Surgical treatment of Neer Group VI proximal humeral fractures: retrospective comparison of PHILOS® and hemiarthroplasty

Clinical Outcome of Carbon Fiber Reinforced Polyetheretherketone Plates in Patients with Proximal Humeral Fracture: One-Year Follow-Up

BACKGROUND

Proximal humerus fractures are seen frequently, particularly in older patients. The development of new osteosynthesis materials is being driven by the high complication rates following surgical treatment of proximal humerus fractures. Plate osteosyntheses made of steel, titanium and, for several years now, carbon fiber-reinforced polyetheretherketone (CFR-PEEK) are used most frequently.

METHODS

A prospective, randomized study was conducted in order to evaluate whether there are differences in the functional postoperative outcome when comparing CFR-PEEK and titanium implants for surgical treatment of proximal humerus fractures. The primary outcome of shoulder functionality 1 year after surgery was measured with the DASH score, the Oxford Shoulder Score, and the Simple Shoulder Test.

RESULTS

Bony consolidation of the respective fracture was confirmed in all the patients included in the study within the scope of postoperative follow-up care. No significant differences in the DASH score, Oxford Shoulder Score, or Simple Shoulder Test were observed 1 year post-operatively when comparing the implant materials CFR-PEEK and titanium.

CONCLUSIONS

There are no differences in terms of the functional outcome between CFR-PEEK plates and titanium implants 1 year after surgery. Studies on the long-term outcomes using CFR-PEEK plates in osteoporotic bone should be the subject of further research.

A Standardized Operative Protocol for Fixation of Proximal Humeral Fractures Using a Locking Plate to Minimize Surgery-Related Complications

The current literature suggests that up to 55% of complications after plate osteosynthesis treatment for patients with proximal humerus fractures are attributed to the surgical procedure. The hypothesis of this study was that a standardized surgical protocol would minimize surgery-related adverse events. This prospective cohort study included 50 patients with a mean age of 63.2 (range 28-92) years treated by one single surgeon using a previously published standardized surgical protocol. Clinical and radiological follow-up examinations were conducted for up to 24 months using Constant-Murley Score (CS), Subjective Shoulder Value (SSV) and radiographs in true anteroposterior, axial and y-view. Finally, CS was 73.9 (standard deviation [SD]: 14.0) points (89% compared to the uninjured shoulder), and SSV was 83.3% (SD: 16.7) at two years of follow-up. Postoperative radiologic evaluation revealed no primary surgical-related or soft-tissue-related complications (0%). The main complications were secondary, biological complications (20%), largely represented by avascular necrosis (8%). Eight patients underwent revision surgery, mainly for implant removal. In addition, a total of four patients were revised using a hemiarthroplasty (n = 2), reverse shoulder arthroplasty (n = 1) or re-osteosynthesis. The use of our standardized surgical technique on proximal humerus fractures improves fixation with regard to primary stability and prevents primary, surgical-technique-related complications. The subjective grading of a high level of difficulty surgery was associated with more complications.

Radiocapitellar Arthroplasty: Systematic Review

Introduction

Primary elbow osteoarthritis affects approximately 2% of the population, and has been treated with arthroplasty. However, total elbow arthroplasty (TEA) implants currently have severe weight limitations and issues with longevity. In patients with unicompartmental arthritis, unicompartmental arthroplasty may be used instead of TEA. We describe the use of Uni-Elbow Radio-Capitellum and Lateral Resurfacing Elbow for radiocapitellar arthroplasty (RCA) in this article.

Methods

Reviewers independently searched databases for keywords, such as radiocapitellar arthroplasty, RCA, uni-elbow radiocapitellum, UNI-E, and lateral resurfacing elbow, LRE. The measured outcomes of interest were the change in motion arc and patient-reported outcome scores. Studies that were not of appropriate quality determined by the Cochrane risk of bias summary tool and review studies were excluded.

Results

RCA resulted in a postoperative 38.3° ± 28.5° increase in elbow flexion-extension (P < .001), and 35.2° ± 28.6° increase in elbow pronation-supination (P < .001). Mayo Elbow Performance Score was significantly increased by 44.8 ± 12.6. DASH Score saw a significant reduction by 45.0 ± 14.6 points (P < .001), while the American Shoulder and Elbow Surgeons Score increased by 47.0 ± 10.6 points (P < .001). Of the 105 adult patients 16.2% experienced complications such as minor stiffness, ulnar neuropathy, component loosening, or radial head UNI-E stem failure. Reported complications were higher in the UNI-E group than in the LRE group.

Conclusion

RCA has shown promise as an option to treat radiocapitellar arthritis, particularly when excising the radial head causes lateral column instability.

Surgical treatment of proximal humerus fractures: a systematic review and meta-analysis

INTRODUCTION

The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing surgical interventions for proximal humerus fractures.

METHODS

Systematic review of Medline, Embase, Scopus, and Google Scholar, including all level 1-3 studies from 2000 to 2022 comparing surgical treatment with ORIF, IM nailing, hemiarthroplasty, total and reverse shoulder arthroplasty (RTS) was conducted. Clinical outcome scores, range of motion (ROM), and complications were included. Risk of bias was assessed using the Cochrane Collaboration's ROB2 tool and ROBINs-I tool. The GRADE system was used to assess the overall quality of the body of evidence. Heterogeneity was assessed using χ² and I² statistics.

RESULTS

Thirty-five studies were included in the analysis. Twenty-five studies had a high risk of bias and were of low and very low quality. Comparisons between ORIF and hemiarthroplasty favored ORIF for clinical outcomes (p = 0.0001), abduction (p = 0.002), flexion (p = 0.001), and external rotation (p = 0.007). Comparisons between ORIF and IM nailing were not significant for clinical outcomes (p = 0.0001) or ROM. Comparisons between ORIF and RTS were not significant for clinical outcomes (p = 0.0001) but favored RTS for flexion (p = 0.02) and external rotation (p = 0.02). Comparisons between hemiarthroplasty and RTS favored RTS for clinical outcomes (p = 0.0001), abduction (p = 0.0001), and flexion (p = 0.0001). Complication rates between groups were not significant for all comparisons.

CONCLUSIONS

This meta-analysis for surgical treatment of proximal humerus fractures demonstrated that ORIF is superior to hemiarthroplasty, ORIF is comparable to IM nailing, reverse shoulder arthroplasty is superior to hemiarthroplasty but comparable to ORIF with similar clinical outcomes, ROM, and complication rates. However, the study validity is compromised by high risk of bias and low level of certainty. The results should therefore be interpreted with caution. Ultimately, shared decision making should reflect the fracture characteristics, bone quality, individual surgeon's experience, the patient's functional demands, and patient expectations.

LEVEL OF EVIDENCE

Level III; systematic review and meta-analysis.

Why locking plates for the proximal humerus do not fit well

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE OR CLINICAL RELEVANCE

Basic science study.

Long-stemmed Hemiarthroplasty with Cerclage Wiring for the Treatment of Split-Head Fractures of the Proximal Humerus with Metaphyseal Extension: A Report of 2 Cases

Introduction

Complex fractures of the proximal humerus with splitting-head component and metaphyseal propagation are very rare injuries that are difficult to treat. Preservation of the humeral head is always considered except in cases with severe comminution and compromised vascularity where shoulder hemiarthroplasty is an alternative option.

Case Report

We present two male patients, 57- and 62-years-old who sustained such a complex proximal humeral fracture after a high-energy injury. They both managed with long-stemmed shoulder hemiarthroplasty and cerclage wiring of the metaphyseal area. They both demonstrated good clinical and radiological outcome at 32- and 24-months postoperatively.

Conclusion

We report the functional and radiological outcomes of two cases of a rare proximal humeral fracture's pattern - combination of splitting-head and metaphyseal comminution – that were managed with long-stemmed hemiarthroplasty and cerclage wire and demonstrated good midterm clinical outcome.

Cow-hitch fixation in fracture hemiarthroplasty

Background

The treatment of complex proximal humerus fractures with hemiarthroplasty is associated with a high failure rate due to secondary displacement of the tuberosities. It was the aim of this in-vitro study to compare the mechanical stability of tuberosity reattachment obtained with the so-called “Cow-Hitch” (CH) cerclage compared with conventional tuberosity reattachment.

Methods

A 4-part proximal humerus fracture was created in 10 fresh-frozen, human cadaveric shoulders. The greater and lesser tuberosity were reattached to the hemiarthroplasty stem with in total 4 CH Cerclages in the Cow-Hitch group. The conventional technique—recommended for the tested implant—was used in the control group using 6 sutures. A total of 5000 loading cycles with forces of 350N were applied, while motion (in mm) of the tuberosities was recorded in 3 directions (anteroposterior = AP, mediolateral = ML, inferosuperior = IS) with a telecentric camera.

Results

After 5000 loading cycles, the CH group showed less fragment displacement (AP: 2.3 ± 2.3 mm, ML: 1.8 ± 0.9 mm, IS: 1.3 ± 0.5 mm) than the conventional group (AP: 9.8 ± 12.3 mm, ML: 5.5 ± 5.6 mm, IS: 4.5 ± 4.7 mm). The differences were not statistically significant (AP: P = .241; ML: P = .159; IS: P = .216). The lesser tuberosity fragment displacement in the CH group after 5000 cycles was less in the AP (2.3 ± 3.3 vs. 4.0 ± 2.8, P = .359) and IS (1.9 ± 1.2 vs. 3.1 ± 1.8; P = .189) directions but higher in the ML direction (7.2 ± 5.7 vs 6.3 ± 3.6, P = .963).

Conclusions

In-vitro, “Cow-Hitch” cerclage results in mean greater tuberosity displacements of 2 mm and reliably prevents displacements greater than 5 mm. In contrast, the conventional fixation technique yields unreliable, variable stability with low to complete displacement upon cyclical loading.

Outcomes of Management of Proximal Humeral Fractures with Patient-Specific, Evidence-Based Treatment Algorithms

BACKGROUND

Previous studies have identified risk factors for different types of treatment of proximal humeral fracture (PHF) and allowed the development of a patient-specific, evidence-based treatment algorithm with the potential of improving overall outcomes and reducing complications. The purpose of this study was to evaluate the results and complications of treating PHF using this algorithmic approach.

METHODS

All patients with isolated PHF between 2014 and 2017 were included and prospectively followed. The initial treatment algorithm (Version 1 [V1]) based on patients' functional needs, bone quality, and type of fracture was refined after 2 years (Version 2 [V2]). Adherence to protocol, clinical outcomes, and complications were analyzed at a 1-year follow-up.

RESULTS

The study included 334 patients (mean age, 66 years; 68% female): 226 were treated nonoperatively; 65, with open reduction and internal fixation (ORIF); 39, with reverse total shoulder arthroplasty (RTSA); and 4, with hemiarthroplasty. At 1 year, the preinjury EuroQol 5-Dimension (EQ-5D) values were regained (0.88 and 0.89, respectively) and the mean relative Constant Score (CS) and Subjective Shoulder Value (SSV) (and standard deviation [SD]) were 96% ± 21% and 85% ± 16%. Overall complications and revision rates were 19% and 13%. Treatment conforming to the algorithm outperformed non-conforming treatment with respect to relative CS (97% versus 88%, p = 0.016), complication rates (16.3% versus 30.8%, p = 0.014), and revision rates (10.6% versus 26.9%, p < 0.001).

CONCLUSIONS

Treating PHF using a patient-specific, evidence-based algorithm restored preinjury quality of life as measured with the EQ-5D and approximately 90% normal shoulders as measured with the relative CS and the SSV. Adherence to the treatment algorithm was associated with significantly better clinical outcomes and substantially reduced complication and revision rates.

LEVEL OF EVIDENCE

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

Efficacy of Hemiarthroplasty vs. Locking Plate Fixation for Proximal Humerus Fractures: A Meta-Analysis

Background: Proximal humerus fractures are common in a clinic and account for ~6% of all adult fractures. Hemiarthroplasty (HA) or locking plate (LP) fixation is currently recommended for the treatment of complex proximal humerus fractures (PHFs); however, there is no uniform standard for optimal surgical treatment or functional recovery. We conducted a meta-analysis to compare the efficacy of LP and HA in the treatment of PHFs. Methods: Relative studies associated with HA and LP were searched in December 2020 in the PubMed, Embase, Cochrane Library, and OVID databases. The quality of the studies, functional outcomes (including the Constant-Murley score (CMS), American Shoulder and Elbow Surgeons Score (ASES), Simple Shoulder Test (SST), Short Form Health Survey (SF-12v2), complications, and reoperation rate were extracted and analyzed with the Stata 14.0 software. Results: A total of 958 patients from 12 studies were included in the meta-analysis, which showed that patients treated with LP had a significantly lower reoperation rate, a higher complication rate, and a higher CMS score than those treated with HA. There were no significant differences in ASES, SST, or SF-12v2 scores between treatment groups. Conclusions: Compared with HA, LP exhibited better clinical efficacy in some aspects. However, large sample and randomized, controlled studies are needed for further validation.

Reverse total shoulder arthroplasty provides better shoulder function than hemiarthroplasty for displaced 3- and 4-part proximal humeral fractures in patients aged 70 years or older: a multicenter randomized controlled trial

BACKGROUND

The most appropriate treatment for displaced multiple-fragment proximal humeral fractures in elderly patients is currently unclear. Reverse total shoulder arthroplasty (rTSA) is a promising treatment option that is being used increasingly. The purpose of this study was to compare the outcome of rTSA vs. hemiarthroplasty (HA) for the treatment of displaced 3- and 4-part fractures in elderly patients.

METHODS

This was a multicenter randomized controlled trial. We included patients aged ≥ 70 years with displaced 3- or 4-part proximal humeral fractures between September 2013 and May 2016. The minimum follow-up period was 2 years, with outcome measures including the Constant score (primary outcome), Western Ontario Osteoarthritis of the Shoulder index, EQ-5D (EuroQol 5 Dimensions) index, and range of motion, as well as pain and shoulder satisfaction assessed on a visual analog scale.

RESULTS

We randomized 99 patients to rTSA (48 patients) or HA (51 patients). Fifteen patients were lost to follow-up, leaving 41 rTSA and 43 HA patients for analysis. The mean age was 79.5 years, and there were 76 women (90%). The rTSA group had a mean Constant score of 58.7 points compared with 47.7 points in the HA group, with a mean difference of 11.1 points (95% CI, 3.0-18.9 points; P = .007). Compared with HA patients, rTSA patients had greater mean satisfaction with the shoulder (79 mm vs. 63 mm, P = .011), flexion (125° vs. 90°, P < .001), and abduction (112° vs. 83°, P < .001), but there was no difference in Western Ontario Osteoarthritis of the Shoulder index, pain, or EQ-5D index scores. We identified 3 and 4 adverse events in the rTSA and HA groups, respectively. Among patients aged ≥ 80 years (n = 38), there was no difference between rTSA treatment and HA treatment in pain (17 mm vs. 9 mm, P = .17) or shoulder satisfaction (77 mm vs. 74 mm, P = .73).

CONCLUSION

We found that rTSA provides better shoulder function than HA as measured with the Constant score, further emphasized by rTSA patients being more satisfied with their shoulder function. The difference appears to be mainly a result of better range of motion (abduction and flexion) in the rTSA group. The results also indicate that patients aged ≥ 80 years benefit less from rTSA than patients aged 70-79 years.

Novel Technical Factors Affecting Proximal Humerus Fixation Stability

OBJECTIVES

Intra-articular screw cut-out is a common complication after proximal humerus fracture (PHF) fixation using a locking plate. This study investigates novel technical factors associated with mechanical failures and complications in PHF fixation.

DESIGN

A retrospective radiological study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Clinical and radiological data from consecutive PHF patients treated between January 2007 and December 2013 were reviewed.

INTERVENTION

Open reduction and internal fixation with the Synthes Philos locking plate.

MAIN OUTCOME MEASUREMENTS

Postoperative radiographs were assessed for quality of initial reduction, humeral head offset, screw length, number and position, restoration of medial calcar support or the presence of calcar screws, and intra-articular screw perforations. Using SliceOMatic software, we validated a method to accurately identify screws of 45 mm or longer on AP radiographs. Follow-up radiographs were reviewed for complications.

RESULTS

Among 110 patients included [mean age 60 years, 78 women (71%), follow-up 2.5 years] and the following factors were associated with a worse outcome. (1) Screws >45 mm in proximal rows [Odds Ratio (OR) = 5.3 for screw cut-out); (2) lateral translation of the humeral diaphysis over 6 mm (OR = 2.7 for loss of reduction); (3) lack in medial support by bone contact (OR = 4.9 for screw cut-out); (4) varus reduction increased the risk of complications (OR = 4.3).

CONCLUSION

The importance of reduction and calcar support in PHF fixation is critical. This study highlights some technical factors to which the surgeon must pay attention: avoid varus reduction, maximize medial support, avoid screws longer than 45 mm in the proximal rows, and restore the humeral offset within 6 mm or less.

LEVEL OF EVIDENCE

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

LEVEL OF EVIDENCE

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

Radiographic parameter(s) influencing functional outcomes following angular stable plate fixation of proximal humeral fractures

PURPOSE

Radiographic parameters which correlate with poor clinical outcome after proximal humeral fractures could be helpful indicators to answer the question which patients should be followed up closer. Moreover, during surgery, radiographic parameters correlating with unfavourable outcome should be avoided. The primary aim of the study was to compare radiographic measurements between the injured and the contralateral, uninjured shoulder. The secondary aim was to correlate these radiographic parameters with post-operative shoulder function.

METHODS

Fifty-eight patients (age: 55.6 ± 14.4 years, age at surgery) following angular stable plate fixation of a proximal humeral fracture (2-part fractures according to Neer: 24, 3-part: 25, 4-part: 9) were included in this retrospective cohort study. All patients were followed up at least six years (7.9 ± 1.4 after surgical intervention). During follow-up examination, the Constant score (CS) was assessed, and radiographs of both shoulders were taken. Radiographs were analyzed regarding lateral humeral offset, distance between tuberculum and head apex, head diameter, head height, perpendicular height, perpendicular center, vertical height, and angles between head and humeral shaft (CCD and HSA). These parameters were compared between the injured and uninjured shoulder. The cohort was divided in two groups: patients with a CS category of excellent/good and satisfying/worse. Both groups were tested regarding differences of demographic and radiographic parameters.

RESULTS

The distance between tuberculum and head apex (2.6 ± 3.4 mm vs. 4.3 ± 2.1 mm; p = 0.0017), the CCD (123.1 ± 12.9° vs. 130.1 ± 7.3°; p = 0.0005), and the HSA (33.1 ± 12.8° vs. 40.1 ± 7.3°; p = 0.0066) were significantly smaller on the treated shoulder compared to the uninjured side. Patients reached a Constant score of 80.2 ± 17.4 (95% CI 75.6-84.8) points. Regarding outcome categories of the Constant score, 46 patients had a good to excellent outcome, and 12 patients had a satisfying or bad outcome. The comparison of these groups revealed that patients with inferior outcome in the long-term follow-up were older, female, had a more complex fracture type (AO classification), smaller lateral humeral offset, smaller head diameter and height, lower perpendicular height, and lower CCD and HSA angles.

CONCLUSION

If the abovementioned parameters cannot be restored sufficiently during surgery, (reversed) shoulder arthroplasty might be a better solution to reach good post-operative outcome. Moreover, patients presenting these radiographic characteristics in the follow-up, older patients, and patients with a more complex fracture type should be followed up closer to possibly prevent poor shoulder function.

TRIAL REGISTRATION

83 250/2011BO2.

Biological sex impacts perioperative complications after reverse shoulder arthroplasty for proximal humeral fracture

Background

The purpose of this study was to determine the difference in complication rates between males and females undergoing reverse shoulder arthroplasty for proximal humerus fractures. We hypothesized that (1) females were more likely to undergo reverse shoulder arthroplasty for fracture, and (2) males were more likely to sustain a perioperative complication.

Methods

The National Surgical Quality Improvement Program database was queried to identify patients who underwent reverse shoulder arthroplasty for proximal humerus fracture between 2011 and 2018. Patients were stratified based on biological sex. Patient demographics, comorbidities, and 30-day perioperative complication rates were collected. Univariate analyses and multiple variable logistic regression modeling were performed.

Results

About 905 patients were included in the analysis—175 (19.3%) were male and 730 (80.7%) were female. Males were more likely to sustain perioperative complications (26.3% vs. 14.1%; P < .001)—pneumonia (2.9% vs. 0.5%; P = .016), unplanned intubation (2.3% vs. 0.4%; P = .029), and unplanned reoperation (9.1% vs. 1.1%; P < .001). On multivariate analysis, males were at a 2.4-fold increase risk of developing any complication (OR = 2.38 [95% CI 1.55-3.65]; P < .001) and a 10-fold increase risk of returning to the operating room for an unplanned reoperation (OR = 10.59 [95% CI 4.23-27.49]; P < .001) compared with females.

Conclusion

Females were more likely to undergo reverse shoulder arthroplasty for proximal humerus fracture, but males were at increased risk of sustaining short-term complications. This study provides useful information for clinicians to consider when counseling their patients during the perioperative period.

Arthroscopic-Assisted Removal of Proximal Humerus Locking Plates With Capsular Release Significantly Improves Range of Motion and Function

Purpose

To investigate the clinical outcomes following the arthroscopic removal of proximal humerus locking plates for symptomatic hardware after open reduction and internal fixation (ORIF) of proximal humerus fractures.

Methods

Patients who underwent arthroscopic removal of hardware (ROH) with capsular release due to pain and/or immobility after receiving locking plates to treat proximal humerus fractures from 2009 to 2016 were identified. Operative and clinic records were reviewed to obtain demographic information, concomitant procedures during ROH, and pre- and postoperative active shoulder range of motion. Postoperative patient-reported outcomes included the QuickDASH, PROMIS Pain Intensity, Constant, and University of California, Los Angeles shoulder rating scale.

Results

In total, 88 patients were included. Patients were evaluated at a minimum of 6 weeks postoperatively after ROH. Patients with pre- and postoperative active range of motion values demonstrated significant improvements in mean forward elevation (n = 69; 78.4%; 115.1° to 152.1°, P < .001), abduction (n = 29; 33.0%; 70.9° to 138.7°, P < .001), external rotation (n = 49; 55.7%; 43.7° to 58.6°, P = .012), and internal rotation (n = 45; 51.1%; 25.7° to 61.9°, P < .001). Patients also reported positive patient-reported scores, including the QuickDASH (4.1 ± 7.8), PROMIS Pain Intensity (3.5 ± 0.9), Constant (84.6 ± 10.7), and University of California, Los Angeles shoulder rating scale (33 ± 2.9), which were measured 70.6 ± 26.6 months postoperatively. There were no surgical complications, no arthroscopic cases were converted to open, but 2 reported refractures (2.3%).

Conclusions

Arthroscopic-assisted removal of proximal humerus locking plates significantly improves motion and function while allowing for management of concomitant shoulder pathology and potentially avoiding open surgery complications. Given that patients undergoing this procedure frequently have multiple comorbidities, arthroscopic-assisted removal with smaller incisions may minimize risks while restoring shoulder mobility. Therefore, arthroscopic ROH for patients experiencing symptomatic hardware after ORIF is recommended.

Level of Evidence

Level IV, therapeutic case series.

The effect of current and former tobacco use on outcomes after primary reverse total shoulder arthroplasty

BACKGROUND

The purpose of this study was to determine the influence of current and former tobacco use on minimum 2-year clinical and radiographic outcomes after reverse total shoulder arthroplasty (RTSA).

METHODS

Review of primary RTSA patient data identified 186 patients with at least 2 years of follow-up. Patients were classified as nonsmokers (76 patients), former smokers (89 patients), or current smokers (21 patients). Assessment included preoperative and postoperative visual analog scale pain scores, American Shoulder and Elbow Surgeons scores, strength, range of motion, complications, revisions, and narcotic use. Radiographs were analyzed for signs of loosening or mechanical failure.

RESULTS

Overall mean age of the patients was 70 (48-87) years, and mean follow-up was 2.6 (2.0-5.7) years. Smokers (62.1 years) were significantly younger than nonsmokers (70.7 years) and former smokers (70.8 years; P = .00002). All patients had significant improvements in pain, American Shoulder and Elbow Surgeons score, strength, and forward flexion range of motion; however, smokers had higher visual analog scale pain scores (mean, 2.5) than nonsmokers (mean, 1.8) or former smokers (mean, 1.0; P = .014). Otherwise, no differences were found regarding any of the postoperative parameters (P > .05).

CONCLUSIONS

Aside from increased patient-reported pain, current tobacco use does not appear to negatively affect outcomes after primary RTSA. The RTSA design obviates the need for a functioning rotator cuff, possibly mitigating tobacco's negative effects previously demonstrated in rotator cuff repair and anatomic total shoulder arthroplasty. Former users obtained outcomes similar to those of nonusers, suggesting that tobacco use is a modifiable risk factor to achieve optimal pain relief after RTSA.

Mid-term results after proximal humeral fractures following angular stable plate fixation in elderly patients-which scores can be evaluated by a telephone-based assessment?

BACKGROUND

The aim was to evaluate postsurgical outcome in elderly patients (> 70 years) after open reduction and internal fixation (ORIF) of proximal humeral fractures and compare the test-retest agreement of scores which are frequently used to assess the outcome of upper extremity disorders.

METHODS

Ninety patients (78.1 ± 5.2 years) with a minimum follow-up of 2 years (3.7 ± 0.9 years) following angular stable plate fixation of a proximal humeral fracture (2-part: 34, 3-part: 41, 4-part: 12) were enrolled. Two telephone-based interviews assessed Disabilities of the Arm, Shoulder and Hand Score (DASH), Oxford Shoulder Score (OSS), and Constant Score adjusted for interview assessment (CS) by two independent interviewers. Correlations, Bland-Altman analyses, Cross tabulation, and weighted Kappa measure of agreement (k) were calculated to assess differences and the test-retest agreement between the categories of each score.

RESULTS

In the first and second interview, we could state fair outcomes: CS 91 (range 40-100) and 65.5 (23-86), DASH 12.5 (0-64.2) and 18.3 (0-66.7), and OSS 58 (33-60) and 55 (25-60) points. The test-retest correlations were r = 0.67, r = 0.77, and r = 0.71 for CS, DASH, and OSS. Bland-Altman analyses showed absolute mean individual score differences of - 22.3, 4.9, and - 3.0 for CS, DASH, and OSS. Limits of agreement represented possible differences of 21.6%, 15.5%, and 9.0% of CS, DASH, and OSS. The category agreements were medium to high: CS 55.9% (k = 0.08), DASH 87.2% (k = 0.62), and OSS 99.3% (k = 0.74).

CONCLUSION

Patients showed good subjective outcomes. The test-retest agreement of the interview-adjusted CS was low, but telephone-based assessment of OSS and DASH present as an alternative to collect outcomes in elderly patients.

TRIAL REGISTRATION

(250/2011BO2).

Clinical and Radiographic Outcomes After Surgical Treatment of Proximal Humeral Fractures with Head-Split Component

BACKGROUND

Head-split fractures are a subgroup of proximal humeral fractures in which the fracture line affects the articular surface. Limited data are available regarding outcomes and risk factors for failure following surgical treatment of this rare fracture type.

METHODS

Of 45 patients with head-split fractures identified, a total of 30 (67%) were included in this retrospective study, with a mean follow-up of 49 ± 18 months (range, 12 to 83 months). Of those 30, 24 were treated with open reduction and internal fixation (ORIF), 4 with reverse total shoulder arthroplasty (RTSA), and 2 with hemiarthroplasty. Subjective Shoulder Value, Simple Shoulder Test, Constant score, and biplanar radiographs were assessed. Fracture pattern, quality of reduction, eventual complications, revision procedures, and clinical failure (adjusted Constant score < 40) were analyzed, and risk factors for failure were calculated.

RESULTS

The overall complication rate was 83% (ORIF: 21 of 24 [88%]; RTSA: 3 of 4 [75%]; and hemiarthroplasty: 1 of 2 [50%]). The most common complications following ORIF were humeral head osteonecrosis (42%), malunion of the lesser tuberosity (33%), and screw protrusion (29%), whereas all complications following RTSA were related to tuberosity problems. Revision was performed in 7 of 24 (29%) of initial ORIF patients, and no revisions were performed in RTSA or hemiarthroplasty patients. Four patients (17%) who underwent primary ORIF underwent conversion to RTSA, and 3 patients (12.5%) had screw removal due to penetration. The overall clinical failure rate was 50% (ORIF: 12 of 24 [50%]; RTSA: 1 of 4 [25%]; and hemiarthroplasty: 2 of 2 [100%]). No significant association was found between preoperative factors and clinical failure. ORIF and primary RTSA showed higher average clinical outcome scores than primary hemiarthroplasty and secondary RTSA. In general, patients who required revision had worse Subjective Shoulder Value (p = 0.014), Simple Shoulder Test (p = 0.028), and adjusted Constant scores (p = 0.069).

CONCLUSIONS

Head-split fractures of the humerus treated with ORIF showed high complication and revision rates. RTSA resulted in comparable clinical outcomes and complication rates; however, the complications associated with RTSA were mostly related to tuberosity problems, which in this small series did not require revision. Therefore, RTSA may be the most predictable treatment option for head-split fractures in elderly patients.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete list of levels of evidence.

Evidence-based algorithm to treat patients with proximal humerus fractures-a prospective study with early clinical and overall performance results

BACKGROUND

On the basis of patients' demands, bone quality, and fracture type, we developed an evidence-based treatment algorithm for proximal humerus fractures (PHF) that includes all treatment modalities from open reduction and internal fixation, hemiprosthesis, to reverse total shoulder arthroplasty. This study was done to assess its feasibility and early clinical outcome.

MATERIALS AND METHODS

Patients with isolated PHF in 2014 and 2015 were included in this prospective study. The quality of life (EQ-5D) and the level of autonomy before injury were recorded. The fractures were classified and local bone quality was measured. When possible, patients were treated according to the algorithm. Radiographic and clinical follow-up-Constant score, subjective shoulder value, and EQ-5D-took place after 3 months and 1 year. The rate of unplanned surgery was analyzed.

RESULTS

A total of 192 patients (mean age 66 years; 58 male, 134 female) were included. Of these, 160 (83%) were treated according to the algorithm. In total, 132 patients were treated conservatively, 36 with open reduction and internal fixation and 24 with reverse total shoulder arthroplasty or hemiarthroplasty. Generally, the mean EQ-5D before trauma and 1 year after treatment was equal to 0.88 to 0.9 points. After 1 year, the overall mean relative Constant score was 95% and mean subjective shoulder value 84%. Unplanned surgery was necessary in 21 patients.

CONCLUSION

This comprehensive algorithm is designed as a noncompulsory treatment guideline for PHF, which prioritize the patient's demands and biology. The high adherence proves that it is a helpful tool for decision making. Furthermore, this algorithm leads to very satisfying overall results with low complication and revision rates.

Risk Factors for Mortality and Readmission After Shoulder Hemiarthroplasty for Fracture

BACKGROUND

Limited information exists regarding mortality and readmission following proximal humerus fracture. This study examines risk factors following hemiarthroplasty for these fractures.

METHODS

A retrospective analysis of prospectively collected data on 788 patients treated with hemiarthroplasty for acute proximal humerus fracture from January 2005 to December 2011 was conducted. One-year mortality and 30- and 90-day hospital readmission were evaluated. Patient risk factors included age, race, gender, diabetes, American Society of Anesthesiologists (ASA) score, and body mass index.

RESULTS

One-year mortality rate was 5.2%. Patients with ASA ≥3 had 2.37 times (95% confidence interval [CI]: 1.05-5.32) greater mortality risk versus patients with ASA1/2. The 30-day readmission rate was 8.4% and at 90 days was 12.6%. Females had 0.53 risk of readmission versus males (95% CI: 0.29-0.96). Patients with ASA ≥3 had 1.79 (95% CI: 1.04-3.09) risk of 90-day readmission versus patients with ASA1/2; females had 0.52 (95% CI: 0.31-0.85) risk of readmission versus males. Increased age increased all odds ratios.

CONCLUSIONS

Readmission rate after hemiarthroplasty for proximal humerus fracture is significant both at 30 and 90 days and is higher in males. Age and ASA ≥3 correlate with this. Diabetes and obesity were not significant risk factors for readmission or mortality.

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

OBJECTIVES

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

METHODS AND FINDINGS

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

CONCLUSIONS

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

Cost-effectiveness of Open Reduction and Internal Fixation Compared With Hemiarthroplasty in the Management of Complex Proximal Humerus Fractures

Objectives

To determine if open reduction and internal fixation (ORIF) is more cost-effective than hemiarthroplasty (HA) in the management of proximal humerus fracture.

Design

Retrospective cohort study with cost-effectiveness analysis.

Setting

Tertiary referral center in Rochester, NY.

Patients/participants

The records of 459 consecutive patients in whom a proximal humerus fracture was treated surgically at our institution between the years 2002 and 2012 were studied retrospectively. We identified 30 consecutive patients with a mean follow-up of 60.3 months (13.6–134.5 months) of which 15 patients underwent primary ORIF and another 15 underwent primary HA for the management of head-splitting fracture or fracture-dislocation of the proximal humerus.

Intervention

HA or ORIF for the management of proximal humerus fracture.

Main outcome measurements

SF-36 scores were converted to utility weights, and a cost-effectiveness model was designed to evaluated ORIF and HA.

Results

Given the baseline assumptions, ORIF was slightly more costly but also more effective (0.75 quality-adjusted life years [QALY] vs 0.67 QALY) than HA. The incremental cost-effectiveness ratio (ICER) was $5319/QALY for ORIF compared to HA, which is less than the cost-effectiveness standard utilized based on a willingness to pay of $50,000/QALY.

Conclusions

Compared to HA, ORIF is the more cost-effective approach for the surgical management of complex proximal humerus fractures. These data are limited by patient selection which would impact the relative utility scores. These results suggest that ORIF should be considered the preferable surgical approach given payer and patient perspectives. Level of Evidence: This is a Level III retrospective, cohort therapeutic study.

Establishing the appropriate position of proximal humerus locking plates: a cadaveric study of five plating systems and their anatomic reference measurements

BACKGROUND

The present study aimed to determine anatomic references for the placement of five proximal humerus locking plates.

METHODS

Five proximal humerus locking-plate systems were placed on six human shoulder cadavers. Plates were positioned by fluoroscopic confirmation so that the inferior oblique screw was within 5 mm of the inferomedial cortex. Plate position was measured using the superior border of the pectoralis major tendon (PMT) to the bottom of the first slotted or nonlocking hole and top of the plate to the top of the greater tuberosity. The distance from the PMT insertion to the top of the humeral head was measured as a control.

RESULTS

There was consistency within each plating system for both the distance from the PMT insertion to the first hole and the top of the plate to the greater tuberosity: Synthes first-generation [mean (SD) 13.7 mm (3.1 mm); 10 mm (1.3) mm], Synthes second-generation [28.2 mm (2.2 mm); 18.5 mm (2.7 mm)], Biomet OptiLock® [25.5 mm (2.7 mm); 18.7 mm (2 mm)], Stryker AxSOS® [5 mm (2.8 mm); 12.3 mm (3.3 mm)] and Acumed Polarus® [9.5 mm (1.8 mm); 14.8 mm (1.6 mm)].

CONCLUSIONS

The present study provides measurements that improve the accuracy of plate positioning for five plating systems.

Reverse shoulder arthroplasty for complex fractures of the proximal humerus in elderly patients: impact on the level of independency, early function, and pain medication

BACKGROUND

This study investigated early functional outcome, quality of life, and the level of independency in elderly patients after primary reverse shoulder arthroplasty (RSA) for complex fractures of the proximal humerus.

METHODS

This was a prospective case series that included 33 patients, aged ≥70 years, with a high level of independency who received RSA for complex fractures of the humerus (Orthopaedic Trauma Association B2/C) from January 2012 to April 2014.

RESULTS

Level of independency, quality of life (Short Form 36 Health Survey score), early functional outcome (Constant-Murley score, Disabilities of the Arm, Shoulder and Hand Outcome Measure), and pain medication (World Health Organization grading) were obtained at the 6-month follow-up and 1 year after surgery. The Constant-Murley score was 64 ± 14 after 6 months and 71 ± 12 at 1 year (P < .001), reaching 87% compared with the contralateral shoulder. The Disabilities of the Arm, Shoulder and Hand score reached 29 ± 20 at 6 months and 30 ± 21 at 1 year. The Short Form 36 score was comparable to normative data. After 6 months, 84% of our study group were back at their previous level of independency. Within 1 year, this rate increased to 91%. At the 1-year follow-up, analgesia intake was back at the level before the injury in 97% of the patients.

CONCLUSIONS

Primary RSA provides good early functional results, reliable pain control, and excellent restoration of an independent life style in elderly patients. Thus, RSA may be considered for active patients with a high demand on shoulder function.

[Not Available]

Zusammenfassung. Zusammenfassung: Die Komplikationsrate nach Osteosynthese von proximalen Humerusfrakturen ist trotz neu entwickelten Implantaten hoch. Wir sind der Meinung, dass die hohe Individualität der Patienten auch einen möglichst individuellen Therapieansatz benötigt. Somit definierten wir einen evidenzbasierten Behandlungsalgorithmus, der die Patientenindividualität und das ganze Behandlungsspektrum beinhalten sollte. Wir suchten dabei nach einem optimalen Weg zwischen Risiko (Komplikationen) und Ertrag (Schulterfunktion). Vor allem die Lebensqualität sollte nach der Frakturbehandlung wieder möglichst gut sein. Die ersten Resultate unserer prospektiven Untersuchung sind vielversprechend. Die konservativen Wege im Algorithmus scheinen gut zu funktionieren, nur sehr selten musste davon abgewichen werden. Es zeigt sich jedoch, dass vor allem die Osteosynthesen noch immer komplikationsbelastet sind. Diesbezüglich gilt es, den Algorithmus und die chirurgische Technik in Zukunft noch zu verbessern.

Effect of smoking on complications following primary shoulder arthroplasty

BACKGROUND

The purpose of this study was to examine the effect of smoking on the incidence of complications after primary anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA).

METHODS

All patients who underwent primary TSA or RSA at our institution between 2002 and 2011 and had a minimum 2-year follow-up were included. Smoking status was assessed at the time of surgery. Current smokers, former smokers, and nonsmokers were compared for periprosthetic infection, fractures (intraoperative and postoperative), and loosening after surgery.

RESULTS

The cohort included 1834 shoulders in 1614 patients (814 in smokers and 1020 in nonsmokers). Complications occurred in 73 patients (75 shoulders; 44 in smokers and 31 in nonsmokers). There were 20 periprosthetic infections (16 in smokers and 4 in nonsmokers), 27 periprosthetic fractures (14 in smokers and 13 in nonsmokers), and 28 loosenings (14 in smokers and 14 in nonsmokers). Smokers had lower periprosthetic infection-free survival rates (95.3%-99.4% at 10 years; P = .001) and overall complication-free survival rates (78.4%-90.2%; P = .012) than nonsmokers. Multivariable analyses showed that both current and former smokers had significantly higher risk of periprosthetic infection in comparison with nonsmokers (hazard ratio [HR], 7.27 and 4.56, respectively). In addition, current smokers showed a higher risk of postoperative fractures than both former smokers (HR, 3.63) and nonsmokers (HR, 6.99).

CONCLUSIONS

This study demonstrates that smoking is a significant risk factor of complications after TSA and RSA. These findings emphasize the need for preoperative collaborative interventions, including smoking cessation programs.

Effectiveness and Safety of Interventions for Treating Adults with Displaced Proximal Humeral Fracture: A Network Meta-Analysis and Systematic Review

Purpose

Network meta-analysis (NMA) is a comparatively new evidence-based technique in medical disciplines which compares the relative benefits associated with multiple interventions and obtains hierarchies of these interventions for various treatment options. We evaluated the effectiveness and safety of open reduction and internal fixation (ORIF), hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), intramedullary nailing (IN) and non-operative treatment (NOT) of displaced proximal humeral fractures in adults using Bayesian NMA of data from clinical trials.

Method

PUBMED, EMBASE and CENTRAL in July 2016 were searched and clinical trials that evaluated interventions for treating adults with displaced proximal humeral fractures were identified. Methodological qualities of studies were assessed by the Newcastle—Ottawa Scale and risk of bias using the Cochrane Collaboration tool.

Result

Thirty-four trials involving 2165 participants were included in the study. RSA had significantly the highest Constant score and lower total incidence of complications than ORIF, HA and IN. Moreover, RSA resulted in a lower incidence of additional surgery than ORIF and IN. The rank of treatments in terms high Constant score was: RSA, ORIF, IN, NOT and HA. The rank for reduction in total incidence of complications was: RSA, NOT, HA, IN and ORIF. For lowering the risk of additional surgery, the rank was: RSA, NOT, HA, IN and ORIF.

Conclusion

RSA had the highest probability for improving functional outcome and reduction in the total incidence of complications and requiring additional surgery among the five interventions for treating adults with displaced proximal humeral fracture.

Significant Differences Between Local Reporting and Central Assessment of Radiographic Complications in a Prospective, Multicenter Study About Locking Plate Fixation of Proximal Humerus Fractures

OBJECTIVES

To compare reporting outcomes of radiographic complications conducted by an independent review board and the responsible on-site study personnel in a multicenter study about locking plate fixation of proximal humeral fractures.

DESIGN

Prospective, multicenter study; setting: 9 level I trauma centers.

PATIENTS

One hundred fifty patients (age 50-90) with a radiographically confirmed displaced proximal humeral fracture fixed with a locking plate were included in the study.

INTERVENTION

All radiographic data were reevaluated by an independent review board according to predefined criteria.

MAIN OUTCOME MEASUREMENTS

Differences in outcomes between the review board and the on-site assessment were analyzed with a paired t test. Interrater agreements between the central review board and on-site assessments were estimated by means of kappa statistics.

RESULTS

The review board revealed significantly more radiographic complications than the on-site assessment (P = 0.006), except for the complication "head necrosis." The interrater agreement was slight to moderate in all calculated categories.

CONCLUSIONS

Implementation of a complication review board using predefined criteria is recommended for clinical studies to prevent underreporting of radiographic complications by on-site assessment.

Excision and Reimplantation of the Proximal Humerus After Fracture-Dislocation

Fractures of the proximal humerus are common and the treatment for both displaced and comminuted variants remains controversial. Treatment options initially consisted of closed reduction, traction, casting, and abduction splints. In the early 1930s, operative treatment for displaced fractures gained popularity, which continued in the 1940s and 1950s. Humeral head replacement for severely displaced fractures of the proximal humerus was introduced in the 1950s. In the 1970s, the Association for Osteosynthesis/Association for the Study of Internal Fixation popularized plates and screws for fracture fixation, and humeral head prostheses were redesigned. The traditional management of severely displaced proximal humerus fractures has been with arthroplasty because of the significant risk of osteonecrosis of the humeral head following open reduction and internal fixation. The authors present a case of a 51-year-old right-hand-dominant man who sustained a seizure along with a posteriorly displaced proximal humerus fracture-dislocation of the right upper extremity. This was treated with surgical extrusion of the entire humeral head and subsequent open reduction and internal fixation. During the surgical procedure, the patient's humeral head was completely extruded from the body through a posterior incision and then reduced back to the proximal humerus through the standard anterior deltopectoral approach. After 4 years of follow-up, the patient remains pain free, has functional range of motion, and is without signs of osteonecrosis on plain radiographs. This case illustrates that even with complete disruption of the vascular supply to the humeral head, revascularization after osteosynthesis is possible. [Orthopedics. 2016; 39(4):e779-e782.].

Surgical Management of Proximal Humeral Fractures: The Emerging Role of Reverse Total Shoulder Arthroplasty

Acute proximal humeral fractures are common injuries in elderly patients. These fractures can lead to significant pain and functional loss. Nonoperative treatment offers high rates of satisfactory function and pain relief in the majority of fractures, particularly in elderly patients. Open reduction and internal fixation, closed reduction and percutaneous pinning, and hemiarthroplasty are used for treating displaced proximal humeral fractures, depending on patient and fracture characteristics. Recently, reverse total shoulder arthroplasty has gained popularity for treatment of complex proximal humeral fractures due to a rapid recovery of active elevation and activities of daily living function. Although complications remain a concern, early results of reverse total shoulder arthroplasty for proximal humeral fractures have been promising. Future comparative outcome studies are needed to define the indications for reverse total shoulder arthroplasty instead of nonoperative and other operative options. Optimal treatment of proximal humeral fractures requires clinical judgment based on fracture characteristics, bone quality, patient factors, and surgeon experience with the array of available techniques. [Orthopedics. 2016; 39(3):e465-e473.].

Open reduction internal fixation has fewer short-term complications than shoulder arthroplasty for proximal humeral fractures

BACKGROUND

Open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and anatomic or reverse total shoulder arthroplasty (TSA/RTSA) are surgical treatment options for proximal humeral fractures (PHFx). Little is known about comparative complication rates. We aimed to determine whether ORIF for PHFx has fewer 30-day complications than HA and TSA/RTSA and to define independent risk factors for 30-day complications.

METHODS

Patients who underwent ORIF, HA, or TSA/RTSA for PHFx between 2006 and 2013 were identified from the National Surgical Quality Improvement Program database. Potential patient and surgical risk factors and 30-day postoperative complications were extracted. Univariate and multivariate analyses were conducted.

RESULTS

We identified 1791 patients (1262 ORIF, 404 HA, and 125 TSA/RTSA). The overall complication rate was 13.0% in ORIF, 22.0% in HA, and 23.2% in TSA/RTSA (P < .001), driven primarily by rates of blood transfusion. Multivariate analyses demonstrated ORIF was an independent protective factor against minor complications (P = .009) and overall complications (P = .028) but not against major complications (P = .351). Risk factors for overall complications included preoperative sepsis (P < .001), higher American Society of Anesthesiologists Physical Status Classification (P < .001), dependent functional status (P = .002), transfusion of at least 5 units in the 72 hours before surgery (P = .002), longer operative time (P = .003), and a history of chronic obstructive pulmonary disease (P = .028).

CONCLUSIONS

After adjusting for patient factors, ORIF for PHFx remains an independent protective factor against overall complications and minor complications compared with HA and TSA/RTSA, primarily due to lower rates of blood transfusion. Patient comorbidities play a larger role than the procedure selected in predicting short-term complications.

The amount of impaction and loss of reduction in osteoporotic proximal humeral fractures after surgical fixation

After surgical fixation, osteoporotic proximal humeral fractures often show high impaction and loss of reduction. This study aims at assessing the amount of impaction and loss of reduction at a short and medium follow-up. We found an alarming percentage of cases showing these complications in the first postoperative months.

INTRODUCTION

This study seeks to quantify the amount of humeral head impaction and loss of reduction in a consecutive series of osteoporotic proximal humerus fractures treated with a locking plate.

METHODS

A series of displaced proximal humerus fractures were prospectively treated with minimally invasive reduction and ostheosynthesis using a locking plate. Diagnosis and classification of fractures were based on X-ray examination and CT scan. Proximal humerus cortical bone thickness (CBTAVG) was studied to assess osteoporosis. Amount of loss of reduction and head fragment impaction were noted at 3 and 18 months of follow-up. Constant score was calculated at 6 and 18 months of follow-up.

RESULTS

Thirty-one osteoporotic fractures were studied. Most of the fractures (21, 67.7 %) had a CBTAVG of less than 4 mm. At 3 months of follow-up, 7 cases (22.5 %) had significant loss of reduction and the mean amount of impaction was 2.8 mm. At 18 months of follow-up, only 1 additional fracture showed loss of reduction and mean impaction was 3 mm (p < 0.05). At 6 months follow-up, the mean Constant score was 58 %; while at 18 months, it was 70 % (p = 0.02). Amount of impaction was significantly correlated to age of patients (p = 0.031), female sex (p = 0.011), CBTAVG (p = 0.019), and metaphyseal comminution (p = 0.013).

CONCLUSIONS

Osteoporotic proximal humerus fractures may present an important impaction and loss of reduction in the first 3 months after surgery even if treated with a rigid device and multiple head screws. Surgeons treating these osteoporotic fractures should be aware of these complications even when using a rigid device.

Total shoulder arthroplasty for proximal humerus fracture is associated with increased hospital charges despite a shorter length of stay

BACKGROUND

Operation choice is a complex decision in the surgical management of proximal humerus fractures. Recently, there has been an increase in the use of total shoulder arthroplasty (TSA) for complex fracture patterns.

HYPOTHESIS

Patients with proximal humerus fractures who receive TSA are more likely to have higher hospital charges and a prolonged length of stay relative to patients receiving hemiarthroplasty (HA), open reduction with internal fixation (ORIF) or closed reduction with internal fixation (CRIF).

MATERIALS AND METHODS

A statewide electronic database was used to identify 13,316 hospital admissions from 2000-2011 were a proximal humerus fracture was surgically managed in an effort to determine the effect of operation choice on cost and length of stay. A univariate analysis was preformed to examine overall trends in surgical management. Additionally, a periodic, multivariate logistic regression analysis was used to determine how operation choice affected the odds of a high cost hospital stay or a prolonged length of stay after controlling for age, comorbidity burden, gender, and insurance type.

RESULTS

After controlling for confounding factors, patients receiving total shoulder arthroplasty (TSA) were 2.25 times more likely to have high total hospital charges than patients receiving HA and 3.21 times more likely than patients receiving ORIF. Additionally, TSA was found to be a significant negative predictor of prolonged length of stay (pLOS). HA, ORIF and CRIF did not significantly predict pLOS.

DISCUSSION

The use of TSA for acute proximal humerus fractures is associated with increased hospital costs despite a shorter length of stay when compared to other operative choices. As reverse total shoulder arthroplasty becomes more popular for treatment of this injury, it is important that functional outcomes be interpreted in the context of relative cost trade-offs.

LEVEL OF EVIDENCE

Level IV.

Open Reduction and Internal Fixation of Fractures of the Proximal Part of the Humerus

Introduction

We describe the surgical technique for open reduction and internal fixation (ORIF) of proximal humeral fractures with a locking plate.

Step 1 Preoperative Planning

To choose the right candidate, obtain a full understanding of the patient's fracture pattern, activity level and demands, and bone quality; be aware of predictors of complications and poor outcomes.

Step 2 Patient Positioning

Place the patient in the beach-chair position with the arm draped free or in a hydraulic device with good access for the image intensifier.

Step 3 Approach

The deltopectoral approach is generally preferred because of the exposure obtained, the possibility of distal extension, and the minimal risk of nerve injury.

Step 4 Reduction and Fixation of the Tuberosities the Key to Obtaining Marionette-Like Control

The control, reduction, and fixation of the tuberosities are crucial to restore the anterior-posterior force couple of the shoulder and must therefore be done properly no matter what the fracture pattern looks like.

Step 5 Fracture Reduction

After carrying out Steps 1 through 4, perform the reduction techniques for the specific fracture type as described below for types that we think suitable for ORIF with a locking plate.

Step 6 Fixation Implant-Specific Considerations

Plate length and positioning, humeral head screw placement, distal locking, confirming the screw tip position with the image intensifier, and securing the tuberosities.

Step 7 Tenotomy or Tenodesis of the Long Biceps Tendon

Perform a biceps tenotomy if the biceps is displaced out of the groove by the fracture pattern or if you have to open the rotator interval.

Step 8 Wound Closure

Do not close the deltopectoral interval.

Step 9 Rehabilitation

As the failure rate of ORIF of proximal humeral fractures is high, do not force an active rehabilitation protocol.

Results

In our analysis of 269 fractures followed for twelve months, we found that the Constant-Murley score (CMS) and Short Form-36 (SF-36) score improved continuously during the first six months postoperatively.IndicationsContraindicationsPitfalls & Challenges.

Factors predicting complication and reoperation rates following surgical fixation of proximal humeral fractures

BACKGROUND

The purpose of this study was to report complication and reoperation rates following non-arthroplasty fixation of shoulder fractures determined on the basis of observational, population-based data from all inpatient admissions in California over an eleven-year period.

METHODS

Records from all inpatient hospital discharges and subsequent readmissions related to operative non-arthroplasty treatment of proximal humeral fractures were obtained for patients in California from December 1994 through December 2005. These admissions were evaluated to identify patient and hospital characteristics associated with short and intermediate-term complications (within and after ninety days, respectively) as well as reoperation rates. Procedures performed included open reduction and internal fixation in 9254 patients, closed reduction and internal fixation in 1903 patients, and internal fixation without reduction in 302 patients.

RESULTS

The short-term complications included mortality in 401 patients (3.5%), which was associated with a higher Charlson comorbidity index (odds ratio [OR] = 1.5, p < 0.001) and male sex (OR = 1.7, p < 0.001); and pulmonary embolism in sixty patients (0.5%), which was associated with male sex (OR = 2.2, p = 0.007) and patient age of seventy-five years or older (OR = 3.6, p = 0.001). Intermediate-term reoperations included conversion to hemiarthroplasty in 174 patients (1.5%); and conversion to total shoulder arthroplasty in eight patients (0.07%), which was associated with an age of fifty to sixty-four years (hazard ratio = 2.8, p = 0.007). Overall, an age of sixty-five years or older, male sex, residence in an area with an income in the lowest two quintiles, and the presence of preexisting comorbidities were associated with elevated risks of short-term complications but not of intermediate-term conversion to arthroplasty. The ninety-day revision rate was 5.3%.

CONCLUSIONS

Surgical fixation of proximal humeral fractures has a low complication and mortality profile. The data provided in this study can serve in counseling patients about risks associated with operative fixation of displaced proximal humeral fractures.

The incidence of proximal humeral fractures in New York State from 1990 through 2010 with an emphasis on operative management in patients aged 65 years or older

BACKGROUND

Proximal humeral fractures are commonly encountered injuries. The development of locking plate technology and reverse shoulder arthroplasty may have changed the treatment patterns of these fractures.

METHODS

We used the Statewide Planning and Research Cooperative System database in New York State to determine the incidence of proximal humeral fractures from 1990 through 2010 and the choice of treatment: closed reduction-internal fixation, open reduction-internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA).

RESULTS

The population-adjusted incidence per 100,000 increased from 15.35 in 1990 to 19.4 in 2010 (P < .0001). In patients aged 65 years or older, the incidence increased from 78.9 in 1990 to 101.0 in 2010 (P < .0001). In 1990, 20.4% of proximal humeral fractures were treated operatively; in 2010, this increased to 28.6% (P < .0001). Closed reduction-internal fixation/ORIF accounted for 58.4% of operative cases in 1990, decreasing to 46.6% in 2001 and increasing to 59.4% in 2010. HA was used in 27.1% of operative cases in 1990, increasing to 41% in 2001 and decreasing to 29.4% in 2010. TSA was used in 6.4% of operative cases in 1990, decreasing to 1.5% in 2001 with an increase to 7.5% in 2010.

DISCUSSION

The incidence of proximal humeral fractures in patients aged 65 or older increased by 28% between 1990 and 2010, and operative management increased by more than 40%. The use of ORIF increased between 2001 and 2010, corresponding with the use of locking plate technology. There was an associated decrease in HA. TSA increased between 2006 and 2010, corresponding to the use of reverse shoulder arthroplasty.

A review of management options for proximal humeral fractures

Proximal humeral fractures are common and although the majority can be managed non-operatively, the optimal treatment of displaced or complex fractures remains controversial. Non-operative treatment is typically selected for minimally displaced fractures where union rates are high and good or excellent outcomes can be expected in approximately 80% of cases. The aims of surgical fixation are to restore articular surface congruency, alignment and the relationship between the tuberosities and the humeral head. Hemiarthroplasty provides patients with reliable pain relief and its indications include fracture dislocations, humeral head splitting fractures and some three- and four- part fractures. The key areas of surgical technique that influence functional outcome include correctly restoring the humeral height, humeral version and tuberosity position. Function, however, is poor if the tuberosities either fail to unite or mal-unite. The interest in reverse shoulder arthroplasty as an alternative option has therefore recently increased, particularly in older patients with poor bone quality and tuberosity comminution. The evidence supporting this, however, is currently limited to multiple case series with higher level studies currently underway.

The amount of humeral head impaction of proximal humeral fractures fixed with the Humerusblock device

PURPOSE

The Humerusblock is a minimally invasive device allowing fixation of proximal humeral fractures. A drawback of the device is possible K-wire perforation of the head with the need for early removal of the implant. We assessed the amount of humeral head impaction and its role in the postoperative varus/valgus deviation of the humeral head in fractures of the upper humerus treated with Humerusblock.

METHODS

Fractures were classified according to the Codman-Lego system. The length of the posteromedial metaphyseal extension and integrity of medial hinge were measured; metaphyseal comminution was assessed. Accuracy of fracture reduction was classified as excellent to poor. An original method of measurement of amount of postoperative impaction of the humeral head was developed. The impaction and varus/valgus inclination of the heads were measured comparing postoperative and three-month follow-up radiographs. Constant score and its relation to sintering was calculated at 12-month follow-up.

RESULTS

Forty-three fractures were available for follow-up. The amount of humeral head impaction was 3.9 mm on average and was directly correlated with patient's age, sex, Codman-Lego classification, varus inclination and mataphyseal comminution. The postoperative cervico-diaphyseal angle was restored in 35 cases, with 81 % good results. The Humerusblock was removed in 41 % of cases because of K-wire perforation of the humeral head. A negative correlation was found between impaction and Constant score.

CONCLUSIONS

The amount of humeral head impaction is related to patients' age, sex, and fracture patterns, being the most prone to compaction those with metaphyseal comminution. Humeral head impaction negatively affects final Constant score.

Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty

BACKGROUND

Significant controversy surrounds optimal treatment of displaced 4-part proximal humeral fractures. Reverse total shoulder arthroplasty (RTSA) has recently been proposed as an alternative to hemiarthroplasty (HA) and open reduction-internal fixation (ORIF). Several authors have questioned the additional implant cost for RTSA. The purpose of this study was to compare outcomes and cost of RTSA, HA, and ORIF.

MATERIALS AND METHODS

We prospectively evaluated patients who underwent RTSA for displaced 3- and 4-part proximal humeral fractures and then retrospectively developed age- and sex-matched control groups with 3- and 4-part proximal humeral fractures who underwent HA and ORIF. Range of motion including active forward elevation and external rotation and time to achieve active forward elevation >90° were recorded. American Shoulder and Elbow Surgeons (ASES), Short-Form 12-item (SF-12), and Simple Shoulder Test (SST) scores were recorded. In addition, treatment cost was assessed by Medicare data and implant list prices.

RESULTS

This study enrolled 27 patients; 9 underwent RTSA, 9 HA, and 9 ORIF. Minimum follow-up was 1 year. No significant differences were seen in SST, ASES, or SF-12 scores. Significantly more patients achieved >90° of active forward elevation after RTSA (P = .012). RTSA provided significant cost savings to Medicare compared with HA and ORIF (P = .002.)

CONCLUSION

In this case-control study, RTSA appears to provide superior range of motion earlier and more predictably than HA and ORIF, with significant cost savings to Medicare.

Biomechanical evaluation of locking plate fixation of proximal humeral fractures augmented with calcium phosphate cement

OBJECTIVES

To evaluate the influence of calcium phosphate cement augmentation on failure of locking plate fixation of proximal humeral fracture fixation in a cadaveric fracture model.

METHODS

A 5-mm wedge osteotomy was created in each of 11 paired fresh-frozen human cadaveric humeri (age > 65 years). Specimens were randomly assigned to receive either locked plate fixation (group 1) or locked plate fixation with cement augmentation (group 2). Constructs were tested for axial stiffness, load to failure, and failure mode using a material testing machine.

RESULTS

Cement-augmented specimens resisted higher loads (1936 ± 609 N) in comparison to nonaugmented specimens (1373 ± 590 N) (P = 0.01). In group 1, varus displacement and glenohumeral screw perforation occurred in all cases. Varus displacement occurred in 2 cases in group 2, whereas glenohumeral screw perforation did not occur in any of the cases. Cement augmentation led to a significant increase in axial stiffness (P = 0.04).

CONCLUSIONS

Calcium phosphate cement-augmented locking plates enhanced fixation stability in proximal humeral fractures and reduced glenohumeral screw perforation in this 2-part cadaveric model. The ultimate advantage of this method remains to be determined in vivo.

The musculoskeletal effects of cigarette smoking

➤ Cigarette smoking decreases bone mineral density and increases the risk of sustaining a fracture or tendon injury, with partial reversibility of these risks with long-term cessation of smoking. ➤ Cigarette smoking increases the risk for perioperative complications, nonunion and delayed union of fractures, infection, and soft-tissue and wound-healing complications. ➤ Brief preoperative cessation of smoking may mitigate these perioperative risks. ➤ Informed-consent discussions should include notification of the higher risk of perioperative complications with cigarette smoking and the benefits of temporary cessation of smoking.

Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome

BACKGROUND

Locking plates for open reduction-internal fixation (ORIF) of proximal humeral fractures are widely used. We observed an unusually high number of patients with complications referred to our institution. It was the purpose of this study to report these complications, as well as their treatment and outcome.

MATERIALS AND METHODS

From 2003 to 2010, all patients treated for complications after ORIF with locking plates for proximal humeral fractures were prospectively collected and retrospectively analyzed. Patients were followed up clinically and radiographically.

RESULTS

In total, 121 patients (67 women and 54 men; mean age, 59 years) were referred after primary locking plate ORIF; 80% had a 3- or 4-part fracture. A mean of 3 complications occurred per patient, including malreduction, primary screw cutout, malunion, nonunion, avascular necrosis, and infection. Secondary screw cutout was found in 57% of patients, causing glenoid destruction in 33% of patients. A mean of 1.5 revision surgeries were needed. Hemiarthroplasty, total shoulder arthroplasty, and reverse shoulder arthroplasty improved the mean Constant score (24 to 55 points, P < .05; 29 to 54 points, P = .3; and 25 to 48 points, P < .05, respectively) after a mean of 24 months. In 6 patients, glenoid implantation was no longer possible because of the destruction by perforated head screws.

CONCLUSION

In this negatively selected series, complications resulted in secondary arthroplasties in over 50% of the patients. Shoulder function, though improved, remained substantially restricted even after revision surgery. Glenoid destruction by locking screws was the most devastating and previously almost unseen complication, which limited the options of treatment.