Treatment of proximal humerus fractures in the elderly: a systemic review of 409 patients

Assessing complications and functional outcomes in proximal humerus fracture management: a retrospective comparison between conservative and intramedullary nailing treatments

INTRODUCTION

Fractures of the proximal end of the humerus (FPH) are the second most common fractures in the upper limb after fractures of the distal radius and are two to three times as common in women than in men. Therefore, the main objective of the present study was to compare and analyze the complications and the functional outcomes in patients with displaced FPH receiving conservative and surgical treatments with intramedullary nailing.

METHODS

A retrospective cross-sectional study was conducted to establish the differences in complications risks between surgical and non-surgical treatment of the FPH. For this purpose, the clinical and radiological results of 67 consecutive patients were analyzed.

RESULTS

A total of 25 patients were included in the non-surgically treated group. A total of 42 patients were included in the surgically treated group. Complications occurred in a total of 4 (16.0%) patients after the non-surgical treatment. Those included frozen shoulder (n = 2), nonunion (n = 1), and avascular necrosis of the humeral head (n = 1). Complications occurred in a total of 18 (42.6%) patients after the surgical treatment. Non-surgically treated patients had statistically significantly (p < 0.05) lower scores in the Constant-Murley scale in all of the categories.

CONCLUSION

The present study demonstrates an overall prevalence of complications to be 16% in patients treated conservatively and 42.6% in patients treated surgically. In the non-surgical cohort, the frozen shoulder was the most frequently observed complication (8%). Interestingly, non-anatomical repositioning was the most prevalent complication in surgically treated patients. Due to the complexity of the FPH, we believe that the surgeon needs to have comprehensive knowledge regarding the characteristics of this fracture, the available treatment options, and the possible complications that may occur. This can enhance patient safety and provide satisfactory clinical outcomes.

Clinical outcomes of conservative versus surgical treatment for patients with proximal humeral fracture before physiotherapy

Fear of movement, pain, and loss of shoulder function are the most common problems irrespective of their approach to management after proximal humeral fracture (PHF). However, it has been unclear whether there could be differences between both treatments in early clinical outcomes. It can help physiotherapists to guide in choosing treatment approaches. This study aimed to compare kinesiophobia, pain, range of motion (ROM), shoulder function, and Quality of life (QoL) in patients treated with either conservative (CT) versus surgical (ST) after PHF. In addition, it aimed to determine correlations between fear of movement and seconder outcome measures. This cross-sectional study enrolled the patients having 5-6 weeks (being permitted active movement) after being treated either CT or ST and receiving no physical therapy. Pain, passive and active ROMs, shoulder function, fear of movement, and QoL were evaluated. 42 patients were recruited. Kinesiophobia scores were similar (p=0.55) and moderate in both groups. There was a significant difference in degrees of shoulder active flexion, active and passive abduction in favor of the CT group (p=0.05, p=0.02, p=0.04, respectively). However, there was no difference between groups regarding the remaining clinical outcomes. Furthermore, kinesiophobia showed a moderate negative correlation with energy/fatigue, social functioning, and general health. These findings showed that patients treated surgically did not have more kinesiophobia, less function, and QoL before starting physiotherapy, despite having soft tissue damage and different types of fractures. However, surgically treated patients had significantly less range of motion.

Acute management of fractures in primary care - a cost minimisation analysis

BACKGROUND

In Norway, primary healthcare has first-line responsibility for all medical emergencies, including traumas and fractures. Normally, patients with suspected fractures are referred to specialist care in hospitals. However, the cooperating municipalities of Bykle and Valle have X-ray facilities and handle minor fractures locally. The aim of this study was to estimate the costs of X-ray diagnosis and initial treatment of fractures at the local primary care centre compared with initial transport and treatment in hospital.

METHODS

We conducted a cost minimisation analysis by comparing expected costs of initial examination with X-ray and treatment of patients with fractures or suspected fractures at two possible sites, in the local municipality or at the hospital. A cost minimisation analysis is an economic evaluation based on the assumption that the outcomes of the two treatment procedure regimens are equal. Costs were estimated in Euros (EUR) using 2021 mean exchange rates.

RESULTS

In 2019, we identified a total of 403 patients with suspected fractures in the two municipalities. Among these, 12 patients bypassed the primary care system as they needed urgent hospital care. A total of 391 injured patients were assessed with X-ray at the primary health care centres, 382 received their initial treatment there, and nine were referred to hospital. In an alternative hospital model, without X-ray and treatment possibilities in the municipality, the 382 patients would have been sent directly to hospital for radiological imaging and treatment. The total cost was estimated at EUR 367,756 in the hospital model and at EUR 69,835 in the primary care model, a cost saving of EUR 297,921.

CONCLUSION

Based on cost minimisation analysis, this study found that radiological diagnosis of suspected fractures and initial treatment of uncomplicated fractures in primary care cost substantially less than transport to and treatment in hospital.

Surgery with locking plate or hemiarthroplasty versus nonoperative treatment of 3-4-part proximal humerus fractures in older patients (NITEP): An open-label randomized trial

BACKGROUND

Proximal humerus fractures (PHFs) are common fractures, especially in older female patients. These fractures are commonly treated surgically, but the consensus on the best treatment is still lacking.

METHODS AND FINDINGS

The primary aim of this multicenter, randomized 3-arm superiority, open-label trial was to assess the results of nonoperative treatment and operative treatment either with locking plate (LP) or hemiarthroplasty (HA) of 3- and 4-part PHF with the primary outcome of Disabilities of the Arm, Shoulder, and Hand (DASH) at 2-year follow-up. Between February 2011 and December 2019, 160 patients 60 years and older with 3- and 4-part PHFs were randomly assigned in 1:1:1 fashion in block size of 10 to undergo nonoperative treatment (control) or operative intervention with LP or HA. In total, 54 patients were assigned to the nonoperative group, 52 to the LP group, and 54 to the HA group. Five patients assigned to the LP group were reassigned to the HA group perioperatively due to high comminution, and all of these patients had 4-part fractures. In the intention-to-treat analysis, there were 42 patients in the nonoperative group, 44 in the LP group, and 37 in the HA group. The outcome assessors were blinded to the study group. The mean DASH score at 2-year follow-up was 30.4 (standard error (SE) 3.25), 31.4 (SE 3.11), and 26.6 (SE 3.23) points for the nonoperative, LP, and HA groups, respectively. At 2 years, the between-group differences were 1.07 points (95% CI [-9.5,11.7]; p = 0.97) between nonoperative and LP, 3.78 points (95% CI [-7.0,14.6]; p = 0.69) between nonoperative and HA, and 4.84 points (95% CI [-5.7,15.4]; p = 0.53) between LP and HA. No significant differences in primary or secondary outcomes were seen in stratified age groups (60 to 70 years and 71 years and over). At 2 years, we found 30 complications (3/52, 5.8% in nonoperative; 22/49, 45% in LP; and 5/49, 10% in HA group, p = 0.0004) and 16 severe pain-related adverse events. There was a revision rate of 22% in the LP group. The limitation of the trial was that the recruitment period was longer than expected due to a high number of exclusions after the assessment of eligibility and a larger exclusion rate than anticipated toward the end of the trial. Therefore, the trial was ended prematurely.

CONCLUSIONS

In this study, no benefit was observed between operative treatment with LP or HA and nonoperative treatment in displaced 3- and 4-part PHFs in patients aged 60 years and older. Further, we observed a high rate of complications related to operative treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01246167.

A systematic review of biopsychosocial prognostic factors of recovery after a proximal humerus fracture

BACKGROUND

Proximal humerus fracture (PHF) is a common upper extremity injury. PHF often causes prolonged disability and interferes with independent function.

PURPOSE

This study reviewed and summarized prognostic factors of recovery following PHF and classified them within the International Classification of Functioning, Disability and Health (ICF) with each domain sub-categorized by modifiability.

STUDY DESIGN

Systematic review.

METHODS

We searched MEDLINE, CINAHL, EMBASE, and PsychINFO from the date of database inception to March 2019 and updated searches in December 2021. Studies included examining an association between prognostic factors and recovery with at least a 6-month follow-up. Two independent reviewers used the Quality in Prognosis Studies tool for methodological bias and levels of evidence. Designs showed wide variability in terms of characteristics of the included population, definition of recovery, assessment of prognostic factors, and outcome measures used. This prevented pooled estimates from being produced. Prognostic factors linked to ICF domains were possible.

RESULTS

Twenty-three studies including 4323 participants aged ≥18 met inclusion criteria. The risk of bias was low (35%), moderate (30%), and high (35%) across the included studies. Moderate evidence showed a significant association between pre-fracture functional independence and post-fracture complications with recovery. Fracture type, structural deformity, medication use, age, and gender were prognostic factors with inconclusive evidence. We assigned a weak level of evidence to the remaining 20 factors due to limited data. Immediate rehabilitation, compliance to post-fracture rehabilitation exercise, task-oriented exercise, and pain self-efficacy (i.e., coping behavior) are modifiable and are tapped into the ICF contextual factors.

CONCLUSIONS

An array of factors that fit within an ICF biopsychosocial framework have been investigated as potential mediators of outcomes after PHF. The evidence is incomplete conceptually and in terms of research design quality. Preoperative functional status is predictive of functional recovery emphasizing the importance of healthy aging.

Influence of Proximal Humeral Cortical Bone Thickness on the Radiographic Outcome After Osteosynthesis of Proximal Humeral Fractures: Propensity Matching Score Analysis

Introduction

Osteoporosis can affect the surgical outcomes of proximal humeral fractures in older people. Recently, the cortical bone thickness of the proximal humerus on plain radiograph has been proposed to reflect local osteoporosis of the proximal humerus; however, its effect on the surgical outcome of proximal humeral fractures remains unclear. The purpose of this study is to investigate the influence of cortical bone thickness on postoperative radiographic outcomes after osteosynthesis for proximal humeral fractures.

Materials and Methods

We retrospectively identified 190 patients (≥50 years) who underwent osteosynthesis with an intramedullary nail or plate for proximal humeral fractures. The patients were categorized into 2 groups according to the cut-off value of an average proximal humerus cortical bone thickness of 6 mm on plain radiographs: patients with and without local osteoporosis. After propensity score matching, we compared the incidence of postoperative radiographic complications between the 2 groups. We also performed subgroup analyses of outcomes in a subgroup of patients who underwent intramedullary nailing and those who underwent plate fixation.

Results

Propensity score matching yielded 60 patients in each group. No significant difference in complication rates was observed between the 2 groups. However, in the intramedullary nailing subgroup, the incidence of reduction loss was significantly higher in patients with local osteoporosis than in those without local osteoporosis (51.7% vs 14.3%, P = .002).

Discussion

The proximal humeral cortical bone thickness had no significant effect on the overall radiographic outcome; however, reduction loss after intramedullary nailing was susceptible to local osteoporosis of the proximal humerus.

Conclusion

Our study suggests that plate fixation is advantageous in preventing postoperative reduction loss in patients with lower cortical bone thickness.

Homogeneity in Surgical Series: Image Reporting to Improve Evidence

Good clinical practice guidelines are based on randomized controlled trials or clinical series; however, technical performance bias among surgical trials is under-assessed. The heterogeneity of technical performance within different treatment groups diminishes the level of evidence. Surgeon variability with different levels of experience-technical performance levels even after certification-influences surgical outcomes, especially in complex procedures. Technical performance quality correlates with the outcomes and costs and should be measured by image or video-photographic documentation of the surgeon's view field during the procedures. Such consecutive, completely documented, unedited observational data-in the form of intra-operative images and a complete set of eventual radiological images-improve the surgical series' homogeneity. Thereby, they might reflect reality and contribute towards making necessary changes for evidence-based surgery.

The Proximal Humerus Outcome Score at One Year (POSY) Predicts Which Patients Have Poor Functional Outcomes Following Operative Fixation of Proximal Humerus Fractures

Background: The ability to predict long-term outcomes following surgical fixation of proximal humerus fractures would help identify patients at risk of poor functional outcomes. The purpose of this study was to develop a simple score based on preoperative data that can accurately predict functional outcomes for patients following operative management of proximal humerus fractures.

Methods: Over a 12-year period, all proximal humerus fractures surgically treated with a locked proximal humerus plate at a single institution were enrolled in a prospective database. Inclusion criteria in this analysis were any patient with a minimum of a one-year functional outcome score. Patients were assigned to the poor outcome cohort if their Disabilities of the Arm, Shoulder, and Hand (DASH) score at that time point was greater than 10 points above the mean DASH score. Logistic regression was used to build a predictive formula for cohort membership using p < 0.15 and an area under the receiver operator characteristic curve (AUROC) value was calculated to define the overall predictive capacity.

Results: A total of 165 patients with an average age of 60.91±13.5 years met the inclusion criteria, with 47 (28.5%) patients assigned to the poor outcome group and 118 (71.5%) patients assigned to the good outcome group. Older age (p = 0.088), BMI (p = 0.019), age-adjusted CCI (p = 0.001), non-Caucasian race (p = 0.017), no college degree (p < 0.0005), unemployed (p < 0.0005), and worker’s compensation case (p = 0.002) were found to be significant predictors of poorer outcome and were used to create a final formula through logistic regression which predicted the probability of a poor outcome (Nagelkerke R Square = 0.403; Hosmer and Lemeshow = 0.902; AUROC = 0.839 [CI: 0.762-0.917]). Once each patient was assigned a score, cutoff values were defined that divided the cohort into three groups. High-risk patients had a score above 50%, and 19 (73.1%) of these patients had a poor outcome.

Conclusions: The POSY score is a tool that can predict the functional outcome at one year or greater following surgical intervention for a proximal humerus fracture. Patients who score above 50% are considered at high risk for a poor functional outcome. In the era of value-based care, the POSY score may be used to direct resource utilization while improving outcomes.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely, including in the use of surgery. This is an update of a Cochrane Review first published in 2001 and last updated in 2015.

OBJECTIVES

To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registries, and bibliographies of trial reports and systematic reviews to September 2020. We updated this search in November 2021, but have not yet incorporated these results.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults.  DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. We prepared a brief economic commentary for one comparison.

MAIN RESULTS

We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. Six comparisons were tested by 2 to 10 trials, the others by small single-centre trials only. Twelve studies evaluated non-surgical treatments, 10 compared surgical with non-surgical treatments, 23 compared two methods of surgery, and two tested timing of mobilisation after surgery. Most trials were at high risk of bias, due mainly to lack of blinding. We summarise the findings for four key comparisons below. Early (usually one week post injury) versus delayed (after three or more weeks) mobilisation for non-surgically-treated fractures Five trials (350 participants) made this comparison; however, the available data are very limited. Due to very low-certainty evidence from single trials, we are uncertain of the findings of better shoulder function at one year in the early mobilisation group, or the findings of little or no between-group difference in function at 3 or 24 months. Likewise, there is very low-certainty evidence of no important between-group difference in quality of life at one year. There was one reported death and five serious shoulder complications (1.9% of 259 participants), spread between the two groups, that would have required substantive treatment. Surgical versus non-surgical treatment Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures). There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants). There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year (EQ-5D (0: dead to 1: best quality): mean difference (MD) 0.01, 95% CI -0.02 to 0.04; 6 studies, 502 participants). There is low-certainty evidence of little between-group difference in mortality: one of the 31 deaths was explicitly linked with surgery (risk ratio (RR) 1.35, 95% CI 0.70 to 2.62; 8 studies, 646 participants). There is low-certainty evidence of a higher risk of additional surgery in the surgery group (RR 2.06, 95% CI 1.21 to 3.51; 9 studies, 667 participants). Based on an illustrative risk of 35 subsequent operations per 1000 non-surgically-treated patients, this indicates an extra 38 subsequent operations per 1000 surgically-treated patients (95% CI 8 to 94 more). Although there was low-certainty evidence of a higher overall risk of adverse events after surgery, the 95% CI also includes a slightly increased risk of adverse events after non-surgical treatment (RR 1.46, 95% CI 0.92 to 2.31; 3 studies, 391 participants). Open reduction and internal fixation with a locking plate versus a locking intramedullary nail Four trials (270 participants) evaluated surgical intervention for displaced fractures (63% were two-part fractures). There is low-certainty evidence of no clinically important between-group difference in shoulder function at one year (SMD 0.15, 95% CI -0.12 to 0.41; 4 studies, 227 participants), six months (Disability of the Arm, Shoulder, and Hand questionnaire (0 to 100: worst disability): MD -0.39, 95% CI -4.14 to 3.36; 3 studies, 174 participants), or two years (American Shoulder and Elbow Surgeons score (ASES) (0 to 100: best outcome): MD 3.06, 95% CI -0.05 to 6.17; 2 studies, 101 participants). There is very low-certainty evidence of no between-group difference in quality of life (1 study), and of little difference in adverse events (4 studies, 250 participants) and additional surgery (3 studies, 193 participants). Reverse total shoulder arthroplasty (RTSA) versus hemiarthroplasty There is very low-certainty evidence from two trials (161 participants with either three- or four-part fractures) of no or minimal between-group differences in self-reported shoulder function at one year (1 study) or at two to three years' follow-up (2 studies); or in quality of life at one year or at two or more years' follow-up (1 study). Function at six months was not reported. Of 10 deaths reported by one trial (99 participants), one appeared to be surgery-related. There is very low-certainty evidence of a lower risk of complications after RTSA (2 studies). Ten people (6.2% of 161 participants) had a reoperation; all eight cases in the hemiarthroplasty group received a RTSA (very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery. The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures. There is insufficient evidence from randomised trials to inform the choices between different non-surgical, surgical or rehabilitation interventions for these fractures.

Treatment of rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

There is ongoing controversy regarding optimal treatment for full-thickness rotator cuff tears. Given that the evidence surrounding the use of various treatment options has expanded, an overall assessment is required.

OBJECTIVES

The following were compared to determine which resulted in improved patient-reported function, pain, and reoperation rates for each: (1) double-row (DR) fixation and single-row (SR) fixation in arthroscopic cuff repair; (2) latissimus dorsi transfer (LDT) with lower trapezius transfer (LTT), partial rotator cuff repair, and superior capsular reconstruction (SCR); and (3) early and late surgical intervention.

METHODS

Medline, Embase, and Cochrane were searched through to April 20, 2021. Additional studies were identified from reviews. The following were included: (1) All English-language randomized controlled trials (RCTs) in patients ≥18 years of age comparing SR and DR fixation, (2) observational studies comparing LDT with LTT, partial repair, and SCR, and (3) observational studies comparing early vs. late treatment of full-thickness rotator cuff tears.

RESULTS

A total of 15 RCTs (n = 1096 randomized patients) were included in the meta-analysis of SR vs. DR fixation. No significant standardized mean differences in function (0.08, 95% confidence interval [CI] -0.09, 0.24) or pain (-0.01, 95% CI -0.52, 0.49) were observed. There was a difference in retear rates in favor of DR compared with SR fixation (RR 1.56, 95% CI 1.06, 2.29). Four studies were included in the systematic review of LDT compared with a surgical control. LDT and partial repair did not reveal any differences in function (-1.12, 95% CI -4.02, 1.78) on comparison. A single study compared arthroscopically assisted LDT to LTT and observed a nonstatistical difference in the Constant score of 14.7 (95% CI -4.06, 33.46). A single RCT compared LDT with SCR and revealed a trend toward superiority for the Constant score with SCR with a mean difference of -9.6 (95% CI -19.82, 0.62). Comparison of early vs. late treatment revealed a paucity of comparative studies with varying definitions of "early" and "late" treatment, which made meaningful interpretation of the results difficult.

CONCLUSION

DR fixation leads to similar improvement in function and pain compared with SR fixation and results in a higher healing rate. LDT transfer yields results similar to those from partial repair, LTT, and SCR in functional outcomes. Further study is required to determine the optimal timing of treatment and to increase confidence in these findings. Future trials of high methodologic quality comparing LDT with LTT and SCR are required.

Acute versus delayed reverse total shoulder arthroplasty for proximal humeral fractures: a consecutive cohort study

BACKGROUND

The treatment of displaced proximal humeral fractures (PHFs) remains controversial. Open reduction-internal fixation (ORIF) can be challenging, especially in elderly patients with poor bone quality, whereas hemiarthroplasty has had unpredictable outcomes. Conservative treatment may result in severe fracture sequelae with poor outcomes, requiring late reverse total shoulder arthroplasty (RTSA) in many cases. The past few years have seen a shift toward the use of RTSA for the treatment of PHFs. The aim of this study was to compare the outcomes of RTSA between patients with acute fractures and patients who underwent delayed RTSA for fracture sequelae. Our hypothesis was that the outcomes of RTSA for acute PHFs would be better than those of delayed RTSA for fracture sequelae.

METHODS

We followed up 36 patients with a mean age of 79.1 years who underwent primary RTSA for acute PHFs and 56 patients with a mean age of 72.1 years who underwent RTSA in delayed fashion for fracture sequelae, including failed ORIF. The minimum follow-up period was 24 months. The mean follow-up period was 39.3 months in the acute RTSA group and 56.6 months in the delayed RTSA group. Demographic data, radiographs, and surgery data were prospectively collected and analyzed. At final follow-up, range of motion and radiographic analysis findings, as well as the Subjective Shoulder Value (SSV) and Constant score (CS), were recorded.

RESULTS

The clinical results favored the group undergoing acute RTSA for acute PHFs, with a mean SSV of 8.3 of 10 and adjusted CS of 88.9% compared with a mean SSV of 8.0 of 10 and adjusted CS of 77.6% in the group undergoing late RTSA for fracture sequelae-but without statistically significant differences between the groups. Although the acute RTSA group showed slightly better range-of-motion values, no statistically significant differences were found between the groups. No intraoperative complications occurred. The time from injury to the regaining of good pain-free function was significantly shorter in the acute RTSA group.

CONCLUSION

Although there were no statistically significant differences in outcomes between early RTSA for acute PHFs and late RTSA for fracture sequelae, the time from injury to the regaining of good pain-free function was significantly shorter in the acute RTSA group. Therefore, we advocate early RTSA for acute PHFs in elderly patients to provide a quicker recovery and an early return to good predictable outcomes with a much shorter period of pain and discomfort. In cases of failed conservative treatment, malunion, or failed ORIF, salvage RTSA has the potential to provide a good outcome.

Why locking plates for the proximal humerus do not fit well

INTRODUCTION

We compared the angle of the humerus and plate and to assess compatibility of a plate to the proximal humerus using three-dimensional (3D) printed models.

MATERIALS AND METHODS

A total of 120 cases were included, who underwent anteroposterior shoulder radiographs. From these, 30 cases with 3D shoulder computed tomography scans were randomly selected to print 3D model. The lateral angle between the lateral cortex of the humeral shaft and lateral border of the greater tuberosity (GT), neck-shaft angle, and height from the most proximal point of the GT to the angular point were measured. When the plates were applied on the 3D models, the gap from the most proximal point of the GT to the proximal rim of the plate was measured.

RESULTS

The mean lateral angle in plain radiographs was 12.9 ± 2.2° and height from the most proximal point of the GT to the angular point was 44.4 ± 4.7 mm. The bending angles of the three plates were 8° and 10°. Height from the proximal rim of the plate to the bending point was 42.4, 42.0 and 43.8 mm. In 98% of cases, the lateral angle of the humerus was larger than all three plates. In 43% of cases, height of the GT was smaller than height of plates. When plates were applied to the 3D model, the mean gap from GT to plate was 4.8 ± 2.8 mm.

CONCLUSIONS

There was large variation in the lateral angle of the proximal humerus, which was not correlated with the neck-shaft angle. The lateral angle of the humerus was larger than the plates and prone to varus reduction and medial collapse.

LEVEL OF EVIDENCE OR CLINICAL RELEVANCE

Basic science study.

Dynamics of balance indicators, activities of daily living, and quality of life of elderly suffering from Parkinson's disease and frailty after proximal humerus fracture following physiotherapeutic functional training

Balance dysfunction in elderly patients with Parkinson's disease (PD) is a high-risk fall precaution, along with sarcopenia and senile asthenia, which leads to traumas, including fractures of the proximal humerus fractures (PHF). The objective of the study was to determine the effectiveness of a functional training as part of a physical therapy program on balance, upper limb (UL) function, daily living activities, and quality of life in elderly patients with PD and frailty, following proximal humerus fractures. We examined 33 elderly patients with PD and frailty in the recovery period after PHF. The control group included individuals who underwent rehabilitation according to the general principles of kinesitherapy. The treatment group consisted of patients engaged in a program of physical therapy directed at improving balance, function of the upper UL, motor stereotype, and activities of daily living. The effectiveness of the program was evaluated using the Short Physical Performance Battery (SPPB), Berg Balance Scale (BBS), Disability of the Arm, Shoulder and Hand Outcome Measure (DASH), Wrist Dynamometry, Falls efficacy Scale International (FES-I), Barthel Activities of daily living (ADL) Index, Lawton Instrumental activities of daily living (IADL) Scale, PD Questionnaire-39 (PDQ-39). According to all studied indicators, the patients of both groups showed a statistically and significantly better result compared to the initial data (p<0.05), but the treatment group showed better outcomes compared with the control group (p<0.05).

Conversion to hemi-shoulder arthroplasty or reverse total shoulder arthroplasty after failed plate osteosynthesis of proximal humerus fractures: a retrospective study

Objective

To assess the clinical outcomes of hemi-shoulder arthroplasty (HSA) versus reverse total shoulder arthroplasty (RTSA) following failed plate osteosynthesis of proximal humerus fractures in elderly patients.

Methods

This retrospective study identified all patients that had a documented failed plate osteosynthesis of proximal humeral fractures treated with revision HSA or RTSA. Follow-up occurred at 1, 3, 6 and 12 months after surgery and every year thereafter. The primary outcomes were the American Shoulder and Elbow Surgeons (ASES) scores, Simple Shoulder Test (SST) scores, visual analogue scale (VAS) pain scores and the University of California, Los Angeles Shoulder Rating Scale (UCLA SRS) scores. The secondary outcome was the rate of major complications.

Results

A total of 126 patients (126 shoulders) were enrolled in the study. At the final follow-up, the RTSA group had significantly greater improvements in ASES, SST and UCLA SRS scores than the HSA group. The RTSA group had significantly larger decreases in the VAS pain score compared with the HSA group. The rate of major complications was significantly higher in the HSA group than in the RTSA group (44.4% versus 27.5%, respectively).

Conclusion

RTSA provided superior functional outcomes compared with HSA, with a lower rate of major complications after a follow-up period of at least 5 years.

High-Energy Proximal Humerus Fractures in Geriatric Patients: A Review

High-energy proximal humerus fractures in elderly patients can occur through a variety of mechanisms, with falls and MVCs being common mechanisms of injury in this age group. Even classically low-energy mechanisms can result in elevated ISS scores, which are associated with higher mortality in both falls and MVCs. These injuries result in proximal humerus fractures which are commonly communicated via Neer’s classification scheme. There are many treatment options in the armamentarium of the treating surgeon. Nonoperative management is widely supported by systematic review as compared to almost all other treatment methods. ORIF is particularly useful for complex patterns and fracture dislocations in healthy patients. Hemiarthroplasty can be of utility in patients with fracture patterns with high risk of AVN and poor bone quality risking screw cut-out. Reverse total shoulder arthroplasty is a popular method of treatment for geriatric patients also, with literature now showing that even late conversion from nonoperative management or ORIF to rTSA can lead to good clinical outcomes. Prevention is possible and important for geriatric patients. Optimizing medical care including hearing, vision, strength, and bone quality, in coordination with primary care and geriatricians, is of great importance in preventing fractures and decreasing injury when falls do occur. Involving geriatricians on dedicated trauma teams will also likely be of benefit.

Conversion from a failed proximal femoral nail anti-rotation to a cemented or uncemented total hip arthroplasty device: a retrospective review of 198 hips with previous intertrochanteric femur fractures

Background

At present, it is unclear which device (uncemented or cemented total hip arthroplasty [UTA or CTA, respectively]) is more suitable for the conversion of a failed proximal femoral nail anti-rotation (PFNA). The aim of this review was to assess the outcomes of failed PFNAs converted to a UTA or CTA device in elderly individuals with intertrochanteric femoral fractures (IFFs).

Methods

Two hundred fifty-eight elderly individuals (258 hips) with IFFs who underwent a conversion to a UTA or CTA device following failed PFNAs during 2007–2017 were retrospectively identified from the China Southern Medical Centre (CSMC) database. The primary endpoint was the Harris Hip Score (HHS); secondary endpoint was the key orthopaedic complication rate.

Results

The median follow-up was 65 months (60–69 months). Significant distinctions were observed (87.26 ± 16.62 for UTA vs. 89.32 ± 16.08 for CTA, p = 0.021; 86.61 ± 12.24 for symptomatic UTA vs. 88.68 ± 13.30 for symptomatic CTA, p = 0.026). A significant difference in the overall key orthopaedic complication rate was detected (40.8% [40/98] vs. 19.0% [19/100], p = 0.001). Apparent distinctions were detected in terms of the rate of revision, loosening, and periprosthetic fracture (11.2% for UTA vs 3.0% for CTA, p = 0.025; 13.2% for UTA vs 5.0% for CTA, p = 0.043; 10.2% for UTA vs 3.0% for CTA, p = 0.041, respectively).

Conclusion

For elderly individuals with IFFs who suffered a failed PFNA, CTA devices may have a noteworthy advantage in regard to the revision rate and the rate of key orthopaedic complications compared with UTA devices, and CTA revision should be performed as soon as possible, regardless of whether these individuals have symptoms.

Arthroscopic Repair of a Displaced Tuberosity Fragment After Proximal Humerus Locking Plate Fixation: A Case Report

CASE

Locking plate fixation of proximal humerus fractures is known to have high complication rates. Even a technically well-performed surgery can be subject to loss of reduction, which can lead to an adverse functional outcome for the patient. In this case report, we describe a patient who underwent open reduction and internal fixation of a proximal humerus fracture complicated by delayed loss of reduction of a greater tuberosity fragment that was revised using arthroscopic techniques.

CONCLUSION

Arthroscopic repair of displaced greater tuberosity fragments after failed locking plate fixation of proximal humerus fractures can lead to good functional outcomes at 1-year follow-up.

PHILOS plate versus nonoperative treatment in 2-, 3-, and 4-part proximal humeral fractures: Comparison with healthy control subjects

PURPOSE

There is no consensus in the literature on nonoperative treatment of displaced and multipart fractures of proximal humerus as those are normally treated operatively. Our aim was to compare the functional results of nonoperative management and open reduction internal fixation with the proximal humerus internal locking system of 2-, 3-, and 4-part proximal humerus fractures, among themselves and with a healthy control group.

METHODS

Between 2014 and 2018, 92 proximal humerus fractures constituting a nonoperative group (n = 47) and an operative group (n = 45) together with healthy control subjects (n = 45) were analyzed in a tertiary care referral center. The American Shoulder and Elbow Surgeons (ASES) shoulder score and visual analog scale (VAS) pain score were used for subjective functional analysis. Range of motion and muscle strength were analyzed objectively for all patients and healthy control subjects.

RESULTS

In 2-part fractures, VAS scores and hand grip strength were determined as lower in the nonoperative group (p = 0.033 and p = 0.034, respectively). In 3- and 4-part fractures, there was no difference between the two groups in terms of ASES and VAS scores. Patients who underwent surgery had more muscle strength than those in the nonoperative group, but only arm extensor and forearm flexor muscle strengths were statistically significant for 3-part fractures. In cases of 4-part fractures, objective functional results were similar between the two groups.

CONCLUSIONS

With insufficient functional results and high complication rates in surgery, nonoperative management is still the preferred choice for proximal humerus fractures, especially in case of multipart fractures.

Patients undergoing shoulder arthroplasty for failed nonoperative treatment of proximal humerus fracture have low implant survival and low patient-reported outcomes: 837 cases from the Danish Shoulder Arthroplasty Registry

Background and purpose - When nonoperative treatment of proximal humerus fracture (PHF) fails, shoulder arthroplasty may be indicated. We investigated risk factors for revision and evaluated patient-reported outcome 1 year after treatment with either stemmed hemiarthroplasty (SHA) or reverse total shoulder arthroplasty (RTSA) after previous nonoperative treatment of PHF sequelae.Patients and methods - Data were derived from the Danish Shoulder Arthroplasty Registry and included 837 shoulder arthroplasties performed for PHF sequelae between 2006 and 2015. Type of arthroplasty, sex, age, and surgery period were investigated as risk factors. The Western Ontario Osteoarthritis of the Shoulder index (WOOS) was used to evaluate patient-reported outcome (0-100, 0 indicates worst outcome). Cox regression and linear regression models were used in the statistical analyses.Results - 644 patients undergoing SHA and 127 patients undergoing RTSA were included. During a mean follow-up of 3.7 years, 48 (7%) SHA and 14 (11%) RTSA were revised. Men undergoing RTSA had a higher revision rate than men undergoing SHA (hazard ratio [HR] 6, 95% confidence interval [CI] 2-19). 454 (62%) patients returned a complete WOOS questionnaire. The mean WOOS score was 53 for SHA and 53 for RTSA. Patients who were 65 years or older had a better WOOS score than younger patients (mean difference 7, CI 1-12). Half of patients had WOOS scores below 50.Interpretation - Shoulder arthroplasty for PHF sequelae was associated with a high risk of revision and a poor patient-reported outcome. Men treated with RTSA had a high risk of revision.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Proximal humeral fracture in patients with high Charlson comorbidity index: mortality rate according to treatment choice

BACKGROUND

The purpose of this study was to evaluate the relevance of a commonly used morbidity prognostic tool, the Charlson comorbidity index (CCI), in determining the survival rate of patients with isolated proximal humeral fractures (PHFs) and to determine the impact of surgical treatment according to previous comorbidities (measured with CCI).

MATERIALS AND METHODS

All patients who were treated for a single PHF in our institution for 29 consecutive months were included in this retrospective study, with a minimum follow-up of 24 months (mean 52.8 months). Two groups were established according to the type of treatment received (surgical versus non-surgical). Preinjury comorbidities were identified, and the age-adapted CCI was calculated. All complications and mortality rates were prospectively recorded over the complete follow-up period.

RESULTS

Patients with elevated preinjury comorbidities (CCI > 5) demonstrated a significant increase in mortality (HR = 4.64) compared to those with CCI ≤ 5. In addition, patients with high comorbidities (CCI > 5) who underwent surgical treatment demonstrated a statistically significant increase in mortality (HR = 6.92) compared to patients with similarly high comorbidities (CCI > 5) who underwent non-surgical treatment.

CONCLUSIONS

Patients with high preinjury comorbidities (CCI > 5) experienced an increased mortality risk if they underwent surgical treatment for isolated PHFs. The use of a morbidity prognostic tool, such as the CCI, can help predict the outcome (particularly mortality) in these patients and may aid in making decisions in terms of operative versus non-operative treatment to minimize patient mortality.

LEVEL OF EVIDENCE

Level III; Retrospective Comparative Study; Treatment Study.

Does time to surgery affect patient-reported outcome in proximal humeral fractures? A subanalysis of the PROFHER randomized clinical trial

Aims

The aim of this study was to explore whether time to surgery affects functional outcome in displaced proximal humeral fractures

Methods

A total of 250 patients presenting within three weeks of sustaining a displaced proximal humeral fracture involving the surgical neck were recruited at 32 acute NHS hospitals in the United Kingdom between September 2008 and April 2011. Of the 125 participants, 109 received surgery (fracture fixation or humeral head replacement) as per randomization. Data were included for 101 and 67 participants at six-month and five-year follow-up, respectively. Oxford Shoulder Scores (OSS) collected at six, 12, and 24 months and at three, four, and five years following randomization was plotted against time to surgery. Long-term recovery was explored by plotting six-month scores against five-year scores and agreement was illustrated with a Bland-Altman plot.

Results

The mean time from initial trauma to surgery was 10.5 days (1 to 33). Earlier surgical intervention did not improve OSS throughout follow-up, nor when stratified by participant age (< 65 years vs ≥ 65 years) and fracture severity (one- and two-part vs three- and four-part fractures). Participants managed later than reported international averages (three days in the United States and Germany, eight days in the United Kingdom) did not have worse outcomes. At five-year follow-up, 50 participants (76%) had the same or improved OSS compared with six months (six-month mean OSS 35.8 (SD 10.0); five-year mean OSS 40.1 (SD 9.1); r = 0.613). A Bland-Altman plot demonstrated a positive mean difference (3.3 OSS points (SD 7.92)) with wide 95% limits of agreement (-12.2 and 18.8 points).

Conclusion

Timing of surgery did not affect OSS at any stage of follow-up, irrespective of age or fracture type. Most participants had maximum functional outcome at six months that was maintained at five years. These findings may help guide providers of trauma services on surgical prioritization. Cite this article: Bone Joint J 2020;102-B(1):33–41

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

BACKGROUND

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

METHODS AND FINDINGS

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

CONCLUSIONS

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

TRIAL REGISTRATION

ClinicalTrials.gov NCT01246167.

Low revision rate despite poor functional outcome after stemmed hemiarthroplasty for acute proximal humeral fractures: 2,750 cases reported to the Danish Shoulder Arthroplasty Registry

Background and purpose - The revision rate of stemmed hemiarthroplasty (SHA) for acute proximal humeral fractures is low, but does not necessarily reflect the functional outcome. We report the revision rate of SHA for acute proximal humeral fractures and the proportion of arthroplasties that are not revised despite low functional outcome scores. Patients and methods - The Danish Shoulder Arthroplasty Registry was used to identify all patients with a proximal humeral fracture that was treated with a SHA between January 1, 2006 and December 31, 2015. Information on demographics, surgical procedures, and revisions was collected by the registry. The Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 1 year was used as functional outcome score. We converted the score to a percentage of a maximum score with 100 being the best. Results - 2,750 SHAs in 2,719 patients were included. Mean age was 72 years (SD 11); 79% were women. Mean WOOS at 1 year was 55 (SD 26). A total of 101 (4%) arthroplasties were revised, and the 10-year cumulative implant survival rate was 95%. The Cox regression model showed a statistically significant impact on implant survival of age, but not of sex or arthroplasty brand. A WOOS score below 30 and 50 was reported in 11% and 25% of patients, respectively. Interpretation - We found a high implant survival rate, but also a high proportion of patients with a low functional outcome score 1 year after surgery.

Is the Charlson comorbidity index a good predictor of mortality and adverse effects in proximal humerus fractures?

INTRODUCTION

Proximal humerus fractures (PHF) are frequent in elderly patients. This population also suffers from a series of associated comorbidities, and PHF increases morbidity and mortality. The Charlson Comorbidity Index (CCI) is a tool used for calculating comorbidity and therefore the mortality risk.

HYPOTHESIS

Our hypothesis is that CCI is a good predictor of mortality in patients suffering from PHF, and that there is a relationship between CCI and the development of adverse events.

PATIENTS AND METHODS

A retrospective study with prospective data collection of 354 patients who had been diagnosed and treated for a single PHF between August 1st, 2013 and July 31st, 2015 was carried out at our hospital. The minimum follow-up was 24 months (mean 51.1 months). This study included all patients regardless the severity of the fracture, the treatment performed (surgical or conservative treatment) or whether the patient had been admitted to the hospital or was treated as an outpatient. Adverse effects and mortality data were collected and the CCI was calculated.

RESULTS

Patients with high CCI (>5) had a higher mortality risk 4.6 (95% CI [2.4-9.0]) compared to those with CCI<5. During follow-up, 40 (11%) patients died, being the mean follow-up of the patients overall 4.3 years 95% CI [4.1-4.4]. Patients suffering from systemic complications had a higher CCI average (p=0.001) compared to those who did not present adverse effects (HR=6.6; 95% CI [3.5-12.4]). No statistically significant relationship between the type of fracture (p=0.473) and mortality was found.

CONCLUSION

In our study CCI has proven to be a good predictor of mortality and there is a relationship between CCI and the development of adverse effects in patients suffering from PHF, which maybe should be taken into consideration in our therapeutic decision making.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Regional characteristics of cortical bone quality in the proximal humerus of postmenopausal women: a preliminary study

BACKGROUND

Proximal humeral fractures represent the third most common fragility fracture treated in osteoporotic populations, after hip and distal radial fractures. The purpose of this study was to characterize the spatial variability in cortical geometry in the proximal humerus in postmenopausal women.

METHODS

The proximal humeri in 43 healthy postmenopausal women were imaged by computed tomography. Cortical bone mapping was applied to create color 3-dimensional thickness maps for each proximal humerus. Cortical parameters, including the cortical thickness (CTh), cortical mass surface density (CM), and endocortical trabecular density, were measured over the humeral head and metaphyseal region after 15 regions of interest (ROIs) were defined.

RESULTS

In the humeral head region, significant differences in CTh and CM values were detected between the anterior, lateral, and posterior walls (P < .05). The highest CTh and CM were found in the anterior wall in each plane (P < .05). Regarding the endocortical trabecular density, no significant findings were noted in the 3 planes (P > .05). In the metaphyseal region, the cortical structure in the medial column had higher CTh and CM values in ROI 10 compared with the lateral column (P < .05). The highest CTh and CM values of compact bone were seen in ROI 10 of the medial column (ROIs 10-12) (P < .05).

CONCLUSION

Our results showed significant regional variation of cortical bone in the humeral head region in postmenopausal women. Similar conditions were seen in the medial column in the metaphyseal region. This finding provides discriminatory information for stronger fixation of implants.

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

INTRODUCTION

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

METHODS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

NCT03531463; Pre-Results.

Treatment of humerus fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and evolution of practice

OBJECTIVES

The objective of this Health Technology Assessment was to evaluate effectiveness, complications and cost-effectiveness of surgical or non-surgical treatment for proximal, diaphyseal or distal fractures of the humerus in elderly patients. Secondary objectives were to evaluate the intervention costs per treatment of proximal humerus fractures (PHF) and to investigate treatment traditions of PHF in Sweden.

METHODS AND FINDINGS

The assessment contains a systematic review of clinical and health economic studies comparing treatment options for humerus fractures in elderly patients. The results regarding the effectiveness of treatments are summarized in meta-analyses. The assessment also includes a cost analysis for treatment options and an analysis of registry data of PHF. For hemiarthroplasty (HA) and non-operative treatment, there was no clinically important difference for moderately displaced PHF at one-year follow-up regarding patient rated outcomes, (standardized mean difference [SMD]) -0.17 (95% CI: -0.56; 0.23). The intervention cost for HA was at least USD 5500 higher than non-surgical treatment. The trend in Sweden is that surgical treatment of PHF is increasing. When functional outcome of percutaneous fixation/plate fixation/prosthesis surgery and non-surgical treatment was compared for PHF there were no clinically relevant differences, SMD -0.05 (95% CI: -0.26; 0.15). There was not enough data for interpretation of quality of life or complications. Evidence was scarce regarding comparisons of different surgical options for humerus fracture treatment. The cost of plate fixation of a PHF was at least USD 3900 higher than non-surgical treatment, costs for complications excluded. In Sweden the incidence of plate fixation of PHF increased between 2005 and 2011.

CONCLUSIONS

There is moderate/low certainty of evidence that surgical treatment of moderately displaced PHF in elderly patients has not been proven to be superior to less costly non-surgical treatment options. Further research of humerus fractures is likely to have an important impact.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Augment of the Stability in Locking Compression Plate with Intramedullary Fibular Allograft for Proximal Humerus Fractures in Elderly People

Objective

The objective of this study was to compare the clinical outcomes and complications between the locking compression plate (LCP) and LCP with fibular allograft in the treatment of patients with displaced proximal humerus fracture (PHF) in elderly people.

Material and Methods

Between January 2010 and December 2013, a total of 97 elderly patients with displaced PHF were treated by LCP or LCP with fibular allograft, and finally 89 patients were included in our study. All the patients were divided into Group I (patients treated by LCP) and Group II (patients treated by LCP with fibular allograft). Function results were assessed by the disability of the arm, shoulder, and hand (DASH) score and Constant-Murley score (CMS), and complications were also recorded in each group.

Results

The average follow-up was 35.2 months (range, 24-48 months) in Group I and 33.5 months (range, 24-48 months) in Group II. DASH in patients of Group I was significantly higher than that in patients in Group II and patients of Group I had CMS scores significantly lower than patients in Group II (P<0.05). The rates of varus malunion, screw perforation, and loss of reduction>5mm were significantly higher in Group I than in Group II (P<0.05).

Conclusions

The present results showed that that patients treated by LCP with fibular allograft had a better functional outcome and a lower complication rate compared to patients treated by LCP alone. Suitable void filler in the proximal humerus for supporting the head fragment, medial cortical bone, and greater tuberosity might play a key role in reducing the incidence of the complications in elderly patients, especially with osteoporosis.

Calcar screws and adequate reduction reduced the risk of fixation failure in proximal humeral fractures treated with a locking plate: 190 patients followed for a mean of 3 years

Background

Fixation of proximal humeral fractures (PHF) with locking plates has gained popularity over conservative treatment, but surgery may be complicated with infection, non-union, avascular necrosis (AVN) of the humeral head and fixation failure. Failure to achieve structural support of the medial column has been suggested to be an important risk factor for fixation failure. The aims of this study were to examine the effect of calcar screws and fracture reduction on the risk of fixation failure and to assess long-term shoulder pain and function.

Methods

This was a single-centre retrospective study of 190 adult PHF patients treated with a locking plate between 2011 and 2014. Reoperations due to fixation failure were the primary outcome. Risk factors for fixation failure were assessed using the Cox regression analysis. Postoperative shoulder pain and function were assessed by the Oxford Shoulder Score (OSS).

Results

Thirty-one of 190 (16%) patients underwent a reoperation: 14 (7%) due to fixation failure, 10 (5%) due to deep infection and 2 (1%) due to AVN. The absence of calcar screws and fixation with residual varus malalignment (head-shaft angle < 120°) both increased the risk of fixation failure with an adjusted hazard ratio (95% CI) of 8.6 (1.9–39.3; p = 0.005) and 4.9 (1.3–17.9; p = 0.02), respectively. The median (interquartile range) OSS was 40 (27–46).

Conclusion

The use of calcar screws, as well as the absence of postoperative varus malalignment, significantly reduced the risk of fixation failure. We, therefore, recommend the use of calcar screws and to avoid residual varus malalignment to improve the medial support of proximal humeral fractures treated with a locking plate.

Titanium mini locking plate with trans-osseous sutures for the treatment of humeral greater tuberosity fracture osteosynthesis versus PHILOS: a retrospective view

PURPOSE

Greater tuberosity fractures (GTFs) account for 17 to 21% of proximal humerus fractures, most of these fractures are treated conservatively, but treatment for displaced fractures is still controversial. The aim of this study is to compare intra-operative clinical conditions and post-operative outcomes when displaced GTFs are treated with either proximal humeral internal locking system (PHILOS) or mini locking plate with trans-osseous sutures.

METHODS

This is a retrospective study conducted in Shanghai Tenth People's Hospital. A total of 60 patients (22 males and 38 females) with displaced humeral GTF between May 2013 and March 2017 were included, of whom 43 underwent PHILOS implant treatment and 17 underwent titanium mini plate implant with trans-osseous suture treatment. Intra-operative (incision size, intra-operative blood loss, operative duration) and postoperative (Constant-Murley score (CMS) and implant cost) variables were recorded for the comparison.

RESULTS

Mini locking plate with trans-osseous sutures shows better results. Operative duration (PHILOS mean 77.0 minutes vs mean 63.7 minutes, p value < 0.05), blood loss during surgery (PHILOS mean 111.5 vs 66.5 ml, p value < 0.05), incision size (PHILOS mean 7.2 vs 4.6 cm, p value < 0.05), CMS (PHILOS mean 81.0 vs 87.3, p value < 0.05), and implant costs (PHILOS mean 26,192.6 renminbi (RMB) vs mean 21,358.8 RMB, p value < 0.05). On the other hand, 9.30% of impingement in the PHILOS group was observed to have no complications compared to the mini locking plate group.

CONCLUSIONS

Mini locking plate with trans-osseous sutures shows better efficacy in reducing the incision size, operative duration, intraoperative blood loss, and implant cost and in improving CMS. No complication was found with its use. Our data can provide rationale and inform sample- size calculations for such studies. Larger, control studies are needed for better understanding.

Risk preferences and attitudes to surgery in decision making

Background and purpose - There is increasing evidence that several commonly performed surgical procedures provide little advantage over nonoperative treatment, suggesting that doctors may sometimes be inappropriately optimistic about surgical benefit when suggesting treatment for individual patients. We investigated whether attitudes to risk influenced the choice of operative treatment and nonoperative treatment. Methods - 946 Swedish orthopedic surgeons were invited to participate in an online survey. A radiograph of a 4-fragment proximal humeral fracture was presented together with 5 different patient characteristics, and the surgeons could choose between 3 different operative treatments and 1 nonoperative treatment. This was followed by an economic risk-preference test, and then by an instrument designed to measure 6 attitudes to surgery that are thought to be hazardous. We then investigated if choice of non-operative treatment was associated with risk aversion, and thereafter with the other variables, by regression analysis. Results - 388 surgeons responded. Nonoperative treatment for all cases was suggested by 64 of them. There was no significant association between risk aversion and tendency to avoid surgery. However, there was a statistically significant association between suggesting to operate at least 1 of the cases and a "macho" attitude to surgery or resignation regarding the chances of influencing the outcome of surgery. Choosing nonoperative treatment for all cases was associated with long experience as a surgeon. Interpretation - The discrepancy between available evidence for surgery and clinical practice does not appear to be related to risk preference, but relates to hazardous attitudes. It appears that choosing nonoperative treatment requires experience and a feeling that one can make a difference (i.e. a low score for resignation). There is a need for better awareness of available evidence for surgical indications.

Failure and revision rates of proximal humeral fracture treatment with the use of a standardized treatment algorithm at a level-1 trauma center

BACKGROUND

The aims of this study were to evaluate treatment failure and revision rates of proximal humeral fracture (PHF) treatment with a standardized treatment algorithm within the reality of a level-1 trauma center and to identify predictors of subsequent surgery.

MATERIALS AND METHODS

The medical database of a level-1 trauma center was screened for all primary treatments of PHFs between January 2009 and June 2012. Medical records and imaging were analyzed to identify the fracture morphology, pre-existing diseases, revision surgeries and treatment failures (conversion to another treatment). The patients were asked about subsequent surgeries by phone. A functional outcome questionnaire was mailed to participating patients.

RESULTS

Follow-up data were available for 423 of 521 patients (312 females, 111 males). The mean age at the time of primary treatment was 68.3 years; mean follow-up was 24.6 ± 12.3 months. The overall rate of mandatory re-operations was 15.6%, including a failure rate of 8.3%; another 7.6% of patients had additional arthroscopic surgeries. Treatment with anatomic hemi-prostheses was associated with the highest re-operation rates, and lowest outcomes. Involvement of the medial calcar region, complex fracture morphologies, cigarette smoking and alcohol-abuse were predictors for subsequent surgery. Patients without subsequent surgery had significantly higher functional outcome scores than patients with additional surgery.

CONCLUSIONS

With the use of a standardized treatment algorithm no treatment modality was at significantly higher risk for having additional surgery. Complex fracture types, involvement of the medial calcar, cigarette-smoking and alcohol-abuse were associated with subsequent surgeries.

LEVEL OF EVIDENCE

Level IV case series.

Surgical management of complex proximal humeral fractures: pinning, locked plate and arthroplasty : Clinical results and functional outcome on retrospective series of patients

PURPOSE

The aim of the study was to compare the clinical results and related complications of four different surgical treatments of complex proximal humeral fractures according to their classification and features of patients.

METHODS

Between 2007 and 2011, 92 consecutive patients with diagnosis of three-four-part displaced fractures, fractures with head dislocation and head-splitting fractures were evaluated postoperatively with Constant-Murley score, disability of arm, shoulder and hand score and simple shoulder test.

RESULTS

All the treatment modalities showed from optimal to good mean functional results. The statistical analysis comparing each treatment group showed better outcomes scores (p < 0.05) for: locked plating versus HA, locked plating versus RSA and RSA versus HA. No differences between postoperative range of motion, complication rate and overall revision rate of the treatment groups were found at the end of follow-up (p > 0.05). Overall complication rate of surgical treatment of complex PHF was 31.5% (29 patients) with overall revision rate of 14.1%. Among patients with complications 77.8% of HA (7 of 9) required revision surgery (p < 0.05).

CONCLUSIONS

The treatment of complex PHF is nowadays a challenge even for skilled shoulder surgeons. The several viable operative options give good results whenever used for the correct indication. The range of reported complications from 18.2 to 37.5% remains concerning, but most of them did not affect clinical outcome in this series. Accurate preoperative characterization of the fracture pattern is necessary, and high surgical skills of the different operative techniques, including arthroplasty, are recommended to meet the increased functional expectations of patients.

LEVEL OF EVIDENCE

Therapeutic series, Level IV.

Nonoperative management versus reverse shoulder arthroplasty for treatment of 3- and 4-part proximal humeral fractures in older adults

BACKGROUND

The treatment of 3- and 4-part proximal humeral fractures in the older adult is controversial. No study has directly compared reverse shoulder arthroplasty (RSA) with nonoperative treatment for these fractures. The purpose of this study was to compare clinical and patient-reported outcomes between RSA and nonoperative treatment groups.

METHODS

A retrospective review was performed on all 3- and 4-part proximal humeral fractures treated with either RSA or nonoperative treatment with minimum 1-year follow-up. All patients in the nonoperative cohort were offered RSA but declined. Objective patient data were obtained from medical records. Patient-reported outcomes including visual analog scale score, Single Assessment Numeric Evaluation score, Penn Shoulder Score, American Shoulder and Elbow Surgeons score, resiliency score, and Veterans Rand-12 scores were obtained at follow-up. Statistical analysis was performed by use of the Student t test for continuous variables and χ² analysis for nonparametric data.

RESULTS

We analyzed 19 nonoperative and 20 RSA patients with a mean follow-up period greater than 2 years (29 months in nonoperative group and 53 months in RSA group). There were no differences in range of motion between groups (forward elevation, 120° vs 119° [P = .87]; external rotation, 23° vs 31° [P = .06]). No differences between the nonoperative and RSA groups were noted for any patient-reported outcomes. Among patients receiving RSA, there was no difference in outcomes in those undergoing surgery less than 30 days after injury versus those receiving delayed RSA.

CONCLUSIONS

This study suggests that there are minimal benefits of RSA over nonoperative treatment for 3- and 4-part proximal humeral fractures in older adults.

Proximal humeral fractures in Sweden-a registry-based study

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Limits of internal fixation in long-bone fracture

Alternatives to internal fixation of long-bone fracture comprise, depending on location, external fixation or joint replacement. Limitations comprise risk of infection and functional outcome quality, which vary according to technique. The present study examines these limitations, based on comparative or large-scale studies from which certain significant results emerge. Four main questions are dealt with: (1) the present role of locking plates; (2) conditions for intramedullary nailing in Gustilo grade IIIb open fracture; (3) the limitations of conversion from external fixation to intramedullary nailing in open lower leg fracture; (4) and the limitations of definitive anterograde femoral nailing in multiple trauma. Locking plate fixation has yet to prove clinical superiority in any of the anatomic sites for which good-quality comparative analyses are available. Infection risk in Gustilo grade IIIb open lower leg fracture is equivalent when treated by intramedullary nailing or external fixation, if wound care and debridement are effective, antibiotherapy is initiated rapidly and skin cover is restored within 7days. Conversion from primary external fixation to intramedullary nailing is possible if the external fixator was fitted less than 28days previously and skin cover was restored within 7days. The pulmonary and systemic impact of peripheral lesions or definitive anterograde intramedullary nailing of femoral fracture in multiple trauma calls for caution and what is known as "damage-control orthopedics" (DCO), a term covering the general consequences of both the initial trauma and its treatment. Femoral intramedullary nailing is thus contraindicated in case of hemorrhagic shock (blood pressure<90mmHg), hypothermia (<33°C), coagulation disorder (platelet count<90,000) or peripheral lesions such as multiple long-bone fractures, crushed limb or primary pulmonary contusion. In such cases, external fixation or retrograde nailing with a small-diameter nail and without reaming are preferable.

Operative repair of proximal humerus fractures in septuagenarians and octogenarians: Does chronologic age matter?

BACKGROUND

With an expected doubling of the geriatric population within the next thirty years it is becoming increasingly important to determine who among the elderly population benefit from orthopaedic interventions. This study assesses post-operative outcomes in patients aged seventy or greater who sustained a proximal humerus fracture and were treated surgically as compared to a younger geriatric cohort to determine if there is a chronologic age after which post-operative outcomes significantly decline.

METHODS

A retrospective chart review was conducted for 201 patients who sustained fractures of the proximal humerus (OTA 11A-C) and were treated operatively by open reduction and internal fixation. Data from 132 independent, active patients aged fifty-five or older was identified and analyzed. Forty-seven patients age 70 or older were compared to 78 patients aged 55-69. Average length of follow-up was 19.5 months. All complications were recorded. Univariate and multivariate analysis was conducted to assess for differences between groups.

RESULTS

95% of patients achieved fracture union within 6 months. No significant differences were found between cohorts with regard to gender, fracture severity, or CCI (p = 0.197, p = 0.276, p = 0.084, respectively). Functional outcome scores, shoulder range of motion, and complications rates for patients aged 70 and older were not significantly different from patients aged 55-69. There were 10 complications in the older elderly cohort (21%), 6 of which required re-operation and 13 complications in the young elderly cohort (17%), 8 of which required re-operation.

CONCLUSIONS

Operative fracture repair using locked plating of the proximal humerus in septuagenarians and octogenarians can provide for excellent long-term outcomes in appropriately selected patients. These patients tend to have long term functional outcome scores, post-operative range of motion, and complication rates that are comparable to younger geriatric patients. Physicians should not exclude patients for repair of proximal humerus fractures based on chronological age cutoffs.

Glenohumeral arthritis as a risk factor for proximal humerus nonunion

BACKGROUND

Proximal humerus fractures are common injuries and nonsurgical treatment has proven to yield good to excellent clinical results. A small percentage of these fractures go on to delayed or nonunion and the incidence and risk factors for this complication are poorly understood. We hypothesize that adjacent joint stiffness of the glenohumeral joint might lead to an increased rate of nonunion for proximal humerus fractures.

METHODS

A search of the entire Medicare database from 2005 to 2011 was performed to identify 38,754 patients who sustained a proximal humerus fracture including 13,802 with co-existing ipsilateral shoulder osteoarthritis (OA) and 24,952 with co-existing diagnosis of rheumatoid arthritis (RA). A cohort of 301,987 patients served as a control. Medical co-morbidities and fracture complications were compared between the cohorts.

RESULTS

The incidence of delayed union at 3 and 6 months for OA and RA groups were significantly increased compared to control at 0.79% and 1.74%, and 0.67% and 1.86%, respectively (p < 0.001). Nonunion rates were also significantly increased (p < 0.001) in the OA and RA cohorts at 9 months and 1 year with incidences of 2.39%, 2.89% and 2.59% and 3.08%, Respectively. The incidence of nonunion in the control cohort at the same time points was 1.13% and 1.35%.

CONCLUSIONS

The coexistence of shoulder OA or a diagnosis of RA nearly doubled in the incidence of proximal humerus nonunion. This is the first study investigating this association in the shoulder and should be considered along with traditional nonunion risk factors in the treatment algorithm.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Objectives

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

Methods

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

Results

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

Conclusions

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

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

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

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Epidemiology of proximal humerus fractures

There are only a few previous population-based studies that include both inpatient and outpatient treatment data. The aim of this study was to investigate the epidemiology of proximal humerus fractures. The incidence of proximal humerus fractures increases with age, and we observe a seasonal variation strongly favoring winter months.

PURPOSE

Proximal humerus fractures are the third most common osteoporotic fracture type observed in elderly patients, after wrist and hip fractures. However, few previous population-based studies include both inpatient and outpatient treatment data. The aim of this study was to investigate the incidence, fracture morphology, and treatment method provided in cases of proximal humerus fractures.

METHODS

We retrospectively studied patient records from a mid-sized town in Finland between the years 2006 and 2010. The following data were collected from the medical records: age, sex, date of the fracture, laterality of the fracture, mechanism of injury, treatment method, and other associated fractures at the time of the original injury. Sex and age distributions of the patient population at risk (>18 years old) were calculated for the study period.

RESULTS

A total of 678 patients (females n = 503, 73 %) with 692 proximal humerus fractures were identified. The unadjusted incidence was 82 (95 % CI 76 to 88) per 100,000 person-years, 114 (95 % CI 104 to 124), and 47 (95 % CI 41 to 54) per 100,000 person-years in females and males, respectively. Incidence increased toward the older age groups. Clear seasonal variation was observed, two-part fractures were most common (428, 62 %), the majority of the fractures (n = 539, 78 %) were treated nonoperatively with a sling.

CONCLUSION

The incidence of proximal humerus fractures increases with age, and we observe a seasonal variation strongly favoring winter months. It is evident that proximal humerus fractures cause considerable morbidity among elderly people and consume health care resources.