Proximal humeral fracture treatment in adults

Plate osteosynthesis of proximal humerus fracture is associated with significant complications and poor functional score for patients older than 45 years: a cohort study

BACKGROUND

Despite the introduction of new implants and biomechanical improvements for proximal humerus fractures (PHF), the complication rate remains significant, particularly in older adults. This study aimed to identify risk factors for complications and failure following plate osteosynthesis for PHF and discuss an age cut-off that surgeons should consider for complications.

METHODS

Adults with PHF treated with the proximal humerus internal locking system at our large tertiary academic referral center between 2015 and 2020 were retrospectively identified. Univariate analysis was used to compare patients with and without complications. Then, a multivariate regression analysis was conducted to assess the possible complication risk factors. The receiver operating characteristic (ROC) curve of age was drawn to predict complication-free and favorable functional outcomes at the most recent follow-up. Oxford Shoulder Score (OSS) was considered favorable if OSS < 10.

RESULTS

A total of 135 patients were identified, with a mean age of 44 years (range 18-85 years) and a mean follow-up duration of 4.6 years (range 2-8 years). Complications were observed in 19 cases (14.1%), namely nonunion (n = 5), avascular necrosis (n = 1), infection (n = 1), intra-articular screw perforation (n = 1), arthritic changes (n = 5), and superior humeral head migration (n = 5). Eight patients (5.9%) needed revision surgery. Older age (OR = 1.09) and Neer IV class (OR = 8.3) were associated with an increased likelihood of complication (P < .001, P = .02, respectively) in logistic multinominal regression analysis. The ROC curve for age in predicting complication-free cases had an area under the curve of 0.829, indicating age as a significant predictor of open reduction and internal fixation (ORIF) outcomes in PHF (P < .05). The optimal cut-off for age was 44 years, which yielded a sensitivity of 100% and a specificity of 65.7. The age ROC curve for predicting favorable OSS (OSS < 10) had an OSS of 0.829, indicating that age could predict the favorable OSS outcomes of ORIF in PHF. The optimal age cut-off was 46 years, yielding a sensitivity of 70.0% and a specificity of 78.6%.

CONCLUSION

The outcomes of ORIF for PHF in patients older than 45 years are associated with significantly higher complication rates and poorer functional outcomes. Surgeons should possibly consider other treatment options for PHF in each older patient individually, especially with Neer type IV fractures.

Biomechanical evaluation of novel 3D-printed magnesium alloy scaffolds for treating proximal humerus fractures with medial column instability

BACKGROUND

Patients with complex proximal humerus fractures (PHFs) have a higher complication rate when treated with locking compression plate (LCP) alone. This increased complication rate may be due to humeral head collapse and insufficient medial column support in the proximal humerus. In response, we proposed the use of bionic porous 3D-printed magnesium alloy scaffolds (MAS) in combination with LCP for the treatment of PHFs. The aim of this study is to compare the biomechanical characteristics of the LCP alone versus LCP-MAS fixation constructs in treating PHFs with medial column instability.

METHODS

A three-dimensional model of a PHF with medial column instability was developed using computed tomography, and fixation was applied using LCP and LCP-MAS. Finite element analysis was employed to evaluate the biomechanical characteristics of these two fixation models, focusing on construct stiffness, von Mises stress distribution, and fracture displacements.

RESULTS

The construct stiffness of the LCP-MAS fixation construct was approximately 3.50 to 7.30 times greater than that of the LCP fixation construct under normal bone conditions, and 2.60 to 4.90 times greater under osteoporotic bone conditions. The LCP-MAS fixation reduced the maximum von Mises stress on the implants by at least 70 %-80 %. Furthermore, the LCP-MAS fixation significantly minimized fracture displacement compared to LCP alone.

CONCLUSIONS

The findings of this study suggest that the additional use of MAS can significantly enhance both the overall and local stability of PHFs. Thus, the LCP-MAS fixation approach presents a viable alternative for the treatment of PHFs.

Proximal humeral fractures in Finland: regional differences in incidence and methods of treatment

BACKGROUND

Proximal humeral fractures (PHFs) are one of the most common fragility fractures and there is accumulating evidence that even displaced PHFs should be treated conservatively. The treatment should be as effective and standardized as possible regardless of the hospital district of the patient. The aim of this study was to describe possible regional variation in incidence and treatment methods of PHFs in Finland.

METHODS

The study included all Finnish inhabitants aged 16 years and older with PHF diagnosis between 1997 and 2019. All records are based on data from 2 national registers. The fractures and operations were organized according to hospital district of the patient and annual incidences of PHFs, and different treatment methods were calculated for each hospital district.

RESULTS

Between 1997 and 2019, 79,053 PHFs were identified. 64,117 of PHFs were treated conservatively and 14,936 operatively. The incidence of conservative treatment corresponded closely to the fracture incidence per hospital district. Internal fixation incidence generally increased toward the end of the first half of the study period and declined thereafter, and hemiarthroplasty was replaced by total shoulder arthroplasty as the most common type of arthroplasty by the end of the period. We found regional variation in the incidence of PHFs, with a low of 61.4 per 105 in Åland, and a high of 97.7 per 105 in East-Savo.

CONCLUSION

In Finland, the treatment of PHFs did not differ fundamentally between hospital districts and a general evidence-based shift in treatment practice was shown. We found regional variation in the incidence of PHFs, and it seems that the higher incidence of PHFs is concentrated in Eastern Finland.

Complications after reverse shoulder arthroplasty for proximal humerus nonunion

BACKGROUND

Proximal humerus nonunion is a challenging complication of fractures that can be treated surgically with either open reduction internal fixation (ORIF) or reverse total shoulder arthroplasty (RTSA). The few studies published on this subject have shown high rates of complications and revision surgery when RTSA has been performed for proximal humerus nonunion. The purpose of this study was to determine the rates of complications and revision of this procedure at our institution, as well as to identify any variables that may impact risks of complications and reoperations.

METHODS

A single-institution retrospective review of all patients who underwent RTSA for proximal humerus nonunion between 2005 and 2021 was performed. Nonunion was defined as imaging evidence of lack of union, at least 90 days after the index fracture. Patients with less than 1 year of clinical follow-up were excluded. Fifty patients were included, with the majority being female (78%). The mean age at time of RTSA was 71 (range: 54-86) years and most patients were initially treated nonoperatively (74%). Mean total follow-up was 49 (range: 11-130) months. Demographic and surgical variables were recorded. Primary outcomes were complications and reoperations. Complications were divided into surgical (those directly related to RTSA), or other (those unrelated to RTSA). Secondary outcomes included visual analog scale pain scores and range of motion.

RESULTS

A total of 17 shoulders (34%) sustained complications after revision shoulder arthroplasty, with 10 (20%) requiring reoperation. Six patients (12%) sustained dislocations and 5 (10%) had radiographic evidence of humeral loosening. No variables examined, including nonoperative vs. surgical management of the index fracture, prosthesis type, or management of tuberosities, influenced the risk of dislocation. Survivorship free from reoperation at 2 years was 73%. Younger age at time of RTSA and the presence of diabetes mellitus both increased the risk of reoperation significantly (P = .013 and P = .037, respectively). There was a trend towards increased risk of reoperation in patients who were treated with initial ORIF (hazard ratio = 2.95); however, this did not reach statistical significance (P = .088). Three patients (6%) sustained a periprosthetic fracture after a fall.

CONCLUSION

RTSA provides improved pain and function for properly selected patients with proximal humerus nonunion. Dislocation, humeral loosening, and reoperation rates remain high when RTSA is performed for nonunion compared to other diagnoses. In this study, younger age and diabetes mellitus increased the odds of reoperation. Every effort must be made to optimize implant stability and humeral component fixation when RTSA is performed for proximal humerus nonunion.

Adoption of reverse total shoulder arthroplasty for surgical treatment of proximal humerus fractures differs by patient race

BACKGROUND

Reverse total shoulder arthroplasty (rTSA) has gained popularity for the operative treatment of proximal humerus fractures (PHF). The purpose of this study was to compare racial differences in surgical management of PHF between open reduction and internal fixation (ORIF), hemiarthroplasty, and rTSA. Our hypothesis was that there would be no difference in fixation by race.

METHODS

The National Surgical Quality Improvement Program database was queried for ORIF, rTSA, and hemiarthroplasty between 2006 and 2020 for patients with a PHF. Race, ethnicity, age, sex, body mass index, and American Society of Anesthesiologists (ASA) class were recorded. Chi squared tests were performed to assess relationships between patient factors and operative intervention. Factors significant at the 0.10 level in univariable analyses were included in a multivariable multinomial model to predict operative intervention.

RESULTS

Seven thousand four hundred ninety-nine patients underwent surgical treatment for a PHF, including 526 (7%) undergoing hemiarthroplasty, 5011 (67%) undergoing ORIF, and 1962 (26%) undergoing rTSA. 27% of white patients with PHF underwent rTSA compared to 21% of Black patients, 16% of Asian patients, and 14% of Native American and Alaskan Native patients (P < .001). In the multivariable analysis, utilization of rTSA increased over time (OR 1.2 per year since 2006, P < .001) and hemiarthroplasty decreased over time (OR 0.86 per year since 2006, P < .001). Non-White patients had significantly lower odds of undergoing rTSA vs. ORIF (OR 0.75, 95% CI 0.58-0.97), as did male patients (OR 0.77, 95% CI 0.66-0.88). Patients over 65 (OR 3.86, 95% CI 3.39-4.38), patients with higher ASA classifications (ASA2: OR 3.24, 95% CI 1.86-5.66, ASA3: OR 4.77, 95% CI 2.74-8.32, ASA4: OR 5.25, 95% CI 2.89-9.54), and patients who were overweight (OR 1.33, 95% CI 1.14-1.55) or obese (OR 1.52, 95% CI 1.32-1.75) had higher odds of undergoing rTSA vs. ORIF.

DISCUSSION

As utilization of rTSA increases, understanding disparities in surgical treatment of PHF is crucial to improving outcomes and equitable access to emerging orthopedic technologies. While patient factors such as age, body mass index, and comorbidities are known to directly impact outcomes and thus may be predictive of the type of surgical intervention, patient race should not dictate treatment.

Results of open reduction and internal fixation of proximal humerus fractures using a proximal humeral plating system with smooth pegs

Background

The aim of this study was to evaluate clinical results and complication rate in patients with proximal humeral fracture treated with Anatomical Locking Plate System (A.L.P.S.) Proximal Humeral Plating System with smooth pegs.

Methods

Retrospective evaluation of 116 consecutive patients treated with A.L.P.S. Proximal Humeral Plating System. Shoulder function was evaluated by Constant score and disabilities of arm, shoulder and hand (DASH). Furthermore, European Quality of life 5 Dimensions (EQ-5D) and single shoulder value (SSV) were assessed. Fractures were classified according to Neer.

Results

Fifty-two patients were included with a mean follow-up of 49 months. Mean Constant score was 62.8. Mean DASH was 17, and the mean EQ-5D was 0.91. According to Neer classification 63% (n = 33) of the fractures were two-part, 31% (n = 16) three-part, and 6% (n = 3) four-part fractures. Peg penetration was registered in 13 cases (25%, n = 52). In total a reoperation rate of 23% (n = 12) and an overall complication rate of 37% (n = 19) were recorded.

Discussion/conclusion

Open reduction and plate fixation with the A.L.P.S. Proximal Humeral Plating System with smooth pegs provides a stable fixation with good clinical outcome and complication and reoperation rates in line with previous studies with plates using screws in the humeral head.

Clinical Outcome and Quality of Life after Modular Reverse Total Shoulder Arthroplasty in Comparison with Joint-Preserving Locking Plate Osteosynthesis in Aged Patients: A Retrospective Comparison Study

OBJECTIVES

Proximal humeral fractures (PHFs) show a high incidence in aged patients. While nondisplaced fractures achieve good results by conservative treatment, surgical procedures are discussed controversially. Next to open reduction and internal fixation (ORIF), the primary use of reverse shoulder arthroplasty (RSA) has become increasingly important. The aim of this study was to investigate the clinical function, activities of daily living (ADL), as well as pain assessment in patients with PHFs, treated by ORIF or RSA.

METHODS

A retrospective comparison study was assessed. From November 2011 to March 2016, 34 patients (17 matched pairs) that had undergone either ORIF or RSA of the proximal humerus, were included in this study. Pain was measured by numeric rating scale (NRS). ADL were obtained by Katz-Index and SF-12. Moreover, shoulder function was assessed using the Oxford Shoulder Score (OSS). The maximum range of motion (ROM) was also recorded. From November 2011 to March 2016, 34 patients (17 matched pairs) that had undergone either ORIF (Figure or RSA of the proximal humerus) were included in this study. For statistical analyses, Student's t-test, Wilcoxon test, and Chi-Quadrat test were used. Statistical significance was indicated with p < 0.05.

RESULTS

Totally 34 patients with an average age of 76.6 years were included. Surgical treatment was performed on average 5.2 days after diagnosis, differing significantly between the two groups (RSA/ORIF: 6.9/3.5 days) The operation time of RSA (97 min) was significantly longer than for ORIF (78 min). Pain assessment, as well as the Katz-Index and the SF-12, showed no significant differences. Moreover, clinical shoulder function showed no significant discrepancies between the two surgical techniques.

CONCLUSIONS

Aged patients with PHFs treated with RSA display similar results regarding clinical function, ADL as well as pain perception compared with ORIF. However, revision surgery rate was lower in patients who underwent RSA. Thus, the surgical treatment of PHFs by RSA represents an excellent alternative, especially with regard to an aging patient population.

A high hospital frailty risk score indicates an increased risk for complications following surgical treatment of proximal humerus fractures

BACKGROUND

Approximately 70 % of proximal humerus fractures (PHF) occur after the age of 60. High complication rates have been described in correlation with the treatment of PHF. Major risk factors for the outcome might be frailty, mobility and comorbidities of patients at the time of hospital admission. The aim of this study was to create risk adjusted quality indicators for surgical treatment of proximal humerus fractures based on German claims data and to evaluate the impact of the Hospital Frailty Risk Score (HFRS) on risk adjustment.

METHODS

Retrospective claims data (2015-2021) were used to create risk adjusted quality indicators for eight outcomes by clustered multivariable logistic regression. The comparison of different risk adjustment model performances was done by ROC-AUC and Standardized Mortality/Morbidity Ratios.

RESULTS

In total, N = 34,912 patients (median age 75 years, 80.3 % female) were included. The most common surgical procedure was open reduction and internal fixation with plate osteosynthesis with 39.7 %, followed by reverse shoulder arthroplasty with 25.3 %. The most influential risk factor for all outcomes was a high HFRS with an Odds Ratio of 2.0 (95 %-Confidence Interval 1.8-2.3) for any secondary surgery (365 days) up to an Odds Ratio of 17.6 (95 %-Confidence Interval 14.9-20.8) for general complications during the index stay.

CONCLUSION

Comparative quality reporting for the surgical treatment of PHF appears feasible with the developed models for risk adjustment using claims data. Preoperative evaluation of HFRS in PHF can contribute to risk assessment, and individual patient management. It therefore enables personalized treatment decisions.

The Clinical and Radiological Outcomes and Complications of Bilboquet Implant for Proximal Humerus Fractures: A Systematic Review

Background/Objectives: There is no consensus in the literature regarding the optimal treatment for complex proximal humerus fractures (PHFs). The aim of this study is to evaluate the clinical, functional, and radiological outcomes, and complications, associated with the Bilboquet implant in the treatment of PHFs. Methods: The search was conducted from the first description of the Bilboquet device in 1994 to June 2024, across PubMed, Web of Science, and Google Scholar, using specific keywords such as ("Bilboquet" OR "Bilboquet prosthesis" OR "Bilboquet device") AND ("proximal humerus fracture" OR "shoulder fracture"), along with Boolean operators. The inclusion criteria comprised studies published in English or French that focused on the use of the Bilboquet implant for PHFs. Eligible study designs included case series, cohort studies, randomized controlled trials (RCTs), and non-RCTs evaluating clinical, functional, and radiological outcomes, and complications. Studies that do not contain relevant results to this systematic review, pediatric populations, or the use of alternative implants were excluded. Results: A total of eight studies (235 patients) published between 1996 and 2021 were included. The mean age was 68.6 years (56 to 76.8) in all the studies. The majority of patients, 76.2%, were females, with male patients accounting for only 23.8%. A total of 10 (4.3%) patients had 2-part fractures, 40% of patients had 3-part fractures, and 55.7% of patients had 4-part fractures. The mean follow-up was 36.4 months (25.8-88.7), with a mean constant score of 69.7 (62-78.6). Complications included non-union in 2.65% of cases, avascular necrosis in 19.7%, revision surgery in 5.1%, and protrusion of the staple in 4.3%. Conclusions: Despite limited knowledge of the Bilboquet implant, it shows promise in managing complex PHFs in both young and older adults, with favorable clinical and radiological outcomes. It offers advantages over traditional fixation methods and allows easy conversion to arthroplasty if osteonecrosis occurs. However, the long-term outcomes require further study. While early results are promising, larger randomized studies are needed to confirm its broader clinical utility.

The Application of Bidirectional Rapid Reductor in Minimally Invasive Plate Osteosynthesis for the Treatment of Proximal Humeral Fractures: A Case Series

OBJECTIVE

Rapid and effective reduction is difficult for minimally invasive plate osteosynthesis (MIPO) surgery. This study aims to introduce a bidirectional rapid reductor (BRR) designed to assist in the reduction during MIPO surgery for proximal humeral fractures (PHFs).

METHODS

This retrospective study was conducted between June 2021 and February 2022 in the Third Hospital of Hebei Medical University, involving patients diagnosed with PHFs. A detailed technical approach of BRR in MIPO surgery was described, and the patients' outcomes based on postoperative radiographic results including x-ray postoperative follow-up, and clinical outcome parameters including visual analogue scale (VAS) and constant-Murley score at last follow-up were reported.

RESULTS

A total of 12 patients were included in this study, comprising three males and nine females, with an average age of 67.58 years. The mean operative time was 70.92 min (range 63-80 min). The mean blood loss was 102.27 mL (range 50-300 mL). The mean VAS and constant-Murley scores at final follow-up were 0.33 and 88, respectively. All patients had their fractures healed without secondary displacement at last follow-up. One patient experienced shoulder stiffness post-operation. There were no adverse events or complications following the use of this technique, such as acromion fracture, nerve or blood vessel injury.

CONCLUSION

The BRR can assist MIPO for good reduction of PHFs. However, the efficacy should be validated with a large-sample randomized controlled trial and longer follow-up.

Proximal humeral fractures with vascular compromise

Aims

Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries.

Methods

A total of 3,497 adult patients with a proximal humeral fracture were managed between January 2015 and December 2022 in a single tertiary trauma centre. Their mean age was 66.7 years (18 to 103) and 2,510 (72%) were female. We compared the demographic data, clinical features, and configuration of those whose fracture was complicated by vascular compromise with those of the remaining patients. The incidence of vascular compromise was calculated from national population data, and predictive factors for its occurrence were investigated using univariate analysis.

Results

A total of 18 patients (0.5%) had a proximal humeral fracture and clinical evidence of vascular compromise, giving an annual incidence of 0.29 per 100,000 of the population. Their mean age was 68.7 years (45 to 92) and ten (56%) were female. Evidence of a mixed pattern neurological deficit (brachial plexus palsy) (odds ratio (OR) 380.6 (95% CI 85.9 to 1,685.8); p < 0.001), complete separation of the proximal shaft from the humeral head with medial displacement (OR 39.5 (95% CI 14.0 to 111.8); p < 0.001), and a fracture-dislocation (OR 5.0 (95% CI 1.6 to 15.3); p = 0.015) were all associated with an increased risk of associated vascular compromise. A policy of reduction and fixation of the fracture prior to vascular surgical intervention had favourable outcomes without vascular sequelae.

Conclusion

The classic signs of distal ischaemia are often absent in patients with proximal injuries to major vessels. We were able to identify specific clinical and radiological 'red flags' which, particularly when present in combination, should increase the suspicion of a fracture with an associated vascular injury, and facilitate early diagnosis and appropriate combined orthopaedic and vascular intervention.

Augmented versus non-augmented locking-plate fixation in proximal humeral fractures

Aims

Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures.

Methods

The search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles involving patients with complex proximal humeral fractures treated using open reduction with locking-plate fixation, with or without augmentation, were considered. A meta-analysis of comparative studies comparing locking-plate fixation with cement augmentation or with bone-graft augmentation versus locking-plate fixation without augmentation was performed.

Results

A total of 19 studies were included in the qualitative synthesis, and six comparative studies were included in the meta-analysis. Overall, 120 patients received locking-plate fixation with bone-graft augmentation, 179 patients received locking-plate fixation with cement augmentation, and 336 patients received locking-plate fixation without augmentation. No statistically relevant differences between the augmented and non-augmented cohorts were found in terms of the Disabilities of the Arm, Shoulder and Hand questionnaire score and Constant-Murley Score. The cement-augmented group had a significantly lower rate of complications compared to the non-augmented group.

Conclusion

While locking-plate fixation with cement augmentation appears to produce a lower complication rate compared to locking-plate fixation alone, functional outcomes seem comparable between augmented and non-augmented techniques.

Primary stability in locking plate fixation for proximal humeral fractures may be increased by using an additional nail osteosynthesis in combination with locking plate osteosynthesis-A biomechanical comparison

BACKGROUND

Stability is regarded as an important factor for proper healing and avoiding secondary dislocation in osteoporotic fractures of the proximal humerus. Several surgical techniques have been proposed for treatment, including intramedullary nail osteosynthesis and locking plate fixation. This study introduces a novel approach that combines both techniques and compares its primary stability with conventional methods.

METHODS

The study involved 25 osteoporotic humeri with two-part fracture models, which were randomly assigned to locking-plate fixation, intramedullary nailing, or a combination of both techniques. The specimens were subjected to sinusoidal loading at 250 N in 20° abduction for 5000 cycles and then to quasi-static loading until failure. Fracture movement, failure mode, and failure load were measured and compared among the groups.

FINDINGS

The groups fixated with intramedullary nailing and the groups fixated with intramedullary nailing and locking plate fixation showed significantly lower fracture motion than the group using locking plate fixation only (p < 0.005) and significantly higher load to failure (p = 0.007 and p = 0.0062, respectively). There was no significant difference between the group using intramedullary nailing and the group using locking-plate fixation and intramedullary nailing in fracture movement or load-to-failure (p > 0.005).

INTERPRETATION

The results indicate that locking plate fixation provides less primary stability than intramedullary nailing or the combined of both techniques. This combined approach may offer advantages as a treatment for complex proximal humeral fractures in osteoporotic bone, and specific implants should be developed to ensure optimal treatment.

Risk factors for surgical site infection after closed proximal humerus fractures

Proximal humerus fractures are common in clinical practice, and there are relatively a few studies on postoperative incision infections of such fractures. The purpose of this study was to explore the risk factors for surgical site infection (SSI) after internal fixation in patients with closed proximal humerus fractures. Patients with closed proximal humerus fractures who underwent surgery from January 2016 to January 2022 were retrospectively analysed. Cases with superficial or deep infections within 3 months after surgery were in the infection group and the remaining cases were in the non-infection group. The types of pathogenic bacteria in the infection group were analysed. The potential risk factors for SSI in all patients were recorded: (1) patient-related factors: gender, age, body mass index (BMI), smoking, comorbidities; (2) trauma-related factors: mechanism of injury, Injury Severity Score, visual analogue scale, fracture type, soft tissue condition and combined dislocation; (3) laboratory-related indexes: haemoglobin, albumin; (4) surgery-related factors: time from injury to surgery, American Society of Anesthesiologists anaesthesia classification, surgical time, fixation mode, intraoperative blood loss, suture method, bone graft and postoperative drainage. The risk factors for the occurrence of SSI were analysed using univariate analysis and multivariate logistic regression. The incidence of SSI was 15.7%. The most common bacterium in the infection group was Staphylococcus aureus. High BMI (p = 0.033), smoking (p = 0.030), an increase in mean time from injury to definitive surgery (p = 0.013), and prolonged surgical time (p = 0.044) were independent risk factors for the development of SSI after closed proximal humeral fractures. In patients with closed proximal humerus fractures, weight loss, perioperative smoking cessation, avoidance of delayed surgery, and shorter surgical time may be beneficial in reducing the incidence of SSI.

Satisfactory Short-Term Outcomes of Reverse Shoulder Arthroplasty for Complex Three- and Four-Part Fractures of the Humeral Head in Octogenarians

BACKGROUND

Proximal humeral fractures with severe comminution and poor bone quality are among the most common injuries in the elderly population. Reverse shoulder arthroplasty (RSA) has been widely used to manage complex three- and four-part humeral head fractures. The purpose of the present study was to report the result of this technique in the demanding population of octogenarians.

MATERIALS AND METHODS

 Twenty-six patients above the age of 80 years were included in the study and followed for a minimum of one-year follow-up. To assess the functional outcomes the postoperative range of motion (ROM), the Constant score, the visual analog scale for pain, and the disability of the arm and shoulder score (DASH) were measured at 6 and 12 months. Radiological assessment and potential complications were also recorded.

RESULTS

The mean age of the study population was 81.9 years (81-86) at the time of surgery. There was a statistically significant improvement in all outcomes over the follow-up intervals. Shoulder ROM was 125.7o for flexion, 98.2o for abduction, 42.2o for internal rotation, and 43.2o for external rotation at 12 months. The mean Constant, DASH, and VAS scores at the last follow-up were 61.3, 31.9, and 0.5, respectively. Reported complications include one superficial surgical site infection.

CONCLUSION

RSA is a safe and reliable surgical option with satisfactory outcomes to manage complex three- and four-part fractures of the humeral head as it can provide prompt pain relief and function in octogenarians.

Risk factors for osteonecrosis of the humeral head after internal fixation of proximal humeral fractures: a systematic review and meta-analysis

BACKGROUND

Osteonecrosis of the humeral head (ONHH) is a severe complication after the internal fixation of proximal humeral fractures (IFPHF). The risk factors remain controversial though many studies have reported. In this research, meta-analysis was used to evaluate which surgeon-level factors can be modified to lower the risk and we hope to provide evidence-based support for preventing ONHH.

METHODS

Literature was retrieved from PubMed, Cochrane Library, Embase, Web of Science, and Scopus for eligible studies published up to January 2023. The pooled odds ratios (ORs) were calculated with their corresponding 95% confidence intervals (CIs) to evaluate. STATA 15.1 software was applied for data synthesis, sensitivity synthesis, and publication bias.

RESULTS

45 articles were published between 2000 and 2022, and 2482 patients were finally included. All articles were observational research, with 7 case-control studies and 38 cohort studies, and the Newcastle Ottawa Scale (NOS) score ranged from 7 to 9. The pooled results suggested that age (OR 0.32, 95% CI 0.14-0.74, P = 0.01), reduction quality (OR 0.08, 95% CI 0.01-0.44, P = 0.00), fracture type (OR 0.44, 95% CI 0.25-0.78, P = 0.01), surgical approach (OR: 4.06, 95% CI 1.21-13.61, P = 0.02) and fixation implant (OR = 0.68, 95% CI = 0.34-1.33, P = 0.02) were risk factors for ONHH after IFPHF. According to sensitivity analysis, Begg (P = 0.42) and Egger (P = 0.68) tests, the results were stable and exhibited no publication bias.

CONCLUSIONS

The study showed that age, reduction quality, fracture type, surgical approach and fixation implant were risk factors for ONHH after IFPHF, while gender, varus or valgus, timely operation, injured side, and the existence of medial support have little influence on ONHH, as they could not be considered risk factors and still need further investigations.

Endosteal strut using a hydroxyapatite/poly-L-lactide mesh tube with a proximal humeral locking plate for the treatment of proximal humeral fractures

PURPOSE

Proximal humeral fractures cause large intramedullary bone defects after humeral-head reduction. Hydroxyapatite/poly-L-lactide (HA/PLLA) materials are widely used for various fractures. However, the efficacy of endosteal strut using a HA/PLLA mesh tube (ES-HA/PLLA) with a locking plate for treating proximal humeral fractures was not reported. The purpose of this study is to examine the efficacy of ES-HA/PLLA with a proximal humeral locking plate in proximal humeral fractures.

METHODS

Seventeen patients with proximal humeral fractures treated using ES-HA/PLLA with a locking plate from November 2017 to November 2021 were evaluated. The range of motion of the shoulder and postoperative complications were assessed at the final follow-up. Radiographs were evaluated to assess bone union and loss of reduction by measuring humeral-head height (HHH) and humeral neck-shaft angle (NSA).

RESULTS

The average flexion and external rotation of the shoulder at the final follow-up were 137° (range, 90-180°) and 39° (range, - 10 to 60°), respectively. All fractures were united. The average HHH and NSA just after the surgery and final follow-up were 12.5 mm and 11.6 mm and 129.9° and 127.4°, respectively. Two patients presented screw perforation of the humeral head. One patient underwent implant removal due to infection. Avascular necrosis of the humeral head was observed in one patient with arthritis mutilans.

CONCLUSIONS

The use of ES-HA/PLLA with a proximal humeral locking plate resulted in bone union in all patients and prevented postoperative loss of reduction. ES-HA/PLLA is one of the treatment options for proximal humeral fractures.

Fracture line and comminution zone characteristics, and rotator cuff footprint involvement in OTA/AO 11C3-type proximal humeral fractures: complex proximal humerus fracture map

PURPOSE

To identify fracture characteristics and zones of comminution as well as the relationship with anatomic landmarks and rotator cuff footprint involvement in OTA/AO 11C3-type proximal humerus fractures.

METHODS

Computed tomography images of 201 OTA/AO 11C3 fractures were included. Fracture lines were superimposed to a 3D proximal humerus template, created from a healthy right humerus, after fracture fragment reduction on 3D reconstruction images. Rotator cuff tendon footprints were marked on the template. Lateral, anterior, posterior, medial, and superior views were captured for the interpretation of fracture line and comminution zone distribution as well as to define the relationship with anatomic landmarks and rotator cuff tendon footprints.

RESULTS

A total of 106 females and 95 males (mean age = 57.5 ± 17.7 [range 18-101] years) with 103 C3.1-, 45 C3.2-, and 53 C3.3-type fractures were included. On the lateral, medial, and superior humeral surfaces, fracture lines and comminution zones were distributed differently in 3 groups. Tuberculum minus and medial calcar region were significantly less severely affected in C3.1 and C3.2 fractures than C3.3 fractures. The supraspinatus footprint was the most severely affected rotator cuff footprint area.

CONCLUSIONS

Specifically defining the certain differences for repeatable fracture patterns and comminution zones in OTA/AO 11C3-type fractures and the relationship between the rotator cuff footprint and the joint capsule may contribute to the decision-making process of surgeons.

A Transosseous Suture as an Alternative to Suture Anchor on Anterior-Avulsion Greater Tuberosity Fragment Fixation in Neer Three-Part Proximal Humeral Fracture: A Biomechanical Study

OBJECTIVE

Greater tuberosity (GT) fragments were communicated, and additional techniques to increase the GT fragment stability after the locking plate fixation was necessary. This study aimed to analyze the reinforcement effects on the anterior-avulsion GT fragment in Neer three-part proximal humeral fractures (PHFs) using transosseous suture and suture anchor techniques.

METHODS

Eighteen fresh-frozen human cadaveric shoulder specimens were used in the study. Standardized fracture of the GT and surgical neck was created in 18 human cadaveric proximal humerus. The GT fragments were reinforced with transosseous suture (TS), suture anchor (SA), and suture in addition to the PHILOS plate fixation. The fixed humerus was tested by applying static loading to the supraspinatus tendon. Load forces and fragment displacement were evaluated by a biomechanical testing machine, and the load to 3- and 5-mm displacements, load to failure, and mode of failure were recorded for all specimens. Nonparametric variables were examined by the Kruskal-Wallis test, and the Bonferroni post hoc test was used to analyze the mean loads to create 3- and 5-mm displacements as well as the failure load.

RESULTS

The age, female proportion, and bone mineral density showed no statistically significant differences between the three groups. The mean loading force to create 3-mm and 5-mm displacement in the TS group (254.9 ± 77.4, 309.6 ± 152.7) were significantly higher than those in the suture group (136.1 ± 16.7, 193.4 ± 14.5) (P = 0.024, P = 0.005). For the SA group, the force to create 3- and 5-mm displacement (204.3 ± 60.9, 307.8 ± 73.5) were comparable to those in the TS group (P = 0.236, P = 0.983). Moreover, the loading force to failure in the TS group (508.6 ± 217.7) and SA group (406.6 ± 114.9) was significantly higher than that in the suture group (265.9 ± 52.1) (P = 0.021, P = 0.024). In the TS group, three failed due to tendon-bone junction rupture; bone tunnel broken occurred in two specimens; suture rupture could also be seen in one specimen. All specimens in the suture group failed because of suture rupture. In the SA group, three specimens failed due to suture rupture; two failed secondary to tendon-bone junction rupture; and one failed because of shaft fracture.

CONCLUSIONS

Transosseous suture is a new type of reinforcement for GT fragment in Neer-three part PHFs. The transosseous suture was superior to the suture only in the reinforcement of the anterior-avulsion GT fragment of Neer three-part PHFs, and it had comparable biomechanical strength to the suture anchor.

Clinical Application of Nail-Plate Fixation in the Treatment of Complex Proximal Third Humeral Fracture: A Case Report and Literature Review

BACKGROUND

Proximal humeral fractures with increasing incidence are common over the past decades. Among them, the complicated and displaced ones, especially combined with the proximal third humeral shaft fractures, need to be treated surgically. Humeral intramedullary nail and locking plate are the most frequently used options. However, few studies address the application of nail-plate combination for management.

CASE PRESENTATION

A 49-year-old man struck by a car was referred to our emergency trauma center. The X-ray and three-dimensional computed tomography (CT) showed a complex proximal humeral fracture with proximal third shaft fracture. No evidence of other associated injuries and neurovascular symptom of the injured left upper limb was shown by physical examination. Nail-plate fixation was performed to restore the anatomic integrity of proximal humerus. The injured arm was maintained in a broad arm sling for 14 days after surgery. The active as well as positive movements under the instruction were encouraged as long as the pain could be tolerated from postoperative day 2. One year after the surgery, the fracture was healed, and the patient regained normal shoulder motion. The good clinical outcomes were obtained by application of nail-plate fixation to treat complex proximal third humeral shaft fractures. Thus, this surgical intervention could be performed as an alternative.

Optimal Treatment of Proximal Humeral Fractures in the Elderly: Risks and Management Challenges

Proximal humeral fractures (PHFs) are a common type of fracture, particularly in older adults, accounting for approximately 5-6% of all fractures. This article provides a comprehensive review of PHFs, focusing on epidemiology, injury mechanism, clinical and radiographic assessment, classification systems, and treatment options. The incidence of PHFs varies across regions, with rates ranging from 45.7 to 60.1 per 100,000 person-years. Females are more susceptible to PHFs than males, and the incidence is highest in women over the age of 85. The injury mechanism of PHFs is typically bimodal, with high-energy injuries predominant in younger individuals and low-energy injuries in the elderly. Clinical assessment of PHFs involves obtaining a thorough history, physical examination, and evaluation of associated injuries, particularly neurovascular injuries. Radiographic imaging helps assess fracture displacement and plan for treatment. The Neer classification system is the most commonly used classification for PHFs, although other systems, such as AO/OTA, Codman-Hertel, and Resch classifications, also exist. The choice of treatment depends on factors such as patient age, activity level, fracture pattern, and surgeon expertise. Nonoperative management is typically preferred for elderly patients with minimal displacement, while operative fixation is considered for more complex fractures. Nonoperative treatment involves sling immobilization followed by physiotherapy, with good outcomes reported for certain fracture patterns. Operative management options include closed reduction and percutaneous pinning (CRPP), open reduction and internal fixation (ORIF), or arthroplasty. CRPP is suitable for specific fracture patterns, but the quality of reduction is crucial for favorable outcomes. ORIF is used when CRPP is not feasible, and various surgical approaches are available, each with its advantages and potential complications. PHFs are a significant clinical challenge due to their prevalence and complexity. Treatment decisions should be patient centered based on patient factors and fracture severity.

Three-Dimensional Measurement of Proximal Humerus Fractures Displacement: A Computerized Analysis

Neer's classification for proximal humerus fractures (PHFs) uses 10 mm and 45° thresholds to distinguish displaced fragments. While this system was originally developed referencing 2D X-rays, fracture displacements occur in three dimensions. Our work aimed to develop a standardized and reliable computerized method for measuring PHF 3D spatial displacements. CT scans of 77 PHFs were analyzed. A statistical shape model (SSM) was used to generate the pre-fracture humerus. This predicted proximal humerus was then used as a "layer" to manually reduce fragments to their native positions and quantify translation and rotation in three dimensions. 3D computerized measurements could be calculated for 96% of fractures and revealed that 47% of PHFs were displaced according to Neer's criteria. Valgus and varus head rotations in the coronal plane were present in 39% and 45% of cases; these were greater than 45° in 8% of cases and were always associated with axial and sagittal rotations. When compared to 3D measurements, 2D methods underestimated the displacement of tuberosity fragments and did not accurately assess rotational displacements. The use of 3D measurements of fracture displacement is feasible with a computerized method and may help further refine PHF analysis and surgical planning.

Nonanatomic healing of the greater tuberosity after plating in proximal humeral fractures: a case control study

BACKGROUND

Open reduction and plate internal fixation (ORIF) is one of the most common treatment methods for proximal humeral fractures. Complications associated with the greater tuberosity (GT) are rarely reported, therefore, the purpose of this study was to analyze the complications associated with the GT and the risk factors after locked-plate internal fixation.

METHODS

We retrospectively analyzed the medical and radiographic data of patients with proximal humeral fractures involving the GT treated with locking plates between January 2016 and July 2019. We divided all patients into two groups, the anatomic GT healing group and the nonanatomic GT healing group, depending on the radiographic outcomes of the GT. Clinical outcome was assessed by the Constant scoring system. Potential risk factors included preoperative and intraoperative factors. Preoperative factors included sex, age, body mass index, fracture type, fracture-dislocation, proximal humeral bone mineral density, humeral head extension, hinge integrity, comminuted GT, volume and surface area of the main GT fragment, and displacement of the main GT fragment. Intraoperative factors were adequate medial support, residual head-shaft displacement, head-shaft angle and residual GT displacement. Univariate logistic regression and multivariate logistic regression were used to identify risk factors.

RESULTS

There were 207 patients (130 women and 77 men; mean age, 55 years). GT anatomic healing was observed in 139 (67.1%) patients and nonanatomic healing in 68 (32.9%). Patients with GT nonanatomic healing had significantly inferior Constant scores than those with GT anatomic healing (75.0 ± 13.9 vs. 83.9 ± 11.8, P < 0.001). Patients with high GT malposition had worse Constant scores than patients with low GT malposition (73.3 ± 12.7 vs. 81.1 ± 11.4, P = 0.039). The multivariate logistic model showed that GT fracture characteristics were not risk factors for nonanatomic GT healing, while residual GT displacement was.

CONCLUSIONS

Nonanatomic healing of the GT is a high-rate complication of proximal humeral fractures, resulting in inferior clinical outcomes, especially for high GT malposition. Fracture characteristics of the GT are not risk factors for GT nonanatomic healing and GT comminution should not be regarded as a contraindication to ORIF for proximal humeral fractures.

The effect of integrity of lesser tuberosity-medial calcar on postoperative outcome in the proximal humeral fracture

BACKGROUND

In proximal humeral fractures, the medial calcar is often considered an important stabilizing structure. When the medial calcar is disrupted, some patients may have accompanying humeral lesser tuberosity comminution that has not been noticed. To investigate the impacts of comminuted fragments of lesser tuberosity and calcar on postoperative stability, CT results, number of fragments, cortical integrity, and the variation of neck-shaft angle were compared in patients with proximal humeral fractures.

MATERIALS AND METHODS

From April 2016 to April 2021, this study included patients with senile proximal humeral fractures diagnosed by CT three-dimensional reconstruction with lesser tuberosity fractures and medial column injuries. The number of fragments in the lesser tuberosity and the continuity of medial calcar were evaluated. Postoperative stability and shoulder function were evaluated by comparing changes in neck-shaft angle and the DASH upper extremity function score from 1 week to 1 year after the operation.

RESULTS

A total of 131 patients were included in the study, and the results showed that the number of fragments of the lesser tuberosity was related to the integrity of the medial cortex of the humerus. That is, when there were more than two lesser tuberosity fragments, the integrity of humeral medial calcar was poor. The positive rate of the lift-off test was higher in patients with lesser tuberosity comminutions 1 year after surgery. In addition, patients with more than two lesser tuberosity fragments and continuous destruction of the medial calcar had large variations in the neck-shaft angle, high DASH scores, poor postoperative stability, and poor recovery of shoulder joint function 1 year postoperatively.

CONCLUSION

The number of humeral lesser tuberosity fragments and the integrity of the medial calcar were associated with the collapse of the humeral head and the decrease in shoulder joint stability after the proximal humeral fracture surgery. When the number of lesser tuberosity fragments was greater than two and the medial calcar was damaged, the proximal humeral fracture had poor postoperative stability and poor functional recovery of the shoulder joint, which required auxiliary internal fixation treatment.

Displaced varus proximal humerus fracture with conservative treatment: a case report

The authors report a case of an elderly female with a displaced varus misalignment of a proximal humerus fracture which met the indications for surgery, but the patient was treated conservatively with an arm sling due to the wishes of the patient and her relatives. The clinical outcome was nearly full function compared with the right shoulder.

Presentation of case

A 65-year-old Thai female presented with right shoulder pain 1 h after a fall during which her right shoulder hit the floor. Radiographs of the right shoulder in anteroposterior and lateral transcapular views showed a proximal humerus fracture with varus misalignment. The patient and her relatives decided on conservative treatment with an arm sling. At 12 weeks following the fall she was able to move her right shoulder nearly equally to the left shoulder.

Intervention and outcome

The authors discussed the treatment options with the patient and her relatives and recommended open reduction and internal fixation with a locking plate and screw, but they decided on conservative treatment with an arm sling. At 12 weeks following the fall she was able to move her right shoulder nearly equally to the left shoulder. She had no pain and could do normal life activities with the right shoulder.

Relevance and impact

Patients with severe varus deformity are usually treated with surgery. If there are contraindications for surgery, the stability of the fracture should first be evaluated through radiographs of the fracture in various arm positions.

Reverse Total Shoulder Arthroplasty Demonstrates Better Outcomes Than Angular Stable Plate in the Treatment of Three-part and Four-part Proximal Humerus Fractures in Patients Older Than 70 Years

BACKGROUND

Proximal humeral fractures are traditionally treated with open reduction and internal fixation (ORIF), but reverse total shoulder arthroplasty (RTSA) has emerged as an increasingly popular treatment option. Although ORIF with angular locking plates is a common treatment for proximal humerus fractures, prior reports suggest high failure and complication rates. Although RTSA has become an increasingly popular option for complex proximal humeral head fractures given its low complication rates, there are concerns it may lead to limited postoperative ROM. Thus, the optimal treatment for patients older than 70 years from a functional and radiographic perspective remains unclear.

QUESTIONS/PURPOSES

(1) In patients older than 70 years with three-part and four-part proximal humerus fractures, does RTSA result in better functional outcome scores (Constant, American Shoulder and Elbow Surgeons [ASES], and DASH scores) than ORIF with a locking plate? (2) Does RTSA result in greater ROM than ORIF? (3) Does RTSA result in a lower risk of complications than ORIF? (4) In patients with either procedure, what are the rates of negative radiographic outcomes in those treated with ORIF (such as malunion, bone resorption, malalignment, or avascular necrosis) or those with RTSA (such as resorption, notching, and loosening)? (5) At a minimum of 2 years of follow-up, does ORIF result in a greater number of revision procedures than RTSA?

METHODS

Between January 1, 2013, and June 30, 2018, we treated 235 patients for a proximal humeral fracture. We considered only patients without previous ipsilateral fracture or surgery, other fractures, or radial nerve injuries; age older than 70 years; and patients without neurologic disease or cognitive dysfunction as potentially eligible. Sixty-nine percent (162 patients) of the patients were eligible; a further 31% (73 patients) were excluded because 18% (13 of 73 patients) did not meet the inclusion criteria, 62% (45 patients) underwent nonoperative treatment, and 21% (15 patients) declined to participate. Patients were nonrandomly allocated to receive RTSA if they had supraspinatus Goutallier/Fuchs Grade 3 or 4 atrophy or ORIF if they had supraspinatus Goutallier/Fuchs Grade 1 or 2 atrophy. This left 81 patients who were treated with RTSA and another 81 patients who were treated with ORIF. Among the 81 patients treated with RTSA, 11% (nine patients) were lost to the minimum study follow-up of 2 years or had incomplete datasets, leaving 89% (72 patients) for analysis. Among the 81 patients treated with ORIF, 19% (15 patients) were lost before the minimal study follow-up of 2 years or had incomplete datasets, leaving 82% (66 patients) for analysis. The median follow-up for both groups was 53 months (range 24 to 72 months). The mean age was 76 ± 2.9 years in the RTSA group and 73 ± 2.9 years in the ORIF group. In the RTSA group, 27 patients had a three-part fracture and 45 patients had a four-part fracture. In the ORIF group, 24 patients had three-part fractures and 42 patients had four-part fractures (p = 0.48). Shoulder function was assessed using functional outcome questionnaires (ASES, DASH, and Constant) and active ROM measurements. A surgical complication was defined as any instance of dislocations, fractures, adhesive capsulitis, nerve injuries, or surgical site infections. Radiographic outcomes after ORIF (malunion, tuberosity resorption, or avascular necrosis) and RTSA (notching and osteolysis) were assessed. In calculating the revision rate, we considered unplanned revision procedures only.

RESULTS

Compared with patients treated with ORIF, patients treated with RTSA had superior improvements in Constant (85.0 ± 7.0 versus 53.0 ± 5.0; mean difference 32 [95% CI 30 to 34]; p < 0.01), ASES (46.3 ± 3.7 versus 30.0 ± 3.5; mean difference 16 [95% CI 15 to 18]; p < 0.01), and DASH scores (40.5 ± 4.2 versus 30.5 ± 2.6; mean difference 10 [95% CI 9 to 11]; p < 0.01). The mean elevation was 135° ± 7° for patients with RTSA and 100° ± 6° for patients with ORIF (mean difference 35 o [95% CI 33 to 37]; p < 0.01). The mean abduction was 131° ± 7° for patients with RTSA and 104° ± 6° for those with ORIF (mean difference 27 o [95% CI 25° to 29°]; p < 0.01). The mean external rotation was 85° ± 5° for patients with RTSA and 64° ± 5° for those with ORIF (mean difference 21° [95% CI 19° to 23°]; p < 0.01). The mean internal rotation was 45° ± 6° for patients with RTSA and 40° ± 6° for those with ORIF (mean difference 5° [95% CI 3° to 7°]; p < 0.01). The risk of complications was not different between patients with ORIF and those with RTSA (5% [three of 66] versus 1% [one of 72]; relative risk 3.3 [95% CI 0.3 to 30.7]; p = 0.30). Among patients with ORIF, 8% had varus malunions (five of 66), 6% had resorption of the greater tuberosity (four of 66), and 2% had avascular necrosis of the humeral head (one of 66). In the RTSA group, 24% (17 of 72 patients) demonstrated reabsorption of periprosthetic bone and 79% of patients (57 of 72) exhibited no notching. The risk of revision was not different between the RTSA and ORIF groups (0% [0 of 72] versus 9% [six of 66]; relative risk 0.07 [95% CI 0.0 to 1.2]; p = 0.07).

CONCLUSION

In patients older than 70 years with three-part and four-part proximal humerus fractures, primary RTSA resulted in better patient-reported outcome scores and better ROM than ORIF with an angular stable locking plate. Our findings might help surgeons decide between internal fixation and arthroplasty to surgically treat these injuries in older patients. Although RTSA seems to be a preferable treatment modality in view of these findings, longer follow-up is required to evaluate its longevity compared with ORIF with an angular locking plate. Dissimilar to ORIF, which is generally stable once healed, arthroplasties are at a continued risk for loosening and infection even after healing is complete.

LEVEL OF EVIDENCE

Level II, therapeutic study.

30-Day Postoperative Complications After Surgical Treatment of Proximal Humerus Fractures: Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty

INTRODUCTION

The purpose of this study was to evaluate risk factors associated with complications after reverse total shoulder arthroplasty (TSA) and hemiarthroplasty for the treatment of proximal humerus fractures.

METHODS

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database was conducted. Current Procedural Terminology codes were used to identify patients treated for proximal humerus fracture with reverse TSA or hemiarthroplasty between 2005 and 2018.

RESULTS

One thousand five hundred sixty-three shoulder arthroplasties were conducted: 436 hemiarthroplasties and 1,127 reverse TSA. The overall complication rate was 15.4% (15.7% reverse TSA; 14.7% hemiarthroplasty) (P = 0.636). Most frequent complications included transfusion 11.1%, unplanned readmission 3.8%, and revision surgery 2.1%. A 1.1% incidence of thromboembolic events was noted. Complications occurred most frequently in patients older than 65 years; male; and patients with anemia, American Society of Anesthesiologists classification III-IV, inpatient procedure, bleeding disorders, duration of surgery >106 minutes, and length of stay >2.5 days. Patients with body mass index >36 kg/m2 had a decreased risk of 30-day postoperative complications.

DISCUSSION

There was a 15.4% complication rate in the early postoperative period. In addition, no notable difference was found in complication rates between groups (hemiarthroplasty: 14.7%; reverse TSA 15.7%). Future studies are needed to determine whether there is a difference between these groups in the long-term outcome and survivorship of these implants.

Should valgus-impacted proximal humerus fractures necessarily be operated on? Radiological versus functional results

Background/aim

Impacted valgus proximal humerus fracture has been known to be challenging in terms of treatment and outcomes since it was defined. Moreover, it is a type of fracture that is difficult to treat. In addition, exact limits have not yet been determined regarding which parameters affect patients' functional and reported outcomes. The purpose of this study was to compare the radiological results of patients with impacted valgus proximal humerus fractures treated conservatively and surgically and to evaluate the effect of these radiological parameters on functional outcomes.

Materials and methods

A total of 79 patients who were treated between 2015 and 2021 with a diagnosis of impacted valgus fracture were evaluated retrospectively. Patients treated conservatively (Group 1) and surgically (Group 2) were evaluated in terms of radiological measurements (tubercle displacement (TD), cephalodiaphyseal angle (CDA), medial hinge (MH), cephaloglenoid angle (CGA), medial hinge impaction (MHI), American Shoulder and Elbow Surgeons Shoulder Score (ASES), Constant Shoulder Score, and functional outcomes (range of motion). The effect of radiological parameters on clinical outcomes was analyzed by a correlation test.

Results

In the postoperative period, the ASES and Constant scores of the patients in Group 2 were significantly higher than those of the patients in Group 1. Additionally, Group 2 had better results in terms of passive extension, active internal rotation, and active/passive external rotation. Patients in both groups exhibited improvements in radiological parameters, and the correlation test showed that MH and MHI were mostly related to ASES and Constant scores.

Conclusion

The monitoring and treatment of impacted valgus proximal humerus fractures remain controversial. Although radiological parameters are a guide for orthopedic surgeons, the limits have not been clearly defined. In this study, in addition to all parameters, the effect of MH and MHI on functional results was emphasized.

Effect of Fibular Allograft Augmentation in Medial Column Comminuted Proximal Humeral Fractures: A Randomized Controlled Trial

BACKGROUND

Previous observational studies and meta-analyses have recommended augmentation with a fibular allograft (FA) during the treatment of proximal humeral fractures with locking plates (LPs). However, to our knowledge, randomized controlled trials comparing open reduction and internal fixation (ORIF) with and without FA have not been performed to date.

METHODS

This was a randomized controlled trial in which adults with a medial column comminuted proximal humeral fracture were randomly allocated to undergo ORIF with an LP (the LP group) or with an LP augmented with an FA (the FA group). Patients were followed for 24 months. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score at 12 months after the surgical procedure. The secondary outcomes included the DASH score at other time points, shoulder function, pain score, satisfaction, complications, and changes in neck-shaft angle and humeral head height.

RESULTS

From October 20, 2016, to December 24, 2019, 80 patients were randomized. There were 52 women (65%), and the mean patient age (and standard deviation) was 65 ± 14 years. Of the 80 patients, 39 were allocated to the FA group and 41 were allocated to the LP group. At the primary time point (12 months), the unadjusted mean between-group difference in DASH score was -1.2 (95% confidence interval [CI], -7.3 to 5.0; p = 0.71) favoring the FA group, and, with adjustment for smoking, alcohol drinking, and diabetes, the between-group difference was -1.4 (95% CI, -7.7 to 5.0; p = 0.67) favoring FA. No significant differences between the 2 groups were found among the secondary outcomes.

CONCLUSIONS

No additional benefit was found for FA augmentation in treating medial column comminuted proximal humeral fractures.

LEVEL OF EVIDENCE

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

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

OBJECTIVES

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

DATA SOURCES

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Osteoporosis does not affect bone mineral density change in the proximal humerus or the functional outcome after open reduction and internal fixation of unilateral displaced 3- or 4-part fractures at 12-month follow-up

BACKGROUND

The aim of this prospective study was to investigate bone mineral density (BMD) changes in the proximal humerus of the shoulder during a healing period of 12 months after displaced 3- or 4-part proximal humerus fractures treated with open reduction and internal fixation (ORIF) with an anatomic angular stable locking plate and the influence on fracture healing and functional outcomes.

METHODS

In a prospective multicenter study, 36 patients (29F and 7M, age range: 38-83) with unilateral displaced 3- or 4-part proximal humerus fractures were included for ORIF. Dual-energy x-ray absorptiometry for osteoporosis status was employed. Postoperative and 6-week, 3-, 6-, and 12-month shoulder radiographs and dual-energy x-ray absorptiometry of the shoulder with BMD measures in 4 templated regions of interest (ROIs) were performed. Functional outcomes, Western Ontario Osteoarthritis of the Shoulder index, Constant score, visual analog scale pain (VAS), and 36-Item Short Form Survey, were collected.

RESULTS

A total of 17 of 36 patients had osteoporosis. We found no differences in BMD changes, functional outcomes, radiology, or need for revision surgery between the osteoporosis and nonosteoporosis groups. The BMD values gradually declined from baseline to 3-month follow-up in all 4 ROIs of the operated shoulders. All 4 ROIs in the operated shoulder presented with a reduction in BMD at 3, 6, and 12 months compared with baseline, whereas no significant BMD changes were seen in the healthy shoulder during the study period. The functional outcomes displayed an increase in Constant score from 3 to 12 months, but a decrease in domains of the 36-Item Short Form Survey from preinjury to 12 months (physical functioning, general health, and bodily pain). Preinjury and 12-month Western Ontario Osteoarthritis of the Shoulder index, VAS pain at rest, and VAS pain at activity were comparable.

CONCLUSION

BMD changes appeared swiftly in the proximal humerus, after the treatment of displaced 3- or 4-part fractures with ORIF, particularly affecting the proximal diaphysis of the humerus. Shoulder function was restored to preinjury levels for most of the patients. Osteoporosis may not be regarded as a contraindication for the treatment of displaced 3- or 4-part fractures with ORIF.

Proximal humerus fractures (PHFs): comparison of functional outcome 1 year after minimally invasive plate osteosynthesis (MIPO) versus open reduction internal fixation (ORIF)

PURPOSE

Osteosynthetic treatment strategies of PHFs include MIPO or ORIF techniques. The aim of this study was to compare the 1 year outcome following either technique in type B PHFs.

METHODS

This study was designed as a retrospective cohort study of patients treated at one academic Level 1 trauma center. Patients from 2009 to 2019 who required surgical treatment of a type B PHF were eligible to be included in this study. Patients with A- or C-type fractures or patients requiring arthroplasty were excluded. All patients were treated with Proximal Humerus Interlocking System (PHILOS) and stratified according the approach into Group MIPO or Group ORIF. Outcome measures include local complications that occurred during hospitalization, nonunion after 12 months, and range of motion after 1 year follow-up.

RESULTS

This study included 149 (75.3%) patients in Group ORIF, and 49 (24.7%) in Group MIPO. The fracture morphology and concomitant injuries were comparable amongst these groups. When compared with Group MIPO, Group ORIF had a 2.6 (95% CI 0.6-11.7) higher risk of suffering from local complications. The rate of postoperative nerve lesions was comparable (OR 0.9, 95% CI 0.1-9.7) as was the rate of soft tissue complications (OR 2.0, 95% CI 0.2-17.2). The risk for nonunion was 4.5 times higher (95% 1.1-19.5) in Group ORIF when compared with Group MIPO. Group MIPO had a higher chance of flexion above 90° (OR 8.2, 95% CI 2.5-27.7).

CONCLUSION

This study provides indications that patients following surgical treatment of PHFs in MIPO technique might have favourable outcome. Large-scale and high-quality studies are warranted to confirm these results.

Technique and clinical results of a new intramedullary support nail and plate system for fixation of 3- or 4- part proximal humeral fractures in older adults

BACKGROUND

Internal fixation of complex proximal humeral fractures (PHF) with osteoporosis is associated with a high incidence of complications. This study introduces the technique and clinical results of a novel intramedullary support nail and plate system (ISNPs) for the internal fixation of 3- or 4- part PHF in older adults. The ISNPs combines the concept of intramedullary support and dynamic fixation into a locking plate fixation system that can be applied using a minimally invasive surgical approach.

METHODS

A total of 46 consecutive patients diagnosed with 3- or 4-part PHF that met the criteria were included in this study, including 18 in the ISNPs group and 28 in the conventional locking plate (LP) group. Clinical results, including operative time, intraoperative bleeding, reduction quality, subjective outcome ratings, and complications, were compared between the two groups. Functional outcomes were evaluated using the Constant score and disability of the arm, shoulder, and hand (DASH) questionnaire at 1-year follow-up.

RESULTS

There were no significant differences in age, sex, local bone quality, Neer-fracture type, and follow-up time between the ISNPs and LP groups. For clinical analysis, there were no significant differences in intraoperative bleeding and operation time between the ISNPs and LP groups. Significant differences were observed in the percentage of the malreduced cases, Constant and DASH score analysis, and the patients' subjective evaluation ('excellent' and 'good' %) between the two groups.

CONCLUSION

The ISNPs technique proposed in this study provides a novel hybrid internal fixation model for complex PHF with osteoporosis. The clinical results at 1-year follow-up confirmed the advantage of applying it to 3- or 4- part PHF in older patients. Further studies are required to optimize its design and explore its optimal indications.

Proximal humeral fractures treated with a low-profile plate with enhanced fixation properties

BACKGROUND

Our purpose was to evaluate the clinical and radiographic outcomes of proximal humeral fractures treated with a new generation plating system and compare results with a meta-analysis of recent literature.

METHODS

Between 2014 and 2017, 93 patients (18 males, 75 females) with proximal humerus fractures were treated with open reduction and internal fixation (ORIF) using a Pantera® Plate. These low-profile plates are anatomically shaped and include "cross-elements" that form a three-dimensional scaffold in bone to enhance fixation stability. According to Neer classification, there were 24 two-part fractures, 49 three-part fractures and 20 four-part fractures (4 with dislocated heads). X-rays and Constant Shoulder Scores (CSS) were used to evaluate healing, complications, and clinical outcomes. Results were compared with a meta-analysis of similar studies reported in literature over the last 10 years.

RESULTS

Eighty-three patients with a minimum follow-up of 2 years had a mean CSS of 72 (53-90) graded as excellent for 23 patients (28%), good for 35 (42%), fair for 14 (17%), and poor for 11 (13%). Fractures healed without complication in 75 (91%) patients. Eight (9%) complications were observed, i.e., three avascular necrosis of the humeral head, one case of implant loosening, two cases of subacromial impingement and two superficial infections. There was no significant correlation between Neer fracture stage and patient outcome (p = 0.257). Compared to the literature, this method had a lower complication grade (p = 0.03), though it did not significantly differ in its clinical outcomes (p = 0.08).

CONCLUSIONS

The investigated plating system includes design features that can potentially increase utility for ORIF of proximal humeral fractures. While the complication profile was signficantly less than reported in the literature for standard proximal humerus plates, clinical outcomes were similar. Further studies will be required to better understand the role of plate design on treatment of these challenging fractures.

LEVEL OF EVIDENCE

IV, therapeutic study.

Management of Proximal Humerus Fractures in Adults-A Scoping Review

Proximal humerus fractures are the third most common fracture type in adults, with their incidence increasing over time. There are varied approaches to both the classification and treatment of proximal humerus fractures. Optimal treatments for this fracture type are still widely open to debate. This review summarizes the current and historical treatment modalities for proximal humerus fractures. In this paper, we provide updates on the advances and trends in the epidemiology, classification, and operative and nonoperative treatments of proximal humerus fractures.

Using the Greater Tuberosity as a Reference for Placement of Proximal Humerus Plates Leads to a High Rate of Calcar Screw Malposition

OBJECTIVES

Achieving calcar fixation is critical to minimize the failure of proximal humerus fractures repaired with proximal humeral locking plates (PHLPs). Many operative technique manuals reference the greater tuberosity (GT) for plate placement. The objective of this study was to examine the accuracy of calcar screw placement when PHLPs were placed based on distance from the GT.

METHODS

Twenty cadaveric specimens were acquired representing a height distribution across the US population. Thirteen different PHLPs were applied. A drill bit was placed through the designated calcar screw hole and measured on radiographs, with the inferior 25% of the head representing an ideal placement.

RESULTS

Three hundred fifty constructs were studied. In 28% of the specimens, the calcar screw was misplaced. In 20% of the specimens, it was too low, whereas in 8%, it was too high. The calcar screw missed low in 30% of patients shorter than 5 feet, 5.5 inches versus 8% of taller patients ( P = 0.007). It missed high in 13% of taller patients versus 2% of shorter patients ( P = 0.056). Calcar screws in variable-angle plates missed 0% of the time, whereas those in fixed-angle plates missed 36% of the time ( P = 0.003).

CONCLUSIONS

Placement of PHLPs based on distance from the GT results in unacceptable position of the calcar screw 28% of the time and up to 36% in fixed-angle plates. This could be further compounded if the GT is malreduced. Current technique guide recommendations result in an unacceptably high rate of calcar screw malposition.

The Evolution of Reverse Total Shoulder Arthroplasty and Its Current Use in the Treatment of Proximal Humerus Fractures in the Older Population

Proximal humerus fracture (PHF) is a common injury in the older population. While the majority of these fractures are treated non-operatively, a small subset of patients may benefit from surgical treatment. However, there continues to be an ongoing debate regarding the indications and ideal surgical treatment strategy. The use of reverse total shoulder arthroplasty (RTSA) has resulted in a paradigm shift in the treatment of PHFs in the older population. Unique biomechanical principles and design features of RTSA make it a suitable treatment option for PHFs in the older population. RTSA has distinct advantages over hemiarthroplasty and internal fixation and provides good pain relief and a reliable and reproducible improvement in functional outcomes. As a result, there has been an exponential increase in the volume of RTSA in the older population in last decade. The aim of this paper is to review the current concepts, outcomes and controversies regarding the use of RTSA for the treatment of PHFs in the older population.

Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures: Current Concepts

Complex proximal humeral fractures, especially in elderly patients, often require arthroplastic surgical treatment. Traditionally, shoulder hemiarthroplasty (HA) is the method of choice, resulting in long implant survival and a painless shoulder; however, shoulder HA has heterogeneous clinical outcomes related to the correct position of the implant, both in terms of height and version, and the anatomical consolidation of tuberosities. Today, reverse shoulder arthroplasties are increasingly used to treat such fractures. These techniques result in better functional outcomes compared to HAs, especially regarding anterior flexion, but implant longevity has not been established. The development of specific prosthetic humeral components for the treatment of fractures, which were recently introduced in the clinical practice, led to better clinical outcomes.

Risk factors for fracture-related infection after open reduction and internal fixation of proximal humerus fractures: A multicenter retrospective study of 496 fractures (TRON group study)

INTRODUCTION

One of the complications of the surgical therapy for proximal humerus fractures is fracture-related infection (FRI). This multicenter study aimed to investigate the incidence of FRI and clarify the risk factors associated with FRI in patients receiving open reduction and internal fixation for proximal humerus fracture.

MATERIAL AND METHODS

Among 684 patients diagnosed as having proximal humerus fracture and who were treated by surgical therapy in 13 institutions (named TRON group) from 2015 through 2020, 496 patients (men, n = 134, women, n = 362; mean [SD] age, 68.5 [14.5] years; mean [SD] body mass index [BMI], 23.0 [4.4] kg/m²) were included as subjects. Excluded were 188 patients due to less than 12 month's follow-up, patients who underwent osteosynthesis using neither plate nor nail and those with open fracture. We extracted the following as risk factors of FRI: sex, BMI, smoking status, diabetes, glenohumeral fracture dislocation, fracture classification, approach, implant, waiting period, type of anesthesia, operative time and blood loss during surgery. We conducted logistic regression analysis to investigate the risk factors of FRI using these extracted items as explanatory variables and the presence or absence of FRI as the response variable.

RESULT

FRI occurred after surgery for proximal humerus fracture in 9 of the 496 patients (1.8%). The causative organism was methicillin-susceptible Staphylococcus aureus in 4 patients, Pseudomonas aeruginosa in one patient and Enterococcus faecalis in one patient. In the other 3 patients, causative organisms were not detected. The univariate analysis showed significant differences for present of glenohumeral fracture dislocation (p = 0.004). Logistic regression analysis showed glenohumeral fracture dislocation to be the significant explanatory factor for FRI (odds ratio 12.3, p = 0.0375).

CONCLUSION

This study revealed an infection rate following open reduction and internal fixation of proximal humerus fracture of 1.8% (9 patients) and that Staphylococcus was the most frequent causative organism. Glenohumeral fracture dislocation is a significant risk for postoperative FRI.

Effects of fibular strut augmentation for the open reduction and internal fixation of proximal humeral fractures: a systematic review and meta-analysis

BACKGROUND

There is still a lack of remarkable consensus regarding the clinical efficacy of the application of fibular strut augmentation (FSA) combined with a locking plate for proximal humeral fractures. A systematic review and meta-analysis to assess the effect of the use of FSAs in open reduction and internal fixation of proximal humeral fractures was conducted.

METHODS

A literature search was conducted in PubMed, Embase, Cochrane, Web of Science Core Collection, and ClinicalTrials.gov to identify trials that compared the clinical outcomes of proximal humeral fractures treated using a locking plate with or without FSA. The primary outcome measures were postoperative complications, radiographical findings, functional recovery scores, and postoperative range of motion (ROM). Data were pooled and analysed using a random-effects model based on the Der Simonian and Laird method.

RESULTS

Eight studies involving 596 participants were included for further analysis. Compared with using a locking plate independently, the additional application of FSA was associated with the likelihood of lower risk of overall complications (OR 0.37; 95% CI 0.22-0.65; I² = 12.22%; 95% PI 0.14-0.98) and the rate of patients with orthopaedic complications (OR 0.48; 95% CI 0.25-0.92; I² = 7.52%; 95% PI 0.16-1.45), less changes in postoperative humeral head height (MD - 2.40; 95% CI - 2.49 to - 2.31; I² = 0.00%; 95% PI - 2.61 to - 2.20) and the neck-shaft angle (MD - 6.30; 95% CI - 7.23 to - 5.36; I² = 79.32%; 95% PI - 10.06 to - 2.53), superior functional outcomes (Constant-Murley score: MD 5.07; 95% CI 3.40 to 6.74; I² = 0.00%; 95% PI 2.361-7.78; American Shoulder and Elbow Surgeons Score: MD 5.08; 95% CI 3.67 to 6.49; I² = 0.00%; 95% PI 1.98-8.18), and better postoperative ROM in terms of forward elevation and external rotation. However, the evidence regarding postoperative abduction was insufficient.

CONCLUSION

Meta-analytic pooling of current evidence showed a significant association between the application of FSAs and favourable clinical outcomes in terms of postoperative complications, radiographical findings, functional recovery, and postoperative elevation and external rotation.

3D-Printed Models versus CT Scan and X-Rays Imaging in the Diagnostic Evaluation of Proximal Humerus Fractures: A Triple-Blind Interobserver Reliability Comparison Study

BACKGROUND

Proximal humerus fractures (PHFs) are one of the most frequent fractures in the elderly and are the third most fractures after those of the hip and wrist. PHFs are assessed clinically through conventionally standard imaging (X-ray and computed tomography (CT) scans). The present study aims to conduct the diagnostic evaluation and therapeutic efficacy of the 3D-printed models (3DPMs) for the PHFs, compared with the standard imaging.

OBJECTIVES

In terms of fracture classification and surgical indication, PHFs have poor interobserver agreement between orthopedic surgeons using traditional imaging such as X-rays and CT scan. Our objective is to compare interobserver reliability in diagnostic evaluation of PHFs using 3DPMs compared to traditional imaging.

METHODS

The inclusion criteria were elders aged >65 years, fracture classification AO/OTA 11 B and 11 C, and no pathological fractures or polytrauma. In addition, 9 PHFs were assessed by 6 evaluators through a questionnaire and double-blinded administered for each imaging (X-ray and CT scan) and 3DPMs for each fracture. The questionnaire for each method regarded Neer classification, Hertel classification, treatment indication (IT), and surgical technique (ST). Interobserver reliability was calculated through the intraclass correlation coefficient (ICC).

RESULTS

Nine patients with PHF were included in the study (66% female). The Neer and Hertel classifications between imaging types had similar ICC values between raters with no statistical differences. IT reliability using CT scan and 3DPMs (ICC = 1; (p=0.116)) assessed better agreement compared with X-rays IT. The ST reliability using 3DPMs (ICC = 0.755; p=0.002) was statistically superior to traditional imaging (ST-RX ICC = -0.004 (p=0.454); ST-CT ICC = 0.429 (p=0.116)).

CONCLUSION

Classification systems like Neer and Hertel offer poor reliability between operators. The 3DPMs for evaluating diagnostics are comparable to CT images but superior to the surgical technique agreement. The application of 3DPMs is effective for preoperative fracture planning and the modeling of patient-specific hardware.

Development and Internal Validation of Novel Risk Tools to Predict Subsequent Shoulder Surgery After Proximal Humerus Fractures

OBJECTIVE

To (1) identify predictors of subsequent surgery after initial treatment of proximal humerus fractures (PHFs) and (2) generate valid risk prediction tools to predict subsequent surgery.

METHODS

We identified patients ≥50 years with PHF from 2004 to 2015 using health data sets in Ontario, Canada. We used procedural codes to classify patients into treatment groups of (1) surgical fixation, (2) shoulder replacement, and (3) conservative. We used procedural and diagnosis codes to capture subsequent surgery within 2 years after fracture. We developed regression models for two-thirds of each group to identify predictors of subsequent surgery and the regression equations to develop risk tools to predict subsequent surgery. We used the final third of each cohort to evaluate the discriminative ability of the risk tools using c-statistics.

RESULTS

We identified 20,897 patients with PHF, 2414 treated with fixation, 1065 with replacement, and 17,418 treated conservatively. Predictors of reoperation after fixation included bone grafting and nail or wire fixation versus plate fixation, whereas poor bone quality was associated with reoperation after initial replacement. In conservatively treated patients, more comorbidities were associated with subsequent surgery, whereas age 70+ and discharge home after presentation lowered the odds of subsequent surgery. The risk tools were able to discriminate with c-statistics of 0.75-0.88 (derivation) and 0.51-0.79 (validation).

CONCLUSIONS

Our risk tools showed good to strong discriminative ability for patients treated conservatively and with fixation. These data may be used as the foundation to develop a clinically informative tool.

LEVEL OF EVIDENCE

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

The influence of fracture severity on postoperative outcome and quality of life after locking plate fixation of proximal humeral fractures

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

Operative Treatment of Proximal Humeral Fractures with Reverse Total Shoulder Arthroplasty in Patients ≥65 Years Old: A Critical Analysis Review

»

The majority of proximal humeral fractures (PHFs) in patients who are ≥65 years of age are treated nonoperatively, but certain complex fracture patterns benefit from surgical intervention. However, there continues to be debate regarding the indications for surgery and the optimal surgical treatment (repair versus replacement) in this population.

»

Reverse total shoulder arthroplasty (RTSA) has grown in popularity for surgical treatment of fracture-dislocations and displaced complex PHFs in patients who are ≥65 years of age; it has definite advantages over surgical repair and hemiarthroplasty, but this finding requires additional higher-quality evidence.

»

RTSA provides early pain relief and return of shoulder function as well as predictable elevation above shoulder level in the forward plane, but the indications for and understanding of the effect of timing on RTSA after a PHF continue to evolve.

»

RTSA for an acute PHF is indicated in patients who are ≥65 years of age with 3- and 4-part fracture-dislocations, head-split fractures, and severely displaced fractures, and is an option in patients who are not able to tolerate nonoperative treatment of severely displaced 3- and 4-part fractures.

»

RTSA is also indicated as a salvage operation for PHFs that have failed initial surgical repair (i.e., fixation failure, implant failure, rotator cuff failure, or osteonecrosis) and is an option for symptomatic nonunion or malunion after nonoperative treatment.

Surgeons Consider Initial Nonoperative Treatment With Potential for Future Conversion to Reverse Arthroplasty a Reasonable Option for Older, Relatively Infirm, and Less-Active Patients

OBJECTIVES

Two recent developments favor initial nonoperative treatment of proximal humerus fractures among the older, relatively infirm, less-active patients that represent most patients with such fractures: (1) evidence of minimal benefit of open reduction, internal fixation over nonoperative treatment, and (2) evidence of the effectiveness of the reverse total shoulder arthroplasty. As one step in determining the feasibility of a strategy of initial nonoperative treatment of proximal humerus fracture among older, relatively infirm, less-active people, we performed a survey-based experiment to measure factors associated with surgeon recommendation for initial nonoperative treatment.

METHODS

Members of the Science of Variation Group viewed 8 hypothetical patients with radiographs of complex proximal humeral fractures and 7 randomized patient variables. For each scenario, surgeons were asked whether they would recommend (1) initial nonoperative treatment with bailout reverse arthroplasty or (2) immediate reverse arthroplasty.

RESULTS

The mean percentage of recommendations for initial nonoperative treatment was 63%, with wide variation by surgeon (range 0%-100%). In multilevel mixed-effects logistic regression, recommendation for initial nonoperative treatment was associated with specific radiographs, older age, having a comorbidity, being homebound, surgical subspecialists, and more than 20 years in practice.

CONCLUSIONS

These findings suggest that surgeons may consider initial nonoperative treatment with potential for future conversion to reverse arthroplasty an acceptable treatment option, particularly for older, less-active, more infirm individuals, and relatively less displaced fractures with little comminution.

Comparison of 30-day complications between reverse shoulder arthroplasty and open reduction internal fixation for the treatment of proximal humerus fractures

PURPOSE

While the use of open reduction internal fixation (ORIF) has remained stable over the last decade, there has been a significant increase in the use of reverse total shoulder arthroplasty (RTSA) for proximal humerus fractures (PHFs). This study sought to compare the complication profiles of RTSA to ORIF in a large, validated, retrospective cohort.

METHODS

Patients who underwent surgical treatment for PHFs with RTSA or ORIF were identified in a national database (NSQIP) using CPT and ICD codes. Demographics and comorbidities were identified for each cohort of patients. Thirty-day complications were analyzed with univariate and multivariate analyses using Chi-square, Fischer's exact and analysis of variance testing.

RESULTS

The total number of patients included in this study was 2157.522 (24.2%) underwent RTSA and 1635 (75.8%) underwent ORIF. Patients undergoing RTSA were older with an average age of 73.52 years compared with 63.84 years in those undergoing ORIF (p < 0.001). Patients with RTSA were more likely to experience any complications (p < 0.001), pulmonary complications (p = 0.029), extended length of stay > 3 days (p < 0.001), and perioperative transfusion requirement (p < 0.001) after univariate analysis. After controlling for demographic differences, the only statistically significant complication was perioperative transfusion requirement (OR 1.383).

CONCLUSION

After controlling for demographic variables and comorbidities, RTSA placed patients at increased risk for perioperative blood transfusion. Patients undergoing RTSA should be counseled prior to surgery regarding the risk for transfusion and potentially optimized medically through multidisciplinary care if the surgeon elects to proceed with RTSA versus ORIF for the treatment of PHFs.

[Comparison of locking plate and intramedullary nail in treatment of Neer two- and three-part fractures of the proximal humerus in the elderly]

OBJECTIVE

To compare the effectiveness of locking plate and intramedullary nail in treatment of Neer two- and three-part fractures of the proximal humerus in the elderly.

METHODS

A retrospective analysis was conducted on 86 elderly patients with Neer two- and three-part fractures of the proximal humerus met the selection criteria between January 2015 and December 2018. Forty-six patients were treated with locking plate fixation (locking plate group), and 40 patients with intramedullary nail fixation (intramedullary nail group). There was no significant difference in gender, age, cause of injury, fracture side and type, time from injury to operation, and comorbidities between the two groups ( P>0.05). Visual analogue scale (VAS) score, American Shoulder and Elbow Surgery (ASES) score, Constant-Murley score, and shoulder range of motion (forward flexion, abduction, and external rotation) were compared between the two groups. X-ray films were taken to assess the fracture healing, and the neck-shaft angle was measured at 2 days after operation and at last follow-up, and the difference between the two time points was calculated.

RESULTS

Patients in both groups were followed up 18-40 months, with an average of 30.4 months. There was no significant difference in follow-up time between the two groups ( t=-0.986, P=0.327). X-ray films reexamination showed that the fractures of two groups healed, and the healing time was (11.3±2.1) weeks in locking plate group and (10.3±2.0) weeks in intramedullary nail group, which had significant difference between the two groups ( t=2.250, P=0.027). The difference of neck-shaft angle was (7.63±7.01)° in locking plate group and (2.85±2.82)° in intramedullary nail group, which had significant difference between the two groups ( t=4.032, P<0.001). There was no significant difference in Constant-Murley score, ASES score, VAS score, and shoulder range of motion between the two groups at last follow-up ( P>0.05). Complications occurred in 13 cases (28.3%) of locking plate group and in 4 cases (10.0%) of intramedullary nail group, and the difference between the two groups was significant ( χ 2=4.498, P=0.034).

CONCLUSION

Both locking plates and intramedullary nails can be used for the treatment of Neer two- and three-part fractures of the proximal humerus in the elderly. The intramedullary nail fixation surgery is more minimally invasive, which has fewer postoperative complications and faster fracture healing.

The potential of locking plate with intramedullary fibular allograft to manage proximal humeral fracture with an unstable medial column

PURPOSE

To evaluate the potential of locking compression plate with intramedullary fibular allograft in managing proximal humeral fractures with an unstable medial column.

METHODS

Between March 2007 and March 2015, we retrospectively analyzed 63 patients who underwent locking plate fixation for proximal humeral fracture with an unstable medial column. All patients were assigned into group 1 (patients treated with locking plate) and group 2 (patients treated with locking plate with intramedullary fibular allograft). Groups 1 and 2 were composed of 29 and 34 patients, respectively. We analyzed bone union, the neck-shaft angle, the Constant score, the range of motion, and complications.

RESULTS

The mean average bone union time of the patients was 13.9 weeks in group 1 and 11.3 weeks in group 2. The average Constant score was 67.4 in group 1 and 73.6 in group 2 (p < 0.05). The mean preoperative NSA, postoperative NSA, and NSA at the last follow-up were 104.4°, 125.8°, and 115.8°, respectively, in group 1, and 109.0°, 130.3°, and 127.1°, respectively, in group 2. The mean forward flexion, abduction, external rotation, and internal rotation were 109.0°, 48.2°, 34.0°, and L5, respectively, in group 1, and 127.5°, 118.2°, 38.7°, and L1, respectively, in group 2. In group 1, avascular necrosis occurred in one patient and screw cutout in two patients. In group 2, screw cutout occurred in one patient.

CONCLUSION

In patients aged over 65 years with proximal humeral fractures, an unstable medial column was associated with poor clinical results owing to varus collapse. To prevent this, an intramedullary fibular allograft was used, and radiologic and clinical results were better with this approach than with a locking plate alone. Therefore, locking plate fixation using a fibular allograft is one of the possible treatments for patients with an unstable medial column.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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