1
|
Mishra P, Iqbal M, Faraj A. Functional Outcome of Distal Radial Fractures in Patients With a Mean Age of 75 Years at a Mean Follow-Up of 5.4 Years. Cureus 2020; 12:e11959. [PMID: 33312828 PMCID: PMC7725202 DOI: 10.7759/cureus.11959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Purpose Distal radial fractures in the elderly are common and present in a wide spectrum of severity. Their management is varied. The aim of this retrospective case review is to evaluate the late functional outcome of surgically treated distal radial fractures in the elderly population. Methods Forty-two patients (36 female and six male) were surgically treated for an unstable distal radial fracture. The mean age of the patients was 75 years. Frykman classification was used to assess the severity of the injury. Surgical options used were reduction and K wires (19 patients) or open reduction and internal fixation (ORIF) using volar distal radial plate fixation (23 patients). At a mean follow-up of 5.4 years, a validated questionnaire (Patient Rated Wrist Evaluation-PRWE) of the functional ability was completed for each patient. Results The outcome in both groups was satisfactory (PRWE 40-50) with no significant statistical difference, however, a better functional outcome (<40 PRWE) was achieved in the K wire group compared to the ORIF group. Factors such as post injury fear from fall, weakness of grip, wrist pain, and other comorbidities altered the predicted functional outcome score. Conclusion In conclusion, surgically treated fractures in the elderly generally lead to good outcomes. However, confounding factors can contribute to unpredictable results despite good surgical reduction and fixation.
Collapse
Affiliation(s)
- Pranav Mishra
- Trauma and Orthopaedic Surgery, Scarborough Hospital, Scarborough, GBR.,Trauma and Orthopaedics, University Hospitals Leicester, Leicester, GBR
| | - Mohammad Iqbal
- Orthopaedics and Trauma, Scarborough Hospital, Scarborough, GBR
| | - Adnan Faraj
- Orthopaedics and Trauma, Scarborough Hospital, Scarborough, GBR
| |
Collapse
|
2
|
Frank FA, Niehaus R, Borbas P, Eid K. Risk factors for secondary displacement in conservatively treated proximal humeral fractures. Bone Joint J 2020; 102-B:881-889. [PMID: 32600138 DOI: 10.1302/0301-620x.102b7.bjj-2020-0045.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Conservative treatment of moderately displaced proximal humeral head fractures yields good clinical results, but secondary fragment displacement may occur. Identification of those fractures at risk of displacement may influence initial decision-making. METHODS A total of 163 shoulders in 162 patients with conservatively treated isolated proximal humeral fractures were included. The fractures occurred between January 2015 and May 2018. The mean age of the patients was 69 years (26 to 100) and the mean follow-up was 144 days (42 to 779). The fractures were classified according to Neer. Scores for osteoporosis (Tingart, Deltoid Tuberosity Index (DTI)) and osteoarthritis (OA) of the glenohumeral joint were assessed. Translation of the head on follow-up radiographs of more than 10 mm was defined as displacement. Eccentric head index (EHI) describes the offset of the humeral head centre in relation to the diaphyseal axis. The ratio was estimated on anteroposterior (AP) and Neer views. Medial hinge was considered intact if the medial cortex proximal and distal to the fracture was in line on AP view. RESULTS Secondary fracture displacement occurred in 41 patients (25.2%). Clinical risk factors were alcohol abuse (odds ratio (OR) 6.8; 95% confidence interval (CI) 1.3 to 36; p = 0.025) and previously diagnosed osteoporosis (OR 4.6; 95% CI 0.6 to 34; p = 0.136). Age (OR 1.1; 95% CI 1.0 to 1.1; p = 0.003) and sex (OR 0.9; 95% CI 0.3 to 2.8; p = 0.867) were not independent factors. Radiological risk factors were OA grade 3 (OR 16.4; 95% CI 0.25 to 37.6; p = 0.107) and osteoporosis with the DTI (OR 10; 95% CI 0.8 to 250; p = 0.031) being more predictive than the Tingart score (OR 2.3; 95% CI 0.8 to 4.7; p = 0.041). A high EHI (AP/Neer > 0.4, OR 18.9; 95% CI 2.1 to 30.9/3.0; 95% CI 1.1 to 8.0; p = 0.002/p = 0.033) and a disrupted medial hinge (OR 3.7; 95% CI 1.1 to 12.6; p = 0.039) increased the risk of secondary displacement significantly. Neer classification had no influence. CONCLUSION During conservative treatment, a quarter of patients showed secondary fracture displacement of at least 10 mm. Patients with alcohol abuse, severe OA, and osteoporosis are at risk. Newly defined EHI and disrupted medial hinge are relevant predictors for secondary displacement. Cite this article: Bone Joint J 2020;102-B(7):881-889.
Collapse
Affiliation(s)
- Florian A Frank
- Orthopaedic Surgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Richard Niehaus
- Orthopaedic and Trauma Surgery, Kantonsspital Baden, Baden, Switzerland
| | - Paul Borbas
- Orthopaedic and Trauma Surgery, Kantonsspital Baden, Baden, Switzerland
| | - Karim Eid
- Kantonsspital Baden, Baden, Switzerland
| |
Collapse
|
3
|
Nowak LL, Davis AM, Mamdani M, Beaton D, Schemitsch EH. A concept analysis and overview of outcome measures used for evaluating patients with proximal humerus fractures. Disabil Rehabil 2019; 43:1450-1462. [PMID: 31479302 DOI: 10.1080/09638288.2019.1649728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE It is unclear to which degree existing studies evaluate the primary goal of treatment for patients with proximal humerus fractures (restoration of daily activities). Our purpose was to systematically review and analyze the concepts reflected by outcome measures used in studies of patients with proximal humerus fractures. METHODS We reviewed three databases from 2000 to 2018. Two reviewers categorized outcomes in each study into concepts of the International Classification of Functioning, Disability and Health framework. RESULTS The most commonly represented concept across 35 studies was "Body Function/Structure Impairment", followed by aggregate measures that reflect multiple concepts to varying degrees. All patient-reported aggregate measures such as the Disabilities of the Arm, Shoulder, and Hand, American Shoulder and Elbow Surgeon's, and Oxford Shoulder scores better reflected "Activity Limitations", however, these measures were only reported in 34% of studies. CONCLUSION There may be misalignment between what studies measure, and the primary goal of treatment for patients with proximal humerus fractures. The Disabilities of the Arm, Shoulder and Hand, American Shoulder and Elbow Surgeon's, and Oxford Shoulder scores reflect concepts that more adequately address the restoration of daily activities following these injuries, and future studies should include at least one of these measures.Implications for rehabilitationWe have shown that there is a misalignment between what existing studies are measuring (primarily objective measures of impairment) and the primary goal of treatment and rehabilitation (restoring activities of daily living).This suggests that existing studies evaluating different treatment types for proximal humerus fracture patients are providing inadequate information to make evidence-based treatment and rehabilitation decisions following theses injuries.Our results tentatively suggest that the Disabilities of the Arm, Shoulder and Hand, the American Shoulder and Elbow Surgeon's, and Oxford Shoulder scores may better reflect limitations in daily activities following these injuries and should be used in future studies and by clinicians.
Collapse
Affiliation(s)
- Lauren L Nowak
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Clinical Orthopaedic Research, St. Michael's Hospital, Toronto, Canada
| | - Aileen M Davis
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Health Care and Outcomes Research, Krembil Research Institute, University Health Network, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Muhammad Mamdani
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Li Ka Shing Centre for Healthcare Analytics Research and Training, St. Michael's Hospital, Toronto, Canada
| | - Dorcas Beaton
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Musculoskeletal Health & Outcomes Research, Institute for Work Health, Toronto, Canada
| | - Emil H Schemitsch
- Institute of Medical Science, University of Toronto, Toronto, Canada.,Clinical Orthopaedic Research, St. Michael's Hospital, Toronto, Canada.,Division of Orthopaedic Surgery, London Health Sciences Centre, London, Canada
| |
Collapse
|
4
|
Outcomes following fixation for proximal humeral fractures. J Clin Orthop Trauma 2019; 10:468-473. [PMID: 31061571 PMCID: PMC6491912 DOI: 10.1016/j.jcot.2019.01.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 01/30/2019] [Indexed: 11/23/2022] Open
Abstract
Fractures of the proximal humerus are a very common presentation in modern Trauma and Orthopaedic practice. In an ever-aging population, the incidence has dramatically increased resulting in a large socioeconomical burden. The surgical management of these injuries has evolved over the years. Patient outcomes are variable and there is no consensus on treatment approach. This review article focuses on the outcomes following fracture fixation using common surgical techniques.
Collapse
|
5
|
Mellstrand Navarro C, Brolund A, Ekholm C, Heintz E, Hoxha Ekström E, Josefsson PO, Leander L, Nordström P, Zidén L, Stenström K. Treatment of humerus fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and evolution of practice. PLoS One 2018; 13:e0207815. [PMID: 30543644 PMCID: PMC6292626 DOI: 10.1371/journal.pone.0207815] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 11/05/2018] [Indexed: 01/14/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Cecilia Mellstrand Navarro
- Department of Hand Surgery, Karolinska Institute, Institution for Clinical Research and Education, Södersjukhuset Hospital, Stockholm, Sweden
| | - Agneta Brolund
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Carl Ekholm
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Mölndal, Sweden
| | - Emelie Heintz
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Emin Hoxha Ekström
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | | | - Lina Leander
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| | - Peter Nordström
- Department of Community Medicine and Rehabilitation, Geriatrics, Umeå, Sweden
| | - Lena Zidén
- Department of Health and Rehabilitation, The Sahlgrenska Academy at the University of Gothenburg, Institute of Neuroscience and Physiology, Gothenburg, Sweden
| | - Karin Stenström
- Swedish Agency for Health Technology Assessment and Assessment of Social Services, Stockholm, Sweden
| |
Collapse
|
6
|
Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, van der Velde D, van Heijl M, Leenen LPH, Groenwold RHH, Houwert RM. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elbow Surg 2018; 27:1526-1534. [PMID: 29735376 DOI: 10.1016/j.jse.2018.03.009] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/06/2018] [Accepted: 03/11/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is no consensus on the choice of treatment for displaced proximal humeral fractures in older patients (aged > 65 years). The aims of this systematic review and meta-analysis were (1) to compare operative with nonoperative management of displaced proximal humeral fractures and (2) to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. METHODS The databases of MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were searched on September 5, 2017, for studies comparing operative versus nonoperative treatment of proximal humeral fractures; both RCTs and observational studies were included. The criteria of the Methodological Index for Non-Randomized Studies, a validated instrument for methodologic quality assessment, were used to assess study quality. The primary outcome measure was physical function as measured by the absolute Constant-Murley score after operative or nonoperative treatment. Secondary outcome measures were major reinterventions, nonunion, and avascular necrosis. RESULTS We included 22 studies, comprising 7 RCTs and 15 observational studies, resulting in 1743 patients in total: 910 treated operatively and 833 nonoperatively. The average age was 68.3 years, and 75% of patients were women. There was no difference in functional outcome between operative and nonoperative treatment, with a mean difference of -0.87 (95% confidence interval, -5.13 to 3.38; P = .69; I2 = 69%). Major reinterventions occurred more often in the operative group. Pooled effects of RCTs were similar to pooled effects of observational studies for all outcome measures. CONCLUSIONS We recommend nonoperative treatment for the average elderly patient (aged > 65 years) with a displaced proximal humeral fracture. Pooled effects of observational studies were similar to those of RCTs, and including observational studies led to more generalizable conclusions.
Collapse
Affiliation(s)
- Reinier B Beks
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Utrecht Traumacenter, Utrecht, The Netherlands.
| | - Yassine Ochen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Utrecht Traumacenter, Utrecht, The Netherlands
| | - Herman Frima
- Department of Surgery, Kantonsspital Graubünden, Chur, Switzerland
| | | | | | - Tim K Timmers
- Department of Surgery, Meander Medisch Centrum, Amersfoort, The Netherlands
| | | | - Mark van Heijl
- Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands; Department of Surgery, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rolf H H Groenwold
- Julius Center for Health Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R Marijn Houwert
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Utrecht Traumacenter, Utrecht, The Netherlands
| |
Collapse
|
7
|
Tamimi I, Montesa G, Collado F, González D, Carnero P, Rojas F, Nagib M, Pérez V, Álvarez M, Tamimi F. Displaced proximal humeral fractures: when is surgery necessary? Injury 2015; 46:1921-9. [PMID: 26120018 DOI: 10.1016/j.injury.2015.05.049] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/12/2015] [Accepted: 05/31/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Several therapeutic methods have been traditionally used in the treatment of displaced proximal humeral fractures; however, the indication of these treatments is still controversial. The purpose of this study was to compare the medium-term functional results of four methods commonly used in the treatment of proximal humeral fractures [conservative treatment, proximal humeral nails (PHN), percutaneous K-wiring (PKW), and locking-plates (LP)] taking into consideration the type of fracture and the age of the patients. METHODS We conducted a retrospective cohort study on patients with proximal humeral fractures treated with one of the following methods: conservative treatment, PHN, PKW, or LP. Functional results were assessed using the absolute Constant score and the disabilities of the arm shoulder and hand score (DASH). The functional outcome was analysed according to age (≥65 years and <65 years) and fracture type (displaced 2-fragment and 3-4-fragment fractures). RESULTS A total of 113 patients were included in the study, with a mean age of 65.3 SD 15.2 years and average follow-up time of 26.2 SD 12.6 months. Patients under 65 years had higher Constant scores when treated with PHN and PKW than those treated conservatively (77.2 vs. 54.7, p=0.01 and 74.0 vs. 54.7, p=0.03, respectively). Patients above 65 years had higher Constant scores when treated with PKW compared to PHN and conservative treatment (68.7 vs. 51.9, p=0.02 and 68.7 vs. 55.9, p=0.029, respectively). In 2-fragment fractures, PKW resulted in higher Constant scores than conservative treatment (70.4 vs. 53.9, p=0.048). No differences were found in the final outcome between patients treated with LP and those treated conservatively regardless of age, and fracture type. There were also no differences between any of the evaluated methods in the treatment of 3-4-fragment fractures. CONCLUSION The use of PKW was associated with better functional results than conservative treatment in individuals of all ages, especially in patients with 2-fragment fractures; PKW also achieved better functional results than PHN in elderly patients. PHN was superior to conservative treatment in young individuals. No significant differences were found between LP and conservative treatment in any of the analysed categories.
Collapse
Affiliation(s)
| | - Guillermo Montesa
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Francisco Collado
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - David González
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Pablo Carnero
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Facundo Rojas
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Mohamed Nagib
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Verónica Pérez
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Miguel Álvarez
- Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
| | - Faleh Tamimi
- Faculty of Dentistry, McGill University, Montreal, Canada
| |
Collapse
|
8
|
|