Treatment choice affects inpatient adverse events and mortality in older aged inpatients with an isolated fracture of the proximal humerus

A high hospital frailty risk score indicates an increased risk for complications following surgical treatment of proximal humerus fractures

BACKGROUND

Approximately 70 % of proximal humerus fractures (PHF) occur after the age of 60. High complication rates have been described in correlation with the treatment of PHF. Major risk factors for the outcome might be frailty, mobility and comorbidities of patients at the time of hospital admission. The aim of this study was to create risk adjusted quality indicators for surgical treatment of proximal humerus fractures based on German claims data and to evaluate the impact of the Hospital Frailty Risk Score (HFRS) on risk adjustment.

METHODS

Retrospective claims data (2015-2021) were used to create risk adjusted quality indicators for eight outcomes by clustered multivariable logistic regression. The comparison of different risk adjustment model performances was done by ROC-AUC and Standardized Mortality/Morbidity Ratios.

RESULTS

In total, N = 34,912 patients (median age 75 years, 80.3 % female) were included. The most common surgical procedure was open reduction and internal fixation with plate osteosynthesis with 39.7 %, followed by reverse shoulder arthroplasty with 25.3 %. The most influential risk factor for all outcomes was a high HFRS with an Odds Ratio of 2.0 (95 %-Confidence Interval 1.8-2.3) for any secondary surgery (365 days) up to an Odds Ratio of 17.6 (95 %-Confidence Interval 14.9-20.8) for general complications during the index stay.

CONCLUSION

Comparative quality reporting for the surgical treatment of PHF appears feasible with the developed models for risk adjustment using claims data. Preoperative evaluation of HFRS in PHF can contribute to risk assessment, and individual patient management. It therefore enables personalized treatment decisions.

Comparison between arthroplasty and non-operative treatment for proximal humeral fractures: a systematic review and meta-analysis

Background

The clinical efficacy of reverse shoulder arthroplasty (RSA), hemiarthroplasty (HA), and non-surgical management in the treatment of proximal humeral fractures (PHFs) is inconclusive. This systematic review and meta-analysis compared the clinical outcomes of arthroplasty and non-surgical management of PHFs.

Methods

The databases of PubMed, Embase, Web of Science, and Cochrane Library were searched on 5 May 2023 for studies comparing arthroplasty and non-surgical treatment of PHFs. Both randomized controlled trials (RCTs) and non-randomized controlled trials (nRCTs), were included. Standard methodological quality assessments were conducted for both types of studies. The primary outcome was the Constant-Murley Score (CMS) after surgical or non-surgical treatment. Secondary study outcomes included the visual analog scale (VAS), range of motion, and complications. All functional scores and complications were subjected to subgroup and sensitivity analyses.

Results

A total of four RCTs and six nRCTs were included in this study, which provided 508 patients in total for meta-analysis: 238 treated with arthroplasty and 270 treated non-surgically, of which 83 were treated with HA and 155 with RSA. All relevant information was collected, including functional scores, VAS, range of motion, and complications. The study found no significant difference in functional outcomes (mean difference, 2.82; 95% confidence interval, -0.49 to 6.14; P = 0.10; I 2 = 77%) and complications (mean difference, 1.08; 95% confidence interval, 0.51-2.25; P = 0.85; I 2 = 47%) between arthroplasty and non-surgical treatment. Both RCTs and nRCTs showed the same results. However, VAS scores were significantly lower in surgical treatment compared to non-surgical treatment. Subgroup and sensitivity analyses showed that RSA could achieve better functional scores than non-surgical treatment (mean difference, 6.00; 95% confidence interval, 1.97-10.03; P = 0.004; I 2 = 0%), while the results for HA were not significant (P > 0.05).

Conclusion

There were no significant differences in complications between arthroplasty and non-surgical treatment for PHFs. RSA could achieve better functional results than non-surgical treatment, while HA could only achieve better forward flexion.

The Association between Race and Extended Length of Stay in Low-energy Proximal Humerus Fractures in Elderly Patients

INTRODUCTION

Proximal humerus fractures (PHFs) are one of the most common fractures among patients aged 65 years and older, commonly due to low-energy mechanisms. It is essential to identify drivers of increased healthcare utilization in geriatric PHF patients and bring awareness to any disparities in care. Here, we identify factors associated with the likelihood of inpatient admission and prolonged hospital stay among patients aged 65 years and older who sustain PHF due to falls.

METHODS

A national database was used to identify patients aged 65 years and older who suffered proximal humeral fractures due to a fall. Patient factors were analyzed for association with the likelihood of admission and odds of prolonged stay (≥5 days).

RESULTS

In the study period, 75,385 PHF patients who met our inclusion criteria presented to the emergency department and 14,118 (18.7%) were admitted. Black race was significantly associated with decreased odds of admission ( P < 0.001) and increased likelihood of prolonged stay ( P = 0.007) compared with White patients. Patients aged 75 to 84 and 85+ were both more likely to be admitted ( P < 0.001) and experienced a prolonged hospital stay ( P = 0.015). Patients undergoing surgical intervention with reverse total shoulder arthroplasty were associated with admission and prolonged length of stay ( P < 0.001). Hospitals in Midwestern ( P < 0.001) and Western ( P < 0.001) regions exhibited lower rates of admission and Northeastern hospitals were associated with prolonged stays ( P = 0.001). Finally, trauma and nonmetropolitan ( P < 0.001) centers were associated with admission.

CONCLUSION

Our study highlights the notable influence of age and race on the likelihood of hospital admission and prolonged hospital stay. Specifically, Black patients exhibited prolonged hospital stay, which has been associated with lower-quality care, warranting additional exploration. Understanding these demographic and hospital-related factors is essential for optimizing resource allocation and reducing healthcare disparities in the care of PHF patients, especially as the population ages and the incidence of PHF continues to rise.

Factors affecting hospital admission, hospital length of stay and new discharge destination post proximal humeral fracture: a retrospective audit

BACKGROUND

Outcomes following proximal humeral fracture (PHF) may be impacted by a range of clinical, fracture and premorbid factors. The aim of this study was to examine factors impacting hospital admission; length of stay (LOS) and new discharge destination for patients presenting to hospital with PHF.

METHODS

Retrospective audit conducted at a tertiary health service. Data was collected from adult patients presenting to hospital with a PHF over a 54-month period. Fractures that were pathological or sustained during admission were excluded. Univariable and multivariable logistic and negative binomial regression were used to explore factors associated with hospital admission, LOS and new discharge destination.

RESULTS

Data were analyzed from 701 participants (age 70 years (IQR 60, 81); 72.8% female); 276 (39.4%) participants required a hospital admission. New discharge destination was required for 109 (15.5%) participants, of whom 49 (45%) changed from home alone to home with family/friend(s). Greater comorbidities, as indicated by the Charlson Comorbidity Index score, were associated with hospital admission, longer LOS and new discharge destination. Premorbid living situations of home with family/friend(s) or from an external care facility were associated with a decreased likelihood of hospital admission, shorter LOS and reduced risk of a new discharge destination. Surgical treatment was associated with shorter LOS. Older age and dementia diagnosis were associated with a new discharge destination.

CONCLUSIONS

Many factors potentially impact on the likelihood or risk of hospitalization, LOS and new discharge destination post PHF. Patients with greater comorbidities are more likely to have negative outcomes, while patients who had premorbid living situations of home with family/friend(s) or from an external care facility are more likely to have positive outcomes. Early identification of factors that may impact patient outcomes may assist timely decision making in hospital settings. Further research should focus on developing tools to predict hospital outcomes in the PHF population.

The Arterial Axis Lesions in Proximal Humeral Fractures-Case Report and Literature Review

BACKGROUND

This comprehensive review delves into the nuanced domain of arterial axis lesions associated with proximal humeral fractures, elucidating the intricate interplay between fracture patterns and vascular compromise. Proximal humeral fractures, a common orthopedic occurrence, often present challenges beyond the skeletal realm, necessitating a profound understanding of the vascular implications.

METHODS

The study synthesizes the existing literature, presenting a collective analysis of documented cases and their respective clinical outcomes. The spectrum of arterial axis lesions, from subtle vascular compromise to overt ischemic events, is systematically examined, highlighting the varied clinical manifestations encountered in proximal humeral fractures. Diagnostic modalities, including advanced imaging techniques such as angiography and Doppler ultrasound, are scrutinized for their efficacy in identifying arterial axis lesions promptly. The review emphasizes the critical role of early and accurate diagnosis in mitigating the potential sequelae associated with vascular compromise, thereby underscoring the importance of a vigilant clinical approach.

RESULTS

Therapeutic strategies, ranging from conservative management to surgical interventions, are critically evaluated in the context of existing evidence. The evolving landscape of endovascular interventions and their applicability in addressing arterial axis lesions specific to proximal humeral fractures is explored, providing valuable insights for clinicians navigating the therapeutic decision-making process. Furthermore, the review addresses gaps in current knowledge and proposes avenues for future research, emphasizing the need for tailored, evidence-based guidelines in the management of arterial axis lesions in proximal humeral fractures. By consolidating current understanding and pointing towards areas warranting further exploration, this review contributes to the ongoing discourse surrounding the intricacies of vascular complications in orthopedic trauma.

CONCLUSIONS

this comprehensive review provides a synthesized overview of arterial axis lesions in proximal humeral fractures, offering a valuable resource for clinicians, researchers, and educators alike. The findings underscore the multifaceted nature of these lesions and advocate for a holistic, patient-centered approach to their management.

Proximal Humerus Fractures in the Elderly U.S. Population: A Cross-Sectional Study of Treatment Trends and Comparison of Complication Rates after Joint Replacement, Open Reduction and Internal Fixation, and Non-Surgical Management

Proximal humerus fracture (PHF) treatment remains challenging. Multiple therapy options exist, and the optimal choice of management has been increasingly discussed in the literature. The aim of this study was to (1) analyze trends in the propensity of proximal humerus fracture treatments and (2) compare complication rates after joint replacement, surgical repair, and non-surgical treatment in terms of mechanical complications, union failure, and infection rates. In this cross-sectional study, patients aged 65 years or older with proximal humerus fractures occurring between 1 January 2009 and 31 December 2019 were identified from Medicare physician service claims records. The Kaplan-Meier method with the Fine and Gray adjustment was used to calculate the cumulative incidence rates for malunion/nonunion, infection, and mechanical complications for the following treatment categories: shoulder arthroplasty, open reduction and internal fixation (ORIF), and non-surgical treatment, respectively. Semiparametric Cox regression was performed incorporating 23 demographic, clinical, and socioeconomic covariates to determine risk factors. Between 2009 through 2019, conservative procedures decreased by 0.9%. ORIF procedures decreased from 9.51% (95% CI: 8.7-10.4) to 6.95% (95% CI: 6.2-7.7), whereas shoulder arthroplasties rose from 1.99% (95% CI: 1.6-2.4), to 5.45% (95% CI: 4.8-6.2). PHFs managed through ORIF were associated with higher union failure rates compared to conservatively treated fractures (HR = 1.31, 95% CI: 1.15-1.5, p < 0.001). The risk of developing an infection was increased after joint replacement compared to ORIF (2.66% vs. 1.09%, HR = 2.09, 95% CI: 1.46-2.98, p < 0.001). Mechanical complications were more common after joint replacement (6.37% vs. 4.85%, HR = 1.66, 95% CI: 1.32-2.09, p < 0.001). Complication rates differed significantly across treatment modalities. This should be considered when choosing a management procedure. Vulnerable elderly patient cohorts could be identified, and the optimization of modifiable risk factors might lead to a decrease of complication rates in both surgically and non-surgically treated patients.

Management of Proximal Humeral Fractures in Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

Differences in function, pain, and reoperation rates were compared between the following treatment options: (1) operative vs. nonoperative treatment and (2) various surgical treatments including open reduction internal fixation, intramedullary nail, hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA).

DATA SOURCES

MEDLINE, Embase, and Cochrane were searched through February 1, 2022. All English-language randomized trials comparing operative and nonoperative treatment of proximal humeral fractures with a control group in patients 18 years or older were included.

DATA EXTRACTION

Demographic data, functional and pain scores and re-operation rates were extracted. Study quality was determined with the Cochran risk of bias tool and the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE). Heterogeneity was determined with the I-squared statistic.

DATA SYNTHESIS

Meta-analysis of included studies using mean difference and odds ratios where appropriate.

CONCLUSIONS

Surgical treatment with either locked plates or HA results in similar functional scores and pain outcomes as nonoperative treatment, although plates were associated with higher reoperation rates in 3-part and 4-part fractures. In 3-part and 4-part fractures, RSA results in higher function and pain scores compared with HA. Further high-quality trials should focus on RSA, and further study is required to better define the role of open reduction internal fixation in the younger patient population.

LEVEL OF EVIDENCE

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

Morbidity and mortality of fragility proximal humerus fractures: a retrospective cohort study of patients presenting to a level one trauma center

PURPOSE

Fragility fractures are a significant source of morbidity and have high associated mortality. Identifying risk factors for poor outcomes is essential for guiding treatment and for setting expectations for patients and their families. Although fragility hip fractures have been abundantly explored, there is a paucity of information regarding proximal humerus fractures (PHFs).

METHODS

We retrospectively review the electronic medical records of 379 patients who presented to a level 1 trauma center with a PHF secondary to a fall. Patient demographics, handedness, comorbidities, treatment, imaging data, follow-up data, and death date (if applicable) were recorded.

RESULTS

Our cohort consisted of 279 females and 100 males with an average age of 71.4 years. Distribution of injuries was 178 left, 141 right, and 7 bilateral. Compared with handedness, 179 were ipsilateral, 141 were contralateral, and 59 were unknown. A total of 81.3% of injuries were treated nonoperatively, whereas 18.7% were managed surgically. One-year mortality was 17.4%, and 2-year mortality was 24.0%.Males demonstrated a 2.28 increased risk of 1-year mortality (P = .004). Patients who died within 1 year of fracture had significantly higher Charlson comorbidity index scores (P < .0001) and age (P = .0003). Risk of death was significantly lower in patients who underwent surgery compared with those who were treated nonoperatively (P = .01). Patients who used an assist device before fracture had 4.2 increased risk of 1-year mortality (P < .0001). Patients who presented from nursing homes or assisted living had a 2.1 increased risk of 1-year mortality (P = .02). Patients with severe liver disease had a 5.5 increased risk of 1-year mortality (P < .0001), and those with metastatic cancer had a 13.7 increased risk of 1-year mortality (P < .0001). Bilateral fractures, side of injury in relation to handedness, rehospitalization, Neer classification, and PCP follow-up within 30 days were not associated with increased mortality.

CONCLUSIONS

Increased understanding risk factors for mortality after PHF will allow for more informed patient discussions regarding treatment outcomes and risk of death. Our data suggest that mortality at 1 year for fragility PHF is universally high regardless of risk factors. This risk is increased in patients who are older, functionally limited, or who have medical comorbidities. Our data demonstrate the importance of medical optimization of patients with a fragility PHF and underscore the importance of fall prevention in high-risk patients.

Clinical outcomes and structural integrity rate of arthroscopic augmented rotator cuff repairs using extracellular porcine matrix patch

Background

Structural failure rate in rotator cuff repairs is still high. The purpose of the study is to assess the structural integrity of a series of augmented rotator cuff repairs with porcine matrix patch and report the functional outcomes.

Methods

Between 2014 and 2017, 44 consecutive patients underwent arthroscopic double-row repair of medium to massive rotator cuff tears with extracellular porcine dermal matrix augmentation. At one-year follow-up, magnetic resonance imaging scan was performed to assess the integrity of the repair. Oxford Shoulder Score (OSS), Constant Score (CS) and Visual Analogue Scale pain score, together with range of motion were used to assess patients.

Results

Patients mean age was 68 (53-82); mean follow-up was 17.2 (12-24) months. On magnetic resonance imaging scans, seven rotator cuff repair failures (15.9%) were observed: tear size was an independent predictor of re-rupture at one-year follow-up. Clinical scores showed a statistically significant improvement at three months and until final follow-up (p< 0.001). No complications occurred.

Conclusion

Observed structural failure rate of 15.9% is lower than those reported in the literature for standard rotator cuff repair of medium to massive tears in similar cohorts to ours. Extracellular matrix augmentation for rotator cuff repair was shown to be a safe and reliable support to the repairs and patients recovered good shoulder function.Level of Evidence: Level IV.

Surgeons Consider Initial Nonoperative Treatment With Potential for Future Conversion to Reverse Arthroplasty a Reasonable Option for Older, Relatively Infirm, and Less-Active Patients

OBJECTIVES

Two recent developments favor initial nonoperative treatment of proximal humerus fractures among the older, relatively infirm, less-active patients that represent most patients with such fractures: (1) evidence of minimal benefit of open reduction, internal fixation over nonoperative treatment, and (2) evidence of the effectiveness of the reverse total shoulder arthroplasty. As one step in determining the feasibility of a strategy of initial nonoperative treatment of proximal humerus fracture among older, relatively infirm, less-active people, we performed a survey-based experiment to measure factors associated with surgeon recommendation for initial nonoperative treatment.

METHODS

Members of the Science of Variation Group viewed 8 hypothetical patients with radiographs of complex proximal humeral fractures and 7 randomized patient variables. For each scenario, surgeons were asked whether they would recommend (1) initial nonoperative treatment with bailout reverse arthroplasty or (2) immediate reverse arthroplasty.

RESULTS

The mean percentage of recommendations for initial nonoperative treatment was 63%, with wide variation by surgeon (range 0%-100%). In multilevel mixed-effects logistic regression, recommendation for initial nonoperative treatment was associated with specific radiographs, older age, having a comorbidity, being homebound, surgical subspecialists, and more than 20 years in practice.

CONCLUSIONS

These findings suggest that surgeons may consider initial nonoperative treatment with potential for future conversion to reverse arthroplasty an acceptable treatment option, particularly for older, less-active, more infirm individuals, and relatively less displaced fractures with little comminution.

The Surgical Treatment of Proximal Humeral Fractures in Elderly Patients—An Analysis of the Long-Term Course of Locked Plate Fixation and Reverse Total Shoulder Arthroplasty Based on Health Insurance Data

BACKGROUND

The goal of this study is to compare mortality, the frequency of major adverse events, and complication rates after the surgical treatment of proximal humeral fractures with locked plate fixation (LPF) and reverse total shoulder arthroplasty (RTSA) in elderly patients.

METHODS

Health insurance data from patients aged 65 and above over the period January 2010 to September 2018 were retrospectively evaluated. The median follow-up duration after locked plate fixation (40 419 patients) or reverse total shoulder arthroplasty (13 552 patients) was 52 months. Hazard ratios adapted to the patients' risk profiles were determined with the aid of multivariate Cox regression models. The p-values were adjusted with the Bonferroni- Holm method.

RESULTS

After adaptation to the patients' risk profiles, reverse total shoulder arthroplasty was found to be associated with statistically significantly lower mortality (HR: 0.92; 95% confidence interval: [0.88; 0.95]; p <0.001) and fewer major adverse events (HR: 0.92 [0.89; 0.95]; p <0.001) than locked plate fixation. Eight years after surgery, the risk of surgical complications was twice as high for LPF (12.2% [11.9; 12.7]; HR for RTSA versus LPF: 0.5 [0.46; 0.55]; p <0.001 for both), with 3.8% [3.6; 4.0] of the patients receiving a secondary RTSA. Surgical complications were more common (p <0.05) in patients carrying a diagnosis of osteoporosis, obesity, alcohol abuse, chronic polyarthritis, or frozen shoulder.

CONCLUSION

The long-term findings accord with clinical short-term findings from other studies and support the current trend toward more liberal use of inverse shoulder endoprosthesis in elderly patients.

Analysis of predictors of mortality after surgical and non-surgical management in proximal humerus fractures

BACKGROUND

Proximal humerus fractures are one of the main osteoporotic fractures. Choosing between conservative or surgical treatment is a controversial topic in the literature, as is the functional impact. The main aim of our study was to analyse whether patient comorbidities should influence the final therapeutic decision for these fractures.

MATERIAL AND METHODS

We collected data from 638 patients with proximal humerus fractures. The main variable collected was exitus. We also collected the following data: age, gender, type of fracture, laterality, type of treatment, production mechanism, comorbidities and the Charlson comorbidity index (CCI) for each patient. The therapeutic indication used the criteria established by the Upper Limb Unit in our centre. We performed chi-square tests, Fischer's exact tests and Student's t-tests to compare the variables. We used the Kaplan-Meier method to analyse both the overall and disease-specific survival rates. We employed the Cox regression model to analyse factors associated with mortality.

RESULTS

Patients with a CCI greater than 5 showed greater mortality (HR  = 3.83; p  < 0.001) than those with a CCI lower than 5. Within the patients who underwent surgery, those with a CCI higher than 5 had an increased mortality rate (HR  = 22.6; p < 0.001) compared with those with a CCI lower than 5. Within the patients who received conservative treatment, those with a CCI over 5 showed greater mortality (HR  = 3.64; p  < 0.001) than those with a CCI under 5.

CONCLUSIONS

Patients with proximal humerus fractures and associated comorbidities (CCI > 5) presented higher mortality than healthier patients. This mortality risk was greater in patients with comorbidities if surgical treatment was indicated rather than conservative treatment. Patient's comorbidities should be a fundamental parameter when planning the therapeutic strategy.

LEVEL OF EVIDENCE

Level 3.

In-hospital Complications Are More Likely to Occur After Reverse Shoulder Arthroplasty Than After Locked Plating for Proximal Humeral Fractures

BACKGROUND

Currently, there seems to be a paradigm change in the surgical treatment of proximal humeral fractures in patients aged 65 years and older, with a considerable increase in the use of reverse total shoulder arthroplasty (RTSA) compared with angular stable internal fixation (locking plate fixation). However, even among shoulder specialists there is controversy regarding the best treatment strategy.

QUESTIONS/PURPOSES

To evaluate for (1) a greater risk of in-hospital major adverse events, (2) a greater risk for in-hospital surgical complications, and (3) a greater risk of 30-day mortality, locking plate fixation and RTSA were compared for the treatment of proximal humerus fractures of patients aged 65 years and older after controlling for potentially confounding variables in a large-database analysis.

METHODS

Health claims data of the largest German insurance company including approximately one-third of the population (26.5 million policyholders) between 2010 and 2018 were analyzed. This database was chosen because of its size, nationwide distribution, and high quality/completeness. In total, 55,070 patients (≥ 65 years of age) treated with locking plate fixation (75% [41,216]) or RTSA (25% [13,854]) for proximal humeral fracture were compared. As primary endpoints, major adverse events (including acute myocardial infarction, stroke, organ failure, resuscitation, and death) and surgical complications (infection, hematoma, loss of reduction, dislocation, and revision surgery) were analyzed. The risk of all endpoints was analyzed with multivariable logistic regression models in the context of comorbidities to address existing group differences.

RESULTS

After controlling for potentially confounding variables such as age, sex, and risk profile, RTSA was associated with a higher risk for major adverse events (OR 1.40 [95% CI 1.29 to 1.53]; p < 0.001) and surgical complications (OR 1.13 [95% CI 1.05 to 1.21]; p < 0.01) compared with locking plate fixation. There was no evidence for an increase in mortality (OR 0.98 [95% CI 0.86 to 1.12]; p = 0.81).

CONCLUSION

The increased in-hospital risk for major adverse events and surgical complications may moderate the enthusiasm associated with RTSA for proximal humeral fractures in patients 65 years and older. Treatment decisions should be based on individual risk estimation to avoid potential harmful events. Future studies must include long-term outcomes and quality of life to enlighten these findings in a broader context.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Efficacy of the modified Frailty Index and the modified Charlson Comorbidity Index in predicting complications in patients undergoing operative management of proximal humerus fracture

BACKGROUND

Comorbidity indices such as the 5-factor modified Frailty Index (mFI-5) and modified Charlson Comorbidity Index (mCCI) are widely used in outcomes research.

METHODS

A total of 3893 patients who underwent total shoulder arthroplasty (n=975), hemiarthroplasty (n=495), or open reduction and internal fixation (n=2423) for the treatment of proximal humerus fracture from 2005-2017 were identified from the National Surgical Quality Improvement Program database. Data regarding demographics, comorbidities, American Society of Anesthesiologists class, and postoperative complications were collected, and the mFI-5 and mCCI were calculated for each case. Multivariate logistic regression models and receiver operating characteristic curve analyses were performed.

RESULTS

The patient population had a mean age of 68.0 ± 13.2 years, body mass index of 29.1 ± 8.1 and mean operative time of 119.9 ± 55.5 minutes. The most common complications within this cohort were extended length of stay (4 days or more) (1085/3893; 27.87%), transfusion (377/3893; 9.68%), unplanned reoperation (97/3893; 2.49%), urinary tract infection (43/3893; 1.10%), death (42/3893; 1.08%), and deep vein thrombosis (40/3893; 1.03%). After accounting for patient demographics, the mFI-5 (odds ratio [OR] = 1.105, P < .001) and mCCI (OR = 1.063, P < .001) were significantly associated with incidence of any adverse event. Both comorbidity indices had low positive predictive value and high negative predictive value for all adverse events.

CONCLUSION

The comorbidity indices mCCI and mFI-5 are both strongly associated with adverse events but have moderate ability to predict complications following surgical treatment of proximal humerus fractures.

Can We Stratify Quality and Cost for Older Patients With Proximal and Midshaft Humerus Fractures?

Introduction:

This study sought to investigate whether a validated trauma triage tool can stratify hospital quality measures and inpatient cost for middle-aged and geriatric trauma patients with isolated proximal and midshaft humerus fractures.

Materials and Methods:

Patients aged 55 and older who sustained a proximal or midshaft humerus fracture and required inpatient treatment were included. Patient demographic, comorbidity, and injury severity information was used to calculate each patient’s Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA). Based on scores, patients were stratified to create minimal, low, moderate, and high risk groups. Outcomes included length of stay, complications, operative management, ICU/SDU-level care, discharge disposition, unplanned readmission, and index admission costs.

Results:

Seventy-four patients with 74 humerus fractures met final inclusion criteria. Fifty-eight (78.4%) patients presented with proximal humerus and 16 (21.6%) with midshaft humerus fractures. Mean length of stay was 5.5 ± 3.4 days with a significant difference among risk groups (P = 0.029). Lower risk patients were more likely to undergo surgical management (P = 0.015) while higher risk patients required more ICU/SDU-level care (P < 0.001). Twenty-six (70.3%) minimal risk patients were discharged home compared to zero high risk patients (P = 0.001). Higher risk patients experienced higher total inpatient costs across operative and nonoperative treatment groups.

Conclusion:

The STTGMA tool is able to reliably predict hospital quality measures and cost outcomes that may allow hospitals and providers to improve value-based care and clinical decision-making for patients presenting with proximal and midshaft humerus fractures.

Level of Evidence:

Prognostic Level III.

Nonsensus in the treatment of proximal humerus fractures: uncontrolled, blinded, comparative behavioural analysis between Homo chirurgicus accidentus and Macaca sylvanus

OBJECTIVE

To investigate the inter-rater reliability of Barbary macaques compared with an expert group of surgeons for the choice of treatment and predicted outcome of proximal humerus fractures.

DESIGN

Uncontrolled, blinded, comparative behavioural analysis.

SETTING

Germany and United States.

PARTICIPANTS

10 blinded experts in the field of orthopaedic trauma surgery (Homo chirurgicus accidentus), with special focus on upper extremity surgery from Germany and the US, and five Barbary macaques (Macaca sylvanus) from a semi-free range enclosure.

MAIN OUTCOME MEASURES

The reliability of agreement between raters assessed with Fleiss' ĸ.

RESULTS

Barbary macaques seem to have inferior inter-rater reliability in comparison with experts for choice of treatment (non-surgical v surgical), but for the geriatric age group most frequently affected by proximal humeral fractures, they performed similarly to the experts in their choices of treatment and choice of surgical procedure. Agreement about predicted outcome was poor among the macaques and slight among the experts. All experts almost always predicted the outcome incorrectly and tended to underestimate it. While only 4 (4.4%) of 90 experts' predictions were correct, 13 (28.9%) of 45 macaques' predictions were correct.

CONCLUSIONS

Consensus on treatment and expected outcomes of proximal humeral fractures is lacking even beyond the human species. Although Barbary macaques tend to predict the clinical outcome more accurately, their reliability to assist surgeons in making a consistent decision is limited. Future high quality research is needed to guide surgeons' decision making on the optimal treatment of this common injury.

Mortality after a proximal humeral fracture

Aims

The aims of this study were to investigate the mortality following a proximal humeral fracture. Data from a large population-based fracture register were used to quantify 30-day, 90-day, and one-year mortality rates after a proximal humeral fracture. Associations between the risk of mortality and the type of fracture and its treatment were assessed, and mortality rates were compared between patients who sustained a fracture and the general population.

Methods

All patients with a proximal humeral fracture recorded in the Swedish Fracture Register between 2011 and 2017 were included in the study. Those who died during follow-up were identified via linkage with the Swedish Tax Agency population register. Age- and sex-adjusted controls were retrieved from Statistics Sweden and standardized mortality ratios (SMRs) were calculated.

Results

A total of 18,452 patients who sustained a proximal humeral fracture were included. Their mean age was 68.8 years (16 to 107) and the majority (13,729; 74.4%) were women. A total of 310 (1.68%) died within 30 days, 615 (3.33%) within 90 days, and 1,445 (7.83%) within one year after the injury. The mortality in patients sustaining a fracture and the general population was 1,680/100,000 and 326/100,000 at 30 days, 3,333/100,000 and 979/100,000 at 90 days, and 7,831/100,000 and 3,970/100,000 at one year, respectively. Increasing age, male sex, low-energy trauma, type A fracture, concomitant fractures, and non-surgical treatment were all independent factors associated with an increased risk of mortality.

Conclusion

Compared with the general population, patients sustaining a proximal humeral fracture have a significantly higher risk of mortality up to one year after the injury. The risk of mortality is five times higher during the first 30 days, diminishing to two times higher at one year, suggesting that these patients constitute a strikingly frail group, in whom appropriate immediate management and medical optimization are required. Cite this article: Bone Joint J 2020;102-B(11):1484–1490.

Clinical results of reverse shoulder arthroplasty for comminuted proximal humerus fractures in elderly patients: a comparison between nonporous stems versus trabecular metal stems

Background

This study compared the clinical results for nonporous stems vs. trabecular metal (TM) stems used in reverse shoulder arthroplasty (RSA) for comminuted proximal humeral fractures (CPHFs) in elderly patients.

Methods

In this retrospective study, a total of 41 shoulders (39 women) of patients with CPHF aged >70 years who underwent RSA were investigated. The minimum follow-up period was 2 years. A total of 15 shoulders were treated with Grammont-style RSA using nonporous stems (the G-RSA group), and 26 shoulders were treated with RSA combining TM stems (the FR-RSA group). The American Shoulder and Elbow Surgeons (ASES) shoulder score, Constant score, shoulder joint range of motion (ROM), and radiographic findings were compared between the 2 groups.

Results

ASES scores and Constant scores were significantly higher in the FR-RSA group than in the G-RSA group. External rotation at the side in the FR-RSA group was significantly higher than that in the G-RSA group. In the FR-RSA and G-RSA groups, the union rates at the greater tuberosity (GT) were 88.5% and 46.7%, respectively, and scapular notching rates were 20% and 7.7%, respectively. Based on a subanalysis, the age was lower, body mass index was higher, and ASES scores, Constant scores, and external rotation ROM were higher in the GT union group than in the GT nonunion group.

Conclusion

GT bone union rates were high, and external rotation ROM of the shoulder joint were more improved for RSA using TM stems than those for RSA using nonporous stems in elderly patients with CPHF.

Mortality after a proximal humeral fracture

AIMS

The aims of this study were to investigate the mortality following a proximal humeral fracture. Data from a large population-based fracture register were used to quantify 30-day, 90-day, and one-year mortality rates after a proximal humeral fracture. Associations between the risk of mortality and the type of fracture and its treatment were assessed, and mortality rates were compared between patients who sustained a fracture and the general population.

METHODS

All patients with a proximal humeral fracture recorded in the Swedish Fracture Register between 2011 and 2017 were included in the study. Those who died during follow-up were identified via linkage with the Swedish Tax Agency population register. Age- and sex-adjusted controls were retrieved from Statistics Sweden and standardized mortality ratios (SMRs) were calculated.

RESULTS

A total of 18,452 patients who sustained a proximal humeral fracture were included. Their mean age was 68.8 years (16 to 107) and the majority (13,729; 74.4%) were women. A total of 310 (1.68%) died within 30 days, 615 (3.33%) within 90 days, and 1,445 (7.83%) within one year after the injury. The mortality in patients sustaining a fracture and the general population was 1,680/100,000 and 326/100,000 at 30 days, 3,333/100,000 and 979/100,000 at 90 days, and 7,831/100,000 and 3,970/100,000 at one year, respectively. Increasing age, male sex, low-energy trauma, type A fracture, concomitant fractures, and non-surgical treatment were all independent factors associated with an increased risk of mortality.

CONCLUSION

Compared with the general population, patients sustaining a proximal humeral fracture have a significantly higher risk of mortality up to one year after the injury. The risk of mortality is five times higher during the first 30 days, diminishing to two times higher at one year, suggesting that these patients constitute a strikingly frail group, in whom appropriate immediate management and medical optimization are required.

Surgical treatment of complex proximal humeral fractures in elderly patients: a matched-pair analysis of angular-stable plating vs. reverse shoulder arthroplasty

BACKGROUND

To date, there is a lack of consensus regarding the type of surgical treatment for complex proximal humeral fractures (PHFs) in elderly patients, especially between joint preservation and joint replacement techniques.

MATERIALS AND METHODS

We matched 60 patients (aged 73.2 ± 6.4 years) with complex PHFs in terms of sex, age, and Charlson Comorbidity Index, who underwent locking-plate open reduction-internal fixation (ORIF) or reverse shoulder arthroplasty (RSA) (2011-2017). Postoperative range of motion and functional outcome were assessed using the American Shoulder and Elbow Surgeons shoulder score, Oxford Shoulder Score, Constant-Murley score, and Disabilities of the Arm, Shoulder and Hand score at a mean follow-up of 49 months (ORIF group) and 38 months (RSA group). Complications and unplanned revision surgery were recorded, and all radiographs were analyzed.

RESULTS

ORIF resulted in numerically, although not statistically significantly, greater mean shoulder motion vs. RSA. Significantly better outcome was reported for the Oxford Shoulder Score (P = .034) and Disabilities of the Arm, Shoulder and Hand score (P = .026) in the ORIF group, although no significant differences were observed in the American Shoulder and Elbow Surgeons shoulder score and Constant-Murley score. The complication rate (30% vs. 10%) and revision rate (20% vs. 3%) were significantly higher in the ORIF group (P = .028), with patients who had complications or required revision having worse functional results.

CONCLUSION

Favorable results are achievable through both angular-stable plating and RSA. Although ORIF may be associated with a superior functional outcome, exceeding the minimal clinically important difference, RSA was linked to significantly fewer complications and revisions.

Proximal humeral fracture in patients with high Charlson comorbidity index: mortality rate according to treatment choice

BACKGROUND

The purpose of this study was to evaluate the relevance of a commonly used morbidity prognostic tool, the Charlson comorbidity index (CCI), in determining the survival rate of patients with isolated proximal humeral fractures (PHFs) and to determine the impact of surgical treatment according to previous comorbidities (measured with CCI).

MATERIALS AND METHODS

All patients who were treated for a single PHF in our institution for 29 consecutive months were included in this retrospective study, with a minimum follow-up of 24 months (mean 52.8 months). Two groups were established according to the type of treatment received (surgical versus non-surgical). Preinjury comorbidities were identified, and the age-adapted CCI was calculated. All complications and mortality rates were prospectively recorded over the complete follow-up period.

RESULTS

Patients with elevated preinjury comorbidities (CCI > 5) demonstrated a significant increase in mortality (HR = 4.64) compared to those with CCI ≤ 5. In addition, patients with high comorbidities (CCI > 5) who underwent surgical treatment demonstrated a statistically significant increase in mortality (HR = 6.92) compared to patients with similarly high comorbidities (CCI > 5) who underwent non-surgical treatment.

CONCLUSIONS

Patients with high preinjury comorbidities (CCI > 5) experienced an increased mortality risk if they underwent surgical treatment for isolated PHFs. The use of a morbidity prognostic tool, such as the CCI, can help predict the outcome (particularly mortality) in these patients and may aid in making decisions in terms of operative versus non-operative treatment to minimize patient mortality.

LEVEL OF EVIDENCE

Level III; Retrospective Comparative Study; Treatment Study.

Low risk of revision after reverse shoulder arthroplasty for acute proximal humeral fractures

Background

Reverse shoulder arthroplasty (RSA) has gained popularity in the treatment of proximal humeral fractures (PHFs), especially in elderly patients. The purpose of this study was to investigate the use of RSA implants for acute PHFs and risk of revision, as well as risk factors for revision.

Methods

RSA implants for acute PHFs were identified from the Nordic Arthroplasty Register Association registry data from 2004 to 2016. Kaplan-Meier survival analysis was used to calculate implant survival. Cox multiple regression analysis was used to calculate the adjusted revision rate for sex, age, country of operation, and year of surgery.

Results

The study included 1523 RSA implants for PHFs (84% women; average age, 77 years; average follow-up time, 2.5 years). The 5-year cumulative implant survival rate was 97% (confidence limits, 95.5% and 98%). Revision was performed for 33 implants (2%). The most common reason for revision was instability, occurring in 11 cases (0.7%), followed by fracture, occurring in 6 (0.4%), and infection, occurring in 5 (0.3%). Four different arthroplasty brands were used in this cohort, with the Delta Xtend in two-thirds of cases (n = 1025). Age younger than 60 years and male sex were associated with slightly higher rates of revision; however, these differences did not reach statistical significance (hazard ratio of 2.02 with P = .075 and hazard ratio of 3.23 with P = .057, respectively).

Conclusion

The use of RSA for acute PHFs is increasing in the Nordic countries. The short-term risk of revision is low. The main reason for revision of RSA for this indication is instability.

Complications after surgical treatment of proximal humerus fractures in the elderly-an analysis of complication patterns and risk factors for reverse shoulder arthroplasty and angular-stable plating

BACKGROUND

To date, there is a lack of consensus regarding surgical treatment recommendations for complex proximal humerus fracture (PHF) patterns, especially between joint preservation and joint replacement techniques.

METHODS

Between 2012 and 2017, 146 patients (aged 74.1 ± 8.0 years) with complex PHF were treated with locking plates (open reduction-internal fixation [ORIF]) or reverse total shoulder arthroplasty (RTSA). Complications and unplanned revision surgery were recorded in a mid-term follow-up. Potential patient and surgical risk factors for complications were extracted. Univariate and multivariate analyses were conducted.

RESULTS

Follow-up data were available for 125 patients, 66 (52.8%) of whom were treated with locking plates, and 59 (41.2%) with RTSA. Both groups had comparable Charlson indices. The overall complication rate was 37.8% for ORIF and 22.0% for RTSA, with a revision rate of 12.1% and 5.1%, respectively, as driven primarily by persistent motion deficits. Multivariate analyses demonstrated no significant differences between the 2 procedures (P = .500). However, age was an independent protective factor against overall complications (P = .018). Risk factors for major complications in ORIF included osteoporosis, varus impaction fractures, posteromedial metaphyseal extensions <8 mm, head-shaft displacements >4 mm, and multifragmentary greater tuberosities. For RTSA, higher complication rates were seen in patients with higher Charlson indices, diabetes, or altered (greater) tuberosities. In contrast, Neer's classification system was not predictive in either group.

CONCLUSIONS

RTSA led to fewer complications than ORIF and thus can be considered a valuable option in complex PHF of the elderly. Paying attention to specific prognostic factors may help to reduce the complication rate.

Is the Charlson comorbidity index a good predictor of mortality and adverse effects in proximal humerus fractures?

INTRODUCTION

Proximal humerus fractures (PHF) are frequent in elderly patients. This population also suffers from a series of associated comorbidities, and PHF increases morbidity and mortality. The Charlson Comorbidity Index (CCI) is a tool used for calculating comorbidity and therefore the mortality risk.

HYPOTHESIS

Our hypothesis is that CCI is a good predictor of mortality in patients suffering from PHF, and that there is a relationship between CCI and the development of adverse events.

PATIENTS AND METHODS

A retrospective study with prospective data collection of 354 patients who had been diagnosed and treated for a single PHF between August 1st, 2013 and July 31st, 2015 was carried out at our hospital. The minimum follow-up was 24 months (mean 51.1 months). This study included all patients regardless the severity of the fracture, the treatment performed (surgical or conservative treatment) or whether the patient had been admitted to the hospital or was treated as an outpatient. Adverse effects and mortality data were collected and the CCI was calculated.

RESULTS

Patients with high CCI (>5) had a higher mortality risk 4.6 (95% CI [2.4-9.0]) compared to those with CCI<5. During follow-up, 40 (11%) patients died, being the mean follow-up of the patients overall 4.3 years 95% CI [4.1-4.4]. Patients suffering from systemic complications had a higher CCI average (p=0.001) compared to those who did not present adverse effects (HR=6.6; 95% CI [3.5-12.4]). No statistically significant relationship between the type of fracture (p=0.473) and mortality was found.

CONCLUSION

In our study CCI has proven to be a good predictor of mortality and there is a relationship between CCI and the development of adverse effects in patients suffering from PHF, which maybe should be taken into consideration in our therapeutic decision making.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Deltoid-split approach versus deltopectoral approach for proximal humerus fractures: A systematic review and meta-analysis

PURPOSE

To investigate the evidence of deltoid-split approach (DS) versus deltopectoral approach (DP) in treatment of proximal humerus fractures from current RCT and prospective literatures.

METHODS

The electronic literature database of Pubmed, Embase, and Cochrane library was searched at December 2017. The data complications (including implant failure, humeral head necrosis, infection, radiological adverse events, nonunion rate, subacromial impingement, and damage of the axillary nerve), functional outcomes (including Constant, NEER, DASH, ADL, VAS score), operation time, hospital stay and intraoperative blood loss were extracted and analyzed by STATA 11.0 software.

RESULTS

Three RCTs and three prospective comparative studies were included in this meta-analysis. The meta-analysis showed that the DS group had a significantly low humeral head necrosis rate and short operation time. No significant difference was found in total complication rate, functional outcome, and other Perioperative parameters between DS and DP groups.

CONCLUSION

The prospective evidence suggested that DS approach for proximal humerus fractures had less humeral head necrosis and short operation time than DP approach. Both DS and DP approach had similar results in functional outcomes, total complication, VAS, and hospital stay.

Three- and four-part displaced proximal humeral fractures in patients older than 70 years: reverse shoulder arthroplasty or nonsurgical treatment?

BACKGROUND

The objective of our study was to evaluate the results of surgical treatment by reverse shoulder arthroplasty (RSA) compared with nonsurgical treatment after 2 years of follow-up in patients aged 70 years or older with displaced 3-part or 4-part proximal humeral fractures.

METHODS

Two groups were formed: the RSA group (n = 28) and the nonsurgical group (n = 32). Minimum follow-up was 2 years. We included patients with 3-part or 4-part fractures according to the Neer classification. Main outcome measures were the Constant-Murley score, the 11-item version of the Disabilities of the Arm, Shoulder and Hand score, and the Subjective Shoulder Value score. An autonomy score, a cognitive assessment score, and a pain score were also measured.

RESULTS

Clinical features in the 2 groups were not significantly different. The Constant-Murley mean score was significantly higher for the RSA group (82.1% vs. 76.8%; P = .03). Amplitudes were all higher in favor of the RSA group (P < .02). There was no significant difference in mean score on the 11-item version of the Disabilities of the Arm, Shoulder and Hand score, the preoperative and postoperative Subjective Shoulder Value score, the autonomy score, the cognitive assessment score, or the pain score in both groups at the last follow-up. The complication rate was higher for the RSA group.

CONCLUSIONS

These results suggest that RSA treatment of proximal humeral fractures with 3-part or 4-part displaced fragments in elderly patients provides better functional outcomes than does nonsurgical treatment. However, the observed clinical difference was relatively small. This solution must be proposed only to patients who have a significant functional demand.

ORIF versus arthroplasty for open proximal humerus fractures: Nationwide Inpatient Sample data between 1998 and 2013

BACKGROUND

Limited data exists in analyzing open reduction and internal fixation (ORIF) and arthroplasty in the management of open proximal humerus fractures. We analyzed differences in hospital course between these procedures, patient demographics, complication rate, length of stay, hospital charges, and mortality rate.

MATERIALS AND METHODS

This is a retrospective review of the Nationwide Inpatient Sample database. ICD-9 codes identified patients hospitalized for open proximal humerus fractures from 1998 to 2013 who underwent ORIF or shoulder arthroplasty (hemi-, total, or reverse). Demographics and in-hospital complications were compared. Logistic regression controlling for age, gender, and Deyo index tested the impact of ORIF vs ARTH on any complications.

RESULTS

Seven hundred thirty patients were included (ORIF, n = 662 vs ARTH, n = 68). ORIF patients were younger (p < 0.001), more likely to be males (p < 0.001), and had a lower Deyo score (p = 0.012). Both groups had comparable complication rates (21.4% vs 18.0%, p = 0.535), lengths of stay (7.86 days vs 7.44 days, p = 0.833), hospital charges ($76,998 vs $64,133, p = 0.360), and mortality rates (0.2% vs 0%, p = 0.761). Type of surgery was not a predictor of any complications (OR = 0.67 [95% CI 0.33-1.35], p = 0.266), extended length of stay (OR = 1.01 [95% CI 0.58-1.78], p = 0.967), or high hospital charges (OR = 1.39 [95% CI 0.68-2.86], p = 0.366).

CONCLUSION

We revealed no differences in hospital course between ORIF and arthroplasty for management of open proximal humerus fractures. Although differences in demographics existed, no differences in complication rates, length of stay, hospital charges and mortality rates were noted. Future studies can evaluate the long-term outcomes of these procedures.

LEVEL OF EVIDENCE

Level III.

Open reduction internal fixation vs non-operative management in proximal humerus fractures: a prospective, randomized controlled trial protocol

BACKGROUND

Proximal humerus fractures are the third most common fracture in the elderly population and are expected to increase due to the aging population. Surgical fixation with locking plate technology has increased over the last decade despite a lack of proven superiority in the literature. Three previous randomized controlled trials have not shown a difference in patient-centered outcomes when comparing non-operative treatment with open reduction and internal fixation. Low patient enrollment and other methodological concerns however limit the generalizability of these conclusions and as a result, management of these fractures remains a controversy. By comparing the functional outcomes of locked plate surgical fixation versus non-operative treatment of displaced three and four-part proximal humerus fractures in the elderly population with a large scale, prospective, multi-centered randomized controlled trial, the optimal management strategy for this common injury may be determined.

METHODS

We will conduct a prospective, single blind randomized controlled parallel arm trial to compare non-operative management of proximal humerus fractures with open reduction and internal fixation using locked plating technology. One-hundred and sixty patients > age 60 with acute 3- or 4- part proximal humerus fractures will be randomized to either open reduction and internal fixation with locked plating technology or non-operative management treatment arms. The primary outcome measure is the Constant Score at 24 months post-operative. Secondary outcome measures include the American Shoulder and Elbow Surgeon's Score (ASES), EuroQol EQ-5D-5 L Health Questionnaire Score, short form PROMIS upper extremity score and IPAQ for the elderly score. Further outcome measures include assessment of the initial classification, displacement and angulation and the quality of surgical reduction via a standard computed tomography (CT) scan; rates of non-union, malunion, arthrosis, osteopenia or other complications including infection, nerve injury, intra-articular screw penetration, reoperation rates and hospital re-admission rates.

DISCUSSION

The results of this trial will provide Level 1 evidence to guide decision-making in the treatment of proximal humerus fractures in the elderly population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02362100 . Registered 5 Feb 2015.

Trends in incidence of proximal humerus fractures, surgical procedures and outcomes among elderly hospitalized patients with and without type 2 diabetes in Spain (2001-2013)

BACKGROUND

Several studies have reported that diabetic persons have an increased risk for fractures than non-diabetes patients. The association between proximal humerus fractures and type 2 diabetes (T2DM) is unclear and some studies point to insulin treatment, hypoglycaemic episodes consequently to inadequate control of diabetes or, more recently, to an alteration of trabecular bone. We examined trends in the incidence of proximal humerus fractures, surgical procedures and outcomes among hospitalized patients aged ≥65 years, with and without T2DM in Spain, 2001-2013.

METHODS

This retrospective, observational study was conducted using the Spanish National Hospital Discharge Database to select all hospital admissions with proximal humerus fracture. We calculated incidences overall and stratified by diabetes status, year and sex. We analyzed surgical procedures, comorbidities, length of stay, in-hospital complications and in-hospital mortality.

RESULTS

We identified 43,872 patients with proximal humerus fracture (18.3% had a T2DM diagnosis). Age-adjusted incidence rates elevated steadily over the study period for men and women with and without T2DM, independently of diabetes status, although we found a stable trend in the later years. Patients with T2DM had lower relative risk of proximal humeral fracture incidence: 0.87 (95%IC 0.82-0.93) for men and 0.97 (95%IC 0.95-1.00) for women. In-hospital complications were 4.0% of diabetic men vs. 2.6% in non-diabetic (p < 0.001) and 2.9% among T2DM women vs. 1.7% in those without (p < 0.05). The use of open reduction of fracture with internal fixation and arthroplasty is increasing overtime and closed reduction with internal fixation is decreasing. Presence of T2DM in women was associated with higher in-hospital mortality (OR 1.67; 95%CI 1.29-2.15). Comorbidities, in-hospital complications and older age were predictors of higher in-hospital mortality in both sexes.

CONCLUSIONS

The incidence of proximal humerus fractures seems to be increasing in Spain. The incidence is lower among men with than without T2DM. T2DM is associated to higher in-hospital complications in both sexes. The use of open reduction of fracture with internal fixation and arthroplasty is increasing overtime beside diabetes status. Women with T2DM have higher in-hospital mortality than those without the disease.

The Applications of Finite Element Analysis in Proximal Humeral Fractures

Proximal humeral fractures are common and most challenging, due to the complexity of the glenohumeral joint, especially in the geriatric population with impacted fractures, that the development of implants continues because currently the problems with their fixation are not solved. Pre-, intra-, and postoperative assessments are crucial in management of those patients. Finite element analysis, as one of the valuable tools, has been implemented as an effective and noninvasive method to analyze proximal humeral fractures, providing solid evidence for management of troublesome patients. However, no review article about the applications and effects of finite element analysis in assessing proximal humeral fractures has been reported yet. This review article summarized the applications, contribution, and clinical significance of finite element analysis in assessing proximal humeral fractures. Furthermore, the limitations of finite element analysis, the difficulties of more realistic simulation, and the validation and also the creation of validated FE models were discussed. We concluded that although some advancements in proximal humeral fractures researches have been made by using finite element analysis, utility of this powerful tool for routine clinical management and adequate simulation requires more state-of-the-art studies to provide evidence and bases.

Predictors of Mortality in Elder Patients With Proximal Humeral Fracture

Background

Known possible consequences of proximal humerus fractures include impaired shoulder function, decreased independence, and increased risk for mortality. The purpose of this report is to describe the survival and independence of elderly patients with fractures of the proximal humerus, treated in our institution, relative to patient characteristics and treatment method.

Methods

Retrospective cohort study from 2006 to 2012.

Setting

Community-based hospital with level 1 designation.

Patients/Participants

Three hundred nineteen patients ≥60 years who presented to the emergency department with an isolated fracture of the proximal humerus were either admitted to the inpatient ward for the organization and provision of immediate definitive care or discharged with the expectation of coordination of their care as an outpatient. Treatment was nonoperative or operative.

Outcome Measures

One- and 2-year mortality.

Results

Significant predictors of mortality at 1 year included Charlson Comorbidity Index (CCI; continuous, hazard ratio [HR] = 1.40; 95% confidence interval [CI]: 1.06-1.86), body mass index (BMI; <25 vs ≥25; HR = 3.43; 95% CI: 1.45-8.14), and American Society of Anesthesiologists (ASA) disease severity score (3-4 vs 1-2; HR = 4.48; 95% CI: 1.21-16.55). In addition to CCI and BMI, reliance on a cane/walker/wheelchair at the time of fracture predicted mortality at 2 years (vs unassisted ambulation; HR = 3.13; 95% CI: 1.59-5.88). Although the Neer classification of fracture severity significantly correlated with inpatient admission (P < .001), it was not significantly associated with mortality or with loss of living or ambulatory independence. Among admitted patients, 64% were discharged to a facility with a higher level of care than their prefracture living facility. Twenty percent of study patients experienced a loss in ambulatory status by at least 1 level at 1 year postfracture.

Conclusion

In a cohort of elderly patients with fractures of the proximal humerus, patient characteristics including comorbidities, ASA classification, and lower BMI were associated with increased mortality. Specifically, those admitted at the time of fracture and treated nonoperatively had the highest mortality rate and, likely, represent the frailest cohort. Those initially treated as outpatients and later treated operatively had the lowest mortality and, likely, represent the healthiest cohort. These data are inherently biased by prefracture comorbidities but help stratify our patients' mortality risk at the time of injury.

Minimal invasive percutaneous plate osteosynthesis (MIPPO) through deltoid-pectoralis approach for the treatment of elderly proximal humeral fractures

BACKGROUND

Current treatments for proximal humeral fractures include conservative treatment, conventional open reduction internal fixation (ORIF) and MIPPO through deltoid-splitting approach. The aim of this study was to evaluate the clinical outcome of MIPPO versus ORIF via the deltoid-pectoralis approach in elderly patients with proximal humeral fractures.

METHODS

Thirty-six patients with proximal humeral fractures were enrolled in this study. Following the randomized block and single-blinded principle, the patients were assigned to two groups and treated with either conventional ORIF or MIPPO, both through the deltoid-pectoralis approach. Surgical outcomes were evaluated by the NEER score, Constant-Murley score, blood loss, length of operation, radiological imaging and clinical examination. The patients were followed up for 4-24 (mean 10) months.

RESULTS

According to Constant-Murley score, the surgical outcome was excellent in 14 cases, satisfactory in 2 cases and unsatisfactory in one case in MIPPO group versus 10, 5 and 4 in conventional ORIF group. MIPPO was significantly advantageous over conventional ORIF in terms of NEER score, Constant-Murley, length of operation and intraoperative blood loss. In addition, MIPPO was also more advantageous in several indexes in patients with BMI > 26.0 and NEER type III fracture.

CONCLUSION

The results of our study have demonstrated that MIPPO through the deltoid-pectoralis approach is an effective alternative for the treatment of proximal humeral fractures in elderly patients.

TRIAL REGISTRATION

The trial registration number (TRN): ChiCTR-INR-17011098 (retrospectively registered at 2017-04-09).

Increased risk of 30-day postoperative complications for diabetic patients following open reduction-internal fixation of proximal humerus fractures: an analysis of 1391 patients from the American College of Surgeons National Surgical Quality Improvement Program database

Background

Prior database studies have shown that complication rates following surgical treatment of proximal humerus fractures are low. However, diabetes has been shown across orthopedics to have significantly increased risks of postoperative complications. The purpose of our study was to identify complications for which diabetic patients are at increased risk following operative treatment of proximal humerus fractures.

Methods

The National Surgical Quality Improvement Program database from 2005 to 2014 identified patients >18 years undergoing open reduction-internal fixation for proximal humerus fractures. Patients with incomplete perioperative data were excluded. Patients with non–insulin-dependent diabetes mellitus (NIDDM) and insulin-dependent diabetes mellitus (IDDM) were compared with nondiabetic patients using multivariate logistic regression analysis. Odds ratio (OR) was calculated with a 95% confidence interval, and the significance level was held at P < .05.

Results

There were 1391 patients identified; 1147 (82%) were not diabetic, 91 (7%) had IDDM, and 153 (11%) had NIDDM. Of these, 39.68% (550) were obese (body mass index >30.0). Hypertension, dyspnea, and chronic obstructive pulmonary disease were the most frequent concurrent patient factors in diabetic patients. Postoperatively, patients with diabetes had a statistically significant higher risk of pneumonia (OR, 217.80; P = .002) and length of stay >4 days (OR, 2.05; P = .010). Among diabetics, non–insulin-dependent diabetics had a greater risk of sepsis (OR, 25.84; P = .022) and pneumonia (OR, 12.19; P = .013) than insulin-dependent diabetics.

Conclusion

Both NIDDM and IDDM were associated with a number of adverse postoperative events. Importantly, NIDDM was found to be an independent risk factor for postoperative sepsis and pneumonia, whereas IDDM was identified as an independent risk factor for pneumonia and prolonged length of stay (≥4 days).

Axillary Artery Injury Associated with Proximal Humerus Fracture: A Report of 6 Cases

Proximal humerus fractures are common, but associated injury of the axillary artery is uncommon. The majority of published blunt traumatic axillary artery injuries are associated with anterior glenohumeral dislocation; a few are associated with isolated proximal humerus fractures or fracture-dislocation. Experience within our institution demonstrates that axillary artery injury is often unrecognized on initial presentation owing to palpable peripheral pulses and the absence of ischemia and places the hand at risk of necrosis and amputation if there is prolonged ischemia and the forearm at risk of compartment syndrome after revascularization. Accurate physical examination in combination with a low threshold for Doppler examination or angiography can establish the diagnosis of axillary artery injury. We present 6 cases of axillary artery injury associated with proximal humerus fractures in order to highlight the potential for this vascular injury in the setting of a proximal humerus fracture.

Hemiarthroplasty versus reverse shoulder arthroplasty in 4-part displaced fractures of the proximal humerus: Multicenter retrospective study

INTRODUCTION

Complex 4-part fractures of the proximal humerus are one of the most difficult fractures to manage. For several years, reverse total arthroplasty (RSA) has been proposed as an alternative to hemiarthroplasty (HA) when internal fixation is insufficient. The goal of this study was to compare the short and intermediate term results of these 2 different types of arthroplasty.

MATERIALS AND METHODS

In a retrospective, multicenter study, 57 HA and 41 RSA were reviewed after a follow-up of at least 2 years. The clinical evaluation was based on the absolute and adjusted Constant scores, Simple shoulder value (SSV) and the quick-DASH scores. The radiological assessment included standard radiological tests.

RESULTS

After a mean follow-up of 39 months, the RSA group had a significantly higher adjusted Constant score than the HA group (83% vs 73%, respectively P=0.02). However, there was no significant difference in the absolute Constant score, the quick-DASH or the SSV scores. Active anterior elevation was better in the RSA group, while internal rotation was better in the HA group (130° vs 112°, P=0.01; sacrum vs L3, P=0.03). There was no significant difference in external rotation (28° vs 23°, P=0.31). The rate of complications was higher in the HA group than in the RSA group (24% vs 10%, P=0.01). The radiological rate of union of the greater tuberosity was similar in both groups (70%) and scapular notching was found in 23% of the RSA group.

CONCLUSION

The short and intermediate term clinical outcomes are better with RSA than with HA. The complication rate is higher with HA. Nevertheless, scapular notching occurred in more than 20% of patients with RSA, suggesting that care should be taken when using this prosthesis in young, active patients.

Adverse cardiac events in 56,000 orthopaedic trauma patients: Does anatomic area make a difference?

PURPOSE

Postoperative cardiac events in orthopaedic trauma patients constitute severe morbidity and mortality. It is therefore increasingly important to determine patient risk factors that are predictive of postoperative myocardial infarctions and cardiac arrests. This study sought to assess if there is an association between anatomic area and cardiac complications in the orthopaedic trauma patient.

PATIENTS AND METHODS

From 2006-2013, a total of 361,402 orthopaedic patients were identified in the NSQIP database using Current Procedural Terminology (CPT) codes. Of these, 56,336 (15.6%) patients were identified as orthopaedic trauma patients broken down by anatomic region: 11,905 (21.1%) upper extremity patients (UE), 29,009 (51.5%) hip/pelvis patients (HP), and 15,422 (27.4%) lower extremity patients (LE) using CPT codes. Patients were defined as having adverse cardiac events if they developed myocardial infarctions or cardiac arrests within 30days after surgery. Chi-squared analysis was used to determine if there was an association between anatomic area and rates of cardiac events. Multivariate logistical analysis was used with over 40 patient characteristics including age, gender, history of cardiac disease, and anatomic region as independent predictors to determine whether anatomic area significantly predicted the development of cardiac complications.

RESULTS

There were significant differences in baseline demographics among the three groups: HP patients had the greatest average age (77.6 years) compared to 54.8 years for UE patients and 54.1 years in LE patients (p<0.001). HP patients also had the highest average ASA score (3.0) (p<0.001). There was a significant difference in adverse cardiac events based on anatomic area: 0.27% (32/11,905) UE patients developed cardiac complications compared to 2.15% (623/29,009) HP patients and 0.61% (94/15,422) LE patients. After multivariate analysis, HP patients were significantly more likely to develop cardiac complications compared to both UE patients (OR: 6.377, p=0.014) and LE patients (OR: 2.766, p=0.009).

CONCLUSION

There is a significant difference in adverse cardiac events following orthopaedic trauma based on anatomic region. Hip/Pelvis surgery appeared to be a significant risk factor in developing an adverse cardiac event. Further studies should investigate why hip/pelvic patients are at a higher risk of adverse cardiac events.

Risk comparison of bleeding and ischemic perioperative complications after acute and elective orthopedic surgery in patients with cardiovascular disease

INTRODUCTION

The study objective was to ascertain the incidence of bleeding and ischemic complications related to acute and planned orthopedic surgery in patients with known cardiovascular diseases.

MATERIALS AND METHODS

The study conducted between 2010 and 2013 enrolled 477 patients (289 women, 188 men) with a diagnosed cardiovascular disease or a history of thromboembolic event. Aside from gender, age, height and weight, the study observed other anamnestic data and perioperative laboratory test results that may impact on a bleeding or ischemic event.

RESULTS

Two hundred seventy-two (57 %) patients had acute surgery, and 205 (43 %) patients had elective surgery. Complications arose in 55 (11.6 %) patients, 32 (6.9 %) had bleeding complications, 19 (4.0 %) ischemic complications, and both complications were experienced by 4 (0.8 %) patients. Bleeding developed in 14 (5.1 %) patients who had acute surgery, and in 22 (10.7 %) who had elective surgery. Twenty-two (8.1 %) patients having acute surgery and one (0.1 %) undergoing elective surgery suffered from ischemic complications. The incidence of bleeding complications was significantly higher in elective surgery (p = 0.026, OR 2.22), and when adjusted (general anaesthesia, gender, and use of warfarin), the difference was even higher (p = 0.015, OR 2.44), whereas the occurrence of ischemic complications was significantly higher in acute surgery (p = 0.005, OR 18.0), and when adjusted (age), the difference remained significant (p = 0.044, OR 8.3).

CONCLUSIONS

The study noted a significantly higher incidence of bleeding complications in elective orthopedic surgery when compared with acute surgery. Conversely, the incidence of ischemic complications was significantly higher in patients having acute orthopedic surgery when compared with those operated on electively.

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.

A Comparison of the Charlson and Elixhauser Comorbidity Measures to Predict Inpatient Mortality After Proximal Humerus Fracture

OBJECTIVES

Proximal humerus fractures are very common in infirm elderly patients and are associated with appreciable inpatient mortality. We sought to compare the discriminative ability of the Charlson and Elixhauser comorbidity measures for predicting inpatient mortality after proximal humerus fractures.

METHODS

Data from the Nationwide Inpatient Sample (2002-2011) were obtained. We constructed 2 main multivariable logistic regression models, with inpatient mortality as the dependent variable and 1 of the 2 comorbidity scores, as well as age and sex, as independent variables. A base model that contained only age and sex was also evaluated. The predictive performance of the Charlson and Elixhauser comorbidity measures was assessed and compared using the area under the receiver operating characteristic curve (AUC) derived from these regression models.

RESULTS

Elixhauser comorbidity adjustment provided better discrimination of inpatient mortality [AUC = 0.840, 95% confidence interval (CI), 0.828-0.853] than the Charlson model (AUC = 0.786, 95% CI, 0.771-0.801) and the base model without comorbidity adjustment (AUC = 0.722, 95% CI, 0.705-0.740). In terms of relative improvement in predictive ability, the Elixhauser score performed 46% better than the Charlson score.

CONCLUSIONS

Given that inadequate comorbidity risk adjustment can unfairly penalize hospitals and surgeons that care for a disproportionate share of infirm and sick patients, wider adoption of the Elixhauser measure for mortality prediction after proximal humerus fracture-and perhaps other musculoskeletal injuries-merits to be considered.

Association of perioperative blood transfusion and adverse events after operative treatment of proximal humerus fractures

BACKGROUND

The purpose of this study was to assess the relationship between perioperative blood transfusion for proximal humerus fracture and inpatient mortality, adverse events, prolonged hospital stay, and nonroutine disposition.

METHODS

Among the >55,000 patients with an operatively treated proximal humerus fracture identified in the Nationwide Inpatient Sample between 2008 and 2011, 17% received a perioperative blood transfusion. Multivariable logistic regression analyses addressed the association of blood transfusion with inpatient mortality, adverse events, hospital stay, and nonroutine discharge, accounting for comorbidities and other known confounders.

RESULTS

Perioperative blood transfusion for fracture of the proximal humerus was not associated with inhospital death, but it was independently associated with inpatient adverse events (odds ratio (OR) 4.4, 95% confidence interval (CI) 4.2-4.6), prolonged hospital stay (OR 2.8, 95% CI 2.7-2.9), and increased nonroutine discharge (OR 1.8, 95% CI 1.7-1.9).

CONCLUSIONS

Inpatients with fracture of the proximal humerus who receive transfusion are not more likely to die in hospital, but they do stay longer, experience more adverse events, and are less likely to be discharged home. Additional study is merited to determine if the judicious use of blood transfusion in the perioperative period can decrease inpatient morbidity and health-care resource utilisation.

LEVEL OF EVIDENCE

Level II, Retrospective Design, Prognosis Study.

Factors associated with hospital admission for proximal humerus fracture

BACKGROUND

The number of inpatient admissions for proximal humerus fracture is increasing, but the factors that determine hospitalization are not well documented. We sought to identify predictors of hospital admission among individuals presenting to the emergency department (ED) with a fracture of the proximal humerus.

METHODS

Using the Nationwide Emergency Department Sample for 2010 and 2011, an estimated 285661 patients were identified and separated into those who were admitted to hospital (19%) and those who were discharged directly home (81%). Multivariable logistic regression modeling was used to identify independent predictors of hospital admission.

RESULTS

Factors associated with admission included increasing age and Charlson comorbidity index, ED visit on a weekday, Medicare and Medicaid insurance, open fracture, injury due to motor vehicle crash, polytrauma, urban teaching hospital, and residence in the Northeast. The lowest ratio of hospital admission to home discharge was noted for uninsured patients (0.09).

DISCUSSION

Factors unrelated to medical complexity such as insurance status, geographic region, timing of ED visit, and hospital type are associated with inpatient admission for proximal humerus fracture. Interventions to reduce variation in hospital admission and the influence of nonclinical factors merit attention.

LEVEL OF EVIDENCE

Level II, prognostic study.

Does the timing of surgery for proximal humeral fracture affect inpatient outcomes?

BACKGROUND

Delayed surgical treatment of hip fractures is associated with adverse medical outcomes, but it is unclear whether the same is true for proximal humeral fractures. The purpose of this study was to evaluate the relationship between surgical delay for proximal humeral fracture and inpatient adverse events, in-hospital death, prolonged postoperative stay, and nonroutine discharge.

METHODS

Of the more than 70,000 patients with an operatively treated proximal humeral fracture identified in the Nationwide Inpatient Sample between 2008 and 2011, 87% underwent surgery within 2 days of admission and 13% underwent surgery 3 days or more after admission. Multivariable logistic regression analyses were performed to evaluate the effect of surgical delay on inpatient outcomes and to identify risk factors associated with late surgery.

RESULTS

Surgery 3 days or more after admission for fracture of the proximal humerus had no influence on in-hospital death but was independently associated with inpatient adverse events (odds ratio [OR], 2.1; 95% confidence interval [CI], 2.0-2.2), prolonged postoperative stay (OR, 1.7; 95% CI, 1.7-1.9), and increased nonroutine discharge (OR, 2.7; 95% CI, 2.6-2.9). Risk factors for surgery 3 days or more after admission included advanced age, male sex, Elixhauser comorbidity score, polytrauma, Hispanic race or black race, no insurance coverage, low household income, and weekend admission.

CONCLUSIONS

Even when comorbidities and complexity are controlled for, delaying surgery for proximal humeral fracture is likely to increase inpatient morbidity, postoperative length of stay, and nonroutine discharge. It appears that avoiding nonmedical delays is advantageous.