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Curry M, Tornberg H, Fedorka CJ. Single-stage bilateral uncemented reverse shoulder arthroplasty for traumatic proximal humerus fractures: a case report. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:504-510. [PMID: 39157217 PMCID: PMC11329036 DOI: 10.1016/j.xrrt.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Affiliation(s)
- Michael Curry
- Department of Orthopaedic Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Haley Tornberg
- Department of Orthopaedic Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Catherine J. Fedorka
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA
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Bosch TP, Beeres FJP, Ferree S, Schipper IB, Camenzind RS, Hoepelman RJ, Link BC, Rompen IF, Babst R, van de Wall BJM. Reverse Shoulder Arthroplasty versus Non-Operative Treatment of Three-Part and Four-Part Proximal Humerus Fractures in the Elderly Patient: A Pooled Analysis and Systematic Review. J Clin Med 2024; 13:3344. [PMID: 38893055 PMCID: PMC11172441 DOI: 10.3390/jcm13113344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/29/2024] [Accepted: 06/04/2024] [Indexed: 06/21/2024] Open
Abstract
Background: The treatment of complex proximal humerus fractures in elderly patients is not yet fully elucidated. Of all treatment options, reverse shoulder arthroplasty (RSA) and non-operative treatment (NOT) appear to provide the best results. Evidence to guide the choice between the two is sparse. Therefore, this review provides an overview of the available evidence on RSA versus NOT. Methods: Studies comparing complex proximal humerus fractures in patients aged >65 years treated either with RSA or NOT were included for systematic review and direct comparison via pooled analysis of patient-rated outcome and range of motion. Indirect comparison of case series and non-comparative studies on either treatment was performed separately. Results: Three comparative studies including 77 patients treated with RSA and 81 treated non-operatively were analysed. The RSA group scored better for both the Constant-Murley score (mean difference 6 points) and DASH score (mean difference 8 points). No differences were detected in ASES, PENN score, pain scores, or range of motion between treatment groups. The most common complications for RSA were infection (3%), nerve injury (2%), and dislocation (2%). Reoperation was required in 5%. In the NOT group, common complications included malunion (42%), osteonecrosis (25%), and non-union (3%); no reoperation was required. Patient satisfaction was equal in both groups. Conclusions: The functional outcomes and range of motion after RSA seemed satisfactory and potentially superior to NOT in elderly patients. Patient satisfaction was comparable despite a high malunion and osteonecrosis rate in the non-operative treatment group, which did not require re-interventions.
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Affiliation(s)
- Thomas P. Bosch
- Department of Health Sciences and Medicine, University of Lucerne, 6002 Luzern, Switzerland
- Department of Trauma Surgery, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
| | - Frank J. P. Beeres
- Department of Health Sciences and Medicine, University of Lucerne, 6002 Luzern, Switzerland
- Department of Orthopedics and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Luzern, Switzerland
| | - Steven Ferree
- Department of Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands (R.J.H.)
| | - Inger B. Schipper
- Department of Trauma Surgery, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
| | - Roland S. Camenzind
- Department of Orthopedics and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Luzern, Switzerland
| | - Ruben J. Hoepelman
- Department of Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands (R.J.H.)
| | - Björn-Christian Link
- Department of Orthopedics and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Luzern, Switzerland
| | - Ingmar F. Rompen
- Department of Surgery, University Hospital Heidelberg, 69117 Heidelberg, Germany
| | - Reto Babst
- Department of Health Sciences and Medicine, University of Lucerne, 6002 Luzern, Switzerland
- Department of Orthopedics and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Luzern, Switzerland
| | - Bryan J. M. van de Wall
- Department of Health Sciences and Medicine, University of Lucerne, 6002 Luzern, Switzerland
- Department of Orthopedics and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Luzern, Switzerland
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Colasanti CA, Anil U, Rodriguez K, Levin JM, Leucht P, Simovitch RW, Zuckerman JD. Optimal combination of arthroplasty type, fixation method, and postoperative rehabilitation protocol for complex proximal humerus fractures in the elderly: a network meta-analysis. J Shoulder Elbow Surg 2024:S1058-2746(24)00320-3. [PMID: 38734127 DOI: 10.1016/j.jse.2024.03.040] [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: 09/13/2023] [Revised: 03/13/2024] [Accepted: 03/17/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND The purpose of this study was to define the optimal combination of surgical technique and postoperative rehabilitation protocol for elderly patients undergoing either hemiarthroplasty (HA) or reverse total shoulder arthroplasty (rTSA) for acute proximal humerus fracture (PHF) by performing a network meta-analysis of the comparative studies in the literature. METHODS A systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines of MEDLINE, EMBASE, and Cochrane Library was screened from 2007 to 2023. Inclusion criteria were level I-IV studies utilizing primary HA and/or rTSA published in a peer-reviewed journal, that specified whether humeral stems were cemented or noncemented, specified postoperative rehabilitation protocol, and reported results of HA and/or rTSA performed for PHF. Early range of motion (ROM) was defined as the initiation of active ROM at ≤3 weeks after surgery. Level of evidence was evaluated based on the criteria by the Oxford Centre for Evidence-Based Medicine. Clinical outcomes were compared using a frequentist approach to network meta-analysis with a random-effects model that was performed using the netmeta package version 0.9-6 in R. RESULTS A total of 28 studies (1119 patients) were included with an average age of 74 ± 3.7 and mean follow-up of 32 ± 11.1 months. In the early ROM cohort (Early), the mean time to active ROM was 2.4 ± 0.76 weeks compared to 5.9 ± 1.04 weeks in the delayed ROM cohort (Delayed). Overall, rTSA-Pressfit-Early resulted in statistically superior outcomes including postoperative forward elevation (126 ± 27.5), abduction (116 ± 30.6), internal rotation (5.27 ± 0.74, corresponding to L3-L1), American Shoulder and Elbow Surgeons score (71.8 ± 17), tuberosity union (89%), and lowest tuberosity nonunion rate (9.6%) in patients ≥65 year old with acute PHF undergoing shoulder arthroplasty (all P ≤ .05). In total there were 277 (14.5%) complications across the cohorts, of which 89/277 (34%) were in the HA-Cement-Delayed cohort. HA-Cement-Delayed resulted in 2-times higher odds of experiencing a complication when compared to rTSA-Cement-Delayed (P = .005). Conversely, rTSA-Cement-Early cohort followed by rTSA-Pressfit-Early resulted in a total complication rate of 4.7% and 5.4% (odds ratios, 0.30; P = .01 & odds ratios, 0.42; P = .05), respectively. The total rate of scapular notching was higher in the cemented rTSA subgroups (16.5%) vs. (8.91%) in the press fit rTSA subgroups (P = .02). CONCLUSION Our study demonstrates that patients ≥65 years of age, who sustain a 3-or 4-part PHF achieve the most benefit in terms of ROM, postoperative functional outcomes, tuberosity union, and overall complication rate when undergoing rTSA with a noncemented stem and early postoperative ROM when compared to the mainstream preference-rTSA-Cement-Delayed.
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Affiliation(s)
| | - Utkarsh Anil
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | | | - Jay M Levin
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
| | - Philipp Leucht
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Ryan W Simovitch
- Department of Orthopaedic Surgery, Hospital for Special Surgery, West Palm Beach, FL, USA
| | - Joseph D Zuckerman
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
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Holschen M, Amaziane Y, Meyer L, Galal Y, Bockmann B, Schulte TL, Steinbeck J. Converting to reverse shoulder arthroplasty from primary anatomic shoulder arthroplasty and fracture hemiarthroplasty: a radiographic and clinical outcome analysis at 8-years. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2193-2200. [PMID: 38578440 DOI: 10.1007/s00590-024-03916-8] [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: 02/27/2024] [Accepted: 03/14/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Revision shoulder arthroplasty can be challenging. One of the main considerations for surgeons is the type of implant that was placed in the initial surgery. Anatomic shoulder arthroplasty (ASA) is used for cases of osteoarthritis as well as for fractures of the humeral head. Hemiarthroplasty can be used for complex proximal humerus fractures. The purpose of this study is to determine whether there is a difference in clinical and radiographic outcomes between patients that failed primary fracture hemiarthroplasty (FHA), or ASA for osteoarthritis and then required reoperation with a conversion to reverse shoulder arthroplasty (RSA). METHODS Patients with failed anatomic shoulder replacement, who had undergone conversion to RSA, were enrolled after a mean follow-up of 107 (85-157) months. Two different groups, one with failed ASA implanted for osteoarthritis and one with failed FHA, were created. At follow-up patients were assessed with standard radiographs and clinical outcome scores. RESULTS Twenty-nine patients (f = 17, m = 12; 51%) suffered from a failed ASA (Group A), while the remaining 28 patients (f = 21, m = 74; 49%) had been revised due to a failed FHA (Group B). Patients of Group B had a poorer Constant score (Group A: 60 vs. Group B: 46; p = 0.02). Abduction (Group A: 115° vs. Group B: 89°; p = 0.02) was worse after conversion of a failed FHA to RSA in comparison to conversions of failed ASA. The mean bone loss of the lateral metaphysis was higher in patients with failed FHA (Group A: 5 mm vs. Group B: 20 mm; p = 0.0). CONCLUSION The initial indication for anatomic shoulder arthroplasty influences the clinical and radiological outcome after conversion to RSA. Conversion of failed FHA to RSA is related to an increased metaphyseal bone loss, decreased range of motion and poorer clinical outcomes when compared to conversions of failed ASA implanted for osteoarthritis. LEVEL OF EVIDENCE III Retrospective Cohort Comparison Study.
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Affiliation(s)
- Malte Holschen
- Orthopedic Practice Clinic (OPPK), Schuerbusch 55, 48143, Münster, Germany.
| | - Yacine Amaziane
- Orthopedic Practice Clinic (OPPK), Schuerbusch 55, 48143, Münster, Germany
| | - Lisa Meyer
- Orthopedic Practice Clinic (OPPK), Schuerbusch 55, 48143, Münster, Germany
| | - Youssef Galal
- Banner University Medical Group, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Benjamin Bockmann
- Department of Orthopedics and Trauma Surgery, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Tobias L Schulte
- Department of Orthopedics and Trauma Surgery, St. Josef Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Jörn Steinbeck
- Orthopedic Practice Clinic (OPPK), Schuerbusch 55, 48143, Münster, Germany
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Derksen A, Lill H, Ellwein A, Imrecke J. Tuberosity refixation improves functional outcome following primary reverse shoulder arthroplasty in proximal humeral fracture. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1441-1448. [PMID: 38240825 DOI: 10.1007/s00590-023-03810-9] [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: 08/03/2023] [Accepted: 12/15/2023] [Indexed: 04/02/2024]
Abstract
INTRODUCTION The purpose of this prospective study was to examine clinical results of tuberosity refixation in RSA for the treatment of displaced PHF in elderly patients. We hypothesized that tuberosity refixation would increase clinical outcome. METHODS In this prospective study, 50 patients were included after receive a primary RSA for complex proximal humeral fracture between March 2013 and December 2015 for follow-up after three, 12 and 24 months. A functional and radiological assessment was performed on the patients. RESULTS At final follow-up after a mean period of 25.1 months, data were available for 30 women and 6 men (74% of the included overall study collective) with a mean age of 77 years (range 55-93 years) at time of surgery. The tuberosities were refixated in 74% (n = 37) and in 26% (n = 13) resected. RSA with tuberosity refixation resulted in better clinical shoulder function compared to RSA with non-refixated tuberosities. The data show an external rotation with a significant difference (24.9° vs. 14°, p < 0.05) in favor of participants with refixation. The raw CMS was statistically significant (71.3 vs. 56.3, p < 0.05) after refixation, and SSV was significant improved (82.7% vs. 68%, p < 0.05) in the same group. Among 3 of 50 patients a total of 3 complications occurred with a total of 6% surgical revision. CONCLUSIONS In this prospective study, tuberosity refixation as part of fracture treatment using RSA results in better external rotation, subjective assessment of shoulder recovery (measured by SSV and by raw CMS) in elderly patients, compared with tuberosity excision. LEVEL OF EVIDENCE II, Prospective comparative study.
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Affiliation(s)
- Alexander Derksen
- Department of Orthopaedic Surgery at DIAKOVERE Annastift, Hannover Medical School, Anna-von-Borries-Str. 1-7, 30625, Hannover, Germany.
| | - Helmut Lill
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Humboldtstraße 5, 30169, Hannover, Germany
| | - Alexander Ellwein
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Humboldtstraße 5, 30169, Hannover, Germany
| | - Julia Imrecke
- Department of Orthopaedic and Trauma Surgery, DIAKOVERE Friederikenstift, Humboldtstraße 5, 30169, Hannover, Germany
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Zhao Y, Zhu Y, Lu Y, Li F, Jiang C. Does age affect patient outcomes after humeral head replacement in the treatment of acute proximal humeral fractures? A comparative cohort study with a minimum 10 years long-term follow-up. J Shoulder Elbow Surg 2024; 33:46-54. [PMID: 37331501 DOI: 10.1016/j.jse.2023.05.017] [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: 12/08/2022] [Revised: 04/25/2023] [Accepted: 05/06/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Humeral head replacement (HHR) is now rarely recommended for complex proximal humeral fractures (PHFs) in older patients. However, in relatively young and active patients with unreconstructable complex PHFs, controversy still exists regarding the treatment options of reverse shoulder arthroplasty and HHR. The goal of this study was to compare the survival, functional, and radiographic outcomes of HHR in patients aged <70 years and those aged ≥70 years after a minimum 10 years follow-up. METHODS Eighty-seven out of 135 patients undergoing primary HHR were enrolled and then divided into 2 groups based on age: <70 years and ≥70 years. Clinical and radiographic evaluations were performed with a minimum follow-up of 10 years. RESULTS There were 64 patients (mean, 54.9 years) in the younger group and 23 patients (mean, 73.5 years) in the older group. The younger and older groups had comparable 10-year implant survivorship (98.4% vs. 91.3%). Patients aged ≥70 years had worse American Shoulder and Elbow Surgeons scores (74.2 vs. 81.0, P = .042) and lower satisfaction rates (12% vs. 64%, P < .001) than younger patients. At the final follow-up, older patients had worse forward flexion (117° vs. 129°, P = .047) and internal rotation (17 vs. 15, P = .036). More greater tuberosity complications (39% vs. 16%, P = .019), glenoid erosion (100% vs. 59%, P = .077), and humeral head superior migration (80% vs. 31%, P = .037) were also identified in patients aged ≥70 years. CONCLUSIONS Unlike the increased risk for revision and functional deterioration over time after reverse shoulder arthroplasty for PHFs in younger patients, a high implant survival rate with lasting pain relief and stable functional outcomes could be observed in younger patients after HHR during long-term follow-up. Patients aged ≥70 years had worse clinical outcomes, lower patient satisfaction, more greater tuberosity complications, and more glenoid erosion and humeral head superior migration than those aged <70 years. HHR should not be recommended for the treatment of unreconstructable complex acute PHFs in older patient populations.
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Affiliation(s)
- Yang Zhao
- Department of Sports Medicine, Beijing Jishuitan Hospital, Beijing, China
| | - Yiming Zhu
- Department of Sports Medicine, Beijing Jishuitan Hospital, Beijing, China
| | - Yi Lu
- Department of Sports Medicine, Beijing Jishuitan Hospital, Beijing, China
| | - Fenglong Li
- Department of Sports Medicine, Beijing Jishuitan Hospital, Beijing, China
| | - Chunyan Jiang
- Department of Sports Medicine, Beijing Jishuitan Hospital, Beijing, China.
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How common is nerve injury after reverse shoulder arthroplasty? A systematic review. J Shoulder Elbow Surg 2023; 32:872-884. [PMID: 36427756 DOI: 10.1016/j.jse.2022.10.022] [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: 08/27/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nerve injury following reverse shoulder arthroplasty (RSA) is a known risk factor with wide ranging incidences reported. This systematic review evaluates the overall incidence of nerve injury following primary and revision RSA and summarizes the characteristics of the nerve injuries reported in the current literature. METHODS A systematic review was performed using separate database searches (Pubmed, Embase, Web of Science, Cochrane) following the PRISMA guidelines. Search criteria included the title terms "reverse shoulder," "reverse total shoulder," "inverted shoulder," and "inverted total shoulder" with publication dates ranging from 01/01/2010 to 01/01/2022. Studies that reported neurological injuries and complications were included and evaluated for primary RSA, revision RSA, number of nerve injuries, and which nerves were affected. RESULTS After exclusion, our systematic review consisted of 188 articles. A total of 40,146 patients were included, with 65% female. The weighted mean age was 70.3 years. The weighted mean follow-up was 35.4 months. The rate of nerve injury after RSA was 1.3% (510 of 40,146 RSAs). The rate of injury was greater in revision RSA compared to primary RSA (2.4% vs. 1.3%). Nerve injury was most common in RSAs done for a primary diagnosis of acute proximal humerus fracture (4.0%), followed by cuff tear arthropathy (3.0%), DJD (2.6%), and inflammatory arthritis (1.7%). Massive rotator cuff tears and post-traumatic arthritis cases had the lowest nerve injury rates (1.0% and 1.4%, respectively). The axillary nerve was the most commonly reported nerve that was injured in both primary and revision RSA (0.6%), followed by the ulnar nerve (0.26%) and median nerve (0.23%). Brachial plexus injury was reported in 0.19% of overall RSA cases. CONCLUSION Based on current English literature, nerve injuries occur at a rate of 1.3% after primary RSA compared with 2.4% after revision RSA. The most common nerve injury was to the axillary nerve (0.64%), with the most common operative diagnosis associated with nerve injury after RSA being acute proximal humerus fracture (4.0%). Surgeons should carefully counsel patients prior to surgery regarding the risk of nerve injury.
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30-Day Postoperative Complications After Surgical Treatment of Proximal Humerus Fractures: Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202303000-00002. [PMID: 36867524 PMCID: PMC9988290 DOI: 10.5435/jaaosglobal-d-22-00174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 12/22/2022] [Indexed: 03/04/2023]
Abstract
INTRODUCTION The purpose of this study was to evaluate risk factors associated with complications after reverse total shoulder arthroplasty (TSA) and hemiarthroplasty for the treatment of proximal humerus fractures. METHODS A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database was conducted. Current Procedural Terminology codes were used to identify patients treated for proximal humerus fracture with reverse TSA or hemiarthroplasty between 2005 and 2018. RESULTS One thousand five hundred sixty-three shoulder arthroplasties were conducted: 436 hemiarthroplasties and 1,127 reverse TSA. The overall complication rate was 15.4% (15.7% reverse TSA; 14.7% hemiarthroplasty) (P = 0.636). Most frequent complications included transfusion 11.1%, unplanned readmission 3.8%, and revision surgery 2.1%. A 1.1% incidence of thromboembolic events was noted. Complications occurred most frequently in patients older than 65 years; male; and patients with anemia, American Society of Anesthesiologists classification III-IV, inpatient procedure, bleeding disorders, duration of surgery >106 minutes, and length of stay >2.5 days. Patients with body mass index >36 kg/m2 had a decreased risk of 30-day postoperative complications. DISCUSSION There was a 15.4% complication rate in the early postoperative period. In addition, no notable difference was found in complication rates between groups (hemiarthroplasty: 14.7%; reverse TSA 15.7%). Future studies are needed to determine whether there is a difference between these groups in the long-term outcome and survivorship of these implants.
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9
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The Evolution of Reverse Total Shoulder Arthroplasty and Its Current Use in the Treatment of Proximal Humerus Fractures in the Older Population. J Clin Med 2022; 11:jcm11195832. [PMID: 36233699 PMCID: PMC9570675 DOI: 10.3390/jcm11195832] [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: 09/18/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022] Open
Abstract
Proximal humerus fracture (PHF) is a common injury in the older population. While the majority of these fractures are treated non-operatively, a small subset of patients may benefit from surgical treatment. However, there continues to be an ongoing debate regarding the indications and ideal surgical treatment strategy. The use of reverse total shoulder arthroplasty (RTSA) has resulted in a paradigm shift in the treatment of PHFs in the older population. Unique biomechanical principles and design features of RTSA make it a suitable treatment option for PHFs in the older population. RTSA has distinct advantages over hemiarthroplasty and internal fixation and provides good pain relief and a reliable and reproducible improvement in functional outcomes. As a result, there has been an exponential increase in the volume of RTSA in the older population in last decade. The aim of this paper is to review the current concepts, outcomes and controversies regarding the use of RTSA for the treatment of PHFs in the older population.
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Sato K, Hatta T, Shinagawa K, Okuno H, Nobuta S. Simultaneous Reverse Shoulder Arthroplasty and Open Reduction With Internal Fixation for Bilateral Proximal Humerus Fractures in the Elderly: A Report of Two Cases. Cureus 2022; 14:e28777. [PMID: 36225506 PMCID: PMC9532084 DOI: 10.7759/cureus.28777] [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] [Accepted: 09/04/2022] [Indexed: 12/02/2022] Open
Abstract
Simultaneous bilateral proximal humerus fractures (PHFs) caused by a single trauma are considered rare. We herein report two patients with bilateral PHFs treated based on our treatment strategy: reverse shoulder arthroplasty (RSA) to obtain rigid stability for one shoulder and open reduction with internal fixation (ORIF) to regain the mobility of external and internal rotation for the other. By using Neer’s four-segment fracture classification, patients underwent RSA for one shoulder with the more advanced fracture type and ORIF for the other. In Case 1, a 74-year-old female presented with bilaterally comminuted PHFs and underwent surgical treatment with RSA and ORIF. In Case 2, a 78-year-old female with the comorbidity of rheumatoid arthritis and a history of total elbow arthroplasty for both elbows had bilateral PHFs and underwent surgical treatment with RSA and ORIF. Postoperatively, both patients were instructed to perform exercises including passive range of motion (ROM) for a week, active ROM exercises for two weeks, and muscle strengthening for six weeks after the surgery. At the follow-up, both patients were satisfied with the pain relief and functional recovery. Especially, increased ROM for external and internal rotation was obtained in shoulders with ORIF. These case reports describe a viable treatment option comprising simultaneous RSA and ORIF, and this surgical approach may restore shoulder functions in cases of bilateral PHFs.
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11
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Kimmeyer M, Rentschler V, Schmalzl J, Gerhardt C, Lehmann LJ. [Fracture analysis, indication for endoprosthesis and implant selection in proximal humeral fractures]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:671-680. [PMID: 35833976 DOI: 10.1007/s00113-022-01213-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 06/15/2023]
Abstract
Proximal humeral fractures (PHF) are the third most common fracture in humans and the incidence is increasing. There are basically three treatment strategies: conservative, joint-preserving reconstructive or joint-replacing procedures. In addition to fracture morphology, patient-specific and surgeon-specific factors are particularly important when deciding on treatment. The experience and training of the surgeon also play a decisive role. In the case of joint-preserving treatment, the risk of osteosynthesis failure and of sequelae of the fracture must always be assessed. If conservative or reconstructive treatment methods are not promising, the joint-replacing procedure is the treatment of choice. The anatomical fracture prosthesis is only indicated, if at all, for young patients with a destroyed humeral head with a preserved rotator cuff and large fragments of the tuberosities. In advanced age, the implantation of a reverse endoprosthesis is increasingly used for dislocated, multifragmentary PHF. In both procedures, the anatomical healing of the tuberosities has a significant impact on the functional outcome.
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Affiliation(s)
- M Kimmeyer
- Klinik für Unfall‑, Handchirurgie und Sportmedizin, ViDia Kliniken Karlsruhe, Steinhäuserstraße 18, 76135, Karlsruhe, Deutschland.
| | - V Rentschler
- Klinik für Unfall‑, Handchirurgie und Sportmedizin, ViDia Kliniken Karlsruhe, Steinhäuserstraße 18, 76135, Karlsruhe, Deutschland
| | - J Schmalzl
- Klinik und Poliklinik für Unfall‑, Hand‑, Plastische und Wiederherstellungschirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - C Gerhardt
- Klinik für Unfall‑, Handchirurgie und Sportmedizin, ViDia Kliniken Karlsruhe, Steinhäuserstraße 18, 76135, Karlsruhe, Deutschland
| | - L J Lehmann
- Klinik für Unfall‑, Handchirurgie und Sportmedizin, ViDia Kliniken Karlsruhe, Steinhäuserstraße 18, 76135, Karlsruhe, Deutschland
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Han PF, Yang S, Wang YP, Hou XD, Li Y, Li XY. Reverse shoulder arthroplasty vs. hemiarthroplasty for the treatment of osteoporotic proximal humeral fractures in elderly patients: A systematic review and meta‑analysis update. Exp Ther Med 2022; 24:637. [PMID: 36160890 PMCID: PMC9468857 DOI: 10.3892/etm.2022.11574] [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: 03/30/2022] [Accepted: 08/01/2022] [Indexed: 11/12/2022] Open
Abstract
The present meta-analysis was conducted to compare the safety and effectiveness of reverse shoulder arthroplasty (RSA) and hemiarthroplasty (HA) in the treatment of osteoporotic proximal humeral fractures in elderly patients. The Embase, Pubmed Central, Cumulative Index to Nursing and Allied Health Literature, ProQuest Dissertations and Theses, Cochrane Library and Chinese Biomedical databases were searched between January 2009 and January 2022 to identify relevant studies. According to the search strategy, a total of 210 associated studies were retrieved and 16 were finally included. Review Manager 5.4 software was used for the data analysis. This study indicated that patients in the RSA group had significantly improved treatment outcomes compared with patients in the HA group, as assessed by Constant-Murley Shoulder Outcome Score (95% CI, 1.69-3.76; P<0.001), American Shoulder and Elbow Surgeons score (95% CI, 11.81-24.88; P<0.001) and shoulder range of motion (ROM; 95% CI, 3.41-9.07; P<0.001). However, the HA group was superior to the RSA group in terms of the Oxford Shoulder score (95% CI, 2.89-11.11; P<0.001). There was no significant statistical difference between the two groups in terms of the Disabilities of the Arm, Shoulder and Hand score and complications. Overall, for the treatment of osteoporotic proximal humeral fractures in the elderly, the RSA group had improved postoperative ROM and functional scores compared with the HA group, without significant difference in the incidence of complications. However, HA remains a safe and reliable treatment option.
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Affiliation(s)
- Peng-Fei Han
- Department of Orthopedics, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi 046000, P.R. China
| | - Su Yang
- Graduate School, Graduate Student Department of Changzhi Medical College, Changzhi, Shanxi 046000, P.R. China
| | - Yue-Peng Wang
- Graduate School, Graduate Student Department of Changzhi Medical College, Changzhi, Shanxi 046000, P.R. China
| | - Xue-Dong Hou
- Graduate School, Graduate Student Department of Changzhi Medical College, Changzhi, Shanxi 046000, P.R. China
| | - Yuan Li
- Department of Orthopedics, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, Shanxi 046000, P.R. China
| | - Xi-Yong Li
- Graduate School, Graduate Student Department of Changzhi Medical College, Changzhi, Shanxi 046000, P.R. China
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13
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Vall M, Natera L, Witney-Lagen C, Imam MA, Narvani AA, Sforza G, Levy O, Relwani J, Consigliere P. Reverse shoulder replacement versus hemiarthroplasty for proximal humeral fracture in elderly patients: a systematic review. Musculoskelet Surg 2022; 106:357-367. [PMID: 35974216 DOI: 10.1007/s12306-022-00761-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 07/28/2022] [Indexed: 12/01/2022]
Abstract
This systematic review of the literature aims to analyse current knowledge to inform choice between hemiarthroplasty (HA) and reverse total shoulder arthroplasty (rTSA) for managing proximal humerus fractures (PHF) in elderly patients; the aim is to understand if rTSA can be considered the gold standard for treating PHF in the elderly when surgical fixation or conservative treatment is not viable options. Studies reporting outcomes and complications of PHF treated with shoulder arthroplasty in the elderly were included. Studies were in English and published after 2008. Evidence levels I, II, III and IV were included. According to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PubMed search engines, as well as the Cochrane Central Register of Controlled Trials. General data collected were study design, number of patients treated with HA and rTSA, age of patients (mean, mean and SD, mean and range), length of follow-up, type of implant, and clinical outcomes. rTSA can be regarded as the gold standard for surgical management of displaced 3 and 4-part fractures in the elderly. However, the literature offers mostly low-quality studies, thereby requiring further work to achieve a full understanding of this important topic.
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Affiliation(s)
- M Vall
- Hospital General de Granollers, Barcelona, Spain.,Universitat Autònoma de Barcelona, Campus Bellaterra, Cerdanyola del Vallès, Barcelona, Spain
| | - L Natera
- Hospital General de Granollers, Barcelona, Spain.,The Reading Shoulder Unit, Berkshire Independent Hospital, Reading, UK
| | - C Witney-Lagen
- Hospital General de Granollers, Barcelona, Spain.,University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - M A Imam
- Hospital General de Granollers, Barcelona, Spain.,Ashford and St Peters NHS FT, Chertsey, UK.,Fortius Clinic, London, UK.,Smart Health Unit, University of East London, London, UK
| | - A A Narvani
- Hospital General de Granollers, Barcelona, Spain.,Ashford and St Peters NHS FT, Chertsey, UK.,Fortius Clinic, London, UK
| | - G Sforza
- Hospital General de Granollers, Barcelona, Spain.,The Reading Shoulder Unit, Berkshire Independent Hospital, Reading, UK
| | - O Levy
- Hospital General de Granollers, Barcelona, Spain.,The Reading Shoulder Unit, Berkshire Independent Hospital, Reading, UK.,Orthopaedic Department, Barzilai Medical Centre, Ashkelon, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - J Relwani
- Hospital General de Granollers, Barcelona, Spain.,East Kent Hospitals University NHS Foundation Trust, Ashford, Margate and Canterbury, UK
| | - P Consigliere
- Hospital General de Granollers, Barcelona, Spain. .,The Reading Shoulder Unit, Berkshire Independent Hospital, Reading, UK. .,East Kent Hospitals University NHS Foundation Trust, Ashford, Margate and Canterbury, UK.
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14
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Filho GDRM, Amaral MVG. Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures: Current Concepts. Rev Bras Ortop 2022; 57:529-539. [PMID: 35966425 PMCID: PMC9365482 DOI: 10.1055/s-0040-1721359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 09/16/2020] [Indexed: 11/28/2022] Open
Abstract
Complex proximal humeral fractures, especially in elderly patients, often require arthroplastic surgical treatment. Traditionally, shoulder hemiarthroplasty (HA) is the method of choice, resulting in long implant survival and a painless shoulder; however, shoulder HA has heterogeneous clinical outcomes related to the correct position of the implant, both in terms of height and version, and the anatomical consolidation of tuberosities. Today, reverse shoulder arthroplasties are increasingly used to treat such fractures. These techniques result in better functional outcomes compared to HAs, especially regarding anterior flexion, but implant longevity has not been established. The development of specific prosthetic humeral components for the treatment of fractures, which were recently introduced in the clinical practice, led to better clinical outcomes.
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Affiliation(s)
- Geraldo da Rocha Motta Filho
- Centro de Cirurgia do Ombro e Cotovelo, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
| | - Marcus Vinícius Galvão Amaral
- Centro de Cirurgia do Ombro e Cotovelo, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil
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15
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Imiolczyk JP, Brunner U, Imiolczyk T, Freislederer F, Endell D, Scheibel M. Reverse Shoulder Arthroplasty for Proximal Humerus Head-Split Fractures-A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11102835. [PMID: 35628961 PMCID: PMC9145800 DOI: 10.3390/jcm11102835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 12/04/2022] Open
Abstract
Head-split fractures are proximal humerus fractures (PHF) that result from fracture lines traversing the articular surface. While head-split fractures are rare, surgical treatment of these complex injuries can be extremely challenging and is associated with high rates of complications. Treatment using primary reverse shoulder arthroplasty (RSA) has been associated with moderate complication rates and reproducible clinical results. The aim of this study was to evaluate clinical and radiographic outcomes, and complication rates of RSA for head-split PHF. Twenty-six patients were evaluated based on Constant Score (CS) and range of motion of both shoulders and Subjective Shoulder Value (SSV). Radiographic analysis evaluated tuberosity healing, prosthetic loosening and scapular notching. Patients achieved good clinical results with a CS of 73.7 points and SSV of 82% after a mean follow-up of 50 months. The relative CS comparing operated versus the unaffected shoulder was 92%. Greater tuberosity healing was achieved in 61%. Patients who suffered a high-energy trauma reached a significantly greater functional outcome. Patients who suffered multifragmentation to the humeral head performed the worst. There were no cases of loosening; scapular notching was visible in two cases. The complication rate was 8%. RSA is an adequate treatment option with for head-split PHF in elderly patients.
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Affiliation(s)
- Jan-Philipp Imiolczyk
- Center for Musculoskeletal Surgery, Charité-Universitaetsmedizin, 13353 Berlin, Germany
- Correspondence: (J.-P.I.); (M.S.)
| | - Ulrich Brunner
- Department of Trauma and Orthopedic Surgery, Krankenhaus Agatharied, 83734 Hausham, Germany;
| | - Tankred Imiolczyk
- Department of Mathematics, University of Mannheim, 68131 Mannheim, Germany;
| | - Florian Freislederer
- Department of Shoulder and Elbow Surgery, Schulthess Clinic, 8008 Zurich, Switzerland; (F.F.); (D.E.)
| | - David Endell
- Department of Shoulder and Elbow Surgery, Schulthess Clinic, 8008 Zurich, Switzerland; (F.F.); (D.E.)
| | - Markus Scheibel
- Center for Musculoskeletal Surgery, Charité-Universitaetsmedizin, 13353 Berlin, Germany
- Department of Shoulder and Elbow Surgery, Schulthess Clinic, 8008 Zurich, Switzerland; (F.F.); (D.E.)
- Correspondence: (J.-P.I.); (M.S.)
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16
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Lin CC, Karlin E, Boin MA, Dankert JF, Larose G, Zuckerman JD, Virk MS. Operative Treatment of Proximal Humeral Fractures with Reverse Total Shoulder Arthroplasty in Patients ≥65 Years Old: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202205000-00006. [PMID: 35536998 DOI: 10.2106/jbjs.rvw.21.00245] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
» The majority of proximal humeral fractures (PHFs) in patients who are ≥65 years of age are treated nonoperatively, but certain complex fracture patterns benefit from surgical intervention. However, there continues to be debate regarding the indications for surgery and the optimal surgical treatment (repair versus replacement) in this population. » Reverse total shoulder arthroplasty (RTSA) has grown in popularity for surgical treatment of fracture-dislocations and displaced complex PHFs in patients who are ≥65 years of age; it has definite advantages over surgical repair and hemiarthroplasty, but this finding requires additional higher-quality evidence. » RTSA provides early pain relief and return of shoulder function as well as predictable elevation above shoulder level in the forward plane, but the indications for and understanding of the effect of timing on RTSA after a PHF continue to evolve. » RTSA for an acute PHF is indicated in patients who are ≥65 years of age with 3- and 4-part fracture-dislocations, head-split fractures, and severely displaced fractures, and is an option in patients who are not able to tolerate nonoperative treatment of severely displaced 3- and 4-part fractures. » RTSA is also indicated as a salvage operation for PHFs that have failed initial surgical repair (i.e., fixation failure, implant failure, rotator cuff failure, or osteonecrosis) and is an option for symptomatic nonunion or malunion after nonoperative treatment.
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Affiliation(s)
| | - Elan Karlin
- Georgetown University School of Medicine, Washington, DC
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17
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Marin R, Feltri P, Ferraro S, Ippolito G, Campopiano G, Previtali D, Filardo G, Marbach F, De Marinis G, Candrian C, Surace MF. Impact of tuberosity treatment in reverse shoulder arthroplasty after proximal humeral fractures: A multicentre study. J Orthop Sci 2022:S0949-2658(22)00074-4. [PMID: 35461748 DOI: 10.1016/j.jos.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/22/2022] [Accepted: 03/21/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND To assess how tuberosity treatment affects the short-term clinical outcome of patients with complex proximal humeral fractures (PHFs) treated with reverse shoulder arthroplasty (RSA). METHODS This is a multicentre study on 90 patients affected by acute PHFs (Neer type-4/11C3.2 in 80% of patients, and a Neer type 3/11B3.2 in 20%) treated with RSA and followed at an average of 34 months. Patients were divided into two groups (reconstructed and non-reconstructed tuberosity) according to the surgical fixation of the tuberosities. Then, the "reconstructed tuberosity" was divided into "healed" and "non-healed" groups. All patients were clinically evaluated in terms of ROM and strength in elevation, as well as with 0-10 numerical rating scale (NRS), Constant and Murley Score (CMS), DASH Score, and EQ-VAS. X-rays in anteroposterior and Neer views were performed. RESULTS Based on the status of the tuberosities, 18.9% were non-reconstructed (17 patients) and 81.1% were reconstructed (73 patients): out of these, 11 were correctly healed, 42 healed with malposition, and 20 were reabsorbed. Instability was found in 2/73 patients in the reconstructed group, and in 4/17 patients in the non-reconstructed group. NRS (1.4 vs 0.5), DASH (23.1 vs 13.9), and EQ-VAS (78.1 vs 83.7) scores had better final values in the non-reconstructed group (p < 0.05). However, the non-correctly healed tuberosity group (excision + resorption + malposition/migration) showed worse strength, as well as clinical scores when compared to the correctly healed tuberosity group. CONCLUSION RSA ensures satisfactory functional results for PHFs. Patients with a successfully reconstructed tuberosity have an overall better outcome. However, in this series most of the reconstructed cases presented tuberosity reabsorption, malposition, or migration, which led to lower results. Thus, tuberosity reconstruction must be carefully considered and tuberosity reabsorption or migration factors should be investigated, to optimize tuberosity reconstruction and provide to a higher number of patients a better outcome of RSA for the treatment of PHFs.
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Affiliation(s)
- Roberto Marin
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland; Orthopaedic and Traumatology Unit, ASST-Settelaghi, 21100, Varese, Italy; Interdisciplinary Research Center for Pathology and Surgery of the Musculoskeletal System, Dept. of Biotechnology and Life Sciences, University of Insubria, 21100, Varese, Italy
| | - Pietro Feltri
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland.
| | - Sergio Ferraro
- Orthopaedic and Traumatology Unit, ASST-Settelaghi, 21100, Varese, Italy
| | - Giorgio Ippolito
- Dipartimento di scienze biotecnologe medico chirurgiche (DSBMC), Polo Pontino, Sapienza Università di Roma, 00185, Roma, Italy; Orthopaedic and Traumatology Unit, Istituto Chirurgico Ortopedico Traumatologico (I.C.O.T.) "Marco Pasquali Lasagni", 04100, Latina, Italy
| | - Gennaro Campopiano
- Orthopaedic and Traumatology Unit, Istituto Chirurgico Ortopedico Traumatologico (I.C.O.T.) "Marco Pasquali Lasagni", 04100, Latina, Italy
| | - Davide Previtali
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
| | - Giuseppe Filardo
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Via Buffi 13, 6900, Lugano, Switzerland
| | - Francesco Marbach
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
| | - Giancarlo De Marinis
- Orthopaedic and Traumatology Unit, Istituto Chirurgico Ortopedico Traumatologico (I.C.O.T.) "Marco Pasquali Lasagni", 04100, Latina, Italy
| | - Christian Candrian
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Via Buffi 13, 6900, Lugano, Switzerland
| | - Michele F Surace
- Orthopaedic and Traumatology Unit, ASST-Settelaghi, 21100, Varese, Italy; Interdisciplinary Research Center for Pathology and Surgery of the Musculoskeletal System, Dept. of Biotechnology and Life Sciences, University of Insubria, 21100, Varese, Italy
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18
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Hemiarthroplasty in complex proximal humeral fractures: preserving unity of the tuberosities with the cap technique improves clinical outcome. OTA Int 2022; 5:e169. [PMID: 35949267 PMCID: PMC9359014 DOI: 10.1097/oi9.0000000000000169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/24/2021] [Indexed: 11/26/2022]
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19
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Current Role of Reverse Total Shoulder Arthroplasty for Fractures of the Proximal Humerus. J Orthop Trauma 2022; 36:e98-e105. [PMID: 34294668 DOI: 10.1097/bot.0000000000002238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
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20
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Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty for the Treatment of Proximal Humerus Fractures: A Model-Based Cost-Effectiveness Analysis. J Am Acad Orthop Surg 2021; 29:e1353-e1361. [PMID: 34037546 DOI: 10.5435/jaaos-d-21-00166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/21/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Compared with hemiarthroplasty (HA), reverse total shoulder arthroplasty (RTSA) may provide greater cost and health-related benefits for patients with complex three- and four-part proximal humeral fractures. This study set out to compare RTSA versus HA for the incremental cost per incremental improvement in quality adjusted life years (QALYs) for a hypothetical cohort of patients with proximal humerus fractures. METHODS Parameters and characteristics for a hypothetical cohort of elderly patients with proximal humerus fractures were collected through the literature. A cohort-level Markov decision model was constructed. Incremental cost-effectiveness ratios representing the difference in cost divided by the difference in QALYs were calculated, and scenario, one-way, and probabilistic analysis were conducted. RESULTS RTSA was associated with lower cost and greater effectiveness compared with HA. The predicted cost difference corresponded to a saving of $99,626 per 100 individuals treated, and the predicted difference in QALY was 16.8 per 100 individuals treated. Results were sensitive to the discount rate, the health-related quality of life assigned to health states, and the cost of the surgical procedures. In probabilistic analysis, 77.1% of iterations were cost-effective at a threshold willingness-to-pay for a QALY of $100,000 US dollars. DISCUSSION Findings suggest that RTSA may be a cost-effective alternative to HA for treating elderly patients requiring surgery for proximal humerus fractures. DATA AVAILABILITY The model and corresponding code are available on request to the corresponding author. LEVEL OF EVIDENCE USING THE JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS GUIDANCE Level III.
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21
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Li X. In Older Adults with 3- or 4-Part Dislocated Proximal Humeral Fractures, Reverse Shoulder Arthroplasty Improved Anterior Elevation and Constant Score, but Not DASH Scores, Quality of Life, or Radiographic Outcomes Compared with Hemiarthroplasty. J Bone Joint Surg Am 2021; 103:2142. [PMID: 34546984 DOI: 10.2106/jbjs.21.01006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Xinning Li
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
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22
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Abstract
Background Fracture reverse shoulder arthroplasty (fRSA) in geriatric, complex dislocated proximal humerus fractures is becoming the standard treatment next to conservative treatment. fRSA is a multifaceted, reasonably challenging procedure of which functional outcomes and complication rates are likely to depend on the experience of the surgeon. The goal of this study was to determine whether there is a learning curve for fRSA. Methods All patients with a dislocated multipart proximal humerus fracture that were treated with an fRSA between 2013 and 2019 in a specialized institution were included. The functional outcomes (Constant Shoulder Score, Oxford Shoulder Score, and range of motion), complications, and operation time of fRSA were assessed with linear regression plots and cumulative summation analysis to establish whether a learning curve was present. Results In this cohort study, 50 patients were included. They had a mean age of 77.1 years and were treated with an fRSA by one trauma surgeon. Learning curves were distinguished for functional outcomes, complications, and operation time based on learning targets for daily activity and the mean complications and operation time. Results indicated that an optimal treatment is achieved after performing 20 fRSAs. Conclusion The results show that functional outcomes of PHFs treated with an fRSA improve with surgical experience. Also, outcomes are getting less variable after about 20 procedures. Surgeons starting this procedure should be aware of the learning curve and, therefore, should consider guidance from an experienced surgeon to swiftly optimize functional outcomes and prevent unnecessary complications.
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23
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Jonsson EÖ, Ekholm C, Salomonsson B, Demir Y, Olerud P. Reverse total shoulder arthroplasty provides better shoulder function than hemiarthroplasty for displaced 3- and 4-part proximal humeral fractures in patients aged 70 years or older: a multicenter randomized controlled trial. J Shoulder Elbow Surg 2021; 30:994-1006. [PMID: 33301926 DOI: 10.1016/j.jse.2020.10.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The most appropriate treatment for displaced multiple-fragment proximal humeral fractures in elderly patients is currently unclear. Reverse total shoulder arthroplasty (rTSA) is a promising treatment option that is being used increasingly. The purpose of this study was to compare the outcome of rTSA vs. hemiarthroplasty (HA) for the treatment of displaced 3- and 4-part fractures in elderly patients. METHODS This was a multicenter randomized controlled trial. We included patients aged ≥ 70 years with displaced 3- or 4-part proximal humeral fractures between September 2013 and May 2016. The minimum follow-up period was 2 years, with outcome measures including the Constant score (primary outcome), Western Ontario Osteoarthritis of the Shoulder index, EQ-5D (EuroQol 5 Dimensions) index, and range of motion, as well as pain and shoulder satisfaction assessed on a visual analog scale. RESULTS We randomized 99 patients to rTSA (48 patients) or HA (51 patients). Fifteen patients were lost to follow-up, leaving 41 rTSA and 43 HA patients for analysis. The mean age was 79.5 years, and there were 76 women (90%). The rTSA group had a mean Constant score of 58.7 points compared with 47.7 points in the HA group, with a mean difference of 11.1 points (95% CI, 3.0-18.9 points; P = .007). Compared with HA patients, rTSA patients had greater mean satisfaction with the shoulder (79 mm vs. 63 mm, P = .011), flexion (125° vs. 90°, P < .001), and abduction (112° vs. 83°, P < .001), but there was no difference in Western Ontario Osteoarthritis of the Shoulder index, pain, or EQ-5D index scores. We identified 3 and 4 adverse events in the rTSA and HA groups, respectively. Among patients aged ≥ 80 years (n = 38), there was no difference between rTSA treatment and HA treatment in pain (17 mm vs. 9 mm, P = .17) or shoulder satisfaction (77 mm vs. 74 mm, P = .73). CONCLUSION We found that rTSA provides better shoulder function than HA as measured with the Constant score, further emphasized by rTSA patients being more satisfied with their shoulder function. The difference appears to be mainly a result of better range of motion (abduction and flexion) in the rTSA group. The results also indicate that patients aged ≥ 80 years benefit less from rTSA than patients aged 70-79 years.
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Affiliation(s)
- Eythor Ö Jonsson
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden.
| | - Carl Ekholm
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Björn Salomonsson
- Department of Orthopedics, Karolinska Institutet, Danderyds Sjukhus, Stockholm, Sweden
| | - Yilmaz Demir
- Department of Orthopedics, Karolinska Institutet, Danderyds Sjukhus, Stockholm, Sweden
| | - Per Olerud
- Department of Clinical Science and Education, Section of Orthopaedics, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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24
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Laas N, Engelsma Y, Hagemans FJA, Hoelen MA, van Deurzen DFP, Burger BJ. Reverse or Hemi Shoulder Arthroplasty in Proximal Humerus Fractures: A Single-Blinded Prospective Multicenter Randomized Clinical Trial. J Orthop Trauma 2021; 35:252-258. [PMID: 33470595 DOI: 10.1097/bot.0000000000001978] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare outcomes between hemiarthroplasty (HA) and reversed shoulder arthroplasty (RSA) as a treatment for dislocated 3-part and 4-part proximal humerus fractures in the elderly population. DESIGN Prospective multicenter randomized controlled trial. SETTING Three Level-1 trauma centers. PATIENTS/PARTICIPANTS This study included 31 patients of which 14 were randomized into the HA group and 17 into the RSA group. INTERVENTION Patients randomized to the HA group were treated with a cemented-stem Aequalis-fracture HA and patients randomized to the RSA group with a cemented-stem Aequalis-fracture RSA. MAIN OUTCOME MEASUREMENTS Primary outcomes consisted of range of motion and constant score. Secondary outcomes were the visual analog scale for pain, DASH score, SF-12 scores, and radiographic outcomes. RESULTS After 6 and 12 months of follow-up, RSA showed a significant higher anterior elevation (105 degrees vs. 80 degrees, P = 0.002 and 110 degrees vs. 90 degrees, P = 0.02, respectively) and constant score (60 vs. 41, P = 0.01 and 51 vs. 32, P = 0.05, respectively) compared with HA. There were no significant differences in external and internal rotation. Also, visual analog scale pain, DASH scores, SF-12 scores, and radiological healing of the tuberosities and heterotopic ossification did not show any significant differences between groups. CONCLUSION RSA showed significant superior functional outcomes for anterior elevation and constant score compared with HA for dislocated 3-part and 4-part proximal humerus fractures after short-term follow-up. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Niels Laas
- Department of Orthopaedic Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Yde Engelsma
- Department of Orthopaedic Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Frans J A Hagemans
- Department of Orthopaedic Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Max A Hoelen
- Department of Orthopaedic Surgery, Reinier de Graaf Hospital, Delft, the Netherlands ; and
| | - Derek F P van Deurzen
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Hospital, Amsterdam, the Netherlands
| | - Bart J Burger
- Department of Orthopaedic Surgery, Northwest Clinics, Alkmaar, the Netherlands
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Sabah Y, Decroocq L, Gauci MO, Bonnevialle N, Lemmex DB, Chelli M, Valenti P, Boileau P. Clinical and radiological outcomes of reverse shoulder arthroplasty for acute fracture in the elderly. INTERNATIONAL ORTHOPAEDICS 2021; 45:1775-1781. [PMID: 33893521 DOI: 10.1007/s00264-021-05050-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/16/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The goal of this study was to assess the clinical outcomes associated with anatomic healing of the greater tuberosity in patients treated for proximal humerus fractures with reverse shoulder arthroplasty. Our hypothesis was that anatomic healing of the greater tuberosity leads to less complications and better functional outcomes. METHODS RESULTS: Patients from the GT+ group presented better functional outcomes than the GT- group in all evaluated outcomes. Mean constant score was 61 ± 14 versus 56 ± 15, and the subjective shoulder value (SSV) was 77 ± 14 versus 64 ± 21 (p < 0.001). Forward elevation was 128° ± 28° versus 107° ± 30° and external rotation was 23° ± 17° versus 14° ± 17° (p < 0.001). Twenty patients presented with at least one prosthetic dislocation (7 GT+ vs 13 GT-) while nine patients were revised for humeral loosening (1 GT+ vs 8 GT-). The use of a fracture specific humeral stem was associated with a higher rate of greater tuberosity healing. CONCLUSIONS Non-anatomic healing of the greater tuberosity was associated with a higher dislocation and humeral loosening rate. Anatomic healing of the greater tuberosity lead to better functional outcomes, less humeral-sided complications, and fewer re-operations.
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Affiliation(s)
- Yann Sabah
- IULS CHU de Nice, UR2CA, UCA, 30 voie Romaine, 06000, Nice, France.
| | - Lauryl Decroocq
- IULS CHU de Nice, UR2CA, UCA, 30 voie Romaine, 06000, Nice, France
| | | | | | | | - Mikael Chelli
- IULS CHU de Nice, UR2CA, UCA, 30 voie Romaine, 06000, Nice, France
| | | | - Pascal Boileau
- IULS CHU de Nice, UR2CA, UCA, 30 voie Romaine, 06000, Nice, France
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Pizzo RA, Gianakos AL, Haring RS, Gage MJ, Stevens NM, Liporace FA, Yoon RS. Are Arthroplasty Procedures Really Better in the Treatment of Complex Proximal Humerus Fractures? A Comprehensive Meta-Analysis and Systematic Review. J Orthop Trauma 2021; 35:111-119. [PMID: 33079841 DOI: 10.1097/bot.0000000000001926] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE A meta-analysis and systematic review was performed to compare outcomes of open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (rTSA) for complex proximal humerus fractures. Data sources: MEDLINE, Embase, and Cochrane Library databases were screened. Search terms included reverse total shoulder arthroplasty, open reduction internal fixation, hemiarthroplasty, and proximal humerus fracture. STUDY SELECTION English-language studies published within the past 15 years evaluating outcomes of ORIF, rTSA, or HA for complex proximal humerus fractures with minimum of 1-year follow-up were included, resulting in 51 studies with 3064 total patients. Review articles, basic science studies, biomechanical studies, and cadaveric studies were excluded. DATA EXTRACTION The methodological quality of evidence was assessed using the Jadad scale and methodological index for nonrandomized studies. DATA SYNTHESIS Demographic data were compared using the χ2 test. Mean data were weighted by study size and used to calculate composite mean values and confidence intervals. Continuous data were compared using the Metan module with fixed effects. Count data were compared using the Kruskal-Wallis test. Alpha was set at 0.05 for all tests. CONCLUSIONS Patients undergoing rTSA had lower risks of complication (relative risk 0.41) and reoperation (relative risk 0.28) than HA patients. rTSA resulted in higher Constant scores (standard mean difference 0.63) and improved active forward flexion when compared with HA (standard mean difference 0.76). Pooled mean data demonstrated better outcome scores and active forward flexion of ORIF versus HA and rTSA, although the patients were younger and had more simple fracture patterns. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Richard A Pizzo
- Department of Orthopaedic Surgery, Jersey City Medical Center-RWJ Barnabas Health, Jersey City, NJ
| | - Arianna L Gianakos
- Department of Orthopaedic Surgery, Jersey City Medical Center-RWJ Barnabas Health, Jersey City, NJ
| | - Richard Sterling Haring
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, TN
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC; and
| | - Nicole M Stevens
- Department of Orthopaedic Surgery, New York University Medical Center, New York, NY
| | - Frank A Liporace
- Department of Orthopaedic Surgery, Jersey City Medical Center-RWJ Barnabas Health, Jersey City, NJ
| | - Richard S Yoon
- Department of Orthopaedic Surgery, Jersey City Medical Center-RWJ Barnabas Health, Jersey City, NJ
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27
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Fracture-Specific and Conventional Stem Designs in Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fractures-A Retrospective, Observational Study. J Clin Med 2021; 10:jcm10020175. [PMID: 33419012 PMCID: PMC7825286 DOI: 10.3390/jcm10020175] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/21/2020] [Accepted: 12/31/2020] [Indexed: 11/16/2022] Open
Abstract
Tuberosity healing and stem design can be outcome-dependent parameters in hemiarthroplasty for proximal humerus fractures (PHF). The relevance of fracture-specific stem design in reverse shoulder arthroplasty (RSA) is still a matter of debate. This retrospective study evaluates tuberosity healing and function for fracture specific stems (A) compared to conventional stems (B) in RSA for complex PHF in 26 patients (w = 21, mean age 73.5 years). Clinically, range of motion (ROM), Constant-Murley-Score (CS), Subjective Shoulder Value (SSV), and external rotation lag signs (ERLS) were evaluated. Healing of greater tuberosity (GT) and lesser tuberosity (LT), scapular notching, and loosening were examined radiologically. There were no statistical significant differences with regards to CS (A: 73 ± 11; B: 77 ± 9 points), SSV (A: 78% ± 11%; B: 84% ± 11%), external rotation (A: 18° ± 20°; B: 24° ± 19°), or internal rotation (A: 5.7 ± 2.2; B: 6.7 ± 2.8 CS-points) (p > 0.05). Mean forward flexion was superior for group A (p = 0.036). Consolidation of GT (82%) and LT (73%) was similar in both groups. Anatomical healing was slightly higher in group B (p > 0.05). Scapular notching was found in 27% (A) and 55% (B) (p > 0.05). RSA for PHF provides good to excellent clinical results. The quantitative and qualitative union rate for both cohorts was similar, indicating that fracture stems with open metaphyseal designs to allow for bone ingrowth do not improve tuberosity healing. ERLS correlates with a worse function in CS and ROM in all planes.
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28
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Shah SS, Roche AM, Sullivan SW, Gaal BT, Dalton S, Sharma A, King JJ, Grawe BM, Namdari S, Lawler M, Helmkamp J, Garrigues GE, Wright TW, Schoch BS, Flik K, Otto RJ, Jones R, Jawa A, McCann P, Abboud J, Horneff G, Ross G, Friedman R, Ricchetti ET, Boardman D, Tashjian RZ, Gulotta LV. The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part II. JSES Int 2020; 5:121-137. [PMID: 33554177 PMCID: PMC7846704 DOI: 10.1016/j.jseint.2020.07.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused, updated systematic review for each of the most common complications of RSA by limiting each search to publications after 2010. In this part II, the following were examined: (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures (AF/SSF), and (4) problems/miscellaneous. Methods Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall, 137 studies for instability, 94 for humerus/glenoid fracture, 120 for AF/SSF, and 74 for problems/miscellaneous were included in each review, respectively. Univariate analysis was performed with chi-square and Fisher exact tests. Results The Grammont design had a higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; P = .02). The rate for intraoperative humerus fracture was 1.8%; intraoperative glenoid fracture, 0.3%; postoperative humerus fracture, 1.2%; and postoperative glenoid fracture, 0.1%. The rate of AF/SSF was 2.6% (371/14235). The rate for complex regional pain syndrome was 0.4%; deltoid injury, 0.1%; hematoma, 0.3%; and heterotopic ossification, 0.8%. Conclusions Focused systematic reviews of recent literature with a large volume of shoulders demonstrate that using non-Grammont modern prosthesis designs, complications including instability, intraoperative humerus and glenoid fractures, and hematoma are significantly reduced compared with previous studies. As the indications continue to expand for RSA, it is imperative to accurately track the rate and types of complications in order to justify its cost and increased indications.
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Affiliation(s)
- Sarav S. Shah
- American Shoulder and Elbow Surgeons (ASES) Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
- Corresponding author: Sarav S. Shah, MD, 125 Parker Hill Ave, Boston, MA 02120, USA.
| | | | | | - Benjamin T. Gaal
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Stewart Dalton
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Arjun Sharma
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Joseph J. King
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Brian M. Grawe
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Surena Namdari
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Macy Lawler
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Joshua Helmkamp
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | | | - Thomas W. Wright
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | | | - Kyle Flik
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Randall J. Otto
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Richard Jones
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Andrew Jawa
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Peter McCann
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Joseph Abboud
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Gabe Horneff
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Glen Ross
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | - Richard Friedman
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
| | | | - Douglas Boardman
- ASES Multicenter Taskforce for RSA Complications, Rosemont, IL, USA
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Shah SS, Gaal BT, Roche AM, Namdari S, Grawe BM, Lawler M, Dalton S, King JJ, Helmkamp J, Garrigues GE, Wright TW, Schoch BS, Flik K, Otto RJ, Jones R, Jawa A, McCann P, Abboud J, Horneff G, Ross G, Friedman R, Ricchetti ET, Boardman D, Tashjian RZ, Gulotta LV. The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part I. JSES Int 2020; 4:929-943. [PMID: 33345237 PMCID: PMC7738599 DOI: 10.1016/j.jseint.2020.07.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this 2-part study was to systematically review each of the most common complications of RSA, limiting each search to publications in 2010 or later. In this part (part I), we examined (1) scapular notching (SN), (2) periprosthetic infection (PJI), (3) mechanical failure (glenoid or humeral component), and (4) neurologic injury (NI). Methods Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Overall, 113 studies on SN, 62 on PJI, 34 on mechanical failure, and 48 on NI were included in our reviews. Univariate analysis was performed with the χ2 or Fisher exact test. Results The Grammont design had a higher SN rate vs. all other designs combined (42.5% vs. 12.3%, P < .001). The onlay humeral design had a lower rate than the lateralized glenoid design (10.5% vs. 14.8%, P < .001). The PJI rate was 2.4% for primary RSA and 2.6% for revision RSA. The incidence of glenoid and humeral component loosening was 2.3% and 1.4%, respectively. The Grammont design had an increased NI rate vs. all other designs combined (0.9% vs. 0.1%, P = .04). Conclusions Focused systematic reviews of the recent literature with a large volume of RSAs demonstrate that with the use of non-Grammont modern prosthesis designs, complications including SN, PJI, glenoid component loosening, and NI are significantly reduced compared with previous studies. As the indications for RSA continue to expand, it is imperative to accurately track the rates and types of complications to justify its cost and increased indications.
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Affiliation(s)
- Sarav S Shah
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Benjamin T Gaal
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Alexander M Roche
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Surena Namdari
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Brian M Grawe
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Macy Lawler
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Stewart Dalton
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Joseph J King
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Joshua Helmkamp
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Grant E Garrigues
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Thomas W Wright
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Bradley S Schoch
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Kyle Flik
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Randall J Otto
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Richard Jones
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Andrew Jawa
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Peter McCann
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Joseph Abboud
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Gabe Horneff
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Glen Ross
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Richard Friedman
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Eric T Ricchetti
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Douglas Boardman
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Robert Z Tashjian
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
| | - Lawrence V Gulotta
- American Shoulder and Elbow Surgeons Multicenter Task Force on Reverse Total Shoulder Arthroplasty Complications, Rosemont, IL, USA
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O'Sullivan J, Lädermann A, Parsons BO, Werner B, Steinbeck J, Tokish JM, Denard PJ. A systematic review of tuberosity healing and outcomes following reverse shoulder arthroplasty for fracture according to humeral inclination of the prosthesis. J Shoulder Elbow Surg 2020; 29:1938-1949. [PMID: 32815808 DOI: 10.1016/j.jse.2020.03.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal humerus fractures are common in the elderly population and are often treated with reverse shoulder arthroplasty (RSA). The purpose of this systematic review was to compare tuberosity healing and functional outcomes in patients undergoing RSA with humeral inclinations of 135°, 145°, and 155°. METHODS A systematic review was performed of RSA for proximal humerus fracture using Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines. Radiographic and functional outcome data were extracted to evaluate tuberosity healing according to humeral inclination. Analysis was also performed of healed vs. nonhealed tuberosities. RESULTS A total of 873 patients in 21 studies were included in the analysis. The mean age was 77.5 years (range of 58-97) and the mean follow-up was 26.2 months. Tuberosity healing was 83% in the 135° group compared with 69% in the 145° group and 66% in the 155° group (P = .030). Postoperative abduction was highest in the 155° group (P < .001). No significant difference was found in forward flexion, external rotation, or postoperative Constant score between groups. Patients with tuberosity healing demonstrated 18° higher forward flexion (P = .008) and 16° greater external rotation (P < .001) than those with unhealed tuberosities. CONCLUSION RSA for fracture with 135° humeral inclination is associated with higher tuberosity healing rates compared with 145° or 155°. Postoperative abduction is highest with a 155° implant, but there is no difference in in postoperative forward flexion, external rotation, or Constant score according to humeral inclination. Patients with healed tuberosities have superior postoperative forward flexion and external rotation than those with unhealed tuberosities.
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Affiliation(s)
- Joseph O'Sullivan
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Alexandre Lädermann
- Division of Orthopedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Bradford O Parsons
- Department of Orthopedics, Mount Sinai Medical Center, New York, NY, USA
| | - Brian Werner
- Department of Orthopedics, University of Virginia, Charlottesville, VA, USA
| | | | - John M Tokish
- Department of Orthopedics, Mayo Clinic, Scottsdale, AZ, USA
| | - Patrick J Denard
- Southern Oregon Orthopedics, Medford, OR, USA; Department of Orthopaedic & Rehabilitation, Oregon Health & Science University, Portland, OR, USA.
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31
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Dauwe J, Danker C, Herteleer M, Vanhaecht K, Nijs S. Proximal humeral fracture osteosynthesis in Belgium: a retrospective population-based epidemiologic study. Eur J Trauma Emerg Surg 2020; 48:4509-4514. [PMID: 32816048 DOI: 10.1007/s00068-020-01466-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Proximal humeral fractures (PHF) comprise approximately five percent of all fractures and this percentage will continue to increase due to the aging population with accompanying osteoporosis. Most PHF can be treated conservatively; however, in displaced fractures, surgical treatment is recommended. Retrospective analyses of large groups or even populations are important as they can contribute to the needs of the community. The aim of this study was to assess the epidemiology and management of PHF fixation in Belgium based on the most recently available data from the last 5 years. METHODS The governmental organization National Institute of Health and Disability Insurance provided a population-based database with all PHF treated surgically or nonoperatively. This database was retrospectively assessed. The data included age, sex, region of residence, year and treatment strategy for every patient. Healthcare expenses were also provided. RESULTS A total of 62,290 PHF were identified in Belgium between 2014 and 2018. The incidence was 111 per 100,000 persons/year. The highest incidence was observed in females and people older than 80 years. The average proportion of osteosynthesis was calculated at 21%. The Belgian government spent on average more than two million euros each year on PHF treatment. CONCLUSION The overall incidence of PHF increased by 12% over the last 5 years. The majority were treated nonoperatively in Belgium.
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Affiliation(s)
- Jan Dauwe
- AO Research Institute Davos, Davos, Switzerland. .,Department of Orthopaedic Surgery, University Hospitals Leuven, Leuven, Belgium.
| | | | - Michiel Herteleer
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Kris Vanhaecht
- LIHP, Leuven Institute for Healthcare Policy, Leuven, Belgium
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
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Wendt KW, Jaeger M, Verbruggen J, Nijs S, Oestern HJ, Kdolsky R, Komadina R. ESTES recommendations on proximal humerus fractures in the elderly. Eur J Trauma Emerg Surg 2020; 47:381-395. [PMID: 32767081 DOI: 10.1007/s00068-020-01437-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 07/12/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE The section for the skeletal trauma and sport's injuries of the European Society for Trauma and Emergency Surgery (ESTES) appointed a task force group to reach a consensus among European countries on proximal humeral fractures. MATERIAL/METHODS The task force group organized several consensus meetings until a paper with final recommendations was confirmed during the ESTES Executive Board meeting in Berlin on 25 October 2018. CONCLUSION The Recommendations compare conservative and four possible operative treatment options (ORIF, nailing, hemi- and total reverse arthroplasty) and enable the smallest common denominator for the surgical treatment among ESTES members.
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Affiliation(s)
- Klaus W Wendt
- Medical Coordinator, Trauma Centre Northern Netherlands, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin Jaeger
- Clinic for Orthopedic and Trauma Surgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan Verbruggen
- Department of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stefaan Nijs
- Department of Traumatology, UZ Leuven, Leuven, Belgium
| | - Hans-Jörg Oestern
- Conciliation Board of Medical Liability Cases Germany, Hannover, Germany
| | - Richard Kdolsky
- University Clinic for Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Radko Komadina
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.
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Grassi FA, Alberio R, Ratti C, Surace MF, Piazza P, Messinese P, Saccomanno MF, Maccauro G, Murena L. Shoulder arthroplasty for proximal humerus fractures in the elderly: The path from Neer to Grammont. Orthop Rev (Pavia) 2020; 12:8659. [PMID: 32913595 PMCID: PMC7459385 DOI: 10.4081/or.2020.8659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 11/22/2022] Open
Abstract
Shoulder replacement is indicated for the surgical treatment of proximal humeral fractures in elderly patients, when severe comminution and osteoporosis jeopardize the chances of success of any fixation technique. Two different implants are available for this purpose: anatomical hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RTSA). HA for fractures was popularized by Charles Neer in the ‘50s and for several decades remained the only reliable implant for these injuries. However, many authors reported inconsistent results with HA as a consequence of the high rate of tuberosity and rotator cuff failure. In 1987, Paul Grammont designed the first successful RTSA, which was the end result of a long thought process on functional surgery of the shoulder. This implant was initially used to treat cuff tear arthropathy and shoulder pseudoparalysis, but indications have gradually expanded with time. Since RTSA does not rely on a functional cuff for shoulder elevation, it was felt that results in fractures could be improved by this prosthesis. In this study, the salient features of these implants are described to understand the rationale behind both approaches and highlight their pros and cons. Several clinical studies comparing HA vs RTSA for proximal humeral fractures have been published during the last two decades. A literature review is carried out to analyze and compare outcomes of both implants, analyzing clinical results, radiographic findings and complications. The final goal is to provide an overview of the different factors to consider for making a choice between these two prostheses.
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Affiliation(s)
- Federico A Grassi
- Orthopaedic and Trauma Unit, Department of Health Sciences, University Hospital University of East Piedmont, Novara
| | - Riccardo Alberio
- Orthopaedic and Trauma Unit, Department of Health Sciences, University Hospital University of East Piedmont, Novara
| | - Chiara Ratti
- Orthopaedic and Trauma Unit, Department of Medicine, Surgery and Health Sciences, University Hospital University of Trieste
| | - Michele F Surace
- Interdisciplinary Research Centre for Pathology and Surgery of the Musculoskeletal System, Department of Biotechnology and Life Sciences, University of Insubria, Varese
| | - Piero Piazza
- Orthopaedic Institute, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Piermarco Messinese
- Orthopaedic Institute, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Giulio Maccauro
- Orthopaedic Institute, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Murena
- Orthopaedic and Trauma Unit, Department of Medicine, Surgery and Health Sciences, University Hospital University of Trieste
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Abstract
PURPOSE OF REVIEW The purpose of this review is to examine trends, outcomes, and principles in treatment of proximal humerus fractures in the elderly with a critical focus on reverse shoulder arthroplasty as a developing treatment option. RECENT FINDINGS Recent literature shows an increase in reverse shoulder arthroplasty and a decrease in hemiarthroplasty performed for proximal humerus fractures. More predictable outcomes and lower revision rates are seen in older individuals treated primarily or secondarily with reverse shoulder arthroplasty compared to those treated with hemiarthroplasty. We report current and historical treatments, outcomes, and principles in reverse shoulder arthroplasty for treatment of complex, displaced proximal humerus fractures in older individuals (≥ 65 years old).
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Affiliation(s)
- Brandon J Kelly
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Chad M Myeroff
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA. .,Regions Hospital, Saint Paul, Minnesota, 640 Jackson St, MS 11503L, Saint Paul, MN, 55101, USA. .,TRIA Orthopaedic Center, Woodbury, MN, USA.
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Sayegh MJ, Nixon RA, Perfetti DC, Rokito SE, Sgaglione NA. Changing trends in the management of proximal humerus fractures in New York State. J Orthop 2020; 21:127-130. [PMID: 32255993 DOI: 10.1016/j.jor.2020.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 03/22/2020] [Indexed: 10/24/2022] Open
Abstract
Purpose Reverse shoulder arthroplasty (RSA) as an alternative to hemiarthroplasty (HA) as treatment for proximal humerus fractures has prompted a re-evaluation of utilization trends. Methods Operative treatment for proximal humeral fractures were analyzed using a New York State database. Results After introduction as an ICD-9 code, RSA increased to 39.3% (m = +5.2%/year, r = 0.984). When stratifying by age ≥65, HA decreased to 7.7% (m = -2.8%/year, r = 0.962) while RSA increased to 50.6% (m = +6.4%/year, r = 0.985). Conclusion RSA overtook HA as the arthroplasty procedure of choice for proximal humerus fractures. In patients ≥65, RSA passed ORIF as the most prevalent procedure in 2017. Level of evidence III, Descriptive Epidemiology Study, Large Database Analysis.
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Affiliation(s)
- Michael J Sayegh
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Ryan A Nixon
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Dean C Perfetti
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Steven E Rokito
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Nicholas A Sgaglione
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
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Maugendre E, Gadisseux B, Chantelot C, Clavert P, Ramdane N, Werthel JD, Boileau P. Epidemiology and mortality in older patients treated by reverse shoulder arthroplasty for displaced proximal humerus fractures. Orthop Traumatol Surg Res 2019; 105:1509-1513. [PMID: 31732395 DOI: 10.1016/j.otsr.2019.07.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 06/27/2019] [Accepted: 07/16/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Reverse shoulder arthroplasty (RSA) is rapidly becoming the preferred treatment for displaced proximal humerus fractures in older patients. However, few studies have analyzed the target population and the effect of RSA on survival, although the socioeconomic impact of this type of surgery is considerable. PATIENTS AND METHODS This was a retrospective epidemiological study of all patients with a displaced proximal humeral fracture treated by RSA in 14 public and private hospitals throughout France between 1995 and 2016. The French hospital discharge database (PMSI) was analyzed to isolate an 898-patient cohort who underwent RSA within 6 weeks of the fracture event. In 87% of cases, this was a 3- or 4-fragment fracture. We analyzed the epidemiological characteristics of the patients at the time of fracture, their survival (Kaplan-Meier estimate) and factors that may impact survival. RESULTS The mean age at the time of fracture and surgery was 79 years (46-98 years). Eighty percent of the cohort was female (sex ratio: 0.18 [p=0.0042], with 21% obesity rate [BMI>30]) and 60% of patients were ASA 1-2. The most common comorbidities were cardiovascular and neurological. The survival rate after RSA was 94% at 1 year and 73% at 5years. At the latest follow-up of 19 years, 42% of patients were still alive. In 18% of cases, the patient died within the first 15 days. The presence of comorbidities (ASA score>3-4) (p<0.004) and/or cognitive disorders (p<0.0001) were risk factors for early mortality. The time to surgery, type of fracture, associated fractures and discharge destination (return home, transfer to nursing home) had no effect on postoperative mortality in our cohort. CONCLUSION Despite being older (79 years) at the time of proximal humerus fracture, patients who underwent RSA treatment had a high survival rate (94% at 1 year, 73% at 5years), which is better than the survivorship reported after surgical treatment of femoral neck fractures (81-87% at 1 year, 38% at 5years). The presence of comorbidities (ASA>3-4) and/or cognitive disorders are risk factors for early mortality and should be taken into account to prevent early death. LEVEL OF EVIDENCE IV, Retrospective study.
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Affiliation(s)
- Emmanuel Maugendre
- Service de traumatologie, CHRU de Lille, hôpital Roger Salengro, 2, avenue Oscar-Lambret, 59037 Lille, France
| | - Benjamin Gadisseux
- Service de traumatologie, CHRU de Lille, hôpital Roger Salengro, 2, avenue Oscar-Lambret, 59037 Lille, France
| | - Christophe Chantelot
- Service de traumatologie, CHRU de Lille, hôpital Roger Salengro, 2, avenue Oscar-Lambret, 59037 Lille, France
| | - Philippe Clavert
- Service d'orthopédie-traumatologie, centre de chirurgie orthopédique et de la main, service de chirurgie orthopédique, avenue Baumann, 67400 Illkirch, France
| | - Nassima Ramdane
- EA 2694 - santé publique: épidémiologie et qualité des soins, université de Lille, CHU de Lille, 59000 Lille, France
| | - Jean-David Werthel
- Hôpital Ambroise-Paré Paris, 9, avenue Charles-de-Gaulle, 92104 Boulogne-Billancourt, France
| | - Pascal Boileau
- iULS - Institut universitaire locomoteur and sport, CHU de Nice, hôpital Pasteur 2, 30, voie Romaine, 06000 Nice, France.
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- Société française de chirurgie orthopédique et traumatologique, 56, rue Boissonade, 75014 Paris, France
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Gallinet D, Cazeneuve JF, Boyer E, Menu G, Obert L, Ohl X, Bonnevialle N, Valenti P, Boileau P. Reverse shoulder arthroplasty for recent proximal humerus fractures: Outcomes in 422 cases. Orthop Traumatol Surg Res 2019; 105:805-811. [PMID: 31279769 DOI: 10.1016/j.otsr.2019.03.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/15/2019] [Accepted: 03/14/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The ageing of the population is steadily increasing the frequency of displaced proximal humerus fractures (PHFs) in elderly patients. The last decade has seen a shift from hemi-arthroplasty (HA) to reverse shoulder arthroplasty (RSA) in these patients. The primary objective of this study was to assess short- and long-term outcomes of RSA in a large cohort of elderly patients with recent PHFs. The secondary objectives were to evaluate radiological outcomes and short- and long-term morbidity and mortality rates. HYPOTHESIS Outcomes of RSA to treat PHFs in older patients are satisfactory, reliable, and sustained over time. MATERIAL AND METHODS This retrospective multi-centre study included 898 patients with a mean age of 79 years, among whom 422 underwent a standardised clinical and radiological evaluation at least 1 year after RSA. Some patients were re-evaluated twice. An evaluation within the first 5 years was available for 420 patients (≤5-Y group), whereas 119 patients were re-evaluated more than 5 years after RSA (>5-Y group). Some patients had one re-evaluation either within or after 5 years and others had both an early and a late re-evaluation; thus the total number of re-evaluation was greater than the number of patients. RESULTS Mean active forward elevation was 115°±29°, mean external rotation with the elbow by the side was 17°±19°, mean internal rotation (hand-to-back) was 4.3±2.5 points, mean absolute Constant score was 57±15, and mean Subjective Shoulder Value was 70%±18%. Re-implantation of the tuberosities followed by healing in the anatomical position was associated with significantly better outcomes, notably regarding rotations. Even in the absence of healing in the anatomical position, tuberosity repair was associated with better clinical outcomes compared to tuberosity excision. Humeral loosening occurred in 3.5% of patients and was associated with tuberosity excision. Glenoid loosening was seen in 3.5% of patients and was associated with superior tilt of the glenoid component. The main complication was prosthesis instability, which occurred in 2.5% of patients, a proportion similar to that seen in the general population. Post-operative patient survival was not significantly different from that in the general population of the same age. Prosthesis survival was 91% after 20 years. CONCLUSION Clinical outcomes of RSA for PHF in elderly patients were not only satisfactory but also reproducible and sustained over time. Tuberosity re-implantation around the prosthesis is the key step for optimising the functional outcomes, notably by restoring rotations and decreasing the risk of complications (prosthesis instability and humeral loosening). LEVEL OF EVIDENCE IV, retrospective observational study.
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Affiliation(s)
| | | | - Etienne Boyer
- Service de chirurgie orthopédique et traumatologique, CHU de Besançon, Hôpital Jean-Minjoz, 2, boulevard Fleming 25030 Besançon cedex, France
| | - Gauthier Menu
- Service de chirurgie orthopédique et traumatologique, CHU de Besançon, Hôpital Jean-Minjoz, 2, boulevard Fleming 25030 Besançon cedex, France
| | - Laurent Obert
- Service de chirurgie orthopédique et traumatologique, CHU de Besançon, Hôpital Jean-Minjoz, 2, boulevard Fleming 25030 Besançon cedex, France
| | - Xavier Ohl
- Service de chirurgie orthopédique et traumatologique, CHU de Reims, Hôpital Maison-Blanche, 45, rue Cognacq-Jay, 51092 Reims cedex, France
| | - Nicolas Bonnevialle
- Département de chirurgie orthopédique, CHU de Toulouse, hôpital Riquet, place Baylac, 31059 Toulouse cedex, France
| | | | - Pascal Boileau
- iULS-Institut Universitaire Locomoteur & Sport- CHU Nice Hôpital Pasteur 2, 30, avenue de la Voie-Romaine, 06000 Nice, France; UCA-Université de la Côte d'Azur
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- 56, rue Boissonade, 75014 Paris, France
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Klug A, Wincheringer D, Harth J, Schmidt-Horlohé K, Hoffmann R, Gramlich Y. Complications after surgical treatment of proximal humerus fractures in the elderly-an analysis of complication patterns and risk factors for reverse shoulder arthroplasty and angular-stable plating. J Shoulder Elbow Surg 2019; 28:1674-1684. [PMID: 31056394 DOI: 10.1016/j.jse.2019.02.017] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/10/2019] [Accepted: 02/16/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND To date, there is a lack of consensus regarding surgical treatment recommendations for complex proximal humerus fracture (PHF) patterns, especially between joint preservation and joint replacement techniques. METHODS Between 2012 and 2017, 146 patients (aged 74.1 ± 8.0 years) with complex PHF were treated with locking plates (open reduction-internal fixation [ORIF]) or reverse total shoulder arthroplasty (RTSA). Complications and unplanned revision surgery were recorded in a mid-term follow-up. Potential patient and surgical risk factors for complications were extracted. Univariate and multivariate analyses were conducted. RESULTS Follow-up data were available for 125 patients, 66 (52.8%) of whom were treated with locking plates, and 59 (41.2%) with RTSA. Both groups had comparable Charlson indices. The overall complication rate was 37.8% for ORIF and 22.0% for RTSA, with a revision rate of 12.1% and 5.1%, respectively, as driven primarily by persistent motion deficits. Multivariate analyses demonstrated no significant differences between the 2 procedures (P = .500). However, age was an independent protective factor against overall complications (P = .018). Risk factors for major complications in ORIF included osteoporosis, varus impaction fractures, posteromedial metaphyseal extensions <8 mm, head-shaft displacements >4 mm, and multifragmentary greater tuberosities. For RTSA, higher complication rates were seen in patients with higher Charlson indices, diabetes, or altered (greater) tuberosities. In contrast, Neer's classification system was not predictive in either group. CONCLUSIONS RTSA led to fewer complications than ORIF and thus can be considered a valuable option in complex PHF of the elderly. Paying attention to specific prognostic factors may help to reduce the complication rate.
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Affiliation(s)
- Alexander Klug
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und orthopädische Chirurgie, Frankfurt am Main, Germany.
| | - Dennis Wincheringer
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und orthopädische Chirurgie, Frankfurt am Main, Germany
| | - Jasmin Harth
- Johann Wolfgang Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany
| | - Kay Schmidt-Horlohé
- Orthopaedicum Wiesbaden-Praxis für Orthopädie, Unfallchirurgie und Sportmedizin, Zentrum für Ellenbogenchirurgie, Wiesbaden, Germany
| | - Reinhard Hoffmann
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und orthopädische Chirurgie, Frankfurt am Main, Germany
| | - Yves Gramlich
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Zentrum für Unfallchirurgie und orthopädische Chirurgie, Frankfurt am Main, Germany
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Hu Y, Shi H, Wang F, Ren G, Cheng R, Zhang Z. Functional outcomes of extra-articular scapula fracture fixation with distal humeral Y-type locking plate: a retrospective study. J Orthop Surg Res 2019; 14:176. [PMID: 31196139 PMCID: PMC6567544 DOI: 10.1186/s13018-019-1205-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/20/2019] [Indexed: 11/14/2022] Open
Abstract
Background This study aimed to compare the functional outcomes of the Y-type locking plate with the straight reconstruction locking plate for severe displaced scapular fractures. Methods This was a retrospective cohort study of 37 patients with severe displaced scapular body and neck fractures treated between July 2013 and October 2016 at the Hanzhong Central Hospital. Treatment selection was based on the surgeon’s experience and discussion with the patient. Sixteen patients received Y-type locking plates and 21 patients received straight reconstruction locking plates. The primary indexes were the Constant Shoulder Function (CSF) and Disabilities of the arm, shoulder, and hand (DASH) scores at 3, 6, and 12 months. Results There were 32 males and five females. Mean age was 46.0 ± 10.0 years. The cause of injury included car accident, fall, high fall, and bruising. At 3 months, compared with the straight reconstruction locking plate group, the Y-type locking plate group showed higher CSF scores (82.9 ± 3.5 vs. 79.3 ± 4.4, P = 0.01) and lower DASH scores (9.5 ± 2.5 vs. 12.7 ± 3.9, P = 0.008). There were no differences at 6 and 12 months. There were no differences between the two groups regarding intraoperative blood loss (P = 0.65) and operation time (P = 0.634). There were no complications such as plate rupture and screw prolapse during the 1-year follow-up. Conclusions Open reduction using the distal humeral Y-type locking plate can achieve better short-term functional outcomes (3 months) than the straight reconstruction locking plate for severe displaced scapular body and neck fractures, but outcomes are similar at 6 and 12 months. Level of evidence: II-2.
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Affiliation(s)
- Yuanjun Hu
- Traumatic Orthopaedics Department Ward I, Hanzhong Central Hospital, Hanzhong, 723000, Shaanxi, China
| | - Huiming Shi
- Traumatic Orthopaedics Department Ward I, Hanzhong Central Hospital, Hanzhong, 723000, Shaanxi, China.
| | - Fei Wang
- Traumatic Orthopaedics Department Ward I, Hanzhong Central Hospital, Hanzhong, 723000, Shaanxi, China
| | - Guangtie Ren
- Traumatic Orthopaedics Department Ward I, Hanzhong Central Hospital, Hanzhong, 723000, Shaanxi, China
| | - Ruiping Cheng
- Traumatic Orthopaedics Department Ward I, Hanzhong Central Hospital, Hanzhong, 723000, Shaanxi, China
| | - Zhizhong Zhang
- Traumatic Orthopaedics Department Ward I, Hanzhong Central Hospital, Hanzhong, 723000, Shaanxi, China
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Dillon MT, Prentice HA, Burfeind WE, Chan PH, Navarro RA. The increasing role of reverse total shoulder arthroplasty in the treatment of proximal humerus fractures. Injury 2019; 50:676-680. [PMID: 30738568 DOI: 10.1016/j.injury.2019.01.034] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 01/26/2019] [Accepted: 01/29/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Hemiarthroplasty of the shoulder is a well established treatment for proximal humerus fractures not amenable to open reduction internal fixation. However, orthopedic surgeons have recently increased utilization of reverse total shoulder arthroplasty (RTSA) in the treatment of these injuries. The purpose of this study was to evaluate the use of hemiarthroplasty and RTSA between 2009 and 2016 for the treatment of proximal humerus fractures within a large United States integrated healthcare system. MATERIALS AND METHODS A descriptive study was conducted using our integrated healthcare system's Shoulder Arthroplasty Registry. Shoulder arthroplasty cases performed for an acute proximal humerus fracture between the years of 2009 and 2016 were identified. Revision rates were determined, as well as changes in age and gender distribution of the cohort during the study period. RESULTS In 2015, RTSA utilization surpassed that of hemiarthroplasty for the first time in the healthcare system. The utilization of RTSA in the treatment of proximal humerus fractures increased from 4.5% of all arthroplasties in 2009 to 67.4% of arthroplasties in 2016. During the study period, patients undergoing hemiarthroplasty were younger and less likely to be female. Crude revision rate was 4.0% for hemiarthroplasty and 3.2% for RTSA. CONCLUSIONS RTSA is increasingly being utilized for the treatment of proximal humerus fractures and now appears to be the treatment of choice. While hemiarthroplasty appears to be falling out of favor in the treatment of fractures of the shoulder, surgeons may still be preferentially using the procedure in younger patients.
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Affiliation(s)
- Mark T Dillon
- Department of Orthopedic Surgery, The Permanente Medical Group, Sacramento, CA, USA.
| | | | | | - Priscilla H Chan
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA
| | - Ronald A Navarro
- Department of Orthopedic Surgery, Southern California Permanente Medical Group, Harbor City, CA USA
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Chivot M, Lami D, Bizzozero P, Galland A, Argenson JN. Three- and four-part displaced proximal humeral fractures in patients older than 70 years: reverse shoulder arthroplasty or nonsurgical treatment? J Shoulder Elbow Surg 2019; 28:252-259. [PMID: 30348542 DOI: 10.1016/j.jse.2018.07.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The objective of our study was to evaluate the results of surgical treatment by reverse shoulder arthroplasty (RSA) compared with nonsurgical treatment after 2 years of follow-up in patients aged 70 years or older with displaced 3-part or 4-part proximal humeral fractures. METHODS Two groups were formed: the RSA group (n = 28) and the nonsurgical group (n = 32). Minimum follow-up was 2 years. We included patients with 3-part or 4-part fractures according to the Neer classification. Main outcome measures were the Constant-Murley score, the 11-item version of the Disabilities of the Arm, Shoulder and Hand score, and the Subjective Shoulder Value score. An autonomy score, a cognitive assessment score, and a pain score were also measured. RESULTS Clinical features in the 2 groups were not significantly different. The Constant-Murley mean score was significantly higher for the RSA group (82.1% vs. 76.8%; P = .03). Amplitudes were all higher in favor of the RSA group (P < .02). There was no significant difference in mean score on the 11-item version of the Disabilities of the Arm, Shoulder and Hand score, the preoperative and postoperative Subjective Shoulder Value score, the autonomy score, the cognitive assessment score, or the pain score in both groups at the last follow-up. The complication rate was higher for the RSA group. CONCLUSIONS These results suggest that RSA treatment of proximal humeral fractures with 3-part or 4-part displaced fragments in elderly patients provides better functional outcomes than does nonsurgical treatment. However, the observed clinical difference was relatively small. This solution must be proposed only to patients who have a significant functional demand.
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Affiliation(s)
- Matthieu Chivot
- Aix-Marseille University, Centre National de la Recherche Scientifique, L'Institut des Sciences Moléculaires Unité Mixte de Recherche 7287, Marseille, France; Department of Orthopedic Surgery and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, Marseille, France.
| | - Damien Lami
- Department of Orthopedic Surgery and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, Marseille, France
| | - Paul Bizzozero
- Aix-Marseille University, Centre National de la Recherche Scientifique, L'Institut des Sciences Moléculaires Unité Mixte de Recherche 7287, Marseille, France; Department of Orthopedic Surgery and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, Marseille, France
| | - Alexandre Galland
- Department of Orthopedic Surgery and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, Marseille, France
| | - Jean-Noël Argenson
- Aix-Marseille University, Centre National de la Recherche Scientifique, L'Institut des Sciences Moléculaires Unité Mixte de Recherche 7287, Marseille, France; Department of Orthopedic Surgery and Traumatology, Institute of Movement and Locomotion, St. Marguerite Hospital, Marseille, France
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Launonen AP, Fjalestad T, Laitinen MK, Lähdeoja T, Ekholm C, Wagle T, Mattila VM. Nordic Innovative Trials to Evaluate osteoPorotic Fractures (NITEP) Collaboration: The Nordic DeltaCon Trial protocol-non-operative treatment versus reversed total shoulder arthroplasty in patients 65 years of age and older with a displaced proximal humerus fracture: a prospective, randomised controlled trial. BMJ Open 2019; 9:e024916. [PMID: 30700485 PMCID: PMC6352806 DOI: 10.1136/bmjopen-2018-024916] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The proximal humerus fracture (PHF) is one of the most common fractures in the elderly. The majority of PHFs are treated non-operatively, while 15%-33% of patients undergo surgical treatment. Recent randomised controlled trial (RCT) and meta-analyses have shown that there is no difference in outcome between non-operative treatment and locking plate or hemi-arthroplasty. During the past decade, reverse total shoulder arthroplasty (RTSA) has gained popularity in the treatment of PHF, although there is a lack of RCTs comparing RTSA to non-operative treatment. METHODS This is a prospective, single-blinded, randomised, controlled, multicentre and multinational trial comparing RTSA with non-operative treatment in displaced proximal humeral fractures in patients 65-85 years. The primary outcome in this study is QuickDASH-score measured at 2 years. Secondary outcomes include visual analogue scale for pain, grip strength, Oxford shoulder score, Constant score and the number of reoperations and complications.The hypothesis of the trial is that operative treatment with RTSA produces better outcome after 2 and 5 years measured with QuickDASH. ETHICS AND DISSEMINATION In this protocol, we describe the design, method and management of the Nordic DeltaCon trial. The ethical approval for the trial has been given by the Regional Committee for Medical and Health Research Ethics, Norway. There have been several examples in orthopaedics of innovations that result in failure after medium-term follow-ups . In order to prevent such failures and to increase our knowledge of RSTA, we feel a large-scale study of the effects of the surgery on the outcome that focuses on the complications and reoperations is warranted. After the trial 2-year follow-up, the results will be disseminated in a major orthopaedic publication. TRIAL REGISTRATION NUMBER NCT03531463; Pre-Results.
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Affiliation(s)
| | | | | | | | - Carl Ekholm
- Sahlgrenska University Hospital, Göteborg, Sweden
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Decreased Reoperations and Improved Outcomes With Reverse Total Shoulder Arthroplasty in Comparison to Hemiarthroplasty for Geriatric Proximal Humerus Fractures: A Systematic Review and Meta-Analysis. J Orthop Trauma 2019; 33:49-57. [PMID: 30211792 DOI: 10.1097/bot.0000000000001321] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We sought to compare range of motion, clinical outcome scores, and complications after reverse total shoulder arthroplasty (RSA) and hemiarthroplasty (HA) in geriatric patients with acute proximal humerus fractures. DATA SOURCES We searched MEDLINE (1946-2017), EMBASE (1947-2017), the Cochrane Central Register of Controlled Trials (1898-2017) and ClinicalTrials.gov in October 2017. No limits were used in the database search. We also manually reviewed reference lists of included studies. We did not restrict studies based on language. STUDY SELECTION We included all randomized controlled trials and cohort studies in which the study population had a mean age of 65 years or older, received RSA or HA to treat an acute proximal humerus fracture, and had a minimum follow-up of 6 months. DATA EXTRACTION Two independent reviewers used a standardized data collection form to extract relevant information from included studies. Discrepancies were resolved by a consensus or a third party if consensus could not be reached. Study authors were contacted for missing or incomplete data. DATA SYNTHESIS Using a random effects model, we calculated mean differences (MD) and standardized mean differences (SMD) for continuous outcomes; we calculated relative risk for dichotomous outcomes. RESULTS Fifteen studies were included in the meta-analysis, including 421 patients treated with RSA and 492 treated with HA for a total of 913 patients. Compared with HA, the RSA group had significantly improved pain scores (SMD = 0.74, P < 0.001), outcome scores (SMD = 0.63, P < 0.001), and forward flexion (MD = 24.3 degrees, P < 0.001). Compared with RSA, the HA group had a significantly increased risk of reoperation (relative risk = 2.8, P = 0.02). There were no differences between the groups with regard to external rotation (P = 0.31) or deep infection (P = 0.90). CONCLUSIONS Aggregating available research suggests that RSA results in improved range of motion, clinical outcome scores, and rates of all-cause reoperation with no difference in infection rates. Using RSA for the treatment of acute proximal humerus fractures in the elderly population may result in improved short- and medium-term outcomes compared with HA. Future work should evaluate long-term outcomes to see if the benefits of RSA persist. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Ohl X, Bonnevialle N, Gallinet D, Ramdane N, Valenti P, Decroocq L, Boileau P. How the greater tuberosity affects clinical outcomes after reverse shoulder arthroplasty for proximal humeral fractures. J Shoulder Elbow Surg 2018; 27:2139-2144. [PMID: 30082121 DOI: 10.1016/j.jse.2018.05.030] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/18/2018] [Accepted: 05/21/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Our purpose was to evaluate the clinical and radiologic outcomes of reverse shoulder arthroplasty for proximal humeral fractures in a large cohort of elderly patients and compare the results in the case of tuberosity excision, failed fixation, or anatomic healing. METHODS In this retrospective multicenter study, 420 patients underwent review and radiography with a minimum follow-up period of 12 months. The patients were divided into 3 groups according to the status of the greater tuberosity (GT) on the last anteroposterior radiographs: anatomic GT healing (group A, n = 169); GT resorption, malunion, or nonunion (group B, n = 131); and GT excision (group C, n = 120). Complications were recorded; shoulder function, active mobility, and subjective results were assessed. RESULTS At a mean follow-up of 28 months, the mean Simple Shoulder Value in group A (75%) outperformed the results found in groups B (69%, P < .001) and C (56%, P < .001). Overall, the mean adjusted Constant-Murley score was significantly higher in group A (93% ± 22%) than in group B (82% ± 22%) and group C (80% ± 24%) (P < .001), but there was no difference between groups B and C (P = .88). Anterior active elevation and external rotation were significantly better in group A than in groups B and C (P < .001). The instability rate was significantly higher in group C (n = 15 [12.5%], P < .001) than in group A (n = 2) or group B (n = 3). CONCLUSION In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes. GT excision is associated with the worst functional results and increases the risk of postoperative shoulder instability.
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Affiliation(s)
- Xavier Ohl
- Orthopaedic Department, University Hospital, Reims, France
| | - Nicolas Bonnevialle
- Department of Orthopaedic Surgery, Riquet Hospital, University of Toulouse, Toulouse, France.
| | | | - Nassima Ramdane
- Unité de Méthodologie-Biostatistique et Data Management, Lille, France
| | | | - Lauryl Decroocq
- Department of Orthopaedic Surgery, iULS (Institut Universitaire Locomoteur & Sport), University of Nice Sophia Antipolis, Nice, France
| | - Pascal Boileau
- Department of Orthopaedic Surgery, iULS (Institut Universitaire Locomoteur & Sport), University of Nice Sophia Antipolis, Nice, France
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- French Society of Orthopedic Surgery and Traumatology, Paris, France
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Gallinet D, Ohl X, Decroocq L, Dib C, Valenti P, Boileau P. Is reverse total shoulder arthroplasty more effective than hemiarthroplasty for treating displaced proximal humerus fractures in older adults? A systematic review and meta-analysis. Orthop Traumatol Surg Res 2018; 104:759-766. [PMID: 29969722 DOI: 10.1016/j.otsr.2018.04.025] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/29/2018] [Accepted: 04/19/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The indications for surgical treatment of displaced proximal humerus fractures in older patients have gradually changed in the past 10 years: fewer hemiarthroplasty (HA) procedures but more reverse shoulder arthroplasty (RSA) procedures are being done. The aim of this study was to determine the clinical and radiological outcomes, the complications, reoperations and revisions of RSA and to compare them with those of HA. MATERIAL AND METHODS A systematic review of the literature published between January 2006 and February 2016 was carried out to identify studies reporting or comparing results of HA and RSA for proximal humerus fractures in patients above 65 years of age. These studies were classified based on their quality and level of evidence. Of the 67 studies that were identified and reviewed, 22 were chosen for the analysis. RESULTS The functional outcome (Constant score) after RSA is significantly better and more reproducible that the one obtained after HA. RSA provides significantly better active range of motion in forward flexion and abduction than HA. Conversely, active internal and external rotation are worse after RSA than HA. Reattachment of the tuberosities around the RSA improves the rotation ability. Even if the tuberosities do not heal, the functional outcomes are satisfactory after RSA but not HA due to a major functional deficit. The tuberosity healing rate around the RSA does not decline with age, contrary to HA where age is a negative factor. The overall complication rate is higher after RSA than HA; however the reoperation rate is equal. The revision rate for implant change is higher after HA. CONCLUSION Compared to HA, RSA provides more reproducible function with better recovery of active forward flexion and abduction, even when the tuberosities are not reattached or do not heal properly. The poor rotation ability can be improved by reinserting the tuberosities. While the complication rate after RSA is higher than after HA, the reoperation rate is equal, and the revision rate is lower. LEVEL OF EVIDENCE IV, Systematic review of literature.
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Affiliation(s)
- David Gallinet
- 3, chemin des écoles des Tilleroyes, Bat Séquoia park, 25000 Besancon, France
| | - Xavier Ohl
- Service de chirurgie orthopédique et traumatologique, CHU de Reims, hôpital maison-blanche, 45, rue Cognacq-Jay, 51092 Reims, France
| | - Lauryl Decroocq
- Université de la Côte d'Azur (UCA), CHU de Nice, hôpital Pasteur 2, institut universitaire locomoteur et Sport (iULS), 30, avenue de la voie Romaine, 06000 Nice, France
| | - Choukry Dib
- Institut de la main, 6, square Jouvenet, 75016 Paris, France
| | | | - Pascal Boileau
- Université de la Côte d'Azur (UCA), CHU de Nice, hôpital Pasteur 2, institut universitaire locomoteur et Sport (iULS), 30, avenue de la voie Romaine, 06000 Nice, France.
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- 56, rue Boissonade, 75014 Paris, France
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Holschen M, Siemes MK, Witt KA, Steinbeck J. Five-year outcome after conversion of a hemiarthroplasty when used for the treatment of a proximal humeral fracture to a reverse total shoulder arthroplasty. Bone Joint J 2018; 100-B:761-766. [PMID: 29855243 DOI: 10.1302/0301-620x.100b6.bjj-2017-1280.r1] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Aims The reasons for failure of a hemirthroplasty (HA) when used to treat a proximal humeral fracture include displaced or necrotic tuberosities, insufficient metaphyseal bone-stock, and rotator cuff tears. Reverse total shoulder arthroplasty (rTSA) is often the only remaining form of treatment in these patients. The aim of this study was to evaluate the clinical outcome after conversions from a failed HA to rTSA. Material and Methods A total of 35 patients, in whom a HA, as treatment for a fracture of the proximal humerus, had failed, underwent conversion to a rTSA. A total of 28 were available for follow-up at a mean of 61 months (37 to 91), having been initially reviewed at a mean of 20 months (12 to 36) postoperatively. Having a convertible design, the humeral stem could be preserved in nine patients. The stem was removed in the other 19 patients and a conventional rTSA was implanted. At final follow-up, patients were assessed using the American Shoulder and Elbow Surgeons (ASES) score, the Constant Score, and plain radiographs. Results At final follow-up, the mean ASES was 59 (25 to 97) and the mean adjusted Constant Score was 63% (23% to 109%). Both improved significantly (p < 0.001). The mean forward flexion was 104° (50° to 155°) and mean abduction was 98° (60° to 140°). Nine patients (32%) had a complication; two had an infection and instability, respectively; three had a scapular fracture; and one patient each had delayed wound healing and symptomatic loosening. If implants could be converted to a rTSA without removal of the stem, the operating time was shorter (82 minutes versus 102 minutes; p = 0.018). Conclusion After failure of a HA in the treatment of a proximal humeral fracture, conversion to a rTSA may achieve pain relief and improved shoulder function. The complication rate is considerable. Cite this article: Bone Joint J 2018;100-B:761-6.
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Affiliation(s)
- M Holschen
- Orthopedic Practice Clinic (OPPK) and Raphaelsklinik Münster, Münster, Germany
| | - M-K Siemes
- Orthopedic Practice Clinic (OPPK), Münster, Germany
| | - K-A Witt
- Orthopedic Practice Clinic (OPPK), Münster, Germany
| | - J Steinbeck
- Orthopedic Practice Clinic (OPPK), Münster, Germany
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