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Fraser AN, Wagle TM, Karlberg AC, Madsen JE, Mellberg M, Lian T, Mader S, Eilertsen L, Apold H, Larsen LB, Pripp AH, Fjalestad T. Reverse Shoulder Arthroplasty Is Superior to Plate Fixation for Displaced Proximal Humeral Fractures in the Elderly: Five-Year Follow-up of the DelPhi Randomized Controlled Trial. J Bone Joint Surg Am 2024:00004623-990000000-01208. [PMID: 39303024 DOI: 10.2106/jbjs.23.01431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2024]
Abstract
LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander Nilsskog Fraser
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Department of Orthopaedic Surgery, Diakonhjemmet Hospital, Oslo, Norway
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway
| | - Tone Mehlum Wagle
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Anna Cecilia Karlberg
- Division of Radiology and Nuclear Medicine, Department of Musculoskeletal Radiology, Oslo University Hospital, Oslo, Norway
| | - Jan Erik Madsen
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Megan Mellberg
- Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
| | - Tom Lian
- Department of Orthopaedic Surgery, Vestre Viken Hospital Trust, Bærum, Norway
| | - Simone Mader
- Department of Orthopaedic Surgery, Førde Hospital Trust, Førde, Norway
| | - Lars Eilertsen
- Department of Orthopaedic Surgery, Diakonhjemmet Hospital, Oslo, Norway
| | - Hilde Apold
- Department of Orthopaedic Surgery, Telemark Hospital Trust, Skien, Norway
| | - Leif Børge Larsen
- Department of Orthopaedic Surgery, Vestfold Hospital Trust, Tønsberg, Norway
| | - Are Hugo Pripp
- Oslo Centre for Biostatistics & Epidemiology, Oslo University Hospital, Oslo Norway
| | - Tore Fjalestad
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
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Magnéli M, Axenhus M. Trend, disparities, and projection analysis of public data on shoulder fractures in Sweden: a retrospective analysis of two hundred and sixty two thousand, four hundred and forty four fractures. INTERNATIONAL ORTHOPAEDICS 2024:10.1007/s00264-024-06287-1. [PMID: 39259280 DOI: 10.1007/s00264-024-06287-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 08/17/2024] [Indexed: 09/13/2024]
Abstract
PURPOSE We aimed to identify temporal trends, seasonal changes and regional differences in shoulder fractures in Sweden during 2008-2022. METHODS Data from the Swedish National Board of Health and Welfare were used to assess incidence rates per 100,000 people, categorized by sex, age, and month. RESULTS Results showed an average of 17,496 fractures annually, with a decline in 2020 followed by a resurgence in 2021-2022. Elderly women, especially those over 65, had higher rates. Winter months exhibited increased incidence. CONCLUSIONS Projection analysis indicated a gradual decrease in fractures over the next 15 years. Understanding these patterns can inform preventive strategies and resource allocation for shoulder fractures in Sweden.
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Affiliation(s)
- Martin Magnéli
- Department of Orthopaedic Surgery, Danderyd Hospital, Stockholm, Sweden
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Michael Axenhus
- Department of Orthopaedic Surgery, Danderyd Hospital, Stockholm, Sweden.
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
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Duey AH, Stern BZ, Zubizarreta N, Galatz LM, Parsons BO, Poeran J, Cagle PJ. Surgical treatment of displaced proximal humerus fractures is associated with decreased 1-year mortality in patients aged 65 years and older: a retrospective study of Medicare patients. J Shoulder Elbow Surg 2024; 33:1962-1971. [PMID: 38430980 DOI: 10.1016/j.jse.2024.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 01/01/2024] [Accepted: 01/18/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Proximal humerus fracture (PHF) is a risk factor for 1-year mortality. This study aimed to determine if surgery is associated with lower mortality compared to nonoperative treatment following PHF in older patients. METHODS This retrospective cohort study used the Medicare Limited Data set. Patients aged 65 years and older with a PHF diagnosis in 2017-2020 were included. Treatment was classified as nonoperative, open reduction internal fixation (ORIF), total shoulder arthroplasty (TSA), or hemiarthroplasty. Multivariable logistic regression models examined (a) predictors of treatment type and (b) the association of treatment type with 1-year mortality, adjusting for patient demographics, comorbidities, frailty, and fracture severity among other variables. A subgroup analysis examined how the relationship between treatment type and 1-year mortality varied based on fracture severity. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) are reported. RESULTS In total, 49,072 patients were included (mean age = 76.6 years, 82.3% female). Most were treated nonoperatively (77.5%), 10.9% underwent ORIF, 10.6% underwent TSA, and 1.0% underwent hemiarthroplasty. Examples of factors associated with receipt of operative (versus nonoperative treatment) included worse fracture severity and lower frailty. The 1-year mortality rate after the initial PHF diagnosis was 11.0% for the nonoperative group, 4.0% for ORIF, 5.2% for TSA, and 6.0% for hemiarthroplasty. Compared to nonoperative treatment, ORIF (aOR 0.55; 95% CI [0.47, 0.64]; P < .001) and TSA (aOR 0.59; 95% CI [0.50, 0.68]; P < .001) were associated with decreased odds of 1-year mortality. In the subgroup analysis, ORIF and TSA were associated with a lower 1-year mortality risk for 2-part and 3-/4-part fractures. CONCLUSIONS Compared to nonoperative treatment, surgery (particularly TSA and ORIF) was associated with a decreased odds of 1-year mortality. This relationship remained significant for 2-part and 3-/4-part fractures after stratifying by fracture severity.
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Affiliation(s)
- Akiro H Duey
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brocha Z Stern
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Zubizarreta
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Leesa M Galatz
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bradford O Parsons
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jashvant Poeran
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul J Cagle
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Heo SM, Faulkner H, An VVG, Symes M, Nandapalan H, Sivakumar B. Outcomes following reverse total shoulder arthroplasty vs operative fixation for proximal humerus fractures: a systematic review and meta-analysis. Ann R Coll Surg Engl 2024; 106:562-568. [PMID: 38038170 PMCID: PMC11365726 DOI: 10.1308/rcsann.2022.0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 12/02/2023] Open
Abstract
INTRODUCTION Proximal humerus fractures are common in the older population. A consensus on the optimal management of complex fractures requiring surgery has yet to be reached. A systematic review and meta-analysis was performed to compare clinical outcomes between reverse total shoulder arthroplasty (RTSA) and open reduction and internal fixation (ORIF). METHODS A systematic search of the literature was undertaken using the Medline®, PubMed, Embase™ and Cochrane Central Register of Controlled Trials databases. Prospective and retrospective studies comparing clinical and patient reported results as primary outcome measures were included in this review, with secondary outcome measures including complications and revision surgery. A meta-analysis was conducted. RESULTS A total of 326 patients from 5 studies were eligible for inclusion in this review. Superior Constant-Murley scores (mean difference [MD]: 13.4, 95% confidence interval [CI]: 6.2-20.6; p<0.001), Oxford shoulder scores (MD: 4.3, 95% CI: 1.2-7.4; p=0.007), simple shoulder test scores (MD: 0.95, 95% CI: 0.01-1.89; p=0.05) and DASH (Disabilities of the Arm, Shoulder and Hand) scores (MD: 5.1 [1 study], 95% CI: 2.1-8.1; p=0.034) were noted in patients receiving RTSA. Range of motion and revision surgery rates were also superior in this group. CONCLUSIONS This study suggests that RTSA affords more favourable outcomes and lower revision rates than ORIF following proximal humerus fractures. Definitive conclusions are precluded, however, owing to small sample sizes and risk of bias in retrospective studies.
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Affiliation(s)
- SM Heo
- Hornsby Ku-ring-gai Hospital, Sydney, Australia
| | - H Faulkner
- Hornsby Ku-ring-gai Hospital, Sydney, Australia
| | - VVG An
- Royal Prince Alfred Hospital, Sydney, Australia
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Ju J, Zhou Y, Chen L, Ma M, Zhang Y, Ding Z, Li R, Chen J. The relationship between humeral head angulation and bone void within the humeral head in proximal humerus fractures. Heliyon 2024; 10:e36145. [PMID: 39229528 PMCID: PMC11369451 DOI: 10.1016/j.heliyon.2024.e36145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/04/2024] [Accepted: 08/09/2024] [Indexed: 09/05/2024] Open
Abstract
Background The variability of humeral head angulation in proximal humerus fractures (PHFs) is a noteworthy observation. The purpose of this study was to investigate the potential association between humeral head angulation and bone void within the humeral head in PHFs. Methods We used the reconstruction function in Mimics software to generate three-dimensional models of fractures. Bony landmarks were employed to accurately define the calcar and humeral head zone. Boolean subtraction was performed to calculate the volume of head bone void. Results The cohort consisted of 60 (74.1 %) varus, 21 (25.9 %) valgus, and 23 (22.1 %) neutral angulated PHFs. The mean percentage of humeral head bone void was 38.5 ± 17.8 in varus, 36.3 ± 15.7 in valgus, and 30.1 ± 10.6 in neutral angulated PHFs. A significant difference was observed between the varus and neutral groups (P = 0.035). In addition, an analysis of humeral head bone void was conducted among patients aged over 65 years old, revealing a mean percentage of 42.7 ± 16.4 in varus (27 cases), 34.8 ± 14.5 in valgus (13 cases), and 28.1 ± 11.8 in neutral (8 cases) angulated PHFs. The difference between the varus and neutral groups was also significant (P = 0.023). Conclusion All types of angulation patterns exhibited humeral head bone void to some extent, with the varus-displaced PHFs demonstrating more obvious defects in comparison to the neutral angulated type.
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Affiliation(s)
- Jiabao Ju
- Department of Trauma & Orthopedics, Peking University People's Hospital, Beijing, China
| | - Yongwen Zhou
- Department of Orthopedics, Affiliated Hospital of Panzhihua University, Sichuan, China
| | - Liang Chen
- Department of Orthopedics, Hospital of Traditional Chinese Medicine of Zhongshan, Guangzhou University of Chinese Medicine, Guangdong, China
| | - Mingtai Ma
- Department of Trauma & Orthopedics, Peking University People's Hospital, Beijing, China
| | - Yichong Zhang
- Department of Trauma & Orthopedics, Peking University People's Hospital, Beijing, China
| | - Zhentao Ding
- Department of Trauma & Orthopedics, Peking University People's Hospital, Beijing, China
| | - Renbin Li
- Department of Orthopedics, Fuzhou Second Hospital of Xiamen University, Fujian, China
| | - Jianhai Chen
- Department of Trauma & Orthopedics, Peking University People's Hospital, Beijing, China
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Spoden M, Dröge P, Günster C, Datzmann T, Helfen T, Schaser KD, Schmitt J, Schuler E, Christoph Katthagen J, Nowotny J. A high hospital frailty risk score indicates an increased risk for complications following surgical treatment of proximal humerus fractures. Arch Gerontol Geriatr 2024; 128:105598. [PMID: 39182348 DOI: 10.1016/j.archger.2024.105598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/01/2024] [Accepted: 08/04/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Approximately 70 % of proximal humerus fractures (PHF) occur after the age of 60. High complication rates have been described in correlation with the treatment of PHF. Major risk factors for the outcome might be frailty, mobility and comorbidities of patients at the time of hospital admission. The aim of this study was to create risk adjusted quality indicators for surgical treatment of proximal humerus fractures based on German claims data and to evaluate the impact of the Hospital Frailty Risk Score (HFRS) on risk adjustment. METHODS Retrospective claims data (2015-2021) were used to create risk adjusted quality indicators for eight outcomes by clustered multivariable logistic regression. The comparison of different risk adjustment model performances was done by ROC-AUC and Standardized Mortality/Morbidity Ratios. RESULTS In total, N = 34,912 patients (median age 75 years, 80.3 % female) were included. The most common surgical procedure was open reduction and internal fixation with plate osteosynthesis with 39.7 %, followed by reverse shoulder arthroplasty with 25.3 %. The most influential risk factor for all outcomes was a high HFRS with an Odds Ratio of 2.0 (95 %-Confidence Interval 1.8-2.3) for any secondary surgery (365 days) up to an Odds Ratio of 17.6 (95 %-Confidence Interval 14.9-20.8) for general complications during the index stay. CONCLUSION Comparative quality reporting for the surgical treatment of PHF appears feasible with the developed models for risk adjustment using claims data. Preoperative evaluation of HFRS in PHF can contribute to risk assessment, and individual patient management. It therefore enables personalized treatment decisions.
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Affiliation(s)
| | | | | | - Thomas Datzmann
- Center for Evidence-based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Tobias Helfen
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal UniversityCenter Munich (MUM), LMU University Hospital, LMU Munich, Germany
| | - Klaus-Dieter Schaser
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital, Technische Universität Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - J Christoph Katthagen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Jörg Nowotny
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital, Technische Universität Dresden, Germany
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Root KT, Burnett AJ, Kakalecik J, Harris AB, Ladehoff L, Taneja K, Patrick MR, Hagen JE, King JJ. The Association between Race and Extended Length of Stay in Low-energy Proximal Humerus Fractures in Elderly Patients. J Am Acad Orthop Surg 2024; 32:e759-e768. [PMID: 38595161 DOI: 10.5435/jaaos-d-23-00925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 02/19/2024] [Indexed: 04/11/2024] Open
Abstract
INTRODUCTION Proximal humerus fractures (PHFs) are one of the most common fractures among patients aged 65 years and older, commonly due to low-energy mechanisms. It is essential to identify drivers of increased healthcare utilization in geriatric PHF patients and bring awareness to any disparities in care. Here, we identify factors associated with the likelihood of inpatient admission and prolonged hospital stay among patients aged 65 years and older who sustain PHF due to falls. METHODS A national database was used to identify patients aged 65 years and older who suffered proximal humeral fractures due to a fall. Patient factors were analyzed for association with the likelihood of admission and odds of prolonged stay (≥5 days). RESULTS In the study period, 75,385 PHF patients who met our inclusion criteria presented to the emergency department and 14,118 (18.7%) were admitted. Black race was significantly associated with decreased odds of admission ( P < 0.001) and increased likelihood of prolonged stay ( P = 0.007) compared with White patients. Patients aged 75 to 84 and 85+ were both more likely to be admitted ( P < 0.001) and experienced a prolonged hospital stay ( P = 0.015). Patients undergoing surgical intervention with reverse total shoulder arthroplasty were associated with admission and prolonged length of stay ( P < 0.001). Hospitals in Midwestern ( P < 0.001) and Western ( P < 0.001) regions exhibited lower rates of admission and Northeastern hospitals were associated with prolonged stays ( P = 0.001). Finally, trauma and nonmetropolitan ( P < 0.001) centers were associated with admission. CONCLUSION Our study highlights the notable influence of age and race on the likelihood of hospital admission and prolonged hospital stay. Specifically, Black patients exhibited prolonged hospital stay, which has been associated with lower-quality care, warranting additional exploration. Understanding these demographic and hospital-related factors is essential for optimizing resource allocation and reducing healthcare disparities in the care of PHF patients, especially as the population ages and the incidence of PHF continues to rise.
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Affiliation(s)
- Kevin T Root
- From the College of Medicine, University of Florida, Gainesville, FL (Root and Burnett), Department of Orthopaedic Surgery, University of Florida, Gainesville, FL (Kakalecik, Patrick, Hagen, and King), the Department of Orthopaedic Surgery, Johns Hopkins, Baltimore, MD (Harris), USF Health Morsani College of Medicine, Tampa, FL (Ladehoff), and Renaissance School of Medicine at Stony Brook University, Stony Brook, NY (Taneja)
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Curry M, Tornberg H, Fedorka CJ. Single-stage bilateral uncemented reverse shoulder arthroplasty for traumatic proximal humerus fractures: a case report. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:504-510. [PMID: 39157217 PMCID: PMC11329036 DOI: 10.1016/j.xrrt.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Affiliation(s)
- Michael Curry
- Department of Orthopaedic Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Haley Tornberg
- Department of Orthopaedic Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Catherine J. Fedorka
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA
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Katthagen JC, Raschke MJ, Fischhuber K, Iking J, Marschall U, Sußiek J, Faldum A, Stolberg-Stolberg J, Köppe J. Conservative Versus Operative Treatment of Proximal Humerus Fractures in Older Individuals. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:454-460. [PMID: 38652842 DOI: 10.3238/arztebl.m2024.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Little is known about the frequency and results of conservative treatment of proximal humerus fractures (PHF) in older individuals. METHODS Billing data of the BARMER health insurance carrier for all patients of age ≥ 65 for the years 2005-2021 were retrospectively analyzed with multivariable Cox regression models, taking account of the patients' age, sex, and individual comorbidity profiles. The defined primary endpoints were overall survival (OS), major adverse events (MAE), thromboembolic events (TE), and complications of surgery or of trauma. Multivariable p-values for the effect of treatment on all primary endpoints were jointly adjusted using the Bonferroni-Holm method. RESULTS Of 81 909 patients, 54% were treated conservatively. Conservative treatment was more common in those who received their diagnosis as outpatients (79.5%, vs. 37.2% for inpatients). Operative treatment was associated with significantly longer overall survival (long-term hazard ratio [HR] 0.89, 95% confidence interval [0.86; 0.91]), fewer MAE (0.90 [0.88; 0.92]), and fewer TE (0.89 [0.87; 0.92]), but more complications due to surgery or trauma (1.66 [1,.4; 1.78]; all p < 0.001). By 6 months after diagnosis, 3.1% of the patients who were initially treated conservatively had undergone surgery. Risk factors for failure of conservative treatment were alcohol abuse, obesity, cancer, diabetes mellitus, Parkinson disease, and osteoporosis. CONCLUSION The conservative treatment of PHF is associated with a lower overall rate of complications due to surgery or trauma, but also with more MAE, more TE, and higher mortality. These findings underline the need for individualized and risk-adjusted treatment recommendations.
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Affiliation(s)
- J Christoph Katthagen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Building W1, Albert-Schweitzer-Campus 1, Münster; Research Group Mathematical Surgery, University Hospital Münster, University of Münster; Institute of Biostatistics and Clinical Research, University of Münster; BARMER Institute for Health System Research Wuppertal
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Hornung AL, Rudisill SS, McCormick JR, Streepy JT, Harkin WE, Bryson N, Simcock X, Garrigues GE. Preoperative factors predict prolonged length of stay, serious adverse complications, and readmission following operative intervention of proximal humerus fractures: a machine learning analysis of a national database. JSES Int 2024; 8:699-708. [PMID: 39035667 PMCID: PMC11258835 DOI: 10.1016/j.jseint.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
Background Proximal humerus fractures are a common injury, predominantly affecting older adults. This study aimed to develop risk-prediction models for prolonged length of hospital stay (LOS), serious adverse complications, and readmission within 30 days of surgically treated proximal humerus fractures using machine learning (ML) techniques. Methods Adult patients (age >18) who underwent open reduction internal fixation (ORIF), hemiarthroplasty, or total shoulder arthroplasty for proximal humerus fracture between 2016 and 2021 were included. Preoperative demographic and clinical variables were collected for all patients and used to establish ML-based algorithms. The model with optimal performance was selected according to area under the curve (AUC) on the receiver operating curve (ROC) curve and overall accuracy, and the specific predictive features most important to model derivation were identified. Results A total of 7473 patients were included (72.1% male, mean age 66.2 ± 13.7 years). Models produced via gradient boosting performed best for predicting prolonged LOS and complications. The model predicting prolonged LOS demonstrated good discrimination and performance, as indicated by (Mean: 0.700, SE: 0.017), recall (Mean: 0.551, SE: 0.017), accuracy (Mean: 0.717, SE: 0.010), F1-score (Mean: 0.616, SE: 0.014), AUC (Mean: 0.779, SE: 0.010), and Brier score (Mean: 0.283, SE: 0.010) Preoperative hematocrit, preoperative platelet count, and patient age were considered the strongest predictive features. The model predicting serious adverse complications exhibited comparable discrimination [precision (Mean: 0.226, SE: 0.024), recall (Mean: 0.697, SE: 0.048), accuracy (Mean: 0.811, SE: 0.010), F1-score (Mean: 0.341, SE: 0.031)] and superior performance relative to the LOS model [AUC (Mean: 0.806, SE: 0.024), Brier score (Mean: 0.189, SE: 0.010), noting preoperative hematocrit, operative time, and patient age to be most influential. However, the 30-day readmission model achieved the weakest relative performance, displaying low measures of precision (Mean: 0.070, SE: 0.012) and recall (Mean: 0.389, SE: 0.053), despite good accuracy (Mean: 0.791, SE: 0.009). Conclusion Predictive models constructed using ML techniques demonstrated favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged LOS and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture. Modifiable preoperative factors such as hematocrit and platelet count were identified as significant predictive features, suggesting that clinicians could address these factors during preoperative patient optimization to enhance outcomes. Overall, these findings highlight the potential for ML techniques to enhance preoperative management, facilitate shared decision-making, and enable more effective and personalized orthopedic care by exploring alternative approaches to risk stratification.
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Affiliation(s)
- Alexander L. Hornung
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | | | - John T. Streepy
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - William E. Harkin
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Noah Bryson
- Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, USA
| | - Xavier Simcock
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Grant E. Garrigues
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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11
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Longo UG, Gulotta LV, De Salvatore S, Lalli A, Bandini B, Giannarelli D, Denaro V. Augmented versus non-augmented locking-plate fixation in proximal humeral fractures. Bone Joint J 2024; 106-B:646-655. [PMID: 38945543 DOI: 10.1302/0301-620x.106b7.bjj-2023-1113.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Aims Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures. Methods The search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles involving patients with complex proximal humeral fractures treated using open reduction with locking-plate fixation, with or without augmentation, were considered. A meta-analysis of comparative studies comparing locking-plate fixation with cement augmentation or with bone-graft augmentation versus locking-plate fixation without augmentation was performed. Results A total of 19 studies were included in the qualitative synthesis, and six comparative studies were included in the meta-analysis. Overall, 120 patients received locking-plate fixation with bone-graft augmentation, 179 patients received locking-plate fixation with cement augmentation, and 336 patients received locking-plate fixation without augmentation. No statistically relevant differences between the augmented and non-augmented cohorts were found in terms of the Disabilities of the Arm, Shoulder and Hand questionnaire score and Constant-Murley Score. The cement-augmented group had a significantly lower rate of complications compared to the non-augmented group. Conclusion While locking-plate fixation with cement augmentation appears to produce a lower complication rate compared to locking-plate fixation alone, functional outcomes seem comparable between augmented and non-augmented techniques.
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Affiliation(s)
- Umile G Longo
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Lawrence V Gulotta
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Sergio De Salvatore
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
- IRCCS Istituto Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Alberto Lalli
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Benedetta Bandini
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Diana Giannarelli
- IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Vincenzo Denaro
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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Cederwall A, Karlsson MK, Rosengren BE. Time trends in proximal humeral fractures from 1944 to 2020 - A cohort study in Malmö, Sweden. BMC Musculoskelet Disord 2024; 25:491. [PMID: 38914972 PMCID: PMC11194865 DOI: 10.1186/s12891-024-07602-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 06/14/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Most studies infer increasing incidence of proximal humeral fractures (PHF) from the 1950´s until the 1990´s. Recent time trends are less clear. OBJECTIVES Our primary objective was to identify time trends in the age- and sex-adjusted adult incidence of PHF in Malmö, Sweden, from year 1944 until 2020. Our secondary objectives were to describe the variation in incidence according to age, the monthly distribution, and to compare data from the two most recent decades with earlier. STUDY DESIGN AND METHODS Malmö has one emergency hospital where acute fractures are treated. We identified PHF in adult patients (≥ 18 years) by reviewing relevant radiology examinations during 17 sample years from year 1944 to 2020. We used jointpoint analyses to estimate time trends. RESULTS We identified 3 031 PHF during the study period (3 231 161 person years), 73% were sustained by women with mean age of 69 years (mean age in men 59). Joinpoint analyses indicated an increase in the age- and sex-adjusted incidence of PHF from year 1944 (52 per 100 000 person years) until 1977 (120 per 100 000) and thereafter a decrease until 2020 (85 per 100 000). A seasonal variation with more fractures during winter months, was apparent in earlier but not recent decades. CONCLUSIONS The age- and sex-adjusted incidence of PHF increased in Malmö, Sweden, from the 1940´s until year 1977 and thereafter decreased until 2020. More fractures were seen during winter months in earlier but not recent decades.
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Affiliation(s)
- Anton Cederwall
- Clinical and Molecular Osteoporosis Research Unit, Departments of Orthopedics and Clinical Sciences, Skåne University Hospital Malmo and Lund University, Malmö, 205 02, Sweden.
| | - Magnus K Karlsson
- Clinical and Molecular Osteoporosis Research Unit, Departments of Orthopedics and Clinical Sciences, Skåne University Hospital Malmo and Lund University, Malmö, 205 02, Sweden
| | - Björn E Rosengren
- Clinical and Molecular Osteoporosis Research Unit, Departments of Orthopedics and Clinical Sciences, Skåne University Hospital Malmo and Lund University, Malmö, 205 02, Sweden
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Bieling M, Ellwein A, Lill H, Sehmisch S, Reeh FM. Proximal humerus fracture and acromioclavicular joint dislocation. Innov Surg Sci 2024; 9:67-82. [PMID: 39100718 PMCID: PMC11294519 DOI: 10.1515/iss-2023-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 12/12/2023] [Indexed: 08/06/2024] Open
Abstract
Proximal humerus fractures and injuries to the acromioclavicular joint are among the most common traumatic diseases of the upper extremity. Fractures of the proximal humerus occur most frequently in older people and are an indicator fracture of osteoporosis. While a large proportion of only slightly displaced fractures can be treated non-operatively, more complex fractures require surgical treatment. The choice of optimal treatment and the decision between joint-preserving surgery by means of osteosynthesis or endoprosthetic treatment is often a difficult decision in which both fracture morphology factors and individual factors should be taken into account. If endoprosthetic treatment is indicated, satisfactory long-term functional and clinical results have been achieved with a reverse shoulder arthroplasty. Injuries to the acromioclavicular joint occur primarily in young, athletic individuals. The common classification according to Rockwood divides the injury into 6 degrees of severity depending on the dislocation. This classification forms the basis for the decision on non-operative or surgical treatment. The indication for surgical treatment for higher-grade injuries is the subject of controversial debate in the latest literature. In chronic injuries, an autologous tendon transplant is also performed. Whereas in the past, treatment was often carried out using a hook plate, which was associated with complications, the gold standard today is minimally invasive treatment using Endobutton systems. This review provides an overview of the two injury patterns and discusses the various treatment options.
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Affiliation(s)
- Maren Bieling
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Hannover, Germany
| | - Alexander Ellwein
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Hannover, Germany
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Helmut Lill
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Hannover, Germany
| | - Stephan Sehmisch
- Klinik für Unfallchirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Freya Margaretha Reeh
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Hannover, Germany
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Li DY, Zhang K. Cement-augmented locked plate fixation proximal humerus fractures in elderly patient: a systematic review and meta-analysis. BMC Musculoskelet Disord 2024; 25:368. [PMID: 38730497 PMCID: PMC11084043 DOI: 10.1186/s12891-024-07502-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/07/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND This systemic review and meta-analysis aimed to evaluate the clinical outcomes of proximal humeral fracture in elderly patient fixation using locked plate with or without cement augmentation. METHODS The databases of PubMed, Embase, and Cochrane Library were searched in August 2023 for literature comparing the clinical outcomes of patients with PHFs treated with locked plate alone and locked plate augmented with cement. Data describing study design; level of evidence; inclusion criteria; demographic information; final follow-up; revision rate; implant failure rate; avascular necrosis rate; total complication rate; constant score; and disability of arm, shoulder, and hand (DASH) score were collected. RESULTS Eight studies (one randomized-controlled trial and seven observational studies), involving 664 patients, were identified. Compared with locked plates alone, using cement-augmented locked plates reduced the implant failure rate (odds ratio (OR) = 0.19; 95% confidence interval (CI) 0.10-0.39; P < 0.0001) and total complication rate (OR = 0.45; 95% CI 0.29-0.69; P = 0.0002) and improved DASH scores (mean difference (MD) = 2.99; 95% CI 1.00-4.98; P = 0.003). However, there was no significant difference in clinical outcomes, including revision rate, avascular necrosis rate, and constant score. CONCLUSION In this review and meta-analysis, fixation of the PHFs in elderly patients using locked plates with or without cement augmentation has no significant difference in revision rate, but the implant failure and total complication rates may be lesser on using the cement-augmented locked plate for fixation than on using a locked plate alone. Good results are expected for most patients treated with this technique. TRIAL REGISTRATION The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)21 guidelines were followed to conduct this systematic review and meta-analysis and was registered as a protocol in PROSPERO (CRD42022318798).
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Affiliation(s)
- Dong-Yang Li
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Xi'an, Shaanxi Province, 710054, P.R. China
| | - Kun Zhang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Xi'an, Shaanxi Province, 710054, P.R. China.
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15
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Østergaard HK, Launonen AP, Toft M, Fjalestad T, Sumrein BO, Døssing KV, Axelsen MH, Noe SS, Wagle T, Engebretsen KB, Laitinen MK, Mattila VM, Mechlenburg I. Physiotherapist-supervised exercises versus unsupervised home-based exercises after nonsurgically treated proximal humerus fracture: a multicenter randomized controlled trial. J Shoulder Elbow Surg 2024; 33:994-1003. [PMID: 38311103 DOI: 10.1016/j.jse.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/21/2023] [Accepted: 12/04/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Proximal humerus fracture (PHF) is a common fragility fracture in older adults and can have a substantial impact on upper limb function. Although most patients with PHF can be treated nonsurgically, it is unknown whether older adults benefit from supervised exercise therapy after PHF. Therefore, the objective of this trial was to investigate whether 10 weeks of physiotherapist-supervised exercises once a week were superior to 10 weeks of unsupervised home-based exercises in older adults with a nonsurgically treated displaced 2-part PHF. METHODS This was designed as an assessor-blinded, prospective, randomized controlled trial and took place in 3 Nordic countries. In total, 72 patients (≥60 years) with nonsurgically treated displaced 2-part PHF were randomized to either physiotherapist-supervised exercises once a week for 10 weeks, combined with daily home-based exercises, or to 10 weeks of daily unsupervised home-based exercises. The primary outcome measure was the Disability of the Arm, Shoulder, and Hand (DASH) with a primary endpoint at 3 months. Secondary outcomes were DASH (at 12 months), Constant-Murley Score, the 15D-instrument, Visual Analog Scale, General Self-Efficacy Scale, and Pain Catastrophizing Scale, with follow-up visits after 3 and 12 months. Non-union and patient death within 3 months were counted as complications. RESULTS The mean age of the patients in both groups was 72 years. At 3 months follow-up, the mean DASH score in the supervised group was 25.9 (SD 16.0) compared to 22.4 (SD 18.9) in the unsupervised group. The mean between-group difference (3.5, 95% CI -5.0 to 12.5) was not clinically relevant. None of the secondary outcome measures presented any clinically relevant or statistically significant between-group differences at 3 or 12 months follow-up. One patient in the supervised group and 3 in the unsupervised group were diagnosed with non-union. One patient from each group died before 3 months follow-up. CONCLUSIONS This trial provides no evidence that supervised exercises are superior to unsupervised home-based exercises in improving functional outcome or health-related quality of life in older patients with a nonsurgically treated 2-part PHF. Further, our results suggest that most older adults with a nonsurgically treated 2-part PHF can perform home-based exercises without the supervision of a physiotherapist.
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Affiliation(s)
- Helle K Østergaard
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Antti P Launonen
- Department of Orthopaedics, Tampere University Hospital, Tampere, Finland
| | - Marianne Toft
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark
| | - Tore Fjalestad
- Department of Orthopaedics, Oslo University Hospital, Oslo, Norway
| | - Bakir O Sumrein
- Department of Orthopaedics, Tampere University Hospital, Tampere, Finland
| | - Kaj V Døssing
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark
| | - Mette H Axelsen
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark
| | - Sidsel S Noe
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark
| | - Tone Wagle
- Department of Orthopaedics, Oslo University Hospital, Oslo, Norway
| | - Kaia B Engebretsen
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Minna K Laitinen
- Department of Orthopaedics, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Ville M Mattila
- Department of Orthopaedics, Tampere University Hospital, Tampere, Finland
| | - Inger Mechlenburg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Orthopaedics, Aarhus University Hospital, Aarhus, Denmark
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16
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Parel PM, Bervell J, Agarwal AR, Haft M, Ranson RA, Stadecker M, Nelson S, Rudzki JR, McFarland EG, Srikumaran U. Reverse total shoulder arthroplasty within 6 weeks of proximal humerus fracture is associated with the lowest risk of revision. J Shoulder Elbow Surg 2024:S1058-2746(24)00307-0. [PMID: 38685379 DOI: 10.1016/j.jse.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 02/24/2024] [Accepted: 03/05/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular treatment strategy in the management of complex proximal humeral fractures (PHFs). However, no definitive consensus has been reached regarding the optimal surgical timing of RTSA following PHF, particularly considering nonoperative management is often a viable option. Therefore, the aim of this study was (1) to identify optimal timing intervals that maximize the likelihood of revision following RTSA and (2) to determine differences in revision etiologies using the identified timing intervals. METHODS A retrospective cohort analysis of patients undergoing PHF-indicated RTSA from 2010 to 2021 was conducted using a national administrative claims database. Stratum-specific likelihood ratio (SSLR) analysis was conducted to determine data-driven timing strata between PHF and RTSA that maximized the likelihood of revision surgery within 2 years of RTSA. To control for confounders, multivariable regression analysis was conducted to confirm the identified data-driven strata's association with 2-year revision rates as well as compare the likelihood of various indications for revision including mechanical loosening, dislocation, periprosthetic joint infection (PJI), and periprosthetic fracture (PPF). RESULTS In total, 11,707 patients undergoing TSA following PHF were included in this study. SSLR analysis identified 2 timing categories: 0-6 weeks and 7-52 weeks from the time of PHF to TSA surgery. Relative to the 0-6-week cohort, the 7-52-week cohort was more likely to undergo revision surgery within 2 years (OR 1.93, P < .001). Moreover, the 7-52-week cohort had significantly higher odds of revision indicated for dislocation (OR 2.24, P < .001), mechanical loosening (OR 1.71, P < .001), PJI (OR 1.74, P < .001), and PPF (OR 1.96, P < .001). CONCLUSIONS Using SSLR, we were successful in identifying 2 data-driven timing strata between PHF and RTSA that maximized the likelihood of 2-year revision surgery. As it can be difficult to determine whether RTSA or nonoperative management is initially more appropriate, considering the results of this study, an early trial of 4-6 weeks of nonoperative management may be appropriate without altering the risks associated with RTSA.
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Affiliation(s)
- Philip M Parel
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| | - Joel Bervell
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amil R Agarwal
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mark Haft
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rachel A Ranson
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Monica Stadecker
- The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Sarah Nelson
- Department of Orthopaedic Surgery, Walter Reed National Medical Center, Bethesda, MD, USA
| | - Jonas R Rudzki
- Washington Orthopaedics and Sports Medicine, Washington, DC, USA
| | - Edward G McFarland
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Lecoultre Y, Beeres FJP, Link BC, Pretz F, Tillmann F, Babst R, van de Wall BJM. Cement augmentation for proximal humerus fractures: a meta-analysis of randomized trials and observational studies. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02520-z. [PMID: 38589503 DOI: 10.1007/s00068-024-02520-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 03/30/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION It is unclear if elderly patients treated with plate osteosynthesis for proximal humerus fractures benefit from cement augmentation. This meta-analysis aims to compare cement augmentation to no augmentation regarding healing, complications, and functional results. METHODS PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for randomized clinical trials and observational studies. Effect estimates were pooled across studies using random effects models. The primary outcome is overall complication rate. Stratified analyses were performed for types of complication (implant-related or systemic). Secondary outcomes include re-interventions, hospital stay, operation time, functional scores, and general quality of life. RESULTS Five observational studies and one randomized controlled trial with a total of 541 patients were included. The overall complication rate was significantly lower in the augmented group (15.6% versus 25.4%, OR 0.54 (95%CI 0.33-0.87)). This was caused by a reduction of implant-related complications (10.4% vs. 19.9%, OR 0.49 (95%CI 0.28, 0.88)). No difference in humeral head necrosis was found. Data on re-intervention, hospital stay, and operation time was limited but did not show significant differences. No impact on functional scores and general quality of life was detected. CONCLUSION This meta-analysis shows that cement augmentation may reduce overall complications, mainly by preventing implant-related complications. No difference was detected regarding need for re-intervention, functional scores, general quality of life, and hospital stay. This is the first meta-analysis on this topic. It remains to be seen whether conclusions will hold when more and better-quality data becomes available.
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Affiliation(s)
- Yannic Lecoultre
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland.
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.
| | - Frank J P Beeres
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Björn C Link
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Fabian Pretz
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Franz Tillmann
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Bryan J M van de Wall
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
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18
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Nguyen Manh K, Nguyen Van H, Cao Dinh B, Le Xuan H. OUTCOME OF SHOULDER HEMIARTHROPLASTY FOR COMPLEX PROXIMAL HUMERAL FRACTURE IN VIETDUC UNIVERSITY HOSPITAL. Orthop Rev (Pavia) 2024; 16:115587. [PMID: 38586246 PMCID: PMC10994828 DOI: 10.52965/001c.115587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/05/2024] [Indexed: 04/09/2024] Open
Abstract
ABSTRACTS Translational Study Introduction: The proximal humeral fracture accounts for 4-5% of all fractures1 and traffic accidents are often the main cause of this injury in Vietnam. Shoulder hemiarthroplasty is a suitable option in treating a complex proximal humeral fracture, especially in the elderly, and improves quality of life. This study describes clinical and radiographic characteristics of complex proximal humerus fractures and evaluates the results of shoulder hemiarthroplasty for this type of fracture at Viet Duc University Hospital Materials and methods: A retrospective study of 78 cases with complex proximal humeral fractures underwent shoulder hemiarthroplasty in Viet Duc University Hospital from January 2017 to December 2021. RESULTS Traffic accidents (42 cases, 53.8%); daily-life accidents (34 cases, 43.6%), other causes were less common (2 cases, 2.6%). 74.4% of the patients had no pain, 17.4% mild pain, 7.7% moderate pain, and no patients suffered from severe pain that required regular narcotic analgesics. The mean postoperative Constant score was 67.45 ± 13.20. CONCLUSION In Viet Nam, the most common cause of injury was a traffic accident, primarily occurring in young males with complex proximal humerus fractures, shoulder hemiarthroplasty for complex proximal humerus fractures improves postoperative pain and shoulder function.
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Affiliation(s)
- Khanh Nguyen Manh
- Department of Upper limb surgery and sports medicine Viet Duc Hospital
| | - Hoc Nguyen Van
- Department of Upper limb surgery and sports medicine Viet Duc Hospital
| | - Bang Cao Dinh
- Department of Upper limb surgery and sports medicine Viet Duc Hospital
| | - Hoang Le Xuan
- Department of Upper limb surgery and sports medicine Viet Duc Hospital
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Kus G, Zengin Alpozgen A, Gungor F, Razak Ozdincler A, Altun S. Clinical outcomes of conservative versus surgical treatment for patients with proximal humeral fracture before physiotherapy. Acta Orthop Belg 2024; 90:96-101. [PMID: 38669657 DOI: 10.52628/90.1.12409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Fear of movement, pain, and loss of shoulder function are the most common problems irrespective of their approach to management after proximal humeral fracture (PHF). However, it has been unclear whether there could be differences between both treatments in early clinical outcomes. It can help physiotherapists to guide in choosing treatment approaches. This study aimed to compare kinesiophobia, pain, range of motion (ROM), shoulder function, and Quality of life (QoL) in patients treated with either conservative (CT) versus surgical (ST) after PHF. In addition, it aimed to determine correlations between fear of movement and seconder outcome measures. This cross-sectional study enrolled the patients having 5-6 weeks (being permitted active movement) after being treated either CT or ST and receiving no physical therapy. Pain, passive and active ROMs, shoulder function, fear of movement, and QoL were evaluated. 42 patients were recruited. Kinesiophobia scores were similar (p=0.55) and moderate in both groups. There was a significant difference in degrees of shoulder active flexion, active and passive abduction in favor of the CT group (p=0.05, p=0.02, p=0.04, respectively). However, there was no difference between groups regarding the remaining clinical outcomes. Furthermore, kinesiophobia showed a moderate negative correlation with energy/fatigue, social functioning, and general health. These findings showed that patients treated surgically did not have more kinesiophobia, less function, and QoL before starting physiotherapy, despite having soft tissue damage and different types of fractures. However, surgically treated patients had significantly less range of motion.
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Zheng Y, Tang N, Zhang WJ, Shi W, Zhao WW, Yang K. Comparative efficacy and safety of medical treatments for proximal humerus fractures: a systematic review and network meta-analysis. BMC Musculoskelet Disord 2024; 25:17. [PMID: 38166758 PMCID: PMC10759392 DOI: 10.1186/s12891-023-07053-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 11/21/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Various surgical techniques and conservative therapies are useful tools for treating proximal humerus fractures (PHFs), but it is important to understand how to properly utilize them. Therefore, we performed a systematic review and network meta-analysis to compare and rank the efficacy and safety of medical treatments for PHF. METHODS PubMed, Embase, the Cochrane Library, and the ClinicalTrials.gov databases were systematically searched for eligible randomized controlled trials (RCTs) from inception until June 2022. Conservative therapy-controlled or head-to-head RCTs of open reduction internal fixation (ORIF), intramedullary nailing (IMN), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (RTSA) used for the treatment of adult patients with PHF were included. The surface under the cumulative ranking (SUCRA) probabilities were applied to compare and rank the effects of medical treatments for PHF. RESULTS Eighteen RCTs involving 1,182 patients with PHF were selected for the final analysis. Mostly baseline characteristics among groups were well balanced, and the imbalanced factors only included age, injury type, medial comminution, blood loss, and cognitive function in single trial. The SUCRA probabilities found that RTSA provided the best effect on the Constant-Murley score (SUCRA: 100.0%), and the disabilities of the arm, shoulder and hand (DASH) score (SUCRA: 99.0%). Moreover, HA (SUCRA: 85.5%) and RTSA (SUCRA: 68.0%) had a relatively better effect on health-related quality of life than the other treatment modalities. Furthermore, conservative therapy (SUCRA: 84.3%) and RTSA (SUCRA: 80.7%) were associated with a lower risk of secondary surgery. Finally, the best effects on the risk of complications are varied, including infection was observed with conservative therapy (SUCRA: 94.2%); avascular necrosis was observed in HA (SUCRA: 78.1%), nonunion was observed in RTSA (SUCRA: 69.6%), and osteoarthritis was observed in HA (SUCRA: 93.9%). CONCLUSIONS This study found that RTSA was associated with better functional outcomes, while the comparative outcomes of secondary surgery and complications varied. Optimal treatment for PHF should consider patient-specific factors.
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Affiliation(s)
- Yun Zheng
- R & D Center, Beijing Naton Technology Group Co., Ltd, Peking, China
| | - Nan Tang
- Director of Tianjin Center for Medical Devices Evaluation and Inspection, Tianjin, China
| | - Wen-Jie Zhang
- Comprehensive Business Department, Tianjin Center for Medical Devices Evaluation and Inspection, Tianjin, China
| | - Wei Shi
- Quality Management Department, Tianjin Center for Medical Devices Evaluation and Inspection, Tianjin, China
| | - Wen-Wen Zhao
- Registration and Regulatory Department, Beijing Naton Technology Group Co, Ltd, Building 1, Yard 9, Chengwan Street, Haidian District, Peking, 100094, China.
| | - Kun Yang
- Quality Management Department, Tianjin Center for Medical Devices Evaluation and Inspection, Tianjin, China
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Čellár R, Sokol D. [Bilateral Dorsal Fracture-Dislocation of the Proximal Humerus]. ACTA CHIRURGIAE ORTHOPAEDICAE ET TRAUMATOLOGIAE CECHOSLOVACA 2024; 91:123-126. [PMID: 38801669 DOI: 10.55095/achot2024/014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Fractures of the proximal humerus constitute approximately 5% of all fractures. Shoulder joint injuries without any external mechanical impact during seizures with the occurrence of spasms occur only sporadically. The occurrence rate is reported in approximately 0.4% of patients. Very rarely they occur in the form of epileptic seizure-induced dorsal fracturedislocation impacting both sides. The case report describes a case of a 48-year-old woman with no treatment for epileptic seizures in her medical history. During the first seizure she sustained a bilateral dorsal fracture-dislocation caused by a muscle spasm, without any other mechanical impact. The fractures were classified as a 3-fragment fracture on the right side and a 4-fragment fracture on the left side. After the patient's admission to the inpatient emergency department, reduction under anaesthesia was attempted. Subsequently, after preparation, open reduction and osteosynthesis using an angularly stable plate were performed as a two-stage surgery. No complications were observed postoperatively Currently, at 3 years after surgeries, the female patient has full mobility of her shoulder joints with no subjective difficulties. Key words: epilepsy, seizure, dorsal fracture-dislocation of the proximal humerus.
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Affiliation(s)
- R Čellár
- Klinika ortopédie a traumatológie pohybového ústrojenstva, Lekárskej fakulty Univerzity Pavla Jozefa Šafárika a Univerzitnej nemocnice L. Pasteura, Košice
| | - D Sokol
- Klinika ortopédie a traumatológie pohybového ústrojenstva, Lekárskej fakulty Univerzity Pavla Jozefa Šafárika a Univerzitnej nemocnice L. Pasteura, Košice
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Dong W, Lisitano LSJ, Marchand LS, Reider LM, Haller JM. Weight-bearing Guidelines for Common Geriatric Upper and Lower Extremity Fractures. Curr Osteoporos Rep 2023; 21:698-709. [PMID: 37973761 DOI: 10.1007/s11914-023-00834-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review paper is to summarize current weight-bearing guidelines for common geriatric fractures, around weight-bearing joints, of the upper and lower extremities. RECENT FINDINGS There is an increasing amount of literature investigating the safety and efficacy of early weight-bearing in geriatric fractures, particularly of the lower extremity. Many recent studies, although limited, suggest that early weight-bearing may be safe for geriatric distal femur and ankle fractures. Given the limited data pertaining to early weight-bearing in geriatric fractures, it is difficult to establish concrete weight-bearing guidelines in this population. However, in the literature available, early weight-bearing appears to be safe and effective across most injuries. The degree and time to weight-bearing vary significantly based on fracture type and treatment method. Future studies investigating postoperative weight-bearing protocols should focus on the growing geriatric population and identify methods to address specific barriers to early weight-bearing in these patients such as cognitive impairment, dependence on caregivers, and variations in post-acute disposition.
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Affiliation(s)
- Willie Dong
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Leonard S J Lisitano
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Lucas S Marchand
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Lisa M Reider
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
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23
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Jeong HJ, Park JW, Lee YK, Koo KH, Oh JH. Comparison between osteonecrosis of the humeral and femoral heads - epidemiological analysis of the surgical trend using the nationwide claims database of the republic of Korea. BMC Musculoskelet Disord 2023; 24:878. [PMID: 37951880 PMCID: PMC10638789 DOI: 10.1186/s12891-023-07022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUNDS The humeral head is the second most common site of osteonecrosis, after the femoral head. However, compared to osteonecrosis of the femoral head (ONFH), epidemiological information on osteonecrosis of the humeral head (ONHH) is scarce. We hypothesised that different biomechanical properties of the shoulder from the hip joint might present different epidemiological characteristics of ONHH from those of the ONFH. To evaluate epidemiological differences, we compared trends in the surgical treatment of ONHH and ONFH using the nationwide medical claims database of the Republic of Korea (ROK). METHODS We analysed epidemiological data from the Health Insurance Review and Assessment (HIRA) database of the ROK between 2008 and 2018. HIRA database contains almost all medical information in an anonymised form, including demographics, diagnoses, and types of surgical procedures, generated through healthcare practices in ROK. The annual incidence rates of ONHH and ONFH were calculated based on the total number of the general population. Demographics, annual incidence, and the proportion of post-traumatic osteonecrosis and surgical procedures were compared according to the anatomical site and the affected year. RESULTS The total number of patients treated for ONHH and ONFH during the study period was 1,028 and 66,260, respectively. Although the incidence of ONHH increased, it is a relatively rare disease compared to ONFH. ONHH occurred more frequently in females, while ONFH occurred predominantly in male patients (p < 0.001). Surgical treatment for ONHH was most frequently performed in older patients (63.7%), whereas middle-aged patients had the largest proportion of ONFH (48.9%, p < 0.001). The proportion of post-traumatic osteonecrosis was significantly higher in the ONHH (5.1%) than in the ONFH (1.9%, p < 0.001). Arthroplasty was performed more frequently in the ONHH (96.0%) than in the ONFH (92.9%, p < 0.001). CONCLUSION Despite the anatomical similarities between the hip and shoulder joints, the different biomechanical properties, such as weight-bearing functions, might cause epidemiological differences between ONHH and ONFH.
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Affiliation(s)
- Hyeon Jang Jeong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Jung-Wee Park
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Cheil Orthopedic Hospital, Seoul, Republic of Korea
| | - Joo Han Oh
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea.
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24
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Launonen AP, Sumrein BO, Reito A, Lepola V, Paloneva J, Berg HE, Felländer-Tsai L, Kask K, Rahnel T, Tootsi K, Märtson A, Jonsson KB, Wolf O, Ström P, Døssing K, Østergaard HK, Mechlenburg I, Mattila VM, Laitinen MK. 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. PLoS Med 2023; 20:e1004308. [PMID: 38015877 PMCID: PMC10683994 DOI: 10.1371/journal.pmed.1004308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 10/04/2023] [Indexed: 11/30/2023] Open
Abstract
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.
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Affiliation(s)
- Antti P. Launonen
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Bakir O. Sumrein
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Aleksi Reito
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Vesa Lepola
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Juha Paloneva
- Department of Surgery, Hospital Nova, Wellbeing Services County of Central Finland, Jyväskylä, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Hans E. Berg
- Division of Orthopedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Orthopedics, Karolinska University Hospital, Huddinge, Sweden
| | - Li Felländer-Tsai
- Division of Orthopedics and Biotechnology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Orthopedics, Karolinska University Hospital, Huddinge, Sweden
| | - Kristo Kask
- Department of Orthopaedics, North Estonia Medical Centre, Tallinn, Estonia
| | - Timo Rahnel
- Department of Orthopaedics, North Estonia Medical Centre, Tallinn, Estonia
| | - Kaspar Tootsi
- Department of Traumatology and Orthopaedics, Tartu University, Tartu, Estonia
- Orthopaedics clinic, Tartu University Hospital, Tartu, Estonia
| | - Aare Märtson
- Department of Traumatology and Orthopaedics, Tartu University, Tartu, Estonia
- Orthopaedics clinic, Tartu University Hospital, Tartu, Estonia
| | - Kenneth B. Jonsson
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Olof Wolf
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Peter Ström
- Department of Surgical Sciences, Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Kaj Døssing
- Department of Orthopaedic Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Helle K. Østergaard
- Department of Orthopaedic Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Inger Mechlenburg
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ville M. Mattila
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Minna K. Laitinen
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
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Almaghrabi RA, Almousa AM, Almulla A, Salem O, Almana L. Single-Stage Bilateral Reverse Shoulder Arthroplasty for a Bilateral Four-Part Fracture Dislocation of the Proximal Humerus in an Elderly Patient: A Case Report. Cureus 2023; 15:e49002. [PMID: 38111397 PMCID: PMC10726731 DOI: 10.7759/cureus.49002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2023] [Indexed: 12/20/2023] Open
Abstract
Proximal humerus fractures (PHFs) are a common type of fracture in adults. Although PHFs are common, bilateral presentation is extremely rare. Most PHFs are treated conservatively. In this report, we describe a 69-year-old right-hand-dominant male patient who was involved in a high-impact motor vehicle accident (MVA). The patient's upper limbs were in a fully extended position while he was holding the driving wheel, where he sustained a side impaction to the car by a hard object that caused bilateral four-part PHF with dislocation, which was confirmed on radiological investigations. The orthopedic surgery team believed that surgical treatment was necessary and ideal for these bilateral fracture dislocations, specifically bilateral reverse total shoulder arthroplasty (RTSA). This is due to multiple factors, including the risk of humeral head avascular necrosis (AVN), the patient's advanced age, low demand, poor bone stock, osteoporosis, and a non-fixable fracture pattern. The patient underwent a single-stage bilateral RTSA procedure, which was well tolerated. He was optimized postoperatively. The post-operative X-ray showed good and satisfactory implant positions and orientation. Functional assessment using the Constant-Murley Score (CMS) and Disabilities of the Arm, Shoulder and Hand (DASH) score were calculated at three-months follow-up (right-left: 50-60 and 41-14, respectively), at five-months follow-up (right-left: 34-66 and 38-14, respectively), and at eight-months follow-up (right-left: 40-68 and 24-7.5, respectively). Follow-up X-rays revealed good tuberosities healing, and no loosening or scapular notching. In addition, pain was assessed on a numerical rating scale (NRS), which demonstrated fast pain relief. Short-term follow-up with the patient demonstrated that he was satisfied with the surgery, especially the left side with a pain score on the NRS of one. We selected to share our experience of this complex case with our peers in the field of orthopedic surgery worldwide so that such a procedure could be implemented in similar cases to ensure satisfactory outcomes following bilateral four-part PHF with dislocation.
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Affiliation(s)
- Razan A Almaghrabi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Ali M Almousa
- Orthopedic Surgery, King Fahad Specialist Hospital, Dammam, SAU
| | | | - Omar Salem
- Orthopedic Surgery, King Fahad Specialist Hospital, Dammam, SAU
| | - Latifah Almana
- Orthopedic Surgery, King Fahad Specialist Hospital, Dammam, SAU
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26
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Chua N, Onggo JR, Nambiar M, Onggo JD, Wang KK, Pennington R, Hau R. Functional outcomes of reverse total shoulder arthroplasty in Boileau class 1 and class 2 proximal humeral fracture sequelae: A meta-analysis and systematic review. Shoulder Elbow 2023; 15:43-53. [PMID: 37974647 PMCID: PMC10649513 DOI: 10.1177/17585732221088496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/23/2022] [Accepted: 02/08/2022] [Indexed: 11/19/2023]
Abstract
Background Reverse total shoulder arthroplasty (RTSA) is an increasingly popular salvage treatment option for proximal humeral fracture (PHF) sequelae. This meta-analysis aimed to conduct a pooled analysis of functional outcomes of RTSA in PHF sequelae, with subgroup analysis comparing between intracapsular (Class 1) and extracapsular (Class 2) PHF sequelae. Methods A multi-database search (PubMed, OVID, EMBASE) was performed according to PRISMA guidelines on 27th July 2020. Data from all published literature meeting inclusion criteria were extracted and analysed. Findings Eleven studies were included, comprising 359 shoulders (167 Class 1 and 192 Class 2). The mean age was 68.2 years, and the mean time between injury and surgery was 49 months, (1-516 months). Constant score and forward flexion improved by 31.8 (95%CI: 30.5-33.1, p < 0.001) and 60o (95%CI: 58o-62o, p < 0.001) respectively between pre-operative and post-operative values for both groups. Constant scores were better in Class 1 patients (MD = 3.60, 95%CI: 1.0-6.2, p < 0.001) pre-operatively and post-operatively (MD = 7.4, 95%CI: 5.8-9.0, p < 0.001). Forward flexion was significantly better in Class 1 patients (MD = 13o, 95%CI: 7o-17o, p < 0.001) pre-operatively, but was slightly better in Class 2 patients post-operatively (MD = 7o, 95%CI: 4o-10o, p < 0.001). Overall complication rate was 16.8%. Conclusion Salvage RTSA is effective for PHF sequelae, with multiple factors contributing to the high complication rate.
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Affiliation(s)
- Nina Chua
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
| | - James R Onggo
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Mithun Nambiar
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Jason D Onggo
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Kemble K Wang
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
- Department of Orthopaedic Surgery, Royal Children’s Hospital, Victoria, Australia
- Epworth Eastern Hospital, Box Hill, Victoria, Australia
- Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
| | - Richard Pennington
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
- Epworth Eastern Hospital, Box Hill, Victoria, Australia
| | - Raphael Hau
- Department of Orthopaedic Surgery, Box Hill Hospital, Box Hill, Victoria, Australia
- Epworth Eastern Hospital, Box Hill, Victoria, Australia
- Monash University, Eastern Health Clinical School, Box Hill, Victoria, Australia
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27
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Alzobi OZ, Salman LA, Derbas J, Abudalou A, Hantouly AT, Ahmed G. Epidemiology of proximal humerus fractures in Qatar. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3119-3124. [PMID: 37038016 PMCID: PMC10504139 DOI: 10.1007/s00590-023-03539-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 03/27/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE This study aimed to investigate the epidemiological characteristics and treatment options of proximal humerus fractures at a level one trauma center and to compare our data with the current literature. METHODS A retrospective review was conducted on all patients diagnosed and treated for proximal humerus fractures at Hamad General Hospital, a level one trauma center, between January 2018 and December 2019. Age, gender, mechanism of injury, fracture classification, mode of treatment, implant type, length of hospital stay, associated injuries and complications were analyzed. RESULTS A total of 190 patients with a mean age of 52.4 years were included; 56.8% were males. The incidence of proximal humerus fracture was 4.1/100,000 per year. Falling from a standing height was the most common cause of injury (50.5%). Additionally, Neer's two-part fracture was found to be the most common type (n = 132, 69%). Forty-one patients (21.3%) had other associated injuries. Most fractures were treated nonoperatively with an arm sling (n = 138, 72.6%). CONCLUSION In summary, the incidence of proximal humerus fractures during the two-year study period was found to be 4.1 per 100,000 persons per year. Our results showed a lower incidence of proximal humerus fractures with a predominance of males and younger patients in Qatar's population compared to females and older patients in the developed countries. Our results may contribute to the development of effective strategies for preventing and treating proximal humerus fractures, and can provide important data for further high-level clinical research. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Osama Z Alzobi
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Loay A Salman
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Jawad Derbas
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Abedallah Abudalou
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Ashraf T Hantouly
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Ghalib Ahmed
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar.
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28
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Iking J, Fischhuber K, Stolberg-Stolberg J, Raschke MJ, Katthagen JC, Köppe J. Quality of Life and Pain after Proximal Humeral Fractures in the Elderly: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1728. [PMID: 37893445 PMCID: PMC10608543 DOI: 10.3390/medicina59101728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/17/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: The proximal humeral fracture (PHF) is one of the most common fractures in elderly patients. A PHF might influence the quality of life (QoL) on several different levels, especially in elderly patients, but it is unclear which treatment option results in a better QoL outcome. Therefore, we aimed to systematically review the current literature for studies that have analyzed the QoL and pain of elderly patients treated either surgically or non-operatively for PHF. Materials and Methods: A comprehensive search of the literature was performed in the PubMed database from January to April 2023. Studies describing the QoL or the level of pain of patients older than 60 years with the EuroQoL-5 Dimension (EQ-5D) score or the visual analogue scale (VAS) after the treatment of PHF, either non-operatively (non-OP), with open-reduction and internal fixation using a locking plate (LPF), or with reverse total shoulder arthroplasty (RTSA) were included. Twelve studies were analyzed descriptively and the individual risk of bias was assessed using the ROB2 and ROBINS-I tools. Results: A total of 12 studies with 712 patients at baseline were included (78% female sex, mean age 75.2 years). The reported VAS scores at 12-month follow-up (FU) ranged from 0.7 to 2.5. The calculated overall mean VAS score across all studies showed a decreasing tendency for all treatments, with an increasing FU time up to 12 months after PHF. None of the studies reported any significant differences of the EQ-5D across the groups. The overall calculated EQ-5D indices showed an increasing trend after 6-8 weeks FU, but did not differ significantly between the three treatments. Conclusions: In conclusion, the current literature suggests that there are no clinically important differences between the QoL or pain in elderly patients with PHF after non-operative treatment or surgical treatment with LPF or RTSA. However, the number of studies and level of evidence is rather low and further trials are urgently needed.
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Affiliation(s)
- Janette Iking
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany; (J.I.)
- Research Group “Mathematical Surgery”, University Hospital Muenster, University of Muenster, 48149 Muenster, Germany
| | - Karen Fischhuber
- Research Group “Mathematical Surgery”, University Hospital Muenster, University of Muenster, 48149 Muenster, Germany
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstrasse 56, 48149 Muenster, Germany
| | - Josef Stolberg-Stolberg
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany; (J.I.)
- Research Group “Mathematical Surgery”, University Hospital Muenster, University of Muenster, 48149 Muenster, Germany
| | - Michael J. Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany; (J.I.)
| | - Jan Christoph Katthagen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany; (J.I.)
- Research Group “Mathematical Surgery”, University Hospital Muenster, University of Muenster, 48149 Muenster, Germany
| | - Jeanette Köppe
- Research Group “Mathematical Surgery”, University Hospital Muenster, University of Muenster, 48149 Muenster, Germany
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstrasse 56, 48149 Muenster, Germany
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29
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Koeppe J, Stolberg-Stolberg J, Fischhuber K, Iking J, Marschall U, Raschke MJ, Katthagen JC. The Incidence of Proximal Humerus Fracture-an Analysis of Insurance Data. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:555-556. [PMID: 37732593 PMCID: PMC10546881 DOI: 10.3238/arztebl.m2023.0132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Jeanette Koeppe
- Mathematical Surgery Working Group, University of Münster
- Institute of Biostatistics and Clinical Research, University of Münster
| | - Josef Stolberg-Stolberg
- Mathematical Surgery Working Group, University of Münster
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Münster
| | - Karen Fischhuber
- Mathematical Surgery Working Group, University of Münster
- Institute of Biostatistics and Clinical Research, University of Münster
| | - Janette Iking
- Mathematical Surgery Working Group, University of Münster
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Münster
| | | | - Michael J. Raschke
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Münster
| | - J. Christoph Katthagen
- Mathematical Surgery Working Group, University of Münster
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Münster
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30
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Shi BY, Upfill-Brown A, Wu SY, Trikha R, Ahlquist S, Kremen TJ, Lee C, SooHoo NF. Short-Term Outcomes and Long-Term Implant Survival After Inpatient Surgical Management of Geriatric Proximal Humerus Fractures. J Shoulder Elb Arthroplast 2023; 7:24715492231192068. [PMID: 37559885 PMCID: PMC10408354 DOI: 10.1177/24715492231192068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/21/2023] [Accepted: 07/18/2023] [Indexed: 08/11/2023] Open
Abstract
Introduction The most common surgical options for geriatric proximal humerus fractures are open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty. We used a longitudinal inpatient discharge database to determine the cumulative incidence of conversion to arthroplasty after ORIF of geriatric proximal humerus fractures. The rates of short-term complications and all-cause reoperation were also compared. Patients and Methods All patients 65 or older who sustained a proximal humerus fracture and underwent either ORIF, HA, or shoulder arthroplasty (SA) as an inpatient from 2000 through 2017 were identified. Survival analysis was performed with ORIF conversion to arthroplasty and all-cause reoperation as the endpoints of interest. Rates of 30-day readmission and short-term complications were compared. Trends in procedure choice and outcomes over the study period were analyzed. Results A total of 27 102 geriatric patients that underwent inpatient surgical management of proximal humerus fractures were identified. Among geriatric patients undergoing ORIF, the cumulative incidence of conversion to arthroplasty within 10 years was 8.2%. The 10-year cumulative incidence of all-cause reoperation was 12.1% for ORIF patients and less than 4% for both HA and SA patients. Female sex was associated with increased risk of ORIF conversion and younger age was associated with higher all-cause reoperation. ORIF was associated with higher 30-day readmission and short-term complication rates. Over the study period, the proportion of patients treated with ORIF or SA increased while the proportion of patients treated with HA decreased. Short-term complication rates were similar between arthroplasty and ORIF patients in the later cohort (2015-2017). Conclusion The 10-year cumulative incidence of conversion to arthroplasty for geriatric patients undergoing proximal humerus ORIF as an inpatient was found to be 8.2%. All-cause reoperations, short-term complications, and 30-day readmissions were all significantly lower among patients undergoing arthroplasty, but the difference in complication rate between arthroplasty and ORIF was attenuated in more recent years. Younger age was a risk factor for reoperation and female sex was associated with increased risk of requiring conversion to arthroplasty after ORIF.
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Affiliation(s)
- Brendan Y Shi
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, California
| | - Alexander Upfill-Brown
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, California
| | - Shannon Y Wu
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Rishi Trikha
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, California
| | - Seth Ahlquist
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, California
| | - Thomas J Kremen
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, California
| | - Christopher Lee
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, California
| | - Nelson F SooHoo
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, California
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Sheng N, Wang Q, Xing F, Wang J, Chen Y, Xiang Z. Allografts are not necessary for displaced proximal humeral fractures in patients less than 65 years old, a retrospective cohort study. Injury 2023; 54:110861. [PMID: 37296014 DOI: 10.1016/j.injury.2023.110861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/23/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Displaced proximal humeral fractures (PHF) are frequently treated with locking plates to achieve osteosynthesis. Bone grafts are used as augmentation techniques to improve stability in osteoporotic patients. However, there has been little research into whether bone grafts are necessary for patients younger than 65 years old. This study compared radiographic and clinical outcomes between PHFs augmented with bone grafts or not in a younger population. METHODS Between January 2016 and June 2020, 91 patients treated with a locking plate alone (LP), and 101 patients treated with locking plates augmented with bone grafts (BG) were analyzed. Potential confounding factors for outcomes were adjusted by propensity score-matching analyses. For the retrospective cohort study, 62 patients from each group were evaluated for radiographic outcomes and clinical outcomes and compared. RESULTS Sixth-two patients in each group, both with a mean age of 52 years old, were with a mean follow-up time of 25 months in the LP group and 26 months in the BG group. There was no difference in demographic or surgical characteristics between the two groups after propensity score-matching. With regard to radiographic outcomes, the changes in neck-shaft angle (-5.1 ± 4.9 vs. -3.1 ± 5.3, p = 0.015) and humeral head height (-1.5 ± 2.5 vs. -0.4 ± 2.7, p = 0.002) were more obvious in the BG group. However, regarding functional outcomes, there were no significant differences between the two groups in DASH score, Constant-Murley score, or VAS score. Moreover, the complication rate was not significantly different between two groups. DISCUSSION Allografts only provide minor improvements of stability in radiography for patients less than 65 years old after locking plate fixation of PHFs, but don't improve shoulder function, relieve pain or reduce complications. We concluded that allografts are unnecessary for younger patients with displaced PHFs.
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Affiliation(s)
- Ning Sheng
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Lane 37, Chengdu, 610041, Sichuan Province, China
| | - Qiuke Wang
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200235, China
| | - Fei Xing
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Lane 37, Chengdu, 610041, Sichuan Province, China
| | - Jie Wang
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Lane 37, Chengdu, 610041, Sichuan Province, China
| | - Yunfeng Chen
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200235, China.
| | - Zhou Xiang
- Department of Orthopedics, West China Hospital, Sichuan University, Guoxue Lane 37, Chengdu, 610041, Sichuan Province, China
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Tong CH, Fang CX. Rehabilitation progress following reverse total shoulder replacement and internal fixation for geriatric three and four-part proximal humerus fractures - a propensity score matched comparison. BMC Musculoskelet Disord 2023; 24:566. [PMID: 37434194 DOI: 10.1186/s12891-023-06669-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 06/26/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Proximal humerus fracture is one of the most common fractures in the elderly population. However, in patients with complex fracture patterns, there is still no general consensus in the best treatment method. This study aims to evaluate the outcomes between those treated with reverse total shoulder arthroplasty (rTSA) and open reduction internal fixation (ORIF). METHODS All geriatric patients (> 60 years of age) with proximal humerus fractures undergoing surgical treatment were analysed. There were 25 patients treated with rTSA and 75 with ORIF. Propensity score matching was used to select 25 matching patients from the ORIF group according to age and gender. All patients underwent surgical intervention within 7 days (mean 3.8 days). All patients followed a protocol-driven rehabilitation programme with outcome assessment at 3, 6, 12 and 24 months. Constant score, qDASH, range of motion, rate of complications and revision surgery were recorded and compared. RESULTS Twenty-five rTSA were age and gender matched with 25 ORIF patients. The average age of patients in rTSA and ORIF groups were 77.0 years and 75.2 years respectively. At 3 months, mean Constant score was 37.7 (rTSA) vs 45.5 (ORIF) (p = 0.099). Mean qDASH score was 50.6 (rTSA) vs 29.4 (ORIF) (p = 0.003). Mean forward flexion range was 72.9° (rTSA) vs 94.4° (ORIF) (p = 0.007). Mean abduction range was 64.0° (rTSA) vs 88.6° (ORIF) (p = 0.001). At 2 years, mean Constant score was 72.8 (rTSA) vs 70.8 (ORIF) (p = 0.472). Mean qDASH score was 4.50 (rTSA) vs 11.0 (ORIF) (p = 0.025). Mean forward flexion range was 143° (rTSA) vs 109° (ORIF) (p < 0.001). Mean abduction range was 135° (rTSA) vs 110° (ORIF) (p = 0.025). There was a higher number of complications observed for ORIF (3) than rTSA (1) (p = 0.297) and a higher number of re-operations for ORIF (3) than rTSA (1) (p = 0.297), which was not statistically significant. CONCLUSION rTSA appears to yield a slower recovery at 3 months but a better outcome at 2 years. It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome.
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Affiliation(s)
- Chi Him Tong
- Department of Orthopaedics & Traumatology, Queen Mary Hospital, Hong Kong, Hong Kong.
| | - Christian Xinshuo Fang
- Department of Orthopaedics & Traumatology, The University of Hong Kong, Hong Kong, Hong Kong
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Barreto Rocha DF, Vogel M, Delma SR, Baylor JL, Horwitz DS, Grandizio LC. The Utility of Routine Follow-up Radiographs in the Nonoperative Management of Proximal Humerus Fractures in Patients 65 Years and Older. Orthopedics 2023; 46:e244-e248. [PMID: 36719409 DOI: 10.3928/01477447-20230125-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Whereas prior studies have aimed to define the utility of routine radiographs for the closed treatment of upper extremity fractures, it remains uncertain whether routine radiographs influence management decisions for nonoperative treatment of proximal humerus fractures (PHFs). The purpose of this investigation was to assess the utility of routine radiographic monitoring of closed PHFs in elderly patients initially indicated for nonoperative treatment. We identified all patients 65 years and older who had a PHF from 2016 to 2019. We excluded cases of pathologic fractures or peri-prosthetic fractures, nonunion, malunion, cases with insufficient follow-up, and cases for which surgery was indicated either in the emergency department or at the first orthopedic visit. After applying these exclusion criteria, 402 cases remained. We recorded baseline demographics and fracture descriptions and noted any conversion to operative treatment after the initial office visit. Two-part fractures were most common (56%). Of the 402 fractures indicated for nonoperative treatment, 21 (5%) were converted to operative management during the follow-up period. Nine fractures (2%) were converted to operative management within 30 days of the first office visit. Eight cases (2%) were converted to operative treatment more than 120 days after the initial office visit: 6 due to nonunion and 2 due to posttraumatic arthritis. For patients 65 years and older who undergo initial nonoperative treatment of a PHF, routine follow-up radiographs do not appear to alter management decisions. Given the risk and cost associated with routine radiographs, surgeons should consider forgoing these images in the absence of clinical concern. [Orthopedics. 2023;46(4):e244-e248.].
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Labrum JT, Kuttner NP, Atwan Y, Sanchez-Sotelo J, Barlow JD. Fracture Dislocations of the Glenohumeral Joint. Curr Rev Musculoskelet Med 2023:10.1007/s12178-023-09846-y. [PMID: 37329400 PMCID: PMC10382466 DOI: 10.1007/s12178-023-09846-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE OF REVIEW Proximal humerus fracture dislocations typically result from high-energy mechanisms and carry specific risks, technical challenges, and management considerations. It is vital for treating surgeons to understand the various indications, procedures, and complications involved with their treatment. RECENT FINDINGS While these injuries are relatively rare in comparison with other categories of proximal humerus fractures, fracture dislocations of the proximal humerus require treating surgeons to consider patient age, activity level, injury pattern, and occasionally intra-operative findings to select the ideal treatment strategy for each injury. Proximal humerus fracture dislocations are complex injuries that require special considerations. This review summarizes recent literature regarding the evaluation and management of these injuries as well as the indications and surgical techniques for each treatment strategy. Thorough pre-operative patient evaluation and shared decision-making should be employed in all cases. While nonoperative management is uncommonly considered, open reduction and internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder replacement are at the surgeon's disposal, each with their own indications and complication profile.
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Affiliation(s)
- Joseph T Labrum
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA
| | - Nicolas P Kuttner
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA
| | - Yousif Atwan
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA
| | - Joaquin Sanchez-Sotelo
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA
| | - Jonathan D Barlow
- Department of Orthopaedic Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55902, USA.
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Assiotis A, Uppal HS, Rumian A, Yeoh C. A Unique Presentation of the Glenoid, Coracoid, and Proximal Humerus Fractures. Cureus 2023; 15:e40358. [PMID: 37456475 PMCID: PMC10339778 DOI: 10.7759/cureus.40358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Fractures of the proximal humerus are common injuries with a bimodal age distribution. They usually present in younger patients after high-energy trauma and in elderly patients after lower-energy trauma. Fractures of the proximal humerus are rarely associated with concomitant fractures of the glenoid, and this is a complex injury pattern that indicates the presence of significant instability. Such injuries are usually treated surgically. Even more rarely, patients may present with proximal humerus fractures and fractures of the coracoid process. A male patient presented to our emergency department (ED) after a fall off the loading platform of his heavy goods vehicle (HGV), resulting in a right shoulder injury. During his initial assessment in ED, a computerised tomography (CT) scan demonstrated the presence of a comminuted proximal humerus fracture, a comminuted anterior glenoid wall fracture, and a coracoid process displaced fracture. Surgical fixation of all three fractures was undertaken in the same sitting. This is the first case described in the literature with a combination of the above injuries and serves as a reminder that as trauma complexity and incidence continue to increase, we should maintain a high index of diagnostic suspicion when dealing with such patients. Furthermore, we present our treatment approach for this case and the rationale behind it.
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Affiliation(s)
| | - Harpal S Uppal
- Trauma and Orthopaedics, Lister Hospital, Stevenage, GBR
| | - Adam Rumian
- Trauma and Orthopaedics, Lister Hospital, Stevenage, GBR
| | - Clarence Yeoh
- Trauma and Orthopaedics, Lister Hospital, Stevenage, GBR
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Katthagen JC, Koeppe J, Stolberg-Stolberg J, Rischen R, Freistuehler M, Faldum A, Raschke MJ. Effects of anti-osteoporosis therapy on the risk of secondary fractures and surgical complications following surgical fixation of proximal humerus fracture in older people. Age Ageing 2023; 52:afad097. [PMID: 37368870 DOI: 10.1093/ageing/afad097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/10/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND age-related fragility fractures cause significant burden of disease. Within an ageing society, fracture and complication prevention will be essential to balance health expenditure growth. OBJECTIVE to assess the effect of anti-osteoporotic therapy on surgical complications and secondary fractures after treatment of fragility fractures. PATIENTS AND METHODS retrospective health insurance data from January 2008 to December 2019 of patients ≥65 years with proximal humeral fracture (PHF) treated using locked plate fixation (LPF) or reverse total shoulder arthroplasty were analysed. Cumulative incidences were calculated by Aalen-Johansen estimates. The influence of osteoporosis and pharmaceutical therapy on secondary fractures and surgical complications were analysed using multivariable Fine and Gray Cox regression models. RESULTS a total of 43,310 patients (median age 79 years, 84.4% female) with a median follow-up of 40.9 months were included. Five years after PHF, 33.4% of the patients were newly diagnosed with osteoporosis and only 19.8% received anti-osteoporotic therapy. A total of 20.6% (20.1-21.1%) of the patients had at least one secondary fracture with a significant reduction of secondary fracture risk by anti-osteoporotic therapy (P < 0.001). An increased risk for surgical complications (hazard ratio: 1.35, 95% confidence interval: 1.25-1.47, P < 0.001) after LPF could be reversed by anti-osteoporotic therapy. While anti-osteoporotic therapy was more often used in female patients (35.3 vs 19.1%), male patients showed significantly stronger effects reducing the secondary fracture and surgical complication risk. CONCLUSIONS a significant number of secondary fractures and surgical complications could be prevented by consequent osteoporosis diagnosis and treatment particularly in male patients. Health-politics and legislation must enforce guideline-based anti-osteoporotic therapy to mitigate burden of disease.
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Affiliation(s)
- Jan Christoph Katthagen
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, Muenster 48149, Germany
- Research Group "Mathematical Surgery", University Hospital Muenster, University of Muenster, Muenster 48149, Germany
| | - Jeanette Koeppe
- Research Group "Mathematical Surgery", University Hospital Muenster, University of Muenster, Muenster 48149, Germany
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstrasse 56, Muenster 48149, Germany
| | - Josef Stolberg-Stolberg
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, Muenster 48149, Germany
- Research Group "Mathematical Surgery", University Hospital Muenster, University of Muenster, Muenster 48149, Germany
| | - Robert Rischen
- Clinic for Radiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, Muenster 48149, Germany
| | - Moritz Freistuehler
- Medical Management Division - Medical Controlling, University Hospital Muenster, Niels-Stensen-Straße 8, Muenster 48149, Germany
| | - Andreas Faldum
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstrasse 56, Muenster 48149, Germany
| | - Michael J Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, Muenster 48149, Germany
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Krasney LC, Rennie C, Brustein J, Naylor B. Rare finding of axillary artery dissection secondary to a proximal humerus fracture-dislocation: A case report. Trauma Case Rep 2023; 45:100828. [PMID: 37096136 PMCID: PMC10122036 DOI: 10.1016/j.tcr.2023.100828] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2023] [Indexed: 04/05/2023] Open
Abstract
Case Proximal humerus fractures are a relatively common injury, making up approximately 5 % of all extremity fractures. Concurrent damage to the axillary artery, however, is not a commonly associated trauma. We present a unique case of a proximal humerus fracture-dislocation resulting in an axillary artery dissection and upper extremity ischemia, requiring emergent vascular intervention. Conclusion Axillary artery injury secondary to a proximal humerus fracture-dislocation is a rare, but possibly devastating complication. A thorough physical examination to identify any neurovascular deficits is critical in determining an optimal and timely resolution.
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Affiliation(s)
- Leighann C. Krasney
- Department of Orthopaedic Surgery, UPMC Harrisburg, Harrisburg, PA, United States of America
- Corresponding author at: 4300 Londonderry Road, Harrisburg, PA 17109, United States of America.
| | - Christopher Rennie
- Nova Southeastern University College of Osteopathic Medicine, Tampa, FL, United States of America
| | - Jason Brustein
- Resurgens Orthopaedics, Atlanta, GA, United States of America
| | - Brandon Naylor
- Northside Hospital, Atlanta, GA, United States of America
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Wu Z, Shen W. An updated systematic review and meta‑analysis comparing deltoid‑split approach with deltopectoral approach for proximal humerus fractures. Exp Ther Med 2023; 25:296. [PMID: 37229316 PMCID: PMC10203753 DOI: 10.3892/etm.2023.11995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/15/2023] [Indexed: 05/27/2023] Open
Abstract
The present review and meta-analysis aimed to summarize the currently available data and to compare the important clinical and functional outcomes in patients with proximal humerus fractures who were treated using deltoid split (DS) or deltopectoral (DP) surgical approaches. The PubMed, EMBASE, Scopus and Cochrane Central Register of Controlled Trials databases were systematically searched for randomized controlled trials or observational studies that reported functional outcome data of patients with fracture of proximal humerus who were surgically treated using DS and DP approaches. A total of 14 studies were included in the present meta-analysis. The duration of surgery [min; weighted mean difference (WMD), -16.44; 95% CI, -(25.25-7.63)], amount of blood loss [ml; WMD, -57.99; 95% CI, -(102.74-13.23)] and time to bone union [weeks WMD, -1.66; 95% CI, -(2.30-1.02)] was comparatively lower in patients that underwent DS. There were no statistically significant differences in the pain and quality of life scores, range of movement and risk of complications between the DS and the DP groups. Patients in the DS group had improved shoulder function and constant shoulder score (CSS) at 3 months post-surgery (WMD, 6.36; 95% CI, 1.06-11.65). No differences were observed between the two groups in terms of CSS and disabilities of the arm, shoulder and hand scores at 12 and 24 months post-operatively. The activity of daily living (ADL) score was significantly improved in the DS group at 3 (WMD, 1.23; 95% CI, 0.40-2.06), 6 (WMD, 0.99; 95% CI, 0.72-1.25) and 12 months (WMD, 0.83; 95% CI, 0.18-1.47) after the surgery. The present results suggested that DS and DP surgical approaches were associated with similar clinical outcomes. The DS approach was associated with certain perioperative benefits, as well as reduced time to bone union, improved shoulder function in the early postoperative period and improved ADL scores. These benefits may be considered while choosing between these two surgical approaches.
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Affiliation(s)
- Zhe Wu
- Department of Orthopedics, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, Zhejiang 313000, P.R. China
| | - Wenting Shen
- Department of Orthopedics, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, Zhejiang 313000, P.R. China
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Van Grootven B, Janssens S, De Keyser L, Voortmans J, Nijs S, Flamaing J, Dejaeger M. Prognostic factors and prediction model for 1-year mortality after proximal humeral fracture. Arch Osteoporos 2023; 18:76. [PMID: 37219703 DOI: 10.1007/s11657-023-01260-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 05/02/2023] [Indexed: 05/24/2023]
Abstract
The goal was to investigate if patient characteristics can be used to predict 1-year post-fracture mortality after proximal humeral fracture (PHF). A clinical prediction model showed that the combination of 6 pre-fracture characteristics demonstrated good predictive properties for mortality within 1 year of PHF. INTRODUCTION Proximal humeral fractures (PFH) are the third most common major non-vertebral osteoporotic fractures in older persons and result in an increased mortality risk. The aim of this study was to investigate if patient characteristics can be used to predict 1-year post-fracture mortality. METHODS Retrospective study with 261 patients aged 65 and older who were treated for a PHF in University Hospitals Leuven between 2016 and 2018. Baseline variables including demographics, residential status, and comorbidities were collected. The primary outcome was 1-year mortality. A clinical prediction model was developed using LASSO regression and validated using split sample and bootstrapping methods. The discrimination and calibration were evaluated. RESULTS Twenty-seven (10.3%) participants died within 1-year post-PHF. Pre-fracture independent ambulation (p < 0.001), living at home at time of fracture (p < 0.001), younger age (p = 0.006), higher BMI (p = 0.012), female gender (p = 0.014), and low number of comorbidities (p < 0.001) were predictors for 1-year survival. LASSO regression identified 6 stable predictors for a prediction model: age, gender, Charlson comorbidity score, BMI, cognitive impairment, and pre-fracture nursing home residency. The discrimination was 0.891 (95% CI, 0.833 to 0.949) in the training sample, 0.878 (0.792 to 0.963) in the validation sample and 0.756 (0.636 to 0.876) in the bootstrapping samples. A similar performance was observed for patients with and without surgery. The developed model demonstrated good calibration. CONCLUSIONS The combination of 6 pre-fracture characteristics demonstrated good predictive properties for mortality within 1 year of PHF. These findings can guide PHF treatment decisions.
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Affiliation(s)
- Bastiaan Van Grootven
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Sigrid Janssens
- Department of Public Health and Primary Care, Gerontology and Geriatrics Research Unit, KU Leuven, Leuven, Belgium
| | - Laurence De Keyser
- Department of Public Health and Primary Care, Gerontology and Geriatrics Research Unit, KU Leuven, Leuven, Belgium
| | - Jens Voortmans
- Department of Development and Regeneration, Locomotoric and Neurological Disorders Research Unit, KU Leuven, Leuven, Belgium
| | - Stefaan Nijs
- Department of Development and Regeneration, Locomotoric and Neurological Disorders Research Unit, KU Leuven, Leuven, Belgium
| | - Johan Flamaing
- Department of Public Health and Primary Care, Gerontology and Geriatrics Research Unit, KU Leuven, Leuven, Belgium
- Department of Geriatrics, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Marian Dejaeger
- Department of Public Health and Primary Care, Gerontology and Geriatrics Research Unit, KU Leuven, Leuven, Belgium.
- Department of Geriatrics, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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Walter N, Szymski D, Riedl M, Kurtz SM, Alt V, Lowenberg DW, Lau EC, Rupp M. Proximal Humerus Fractures in the Elderly U.S. Population: A Cross-Sectional Study of Treatment Trends and Comparison of Complication Rates after Joint Replacement, Open Reduction and Internal Fixation, and Non-Surgical Management. J Clin Med 2023; 12:jcm12103506. [PMID: 37240612 DOI: 10.3390/jcm12103506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/05/2023] [Accepted: 05/15/2023] [Indexed: 05/28/2023] Open
Abstract
Proximal humerus fracture (PHF) treatment remains challenging. Multiple therapy options exist, and the optimal choice of management has been increasingly discussed in the literature. The aim of this study was to (1) analyze trends in the propensity of proximal humerus fracture treatments and (2) compare complication rates after joint replacement, surgical repair, and non-surgical treatment in terms of mechanical complications, union failure, and infection rates. In this cross-sectional study, patients aged 65 years or older with proximal humerus fractures occurring between 1 January 2009 and 31 December 2019 were identified from Medicare physician service claims records. The Kaplan-Meier method with the Fine and Gray adjustment was used to calculate the cumulative incidence rates for malunion/nonunion, infection, and mechanical complications for the following treatment categories: shoulder arthroplasty, open reduction and internal fixation (ORIF), and non-surgical treatment, respectively. Semiparametric Cox regression was performed incorporating 23 demographic, clinical, and socioeconomic covariates to determine risk factors. Between 2009 through 2019, conservative procedures decreased by 0.9%. ORIF procedures decreased from 9.51% (95% CI: 8.7-10.4) to 6.95% (95% CI: 6.2-7.7), whereas shoulder arthroplasties rose from 1.99% (95% CI: 1.6-2.4), to 5.45% (95% CI: 4.8-6.2). PHFs managed through ORIF were associated with higher union failure rates compared to conservatively treated fractures (HR = 1.31, 95% CI: 1.15-1.5, p < 0.001). The risk of developing an infection was increased after joint replacement compared to ORIF (2.66% vs. 1.09%, HR = 2.09, 95% CI: 1.46-2.98, p < 0.001). Mechanical complications were more common after joint replacement (6.37% vs. 4.85%, HR = 1.66, 95% CI: 1.32-2.09, p < 0.001). Complication rates differed significantly across treatment modalities. This should be considered when choosing a management procedure. Vulnerable elderly patient cohorts could be identified, and the optimization of modifiable risk factors might lead to a decrease of complication rates in both surgically and non-surgically treated patients.
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Affiliation(s)
- Nike Walter
- Department of Trauma Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany
- Department of Psychosomatic Medicine, University Medical Center Regensburg, 93053 Regensburg, Germany
| | - Dominik Szymski
- Department of Trauma Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany
| | - Moritz Riedl
- Department of Trauma Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany
| | - Steven M Kurtz
- Implant Research Center, Drexel University, Philadelphia, PA 19104, USA
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany
| | - David W Lowenberg
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA 94063, USA
| | | | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, 93053 Regensburg, Germany
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Liu G, Li L, Yang C, Wei L, Li T, Zhu L, Hu J. Hounsfield units predicts the occurrence but not the patterns of proximal humerus fracture in the elderly patients. BMC Musculoskelet Disord 2023; 24:342. [PMID: 37131243 PMCID: PMC10155427 DOI: 10.1186/s12891-023-06442-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 04/18/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Increased incidence of fragility fractures of the proximal humerus has been reported. Proximal humerus Hounsfield unit (HU) measurements based on computed tomography (CT) scans of the shoulder can be used to evaluate bone mineral density (BMD). It is unknown whether HU values can predict the risk of proximal humerus osteoporotic fracture and /or fracture patterns. Therefore, the objectives of this study were to identify whether the HU value is associated with proximal humeral osteoporotic fracture risk, and whether or not it has an impact on the complexity of the fracture. METHODS We identified 60 + years old patients' CT scans between 2019 and 2021 according to the inclusion and exclusion criteria. All patients were divided into two groups based on the presence or lack of a fracture in the proximal humerus, meanwhile, patients with fractures were stratified into simple and comminuted fractures based on the Neer classification. HU values were calculated within the proximal humerus and compared between groups using the Student t-test, and receiver operating characteristic (ROC) curve analysis was used to determine the ability of HU values to predict fracture. RESULTS A total of 138 patients with proximal humerus fracture (PHF) including 62 simple PHFs and 76 complex PHFs and 138 non-fracture patients were enrolled in the study. The HU values decreased as age increased among all patients. Both male and female patients with PHF had significantly lower HU values compared with non-fracture patients, the area under the curve (AUC) of the ROC curve for males and females was 0.8 and 0.723 respectively. Nevertheless, no significant differences were found between simple and complex fractures of the proximal humerus in the HU values. CONCLUSION Decreasing HU values on CT may be an early warning sign of fracture potential, however, it was not a predictive factor for comminuted fracture of the proximal humerus.
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Affiliation(s)
- Gang Liu
- Department of Trauma Center, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou Worker's Hospital, Guangxi, 545005, China
| | - Lu Li
- Department of Medical Imaging, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou Worker's Hospital, Guangxi, 545005, China
| | - Chengzhi Yang
- Department of Trauma Center, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou Worker's Hospital, Guangxi, 545005, China
| | - Lu Wei
- Department of Trauma Center, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou Worker's Hospital, Guangxi, 545005, China
| | - Tao Li
- Department of Medical Imaging, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou Worker's Hospital, Guangxi, 545005, China
| | - Li Zhu
- Department of Medical Imaging, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou Worker's Hospital, Guangxi, 545005, China
| | - Juzheng Hu
- Department of Trauma Center, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou Worker's Hospital, Guangxi, 545005, China.
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Joo PY, Wilhelm C, Adeclat G, Halperin SJ, Moran J, Elaydi A, Rubin LE, Grauer JN. Comparing Race/Ethnicity and Zip Code Socioeconomic Status for Surgical versus Nonsurgical Management of Proximal Humerus Fractures in a Medicare Population. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202305000-00011. [PMID: 37141180 PMCID: PMC10162786 DOI: 10.5435/jaaosglobal-d-22-00205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 01/24/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND This study evaluated the effect of race/ethnicity and socioeconomic status (SES) on surgical utilization after proximal humerus fractures in a large Medicare cohort. METHODS The PearlDiver Medicare claims database was used to identify patients aged 65years and older with isolated, closed proximal humerus fractures, for whom race/ethnicity data were available (65.5% of identified fractures). Patients with polytrauma or neoplasm were excluded. Patient demographic, race/ethnicity, comorbidity, and median household income were compared for surgical versus nonsurgical management. Univariate and multivariable logistic regressions were used to determine disparities of surgical utilization based on the abovementioned factors. RESULTS Of 133,218 patients with proximal humerus fracture identified, surgery was conducted for 4446 (3.3%). Those less likely to receive surgery were older (incrementally by increasing age bracket up to 85 years and older odds ratio [OR], 0.16, P < 0.001), male (OR, 0.79, P < 0.001), Black (OR, 0.51, P < 0.001) or Hispanic (0.61, P = 0.005), higher Elixhauser Comorbidity Index (per 2 increase OR, 0.86, P < 0.001), and low median household income (OR, 0.79, P < 0.001). CONCLUSIONS The independent significance of race/ethnicity and SES point to disparities in surgical decision making/access to care. These findings highlight the need for increased attention on initiatives and policies that seek to eliminate racial disparities and improve health equity independent of SES.
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Affiliation(s)
- Peter Y. Joo
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Christopher Wilhelm
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Giscard Adeclat
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Scott J. Halperin
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jay Moran
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Ali Elaydi
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Lee E. Rubin
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jonathan N. Grauer
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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Rangan A, Gwilym S, Keding A, Corbacho B, Kottam L, Arundel C, Coleman E, DiMascio L, Hewitt C, Jones V, Kassam J, McDaid C, Mitchell N, Mott A, O'Carroll G, Tharmanathan P, Torgerson D. Reverse shoulder arthroplasty versus hemiarthroplasty versus non-surgical treatment for older adults with acute 3- or 4-part fractures of the proximal humerus: study protocol for a randomised controlled trial (PROFHER-2: PROximal Fracture of Humerus Evaluation by Randomisation - Trial Number 2). Trials 2023; 24:270. [PMID: 37055816 PMCID: PMC10098225 DOI: 10.1186/s13063-023-07259-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/16/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Proximal humerus fractures (PHF) are common and painful injuries, with the majority resulting from falls from a standing height. As with other fragility fractures, its age-specific incidence is increasing. Surgical treatment with hemiarthroplasty (HA) and reverse shoulder arthroplasty (RSA) have been increasingly used for displaced 3- and 4-part fractures despite a lack of good quality evidence as to whether one type of arthroplasty is superior to the other, and whether surgery is better than non-surgical management. The PROFHER-2 trial has been designed as a pragmatic, multicentre randomised trial to compare the clinical and cost-effectiveness of RSA vs HA vs Non-Surgical (NS) treatment in patients with 3- and 4-part PHF. METHODS Adults over 65 years of age presenting with acute radiographically confirmed 3- or 4-part fractures, with or without associated glenohumeral joint dislocation, who consent for trial participation will be recruited from around 40 National Health Service (NHS) Hospitals in the UK. Patients with polytrauma, open fractures, presence of axillary nerve palsy, pathological (other than osteoporotic) fractures, and those who are unable to adhere to trial procedures will be excluded. We will aim to recruit 380 participants (152 RSA, 152 HA, 76 NS) using 2:2:1 (HA:RSA:NS) randomisation for 3- or 4-part fractures without joint dislocation, and 1:1 (HA:RSA) randomisation for 3- or 4-part fracture dislocations. The primary outcome is the Oxford Shoulder Score at 24 months. Secondary outcomes include quality of life (EQ-5D-5L), pain, range of shoulder motion, fracture healing and implant position on X-rays, further procedures, and complications. Independent Trial Steering Committee and Data Monitoring Committee will oversee the trial conduct, including the reporting of adverse events and harms. DISCUSSION The PROFHER-2 trial is designed to provide a robust answer to guide the treatment of patients aged 65 years or over who sustain 3- and 4-part proximal humeral fractures. The pragmatic design and recruitment from around 40 UK NHS hospitals will ensure immediate applicability and generalisability of the trial findings. The full trial results will be made available in a relevant open-access peer-reviewed journal. TRIAL REGISTRATION ISRCTN76296703. Prospectively registered on 5th April 2018.
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Affiliation(s)
- Amar Rangan
- Department of Health Sciences & HYMS, University of York, York, YO10 5DD, UK.
| | - Stephen Gwilym
- NDORMS, University of Oxford, Headington, Oxford, OX3 7LD, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Belen Corbacho
- Astellas Pharma S.A.,Torre Emperador Castellana, Paseo de La Castellana- nº 259, D - Planta 31, Madrid, 28046, Spain
| | - Lucksy Kottam
- South Tees Hospitals NHS Trust, Marton Road, Middlesbrough, TS4 3BW, UK
| | - Catherine Arundel
- York Trials Unit, Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Elizabeth Coleman
- York Trials Unit, Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Livio DiMascio
- Barts Health NHS Trust, The Royal London Hospital, Whitechapel Road, London, E1 1FR, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Valerie Jones
- Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK
| | - Jamila Kassam
- Queen Mary University of London, Whitechapel, London, E1 2AD, UK
| | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Natasha Mitchell
- York Trials Unit, Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Andrew Mott
- York Trials Unit, Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Grace O'Carroll
- York Trials Unit, Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Puvan Tharmanathan
- York Trials Unit, Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, YO10 5DD, UK
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Wu RJ, Zhang W, Lin YZ, Fang ZL, Wang KN, Wang CX, Yu DS. Influence of preoperative simulation on the reduction quality and clinical outcomes of open reduction and internal fixation for complex proximal humerus fractures. BMC Musculoskelet Disord 2023; 24:243. [PMID: 36997961 PMCID: PMC10061994 DOI: 10.1186/s12891-023-06348-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 03/20/2023] [Indexed: 04/01/2023] Open
Abstract
PURPOSE Proximal humerus fractures (PHFs) are common. With the development of locking plates, open reduction and internal fixation (ORIF) of the proximal humerus can provide excellent clinical outcomes. The quality of fracture reduction is crucial in the locking plate fixation of proximal humeral fractures. The purpose of this study was to determine the impact of 3-dimensional (3D) printing technology and computer virtual technology assisted preoperative simulation on the reduction quality and clinical outcomes of 3-part and 4-part proximal humeral fractures. METHOD A retrospective comparative analysis of 3-part and 4-part PHFs undergoing open reduction internal fixation was performed. Patients were divided into 2 groups according to whether computer virtual technology and 3D printed technology were used for preoperative simulation: the simulation group and the conventional group. Operative time, intraoperative bleeding, hospital stay, quality of fracture reduction, Constant scores, American Society for Shoulder and Elbow Surgery (ASES) scores, shoulder range of motion, complications, and revision surgeries were assessed. RESULTS This study included 67 patients (58.3%) in the conventional group and 48 patients (41.7%) in the simulation group. The patient demographics and fracture characteristics were comparable in these groups. Compared with the conventional group, the simulation group had shorter operation time and less intraoperative bleeding (P < 0.001, both). Immediate postoperative assessment of fracture reduction showed a higher incidence of greater tuberosity cranialization of < 5 mm, neck-shaft angle of 120° to 150°, and head shaft displacement of < 5 mm in the simulation group. The incidence of good reduction was 2.6 times higher in the simulation group than in the conventional group (95% CI, 1.2-5.8). At the final follow-up, the chance of forward flexion > 120° (OR 5.8, 95% CI 1.8-18.0) and mean constant score of > 65 (OR 3.4, 95% CI 1.5-7.4) was higher in the simulation group than the conventional group, as well as a lower incidence of complications in the simulation group was obtained (OR 0.2, 95% CI 0.1-0.6). CONCLUSIONS This study identified that preoperative simulation assisted by computer virtual technology and 3D printed technology can improve reduction quality and clinical outcomes in treatment of 3-part and 4-part PHFs.
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Affiliation(s)
- Rui-Ji Wu
- Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
- The Second Affiliated College of Zhejiang Chinese Medicine University, Hangzhou, China
| | - Wei Zhang
- Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
| | - Yan-Ze Lin
- Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
- The Second Affiliated College of Zhejiang Chinese Medicine University, Hangzhou, China
| | - Zhang-Lu Fang
- Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
- The Second Affiliated College of Zhejiang Chinese Medicine University, Hangzhou, China
| | - Kang-Nan Wang
- Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
- The Second Affiliated College of Zhejiang Chinese Medicine University, Hangzhou, China
| | - Chang-Xing Wang
- The Second Affiliated College of Zhejiang Chinese Medicine University, Hangzhou, China
- Department of Orthopedic Surgery, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Dong-Sheng Yu
- Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China.
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Ratajczak K, Szczęsny G, Tomaszewski W. Stabilization of Comminuted Fractures of the Proximal Humerus with Intramedullary Nails and Angularly Stable Locking Plates—Functional Results before and during the SARS-COVID-19 Pandemics. Medicina (B Aires) 2023; 59:medicina59030575. [PMID: 36984576 PMCID: PMC10054681 DOI: 10.3390/medicina59030575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/06/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Background and Objectives: Intramedullary nailing (IMN) and angularly stable plating (ASP) are the most popular techniques for the stabilization of comminuted fractures of the proximal humerus, without either one being obviously superior. The aim of the study was to validate the functional outcomes of both stabilization techniques in the COVID-19 pandemic by comparing them with data obtained just before the pandemic, because the limitations of the COVID-19 pandemic are affecting several aspects of social and medical life—being afraid of the transmission of the infection, patients reduce their exposure to healthcare to absolutely essential emergencies. Moreover, working conditions in the operating theater have also become more restrictive. Materials and Methods: Investigations were performed on 112 adult patients with Neer’s three- and four-fragment fractures stabilized with IMN (64) and ASP (48). Treatment effects were validated six months after surgery based on radiographs for evidence of bone union, humeral neck–shaft angle (NSA) and implant placement. Limb function was assessed with the QuickDash and Constant–Murley scores. Data obtained from patients treated in the COVID-19 pandemic were compared with those obtained before the pandemic. Results: The healing of all fractures was satisfactory, but complications developed in six cases. Three patients required secondary interventions due to inadequate repositioning: one after IMN and two after ASP. Additionally, one ASP was complicated by the secondary destabilization of a primarily properly stabilized major tubercle, and in two cases by conflict of the protruding implant with the acromion. ASP was noted to provide better functional results during the COVID-19 pandemic according to the Constant–Murley score (p = 0.0048; Student’s t-test). No significant differences were observed in the pre-COVID-19 pandemic. Conclusions: Our results suggest that ASP is more beneficial for the stabilization of comminuted fractures of the proximal humerus during the COVID-19 pandemic.
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Affiliation(s)
- Karol Ratajczak
- Department of Orthopedic Surgery and Traumatology, Medical University, 02-005 Warsaw, Poland
| | - Grzegorz Szczęsny
- Department of Orthopedic Surgery and Traumatology, Medical University, 02-005 Warsaw, Poland
- Correspondence: ; Tel.: +48-501-167-475
| | - Wiesław Tomaszewski
- ARS MEDICA Foundation for Medical Education and Promotion of Health, Art and Culture, 04-036 Warsaw, Poland
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Early Outcomes of Proximal Humerus Fractures in Adults Treated With Locked Plate Fixation Compared with Nonoperative Treatment: An Age-, Comorbidity-, and Fracture Morphology-Matched Analysis. J Orthop Trauma 2023; 37:142-148. [PMID: 36730947 DOI: 10.1097/bot.0000000000002511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To compare patient-reported outcomes (PROs), range of motion (ROM), and complication rates for proximal humerus fractures managed nonoperatively or with open reduction internal fixation (ORIF). DESIGN Retrospective cohort. SETTING Academic level 1 trauma center. PATIENTS/PARTICIPANTS Four hundred thirty-one patients older than 55 years were identified retrospectively. 122 patients were excluded. 309 patients with proximal humerus fractures met inclusion criteria (234 nonoperative and 75 ORIF). After matching, 192 patients (121 nonoperative and 71 ORIF) were included in the analysis. INTERVENTION Nonoperative versus ORIF (locked plate) treatment of proximal humerus fracture. MAIN OUTCOME MEASUREMENTS Early Visual Analog Score (VAS), ROM, PROs, complications, and reoperation rates between groups. RESULTS At 2 weeks, ORIF showed lower VAS scores, better passive ROM, and patient-reported outcomes measurement information system (PROMIS) scores ( P < 0.05) compared with nonoperative treatment. At 6 weeks, open reduction internal fixation (ORIF) had lower VAS scores, better passive ROM, and PROMIS scores ( P < 0.05) compared with nonoperative treatment. At 3 months, ORIF showed similar PROMIS scores ( P > 0.05) but lower VAS scores and better passive ROM ( P < 0.05) compared with nonoperative treatment. At 6 months, ORIF showed similar VAS scores, ROM, and PROMIS scores ( P > 0.05) compared with nonoperative treatment. There was no difference in secondary operation rates between groups ( P > 0.05). ORIF patients trended toward a higher secondary reoperation rate (15.5% vs. 5.0%) than nonoperative patients ( P = 0.053). CONCLUSIONS In an age-, comorbidity-, and fracture morphology-matched analysis of proximal humerus fractures, ORIF led to decreased pain and improved passive ROM early in recovery curve compared with nonoperative treatment that normalized after 6 months between groups. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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The Influence of Adherence to Orthosis and Physiotherapy Protocol on Functional Outcome after Proximal Humeral Fracture in the Elderly. J Clin Med 2023; 12:jcm12051762. [PMID: 36902549 PMCID: PMC10003098 DOI: 10.3390/jcm12051762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
In the treatment of proximal humeral fractures (PHF), patients are often recommended to wear a sling or orthosis and to perform physiotherapy. However, some patients, especially elderly ones, struggle to comply with these rehabilitation regimens. Therefore, the aim of the study was to evaluate whether these incompliant patients have a worse functional outcome than those who adhere to the rehabilitation protocol. After receiving a diagnosis of a PHF, patients were divided into four groups according to fracture morphology: conservative with sling, operative with sling, conservative with abduction orthosis, and operative with abduction orthosis. At the 6-week follow-up, compliance regarding brace use and physiotherapy performance were assessed, as well as the constant score (CS) and complications or revision surgeries. The CS as well as the complications and revision surgeries were also surveyed after one year. In 149 participants, with a mean age of 73.9 ± 7.2 years, only 37% terminated orthosis and only 49% underwent physiotherapy as recommended. The statistical analysis showed no significant difference in the CS, complications, and revision surgeries between the groups.
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Li T, Li Y, Zhang L, Pang L, Tang X, Zhu J. Venous thromboembolism after arthroscopic shoulder surgery: a systematic review. J Orthop Surg Res 2023; 18:103. [PMID: 36788620 PMCID: PMC9927062 DOI: 10.1186/s13018-023-03592-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 02/08/2023] [Indexed: 02/16/2023] Open
Abstract
PURPOSE To summarize the incidence, risk factors, diagnosis methods, prophylaxis methods, and treatment of venous thromboembolism (VTE) following arthroscopic shoulder surgery. METHODS Literature on VTE after arthroscopic shoulder surgeries was summarized, and all primary full-text articles reporting at least 1 case of deep vein thrombosis (DVT) or pulmonary embolism (PE) after arthroscopic shoulder surgeries were included. Articles were critically appraised and systematically analyzed to determine the incidence, risk factors, diagnosis, prophylaxis, and management of VTE following arthroscopic shoulder surgeries. RESULTS This study included 42 articles in which the incidence of VTE ranges from 0 to 5.71% and the overall incidence was 0.26%. Most VTE events took place between the operation day and the 14th day after the operation (35/51). Possible risk factors included advanced age (> 70 years), obesity (BMI ≥ 30 kg/m2), diabetes mellitus, thrombophilia, history of VTE, prolonged operation time, hormone use, and immobilization after surgery. The most common prophylaxis method was mechanical prophylaxis (13/15). No statistical difference was detected when chemoprophylaxis was applied. The management included heparinization followed by oral warfarin, warfarin alone and rivaroxaban, a direct oral anticoagulant. CONCLUSION Based on the included studies, the incidence rate of VTE after arthroscopic shoulder surgeries is relatively low. The risk factors for VTE are still unclear. CT/CTA and ultrasound were the mainstream diagnosis methods for PE and DVT, respectively. Current evidence shows that chemical prophylaxis did not deliver significant benefits, since none of the existing studies reported statistically different results. High-quality studies focusing on the prophylaxis and management of VTE population undergoing arthroscopic shoulder surgeries should be done in the future.
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Affiliation(s)
- Tao Li
- grid.13291.380000 0001 0807 1581Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Yinghao Li
- grid.13291.380000 0001 0807 1581Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Linmin Zhang
- grid.13291.380000 0001 0807 1581West China School of Medicine, Sichuan University, Chengdu, People’s Republic of China
| | - Long Pang
- grid.13291.380000 0001 0807 1581Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Xin Tang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan Province, People's Republic of China.
| | - Jing Zhu
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Nursing, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, Sichuan Province, People's Republic of China.
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Walter N, Szymski D, Kurtz SM, Lowenberg DW, Alt V, Lau E, Rupp M. Proximal humerus fractures - epidemiology, comparison of mortality rates after surgical versus non-surgical treatment, and analysis of risk factors based on Medicare registry data. Bone Joint Res 2023; 12:103-112. [PMID: 36718643 PMCID: PMC9950668 DOI: 10.1302/2046-3758.122.bjr-2022-0275.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
AIMS The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate? METHODS PHFs occurring between 1 January 2009 and 31 December 2019 were identified from the Medicare physician service records. Incidence rates were determined, mortality rates were calculated, and semiparametric Cox regression was applied, incorporating 23 demographic, clinical, and socioeconomic covariates, to compare the mortality risk between treatments. RESULTS From 2009 to 2019, the incidence decreased by 11.85% from 300.4 cases/100,000 enrollees to 266.3 cases/100,000 enrollees, although this was not statistically significant (z = -1.47, p = 0.142). In comparison to matched Medicare patients without a PHF, but of the same five-year age group and sex, a mean survival difference of -17.3% was observed. The one-year mortality rate was higher after nonoperative treatment with 16.4% compared to surgical treatment with 9.3% (hazard ratio (HR) = 1.29, 95% confidence interval (CI) 1.23 to 1.36; p < 0.001) and to shoulder arthroplasty with 7.4% (HR = 1.45, 95% CI 1.33 to 1.58; p < 0.001). Statistically significant mortality risk factors after operative treatment included age older than 75 years, male sex, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, chronic kidney disease, a concomitant fracture, congestive heart failure, and osteoporotic fracture. CONCLUSION Mortality risk factors for distinct treatment modes after PHF in elderly patients could be identified, which may guide clinical decision-making.Cite this article: Bone Joint Res 2023;12(2):103-112.
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Affiliation(s)
- Nike Walter
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Dominik Szymski
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Steven M. Kurtz
- Implant Research Center, Drexel University, Philadelphia, Pennsylvania, USA
| | - David W. Lowenberg
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Edmund Lau
- Exponent Inc, Menlo Park, California, USA
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany, Markus Rupp. E-mail:
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Medicaid insurance is associated with treatment disparities for proximal humerus fractures in a national database analysis. J Shoulder Elbow Surg 2022:S1058-2746(22)00909-0. [PMID: 36581135 DOI: 10.1016/j.jse.2022.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 11/02/2022] [Accepted: 11/13/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Proximal humerus fractures (PHFs) are the third most common type of fragility fracture in the elderly and are increasing in incidence. Disparities in treatment type, time to surgery (TTS), and complications based upon insurance type have been identified for other orthopedic conditions. Given the incidence and burden of PHFs, we sought to evaluate if insurance type was associated with treatment received, TTS, and complications in the treatment of PHFs. METHODS We used PearlDiver, a national administrative claims database that consists of 122 million patient records. Patients diagnosed with an isolated PHF between 2010 and 2019 were identified by International Classification of Diseases, Ninth and Tenth Revision diagnostic codes and stratified by insurance type (Medicaid, private, or Medicare). Outcomes evaluated were rate of surgery within 3 months of diagnosis with open reduction and internal fixation, hemiarthroplasty, or reverse shoulder arthroplasty; average TTS; 90-day readmissions and medical postoperative complications (deep vein thrombosis, urinary tract infection, pneumonia, sepsis, acute respiratory failure, cerebrovascular event, and acute renal failure); and 1-year surgical postoperative complications (stiffness, noninfectious wound complications, dislocation, and infection). Multivariable logistic regressions adjusting for age, sex, and Elixhauser comorbidity index were utilized to determine the association between insurance type and surgery rate/complications. RESULTS We included 245,396 patients for analysis. Fourteen percent of Medicaid patients (1789/12,498) underwent surgery compared to 17% (25,347/149,830) of privately insured patients and 16% (13,305/83,068) of Medicare patients (pairwise, P < .001). TTS (Medicaid: 11.7 days, private: 10.6 days [P < .001]; Medicare: 10.7 days [P = .003]) varied by insurance type. Private or Medicare-insured patients were less likely to be readmitted (adjusted odds ratio: 0.77 [95% confidence interval (CI): 0.63-0.93] for private vs. Medicaid and 0.71 [95% CI: 0.59-0.88] for Medicare vs. Medicaid) and experienced fewer 90-day postoperative complications (adjusted odds ratio: 0.73 [95% CI: 0.62-0.85] for private vs. Medicaid, 0.65 [95% CI: 0.55-0.77] for Medicare vs. Medicaid), such as acute renal failure. TTS was also associated with differing rates of readmissions and complications. CONCLUSION There are differences in rates of surgery, TTS, and complications after PHFs based on insurance type, representing opportunities for quality improvement initiatives. Potential methods to address these disparities include implementing standardized PHF protocols and/or reimbursement models and quality metrics that reward equitable treatment. Further research and policy adaptations should be incorporated to decrease barriers that patients face and minimize health care inequities seen in the treatment of PHFs based on insurance type.
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