Factors influencing surgical management of proximal humerus fractures: do shoulder and trauma surgeons differ?

The surgical treatment of proximal humerus fractures 2010-2019: United States national case volume and incidence trends

Background

Proximal humerus fractures are the third most common fracture type for patients between the ages of 65 and 89 and occur more frequently in women than men. Given the variety of surgical treatments for proximal humerus fractures, the aim of this study was to (1) report United States national volume and incidence estimates for surgical management of proximal humerus fractures to better understand the changing practice over the past decade and (2) to analyze differences in volume and incidence among age groups, sex, and geographic region.

Methods

Using IBM Marketscan national database, all patients that underwent open reduction internal fixation (ORIF), hemiarthroplasty, or reverse total shoulder arthroplasty (RTSA) between 2010 and 2019 were identified with Current Procedural Terminology codes. The dataset was further stratified to identify patients treated for proximal humerus fractures. IBM Marketscan provided discharge weights that were used to determine estimated national annual volumes of each procedure in IBM SPSS Statistics software (IBM Corp., Armonk, NY, USA). Volume and incidence were adjusted per 1,000,000 persons and calculated for subgroups according to age group, sex, and geographical region. The United States Census Bureau annual population data was used for all incidence calculations.

Results

Over the past decade, the total volume and incidence of surgically treated proximal humerus fractures increased by 13% and 5%, respectively. Although overall incidence decreased, ORIF remained the most common surgical treatment. The greatest decrease in volume and incidence of ORIF occurred in patients ≥75. The incidence of ORIF treatment increased in the South and West while it decreased in the Northeast and Midwest. Total volume and incidence of HA decreased between 2010 and 2019 and this trend remained among all subgroups. Total volume and incidence of RTSA increased by over 300%. The incidence of males and females receiving RTSA increased by 266% and 320%, respectively. Volume and incidence of RTSA increased across all age groups. Volume and incidence of RTSA increased in the Midwest, South, and Western regions while it remained unchanged in the Northeast.

Conclusion

Surgical management trends of proximal humerus fractures have changed greatly over the past decade. ORIF remains the most common surgical treatment for proximal humerus fractures. HA has fallen out of favor while RTSA has seen significant increases in usage across sex, age groups, and geographic regions. These trends represent a change in practice for treating proximal humerus fractures by considering all patient and fracture characteristics when opting for surgical management.

Trends in the surgical management of proximal humerus fractures in Ireland from 2009 to 2022: An increasing usage of reverse shoulder arthroplasty

BACKGROUND

Proximal humeral fractures are a common injury accounting for a significant workload across orthopaedic departments. Though often managed non-operatively, surgical management is indicated for a proportion of patients.

AIMS

The aim of this study is to examine the trends in the management of proximal humeral fractures within Ireland over the past 13 years.

METHODS

A retrospective review of Irish Hospital In-Patient Enquiry (HIPE) data was performed between January 2009 and December 2022. Information regarding demographics including age and gender, along with procedure type were collated after patients with proximal humerus fractures, were identified using relevant ICD 10 codes.

RESULTS

Demographic details remained stable with females and those within the 55-69 year age bracket accounting for the highest proportion of patients. The mean annual number of procedures performed across the study period was 365 (273-508), with an increase from 288 cases in 2009 to 441 in 2022. Open reduction and internal fixation were the most common procedures accounting for 76.4% of cases. There has been a rising usage of total shoulder arthroplasty for fixation with an increase from < 5 cases in 2016 to 84 in 2022. A decrease in the usage of hemiarthroplasty and closed reduction internal fixation was also observed.

CONCLUSIONS

There has been an increasing volume of operatively managed proximal humeral fractures in Ireland, which sustained despite the 2015 publication of the highly publicised PROPHER trial. The increasing utilisation of total shoulder arthroplasty in acute trauma management is notable and necessitates appropriate training for trauma theatre personnel.

Factors influencing choice of treatment for proximal humeral fractures elaborated in a Delphi consensus process

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.

High rate of avascular necrosis but excellent patient-reported outcomes after open reduction and internal fixation (ORIF) of proximal humerus fracture dislocations: should ORIF be considered as primary treatment?

BACKGROUND

Proximal humerus fracture dislocations, excluding 2-part greater tuberosity fracture dislocations, are rare injuries. Outcomes after open reduction and internal fixation (ORIF) of these injuries have not been well described in the literature. The purpose of this study was to report the radiographic and functional outcomes of patients who underwent ORIF of a proximal humerus fracture dislocation.

METHODS

All skeletally mature patients who underwent ORIF of a proximal humerus fracture dislocation between 2011 and 2020 were identified. Patients with isolated greater tuberosity fracture dislocations were excluded. The primary outcome was American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score at a minimum of 2 years. Secondary outcomes were the development of avascular necrosis (AVN) and reoperation rate.

RESULTS

Twenty-six patients met the inclusion criteria. The mean age was 45 years (standard deviation 16), and 77% were men. Median time to reduction and surgery was 1 day (interquartile range [IQR] 1-5). There were 2 (8%) Neer 2-part fractures, 7 (27%) 3-part, and 17 (65%) 4-part fractures. Fifty-four percent (54%) involved the anatomic neck and 31% included a head-split component. Thirty-nine percent (39%) were anterior dislocations. The rate of AVN was 19%. The reoperation rate was 15%. Reoperations included removal of hardware (2), subscapularis repair (1), and manipulation under anesthesia (1). No patients went on to arthroplasty. ASES scores were available for 22 patients (84%) including 4 of 5 patients with AVN. The median ASES score at a mean of 6.0 years postoperatively was 98.3 (IQR 86.7-100, range 63.3-100) and was not different in those with or without AVN (median 98.3 vs. 92.0, P = .175). Only the presence of medial comminution and nonanatomic head shaft alignment on postoperative radiographs were associated with increased risk of AVN.

CONCLUSION

Radiographic rates of AVN (19%) and reoperation (15%) were high in this series of patients undergoing ORIF of proximal humerus fracture dislocations. Despite this, none of the patients required arthroplasty, and patient-reported outcome scores at an average of 6 years postinjury were excellent, with a median ASES score of 98.5. ORIF should be considered as primary method of treatment in proximal humerus fracture dislocations not only in young patients but also middle-aged patients.

Why treatment of proximal humeral fractures remains unresolved despite randomized trials

Most proximal humeral fractures can be treated nonoperatively, but there are specific indications to perform surgery for some of these fractures. Optimal treatment remains subject to debate, since no consensus has been reached for the best therapy for these fractures. This review provides an overview of randomized controlled trials (RCTs) comparing treatment for proximal humeral fractures. Fourteen RCTs comparing different operative and nonoperative types of treatment for PHF are included. Different RCTs comparing the same interventions for PHF have drawn different conclusions. It also highlights reasons why consensus has not been reached based on these data, and how this could be addressed in future research. Previous RCTs have included different patient groups and fracture patterns, may have been prone to selection bias, often were underpowered for subgroup analysis, and showed inconsistency in the outcome measures used. Based on this, and appreciating that treatment may be tailored to specific fracture types and patient characteristic like age, a better way to move forward could be to use a (international) multicenter prospective cohort study. Such a registry-type study should use accurate patient selection and enrollment, well-defined fracture patterns, standardized surgical techniques performed according to the preferences of the surgeon, and with a standardized follow-up.

Technical Tips for Reduction and Stable Fixation of Proximal Humerus Fractures

The surgical treatment of proximal humerus fractures, though common, is associated with surprisingly high complication rates upward of 34%. Obtaining a reduction and placing a stable fixation can be challenging because many fractures treated surgically are comminuted and occur in osteoporotic bone. Nevertheless, innovations in technique and implant design are mitigating some failures. These innovations include the use of fibular strut allograft and other fixation adjuncts, the correct placement of calcar screws and other locking fixation, and having a systematic approach to reduction and intraoperative imaging to ensure the restoration of anatomy. This review and accompanying video highlight various technical strategies to maximize the success of surgical treatment for these challenging injuries.

Arthroplasty as Primary Treatment for Metadiaphyseal Proximal Humerus Fractures: A Viable Alternative to Osteosynthesis for the Elderly

Introduction

in the elderly patient population, where fracture comminution, osteoporotic fractures, and associated arthritis or rotator cuff pathologies dominate, metadiaphyseal proximal humeral fracture is a challenging subset of fractures to treat. This study reports on cementless long-stem reverse total shoulder arthroplasty (RTSA) as primary treatment of metadiaphyseal proximal humeral fractures in elderly patients.

Materials & Methods

Between January 2018 and October 2021, 22 consecutive patients sustained proximal humerus fractures with metadiaphyseal extension and underwent surgery with cementless long-stem RTSA. Patients older than 60 years with minimum 1 year of clinical and radiographic follow-up were included. Patient demographics, range of motion, and patient reported outcomes [Visual Analog Scale (VAS) pain scale, Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), and American Shoulder Elbow Surgeon (ASES) scores] were retrospectively collected. Postoperative X-rays were evaluated for fracture and tuberosity union.

Results

There were 14 eligible patients with a median age of 71 years (range 61-91 years) and a median 13 months follow-up. At final follow-up, the median active elevation was 120° (range 80°-150°), external rotation was 40° (range 0°-50°), and internal rotation was 40° (range 0°-80°). Median VAS was 2 (range 0-8), SST was 71% (range 33%-92%), SSV was 78% (range 20-90%), and ASES was 73 (range 17-90). All patients exhibited radiographic union. There were five minor complications in three patients: postoperative neuropathy, tuberosity nonunion, scapula notching, and proximal humeral stress shielding.

Conclusion

Cementless long-stem RTSA is a viable alternative to primary fracture fixation in the elderly patient population with metadiaphyseal proximal humerus fractures.

Optimal Treatment of Proximal Humeral Fractures in the Elderly: Risks and Management Challenges

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.

Predictors of Mortality in Head-Preserving Treatment for Dislocated Proximal Humerus Fractures: A Retrospective Analysis of 522 Cases with a Minimum Follow-Up of 5 Years

PURPOSE

Proximal humerus fractures (PHFs) are among the most common fractures in elderly patients, but there is still inadequate knowledge about mortality risk factors after such injuries. In order to provide the best possible therapy, individual risk factors have to be considered and evaluated thoroughly. There is still controversy regarding treatment decisions for proximal humerus fractures, particularly for the elderly.

METHODS

In this study, patient data from 522 patients with proximal humerus fractures were obtained from 2004 to 2014 at a Level 1 trauma centre. After a minimum follow-up of 5 years, the mortality rate was assessed, and independent risk factors were evaluated.

RESULTS

A total of 383 patients (out of 522) were included in this study. For our patient collective, the mean follow-up was at 10.5 ± 3.2 years. The overall mortality rate was 43.8% in our respondent group and was not significantly impacted by concomitant injuries. The binary logistic regression model showed an increased risk for mortality by 10% per life year, a 3.9 times higher mortality risk for men and a 3.4 times higher risk for conservative treatment. The most powerful predictor was a Charlson Comorbidity Index of more than 2, with a 20 times higher mortality risk.

CONCLUSIONS

Outstanding independent predictors of death in our patient collective were serious comorbidities, male patients, and conservative treatment. This patient-related information should influence the process of decision making for the individual treatment of patients with PHFs.

Reverse Total Shoulder Arthroplasty with a Cementless and Metaphyseal Stem Fixation Is a Viable Option for the Treatment of Proximal Humeral Fractures with Calcar Involvement

BACKGROUND

The purpose of the study was to evaluate the suitability of reverse total shoulder arthroplasty (RTSA) with a cementless and metaphyseal stem fixation as a treatment for complex proximal humeral fractures (PHFs) with a calcar fragment when this may be fixed with a steel wire cerclage. Clinical and radiographic outcomes were compared with the same RTSA for PHFs without a calcar fragment at a minimum of five-year follow-up.

METHODS

A retrospective analysis was performed on acute PHFs "with a medial calcar fragment" (group A) and "without a calcar fragment" (group B) treated with a RTSA and cementless metaphyseal stem fixation.

RESULTS

At an average follow-up of 6.7 years (5-7.8 years), no statistical difference was observed comparing group A (18 patients) to group B (50 patients) for active anterior elevation (141 ± 15° vs. 145 ± 10°, p = 0.67), active external rotation ER1 (49 ± 15° vs. 53 ± 13°, p = 0.55), and active internal rotation (5 ± 2 vs. 6 ± 2, p = 0.97). Similarly, a comparison of ASES score (89.2 ± 10 vs. 91.6 ± 9, p = 0.23) and Simple Shoulder Test score (91.1 ± 11 vs. 90.4 ± 10, p = 0.49) revealed no significant difference.

CONCLUSION

RTSA with a cementless and metaphyseal stem fixation represents a safe and feasible treatment for complex PHFs with a medial calcar fragment when this may be fixed with a steel wire cerclage.