Results of uncemented hemiarthroplasty as primary treatment of severe proximal humerus fractures in the elderly

Venous thromboembolism following surgical management of proximal humerus fractures: a systematic review

Background

Currently, there is limited information on the incidence of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE) after surgical treatment of proximal humerus fractures (PHFs). Therefore, the purpose of this systematic review is to evaluate the incidence of VTE, DVT, and PE following surgery for PHFs.

Methods

A comprehensive search of several databases was performed from inception to May 27, 2022. Studies were screened and evaluated by 2 reviewers independently utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Only original, English studies that evaluated the incidences of VTE following surgical management of PHFs were included. Surgical procedures consisted of shoulder arthroplasty (SA) including both hemiarthroplasty (Hemi) and reverse shoulder arthroplasty (RSA) in addition to open reduction and internal fixation (ORIF). A pooled incidence for postoperative DVT, PE, and overall VTE was reported.

Results

Twelve studies met the inclusion and exclusion criteria, encompassing a total of 18,238 patients. The overall DVT, PE, and VTE rates were 0.14%, 0.59%, and 0.7%, respectively. VTE was more frequently reported after SA than ORIF, (1.27% vs. 0.53%, respectively). Among SA patients, a higher rate of DVT was seen with RSA (1.2%) with the lowest DVT rate was observed for ORIF with 0.03%.

Conclusions

Symptomatic VTEs following surgical treatment of PHFs, are rare, yet still relevant as a worrisome postoperative complication. Among the various procedures, VTE was the most frequently reported after SA when compared to ORIF, with RSA having the highest VTE rate.

Hounsfield units predicts the occurrence but not the patterns of proximal humerus fracture in the elderly patients

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.

Risk Factors for Severe Proximal Humerus Fracture and Correlation Between Deltoid Tuberosity Index and Bone Mineral Density

Introduction:

The aims of this study were to investigate (1) whether demographic factors would be risk factors for severe proximal humerus fracture (PHF), (2) relationship of radiological parameters with bone mineral density (BMD), deltoid tuberosity index (DTI), or severe PHF, and (3) correlation between DTI and BMD.

Methods:

We conducted a cross-sectional study based on radiographs and medical records taken during admission or the visit to the orthopedic clinic. We reviewed consecutive 100 adult patients who were diagnosed with PHF in our hospital from March 2014 to December 2016. Three- and 4-part fractures were regarded as severe PHFs. Univariable and multivariable logistic regression analyses were performed to evaluate risk factors for severe PHF. Also, we investigated the correlation between BMD and DTI using the additional BMD data of the patients who underwent shoulder surgeries.

Results:

This study included 62 nonsevere PHFs and 38 severe PHFs. There were 30 male and 70 female patients with a mean age of 66.4 ± 16.4 years. Mean T score of BMD was −2.5 ± 0.9 at the time of injury. Logistic regression analyses showed that age (odds ratio: 1.044, range: 1.011-1.079, P = .009) and sex (odds ratio of females: 3.763, range: 1.236-11.459, P = .020) were related to severe PHF. The group satisfying the radiological parameter criteria had significantly higher rates of severe PHF. The correlation coefficient (r) between DTI and T score was 0.555 (P < .001).

Discussion and Conclusion:

Older age and female were the independent risk factors for severe PHF. Conversely, BMD and other medical comorbidities were not risk factors for severe PHF. Deltoid tuberosity index showed significantly high intraclass correlation coefficient and a strong correlation with the T score of BMD. Therefore, DTI may be useful for screening osteoporosis in PHF patients.

Level of Evidence:

Level IV, Cross-sectional study.

Safety and Effectiveness of Shoulder Arthroplasties in Spain: A Systematic Review

The effectiveness and safety of shoulder arthroplasties in the general context of a Spanish patient population remains unclear. The aim of this study was to ascertain both the effectiveness and safety of primary shoulder arthroplasties and the prosthesis types used in Spain. A systematic review of all the available literature evaluating the effectiveness and safety of primary shoulder arthroplasties in Spain was performed. A narrative synthesis was performed, and evidence tables were created in four dimensions: study design, arthroplasty characteristics, safety, and effectiveness. Orthopaedic Data Evaluation Panel (ODEP) scores were used to evaluate prosthesis types. Twenty-one studies were selected that included a total of 1293 arthroplasties. The most common indication was fractures, while the prosthesis most frequently used was the Delta Xtend (ODEP 10A). The most common complication was scapular notching. Prosthesis revision rate was approximately 6% for follow-ups between 12 and 79 months. In addition, significant improvements were observed in the Constant-Murley test score after the intervention. Currently in Spain, shoulder arthroplasty can be considered a safe and effective procedure with functional recovery and pain reduction for eligible patients with humeral fracture, rotator cuff arthropathy, fracture sequelae and malunion of the proximal humerus, and degenerative disease. Future longitudinal research and population-based studies could serve to confirm these results and identify points of improvement.

Primary Shoulder Hemiarthroplasty: What Can Be Learned From 359 Cases That Were Surgically Revised?

BACKGROUND

Primary shoulder hemiarthroplasty is used to address a range of glenohumeral disorders, including fracture, arthritis, avascular necrosis, and capsulorrhaphy arthropathy; some patients with hemiarthroplasties undergo revision surgery for persistent pain or residual shoulder dysfunction. The literature does not clarify the features of the hemiarthroplasties having repeat surgery in a way that can guide surgeons' efforts to minimize the need for revision. To help address this gap, we analyzed the characteristics of patients from our region for whom we performed surgical revision of a prior humeral hemiarthroplasty QUESTIONS/PURPOSES: (1) What are the common characteristics of shoulder hemiarthroplasties having a revision? (2) What are the common characteristics of the subset of revised shoulder hemiarthroplasties that were performed for fracture? (3) What are characteristics of the subset of all revised hemiarthroplasties that were associated with glenoid bone erosion?

METHODS

Data for 983 patients for whom we performed a surgical revision of any type of shoulder arthroplasty between January 1991 and January 2017 were identified in our longitudinally maintained institutional arthroplasty revision database. In each case, revision had been elected by shared patient and surgeon decision-making after consideration of the disorder, degree of compromised comfort and function, treatment alternatives, and the risks of surgery. Of these 983 patients, 359 (37%) had a revision of a prior primary hemiarthroplasty; these patients were the subjects of this investigation. In this group of patients, we investigated the patient demographics, shoulder characteristics, prerevision radiographic findings, and findings at revision surgery. No patients were excluded. The patients having revision of primary hemiarthroplasties had severe loss of self-assessed shoulder comfort and function, with Simple Shoulder Test (SST) scores averaging 2.2 ± 2.2 of the maximum score of 12. The majority of these patients (81%) were women. The medical records of these 359 patients were abstracted to determine the diagnosis for the index primary hemiarthroplasty, clinical characteristics before surgery, and findings at surgical revision. One hundred twelve of the arthroplasties had been performed for fracture-related diagnoses; a subgroup analysis was performed on these patients. Two hundred seventy-three of the 359 patients (76%) had plain radiographs performed within 3 months before revision surgery that were adequate for assessing the radiographic characteristics of the glenoid, humerus, humeral component, and glenohumeral relationships; a subgroup analysis was performed on these patients. The degree of glenoid erosion was measured by a single observer in accordance with established criteria: Grade 1 is no erosion, Grade 2 is erosion limited to subchondral bone, Grade 3 is moderate erosion with medialization, and Grade 4 is medialization beyond the coracoid base. Some patients were included in both of these subgroups.

RESULTS

Common characteristics of the revised hemiarthroplasties included female sex (81%), rotator cuff (89 of 359; 25%) or subscapularis (81 of 359; 23%) failure, problems related to prior fracture (154 of 359; 43%), glenoid erosion 125 of 359; 35%), and component malposition (89 of 359; 25%). Hemiarthroplasties performed for fracture-related problems often were associated with tuberosity malunion or nonunion (58 of 79; 73%) and decentering of the humeral component on the glenoid surface (45 of 71; 63%). Major erosion of the bony glenoid (Grade 3 or 4) was more common in decentered hemiarthroplasties (42 of 102; 41%) than for centered hemiarthroplasties (36 of 146; 25%) (Fisher's exact p = 0.008) and more common for hemiarthroplasties positioned in valgus (28 of 50; 56%) than for those positioned in neutral or varus (40 of 188; 21%) (Fishers' exact p < 0.0001).

CONCLUSIONS

These findings suggest that some revisions of primary hemiarthroplasties may be avoided by surgical techniques directed at centering the prosthetic humeral articular surface on the glenoid concavity using proper humeral component positioning and soft tissue balance, by avoiding valgus positioning of the humeral component, and by managing glenoid disorders with a primary glenohumeral arthroplasty rather than a hemiarthroplasty alone. When durable security of the subscapularis, rotator cuff, and tuberosities is in question, the surgeon may consider a reverse total shoulder arthroplasty.

LEVEL OF EVIDENCE

Level III, therapeutic study.