, and two trials (180 participants) comparing 'polyaxial' and 'monaxial' screws in locking plate fixation. One trial (68 participants) produced some preliminary evidence that tended to support the use of medial support locking screws in locking plate fixation. One trial (54 participants) found fewer adverse events, including re-operations, for the newer of two types of intramedullary nail. One trial (35 participants) found better functional results for one of two types of hemiarthroplasty. One trial (45 participants) found no important effects of tenodesis of the long head of the biceps for people undergoing hemiarthroplasty.Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial: 64 participants) or hemiarthroplasty (one trial: 49 participants). AUTHORS' CONCLUSIONS There is high or moderate quality 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 involving the humeral neck and is likely to result in a greater need for subsequent surgery. The evidence does not cover the treatment of two-part tuberosity fractures, fractures in young people, high energy trauma, nor the less common fractures such as fracture dislocations and head splitting fractures.There is insufficient evidence from RCTs to inform the choices between different non-surgical, surgical, or rehabilitation interventions for these fractures.
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Affiliation(s)
- Helen H G Handoll
- Health and Social Care Institute, Teesside University, Middlesbrough, Tees Valley, UK, TS1 3BA
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Emergency Department Evaluation and Treatment of the Shoulder and Humerus. Emerg Med Clin North Am 2015; 33:297-310. [DOI: 10.1016/j.emc.2014.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
OBJECTIVES Determine the relative position of the main fractured fragments of proximal humerus fractures treated conservatively to compare displacement at 2 time points: injury (0), and 1 year later (1). DESIGN Prospective, comparative cohort study. SETTING Level I trauma center. PATIENTS Eighty-nine prospectively enrolled adults. INTERVENTION Six weeks of sling immobilization and a home-based program rehabilitation protocol started 2 weeks after injury. MAIN OUTCOME MEASUREMENTS Standardized radiographs of injured shoulders were obtained in all patients at times 0 and 1. Computed tomography scans were also obtained at these times in 73 cases. Forty-two computer-assisted measurements of displacement were performed at times 0 and 1 and then compared. Factors related to progression of displacement were analyzed. RESULTS Ninety percent of fractures were classified into 1 of 4 patterns: posteromedial (varus) impaction (46), lateral (valgus) impaction (13), isolated greater tuberosity (15), and anteromedial impaction (6). Head-shaft displacement increased over time. In posteromedial impaction fractures, average fracture settling included 9 degrees in varus, 7 degrees in retroversion, and 3.2 mm in posterior shortening. In valgus-impacted fractures, a decrease in valgus tilt and a tendency toward a more anterior orientation of the articular surface was observed. Greater tuberosity displacement increased more than 5 mm in less than 20% of cases. Age and initial displacement were related to progression of displacement. CONCLUSIONS Proximal humerus fractures treated conservatively settle at the head-shaft junction during healing. Substantial additional displacement of tuberosities was seldom observed. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Tousignant M, Giguère AM, Morin M, Pelletier J, Sheehy A, Cabana F. In-home telerehabilitation for proximal humerus fractures: a pilot study. Int J Telerehabil 2015; 6:31-7. [PMID: 25945227 PMCID: PMC4353003 DOI: 10.5195/ijt.2014.6158] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The objective of this study was to investigate the feasibility of an in-home telerehabilitation program for proximal humerus fractures. Seventeen patients with proximal humerus fractures were recruited by an orthopedic specialist during emergency room visits. Telerehabilitation treatments were given at the patient’s home over an 8-week period using a videoconferencing system. Pain (Short-Form McGill Pain Questionnaire [SF-MPQ]), disabilities including shoulder range of motion (flexion, extension, internal rotation, external rotation, abduction), and upper limb function (Disability of the Arm, Shoulder and Hand questionnaire [DASH]) were measured in face-to-face evaluations before (T1) and immediately after (T2) the program. Participant satisfaction with the health care received was also evaluated at T2 with the Health care satisfaction questionnaire. All the clinical outcomes improved post-intervention (p < 0.05). Also, patient satisfaction was high (overall score of 82 ± 7%). Therefore, in-home teletreatment seems to be a promising way to dispense rehabilitation services for this population.
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Affiliation(s)
- Michel Tousignant
- SCHOOL OF REHABILITATION, FACULTY OF MEDICINE AND HEALTH SCIENCES, UNIVERSITÉ DE SHERBROOKE, SHERBROOKE, QUÉBEC, CANADA ; RESEARCH CENTRE ON AGING, UNIVERSITY INSTITUTE OF GERIATRICS OF SHERBROOKE, SHERBROOKE, QUÉBEC, CANADA
| | - Anne-Marie Giguère
- SCHOOL OF REHABILITATION, FACULTY OF MEDICINE AND HEALTH SCIENCES, UNIVERSITÉ DE SHERBROOKE, SHERBROOKE, QUÉBEC, CANADA
| | - Marilène Morin
- SCHOOL OF REHABILITATION, FACULTY OF MEDICINE AND HEALTH SCIENCES, UNIVERSITÉ DE SHERBROOKE, SHERBROOKE, QUÉBEC, CANADA
| | - Julie Pelletier
- SCHOOL OF REHABILITATION, FACULTY OF MEDICINE AND HEALTH SCIENCES, UNIVERSITÉ DE SHERBROOKE, SHERBROOKE, QUÉBEC, CANADA
| | - Annie Sheehy
- SCHOOL OF REHABILITATION, FACULTY OF MEDICINE AND HEALTH SCIENCES, UNIVERSITÉ DE SHERBROOKE, SHERBROOKE, QUÉBEC, CANADA
| | - François Cabana
- ORTHOPAEDIC SURGERY DIVISION, DEPARTMENT OF DURGERY, FACULTY OF MEDICINE AND HEALTH SCIENCES, UNIVERSITÉ DE SHERBROOKE, SHERBROOKE, QUÉBEC, CANADA
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Maravic M, Briot K, Roux C. Burden of proximal humerus fractures in the French National Hospital Database. Orthop Traumatol Surg Res 2014; 100:931-4. [PMID: 25453923 DOI: 10.1016/j.otsr.2014.09.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 08/18/2014] [Accepted: 09/17/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe the characteristics of patients hospitalized for osteoporotic proximal humerus fracture in 2009 in France, in-patient mortality, and further hospitalizations for hip fracture. METHODS Data were extracted from the French Hospital National Database. We selected patients aged 40 years and over hospitalized for proximal humerus fracture in 2009, without cancer. Based on their unique identification number, we described the next hospitalizations occurring in 2009-2011 whatever the causes. Incidence, in-patient mortality, and hospital costs were calculated. RESULTS We numbered 10,874 patients (77% of women, mean age 72.5 years). The incidence per million was 477 and 163 in women and men, respectively. This incidence increased with age and was higher in women (i.e. 1374 and 320 in women and men aged over 74 years, respectively). Surgical treatment was applied in 56% of patients; median hospital stay was 5 days. Rehabilitation unit was necessary in 26% of cases. In-patient mortality was 1.1%. The overall hospital costs was €34 millions. Rehospitalizations occurred for 61% of the patients and had more co-morbidities than others. Near 8% of the rehospitalized patients were for hip fractures occurring in a median of 353 days after hospitalization for proximal humerus fracture. The hospital costs for these rehospitalizations was €52 millions. CONCLUSION Proximal humerus fractures incidence increases with aging, especially in women. These fractures are associated with a significant in-patient mortality and health care resources utilization. Patients with such fracture must receive high priority for optimal post fracture treatment.
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Affiliation(s)
- M Maravic
- Rheumatology, Lariboisière Hospital, 75010 Paris, France.
| | - K Briot
- Paris Descartes University, Department of Rheumatology, Cochin Hospital, and Epidemiology and Biostatistics Unit, Sorbonne Paris Cité Research Center, 75014 Paris, France
| | - C Roux
- Paris Descartes University, Department of Rheumatology, Cochin Hospital, and Epidemiology and Biostatistics Unit, Sorbonne Paris Cité Research Center, 75014 Paris, France
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Vachtsevanos L, Hayden L, Desai AS, Dramis A. Management of proximal humerus fractures in adults. World J Orthop 2014; 5:685-693. [PMID: 25405098 PMCID: PMC4133477 DOI: 10.5312/wjo.v5.i5.685] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/15/2014] [Accepted: 07/15/2014] [Indexed: 02/06/2023] Open
Abstract
The majority of proximal humerus fractures are low-energy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. Non-operative management has been associated with good functional outcomes in stable, minimally displaced and certain types of displaced fractures. Absolute indications for surgery are infrequent and comprise compound, pathological, multi-fragmentary head-splitting fractures and fracture dislocations, as well as those associated with neurovascular injury. A constantly expanding range of reconstructive and replacement options however has been extending the indications for surgical management of complex proximal humerus fractures. As a result, management decisions are becoming increasingly complicated, in an attempt to provide the best possible treatment for each individual patient, that will successfully address their specific fracture configuration, comorbidities and functional expectations. Our aim was to review the management options available for the full range of proximal humerus fractures in adults, along with their specific advantages, disadvantages and outcomes.
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Bonifacio L, Syson P, Llanes J. Revisiting the outcome of displaced two-part fractures of the humeral neck in elderly patients after conservative treatment. Malays Orthop J 2014; 8:57-60. [PMID: 25279082 PMCID: PMC4093553 DOI: 10.5704/moj.1403.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to evaluate our experience with
regard to the outcome of displaced two-part fractures of the
humeral neck in elderly patients that were treated
conservatively.
Between July 2008 and June 2010, 53 consecutive patients
(42 females and 11 males; mean age = 74; range = 60-92)
with an acute, displaced, two-part fracture of the humeral
neck were treated conservatively using a sling and swathe for
two weeks, followed by a standard rehabilitation protocol.
The inclusion criteria were a displacement of the shaft >50%
of its width and/or angulation of the shaft >45 degrees on
standard radiographs. The exclusion criteria were patients
younger than 60 years of age and those with cognitive or
systemic impairment that would preclude the recommended
physiotherapy. Patients were followed-up for one year, and
were assessed at 3, 6, and 12 months using the Constant-
Murley Score (CMS) and the Disabilities of the Arm,
Shoulder, and Hand Questionnaire (DASH). Patients were
divided into two groups, those below 70 years of age and
those above 70-. Two-way repeated measures analysis of
variance (ANOVA) was used to determine if there were
significant differences between the results at 3, 6 and 12
months for both groups, and if the results were significantly
different between the two groups. Forty-eight out of 53 patients (91%) were able to complete
the follow-up schedule, while five patients died. The mean
CMS improved progressively at three (51.3), six (60.4), and
12 (61.3) months. The mean DASH also improved
progressively at three (38.8), six (34.8), and 12 (32.6)
months. For both groups, the CSS and DASH improved
significantly from three to six months and from three to 12
months. However, the improvements were not significant
from just six to 12 months. Between the two groups, the
results at three, six, and 12 months were not significantly
different from each other. On final follow-up, 42 out of 48
patients (88%) were satisfied with their outcome and
reported that they would choose to undergo the same
treatment if they had to do everything all over again. Conservative management of displaced two-part fractures of
the humeral neck in elderly patients is a safe, efficacious, and
acceptable treatment.
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Affiliation(s)
- L Bonifacio
- Philippine Orthopedic Center, Maria Clara St. corner Banawe Ave., Quezon City, Philippines
| | - P Syson
- Philippine Orthopedic Center, Maria Clara St. corner Banawe Ave., Quezon City, Philippines
| | - J Llanes
- Philippine Orthopedic Center, Maria Clara St. corner Banawe Ave., Quezon City, Philippines
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Lim TK, Koh KH, Shon MS, Lee SW, Park YE, Yoo JC. Intra-articular injection of hyaluronate versus corticosteroid in adhesive capsulitis. Orthopedics 2014; 37:e860-5. [PMID: 25275972 DOI: 10.3928/01477447-20140924-51] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 02/20/2014] [Indexed: 02/03/2023]
Abstract
The goal of this study was to prospectively compare the early clinical results of intra-articular injection of hyaluronate or corticosteroid in patients with idiopathic adhesive capsulitis. The authors' hypothesis was that there would be no difference between groups. Sixty-eight patients with idiopathic adhesive capsulitis were equally randomized to receive either corticosteroid or hyaluronate injection. All patients underwent standard physical examination and magnetic resonance imaging. Intra-articular injection was performed through an anterior approach by the same orthopedic surgeon without image guidance. Patients were followed up 2 and 12 weeks after completion of the injection. The primary outcome was the Constant score at week 12. Secondary outcomes included the visual analog scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, and range of motion at each time point. No significant differences were noted in preoperative demographic features or baseline shoulder function between groups. After treatment, no significant differences were noted in early clinical outcomes (at weeks 2 and 12) with VAS, ASES, and Constant scores between groups (all P>.05). Evaluation of range of motion showed no difference in forward elevation or external rotation at each time point. Internal rotation was significantly lower at week 2 in the hyaluronate group compared with the corticosteroid group (P=.015). Internal rotation improved at week 12, with no significant difference between groups. Patients treated with intra-articular injection of hyaluronate and corticosteroid for idiopathic adhesive capsulitis showed significant improvement in early clinical scores and range of motion without significant differences between groups.
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Use of three-dimensional fluoroscopy to determine intra-articular screw penetration in proximal humeral fracture model. J Shoulder Elbow Surg 2014; 23:1150-5. [PMID: 24581875 DOI: 10.1016/j.jse.2013.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 10/31/2013] [Accepted: 12/03/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal humeral locking plates have significantly improved the treatment of proximal humeral fractures in recent years; however, they are not devoid of complications. Inadvertent screw penetration into the joint is a well-documented complication. Intraoperative 3-dimensional (3D) imaging may assist in detecting intra-articular implant penetration. This study compared the performance of a standard C-arm fluoroscope with a novel 3D imaging fluoroscope in detecting penetrating implants in a proximal humeral fracture model. METHODS Zinc-sprayed proximal humerus sawbones were affixed with a proximal humeral locking plate. Six different constructs were assembled. In each specimen, 1 screw, 2 screws, or no screws were inserted 2-mm proud of the articular surface. Each specimen was imaged with a conventional fluoroscope and a 3D imaging fluoroscope. Overall, 36 image sets were prepared for each modality. These were evaluated by 2 fellowship-trained surgeons for intraobserver and interobserver reliability as well for the accuracy of detecting prominent implants in the 2 imaging methods. RESULTS Overall accuracy for observer A was 89.9% compared with 100% for C-arm fluoroscopy and 3D imaging fluoroscopy (P < .01) and for observer B was 91.1% and 100% (P = .01), respectively. The κ values were 0.74 with C-arm fluoroscopy and 1.0 for the 3D imaging fluoroscopy for observer A, and 0.93 and 1.0, respectively, for observer B. CONCLUSIONS In a proximal humeral fracture model, C-arm fluoroscopy is a highly accurate imaging modality that can minimize the incidence of penetrating screws into the joint. Further clinical studies are required to establish this modality.
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[Treatment of proximal humeral fractures in Germany: Influence of the level of hospital care and the frequency of treatment]. Unfallchirurg 2014; 118:772-9. [PMID: 24682453 DOI: 10.1007/s00113-013-2531-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Various treatment options exist for displaced proximal humeral fractures. The impact of the level of hospital care and frequency of treatment on current treatment regimens in Germany was analyzed. MATERIAL AND METHODS A total of 576 hospitals were included. The survey covered questions on frequency, diagnostics, classification, therapy, complications, and clinical scenarios. RESULTS In all, 48% of the hospitals returned the questionnaire: 73% treat more than 60% of the fractures surgically, mainly with angle-stable implants. The angle-stable plate is the treatment of choice for young patients, but older patients are treated using other treatment options. Problems and complications included malreduction, secondary displacement, screw perforation, avascular necrosis, and impingement. According to treatment indication, implant choice, and common complications, no significant differences between the level of hospital care and frequency of treatment were observed. CONCLUSION Independent of the level of hospital care and frequency of treatment, there is a trend for head-preserving angular-stable surgery with a homogenous level of treatment in Germany.
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Miyake J, Shimada K, Oka K, Tanaka H, Sugamoto K, Yoshikawa H, Murase T. Arthroscopic debridement in the treatment of patients with osteoarthritis of the elbow, based on computer simulation. Bone Joint J 2014; 96-B:237-41. [DOI: 10.1302/0301-620x.96b2.30714] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We retrospectively assessed the value of identifying impinging osteophytes using dynamic computer simulation of CT scans of the elbow in assisting their arthroscopic removal in patients with osteoarthritis of the elbow. A total of 20 patients were treated (19 men and one woman, mean age 38 years (19 to 55)) and followed for a mean of 25 months (24 to 29). We located the impinging osteophytes dynamically using computerised three-dimensional models of the elbow based on CT data in three positions of flexion of the elbow. These were then removed arthroscopically and a capsular release was performed. The mean loss of extension improved from 23° (10° to 45°) pre-operatively to 9° (0° to 25°) post-operatively, and the mean flexion improved from 121° (80° to 140°) pre-operatively to 130° (110° to 145°) post-operatively. The mean Mayo Elbow Performance Score improved from 62 (30 to 85) to 95 (70 to 100) post-operatively. All patients had pain in the elbow pre-operatively which disappeared or decreased post-operatively. According to their Mayo scores, 14 patients had an excellent clinical outcome and six a good outcome; 15 were very satisfied and five were satisfied with their post-operative outcome. We recommend this technique in the surgical management of patients with osteoarthritis of the elbow. Cite this article: Bone Joint J 2014;96-B:237–41.
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Affiliation(s)
- J. Miyake
- Osaka University Graduate School of Medicine, Department
of Orthopaedic Surgery, 2-2 Yamadaoka, Suita, Osaka
565-0871, Japan
| | - K. Shimada
- Osaka Koseinenkin Hospital, Department
of Orthopaedic Surgery, 4-2-78 Fukushima, Osaka
553-0003, Japan
| | - K. Oka
- Osaka University Graduate School of Medicine, Department
of Orthopaedic Surgery, 2-2 Yamadaoka, Suita, Osaka
565-0871, Japan
| | - H. Tanaka
- Osaka University Graduate School of Medicine, Department
of Orthopaedic Surgery, 2-2 Yamadaoka, Suita, Osaka
565-0871, Japan
| | - K. Sugamoto
- Osaka University Graduate School of Medicine, Department
of Orthopaedic Biomaterial Science, 2-2 Yamadaoka, Suita, Osaka
565-0871, Japan
| | - H. Yoshikawa
- Osaka University Graduate School of Medicine, Department
of Orthopaedic Surgery, 2-2 Yamadaoka, Suita, Osaka
565-0871, Japan
| | - T. Murase
- Osaka University Graduate School of Medicine, Department
of Orthopaedic Surgery, 2-2 Yamadaoka, Suita, Osaka
565-0871, Japan
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Rath E, Alkrinawi N, Levy O, Debbi R, Amar E, Atoun E. Minimally displaced fractures of the greater tuberosity: outcome of non-operative treatment. J Shoulder Elbow Surg 2013; 22:e8-e11. [PMID: 23639834 DOI: 10.1016/j.jse.2013.01.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Revised: 01/11/2013] [Accepted: 01/30/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Minimally displaced (<3 mm) and non-displaced fractures of the proximal humerus are a common source of disability; nevertheless, there is no agreement on the recommended rehabilitation program in these patients. The purpose of this study was to evaluate the outcome of this group of patients and describe the rehabilitation protocol we have used for the treatment of this injury. METHODS We retrospectively analyzed the records of patients diagnosed with minimally displaced (<3 mm) fractures of the greater tuberosity who were admitted to our institute between June 2007 and May 2008. Patients were treated with a three-phase protocol. In the first phase, patients were immobilized in a sling for 3 weeks. In the second phase, pendular and active assisted exercises were begun 3 to 6 weeks after the injury. In the third phase, active exercises were commenced starting 6 weeks after injury. RESULTS Sixty-nine patients matched our inclusion and exclusion criteria. At an average follow-up of 31 months (range, 26-41 months), the average Constant score improved from 40 points (range, 33-58 points) to 95 points (range, 75-100 points). Average satisfaction score improved from 4.2 of 10 (range, 2-6) to 9.5 of 10 (range, 7-10). The reported average duration of pain and decreased range of motion from the time of injury was 8.1 months (range, 1-24 months). CONCLUSIONS When the diagnosis of a minimally displaced fracture of the proximal humerus is made, the patient can be reassured that a favorable outcome is anticipated with a staged rehabilitation protocol. Nevertheless, clinicians and patients should be aware that full recovery from the injury may take an average of 8 months.
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Affiliation(s)
- Ehud Rath
- Orthopaedic Division, Tel Aviv Souraski Medical Center, Tel Aviv, Israel.
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