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Matheron G, Mahoney M, Domos P. Conservative treatment of 3- and 4-part proximal humeral fractures: Can poor outcomes be predicted? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2031-2040. [PMID: 38517527 DOI: 10.1007/s00590-024-03890-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/28/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE 3- and 4-part proximal humeral fractures are frequently treated conservatively. This study aims to combine radiographic, and patient reported outcome data to identify factors leading to poor outcomes following conservative treatment. METHODS A retrospective local database analysis identified 3- and 4-part fractures. Radiographic and functional outcomes including Oxford Shoulder Score (OSS), QuickDash (QD), Subjective Shoulder Score (SSV) and VAS pain scores were collected. RESULTS 104 patients were included at mean follow-up of 55 months. Analysis highlighted significant OSS differences in 3- versus 4-part (p = 0.027), dominant arm injury (p = 0.046), age > 65 (p = 0.006), varus coronal neck-shaft angle < 115 versus 115-155 degrees (p = 0.008), posterior head tilt > 155 degrees (p = 0.005), greater tuberosity (GT) displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.032). According to QD scores; age > 65 (p = 0.012), varus neck-shaft angle (p = 0.01), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.006). SSV varied significantly with 3- versus 4-part fractures (p = 0.005), age > 65 (p = 0.04), varus neck-shaft angle (p = 0.001), posterior head tilt (p = 0.005), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.003), and medial calcar hinge displacement > 2 mm (p = 0.001). CONCLUSION We highlight risk factors for unfavourable outcomes following conservative management, aiding surgeons in shared decision-making and patient expectation management.
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Affiliation(s)
- George Matheron
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK.
| | - Melissa Mahoney
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK
| | - Peter Domos
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK
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Kimmeyer M, Schmalzl J, Schmidt E, Graf A, Rentschler V, Gerhardt C, Lehmann LJ. Surgical treatment of fracture sequelae of the proximal humerus according to a pathology-based modification of the Boileau classification results in improved clinical outcome after shoulder arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:757-769. [PMID: 37690026 PMCID: PMC10858156 DOI: 10.1007/s00590-023-03721-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/27/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Fracture sequelae of the proximal humerus were classified by Boileau into four types. Since there are pathomorphological differences and specific characteristics within the four types, we have developed a subclassification. For elderly patients, shoulder arthroplasty is mostly recommended. Based on the available literature and clinical trial results, a subclassification could be created that suggests a specific therapy for each subgroup. The aim of this study was to evaluate the endoprosthetic therapy according to the proposed subclassification and to provide an overview of the clinical and radiological results after endoprosthetic treatment of proximal humerus fracture sequelae. METHODS Patients with fracture sequelae of the proximal humerus who underwent arthroplasty according to the suggestion of the subclassification were included. Minimum time to follow-up was twelve months. General condition and several specific shoulder scores as the Constant-Murley Score (CS) were recorded at the follow-up examination. Complication and revision rates were analyzed. RESULTS In total, 59 patients (72.6 ± 10.0 years, 47 females, 12 males) were included. Mean follow-up time was 31.3 ± 17.0 months. Reverse shoulder arthroplasty was performed in 49 patients and anatomic shoulder arthroplasty was performed in ten patients. The CS increased by 47.3 points from preoperative (15.0) to postoperative (62.3). Good or very good clinical results were seen in 61% of the patients. Complications were observed in twelve (20%) patients and revision surgery was performed in nine (15%) patients. CONCLUSION Due to of the variety of fracture sequelae of the proximal humerus, a modification of the Boileau classification seems necessary. This study shows that endoprosthetic treatment for fracture sequelae can significantly improve the shoulder function in elderly patients. Good clinical results can be achieved with a comparatively low revision rate following the treatment suggestions of the proposed subclassification of the Boileau classification. LEVEL OF EVIDENCE IV Case series.
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Affiliation(s)
- Michael Kimmeyer
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany.
- Alps Surgery Institute, Clinique Générale Annecy, 4 Chemin de La Tour la Reine, 74000, Annecy, France.
| | - Jonas Schmalzl
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, Oberduerrbacher Str. 6, 97080, Würzburg, Germany
| | - Evelin Schmidt
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
- University of Jena, Bachstr. 18, 07743, Jena, Germany
| | - Annika Graf
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Verena Rentschler
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Christian Gerhardt
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Lars-Johannes Lehmann
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
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Klute L, Henssler L, Schliemann B, Königshausen M, Weber N, Alt V, Kerschbaum M. Factors influencing choice of treatment for proximal humeral fractures elaborated in a Delphi consensus process. Arch Orthop Trauma Surg 2023; 143:7053-7061. [PMID: 37658856 PMCID: PMC10635939 DOI: 10.1007/s00402-023-05028-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/09/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION Hitherto, the decision-making process for treatment of proximal humerus fractures (PHF) remains controversial, with no established or commonly used treatment regimens. Identifying fracture- and patient-related factors that influence treatment decisions is crucial for the development of such treatment algorithms. The objective of this study was to define a Delphi consensus of clinically relevant fracture- and patient-related factors of PHF for clinical application and scientific research. METHODS An online survey was conducted among an international panel of preselected experienced shoulder surgeons. An evidence-based list of fracture-related and patient-related factors affecting treatment outcome after PHF was generated and reviewed by the members of the committee through online surveys. The proposed factors were revised for definitions, and suggestions from the first round mentioned in the free text were included as possible factors in the second round of surveys. Consensus was defined as having at least a two-thirds majority agreement. RESULTS The Delphi consensus panel consisted of 18 shoulder surgeons who completed 2 rounds of online surveys. There was an agreement of more than two-thirds of the panel for three fracture-related factors affecting treatment decision in the case of PHF: head-split fracture, dislocated tuberosities, and fracture dislocation. Of all patient-related factors, a two-thirds consensus was reached for two factors: age and rotator cuff tear arthropathy. CONCLUSION This study successfully conducted a Delphi consensus on factors influencing decision-making in the treatment of proximal humeral fractures. The documented factors will be useful for clinical evaluation and scientific validation in future studies.
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Affiliation(s)
- Lisa Klute
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Leopold Henssler
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Benedikt Schliemann
- Department of Trauma, Hand and Reconstructive Surgery, Herz-Jesu Hospital, 48165, Münster, Germany
| | - Matthias Königshausen
- Department of Trauma Surgery and General Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-La-Camp-Platz 1, 44789, Bochum, Germany
| | - Nadine Weber
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
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Misir A, Oguzkaya S, Kizkapan TB, Eken G, Canbaz SB. Fracture line and comminution zone characteristics, and rotator cuff footprint involvement in OTA/AO 11C3-type proximal humeral fractures: complex proximal humerus fracture map. Arch Orthop Trauma Surg 2023; 143:6219-6227. [PMID: 37378893 DOI: 10.1007/s00402-023-04962-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/20/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE To identify fracture characteristics and zones of comminution as well as the relationship with anatomic landmarks and rotator cuff footprint involvement in OTA/AO 11C3-type proximal humerus fractures. METHODS Computed tomography images of 201 OTA/AO 11C3 fractures were included. Fracture lines were superimposed to a 3D proximal humerus template, created from a healthy right humerus, after fracture fragment reduction on 3D reconstruction images. Rotator cuff tendon footprints were marked on the template. Lateral, anterior, posterior, medial, and superior views were captured for the interpretation of fracture line and comminution zone distribution as well as to define the relationship with anatomic landmarks and rotator cuff tendon footprints. RESULTS A total of 106 females and 95 males (mean age = 57.5 ± 17.7 [range 18-101] years) with 103 C3.1-, 45 C3.2-, and 53 C3.3-type fractures were included. On the lateral, medial, and superior humeral surfaces, fracture lines and comminution zones were distributed differently in 3 groups. Tuberculum minus and medial calcar region were significantly less severely affected in C3.1 and C3.2 fractures than C3.3 fractures. The supraspinatus footprint was the most severely affected rotator cuff footprint area. CONCLUSIONS Specifically defining the certain differences for repeatable fracture patterns and comminution zones in OTA/AO 11C3-type fractures and the relationship between the rotator cuff footprint and the joint capsule may contribute to the decision-making process of surgeons.
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Affiliation(s)
- Abdulhamit Misir
- Department of Orthopaedics and Traumatology, Private Safa Hospital, Zafer Mah. Ahmet Yesevi Cad. Gümüş Sk. No: 11A, Bahcelievler, 34194, Istanbul, Turkey.
| | - Sinan Oguzkaya
- Department of Orthopaedics and Traumatology, Bursa Cekirge State Hospital, Bursa, Turkey
| | - Turan Bilge Kizkapan
- Department of Orthopaedics and Traumatology, Basaksehir Pine and Sakura City Hospital, Istanbul, Turkey
| | - Gökay Eken
- Department of Orthopaedics and Traumatology, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Sebati Baser Canbaz
- Department of Orthopaedics and Traumatology, Erciyes University Faculty of Medicine, Kayseri, Turkey
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Razaeian S, Al Marhi O, Wiese B, Zhang D, Bouklas P, Krettek C, Hawi N. Predicting the deltoid tuberosity index in proximal humerus fractures using fracture characteristics and patient age: development of the LBQ-PHF score. BMC Musculoskelet Disord 2023; 24:754. [PMID: 37749531 PMCID: PMC10519058 DOI: 10.1186/s12891-023-06883-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/14/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate (1) whether fracture pattern and age are associated with local bone quality (LBQ), and (2) whether a scoring system based on these variables is able to predict LBQ in proximal humerus fractures (PHF). MATERIALS AND METHODS A retrospective study was performed of all acute PHF at a Level 2 trauma center with plain radiographs and CT between June 2009 and March 2022. Local bone quality was measured by using the deltoid tuberosity index (DTI). In addition to age and gender, fracture morphology was categorized using the following classification systems: Neer, Resch, AO Foundation/Orthopaedic Trauma Association (AO/OTA), and Hertel/LEGO. Additionally, coronal head alignment was calculated by measuring the head-shaft angle. RESULTS Only the Resch classification system revealed a significant relationship between fracture type and bone quality, as there was a significant association between coronal head alignment and DTI (p = 0.001). Valgus head alignment was observed significantly more frequent in patients with low bone quality (p = 0.002). Multinomial logistic regression analysis revealed a significant relative risk ratio for age (RRR = 0.97, [95% CI, 0.94-1], p = 0.039) and a non-significant trend for DTI (RRR = 1.26, [95% CI, 0.96-1.64], p = 0.092) for occurrence of anatomic relative to valgus head alignment. Using a DTI cut-off value of 1.3 instead of 1.4, age and also varus head alignment were identified as significant predictors of LBQ (OR = 1.12, [95% CI, 1.1-1.15], p < 0.001; OR = 0.54, [95% CI, 0.3-0.96], p = 0.037). A scoring system called the LBQ-PHF score (local bone quality in proximal humerus fractures), developed based on these two variables was able to predict LBQ with a sensitivity of 79.2% and a specificity of 86.7%. CONCLUSION Age and coronal humeral head alignment are independent predictors of LBQ in PHF. A simple scoring system developed based on these variables is able to assess BQ with solid predictive characteristics.
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Affiliation(s)
- Sam Razaeian
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Okba Al Marhi
- Department of Trauma Surgery and Orthopaedic Surgery, Helios St. Marienberg Klinik Helmstedt GmbH, Conringstraße 26, 38350, Helmstedt, Germany
| | - Birgitt Wiese
- Hannover Medical School, MHH Information Technology (MIT), Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Panagiotis Bouklas
- Department of Trauma Surgery and Orthopaedic Surgery, Helios St. Marienberg Klinik Helmstedt GmbH, Conringstraße 26, 38350, Helmstedt, Germany
| | - Christian Krettek
- Hannover Humerus Registry (HHR), Traumastiftung gGmbH Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Nael Hawi
- Hannover Humerus Registry (HHR), Traumastiftung gGmbH Carl-Neuberg-Str. 1, 30625, Hannover, Germany
- Orthopaedic and Surgical Clinic Braunschweig (OCP), Mauernstraße 35, 38100, Braunschweig, Germany
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Baker HP, Gutbrod J, Cahill M, Shi L. Optimal Treatment of Proximal Humeral Fractures in the Elderly: Risks and Management Challenges. Orthop Res Rev 2023; 15:129-137. [PMID: 37396822 PMCID: PMC10312335 DOI: 10.2147/orr.s340536] [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] [Received: 03/15/2023] [Accepted: 06/20/2023] [Indexed: 07/04/2023] Open
Abstract
Proximal humeral fractures (PHFs) are a common type of fracture, particularly in older adults, accounting for approximately 5-6% of all fractures. This article provides a comprehensive review of PHFs, focusing on epidemiology, injury mechanism, clinical and radiographic assessment, classification systems, and treatment options. The incidence of PHFs varies across regions, with rates ranging from 45.7 to 60.1 per 100,000 person-years. Females are more susceptible to PHFs than males, and the incidence is highest in women over the age of 85. The injury mechanism of PHFs is typically bimodal, with high-energy injuries predominant in younger individuals and low-energy injuries in the elderly. Clinical assessment of PHFs involves obtaining a thorough history, physical examination, and evaluation of associated injuries, particularly neurovascular injuries. Radiographic imaging helps assess fracture displacement and plan for treatment. The Neer classification system is the most commonly used classification for PHFs, although other systems, such as AO/OTA, Codman-Hertel, and Resch classifications, also exist. The choice of treatment depends on factors such as patient age, activity level, fracture pattern, and surgeon expertise. Nonoperative management is typically preferred for elderly patients with minimal displacement, while operative fixation is considered for more complex fractures. Nonoperative treatment involves sling immobilization followed by physiotherapy, with good outcomes reported for certain fracture patterns. Operative management options include closed reduction and percutaneous pinning (CRPP), open reduction and internal fixation (ORIF), or arthroplasty. CRPP is suitable for specific fracture patterns, but the quality of reduction is crucial for favorable outcomes. ORIF is used when CRPP is not feasible, and various surgical approaches are available, each with its advantages and potential complications. PHFs are a significant clinical challenge due to their prevalence and complexity. Treatment decisions should be patient centered based on patient factors and fracture severity.
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Joseph Gutbrod
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Michael Cahill
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Lewis Shi
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
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Risk factors for intra-articular involvement in proximal humeral fractures. Arch Orthop Trauma Surg 2023; 143:1341-1351. [PMID: 35028706 DOI: 10.1007/s00402-021-04293-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 11/27/2021] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Identification of intra-articular involvement in proximal humeral fractures is important for operative decision making. The aim of this study was to identify the risk factors associated with intra-articular involvement in proximal humeral fractures. MATERIALS AND METHODS One hundred consecutive three-dimensional computed tomography reconstructions of proximal humeral fractures were identified. The fracture lines were then accurately transcribed onto a two-dimensional superior view of the humeral head and each fracture was assessed for intra-articular involvement. Statistical analyses were undertaken to identify risk factors for intra-articular involvement and extent of involvement. Furthermore, for each risk factor, common fracture patterns were identified and compared to anatomical landmarks. RESULTS Overall, 58% of the fractures involved the articular surface. High-energy mechanism, female gender, age ≥ 65, and posterior dislocation were risk factors for intra-articular involvement. Low-energy mechanism, female gender, age ≥ 65, varus angulation, and posterior dislocation were risk factors for increased extension of the fracture onto the articular surface. CONCLUSION Intra-articular involvement in proximal humeral fractures is influenced by demographics and fracture characteristics (mechanism of injury, angulation, and dislocation). Patients with identified risk factors should be appropriately evaluated for intra-articular fractures during preoperative planning to assist in operative decision making. LEVEL OF EVIDENCE Basic science; anatomy study.
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Double Plating for Complex Proximal Humeral Fractures: Clinical and Radiological Outcomes. J Clin Med 2023; 12:jcm12020696. [PMID: 36675625 PMCID: PMC9860712 DOI: 10.3390/jcm12020696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/19/2022] [Accepted: 01/09/2023] [Indexed: 01/17/2023] Open
Abstract
Double plating for proximal humeral fractures (PHF) is an option to increase the primary fixation stability. Clinical data is missing for assessment of clinical and radiological outcome, as well as complications. We retrospectively examined 35 patients with unilateral PHF, who were treated with double plating for PHF between 2013 and 2019. The mean age was 59.5 ± 12 years and the leading fracture type was a varus dislocation (Resch type IV in 55.3%). A head-split was present in 22.9% of the cases. The primary outcome measurement was the radiological neck shaft angle (NSA). The radiological follow-up was 21 ± 16.6 months and the NSA did not differ between the intraoperative and follow-up time point (131.5 ± 6.9° vs. 136.6 ± 13.7°; p = 0.267). The clinical follow-up was 29.5 ± 15.3 months. The Constant-score was 78.5 ± 17 points, the simple-shoulder-test (SST) was 9.3 ± 3.2 points and the subjective shoulder value (SSV) was 78.8 ± 19.5%. The over-all complication rate was 31.4%, and without stiffness 14.3%. An avascular necrosis occurred in two patients (5.7%). In conclusion, this study shows good radiological and functional outcomes after double plating of highly complex proximal humeral fractures, while the complication rate is comparable to the literature. Double plating is a viable option especially for younger patients with complex fractures as a potential alternative to fracture arthroplasty.
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Foruria AM, Martinez-Catalan N, Pardos B, Larson D, Barlow J, Sanchez-Sotelo J. Classification of Proximal Humerus Fractures According to Pattern Recognition is Associated with High Intraobserver and Interobserver Agreement. JSES Int 2022; 6:563-568. [PMID: 35813132 PMCID: PMC9264021 DOI: 10.1016/j.jseint.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The Mayo-Fundación Jiménez Díaz (FJD) classification for proximal humerus fractures aims to identify specific fracture patterns and apply displacement criteria to each pattern. The classification includes 7 common fracture patterns: isolated fractures of the greater or lesser tuberosity, fractures of the surgical neck, impacted fractures involving head rotation in a varus and posteromedial direction or in valgus, and fractures where the humeral head is dislocated (head dislocation), split (head splitting), or depressed (head impaction). The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Mayo-FJD classification system using plain radiographs (xR) and computed tomography (CT). Methods Three fellowship-trained shoulder surgeons blindly and independently evaluated the xR and CT of 103 consecutive proximal humerus fractures treated at a Level I trauma center. Each surgeon classified all fractures according to the Mayo-FJD classification system on 4 separate sessions at least 6 weeks apart. K values were calculated for intraobserver and interobserver reliability. Results The average intraobserver agreement was 0.9 (almost perfect) for xR and 0.9 (almost perfect) for CT scans. The average interobserver agreement was 0.69 (substantial) for xR and 0.81 (almost perfect) for CT scans at the first round, and 0.66 (substantial) for xR and 0.75 (substantial) for CT scans at the second round. Conclusion The pattern-based Mayo-FJD classification scheme for proximal humerus fractures was associated with adequate intraobserver and interobserver agreement using both xR and CT scan. Interobserver agreement was best when fractures were classified using CT scans.
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Affiliation(s)
- Antonio M. Foruria
- Upper Extremity Reconstruction Unit, Orthopedic Surgery Department. Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Natalia Martinez-Catalan
- Upper Extremity Reconstruction Unit, Orthopedic Surgery Department. Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Belen Pardos
- Upper Extremity Reconstruction Unit, Orthopedic Surgery Department. Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Dirk Larson
- Department of Statistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan Barlow
- Upper Extremity Reconstruction division. Orthopedic Surgery Department, Mayo Clinic, Rochester, Minnesota, USA
| | - Joaquín Sanchez-Sotelo
- Upper Extremity Reconstruction division. Orthopedic Surgery Department, Mayo Clinic, Rochester, Minnesota, USA
- Corresponding author: Joaquín Sanchez-Sotelo, MD, PhD, Gonda 14, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Goudie EB, MacDonald DJ, Robinson CM. Functional Outcome After Nonoperative Treatment of a Proximal Humeral Fracture in Adults. J Bone Joint Surg Am 2022; 104:123-138. [PMID: 34878423 DOI: 10.2106/jbjs.20.02018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The functional outcome following nonoperative treatment of a proximal humeral fracture and the factors that influence it are poorly defined. We aimed to prospectively assess patient-reported outcome measures (PROMs) in a patient cohort at 1 year after the injury. METHODS In this study, 774 adult patients sustaining a proximal humeral fracture completed PROM assessments, including the Oxford Shoulder Score (OSS), the EuroQol-5 Dimensions-3 Levels (EQ-5D-3L), and visual analog scale (VAS) assessments of pain, health, and overall treatment satisfaction at 1 year. The mean patient age was 65.6 years, and 73.8% of patients were female. The influences of demographic and fracture measurements and complications on the OSS and EQ-5D-3L were assessed. RESULTS The 1-year mean scores were 33.2 points (95% confidence interval [CI], 32.1 to 34.2 points) for the OSS and 0.58 (95% CI, 0.55 to 0.61) for the EQ-5D-3L. There was considerable heterogeneity in the reported scores, and the 3 demographic variables of higher levels of dependency, higher levels of social deprivation, and a history of affective (mood) disorder were most consistently associated with poorer outcomes, accounting for between 37% and 43% of the score variation. The initial fracture translation potentially leading to nonunion accounted for 9% to 15% of the variation, and a displaced tuberosity fracture was also predictive of 1% to 4% of the outcome variation. There was evidence of a ceiling effect for the OSS, with 238 patients (30.8%) having a score of ≥47 points but a mean outcome satisfaction of only 72.9 points, and this effect was more pronounced in younger, active individuals. At the other end of the spectrum, 239 patients (30.9%) reported an OSS of ≤24 points, and 120 patients (15.5%) had a "worse-than-death" EQ-5D-3L score. CONCLUSIONS Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year, and a substantial proportion of patients have poor perceived functional outcomes. The outcome for the majority of less-displaced fractures is mainly influenced by preexisting patient-related psychosocial factors, although the fracture-related factors of displacement, nonunion, and tuberosity displacement account for a small but measurable proportion of the variation and the poorer outcomes in the minority with more severe injuries. LEVEL OF EVIDENCE Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ewan B Goudie
- The Edinburgh Shoulder Clinic, New Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Dey Hazra RO, Illner J, Szewczyk K, Warnhoff M, Ellwein A, Blach RM, Lill H, Jensen G. Age-Independent Clinical Outcome in Proximal Humeral Fractures: 2-Year Results Using the Example of a Precontoured Locking Plate. J Clin Med 2022; 11:408. [PMID: 35054102 PMCID: PMC8781715 DOI: 10.3390/jcm11020408] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/05/2022] [Accepted: 01/11/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The optimal treatment strategy for the proximal humeral fracture (PHF) remains controversial. The debate is centered around the correct treatment strategy in the elderly patient population. The present study investigated whether age predicts the functional outcome of locking plate osteosynthesis for this fracture entity. METHODS A consecutive series of patients with surgically treated displaced PHF between 01/2017 and 01/2018 was retrospectively analyzed. Patients were treated by locking plate osteosynthesis. The cohort was divided into two groups: Group 1 (≥65 years) and Group 2 (<65 years). At the follow-up examination, the SSV, CMS, ASES, and Oxford Shoulder Score (OS), as well as a radiological follow-up, was obtained. The quality of fracture reduction is evaluated according to Schnetzke et al. Results: Of the 95 patients, 79 were followed up (83.1%). Group 1 consists of 42 patients (age range: 65-89 years, FU: 25 months) and Group 2 of 37 patients (28-64 years, FU: 24 months). The clinical results showed no significant differences between both groups: SSV 73.4 ± 23.4% (Group 1) vs. 80.5 ± 189% (Group 2). CMS: 79.4 ± 21 vs. 81.9 ± 16, ASES: 77.2 ± 20.4 vs. 77.5 ± 23.1, OS: 39.5 ± 9.1 vs. 40.8 ± 8.2; OS: 39.5 ± 9.1 vs. 40.8 ± 8.2. In the radiological follow-up, fractures healed in all cases. Furthermore, the quality of fracture reduction in both groups is comparable without significant differences. The revision rate was 9.5% in Group 1 vs. 16.2% in Group 2. DISCUSSION Both age groups show comparable functional outcomes and complication rates. Thus, the locking plate osteosynthesis can be used irrespective of patient age; the treatment decision should instead be based on fracture morphology and individual patient factors.
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Affiliation(s)
- Rony-Orijit Dey Hazra
- Department of Orthopedic and Trauma Surgery, Diakovere Friederikenstift and Henriettenstift, 30169 Hannover, Germany; (J.I.); (K.S.); (M.W.); (A.E.); (R.M.B.); (H.L.); (G.J.)
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Li K, Liu Z, Li X, Wang J. 3D printing-assisted surgery for proximal humerus fractures: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2022; 48:3493-3503. [PMID: 34997257 DOI: 10.1007/s00068-021-01851-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/29/2021] [Indexed: 11/03/2022]
Abstract
AIM This study aimed to assess the efficacy of three-dimensional (3D) printing to conventional surgeries in proximal humerus fractures (PHFs). METHODS Eight databases were comprehensively searched for data on clinical characteristics and outcomes, including operation time, time to bone healing, blood loss volume, number of intraoperative fluoroscopies, the reduction rate of anatomic proximal humeri, Constant scores, Neer rating, loss of humeral head height, and complications. These data were compared between 3D printing-assisted versus conventional surgeries to learn the efficacy of 3D printing-assisted surgery. RESULTS 3D printing-assisted surgery outperformed conventional procedures in operation time, blood loss volume, time to the union of PHFs, number of fluoroscopies, the reduction rate of anatomic proximal humeri, Constant scores, Neer rating, and complications. CONCLUSION 3D printing-assisted surgery improves operation time, anatomic healing, pain, and motion, with less harm to patients.
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Affiliation(s)
- Kai Li
- Clinical Medical College, Yangzhou University, Yangzhou, 225001, China
| | - Zhendong Liu
- Clinical Medical College, Yangzhou University, Yangzhou, 225001, China
| | - Xiaolei Li
- Department of Orthopaedics, Clinical Medical College of Yangzhou University, Northern Jiangsu People's Hospital, 98 Nantong West Road, Yangzhou, 225001, Jiangsu, China.
| | - Jingcheng Wang
- Northern Jiangsu People's Hospital, Yangzhou, 225001, Jiangsu, China.
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Promising Mid-Term Outcomes after Humeral Head Preserving Surgery of Posterior Fracture Dislocations of the Proximal Humerus. J Clin Med 2021; 10:jcm10173841. [PMID: 34501288 PMCID: PMC8432246 DOI: 10.3390/jcm10173841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/22/2021] [Accepted: 08/25/2021] [Indexed: 11/18/2022] Open
Abstract
Background: The aim of this study was to evaluate the clinical outcome after humeral head preserving surgical treatment of posterior fracture dislocations of the proximal humerus. Methods: Patients with a posterior fracture dislocation of the proximal humerus that were operatively treated in two level-1 trauma centers within a timeframe of 8 years were identified. With a minimum follow-up of 2 years, patients with humeral head preserving surgical treatment were invited for examination. Results: 19/24 fractures (79.2%; mean age 43 years) were examined with a mean follow-up of 4.1 ± 2.1 years. Of these, 12 fractures were categorized as posteriorly dislocated impression type fractures, and 7 fractures as posteriorly dislocated surgical neck fractures. Most impression type fractures were treated by open reduction, allo- or autograft impaction and screw fixation (n = 11), while most surgical neck fractures were treated with locked plating (n = 6). Patients with impression type fractures showed significantly better ASES scores (p = 0.041), Simple Shoulder Test scores (p = 0.003), Rowe scores (p = 0.013) and WOSI scores (p = 0.023), when compared to posteriorly dislocated surgical neck fractures. Range of motion was good to excellent for both groups with no significant difference. Conclusions: This mid-term follow-up study reports good to very good clinical results for humeral head preserving treatment.
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Martínez-Sola R, León-Muñoz VJ, Najem-Rizk AN, Soler-Vasco B, Arrieta-Martínez CJ, López-Sorroche E, Cárdenas-Grande E, Salmerón-Vélez G, Ruiz-Molina JÁ, Martínez-Martínez F, Santonja-Medina F. 'Absolute' inter-observer classifications agreement for proximal humeral fractures with a single shoulder anteroposterior X-ray. J Orthop Surg (Hong Kong) 2021; 29:23094990211010520. [PMID: 33896261 DOI: 10.1177/23094990211010520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Several studies have been carried out, and there is no classification for proximal humeral fractures (PHF) exempted from variability in interpretation and with questioned reliability. In the present study, we investigated the 'absolute diagnostic reliability' of the most currently used classifications for PHFs on a single anterior-posterior X-ray shoulder image. METHODS Six orthopaedic surgeons, with varying levels of experience in shoulder pathology, evaluated radiographs from 30 proximal humeral fractures, according to the 'absolute reliability' criteria. Each of the observers rated each fracture according to Neer, Müller/AO and Codman-Hertel's classification systems. RESULTS The overall inter-observer agreement (κ) has been 0.297 (CI95% 0.280 to 0.314) for the Neer's classification system, 0.206 (CI95% 0.193 to 0.218) for the Müller/AO classification system, and 0.315 (CI95% 0.334 to 0.368) for the Codman-Hertel classification system. We found loss of agreement in Neer's classification as the study progressed, low agreement in the AO classification, and stable values in the different evaluations with the best degree of agreement for Codman-Hertel classification, with a moderate agreement in the second evaluation among the six evaluators. CONCLUSION The Neer, AO, and Hertel-Codman classification systems for PHF with a single radiographic projection have a difficult interpretation for orthopaedic surgeons of varying levels of experience, and therefore substantial agreements are not obtained.
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Affiliation(s)
- Rocío Martínez-Sola
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Vicente J León-Muñoz
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Antoine Nicolas Najem-Rizk
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Beatriz Soler-Vasco
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Carlos J Arrieta-Martínez
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Eva López-Sorroche
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | | | - Guillermo Salmerón-Vélez
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - José Ángel Ruiz-Molina
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Francisco Martínez-Martínez
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Fernando Santonja-Medina
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
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Double plating - surgical technique and good clinical results in complex and highly unstable proximal humeral fractures. Injury 2021; 52:2285-2291. [PMID: 34148652 DOI: 10.1016/j.injury.2021.05.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/28/2021] [Accepted: 05/31/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION A stable fixation of highly unstable proximal humerus fractures remains challenging and complication rates, especially secondary varus dislocation, remains high. Different techniques of double plate osteosynthesis have been suggested for the treatment of complex proximal humeral fractures as they are well established for other fractures. The aim of this study was to evaluate an operative technique using an angular stable lateral plate supported by a one-third tubular plate positioned anteriorly at the lesser tuberosity for unstable proximal humeral fractures. PATIENTS AND METHODS Retrospectively, patients treated with a double plate osteosynthesis were included between January 2014 and December 2017. Out of 31, 25 patients (80.6%) with an average age of 53.1 years ± 12.5 were available for follow-up. 60% of the patients were male. The clinical evaluation consisted of a physical examination and standardised questionnaire including subjective and objective shoulder scores like the Constant-Murley Shoulder Score, Simple Shoulder Score, and Subjective Shoulder Value. RESULTS After a mean follow-up of 30.9 months (range, 12-76 months) eighteen patients (72%) had either excellent or good results regarding the Constant-Murley Shoulder Score with a mean value of 77 points ± 17. Average Simple Shoulder Score was 76% ± 0.2 and Subjective Shoulder Value 72% ± 0.2%. Mean NSA at time of follow-up 135° ± 13°. Nine patients had an implant-removal, five in combination with arthrolysis after a mean of 7.2 months. Three patients underwent surgery for secondary arthroplasty. The study shows a complication rate of 16%. No revision-surgery because of secondary varus dislocation was reported. DISCUSSION Arthroplasty is the less favourable treatment for a younger, active cohort of patients with highly unstable proximal humeral fractures as results are not as good and options for revision are limited. Double plate osteosynthesis can be used in addition to calcar screws, bone graft augmentation, cement augmentation and additional free screws for more multidirectional stability and shows good clinical results despite a higher rate of avascular necrosis and high primary stability with comparable complication-rates to single plate osteosynthesis. It seems to be a valid alternative to primary fracture arthroplasty and can prevent secondary varus displacement.
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Goudie EB, Robinson CM. Prediction of Nonunion After Nonoperative Treatment of a Proximal Humeral Fracture. J Bone Joint Surg Am 2021; 103:668-680. [PMID: 33849049 DOI: 10.2106/jbjs.20.01139] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The prevalence of nonunion after a proximal humeral fracture (PHF) and the risk factors for its occurrence are poorly defined. We aimed to estimate the rate of nonunion in nonoperatively treated patients and to produce a clinical model for its prediction. METHODS Two thousand two hundred and thirty adult patients (median age, 72 years [range, 18 to 103 years]; 75.5% were female) with a PHF underwent assessment of fracture union using standard clinical evaluation and conventional radiographs. We assessed the prevalence of nonunion and measured the effect of 19 parameters on healing. Best statistical practices were used to construct a multivariate logistic regression model. The PHF assessment of risk of nonunion model (PHARON) was externally validated in a subsequent prospectively collected population of 735 patients, treated by the same protocol in our institution. RESULTS Overall, 231 (10.4%) of 2,230 patients developed nonunion. Only 3 (0.8%) of 395 patients with a head-shaft angle (HSA) of >140° developed nonunion; in this cohort, none of the measured candidate variables were independently predictive of nonunion on multivariate logistic regression analysis. In the larger cohort of 1,835 patients with an HSA of ≤140°, 228 (12.4%) developed nonunion. Decreasing HSA, increasing head-shaft translation (HST), and smoking were independently predictive of nonunion on multivariate analysis. The prevalence of nonunion was very low (1%) in the majority with both an HSA of >90° and HST of <50%, whereas the risk was much higher (83.7%) in the 8.3% with an HSA of ≤90° and HST of ≥50%. In both groups, the prevalence of nonunion was much higher in smokers. CONCLUSIONS The prevalence of nonunion after PHF is higher than previously reported. Most patients have favorable risk-factor estimates and a very low risk of this complication, but a smaller subgroup is at much higher risk. The risk can be accurately estimated with PHARON, using standard clinical assessment tools. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ewan B Goudie
- The Edinburgh Shoulder Clinic, New Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Dey Hazra RO, Blach RM, Ellwein A, Katthagen JC, Lill H, Jensen G. Latest Trends in the Current Treatment of Proximal Humeral Fractures - an Analysis of 1162 Cases at a Level-1 Trauma Centre with a Special Focus on Shoulder Surgery. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021; 160:287-298. [PMID: 33530111 DOI: 10.1055/a-1333-3951] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The management of proximal humeral fracture (PHF) is not only complex but ever changing. Published epidemiological data are often dated and do not factor in demographic changes or the latest developments in implant material and surgical techniques. AIMS The primary aim of this study was to evaluate changes in the epidemiology and actual treatment of PHF at a level-1 trauma centre, with a special focus on shoulder surgery. HYPOTHESES 1. Between 2009 to 2012 and 2014 to 2017, an increase in complex PHF entities can be observed. 2. In correlation with fracture complexity, an increasing number of comorbidities, especially osteoporosis, can be observed. METHODS Between 2014 and 2017, a total of 589 patients (73% female; mean age: 68.96 ± 14.9 years) with 593 PHFs were treated. Patient records and imaging (XRs and CTs) of all patients were analysed. Fractures with ad latus displacement of a maximum of 0,5 cm and/or humeral head angulation of less than 20° were classified as non-displaced. Patients with displaced fractures were included in the analysis of the therapeutic algorithm. These results were compared to those of a cohort 2009 to 2012 (566 patients, 569 PHFs), which used the same inclusion criteria. RESULTS The two cohorts showed comparable patient numbers, as well as gender and age distributions. Between 2009 to 2012 and 2014 to 2017, a decrease in 2-part fractures (13.9 to 8.6%) and a simultaneous increase in 4-part fractures (20.4 to 30%), and thus fracture complexity was observed. Further decreases were observed in conservative therapy (27.8 to 20.6%), nail osteosynthesis (10.7 to 2.7%) and anatomic shoulder arthroplasty (5,4 to 1%). Furthermore, there was an increase in the use of locking plate osteosynthesis (43.2 to 56.7%) and reverse shoulder arthroplasty (9 to 18.4%). The general trend shows an increase in surgical therapy between the years (72.2 to 79.4%), as well as an increase in osteoporosis incidence (13 to 20.6%). The greatest numbers of comorbidities were found in 3- and 4-part fractures. CONCLUSION There is an increase in both the complexity of fractures and the number of surgically treated fractures between 2009 and 2012. Furthermore, an increase in osteoporosis numbers can be observed. New implants (PEEK, fenestrated screws for cement augmentation) and new surgical techniques (double plating osteosynthesis) were used as a result of increasing fracture complexity. Moreover, reverse total shoulder arthroplasty was used more commonly.
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Affiliation(s)
| | | | - Alexander Ellwein
- Orthopaedic Clinic, Medical School Hanover (MHH), DIAKOVERE Annastift, Hanover, Germany
| | - Jan Christoph Katthagen
- Trauma, Hand and Reconstructive Surgery, Westphalian Wilhelm's University of Munster, Medical Faculty, Munster, Germany
| | - Helmut Lill
- Orthopaedic and Trauma Clinic, DIAKOVERE Friederikenstift, Hanover, Germany
| | - Gunnar Jensen
- Orthopaedic and Trauma Clinic, DIAKOVERE Friederikenstift, Hanover, Germany
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Gracitelli MEC, Yamamoto GJ, Malavolta EA, Andrade-Silva FB, Kojima KE, Ferreira Neto AA. Tratamento não operatório de fraturas desviadas da extremidade proximal do úmero em idosos: Correlação entre os desvios e os resultados clínicos. Rev Bras Ortop 2020; 57:273-281. [PMID: 35652030 PMCID: PMC9142268 DOI: 10.1055/s-0040-1716760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 07/06/2020] [Indexed: 10/24/2022] Open
Abstract
Resumo
Objetivos Descrever o resultado funcional do tratamento não operatório de fraturas desviadas da extremidade proximal do úmero (FEPU) pela escala da American Shoulder and Elbow Surgeons (ASES, na sigla em inglês) após 12 meses e avaliar se as diferentes classificações e medidas radiográficas iniciais têm correlação com os resultados clínicos.
Métodos Foram avaliados em tempos padronizados (3, 6 e 12 meses), 40 pacientes > 60 anos com FEPU submetidos ao tratamento não operatório. Foram utilizadas as escalas da ASES, Constant-Murley e Single Assessment Numeric Evaluation (SANE, na sigla em inglês). As variáveis radiográficas incluíram as classificações de Neer e Resch, a presença de fratura e desvio dos tubérculos, cominuição metafisária, lesão periosteal medial, desvios angulares e translacionais da cabeça no plano coronal e sagital e desvio dos tubérculos.
Resultados Observamos resultados pela escala de ASES de 77,7 ± 23,2 para toda a amostra, pela de Constant-Murley de 68,7 ± 16 e de 82,6% para a escala em relação ao lado contralateral. A escala de SANE aos 12 meses foi de 84,8 ± 19. Os critérios radiográficos que apresentaram influência negativa no resultado clínico pela escala de ASES aos 12 meses foram a gravidade pela classificação de Neer e pelo desvio angular no plano coronal (mensurado pelo ângulo cabeça-diáfise) e a presença de fratura dos tubérculos.
Conclusão O tratamento não operatório de fraturas desviadas da extremidade proximal do úmero em pacientes idosos resulta em bons resultados clínicos. Os resultados clínicos são influenciados negativamente pelo desvio angular da cabeça do úmero e pela presença de fratura dos tubérculos maior e menor, assim como pela classificação de Neer.
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Affiliation(s)
- Mauro Emilio Conforto Gracitelli
- Grupo de Ombro e Cotovelo, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Gustavo Jum Yamamoto
- Grupo de Ombro e Cotovelo, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Eduardo Angeli Malavolta
- Grupo de Ombro e Cotovelo, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Fernando Brandão Andrade-Silva
- Grupo de Ombro e Cotovelo, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Kodi Edson Kojima
- Grupo de Ombro e Cotovelo, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Arnaldo Amado Ferreira Neto
- Grupo de Ombro e Cotovelo, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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Schmalzl J, Jessen M, Gilbert F, Gerhardt C, Lehmann LJ. Proximal humeral fracture morphology in patients with advanced cuff tear arthropathy: an observational study in a surgically treated cohort. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:517-524. [PMID: 33025159 DOI: 10.1007/s00590-020-02801-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/23/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND In the presence of cuff tear arthropathy (CTA), joint kinematics is alternated and fracture configuration might be different. The purpose of this study was to identify fracture patterns in patients with advanced CTA to facilitate recognition and treatment. METHODS Radiographs and computed tomography scans of all patients undergoing surgical treatment for a proximal humeral fracture (PHF) in our institution during a 5-year period were retrospectively analyzed. Fracture pattern according to the AO-OTA and Resch classification and the presence of CTA were evaluated. Glenoid configuration according to Walch, fatty atrophy of the supraspinatus muscle and the centrum-collum-diaphyseal (CCD) angle were analyzed. RESULTS A total of 574 out of 713 patients were included. Twenty-three patients (4%) with a mean age of 82 ± 8 years showed advanced CTA with acetabularization of the acromion (≥ stage 3 according to Hamada/Fukuda). There were exclusively valgus fractures with a mean CCD angle of 158° ± 18°. Patients with CTA ≥ grade 3 had a nearly twofold greater risk (risk ratio: 1.8; confidence interval (CI): 95% 1.6-1.9; p < 0.0001) of sustaining a valgus fracture compared to patients without or with CTA < grade 3. The risk for a tuberosity fracture was nearly twofold greater in patients without or with mild CTA (risk ratio: 1.68; confidence interval (CI): 95% 1.17-2.40; p = 0.0046) compared to those with advanced CTA. CONCLUSION In advanced CTA, a predominantly valgus fracture pattern can be observed. In addition, fractures of the greater tuberosity were significantly less frequent and were rarely displaced. Up to date, no classification system for PHF has been developed in the setting of CTA although it might indicate a different treatment, and therefore, recognition is crucial. However, when present, this changes the fracture pattern and ability to treat the fracture as the rotator cuff can no longer be utilized as a means of reducing the fragments.
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Affiliation(s)
- Jonas Schmalzl
- Department of Traumatology and Hand Surgery, St. Vincentius Clinic, ViDia Clinics, Suedendstraße 32, 76137, Karlsruhe, Germany. .,Department of Trauma, Hand, Plastic and Reconstructive Surgery, Julius-Maximilians-University of Wuerzburg, Oberduerrbacher Str. 6, 97080, Wuerzburg, Germany.
| | - Malik Jessen
- Department of Traumatology and Hand Surgery, St. Vincentius Clinic, ViDia Clinics, Suedendstraße 32, 76137, Karlsruhe, Germany.,Orthopaedic and Trauma Surgery Centre (OUZ), Medical Faculty Mannheim, Ruprecht-Karls-University, Heidelberg, Germany
| | - Fabian Gilbert
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, Julius-Maximilians-University of Wuerzburg, Oberduerrbacher Str. 6, 97080, Wuerzburg, Germany
| | - Christian Gerhardt
- Department of Traumatology and Hand Surgery, St. Vincentius Clinic, ViDia Clinics, Suedendstraße 32, 76137, Karlsruhe, Germany
| | - Lars-Johannes Lehmann
- Department of Traumatology and Hand Surgery, St. Vincentius Clinic, ViDia Clinics, Suedendstraße 32, 76137, Karlsruhe, Germany.,Orthopaedic and Trauma Surgery Centre (OUZ), Medical Faculty Mannheim, Ruprecht-Karls-University, Heidelberg, Germany
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Simionato IF, Brunelli JPF, Ferreira MT, Matsumoto FY, Britto AG, Mothes FC. Radiographic Evaluation of the Consolidation of Humerus Surgical Neck Fractures Treated With Percutaneous Fixation. Rev Bras Ortop 2020; 55:347-352. [PMID: 32616981 PMCID: PMC7316538 DOI: 10.1055/s-0039-3402463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 05/02/2019] [Indexed: 12/03/2022] Open
Abstract
Objective
To evaluate radiographically the postoperative results of patients with fracture of the proximal humerus in two parts of the surgical neck treated with threaded percutaneous fixation.
Methods
We evaluated the radiographic results of percutaneous fixation with threaded pins on the treatment of proximal humerus fractures in our service. Preoperative and postoperative images of 42 patients were evaluated, evaluating radiographs until 8 weeks postoperatively. We considered on evaluation the fracture deviation on preoperative images, the loss of reduction and no consolidation.
Results
Our consolidation rate was 90.4%, with loss of reduction in 16.6% of the cases and no consolidation rates in just 4 operated cases. We observed a predominance of a specific fracture pattern in the cases with loss of reduction.
Conclusion
The present study allows us to consider the percutaneous fixation technique with threaded pins as an alternative in our therapeutic arsenal for the proximal humerus fracture of the surgical neck. Contraindications are considered for low fracture trait on the metaphysis and with medial/lateral cortical impairment.
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Affiliation(s)
| | | | - Marco Tonding Ferreira
- Grupo de Cirurgia do Ombro e Cotovelo, Santa Casa de Misericórdia de Porto Alegre, RS, Brasil
| | | | - Almiro Gerszon Britto
- Grupo de Cirurgia do Ombro e Cotovelo, Santa Casa de Misericórdia de Porto Alegre, RS, Brasil
| | - Fernando Carlos Mothes
- Grupo de Cirurgia do Ombro e Cotovelo, Santa Casa de Misericórdia de Porto Alegre, RS, Brasil
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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.
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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
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High rate of unexpected positive cultures in presumed aseptic revision of stiff shoulders after proximal humerus osteosynthesis. BMC Musculoskelet Disord 2020; 21:393. [PMID: 32571281 PMCID: PMC7310400 DOI: 10.1186/s12891-020-03430-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 06/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the prevalence of positive microbiology samples after osteosynthesis of proximal humerus fractures at the time of revision surgery and evaluate clinical characteristics of patients with positive culture results. METHODS All patients, who underwent revision surgery after locked platting, medullary nailing or screw osteosynthesis of proximal humeral fractures between April 2013 and July 2018 were retrospectively evaluated. Patients with acute postoperative infections, those with apparent clinical signs of infection and those with ≤1 tissue or only sonication sample obtained at the time of implant removal were excluded. Positive culture results of revision surgery and its correlation with postoperative shoulder stiffness was analyzed in patients with an interval of ≥6 months between the index osteosynthesis and revision surgery. RESULTS Intraoperatively obtained cultures were positive in 31 patients (50%). Cutibacterium acnes was the most commonly isolated microorganism, observed in 21 patients (67.7%), followed by coagulase negative staphylococci in 12 patients (38.7%). There were significantly more stiff patients in the culture positive group compared to the culture-negative group (19/21, 91% vs. 15/26, 58%, p = 0.02). Furthermore, 11 of 12 (91.7%) patients with growth of the same microorganism in at least two samples had a stiff shoulder compared to 23 of 35 (65.7%) patients with only one positive culture or negative culture results (p = 0.14). CONCLUSION Infection must always be considered as a possibility in the setting of revision surgery after proximal humerus osteosynthesis, especially in patients with postoperative stiffness.
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Sun Q, Wu X, Wang L, Cai M. The plate fixation strategy of complex proximal humeral fractures. INTERNATIONAL ORTHOPAEDICS 2020; 44:1785-1795. [PMID: 32535700 DOI: 10.1007/s00264-020-04544-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/18/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE For complex proximal humeral fractures, severe displacement and comminuted fragments lead to poor clinical outcomes. Despite considerable management, the locking plate fixation is still a preference and the proper selection of its strategy for each individual seems to be essential. METHOD The available classification system of the fracture, determination of surgical intervention, the common complications and related causes, and the latest critical surgical strategies with locking plate fixation were discussed in this review. RESULTS The frequent complications with complex proximal humeral fractures after operative treatment present a great challenge to orthopedic surgeons. In order to maintain the stability of locking plate fixation, several options including calcar screw, bone graft, bone cement augmentation, dual plate fixation, and fracture impaction were available for restoration of medial support. CONCLUSION Restoration of medial support seems of importance to provide solid stability and reduced complication for the complex fractures with fixation of locking plates.
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Affiliation(s)
- Qi Sun
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China
| | - Xiaoming Wu
- Department of Orthopedics, Shanghai First People's Hospital, Shanghai Jiao Tong University, Shanghai, 200080, China
| | - Lei Wang
- Department of Orthopedics, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China.
| | - Ming Cai
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China.
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Stoddart M, Pearce O, Smith J, McCann P, Sheridan B, Al-Hourani K. Proximal Humerus Fractures: Reliability of Neer Versus AO Classification on Plain Radiographs and Computed Tomography. Cureus 2020; 12:e8520. [PMID: 32656034 PMCID: PMC7346293 DOI: 10.7759/cureus.8520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction: Several classifications for proximal humeral fractures exist, with excellent reliability and reproducibility of such classifications being a desirable feature. Despite their widespread use, these systems are variable in both reliability and accuracy. We aimed to, a) assess and compare the reliability of the Neer (complete and abbreviated versions) and Arbeitsgemeinschaft für Osteosynthesefragenbeing (AO) classifications, and b) identify if computed tomography (CT) made any difference to the reliability of Neer and AO classifications when compared to plain radiographs alone. Materials and methods: This is a single-centre retrospective study identifying all proximal humeral fractures presenting between February 2016 and February 2017 as a result of trauma that subsequently proceeded to CT. Two specialty orthopaedic trainees analysed the plain radiographs as well as CT images over two rounds, spaced two weeks apart. The Neer 16-grade, abbreviated Neer 6-grade and AO classifications were used. Intra- and inter-observer reliability of each classification system was assessed using the Kappa coefficient. Results: Twenty-two patients were included. The mean age was 62 years (SD 14.5). Management changed in 9/22 patients based on CT. Computed tomography changed Neer-16 type in 16% observations, Neer-6 in 10%, and AO in 23%. This was significant when comparing Neer-6 and AO classifications (p = 0.04). Neer-6 had the best inter-observer reliability (0.737) with the management of one patient changing after CT. On X-ray and CT, intra-observer agreement was substantial, >0.7, using Neer-16 and Neer-6 (p<0.005). Inter-observer agreement for Neer-16 and Neer-6 was substantial, >0.7 (p<0.005). In comparison, intra- and inter-observer agreements for AO were lower on X-ray and CT, 0.4-0.6, (p<0.005). Conclusion: Our study shows that simplicity is key with a high degree of reliability in the abbreviated Neer classification. Computed tomography allowed greater reliability than radiographs in classifying fractures, affecting management decisions in 41% of patients. The comprehensive Neer classification showed similar intra- and inter-observer reliabilities to AO.
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Affiliation(s)
- Michael Stoddart
- Trauma and Orthopaedics, Royal National Orthopaedic Hospital, London, GBR
| | - Oliver Pearce
- Trauma and Orthopaedics, Southmead Hospital, Bristol, GBR
| | - James Smith
- Orthopaedics, Southmead Hospital, Bristol, GBR
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Abstract
BACKGROUND The shoulder girdle is a chain of bones and joints which connect the upper extremity to the axial skeleton. The shoulder as a biomechanical unit has a remarkable range of motion and is therefore frequently prone to injuries of the three major joints (sternoclavicular joint, acromioclavicular joint, glenohumeral joint) and the bony elements (clavicle, scapula, humerus). Projection radiography is still the first imaging modality for injuries of the shoulder and usually sufficient for initial diagnosis and injury classification. Computed tomography (including 3D reconstructions) and magnetic resonance imaging provide additional useful information for the detection of accompanying soft-tissue injury, for surgical planning and in cases of complex anatomy (e.g., scapular fractures). PURPOSE We aim to describe the fundamentals of injuries of the shoulder girdle and the proximal humerus with special emphasis on radiological diagnostics. MATERIALS AND METHODS A selective PubMed literature search was performed using the following terms: "sternoclavicular joint dislocation", "clavicle fracture", "acromioclavicular joint injury", "scapular fracture", "shoulder dislocation", "proximal humerus fracture", and "shoulder girdle injuries". RESULTS The article describes the basics of the anatomy, the trauma mechanism and the epidemiology of the most common injuries of the shoulder girdle and the proximal humerus. Special emphasis is given to radiological diagnostics, including basic projection radiography and advanced cross-sectional imaging.
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Affiliation(s)
- Christian von Falck
- Institut für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - Nael Hawi
- Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Hannover, Deutschland
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26
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Peters PM, Plachel F, Danzinger V, Novi M, Märdian S, Scheibel M, Moroder P. Clinical and Radiographic Outcomes After Surgical Treatment of Proximal Humeral Fractures with Head-Split Component. J Bone Joint Surg Am 2020; 102:68-75. [PMID: 31596803 DOI: 10.2106/jbjs.19.00320] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Head-split fractures are a subgroup of proximal humeral fractures in which the fracture line affects the articular surface. Limited data are available regarding outcomes and risk factors for failure following surgical treatment of this rare fracture type. METHODS Of 45 patients with head-split fractures identified, a total of 30 (67%) were included in this retrospective study, with a mean follow-up of 49 ± 18 months (range, 12 to 83 months). Of those 30, 24 were treated with open reduction and internal fixation (ORIF), 4 with reverse total shoulder arthroplasty (RTSA), and 2 with hemiarthroplasty. Subjective Shoulder Value, Simple Shoulder Test, Constant score, and biplanar radiographs were assessed. Fracture pattern, quality of reduction, eventual complications, revision procedures, and clinical failure (adjusted Constant score < 40) were analyzed, and risk factors for failure were calculated. RESULTS The overall complication rate was 83% (ORIF: 21 of 24 [88%]; RTSA: 3 of 4 [75%]; and hemiarthroplasty: 1 of 2 [50%]). The most common complications following ORIF were humeral head osteonecrosis (42%), malunion of the lesser tuberosity (33%), and screw protrusion (29%), whereas all complications following RTSA were related to tuberosity problems. Revision was performed in 7 of 24 (29%) of initial ORIF patients, and no revisions were performed in RTSA or hemiarthroplasty patients. Four patients (17%) who underwent primary ORIF underwent conversion to RTSA, and 3 patients (12.5%) had screw removal due to penetration. The overall clinical failure rate was 50% (ORIF: 12 of 24 [50%]; RTSA: 1 of 4 [25%]; and hemiarthroplasty: 2 of 2 [100%]). No significant association was found between preoperative factors and clinical failure. ORIF and primary RTSA showed higher average clinical outcome scores than primary hemiarthroplasty and secondary RTSA. In general, patients who required revision had worse Subjective Shoulder Value (p = 0.014), Simple Shoulder Test (p = 0.028), and adjusted Constant scores (p = 0.069). CONCLUSIONS Head-split fractures of the humerus treated with ORIF showed high complication and revision rates. RTSA resulted in comparable clinical outcomes and complication rates; however, the complications associated with RTSA were mostly related to tuberosity problems, which in this small series did not require revision. Therefore, RTSA may be the most predictable treatment option for head-split fractures in elderly patients. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete list of levels of evidence.
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Affiliation(s)
- Paulina-Maria Peters
- Center for Musculoskeletal Surgery, Campus Virchow, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Fabian Plachel
- Center for Musculoskeletal Surgery, Campus Virchow, Charité-Universitaetsmedizin Berlin, Berlin, Germany.,Institute of Tendon and Bone Regeneration, Paracelsus Medical University, Salzburg, Austria
| | - Victor Danzinger
- Center for Musculoskeletal Surgery, Campus Virchow, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Michele Novi
- Azienda Ospedaliera Universitaria Pisana, Università di Pisa, Pisa, Italy
| | - Sven Märdian
- Center for Musculoskeletal Surgery, Campus Virchow, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Markus Scheibel
- Center for Musculoskeletal Surgery, Campus Virchow, Charité-Universitaetsmedizin Berlin, Berlin, Germany.,Department of Shoulder and Elbow Surgery, Schulthess Clinic, Zurich, Switzerland
| | - Philipp Moroder
- Center for Musculoskeletal Surgery, Campus Virchow, Charité-Universitaetsmedizin Berlin, Berlin, Germany
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Cocco LF, Yazzigi JA, Kawakami EFKI, Alvachian HJF, Dos Reis FB, Luzo MVM. Inter-observer reliability of alternative diagnostic methods for proximal humerus fractures: a comparison between attending surgeons and orthopedic residents in training. Patient Saf Surg 2019; 13:12. [PMID: 30899332 PMCID: PMC6410505 DOI: 10.1186/s13037-019-0195-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/04/2019] [Indexed: 01/20/2023] Open
Abstract
Background Proximal humerus fractures are frequent, and several studies show low diagnostic agreement among the observers, as well as an inaccurate classification of these lesions. The divergences are generally correlated with the experience of the surgeons as well as the diagnostic methods used. This paper challenges these problems including alternative diagnostic methods such as 3D models and augmented reality (holography) and including the observers’ period of medical experience as a factor. Methods Twenty orthopedists (ten experts in shoulder surgery and ten experts in traumatology) and thirty resident physicians in orthopedics classified nine proximal humerus fractures randomly distributed as x-ray, tomographies, 3D models and holography, using AO/ASIF and Neer’s classification. In the end, we evaluated the intra- and inter-observer agreement between diagnostic methods and whether the experience of the observers interfered in the evaluations and the classifications used. Results We found overall kappa coefficients ranging from 0.241 (fair) to 0.624 (substantial) between the two classifications (AO / ASIF and Neer), concerning the diagnostic methods used. We identified image modality differences (p = 0.017), where 3D models presented an average kappa coefficient value superior to that of tomographies. There were no differences between kappa scores for x-ray and holography compared to the others. The kappa scores for AO / ASIF classification and Neer classification and subdivided by observer period of experience showed no differences concerning the diagnostic method used. Conclusions 3D models can substantially improve diagnostic agreement for proximal humerus fractures evaluation among experts or resident physicians. The holography showed good agreement between the experts and can be a similar option to x-ray and tomography in the evaluation and classification of these fractures. The observers’ period of experience did not improve the diagnostic agreement between the image modalities studied. Trial registration Registered in the Brazil Platform under no. CAAE 88912318.1.0000.5487.
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Affiliation(s)
- Luiz Fernando Cocco
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP)- Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715, 01 andar, São Paulo, SP CEP 04024-002 Brazil.,2Department of Orthopedics and Traumatology, UNIFESP, São Paulo, Brazil
| | - João Alberto Yazzigi
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP)- Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715, 01 andar, São Paulo, SP CEP 04024-002 Brazil.,2Department of Orthopedics and Traumatology, UNIFESP, São Paulo, Brazil
| | | | | | | | - Marcus Vinicius Malheiro Luzo
- 1Department of Orthopedics and Traumatology, (DOT/UNIFESP)- Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 715, 01 andar, São Paulo, SP CEP 04024-002 Brazil.,2Department of Orthopedics and Traumatology, UNIFESP, São Paulo, Brazil.,3Department of Diagnostic Imaging, UNIFESP, São Paulo, Brazil
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Königshausen M, Mempel E, Rausch V, Gessmann J, Schildhauer TA, Seybold D. Combined fractures of the humeral head and the glenoid. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s11678-019-0508-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Cassidy JT, Coveney E, Molony D. "90/90" Plating of proximal humerus fracture-a technical note. J Orthop Surg Res 2019; 14:41. [PMID: 30744652 PMCID: PMC6371547 DOI: 10.1186/s13018-019-1083-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 01/31/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION While locking plates have markedly improved fixation of proximal humerus fractures, a cohort of fractures remains difficult to treat. This cohort has been identified as fractures with marked medial comminution and varus deformity. Loss of reduction and fixation failure are the most frequently reported complications for this cohort. We report the use of an orthogonal 1/3 tubular plate to augment the proximal humerus locking plate. METHODS The subject underwent osteosynthesis for a four-part proximal humerus fracture with medial comminution. Fixation was performed within 24 h of injury. Standard deltopectoral approach exposed the fracture. Sutures were sited to control the tuberosities and cuff. Initial reduction was held with a K-wire and augmented with a three-hole 1/3 tubular plate. Proximal humerus locking plate was sited in standard fashion including locked medial support screws. Reduction was confirmed both clinically and with intra-operative radiography. RESULTS The technique provided satisfactory results. At 6 months, the fracture had fully united with no loss of reduction. At 1 year, the patient had excellent range of motion. CONCLUSION The use of a 1/3 tubular plate to augment fixation of proximal humerus fractures with medial comminution may provide a simple, reproducible, and cost-effective method to decrease loss of reduction and subsequent malunion.
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Reverse Shoulder Arthroplasty in Acute Fractures of the Proximal Humerus: Does Tuberosity Healing Improve Clinical Outcomes? J Orthop Trauma 2019; 33:e46-e51. [PMID: 30277991 DOI: 10.1097/bot.0000000000001338] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the clinical outcomes of reverse shoulder arthroplasty (RSA) in elderly patients with proximal humeral fractures and assess the role of tuberosity healing on the outcome. DESIGN Case series. SETTING Multicenter clinical study of Level-2 trauma centers. PATIENTS/PARTICIPANTS We included 81 patients with a mean age of 78.5 ± 6.5 years (range, 58.5-90.9 years) and a nonreconstructable proximal humeral fracture. INTERVENTION Modular reverse fracture shoulder arthroplasty. MAIN OUTCOME MEASUREMENTS We determined range of motion, constant score, and the American Shoulder and Elbow Surgeons Shoulder Score as clinical outcomes and evaluated tuberosity healing at 6 weeks, 6 months, 1 year, and 2 years. RESULTS Tuberosities healed in most patients; 37 patients had completely healed tuberosities, and 33 patients had partially healed tuberosities, whereas 11 patients had unhealed tuberosities. However, no significant differences were found in the functional outcomes among the 3 groups (P > 0.05). CONCLUSIONS Our results with a modular reverse prosthesis confirmed similar constant scores, American Shoulder and Elbow Surgeons Shoulder Scores, and tuberosity healing rates as reported in the current clinical evidence for RSA. We could not confirm that tuberosity healing improved functional outcomes; however, it should be noted that tuberosity healing was assessed using standard radiographs. Nevertheless, our study strengthens the consensus that RSA can be recommended for well-selected elderly patients with complex displaced proximal humeral fractures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Katthagen JC, Dey Hazra RO, Raschke MJ, Heilmann L, Michel P, Lill H, Schliemann B. Innovationen bei der Behandlung der proximalen Humerusfraktur. ARTHROSKOPIE 2018. [DOI: 10.1007/s00142-018-0243-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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A morphovolumetric study of head malposition in proximal humeral fractures based on 3-dimensional computed tomography scans: the control volume theory. J Shoulder Elbow Surg 2018; 27:940-949. [PMID: 29415824 DOI: 10.1016/j.jse.2017.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/29/2017] [Accepted: 12/03/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study regards a volumetric analysis of proximal humeral fractures. The main purpose was to investigate the head displacement in relation to the shaft and its link to volume reductions ("bone loss") of the anatomic segments interposed between the head and the shaft: the tuberosities and the calcar. We call this area "control volume." METHODS In 20 fractures, we used 3-dimensional virtual reconstruction to create a reference system that divides geometrically the control volume and allows the evaluation of displacement angles of the humeral head. We calculated the volumetric reduction of control volume segments for each fracture through a specific mathematical protocol. RESULTS The measurement of the head displacement angles in 20 fractures led to following results: in the coronal plane, 10 varus, 6 valgus, 4 neutral; in the sagittal plane, 6 anterior tilt, 9 posterior tilt, 5 neutral position. There was a reduction of control volume in 19 of 20 fractures. Only in 1 fracture was the control volume intact and the fracture was nonimpacted. In 19 impacted fractures, the volume reduction was variable (4% minimum loss, 98% maximum loss). In head varus position, loss was greater in the medial area than in the lateral area. There was generally a clear correspondence between the positions assumed by the head and the volumetric losses of the respective control volume segments. CONCLUSIONS The control volume is an important anatomic and functional area of the proximal humerus. A morphovolumetric 3-dimensional approach improves knowledge about pathomorphology of proximal humeral fractures.
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Katthagen JC, Lutz O, Voigt C, Lill H, Ellwein A. Cement augmentation of humeral head screws reduces early implant-related complications after locked plating of proximal humeral fractures. ACTA ACUST UNITED AC 2018; 13:123-129. [PMID: 29887918 PMCID: PMC5976700 DOI: 10.1007/s11678-018-0440-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/05/2018] [Indexed: 11/09/2022]
Abstract
Background Cement augmentation (CA) of humeral head screws in locked plating of proximal humeral fractures (PHF) was found to be biomechanically beneficial. However, clinical outcomes of this treatment have not been well evaluated to date. Objectives To assess outcomes of locked plating of PHF with additional CA and to compare them with outcomes of conventional locked plating without CA. Methods 24 patients (mean age, 74.2 ± 10.1 years; 22 female) with displaced PHF were prospectively enrolled and treated with locked plating and additional CA. The Constant score (CS), the Simple Shoulder Test (SST), and the Simple Shoulder Value (SSV) were assessed 3 and 12 months postoperatively. Fracture healing and potential complications were evaluated on postoperative radiographs. The CS and complications were compared with the outcomes of a matched group of 24 patients (mean age, 73.9 ± 9.4 years; 22 female) with locked plating of displaced PHF without CA. Results At the 3‑month follow-up, the mean CS was 59.9 ± 15.6 points, the mean SST was 7.5 ± 2.7 points, and the mean SSV was 63.9 ± 21.7%. All scores significantly improved by the 12-month follow-up (p < 0.05; CS, 72.9 ± 17.7; SST, 9.2 ± 3.2; SSV, 77.2 ± 17.3%). There were two cases (8%) of biological complications (n = 1 varus malunion and n = 1 humeral head necrosis). Compared with locked plating without CA, no significant differences were observed between the CS at the 3‑ (57.8 ± 13.4 points; p = 0.62) and 12-month (73.0 ± 12.8 points; p = 0.99) follow-up. However, patients without CA had a significantly increased risk of early loss of reduction and articular screw perforation (p = 0.037). Conclusion Locked plating of proximal humeral fractures with trauma cement augmentation of humeral head screws could be translated from the ex-vivo lab setting into the clinical situation without additional complications. Locked plating of displaced PHF with additional cement augmentation showed similar clinical outcomes but reduced the rate of early implant-related complications compared to locked plating without additional CA.
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Affiliation(s)
- J Christoph Katthagen
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Hannover, Germany.,2Department of Trauma, Hand and Reconstructive Surgery, Universitätsklinikum Münster, Albert-Schweitzer-Str. 1, 48149 Münster, Germany
| | - O Lutz
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Hannover, Germany
| | - C Voigt
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Hannover, Germany
| | - H Lill
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Hannover, Germany
| | - A Ellwein
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Hannover, Germany
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Fisher ND, Barger JM, Driesman AS, Belayneh R, Konda SR, Egol KA. Fracture Severity Based on Classification Does Not Predict Outcome Following Proximal Humerus Fracture. Orthopedics 2017; 40:368-374. [PMID: 28968473 DOI: 10.3928/01477447-20170925-04] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 08/09/2017] [Indexed: 02/03/2023]
Abstract
This study was conducted to determine whether proximal humerus fracture patterns as defined by the Orthopaedic Trauma Association (AO/OTA) classification and the Neer 4-part system predicted functional outcomes for patients treated with open reduction and internal fixation with locked plates and, if so, which system correlated better with outcomes. During a 12-year period, 213 patients with a displaced proximal humerus fracture who underwent surgical treatment with a locking plate at 1 academic institution were prospectively followed. All patients were treated in a similar way and were followed by the operating surgeon at routine intervals. Functional outcomes were measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Of these patients, 164 were available for analysis. Functional outcomes based on DASH scores did not differ significantly by Neer system, AO/OTA classification, or varus/valgus humeral head alignment at more than 12 months postoperatively. However, patients with Neer 4-part fracture and AO/OTA type 11-C fracture had worse shoulder range of motion in terms of forward elevation and external rotation. Time to healing and complication rates also were not significantly different based on either classification system. Fracture classification can predict shoulder range of motion 12 months after surgical fixation, but its use is limited in predicting functional outcome scores, time to healing, and complication rates. Patients who undergo surgical repair of a proximal humerus fracture can expect good functional results independent of the initial injury pattern, but more severe fracture patterns may lead to decreased shoulder range of motion. [Orthopedics. 2017; 40(6):368-374.].
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Intraobserver and interobserver agreement in the classification and treatment of proximal humeral fractures. J Shoulder Elbow Surg 2017; 26:1097-1102. [PMID: 28131681 DOI: 10.1016/j.jse.2016.11.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 11/25/2016] [Accepted: 11/25/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is controversy surrounding the reliability of radiographic measurements and existing classifications for proximal humeral fractures. METHODS Ten orthopedists, divided into 2 groups by length of experience, evaluated radiographs in 3 views from 40 proximal humeral fractures. We evaluated 11 radiographic criteria (including the Neer and pathomorphologic classifications, head-shaft angle, displacement of the humeral shaft, and lesser and greater tuberosities) and treatment indication. We also analyzed the criteria that most influenced the choice of treatment. RESULTS Interobserver reliability was substantial for the presence of fracture of the greater tuberosity (κ = 0.749) and medial metaphyseal comminution (κ = 0.627) and moderate for the pathomorphologic classification (κ = 0.504), displacement of the greater tuberosity (κ = 0.422), and treatment decision (κ = 0.565). Intraobserver reliability was substantial for treatment indication (κ = 0.620) and presence of displacement of the fracture of the greater tuberosity (κ = 0.627 and 0.611) and moderate for the Neer (κ = 0.490) and pathomorphologic (κ = 0.607) classifications. The results were influenced by the observer's experience. The surgical indication was influenced by the pathomorphologic classification in 50% of the evaluators (odds ratio, 4.85; range, 3.30-8.65). CONCLUSION The pathomorphologic classification has higher reliability than the Neer classification and was the factor that most influenced the surgical decision. The determination of the presence of fracture and displacement of the greater tuberosity and medial metaphyseal comminution is reliable with the use of simple radiographs, and the results were influenced by the observer's experience.
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Gracitelli MEC, Malavolta EA, Assunção JH, Kojima KE, dos Reis PR, Silva JS, Ferreira Neto AA, Hernandez AJ. Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial. J Shoulder Elbow Surg 2016; 25:695-703. [PMID: 27085296 DOI: 10.1016/j.jse.2016.02.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/01/2016] [Accepted: 02/12/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Previous studies have shown good clinical results in patients with proximal humeral fractures (PHFs) treated with locking intramedullary nails or locking plates. Our study compared the clinical and radiographic outcomes in patients with 2- and 3-part surgical neck fractures. METHODS In this prospective, randomized controlled trial, 72 patients with 2- or 3-part surgical neck PHFs were randomly assigned to receive fixation with locking intramedullary nails (nail group) or locking plates (plate group). The primary outcome was the 12-month Constant-Murley score. The secondary outcomes included the Disabilities of the Arm, Shoulder and Hand score, the visual analog scale pain score, the shoulder passive range of motion, the neck-shaft angle, and complication rates. RESULTS There was no significant mean treatment group difference in the Constant-Murley score at 12 months (70.3 points for the nail group vs. 71.5 points for the plate group; P = .750) or at individual follow-up assessments. There were no differences in the 3-, 6- and 12-month Disabilities of the Arm, Shoulder and Hand scores, visual analog scale scores, and range of motion, except for the medial rotation at 6 months. The neck-shaft angle was equivalent between the groups at 12 months. There were significant differences over 12 months in total complication rates (P = .002) and reoperation rates (P = .041). There were no significant differences for the rotator cuff tear rate (P = .672). CONCLUSION Fixation of PHFs with locking plates or locking intramedullary nails produces similar clinical and radiologic results. Nevertheless, the complication and reoperation rates were higher in the nail group.
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Affiliation(s)
- Mauro E C Gracitelli
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil.
| | - Eduardo A Malavolta
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Jorge H Assunção
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Kodi E Kojima
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Paulo R dos Reis
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Jorge S Silva
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Arnaldo A Ferreira Neto
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Arnaldo J Hernandez
- Department of Orthopedics and Traumatology, School of Medicine, University of São Paulo (USP), São Paulo, Brazil
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