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Haws BE, Samborski SA, Karnyski S, Soles G, Gorczyca JT, Nicandri GT, Voloshin I, Ketz JP. Risk factors for loss of reduction following locked plate fixation of proximal humerus fractures in older adults. Injury 2023; 54:567-572. [PMID: 36424218 DOI: 10.1016/j.injury.2022.11.043] [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: 07/27/2022] [Revised: 11/06/2022] [Accepted: 11/13/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE To identify characteristics associated with loss of reduction following open reduction and locked plate fixation (ORIF) of proximal humerus fractures in older adults and determine if loss of reduction affects patient reported outcomes (PROs), range of motion (ROM), and complication rates during the first postoperative year. METHODS Patients >55 years old who underwent proximal humerus ORIF were reviewed. Patient and fracture characteristics were recorded. Fixation characteristics were measured on the initial postoperative AP radiograph including humeral head height (HHH) relative to the greater tuberosity (GT), head shaft angle (HSA), screw-calcar distance, and screw tip-joint surface distance. Loss of reduction was defined as GT displacement >5 mm or HSA displacement >10° on final follow up radiographs. Patient, fracture, and fixation characteristics were tested for association with loss of reduction. Outcomes including ROM, visual analog scale pain and PROMIS scores, and complication/reoperation rates during the first postoperative year were compared between those with or without loss of reduction. RESULTS A total of 79 patients were identified, 23 (29.1%) of which had a loss of reduction. Calcar comminution (relative risk [RR]=2.5, 95% Confidence Interval [CI]=1.3-5.0, p<0.01), HHH <5 mm above GT (RR=2.0, CI=1.0-3.9, p = 0.048), and screw-calcar distance ≥12 mm (RR=2.1, CI=1.1-4.1, p = 0.03) were risk factors for loss of reduction. Upon multivariate analysis, calcar comminution was determined to be an independent risk factor for loss of reduction (RR=2.4, CI=1.2-4.7, p = 0.01). Loss of reduction led to higher complication (44% vs 13%, p<0.01) and reoperation rates (30% vs 7%, p<0.01), and decreased achievement of satisfactory ROM (>90° active forward flexion, 57% vs 82%, p = 0.02) compared to maintained reduction, but similar PROs. CONCLUSIONS Calcar comminution, decreased HHH, and increased screw-calcar distance are risk factors for loss of reduction following ORIF of proximal humerus fractures. These morphologic and technical factors are important considerations for prolonged reduction maintenance.
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Affiliation(s)
- Brittany E Haws
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA.
| | - Steven A Samborski
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - Steven Karnyski
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - Gillian Soles
- University of California, Davis, Department of Orthopaedic Surgery, Sacramento, CA, USA
| | - John T Gorczyca
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - Gregg T Nicandri
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - Ilya Voloshin
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - John P Ketz
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
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Maccagnano G, Solarino G, Pesce V, Vicenti G, Coviello M, Nappi VS, Giannico OV, Notarnicola A, Moretti B. Plate vs reverse shoulder arthroplasty for proximal humeral fractures: The psychological health influence the choice of device? World J Orthop 2022; 13:297-306. [PMID: 35317248 PMCID: PMC8935332 DOI: 10.5312/wjo.v13.i3.297] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/06/2021] [Accepted: 02/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Proximal humeral fractures represent the third most common observed osteoporotic fracture; the treatment in three and four-part proximal humeral fractures in patients over 65 years is still controversial. Among the treatments described in literature, open reduction and internal fixation (O.R.I.F) and reverse shoulder arthroplasty (RSA) are gaining an increasing popularity.
AIM To investigate the correct treatment for three and four-part proximal humeral fractures according to psychological aspects.
METHODS It was conducted a prospective study with a series of 63 patients treated with O.R.I.F. (group A) and with RSA (group B) for three and four-part proximal humeral fractures according to Neer classification system. A conservative treatment group, as control, was finally introduced. One independent observer performed clinical and a psychological evaluation at one (T0), six (T1) and twelve months (T2) postoperatively. The Constant’s score and The Disabilities of the Arm, Shoulder and Hand (DASH score) were used for clinical evaluation, while General Anxiety Disorder-7 (GAD-7) and Caregiver Strain Scale (CSS) were used for psychological evaluation.
RESULTS At one month follow up in group A the mean values were DASH score 50.8, Constant score 36.1, GAD-7 score 5.4, CSS 5.0. For the group B, the average values at T0 were: DASH score 54.6, Constant score 32.0; GAD-7 score 6.4, CSS 6.2. At six months in group A the average values were DASH score 42.1, Constant score 47.3, GAD-7 score 4.3, CSS 3.9. For the group B, the average values at T1 were: DASH score 39.1, Constant score 43.2, GAD-7 score 5.7, CSS 5.5. At twelve months in the group A, the mean values were DASH score 32.8, Constant score 60.0, GAD-7 score 3.2, CSS 3.1. For the group B shown these mean values: DASH score 33.6, Constant score 52.9, GAD-7 score 4.3, CSS 4.5. We demonstrated a better clinical and psychological outcome at T2 in the group treated with osteosynthesis compared to the group treated with arthroplasty (Constant P = 0.049, GAD-7 P = 0.012 and CSS P = 0.005). A better clinical and psychological outcome emerged in control group at T2 comparing with surgical group (DASH score P = 0.014, Constant score P < 0.001, GAD-7 P = 0.002 and CSS P = 0.001).
CONCLUSION Both open osteosynthesis and reverse shoulder arthroplasty are valid treatments for proximal humeral fractures. According to the best osteosynthesis results the authors suggested to perform a psychological analysis for each patient in order to choose the appropriate treatment.
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Affiliation(s)
- Giuseppe Maccagnano
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Surgery, University of Foggia, Orthopaedics Unit, General Hospital, Foggia 71122, Italy
| | - Giuseppe Solarino
- Department of Basic Medical Science, Neuroscience and Sensory Organs, Faculty of Medicine and Surgery, University of Bari, Orthopaedics Unit, General Hospital, Bari 70124, Italy
| | - Vito Pesce
- Department of Clinical and Experimental Medicine, Faculty of Medicine and Surgery, University of Foggia, Orthopaedics Unit, General Hospital, Foggia 71122, Italy
| | - Giovanni Vicenti
- Department of Basic Medical Science, Neuroscience and Sensory Organs, Faculty of Medicine and Surgery, University of Bari, Orthopaedics Unit, General Hospital, Bari 70124, Italy
| | - Michele Coviello
- Department of Basic Medical Science, Neuroscience and Sensory Organs, Faculty of Medicine and Surgery, University of Bari, Orthopaedics Unit, General Hospital, Bari 70124, Italy
| | | | - Orazio Valerio Giannico
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, Bari 70124, Italy
| | - Angela Notarnicola
- Department of Basic Medical Science, Neuroscience and Sensory Organs, Faculty of Medicine and Surgery, University of Bari, Orthopaedics Unit, General Hospital, Bari 70124, Italy
| | - Biagio Moretti
- Department of Basic Medical Science, Neuroscience and Sensory Organs, Faculty of Medicine and Surgery, University of Bari, Orthopaedics Unit, General Hospital, Bari 70124, Italy
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Cecere AB, Toro G, De Cicco A, Braile A, Paoletta M, Iolascon G, Schiavone Panni A. How to improve the outcomes of surgically treated proximal humeral osteoporotic fractures? A narrative review. Orthop Rev (Pavia) 2020; 12:8529. [PMID: 32922699 PMCID: PMC7461645 DOI: 10.4081/or.2020.8529] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 04/17/2020] [Indexed: 02/08/2023] Open
Abstract
Proximal humeral fractures (PHF) are the third most common non-vertebral fragility fractures after hip and distal radius. It still controversial which treatment might be more appropriate, and surgically treated outcomes depends also on an appropriate technique. In order to clarify surgical indications, tips and pitfall a narrative review was conducted. Pinning, external fixation, plating and internal fixators has each one its advantages and disadvantages. During the procedure an appropriate use of the fixation device and handling of the soft tissue might be associated with better outcomes. Calcar comminution, varus angulation, medial dislocation of the shaft, fracture-dislocation are factors that could lead to choose a replacement. Hemiarthroplasty and reverse total shoulder arthroplasty are the most common prosthesis used in PHF. The restoration of humeral length and tuberosities might lead to an improvement in clinical outcomes and prosthesis survivorship.
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Affiliation(s)
- Antonio Benedetto Cecere
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples.,Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Annalisa De Cicco
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples
| | - Adriano Braile
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples
| | - Alfredo Schiavone Panni
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples
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Majed A, Thangarajah T, Krekel P, Nelissen R, Reilly P, Bull A, Emery R. Simulation of bone-determined range of motion in proximal humeral fractures. Shoulder Elbow 2018; 10:186-191. [PMID: 29796106 PMCID: PMC5960871 DOI: 10.1177/1758573217713693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 04/18/2017] [Accepted: 05/01/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Predicting the outcome following fractures of the proximal humerus is an important consideration when effectively counselling patients and planning treatment. The purpose of the present study was to analyze different proximal humeral fracture configurations, using a computerized simulation model, aiming to predict the range of motion (ROM). METHODS The computer tomography scans of 79 proximal humeral fractures were analyzed using a customized software system that simulated the range of movement at the glenohumeral joint. Four fracture patterns were investigated: (1) head split fractures; (2) greater tuberosity fractures; (3) lesser tuberosity fractures; and (4) combined tuberosity fractures. RESULTS Intra-articular fractures had the smallest mean (SE) range of abduction and forward flexion [34.3° (6.6°) and 60.7° (12.4°)]. Isolated displaced greater tuberosity resulted in limited abduction but not forward flexion [75.0° (5.9°) and 118.2° (4.9°)]. Isolated lesser tuberosity fractures displayed a ROM comparable to that of healthy subjects [89.3° (3.3°) and 122.6° (3.4°) versus 102.3° (2.8°) and 96.2° (3.8°)]. The reduced head inclination angle was a relatively strong predictor of a limited range of abduction for all fracture types. CONCLUSIONS The present study describes a novel simulation system used to quantify the bone-determined ROM in proximal humeral fractures and may be a useful adjunct in the diagnostic armamentarium for proximal humeral fractures.
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Affiliation(s)
- Addie Majed
- Department of Surgery and Cancer, Imperial College London, UK,Department of Bioengineering, Imperial College London, UK,Shoulder and Elbow Service, Royal National Orthopaedic Hospital, UK,Addie Majed, Division of SORA (Surgery Oncology Reproductive Medicine and Anaesthetics), Imperial College London, 10th Floor QEQM Building, St Mary's Hospital, Praed Street, London W2 1NY, UK.
| | | | - Peter Krekel
- Orthopaedics Department, Leiden University Medical Centre, The Netherlands
| | - Rob Nelissen
- Orthopaedics Department, Leiden University Medical Centre, The Netherlands
| | - Peter Reilly
- Department of Surgery and Cancer, Imperial College London, UK
| | - Anthony Bull
- Department of Bioengineering, Imperial College London, UK
| | - Roger Emery
- Department of Surgery and Cancer, Imperial College London, UK
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Kavuri V, Bowden B, Kumar N, Cerynik D. Complications Associated with Locking Plate of Proximal Humerus Fractures. Indian J Orthop 2018; 52:108-116. [PMID: 29576637 PMCID: PMC5858203 DOI: 10.4103/ortho.ijortho_243_17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Proximal humerus fractures constitute a significant percentage of fragility fractures. The growing use of locking plate has helped treat this problem, but at the same time has brought about complications. Past systematic reviews have documented these complications, however a large number of recent studies have been published since, reporting their own complication rates with different techniques. This study reviews the current complications associated with locking plate of proximal humerus fractures as well as methods to reduce them. A systematic review, following the PRISMA guidelines, was conducted in November 2013 and repeated in March 2015, using PubMed, Scopus, and Cochrane databases, to evaluate locking plate fixation (and complications) of traumatic proximal humerus fractures. Inclusion criteria included adults (>18 years), minimum of 12-month postoperative followup, articles within the last 5 years, and studies with >10 participants. Exclusion criteria included pathologic fractures, cadaveric studies, and nonhuman subjects. Eligible studies were graded using a quality scoring system. Articles with a minimum of 7/10 score were included and assessed regarding their level of evidence per the Journal of Bone and Joint Surgery and Centre for Evidence-Based Medicine guidelines. The initial query identified 51,206 articles from multiple databases. These records were thoroughly screened and resulted in 57 articles, consisting of seven Level 1, three Level 2, 10 Level 3, and 37 Level 4 studies, totaling 3422 proximal humerus fractures treated with locking plates. Intraarticular screw penetration was the most reported complication (9.5%), followed by varus collapse (6.8%), subacromial impingement (5.0%), avascular necrosis (4.6%), adhesive capsulitis (4.0%), nonunion (1.5%), and deep infection (1.4%). Reoperation occurred at a rate of 13.8%. Collapse at the fracture site contributed to a majority of the implant-related complications, which in turn were the main reasons for reoperation. The authors of these studies discussed different techniques that could be used to address these issues. Expanding use of locking plate in the proximal humerus fractures leads to improvements and advancements in surgical technique. Further research is necessary to outline indications to decrease complications, further.
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Affiliation(s)
- Venkat Kavuri
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA,Address for correspondence: Dr. Venkat Kavuri, Department of Orthopaedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, 245 N. 15th St. M.S. 420, Philadelphia, PA 19103, USA. E-mail:
| | - Blake Bowden
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
| | - Neil Kumar
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
| | - Doug Cerynik
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
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Goch AM, Christiano A, Konda SR, Leucht P, Egol KA. Operative repair of proximal humerus fractures in septuagenarians and octogenarians: Does chronologic age matter? J Clin Orthop Trauma 2017; 8:50-53. [PMID: 28360497 PMCID: PMC5359506 DOI: 10.1016/j.jcot.2017.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/03/2017] [Accepted: 01/14/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND With an expected doubling of the geriatric population within the next thirty years it is becoming increasingly important to determine who among the elderly population benefit from orthopaedic interventions. This study assesses post-operative outcomes in patients aged seventy or greater who sustained a proximal humerus fracture and were treated surgically as compared to a younger geriatric cohort to determine if there is a chronologic age after which post-operative outcomes significantly decline. METHODS A retrospective chart review was conducted for 201 patients who sustained fractures of the proximal humerus (OTA 11A-C) and were treated operatively by open reduction and internal fixation. Data from 132 independent, active patients aged fifty-five or older was identified and analyzed. Forty-seven patients age 70 or older were compared to 78 patients aged 55-69. Average length of follow-up was 19.5 months. All complications were recorded. Univariate and multivariate analysis was conducted to assess for differences between groups. RESULTS 95% of patients achieved fracture union within 6 months. No significant differences were found between cohorts with regard to gender, fracture severity, or CCI (p = 0.197, p = 0.276, p = 0.084, respectively). Functional outcome scores, shoulder range of motion, and complications rates for patients aged 70 and older were not significantly different from patients aged 55-69. There were 10 complications in the older elderly cohort (21%), 6 of which required re-operation and 13 complications in the young elderly cohort (17%), 8 of which required re-operation. CONCLUSIONS Operative fracture repair using locked plating of the proximal humerus in septuagenarians and octogenarians can provide for excellent long-term outcomes in appropriately selected patients. These patients tend to have long term functional outcome scores, post-operative range of motion, and complication rates that are comparable to younger geriatric patients. Physicians should not exclude patients for repair of proximal humerus fractures based on chronological age cutoffs.
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Bhat SB, Secrist ES, Austin LS, Getz CL, Krieg JC, Mehta S, Namdari S. Displaced Proximal Humerus Fractures in Older Patients: Shoulder Surgeons Versus Traumatologists. Orthopedics 2016; 39:e509-13. [PMID: 27135449 DOI: 10.3928/01477447-20160427-08] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 11/12/2015] [Indexed: 02/03/2023]
Abstract
Proximal humerus fractures are relatively common, with treatment dependent on fracture-specific, patient-specific, and surgeon-specific factors. This study sought to identify preferences among shoulder specialists and orthopedic traumatologists in the treatment of proximal humerus fractures. An anonymous Internet survey of fellowship-trained shoulder surgeons and traumatologists was conducted with radiographs and select computed tomography images of 15 unique displaced proximal humerus fractures. Participants were asked to classify each case according to Neer criteria and choose management from a list of options. Groups were analyzed using chi-square test for independence, paired t test, and Fleiss' kappa within and between each group. Among shoulder surgeons, there were a total of 19 cases selected for nonoperative management, 204 cases selected for open reduction and internal fixation (ORIF), and 122 cases selected for arthroplasty. Among traumatologists, there were 44 cases selected for nonoperative management, 234 for ORIF, and 67 for arthroplasty. Fleiss' kappa for intraobserver agreement on treatment choice was 0.26 for shoulder surgeons and 0.18 for traumatologists, and chi-square test for independence was significant between the 2 groups (P<.001). Paired t test of the average treatment proportions was significant for nonoperative management and arthroplasty (P=.003) but not significant for differences in rates of ORIF. These results confirm poor consistency in Neer classification among surgeons and suggest that shoulder surgeons were more likely to consider arthroplasty for treatment and that traumatologists were more likely to use ORIF or to manage patients nonoperatively. These variations in care may translate to differences in outcome and cost. [Orthopedics. 2016; 39(3):e509-e513.].
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