Latest Trends in the Current Treatment of Proximal Humeral Fractures - an Analysis of 1162 Cases at a Level-1 Trauma Centre with a Special Focus on Shoulder Surgery

Conservative Versus Operative Treatment of Proximal Humerus Fractures in Older Individuals

BACKGROUND

Little is known about the frequency and results of conservative treatment of proximal humerus fractures (PHF) in older individuals.

METHODS

Billing data of the BARMER health insurance carrier for all patients of age ≥ 65 for the years 2005-2021 were retrospectively analyzed with multivariable Cox regression models, taking account of the patients' age, sex, and individual comorbidity profiles. The defined primary endpoints were overall survival (OS), major adverse events (MAE), thromboembolic events (TE), and complications of surgery or of trauma. Multivariable p-values for the effect of treatment on all primary endpoints were jointly adjusted using the Bonferroni-Holm method.

RESULTS

Of 81 909 patients, 54% were treated conservatively. Conservative treatment was more common in those who received their diagnosis as outpatients (79.5%, vs. 37.2% for inpatients). Operative treatment was associated with significantly longer overall survival (long-term hazard ratio [HR] 0.89, 95% confidence interval [0.86; 0.91]), fewer MAE (0.90 [0.88; 0.92]), and fewer TE (0.89 [0.87; 0.92]), but more complications due to surgery or trauma (1.66 [1,.4; 1.78]; all p < 0.001). By 6 months after diagnosis, 3.1% of the patients who were initially treated conservatively had undergone surgery. Risk factors for failure of conservative treatment were alcohol abuse, obesity, cancer, diabetes mellitus, Parkinson disease, and osteoporosis.

CONCLUSION

The conservative treatment of PHF is associated with a lower overall rate of complications due to surgery or trauma, but also with more MAE, more TE, and higher mortality. These findings underline the need for individualized and risk-adjusted treatment recommendations.

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

Background

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

Methods

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

Results

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

Conclusion

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

Valgising angular stable plate fixation in the treatment of multifragmentary proximal humeral fractures in elderly patients

INTRODUCTION

The frequency of proximal humeral fractures shows an increasing tendency, especially in the elderly, who are frequently affected by osteoporosis. The adequate treatment of complex, displaced fractures poses a serious challenge. Among surgical treatment options, osteosynthesis with an angular stable plate is preferred, however, the implant-related complication rate may be exceptionally high. In our present study, we report the short-term outcomes of our new method of valgising angular stable plate fixation which we use for multifragmentary, displaced proximal humeral fractures in elderly patients.

MATERIALS AND METHODS

We retrospectively evaluated the clinical and radiological outcomes of 52 patients (46 female and 6 male, age: 71.9 ± 9.6) who suffered dislocated three- or four-part fractures and underwent valgising angular stable plate fixation.

RESULTS

Mean follow-up time was 17.3 months, while the functional outcomes were as following: excellent in 26, good in 18, moderate in 5 and poor in 3 patients. The mean Constant-Murley Score was 82.5 ± 11.2. Functional outcomes only showed significant correlation (p = 0.031) with age and were proven unrelated to fracture type, BMI and known primary diseases. The cumulative complication rate was 9.6% and revision rate was 5.8%. Neurological deficit, pseudoarthrosis or avascular humeral head necrosis did not occur during the follow-up period.

CONCLUSIONS

Valgising angular stable plate fixation that we apply for proximal humeral fractures provided favourable functional outcomes and a low postoperative complication rate due to the optimal head and plate placement. The method is especially effective for the treatment of displaced three- and four-part fractures with weakened, osteoporotic bone structure.

Cement-Augmented Screw Fixation with PHILOS Plating for Osteoporotic Proximal Humeral Fractures: An Observation of Mid- and Long-Term Curative Efficacy

OBJECTIVES

The mid- and long-term clinical outcomes of cement-augmented screws in the treatment of osteoporotic proximal humeral fractures have rarely been reported. The aim of this study was to observe the mid- and long-term efficacy of combined cement-augmented screw fixation and PHILOS plating in the treatment of osteoporotic fractures of the proximal humerus.

METHODS

This study retrospectively analyzed data from 19 patients with osteoporotic fractures of the proximal humerus who had undergone internal fixation at the Guizhou Provincial People's Hospital from February 2017 to May 2021. The cohort was comprised of six males and 13 females, aged 75-87 (mean age: 82.52 ± 1.24) years. According to the Neer classification, three, 12, and four patients had two-part, three-part, and four-part fractures, respectively. All patients were treated with open reduction internal fixation with cement-augmented screws and PHILOS plating. Time until fracture healing was recorded postoperatively. Patients were observed for postoperative complications, including humeral head necrosis, loosening or breaking of the augmented screws, screw perforation of the humeral head, and varus fracture displacement. Visual analog scale and Constant scores of the shoulder joint were compared 1, 3, 6, and 12 months after surgery. Scores at the most recent follow-up were used to evaluate shoulder joint function. Measured data conforming to a normal distribution were expressed as mean ± SD. Analysis of variance or rank sum tests were used for intergroup comparisons. A value of p < 0.05 was considered significant.

RESULTS

All 19 patients followed up for 1-4 (average: 2.13 ± 0.61) years. Fractures united in all cases, with a healing time of 8-14 (average: 10.25 ± 1.72) weeks. There were no cases of humeral head necrosis, screw loosening, fractures, or perforation of the humeral head. One patient had mild varus fracture displacement with a reduced neck-shaft angle. There were significant differences in visual analog scale and Constant scores 1, 3, and 6 months after surgery (p < 0.05). The visual analog scale score was 0 at final follow-up in all cases. The Constant score of the shoulder joint was excellent, good, fair, and poor in two, 12, four, and one case, respectively, yielding an excellent and good rate of 73.68%.

CONCLUSIONS

Cement-augmented screw fixation combined with PHILOS plating of osteoporotic proximal humeral fractures had good mid- and long-term clinical efficacy. It should be considered a new option for fracture treatment in such patients.

Assessment of Complication Risk in the Treatment of Proximal Humerus Fractures: A Retrospective Analysis of 4019 Patients

(1) Background: The treatment of proximal humeral fractures (PHFs) is debated controversially. Current clinical knowledge is mainly based on small single-center cohorts. The goal of this study was to evaluate the predictability of risk factors for complications after the treatment of a PHF in a large clinical cohort in a multicentric setting. (2) Methods: Clinical data of 4019 patients with PHFs were retrospectively collected from 9 participating hospitals. Risk factors for local complications of the affected shoulder were assessed using bi- and multivariate analyses. (3) Results: Fracture complexity with n = 3 or more fragments, cigarette smoking, age over 65 years, and female sex were identified as predictable individual risk factors for local complications after surgical therapy as well as the combination of female sex and smoking and the combination of age 65 years or older and ASA class 2 or higher. (4) Conclusion: Humeral head preserving reconstructive surgical therapy should critically be evaluated for patients with the risk factors abovementioned.

Minimum 2-year results of the second-generation CFR-PEEK locking plate on the proximal humeral fracture

PURPOSE

The aim of this study was to analyse and compare the 24-month range of motion results of patients treated with CFR-PEEK2 versus conventional titanium plate osteosyntheses (TAL-P). We hypothesized similar clinical outcomes but a better range of motion in the CFR-PEEK2 group than the TAL-P group in the 2-year follow-up.

METHODS

This retrospective study analysing prospectively collected data included all patients that presented with a PHF and were treated with CFR-PEEK2 between November 2016 and April 2018. Follow-up was performed after a minimum of 24 months, evaluating the functional degree of movement functional scores, including the Subjective Shoulder Value (SSV) as well as an age- and sex-adapted Constant-Murley score (CMS). The 2-year results were compared to the results of a matched pair group comprising patients that were treated with TAL-P during the same period.

RESULTS

Of the 35 patients included (mean age: 61.2 [18-78] years), 30 (86%) patients completed the 24-month follow-up in the CFR-PEEK2-group. After 24 months, the mean CMS was 89.9 points (pt) (44.5-100 pt) and the mean SSV was 86.7% (35-100%). Compared to the matched-pair TAL-P cohort, the 24-month follow-up showed similar results (CMS: 88.6 pt. (40.5-100 pt.) [p = 0.9]; SSV: 76% (30-100%) [p = 0.05]). However, significantly better degrees of forward flexion and internal rotation as well as a better range of motion in abduction was recorded in patients treated with CFR-PEEK2 plates than TAL-P.

CONCLUSION

At the 24-month follow-up, patients who received treatment with CFR-PEEK2 compared to those that received TAL-P showed enhanced range of motion whilst having similar clinical scores.

Age-Independent Clinical Outcome in Proximal Humeral Fractures: 2-Year Results Using the Example of a Precontoured Locking Plate

INTRODUCTION

The optimal treatment strategy for the proximal humeral fracture (PHF) remains controversial. The debate is centered around the correct treatment strategy in the elderly patient population. The present study investigated whether age predicts the functional outcome of locking plate osteosynthesis for this fracture entity.

METHODS

A consecutive series of patients with surgically treated displaced PHF between 01/2017 and 01/2018 was retrospectively analyzed. Patients were treated by locking plate osteosynthesis. The cohort was divided into two groups: Group 1 (≥65 years) and Group 2 (<65 years). At the follow-up examination, the SSV, CMS, ASES, and Oxford Shoulder Score (OS), as well as a radiological follow-up, was obtained. The quality of fracture reduction is evaluated according to Schnetzke et al. Results: Of the 95 patients, 79 were followed up (83.1%). Group 1 consists of 42 patients (age range: 65-89 years, FU: 25 months) and Group 2 of 37 patients (28-64 years, FU: 24 months). The clinical results showed no significant differences between both groups: SSV 73.4 ± 23.4% (Group 1) vs. 80.5 ± 189% (Group 2). CMS: 79.4 ± 21 vs. 81.9 ± 16, ASES: 77.2 ± 20.4 vs. 77.5 ± 23.1, OS: 39.5 ± 9.1 vs. 40.8 ± 8.2; OS: 39.5 ± 9.1 vs. 40.8 ± 8.2. In the radiological follow-up, fractures healed in all cases. Furthermore, the quality of fracture reduction in both groups is comparable without significant differences. The revision rate was 9.5% in Group 1 vs. 16.2% in Group 2.

DISCUSSION

Both age groups show comparable functional outcomes and complication rates. Thus, the locking plate osteosynthesis can be used irrespective of patient age; the treatment decision should instead be based on fracture morphology and individual patient factors.

Reverse total shoulder arthroplasty (RTSA) versus open reduction and internal fixation (ORIF) for displaced three-part or four-part proximal humeral fractures: a systematic review and meta-analysis

Despite rapid medical technology development, various challenges exist in three- and four-part proximal humeral fracture (PHF) management. This condition has led to a notably increased use of the reverse total shoulder arthroplasty (RTSA); however, open reduction and internal fixation (ORIF) is still the most widely performed procedure. Thus, these two modalities are crucial and require further discussion. We aim to compare the outcomes of three- or four-part PHF surgeries using ORIF and RTSA based on direct/head-to-head comparative studies.We conducted a systematic review and meta-analysis based on the Cochrane handbook and PRISMA guidelines. We searched MEDLINE (PubMed), Embase (Ovid), and CENTRAL (Cochrane Library) from inception to October 2020. Our protocol was registered at PROSPERO (registration number CRD42020214681). We assessed the individual study risk of bias using ROB 2 and ROBINS-I tools, then appraised our evidence using the GRADE approach.Six head-to-head comparative studies were included, comprising one RCT and five retrospective case-control studies. We found that RTSA significantly improved forward flexion but was comparable to ORIF in abduction (p = 0.03 and p = 0.47, respectively) and more inferior in external rotation (p < 0.0001). Moreover, RTSA improved the overall Constant-Murley score, but the difference was not significant (p = 0.22). Interestingly, RTSA increased complications (by 42%) but reduced the revision surgery rates (by 63%) compared to ORIF (p = 0.04 and p = 0.02, respectively).RTSA is recommended to treat patients aged 65 years or older with a three- or four-part PHF. Compared to ORIF, RTSA resulted in better forward flexion and Constant-Murley score, equal abduction, less external rotation, increased complications but fewer revision surgeries. Cite this article: EFORT Open Rev 2021;6:941-955. DOI: 10.1302/2058-5241.6.210049.