1
|
Duey AH, Stern BZ, Zubizarreta N, Galatz LM, Parsons BO, Poeran J, Cagle PJ. Surgical treatment of displaced proximal humerus fractures is associated with decreased 1-year mortality in patients aged 65 years and older: a retrospective study of Medicare patients. J Shoulder Elbow Surg 2024; 33:1962-1971. [PMID: 38430980 DOI: 10.1016/j.jse.2024.01.036] [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: 08/08/2023] [Revised: 01/01/2024] [Accepted: 01/18/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Proximal humerus fracture (PHF) is a risk factor for 1-year mortality. This study aimed to determine if surgery is associated with lower mortality compared to nonoperative treatment following PHF in older patients. METHODS This retrospective cohort study used the Medicare Limited Data set. Patients aged 65 years and older with a PHF diagnosis in 2017-2020 were included. Treatment was classified as nonoperative, open reduction internal fixation (ORIF), total shoulder arthroplasty (TSA), or hemiarthroplasty. Multivariable logistic regression models examined (a) predictors of treatment type and (b) the association of treatment type with 1-year mortality, adjusting for patient demographics, comorbidities, frailty, and fracture severity among other variables. A subgroup analysis examined how the relationship between treatment type and 1-year mortality varied based on fracture severity. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) are reported. RESULTS In total, 49,072 patients were included (mean age = 76.6 years, 82.3% female). Most were treated nonoperatively (77.5%), 10.9% underwent ORIF, 10.6% underwent TSA, and 1.0% underwent hemiarthroplasty. Examples of factors associated with receipt of operative (versus nonoperative treatment) included worse fracture severity and lower frailty. The 1-year mortality rate after the initial PHF diagnosis was 11.0% for the nonoperative group, 4.0% for ORIF, 5.2% for TSA, and 6.0% for hemiarthroplasty. Compared to nonoperative treatment, ORIF (aOR 0.55; 95% CI [0.47, 0.64]; P < .001) and TSA (aOR 0.59; 95% CI [0.50, 0.68]; P < .001) were associated with decreased odds of 1-year mortality. In the subgroup analysis, ORIF and TSA were associated with a lower 1-year mortality risk for 2-part and 3-/4-part fractures. CONCLUSIONS Compared to nonoperative treatment, surgery (particularly TSA and ORIF) was associated with a decreased odds of 1-year mortality. This relationship remained significant for 2-part and 3-/4-part fractures after stratifying by fracture severity.
Collapse
Affiliation(s)
- Akiro H Duey
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brocha Z Stern
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Zubizarreta
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Leesa M Galatz
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bradford O Parsons
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jashvant Poeran
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul J Cagle
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| |
Collapse
|
2
|
Malfi P, de Giovanni R, Bernasconi A, Rossi V, Grasso R, Cozzolino A. Reverse shoulder arthroplasty for two-parts proximal humerus fractures with "shish-kebab" technique. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:457-463. [PMID: 39157254 PMCID: PMC11329053 DOI: 10.1016/j.xrrt.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Affiliation(s)
- Paolofrancesco Malfi
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy
| | - Roberto de Giovanni
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy
| | - Alessio Bernasconi
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy
| | - Valentina Rossi
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy
| | - Riccardo Grasso
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy
| | - Andrea Cozzolino
- Department of Public Health, Orthopedic Unit, "Federico II" University, Naples, Italy
| |
Collapse
|
3
|
Bellato E, Fava V, Arpaia A, Calò M, Marmotti A, Castoldi F. Reverse Shoulder Arthroplasty for Proximal Humeral Fractures: Is the Bigliani-Flatow Stem Suitable for Tuberosity Fixation and Healing? J Clin Med 2024; 13:3388. [PMID: 38929917 PMCID: PMC11203955 DOI: 10.3390/jcm13123388] [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: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
Background/Objectives: The aim of the study was to investigate the clinical, functional, and radiographic results of patients affected by three- or four-part proximal humeral fractures treated with reverse total shoulder arthroplasty, to investigate whether a prosthetic stem nonspecifically designed for fractures (i.e., the Bigliani-Flatow stem) promotes tuberosities' healing, and to evaluate the impact of tuberosity fixation and healing on the outcomes. Methods: Patients' data such as gender, age, side and dominancy, comorbidities, complications during or after surgery, and time lapse between trauma and surgery were prospectively collected. The type of fixation of the stem, the thickness and type of liner, and whether the tuberosities were fixed or not were also recorded. The Constant score weighted on the contralateral limb, QuickDASH, Oxford Shoulder Score, and Subjective Shoulder Value were collected. Tuberosities' healing was assessed with X-rays (anteroposterior, Grashey, and axillary views). Results: Overall, 34 patients were included, with an average follow-up of 42 months. Tuberosities were reinserted in 24 cases and their healing rate was 83%. The mean values were the following: a Constant score of 64, Oxford Shoulder Score of 39, Subjective Shoulder Value of 71, and QuickDASH score of 27. There were no significant differences in the scores or range of motion between patients with tuberosities healed, reabsorbed, or not reattached. There was a better external rotation in the group with healed tuberosities and a longer duration of surgery to reattach tuberosities. Conclusions: The treatment of proximal humerus fractures with the Bigliani-Flatow stem is associated with good clinical and functional results. The healing rate of the tuberosities was high and comparable, if not even better, than the mean rates reported for the stems dedicated to fractures of the proximal humerus and was, therefore, also appropriate for this indication.
Collapse
Affiliation(s)
- Enrico Bellato
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
- San Luigi Gonzaga Hospital, 10043 Orbassano, Italy
| | - Valeria Fava
- Orthopaedic and Trauma Unit, ASST-Sette Laghi, University of Insubria, 21100 Varese, Italy;
| | | | - Michel Calò
- San Luigi Gonzaga Hospital, 10043 Orbassano, Italy
| | | | - Filippo Castoldi
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
- San Luigi Gonzaga Hospital, 10043 Orbassano, Italy
| |
Collapse
|
4
|
Anazor FC, Relwani J, Dhinsa BS. Postoperative outcomes of third-generation shoulder hemiarthroplasties for three-and four-part proximal humeral fractures: A systematic review of published studies from 2012 to 2022. J Clin Orthop Trauma 2024; 53:102435. [PMID: 38983585 PMCID: PMC11228791 DOI: 10.1016/j.jcot.2024.102435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 05/19/2024] [Accepted: 06/05/2024] [Indexed: 07/11/2024] Open
Abstract
Background The aim of this study was to provide up-to-date evidence on the outcomes for hemiarthroplasties (HAs) that were performed using modern third-generation prostheses (post-2004) for isolated (excluding head-splits and fracture-dislocations) three-and four-part proximal humerus fractures (PHFs). Methods PubMed, Medline, Embase and the Cochrane register were searched from January 1, 2012, to November 15, 2022, conforming to the PRISMA guidelines. The outcome measures were the complication rates, revision rates, surgery-related postoperative mortality, post-operative clinical outcome scores and radiological outcomes. Results 432 hemiarthroplasties in 432 patients were performed across the 11 eligible studies (two prospective and 9 retrospective). Three studies compared HA versus reverse shoulder replacement (RSR); one study compared HA with locking plate fixation (LPF) and RSR; one study compared HA with LPF. 61.1 % and 19.4 % of hemiarthroplasties were performed using cemented and uncemented techniques respectively, while cementing data was ill-defined in 19.4 % of shoulders. The results for the outcome measures have been derived directly from the included studies and no statistical pooling was performed, due to heterogeneity in the different study designs and outcomes. Descriptive data synthesis from the included studies showed that third generation HAs have higher overall postoperative complication rates, with similar revision and mortality rates when compared to RSR and LPF for three-and four-part PHFs. RSR and LPF showed better statistically significant improvements than HA for the Constant-Murley score, Quick DASH, forward flexion and abduction. Mixed results were observed for the DASH score, ASES score and internal rotation ROM between RSR/LPF versus HA. Conclusion Low to moderate quality evidence from this review showed that even third-generation HA prostheses provided worse overall outcomes than RSR and LPF for three-and four-part PHFs.
Collapse
Affiliation(s)
- Fitzgerald Chukwuemeka Anazor
- Specialty Trainee Registrar (ST3), Trauma and Orthopaedic Surgery, East Midlands North (Nottingham) Orthopaedic Rotation, United Kingdom
| | - Jaikumar Relwani
- Consultant Orthopaedic and Trauma Surgeon, Department of Trauma and Orthopaedics, East Kent Hospitals University NHS Foundation Trust, TN 24 0LZ, United Kingdom
| | - Baljinder Singh Dhinsa
- Consultant Orthopaedic and Trauma Surgeon, Department of Trauma and Orthopaedics, East Kent Hospitals University NHS Foundation Trust, TN 24 0LZ, United Kingdom
- Professor of Regenerative Orthopaedics, Canterbury Christchurch University, United Kingdom
| |
Collapse
|
5
|
Sapienza M, Pavone V, Muscarà L, Panebianco P, Caldaci A, McCracken KL, Condorelli G, Caruso VF, Costa D, Di Giunta A, Testa G. Proximal humeral multiple fragment fractures in patients over 55: Comparison between Conservative treatment and Plate Fixation. Heliyon 2024; 10:e25898. [PMID: 38375257 PMCID: PMC10875435 DOI: 10.1016/j.heliyon.2024.e25898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/21/2024] Open
Abstract
Proximal humerus fractures account for about 5% of fragility fractures. These involve a significant burden of disability and a reduced quality of life. This study aims to compare functional results and surgical outcomes (closed reduction and internal fixation with the internal closure system of the proximal humerus) and the conservative management of proximal humerus fractures by 2-, 3-, 4-parts, in patients older than 55 years. Between January 2017 and April 2019, 65 patients with 2, 3 or 4-part fractures were retrospectively analyzed: 29 patients (5 males and 24 females) with an average age of 70.8 ± 9.9 years treated non-surgically (conservative group (CG)) and 36 patients (11 males and 25 females) with an average age of 66.2 ± 7.1 years treated surgically with plate fixation (operating group (OG)). Using different evaluation scores, we compared the OG and the CG. Through the DASH score we have seen how at 12 months there is a satisfactory result in patients with conservative treatment (p = 0.0019). Constant-Murley scale shows no difference between the two treatments (p = 0.2300). BARTHEL scale and SST score did not give statistically satisfactory results. Also, after one year of follow-up, patients treated with conservative therapy had a higher improvement in their Range of Motion (ROM) values than patients treated with surgical treatment. The results in terms of pain in NPRS at 3, 6, 12 months are better for conservative groups (p = 0,0000). Our findings suggest that conservative treatment in proximal humeral fractures, particularly in multi-fragmented fractures in patients over 55 years of age, designs an excellent alternative to the surgical option.
Collapse
Affiliation(s)
- Marco Sapienza
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Vito Pavone
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Liliana Muscarà
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Pierpaolo Panebianco
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Alessia Caldaci
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | | | - Giuseppe Condorelli
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Vincenzo Fabrizio Caruso
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Danilo Costa
- Orthopaedic Division of Policlinico “G.B. Morgagni”, 95125, Catania, Italy
| | - Angelo Di Giunta
- Orthopaedic Division of Policlinico “G.B. Morgagni”, 95125, Catania, Italy
| | - Gianluca Testa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| |
Collapse
|
6
|
Fidanza A, Caggiari G, Di Petrillo F, Fiori E, Momoli A, Logroscino G. Three-dimensional printed models can reduce costs and surgical time for complex proximal humeral fractures: preoperative planning, patient satisfaction, and improved resident skills. J Orthop Traumatol 2024; 25:11. [PMID: 38418743 PMCID: PMC10902230 DOI: 10.1186/s10195-024-00754-6] [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: 08/23/2023] [Accepted: 02/08/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Proximal humeral fractures (PHFs) are still controversial with regards to treatment and are difficult to classify. The study's objective is to show that preoperative planning performed while handling a three-dimensional (3D) printed anatomical model of the fracture can ensure a better understanding of trauma for both surgeons and patients. MATERIALS AND METHODS Twenty patients (group A, cases) with complex PHF were evaluated preoperatively by reproducing life-size, full-touch 3D anatomical models. Intraoperative blood loss, radiographic controls, duration of surgery, and clinical outcomes of patients in group A were compared with 20 patients (group B, controls) who underwent standard preoperative evaluation. Additionally, senior surgeons and residents, as well as group A patients, answered a questionnaire to evaluate innovative preoperative planning and patient compliance. Cost analysis was evaluated. RESULTS Intraoperative radiography controls and length of operation were significantly shorter in group A. There were no differences in clinical outcomes or blood loss. Patients claim a better understanding of the trauma suffered and the proposed treatment. Surgeons assert that the planning of the definitive operation with 3D models has had a good impact. The development of this tool has been well received by the residents. The surgery was reduced in length by 15%, resulting in savings of about EUR 400 for each intervention. CONCLUSIONS Fewer intraoperative radiography checks, shorter surgeries, and better patient compliance reduce radiation exposure for patients and healthcare staff, enhance surgical outcomes while reducing expenses, and lower the risk of medicolegal claims. LEVEL OF EVIDENCE Level I, prospective randomized case-control study.
Collapse
Affiliation(s)
- Andrea Fidanza
- Unit of Orthopaedics, Department of Life, Health and Environmental Sciences, University of L'Aquila (IT), Piazzale S.Tommasi, 1, 67100, L'Aquila, Italy.
| | - Gianfilippo Caggiari
- Orthopaedic and Traumatology Department, Sassari University Hospital, Sassari, Italy
| | - Francesco Di Petrillo
- Unit of Orthopaedics, Department of Life, Health and Environmental Sciences, University of L'Aquila (IT), Piazzale S.Tommasi, 1, 67100, L'Aquila, Italy
| | - Enrico Fiori
- Orthopaedic and Traumatology Department, Sassari University Hospital, Sassari, Italy
| | - Alberto Momoli
- Unit of Trauma and Orthopaedic, San Bortolo Hospital, Vicenza, Italy
| | - Giandomenico Logroscino
- Unit of Orthopaedics, Department of Life, Health and Environmental Sciences, University of L'Aquila (IT), Piazzale S.Tommasi, 1, 67100, L'Aquila, Italy
| |
Collapse
|
7
|
Mastrantonakis K, Karvountzis A, Yiannakopoulos CK, Kalinterakis G. Mechanisms of shoulder trauma: Current concepts. World J Orthop 2024; 15:11-21. [PMID: 38293258 PMCID: PMC10824064 DOI: 10.5312/wjo.v15.i1.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/08/2023] [Accepted: 12/29/2023] [Indexed: 01/16/2024] Open
Abstract
Acute traumatic injuries to the glenohumeral articulation are common. The types of injuries depend on age, muscle strength, bone density, and biomechanics of the traumatic event. Understanding the different mechanisms of trauma and how they affect the functional anatomical structures of the shoulder joint is crucial for the treatment of these lesions. Therefore, when clinicians have knowledge of these mechanisms they can accurately diagnose and treat shoulder pathology and predict distinct injury patterns. Here, we have described the fundamentals of the mechanisms of injury of the glenohumeral dislocation, dislocation with fracture of the humeral head, and the proximal humerus fracture. We have focused on common injury mechanisms and the correlation with radiological diagnostics. Radiological and laboratory findings of distinct types of injury were also discussed.
Collapse
Affiliation(s)
| | | | - Christos K Yiannakopoulos
- Department of Orthopaedic Surgery, National and Kapodistrian University of Athens, Athens 11527, Greece
| | | |
Collapse
|
8
|
Doursounian L, Gregory T, Miquel A. A prognostic classification of proximal humerus fractures: the cephalic extension staging. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:143-153. [PMID: 37378734 DOI: 10.1007/s00590-023-03626-7] [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: 04/12/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE Recent publications emphasized the role of dorsomedial metaphyseal extension of humeral head as predictor of ischemia after complex proximal humerus fractures (PHFs). We evaluated on preoperative 3D CT scan of PHFs the surface of this metaphyseal extension and its prognostic value on the occurrence of avascular necrosis (AVN). METHODS We followed a series of 25 fixations of complex PHF which had a preoperative 3D CT scan and measured the surface area of the posterior metaphyseal extension (PME) of the head. Using approximations, we calculated the ratio between the PME surface area (PMS) and the articular surface area of the head (HS). The PMS/HS ratio was analyzed against the risk of AVN. RESULTS The measurement of the PMS/HS ratio emphasizes the significance of PME. The incidence of AVN is correlated with the magnitude of PME. Therefore, we include the PME as a fifth element in the characterization of complex PHFs and we propose a 4-stage prognostic classification based on the number of extensions of the humeral head. The head may have 3 extensions: posteromedial (PME), lesser tuberosity (LTE) and greater tuberosity (GTE). The risk of AVN decreases with the number of extensions of the head. CONCLUSION Our study demonstrates a correlation between the occurrence of AVN and the size of PME in complex PHF cases. We propose a four-stage classification system to facilitate treatment decision-making between fixation and prosthesis.
Collapse
Affiliation(s)
- Levon Doursounian
- Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, 75012, Paris, France.
| | - Thomas Gregory
- Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, 93000, Bobigny, France
| | - Anne Miquel
- Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, 75012, Paris, France
| |
Collapse
|
9
|
Descalzo Godoy I, Velasco Alcalde P, Del Olmo Galeano A, Del Río Hortelano J, Martínez Velez D, Fernández González J. Quality of life, functional and radiological outcomes of treatment of three-part and four-part proximal humerus fractures with locking plates and comparison in young versus older than 70 years: a retrospective cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:415-423. [PMID: 37566140 DOI: 10.1007/s00590-023-03675-y] [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: 05/29/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE Verify if the use of locking plates in displaced three- and four-part proximal humerus fractures has meant an improvement even in patients over 70 years of age. MATERIAL AND METHODS We performed surgery with locking plate fixation in 56 consecutive patients with three- and four-part proximal humerus fractures according to Neer's classification between 1/1/15 and 12/31/20 at our Hospital. Patient satisfaction, quality of life, functionality and radiological variables, as well as the comparison between patients older and younger than 70 years were the main outcomes. Likewise, factors and complications that may have influenced these variables were analyzed as secondary outcomes. The analysis of all these variables was performed after a minimum follow-up time of 24 months after surgery. RESULTS 51 patients (92%) ended up satisfied or very satisfied according to the SF-36 test and with no disability or mild disability according to the DASH Score questionnaire. 46 patients (82%) obtained a satisfactory or excellent result according to the Neer scale modified by Cofield and 38 (68%) a good or excellent function according to the Constant Murley questionnaire. In 47 cases (84%) good radiological alignment was observed. Complications occurred in 20 patients (36%). The complications and the results of the SF-36, DASH Score, Neer scale modified by Cofield and Constant Murley tests depended on the radiological alignment (p = 0.009, p = 0.006, p = 0.025, p = 0.0008 and p = 0.0004). There were 37 patients younger than 70 years and 19 older than 70 years with no statistically significant differences when comparing the two groups. CONCLUSIONS This study demonstrates that satisfactory results can be obtained with osteosynthesis with locking plates in displaced proximal humerus fractures even in patients older than 70 years of age. LEVEL OF EVIDENCE III Retrospective Cohort, Treatment Study.
Collapse
Affiliation(s)
- Ignacio Descalzo Godoy
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, C/Diego de León 62, 28006, Madrid, Spain.
| | - Paula Velasco Alcalde
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, C/Diego de León 62, 28006, Madrid, Spain
| | - Alberto Del Olmo Galeano
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, C/Diego de León 62, 28006, Madrid, Spain
| | - Julián Del Río Hortelano
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, C/Diego de León 62, 28006, Madrid, Spain
| | - David Martínez Velez
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, C/Diego de León 62, 28006, Madrid, Spain
| | - Julián Fernández González
- Department of Orthopaedic Surgery and Traumatology, University Hospital La Princesa, Universidad Autónoma de Madrid, C/Diego de León 62, 28006, Madrid, Spain
| |
Collapse
|
10
|
Misir A, Oguzkaya S, Kizkapan TB, Eken G, Canbaz SB. Fracture line and comminution zone characteristics, and rotator cuff footprint involvement in OTA/AO 11C3-type proximal humeral fractures: complex proximal humerus fracture map. Arch Orthop Trauma Surg 2023; 143:6219-6227. [PMID: 37378893 DOI: 10.1007/s00402-023-04962-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/20/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE To identify fracture characteristics and zones of comminution as well as the relationship with anatomic landmarks and rotator cuff footprint involvement in OTA/AO 11C3-type proximal humerus fractures. METHODS Computed tomography images of 201 OTA/AO 11C3 fractures were included. Fracture lines were superimposed to a 3D proximal humerus template, created from a healthy right humerus, after fracture fragment reduction on 3D reconstruction images. Rotator cuff tendon footprints were marked on the template. Lateral, anterior, posterior, medial, and superior views were captured for the interpretation of fracture line and comminution zone distribution as well as to define the relationship with anatomic landmarks and rotator cuff tendon footprints. RESULTS A total of 106 females and 95 males (mean age = 57.5 ± 17.7 [range 18-101] years) with 103 C3.1-, 45 C3.2-, and 53 C3.3-type fractures were included. On the lateral, medial, and superior humeral surfaces, fracture lines and comminution zones were distributed differently in 3 groups. Tuberculum minus and medial calcar region were significantly less severely affected in C3.1 and C3.2 fractures than C3.3 fractures. The supraspinatus footprint was the most severely affected rotator cuff footprint area. CONCLUSIONS Specifically defining the certain differences for repeatable fracture patterns and comminution zones in OTA/AO 11C3-type fractures and the relationship between the rotator cuff footprint and the joint capsule may contribute to the decision-making process of surgeons.
Collapse
Affiliation(s)
- Abdulhamit Misir
- Department of Orthopaedics and Traumatology, Private Safa Hospital, Zafer Mah. Ahmet Yesevi Cad. Gümüş Sk. No: 11A, Bahcelievler, 34194, Istanbul, Turkey.
| | - Sinan Oguzkaya
- Department of Orthopaedics and Traumatology, Bursa Cekirge State Hospital, Bursa, Turkey
| | - Turan Bilge Kizkapan
- Department of Orthopaedics and Traumatology, Basaksehir Pine and Sakura City Hospital, Istanbul, Turkey
| | - Gökay Eken
- Department of Orthopaedics and Traumatology, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Sebati Baser Canbaz
- Department of Orthopaedics and Traumatology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| |
Collapse
|
11
|
Lu KY, Tai TH, Liu YH, Chiang CJ, Loh EW, Wong CC, Wu JJ. Post-Operative Greater Tuberosity Resorption or Malreduction Is Associated with Poor Prognostic Outcomes in Patients with Proximal Humeral Fractures Treated Operatively-A Single-Center Retrospective Cohort Study. Diagnostics (Basel) 2023; 13:2789. [PMID: 37685327 PMCID: PMC10486750 DOI: 10.3390/diagnostics13172789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
(1) Background: Proximal humerus fractures can be a debilitating condition if not properly treated. These fracture patterns are varied and differ in every patient. Functional outcomes may be determined by the integrity of the shoulder girdle involving the rotator cuff insertion. The post-operative resorption or malreduction of the greater tuberosity (GT) is an important factor contributing to the poor functional outcome of a patient. Thus, we intend to evaluate the cause-and-effect relationship between GT complications and clinical prognosis and outcomes. (2) Methods: A single-center retrospective comparative study was performed to evaluate the functional outcomes of patients undergoing operative fixation for this injury. A total of 387 consecutive cases treated operatively from 2019-2021 were included for analysis. (3) Results: 94 cases fulfilled our criteria for analysis. A matched-group comparison of 19 patients each was performed to compare demographics, post-operative fracture characteristics and clinical outcomes. (4) Conclusions: The resorption or malreduction of the GT contributes greatly to the prognostic outcome in patients treated with open reduction and internal fixation (ORIF) surgery. In our demographic study, obesity is another contributing factor affecting the parameters of post-operative reduction in proximal humerus fractures. Appropriate surgical planning and post-operative multidisciplinary care must be taken into consideration to attain a satisfactory prognostic outcome.
Collapse
Affiliation(s)
- Kuan-Yu Lu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
| | - Ting-Han Tai
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
| | - Yu-Hsin Liu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
| | - Chang-Jung Chiang
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - El-Wui Loh
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan;
- Center for Evidence-Based Health Care, Department of Medical Research, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei 11031, Taiwan
- Department of Medical Imaging, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
| | - Chin-Chean Wong
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- International PhD Program for Cell Therapy and Regenerative Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei 11031, Taiwan
| | - Jeffrey J. Wu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-Y.L.); (T.-H.T.); (Y.-H.L.); (C.-J.C.)
| |
Collapse
|
12
|
Shahien A, Likine EF, Soles G, Samborski S, Mehta SK, Ryan SP, Leroy TE, Mullis B, Spitler CA, Tornetta P. Not All Proximal Humerus Fractures Do Well Without Surgery: Anterior Translation Predicts the Need for Surgery. J Orthop Trauma 2023; 37:366-369. [PMID: 37074809 DOI: 10.1097/bot.0000000000002585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 04/20/2023]
Abstract
OBJECTIVES To evaluate the effect of translation on a large series of low-energy proximal humerus fractures initially treated nonoperatively. DESIGN Retrospective multicenter analysis. SETTING Five level-one trauma centers. PATIENTS/PARTICIPANTS Two hundred ten patients (152 F; 58 M), average age 64, with 112 left- and 98 right-sided low-energy proximal humerus fractures (OTA/AO 11-A-C). INTERVENTION All patients were initially treated nonoperatively and were followed for an average of 231 days. Radiographic translation in the sagittal and coronal planes was measured. Patients with anterior translation were compared with those with posterior or no translation. Patients with ≥80% anterior humeral translation were compared with those with <80% anterior translation, including those with no or posterior translation. MAIN OUTCOMES The primary outcome was failure of nonoperative treatment resulting in surgery and the secondary outcome was symptomatic malunion. RESULTS Nine patients (4%) had surgery, 8 for nonunion and 1 for malunion. All 9 patients (100%) had anterior translation. Anterior translation compared with posterior or no sagittal plane translation was associated with failure of nonoperative management requiring surgery ( P = 0.012). In addition, of those with anterior translation, having ≥80% anterior translation compared with <80% was also associated with surgery ( P = 0.001). Finally, 26 patients were diagnosed with symptomatic malunion, of whom translation was anterior in 24 and posterior in 2 ( P = 0.0001). CONCLUSIONS In a multicenter series of proximal humerus fractures, anterior translation of >80% was associated with failure of nonoperative care resulting in nonunion, symptomatic malunion, and potential surgery. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Amir Shahien
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA
| | - Elive F Likine
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Gillian Soles
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, MN
| | - Steven Samborski
- Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, MN
| | - Siddhant K Mehta
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, MS; and
| | - Scott Patrick Ryan
- Department of Orthopaedic Surgery, Tufts University Medical Center, Boston, MA
| | - Taryn E Leroy
- Department of Orthopaedic Surgery, Tufts University Medical Center, Boston, MA
| | - Brian Mullis
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, MS; and
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA
| |
Collapse
|
13
|
Baker HP, Gutbrod J, Cahill M, Shi L. Optimal Treatment of Proximal Humeral Fractures in the Elderly: Risks and Management Challenges. Orthop Res Rev 2023; 15:129-137. [PMID: 37396822 PMCID: PMC10312335 DOI: 10.2147/orr.s340536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/20/2023] [Indexed: 07/04/2023] Open
Abstract
Proximal humeral fractures (PHFs) are a common type of fracture, particularly in older adults, accounting for approximately 5-6% of all fractures. This article provides a comprehensive review of PHFs, focusing on epidemiology, injury mechanism, clinical and radiographic assessment, classification systems, and treatment options. The incidence of PHFs varies across regions, with rates ranging from 45.7 to 60.1 per 100,000 person-years. Females are more susceptible to PHFs than males, and the incidence is highest in women over the age of 85. The injury mechanism of PHFs is typically bimodal, with high-energy injuries predominant in younger individuals and low-energy injuries in the elderly. Clinical assessment of PHFs involves obtaining a thorough history, physical examination, and evaluation of associated injuries, particularly neurovascular injuries. Radiographic imaging helps assess fracture displacement and plan for treatment. The Neer classification system is the most commonly used classification for PHFs, although other systems, such as AO/OTA, Codman-Hertel, and Resch classifications, also exist. The choice of treatment depends on factors such as patient age, activity level, fracture pattern, and surgeon expertise. Nonoperative management is typically preferred for elderly patients with minimal displacement, while operative fixation is considered for more complex fractures. Nonoperative treatment involves sling immobilization followed by physiotherapy, with good outcomes reported for certain fracture patterns. Operative management options include closed reduction and percutaneous pinning (CRPP), open reduction and internal fixation (ORIF), or arthroplasty. CRPP is suitable for specific fracture patterns, but the quality of reduction is crucial for favorable outcomes. ORIF is used when CRPP is not feasible, and various surgical approaches are available, each with its advantages and potential complications. PHFs are a significant clinical challenge due to their prevalence and complexity. Treatment decisions should be patient centered based on patient factors and fracture severity.
Collapse
Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Joseph Gutbrod
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Michael Cahill
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Lewis Shi
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| |
Collapse
|
14
|
Klute L, Henssler L, Pfeifer C, Berner A, Schneider T, Kobeck M, Alt V, Kerschbaum M. Predictors of Mortality in Head-Preserving Treatment for Dislocated Proximal Humerus Fractures: A Retrospective Analysis of 522 Cases with a Minimum Follow-Up of 5 Years. J Clin Med 2023; 12:3977. [PMID: 37373670 DOI: 10.3390/jcm12123977] [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: 04/21/2023] [Revised: 06/04/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
PURPOSE Proximal humerus fractures (PHFs) are among the most common fractures in elderly patients, but there is still inadequate knowledge about mortality risk factors after such injuries. In order to provide the best possible therapy, individual risk factors have to be considered and evaluated thoroughly. There is still controversy regarding treatment decisions for proximal humerus fractures, particularly for the elderly. METHODS In this study, patient data from 522 patients with proximal humerus fractures were obtained from 2004 to 2014 at a Level 1 trauma centre. After a minimum follow-up of 5 years, the mortality rate was assessed, and independent risk factors were evaluated. RESULTS A total of 383 patients (out of 522) were included in this study. For our patient collective, the mean follow-up was at 10.5 ± 3.2 years. The overall mortality rate was 43.8% in our respondent group and was not significantly impacted by concomitant injuries. The binary logistic regression model showed an increased risk for mortality by 10% per life year, a 3.9 times higher mortality risk for men and a 3.4 times higher risk for conservative treatment. The most powerful predictor was a Charlson Comorbidity Index of more than 2, with a 20 times higher mortality risk. CONCLUSIONS Outstanding independent predictors of death in our patient collective were serious comorbidities, male patients, and conservative treatment. This patient-related information should influence the process of decision making for the individual treatment of patients with PHFs.
Collapse
Affiliation(s)
- Lisa Klute
- Clinic of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Leopold Henssler
- Clinic of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Christian Pfeifer
- Clinic of Trauma and Hand Surgery, Altötting, Vinzenz-von-Paul-Straße 10, 84503 Altötting, Germany
| | - Arne Berner
- Clinic of Trauma Surgery, Bad Neustadt, Von-Guttenberg-Straße 11, 97616 Bad Neustadt an der Saale, Germany
| | - Teresa Schneider
- Clinic of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Miriam Kobeck
- Clinic of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Volker Alt
- Clinic of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Maximilian Kerschbaum
- Clinic of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| |
Collapse
|
15
|
The Role of Intramedullary Nailing for Proximal Humerus Fractures: What Works and What Does Not. Curr Rev Musculoskelet Med 2023; 16:85-94. [PMID: 36626085 PMCID: PMC9889584 DOI: 10.1007/s12178-022-09816-w] [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] [Accepted: 12/06/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW The evaluation of proximal humerus fractures (PHFs) should be aimed to answer the following four questions: (1) does the fracture need surgery in each particular patient? (2) if surgery is recommended, is it better to proceed with internal fixation or shoulder arthroplasty, (3) if internal fixation is recommended, what is the ideal fixation device strategy, and (4) how can outcomes be optimized? This review article tries to answer these questions and provides some clarity regarding what works and what does not in PHFs treated with intramedullary nailing. RECENT FINDINGS According to published articles on the treatment of PHFs with intramedullary nails, it is difficult to draw conclusions about outcomes and complications due to great variation in age, type of fracture, and nail designs included in the studies. However, the literature seems to support the use of modern nail designs for PHFs, especially in fractures of the surgical neck as well as varus posteromedial and valgus fractures with no tuberosity involvement. Although the results of IMN in PHF seem to be better in two-part fractures, in more complex fractures, the quality of the reduction achieved seems to influence functional outcomes. Tuberosity malreduction leads to poor clinical outcomes, high rate of complications, and an increased risk of avascular necrosis. Malreduction of the humeral head increases the risk of postoperative loss of reduction, especially for varus posteromedial impacted fractures. A medial nail entry point decreases the risk of postoperative varus malunion, preserves the rotator cuff tendon, and avoids iatrogenic fractures of the GT. To decrease the risk of postoperative stiffness, fracture fixation should be stable enough to allow early mobilization.
Collapse
|
16
|
Scaglione M, Casella F, Ipponi E, Agretti F, Polloni S, Giuntoli M, Marchetti S. Multifocal Humeral Fractures: Clinical Results, Functional Outcomes and Flowchart of Surgical Treatment. Strategies Trauma Limb Reconstr 2022; 17:81-87. [PMID: 35990178 PMCID: PMC9357792 DOI: 10.5005/jp-journals-10080-1559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim and objective Materials and methods Results Conclusion Clinical significance How to cite this article
Collapse
Affiliation(s)
| | - Francesco Casella
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - Edoardo Ipponi
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
- Edoardo Ipponi, Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy, Phone: +39 050993415, e-mail:
| | - Federico Agretti
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - Simone Polloni
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - Michele Giuntoli
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| | - Stefano Marchetti
- Department of Orthopedics and Trauma Surgery, University of Pisa, Pisa, Italy
| |
Collapse
|
17
|
3D-Printed Models versus CT Scan and X-Rays Imaging in the Diagnostic Evaluation of Proximal Humerus Fractures: A Triple-Blind Interobserver Reliability Comparison Study. Adv Orthop 2022; 2022:5863813. [PMID: 35733650 PMCID: PMC9208975 DOI: 10.1155/2022/5863813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/04/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022] Open
Abstract
Background Proximal humerus fractures (PHFs) are one of the most frequent fractures in the elderly and are the third most fractures after those of the hip and wrist. PHFs are assessed clinically through conventionally standard imaging (X-ray and computed tomography (CT) scans). The present study aims to conduct the diagnostic evaluation and therapeutic efficacy of the 3D-printed models (3DPMs) for the PHFs, compared with the standard imaging. Objectives In terms of fracture classification and surgical indication, PHFs have poor interobserver agreement between orthopedic surgeons using traditional imaging such as X-rays and CT scan. Our objective is to compare interobserver reliability in diagnostic evaluation of PHFs using 3DPMs compared to traditional imaging. Methods The inclusion criteria were elders aged >65 years, fracture classification AO/OTA 11 B and 11 C, and no pathological fractures or polytrauma. In addition, 9 PHFs were assessed by 6 evaluators through a questionnaire and double-blinded administered for each imaging (X-ray and CT scan) and 3DPMs for each fracture. The questionnaire for each method regarded Neer classification, Hertel classification, treatment indication (IT), and surgical technique (ST). Interobserver reliability was calculated through the intraclass correlation coefficient (ICC). Results Nine patients with PHF were included in the study (66% female). The Neer and Hertel classifications between imaging types had similar ICC values between raters with no statistical differences. IT reliability using CT scan and 3DPMs (ICC = 1; (p=0.116)) assessed better agreement compared with X-rays IT. The ST reliability using 3DPMs (ICC = 0.755; p=0.002) was statistically superior to traditional imaging (ST-RX ICC = -0.004 (p=0.454); ST-CT ICC = 0.429 (p=0.116)). Conclusion Classification systems like Neer and Hertel offer poor reliability between operators. The 3DPMs for evaluating diagnostics are comparable to CT images but superior to the surgical technique agreement. The application of 3DPMs is effective for preoperative fracture planning and the modeling of patient-specific hardware.
Collapse
|
18
|
Mouraria GG, Cunha RMRD, Coelho SDP, Brigatto RM, Cruz MA, Etchebehere M. Avaliação funcional do ombro após osteossíntese da fratura da tuberosidade maior: Há influência da luxação glenoumeral? Rev Bras Ortop 2022; 58:265-270. [DOI: 10.1055/s-0042-1749416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 04/05/2022] [Indexed: 10/18/2022] Open
Abstract
Resumo
Objetivo Avaliar os resultados funcional e radiográfico pós-operatórios do ombro, em pacientes submetidos a sutura transóssea de fratura da tuberosidade maior (FTM) por acesso anterolateral, e a influência da luxação glenoumeral nesses resultados.
Métodos Realizou-se estudo retrospectivo e avaliação funcional (pela escala de Constant-Murley). Calculou-se a distância entre a tuberosidade maior e a superfície articular do úmero proximal (por meio de radiografia em incidência anteroposterior verdadeira) após a consolidação. Usou-se o teste Exato de Fisher para as variáveis independentes categóricas, e os testes tde Student ou de Mann-Whitney para as não categóricas.
Resultados Ao todo, 26 pacientes preencheram os critérios de inclusão. A associação de luxação glenoumeral com FTM foi observada em 38% da amostra. A média da pontuação na escala de Constant-Murley foi de 82,5 + 8,02. A presença de luxação associada não alterou o resultado funcional. A distância média da consolidação da tuberosidade maior do úmero em relação à superfície articular da cabeça umeral foi de 9 + 4,3 mm abaixo da linha articular da cabeça umeral. Pacientes com luxação associada evoluíram com redução menor, mas isso não influenciou na pontuação na escala de Constant-Murley.
Conclusão As FTMs submetidas ao tratamento cirúrgico com sutura transóssea evoluíram com bom resultado funcional. A presença de luxação dificultou a redução anatômica da tuberosidade maior. Entretanto, isso não influenciou na pontuação na escala de Constant-Murley.
Collapse
Affiliation(s)
- Guilherme Grisi Mouraria
- Grupo de Ombro e Cotovelo, Departamento de Ortopedia, Reumatologia e Traumatologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | - Renato Mason Rodrigues da Cunha
- Grupo de Ombro e Cotovelo, Departamento de Ortopedia, Reumatologia e Traumatologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | - Sérgio de Paula Coelho
- Grupo de Ombro e Cotovelo, Departamento de Ortopedia, Reumatologia e Traumatologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | - Rafael Mulati Brigatto
- Hospital Estadual Sumaré, Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | - Márcio Alves Cruz
- Grupo de Ombro e Cotovelo, Departamento de Ortopedia, Reumatologia e Traumatologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | - Maurício Etchebehere
- Grupo de Ombro e Cotovelo, Departamento de Ortopedia, Reumatologia e Traumatologia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| |
Collapse
|
19
|
Thelen S, Grassmann JP, Schneider M, Jaekel C, Meier DM, Betsch M, Hakimi M, Wild M. The influence of fracture severity on postoperative outcome and quality of life after locking plate fixation of proximal humeral fractures. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2022; 11:Doc03. [PMID: 35692287 PMCID: PMC9178521 DOI: 10.3205/iprs000164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective: For proximal humeral fractures open reduction und internal fixation (ORIF) with a fixed-angle plate is considered the gold standard for surgical management. However, it can lead to poor functional outcomes and is associated with postoperative complications. Therefore, the purpose of this study was to investigate the influence of fracture severity by applying a new classification (simple versus complex) on clinical outcome and quality of life after ORIF of proximal humerus fractures. Methods: We conducted a prospective clinical study with an average follow-up period of 12 (SD 1) months after ORIF of proximal humeral fractures with a fixed-angle plate. The postoperative function and quality of life was measured using the Oxford Shoulder Score (OSS) and the Constant Score. Data was tested for statistical significance with the Mann-Whitney test and Fisher's exact test. Based on the findings of this study a simplified fracture classification system has been developed. Results: Seventy-two patients with a mean age of 65 years (SD 12) with 69% being males were included. According to the Neer classification, 35% (n=25) non-displaced (“one-part fractures”), 19% (n=14) two-part fractures, 15% (n=11) three-part fractures and 31% (n=22) four-part fractures were detected. Regarding the AO/OTA classification, 18% (n=13) were type A fractures, 43% (n=31) type B and 39% (n=28) type C fractures. From these criteria we derived our own fracture classification, including 50% (n=36) simple and 50% (n=36) severe fractures. Patients with simple fracture types achieved significantly higher total values in the Constant Score as well as the OSS (p=0.008; p=0.013). The cumulative incidence of complications in the entire patient collective was 14% (n=10) with humeral head necrosis (n=5) occurring only in the severe fracture group. Conclusions: The postoperative clinical outcome as well as the incidence of humeral head necrosis after ORIF of proximal humeral fractures with a fixed-angle plate correlates with the fracture type and severity. The newly derived fracture classification into simple and severe fractures is suitable with regard to clinical results and complication rate. However, prospective studies comparing ORIF vs. conservative treatment of proximal humeral fractures of the same severity are required. Level of Evidence: III
Collapse
Affiliation(s)
- Simon Thelen
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Jan P. Grassmann
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany,*To whom correspondence should be addressed: Jan P. Grassmann, Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany, Phone: +49 (0) 211-81-04400, Fax: +49 (0) 211-81-04902, E-mail:
| | - Madeleine Schneider
- Department of Orthopedics, Trauma and Hand Surgery, Klinikum Darmstadt, Darmstadt, Germany
| | - Carina Jaekel
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Dana M. Meier
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Marcel Betsch
- Department of Orthopedics and Trauma Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Mohssen Hakimi
- Vivantes Klinikum Am Urban, Department of Orthopedic, Trauma and Hand Surgery, Berlin, Germany
| | - Michael Wild
- Department of Orthopedics, Trauma and Hand Surgery, Klinikum Darmstadt, Darmstadt, Germany
| |
Collapse
|
20
|
Nicolaci G, Maes V, Lollino N, Putzeys G. How to treat proximal and middle one-third humeral shaft fractures: the role of helical plates. Musculoskelet Surg 2022; 107:231-238. [PMID: 35579822 DOI: 10.1007/s12306-022-00748-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/11/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the outcomes of patients affected by proximal and middle one-third humeral shaft fractures treated with humeral helical plates. MATERIAL AND METHODS From October 2016 to June 2020, twenty-four (twenty women, four men) underwent humeral reduction and fixation with humeral helical plates (A.L.P.S.® Proximal Humeral Plating System, Zimmer Biomet) that preserve deltoid muscle insertion and reduce the risk of iatrogenic radial nerve injury. At one and six months after surgery, standard antero-posterior and lateral radiographs were obtained, and at last follow-up (eighteen months on average), clinical evaluation was performed through range of motion assessment, Constant score and DASH score questionnaires. Only descriptive statistical analysis was conducted. RESULTS At six months, all fractures have healed. At last follow-up (average eighteen months, 13-28) mean Constant score was 71 (range 33-96), mean Dash score was 19.2 (range 1.7-63). The average range of motion was calculated as follows: flexion 137.8° (range 90-180); abduction 125.8° (range 85-180°); external rotation 55° (range 20-80°), internal rotation at L3 (range between scapulae-trochanter). Three patients experienced temporary radial nerve palsy from injury, while in one case, a temporary iatrogenic palsy occurred. CONCLUSIONS In our opinion, the helical plate may be an effective surgical tool for management of proximal and middle one-third diaphyseal humeral fractures. The humeral helical plate allows stable fixation avoiding the deltoid tuberosity proximally and radial nerve distally, thus increasing the possibility of rapid functional recovery after surgery.
Collapse
Affiliation(s)
- G Nicolaci
- Università degli Studi di Torino, Via Gianfranco Zuretti 29, 10126, Turin, Italy.
| | - V Maes
- Department of Orthopaedic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - N Lollino
- Ospedale Civile E. Agnelli, SC Ortopedia e Traumatologia, Via Brigata Cagliari 39, 10064, Pinerolo, Italy
| | - G Putzeys
- Department of Orthopaedic Surgery, AZ Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
| |
Collapse
|
21
|
Dipnall JF, Lu J, Gabbe BJ, Cosic F, Edwards E, Page R, Du L. Comparison of state-of-the-art machine and deep learning algorithms to classify proximal humeral fractures using radiology text. Eur J Radiol 2022; 153:110366. [DOI: 10.1016/j.ejrad.2022.110366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/08/2022] [Accepted: 05/16/2022] [Indexed: 12/01/2022]
|
22
|
Outcome of geriatric proximal humeral fractures: a comparison between reverse shoulder arthroplasty versus open reduction and internal fixation. OTA Int 2022; 5:e188. [PMID: 35949265 PMCID: PMC9359012 DOI: 10.1097/oi9.0000000000000188] [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: 11/09/2021] [Accepted: 12/18/2021] [Indexed: 11/25/2022]
Abstract
Objectives: In view of the increased attention to reverse shoulder arthroplasty (rTSA) as a treatment for complex proximal humeral fractures in the elderly, the present study analyzes in-hospital complications and the postoperative management of rTSA versus open reduction and internal fixation (ORIF). Methods: We retrospectively reviewed patients hospitalized from 2016 to 2018 for proximal humeral fractures (ICD-9 codes: S42.21), III- and IV-part, who underwent an ORIF with locking plates, rTSA or nonoperative treatment. In-hospital complications and postoperative management in both groups were included in the analysis. Results: We included n 190 patients (ORIF 90, rTSA 71, nonoperative 29), more likely to be female (82.1% vs 17.9%; P < .01) with an average age of 82years (min. 72, max. 99; SD 6.4). The ORIF and the rTSA groups showed comparable complication rates (15.6% vs 15%, P = .87) but with a significantly shorter hospital stay (8.6 vs 11.5days; P = .01) and shorter duration of surgery (72.9 vs 87.2 minutes; P = .01) in the ORIF group. Significantly more patients after ORIF achieved an independent life postoperatively (53.3% vs 40.8%; P = .013). Conclusions: In this retrospective analysis, ORIF is related to a shorter duration of surgery, a shorter hospital stay and a higher likelihood of independence. Despite the popularity of the rTSA, ORIF remains a reliable treatment option for proximal humeral fractures in the elderly. Level of evidence: III
Collapse
|
23
|
Foruria AM, Martinez-Catalan N, Pardos B, Larson D, Barlow J, Sanchez-Sotelo J. Classification of Proximal Humerus Fractures According to Pattern Recognition is Associated with High Intraobserver and Interobserver Agreement. JSES Int 2022; 6:563-568. [PMID: 35813132 PMCID: PMC9264021 DOI: 10.1016/j.jseint.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The Mayo-Fundación Jiménez Díaz (FJD) classification for proximal humerus fractures aims to identify specific fracture patterns and apply displacement criteria to each pattern. The classification includes 7 common fracture patterns: isolated fractures of the greater or lesser tuberosity, fractures of the surgical neck, impacted fractures involving head rotation in a varus and posteromedial direction or in valgus, and fractures where the humeral head is dislocated (head dislocation), split (head splitting), or depressed (head impaction). The purpose of this study was to evaluate the intraobserver and interobserver agreement of the Mayo-FJD classification system using plain radiographs (xR) and computed tomography (CT). Methods Three fellowship-trained shoulder surgeons blindly and independently evaluated the xR and CT of 103 consecutive proximal humerus fractures treated at a Level I trauma center. Each surgeon classified all fractures according to the Mayo-FJD classification system on 4 separate sessions at least 6 weeks apart. K values were calculated for intraobserver and interobserver reliability. Results The average intraobserver agreement was 0.9 (almost perfect) for xR and 0.9 (almost perfect) for CT scans. The average interobserver agreement was 0.69 (substantial) for xR and 0.81 (almost perfect) for CT scans at the first round, and 0.66 (substantial) for xR and 0.75 (substantial) for CT scans at the second round. Conclusion The pattern-based Mayo-FJD classification scheme for proximal humerus fractures was associated with adequate intraobserver and interobserver agreement using both xR and CT scan. Interobserver agreement was best when fractures were classified using CT scans.
Collapse
Affiliation(s)
- Antonio M. Foruria
- Upper Extremity Reconstruction Unit, Orthopedic Surgery Department. Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Natalia Martinez-Catalan
- Upper Extremity Reconstruction Unit, Orthopedic Surgery Department. Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Belen Pardos
- Upper Extremity Reconstruction Unit, Orthopedic Surgery Department. Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Dirk Larson
- Department of Statistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan Barlow
- Upper Extremity Reconstruction division. Orthopedic Surgery Department, Mayo Clinic, Rochester, Minnesota, USA
| | - Joaquín Sanchez-Sotelo
- Upper Extremity Reconstruction division. Orthopedic Surgery Department, Mayo Clinic, Rochester, Minnesota, USA
- Corresponding author: Joaquín Sanchez-Sotelo, MD, PhD, Gonda 14, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| |
Collapse
|
24
|
Mohanty K, Agarwal R. Trauma. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1007/978-3-030-78529-1_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
25
|
Müller M, Greve F, Crönlein M, Zyskowski M, Pesch S, Biberthaler P, Kirchhoff C, Beirer M. Reconstruction or replacement? A challenging question in surgical treatment of complex humeral head fractures in the elderly. Arch Orthop Trauma Surg 2022; 142:3247-3254. [PMID: 34432097 PMCID: PMC9522728 DOI: 10.1007/s00402-021-04124-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/12/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Surgical treatment of complex humeral head fractures in the elderly is challenging due to osteoporotic bone, comorbidities and reduced compliance. The treatment strategy (reconstruction versus replacement) should allow for a functional aftercare and result in a high patient satisfaction. Major complications leading to surgical revision are crucial and should be avoided. The purpose of this study was to analyse the major complication rate leading to surgical revision and the patient-based outcome in complex humeral head fractures of the elderly population treated either using locking plate fixation (LCP) or reversed total shoulder arthroplasty (rTSA). MATERIALS AND METHODS All patients older than 65 years surgically treated due to a four-part fracture of the proximal humerus between 2003 and 2015 were enrolled in our retrospective study. Major complications and revision rates were recorded and functional outcome was assessed using the Munich Shoulder Questionnaire (MSQ) allowing for qualitative self-assessment of the Shoulder Pain and Disability Index (SPADI), of the Disability of the Arm, Shoulder and Hand (DASH) score and of the Constant Score. RESULTS A cohort of 103 patients with a mean age of 73.4 ± 6.2 years suffering from four-part fractures of the humeral head were enrolled. 63 patients were treated using the LCP fixation compared to 40 rTSAs. There were no significant differences in the patient-reported functional outcome. The revision rate was significantly higher in the LCP group (10/63; 15.9%) compared to the rTSA group (1/40; 2.5%). Reasons for revision were avascular head necrosis, cut-out of screws, secondary dislocation of the greater tuberosity and hypersensitivity to metal. CONCLUSIONS Reversed total shoulder arthroplasty and locking plate fixation are both established surgical procedures for the management of complex proximal humerus fractures in the elderly leading to similar functional results. However the revision rate in the rTSA group was significantly lower. Primary rTSA should, therefore, be favoured in multimorbid elderly patients with an increased complication risk to avoid repeated anaesthesia.
Collapse
Affiliation(s)
- M. Müller
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - F. Greve
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - M. Crönlein
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - M. Zyskowski
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - S. Pesch
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - P. Biberthaler
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - C. Kirchhoff
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - M. Beirer
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| |
Collapse
|
26
|
Bao MH, DeAngelis JP, Wu JS. Imaging of traumatic shoulder injuries – Understanding the surgeon’s perspective. Eur J Radiol Open 2022; 9:100411. [PMID: 35265737 PMCID: PMC8899241 DOI: 10.1016/j.ejro.2022.100411] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/13/2022] [Accepted: 02/23/2022] [Indexed: 12/18/2022] Open
Abstract
Imaging plays a key role in the assessment and management of traumatic shoulder injuries, and it is important to understand how the imaging details help guide orthopedic surgeons in determining the role for surgical treatment. Imaging is also crucial in preoperative planning, the longitudinal assessment after surgery and the identification of complications after treatment. This review discusses the mechanisms of injury, key imaging findings, therapeutic options and associated complications for the most common shoulder injuries, tailored to the orthopedic surgeon’s perspective.
Collapse
|
27
|
The impact of full-thickness rotator cuff tear on shoulder function and quality of life in patients who sustain a proximal humerus fracture—a prospective cohort study. JSES Int 2021; 6:268-274. [PMID: 35252925 PMCID: PMC8888175 DOI: 10.1016/j.jseint.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
28
|
Martínez-Sola R, León-Muñoz VJ, Najem-Rizk AN, Soler-Vasco B, Arrieta-Martínez CJ, López-Sorroche E, Cárdenas-Grande E, Salmerón-Vélez G, Ruiz-Molina JÁ, Martínez-Martínez F, Santonja-Medina F. 'Absolute' inter-observer classifications agreement for proximal humeral fractures with a single shoulder anteroposterior X-ray. J Orthop Surg (Hong Kong) 2021; 29:23094990211010520. [PMID: 33896261 DOI: 10.1177/23094990211010520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Several studies have been carried out, and there is no classification for proximal humeral fractures (PHF) exempted from variability in interpretation and with questioned reliability. In the present study, we investigated the 'absolute diagnostic reliability' of the most currently used classifications for PHFs on a single anterior-posterior X-ray shoulder image. METHODS Six orthopaedic surgeons, with varying levels of experience in shoulder pathology, evaluated radiographs from 30 proximal humeral fractures, according to the 'absolute reliability' criteria. Each of the observers rated each fracture according to Neer, Müller/AO and Codman-Hertel's classification systems. RESULTS The overall inter-observer agreement (κ) has been 0.297 (CI95% 0.280 to 0.314) for the Neer's classification system, 0.206 (CI95% 0.193 to 0.218) for the Müller/AO classification system, and 0.315 (CI95% 0.334 to 0.368) for the Codman-Hertel classification system. We found loss of agreement in Neer's classification as the study progressed, low agreement in the AO classification, and stable values in the different evaluations with the best degree of agreement for Codman-Hertel classification, with a moderate agreement in the second evaluation among the six evaluators. CONCLUSION The Neer, AO, and Hertel-Codman classification systems for PHF with a single radiographic projection have a difficult interpretation for orthopaedic surgeons of varying levels of experience, and therefore substantial agreements are not obtained.
Collapse
Affiliation(s)
- Rocío Martínez-Sola
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Vicente J León-Muñoz
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Antoine Nicolas Najem-Rizk
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Beatriz Soler-Vasco
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Carlos J Arrieta-Martínez
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Eva López-Sorroche
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | | | - Guillermo Salmerón-Vélez
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - José Ángel Ruiz-Molina
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Torrecárdenas, Almería, Spain
| | - Francisco Martínez-Martínez
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Fernando Santonja-Medina
- Department of Orthopaedic Surgery and Traumatology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| |
Collapse
|
29
|
Bougher H, Buttner P, Smith J, Banks J, Na HS, Forrestal D, Heal C. Interobserver and intraobserver agreement of three-dimensionally printed models for the classification of proximal humeral fractures. JSES Int 2021; 5:198-204. [PMID: 33681838 PMCID: PMC7910723 DOI: 10.1016/j.jseint.2020.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Hypothesis This study aimed to examine whether three-dimensionally printed models (3D models) could improve interobserver and intraobserver agreement when classifying proximal humeral fractures (PHFs) using the Neer system. We hypothesized that 3D models would improve interobserver and intraobserver agreement compared with x-ray, two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) and that agreement using 3D models would be higher for registrars than for consultants. Methods Thirty consecutive PHF images were selected from a state-wide database and classified by fourteen observers. Each imaging modality (x-ray, 2D CT, 3D CT, 3D models) was grouped and presented in a randomly allocated sequence on two separate occasions. Interobserver and intraobserver agreements were quantified with kappa values (κ), percentage agreement, and 95% confidence intervals (CIs). Results Seven orthopedic registrars and seven orthopedic consultants classified 30 fractures on one occasion (interobserver). Four registrars and three consultants additionally completed classification on a second occasion (intraobserver). Interobserver agreement was greater with 3D models than with x-ray (κ = 0.47, CI: 0.44-0.50, 66.5%, CI: 64.6-68.4% and κ = 0.29, CI: 0.26-0.31, 57.2%, CI: 55.1-59.3%, respectively), 2D CT (κ = 0.30, CI: 0.27-0.33, 57.8%, CI: 55.5-60.2%), and 3D CT (κ = 0.35, CI: 0.33-0.38, 58.8%, CI: 56.7-60.9%). Intraobserver agreement appeared higher for 3D models than for other modalities; however, results were not significant. There were no differences in interobserver or intraobserver agreement between registrars and consultants. Conclusion Three-dimensionally printed models improved interobserver agreement in the classification of PHFs using the Neer system. This has potential implications for using 3D models for surgical planning and teaching.
Collapse
Affiliation(s)
- Hannah Bougher
- James Cook University, Mackay Clinical School, Mackay, QLD, Australia
| | | | | | - Jennifer Banks
- James Cook University, Mackay Clinical School, Mackay, QLD, Australia
| | - Hyun Su Na
- Mackay Base Hospital, Mackay, QLD, Australia
| | - David Forrestal
- Queensland University of Technology, Brisbane City, QLD, Australia
| | - Clare Heal
- James Cook University, Mackay Clinical School, Mackay, QLD, Australia
| |
Collapse
|
30
|
Closed reduction of glenohumeral dislocations with associated tuberosity fracture in the emergency department is safe. Injury 2021; 52:487-492. [PMID: 33755550 DOI: 10.1016/j.injury.2020.09.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 02/02/2023]
Abstract
AIM A fracture of the tuberosity is associated with 16% of glenohumeral dislocations. Extension of the fracture into the humeral neck can occur during closed manipulation, leading some to suggest that all such injures should be managed under general anaesthesia in the operating theatre. The purpose of this study was to establish the safety of reduction of glenohumeral dislocations with tuberosity fractures in the emergency department (ED). PATIENTS AND METHODS We reviewed 188 consecutive glenohumeral dislocations with associated tuberosity fractures identified from a prospective orthopaedic trauma database. Patient demographics, injury details, emergency department management and complications were recorded. The method of reduction, sedation, grade of clinician and outcome were documented. RESULTS The mean age was 61 years (range 18-96 years) with 79 males and 109 females. The majority of injuries (146, 78%) occurred after a fall from standing height. Closed reduction under sedation in the ED was successful in 162 (86%) cases. Of the remainder, 22 (11%) failed closed reduction under sedation and subsequently went to theatre and 6 (3%) were deemed not suitable for ED manipulation. At presentation 35 (19%) patients had a nerve injury, of which 29 (90%) resolved spontaneously. Two iatrogenic fractures occurred during close manipulation, one in the ED and the other in the operating theatre. Therefore, the risk of iatrogenic propagation of the fracture into the proximal humerus neck was 0.5% if the reduction was performed in the ED, and 1% over-all. More than two attempted reductions predicted a failed ED reduction (P = 0.001). CONCLUSION Closed reduction of glenohumeral dislocations with associated tuberosity fractures in the ED is safe, with a rate of iatrogenic fracture of 1%. These injuries should be managed by those with appropriate experience only after two adequate radiographic views. In cases where there is ambiguity over the integrity of the humeral neck, reduction should be delayed until multiplanar CT imaging has been obtained.
Collapse
|
31
|
Comparison of "Bilboquet" device and locking plate for surgical treatment of proximal humerus complex fractures at two years follow-up. INTERNATIONAL ORTHOPAEDICS 2021; 45:1811-1816. [PMID: 33629174 DOI: 10.1007/s00264-021-04967-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Surgical treatment of three or four part fractures of the proximal humerus is complex. Different conservative techniques have been described. The main goal of this study was to compare the clinical and radiological outcomes of Bilboquet and locking plate at two year follow-up. METHODS This is a retrospective, comparative study, with a continuous series of 41 patients. Bony fixation was achieved with a Bilboquet device in 22 patients or a locking plate in 19 patients. Patient evaluation included clinical data: shoulder range of motion, Constant-Murley shoulder score and DASH (Disabilities of the Arm, Shoulder and Hand) score, and imaging using standard shoulder X-rays. RESULTS Of the 41 patients included, 1 patient was lost to follow-up in the locking plate group. At a mean follow-up of 24 months patients in Bilboquet group showed a Constant score higher than in locking plate (p = 0.02). Range of motion and DASH score were not significantly different between the two groups. avascular necrosis occured in three patients of Bilboquet group (14%) versus in two patients in the locking plate group (11%) (p > 0.5). Complication and reintervention rate were non-significantly higher in the locking plate group than in the Bilboquet group (37 vs 14%). CONCLUSION Bilboquet and locking plate give good functional outcomes in complex proximal humerus fractures. However, the Bilboquet device appears to provide better functional results than locking plate at mid-term follow-up.
Collapse
|
32
|
Fleega BA, Kareim S. Arthroscopic Reduction and Transosseous Suture Fixation of Avulsed Displaced Shoulder Greater Tuberosity Fracture. Arthrosc Tech 2021; 10:e821-e830. [PMID: 33738220 PMCID: PMC7953264 DOI: 10.1016/j.eats.2020.10.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/29/2020] [Indexed: 02/03/2023] Open
Abstract
The results of conservative treatment of displaced proximal humerus fractures are not satisfactory. Open reconstruction and rigid internal fixation, as well as arthroscopic-assisted reduction and internal fixation, are possible in selected cases, mostly young patients. Older patients with osteoporotic, comminuted bone accounts for 70% of the cases. We present an arthroscopic reduction and transosseous suture fixation technique for osteoporotic patients with displaced 2-part greater tuberosity fractures of the proximal humerus. The technique reduces the upward and medially displaced greater tuberosity to its anatomic position and uses longitudinal, horizontal, or a mattress suture fixation as single or combined fixation (Natofix technique).
Collapse
Affiliation(s)
- Basim A.N. Fleega
- Global Orthopedic Clinic (GOC-Giza), Giza, Egypt,Department of Orthopedic Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt,Address correspondence to Basim A. N. Fleega, M.D., Bonnerstrasse 50, 53424 Remagen, Germany.
| | - Said Kareim
- Global Orthopedic Clinic (GOC-Giza), Giza, Egypt,Department of Orthopedic Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| |
Collapse
|
33
|
Schwarz AM, Hohenberger GM, Sauerschnig M, Niks M, Lipnik G, Mattiassich G, Zacherl M, Seibert FJ, Plecko M. Effectiveness of reverse total shoulder arthroplasty for primary and secondary fracture care: mid-term outcomes in a single-centre experience. BMC Musculoskelet Disord 2021; 22:48. [PMID: 33419418 PMCID: PMC7792308 DOI: 10.1186/s12891-020-03903-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 12/21/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The introduction of reverse total shoulder arthroplasty (RSA) as a treatment option in complex proximal humeral fractures, has significantly extended the surgical armamentarium. The aim of this study was to investigate the mid-term outcome following fracture RSA in acute or sequelae, as well as salvage procedures. It was hypothesized that revision RSA (SRSA) leads to similar mid-term results as primary fracture treatment by RSA (PRSA). METHODS This retrospective study describes the radiological and clinical mid-term outcomes in a standardized single-centre and Inlay design. Patients who underwent RSA in fracture care between 2008 and 2017 were included (minimum follow-up: 2 years, minimum age: 60 years). The assessment tools used for functional findings were range of motion (ROM), Visual Analogue Scale, absolute (CS) plus normative Constant Score, QuickDASH, and Subjective Shoulder Value. All adverse events as well as the radiological results and their clinical correlations were statistically analysed (using p < .05and 95% confidence intervals). RESULTS Following fracture RSA, 68 patients were included (mean age: 72.5 years, mean follow-up: 46 months). Forty-two underwent primary RSA (PRSA), and 26 underwent revision RSA (SRSA). Adverse advents were observed in 13% (n = 9/68). No statistically significant results were found for the scores of the PRSA and SRSA groups, while the failed osteosynthesis SRSA subgroup obtained statistically significantly negative values for ROM subzones (flexion: p = .020, abduction: p = .020). Decreased instances of tubercle healing were observed for the in PRSA group relative to the SRSA group (p = .006). The absence of bony healing of the tubercles was related to significant negative clinical and subjective outcomes (all scores: p < .05, external rotation: p= .019). Significant postoperative improvements were evaluated in the SRSA group (CS: 23 to 56 at mean, p = .001), the time from index surgery to operative revision revealed no associations in functional findings. CONCLUSIONS RSA is an effective option in severe shoulder fracture management with predictable results for salvage as well as first-line treatment. Promising mid-term functional results, reasonable implant survival rates, and high patient satisfaction can be achieved. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- A M Schwarz
- AUVA - Trauma Hospital (UKH) Styria | Graz, Teaching Hospital of the Medical University of Graz, Göstinger Straße 24, 8020, Graz, Austria.
| | - G M Hohenberger
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - M Sauerschnig
- AUVA - Trauma Hospital (UKH) Styria | Graz, Teaching Hospital of the Medical University of Graz, Göstinger Straße 24, 8020, Graz, Austria
| | - M Niks
- AUVA - Trauma Hospital (UKH) Styria | Graz, Teaching Hospital of the Medical University of Graz, Göstinger Straße 24, 8020, Graz, Austria
| | - G Lipnik
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - G Mattiassich
- AUVA - Trauma Hospital (UKH) Styria | Graz, Teaching Hospital of the Medical University of Graz, Göstinger Straße 24, 8020, Graz, Austria
| | - M Zacherl
- AUVA - Trauma Hospital (UKH) Styria | Graz, Teaching Hospital of the Medical University of Graz, Göstinger Straße 24, 8020, Graz, Austria
| | - F J Seibert
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - M Plecko
- AUVA - Trauma Hospital (UKH) Styria | Graz, Teaching Hospital of the Medical University of Graz, Göstinger Straße 24, 8020, Graz, Austria
| |
Collapse
|
34
|
Maluta T, Amarossi A, Dorigotti A, Bagnis F, Samaila EM, De Luca L, Pezze L, Magnan B. External fixation can be an option for proximal humerus fractures Neer 3-4. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020017. [PMID: 33559622 PMCID: PMC7944700 DOI: 10.23750/abm.v91i14-s.10979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 11/23/2022]
Abstract
Background: Proximal humeral fractures (PHF) account for 4-6% of all fractures and 25% of humeral fractures. While conservative treatment is the gold standard for simple fractures, there is no consensus about the best treatment choice for complex PHF in the elderly. Recently a new external fixator was introduced in clinical practice for treatment of complex PHF. Aim of the study was to evaluate the functional results of this therapeutic approach. Methods: Data were retrospectively analyzed. Inclusion criteria were: three- and four-part PHF according to Neer, treatment with closed reduction and external fixation, normal Abbreviated Mini Mental Test score, independence in the daily living, non-pathological fracture, glenohumeral joint with moderate osteoarthritic changes and availability of clinical and radiological follow-up. For each patient demographic data, comorbidities, surgery time and estimated blood loss were recorded. Clinical and radiological evaluation were performed at 1, 2, 6, 12 months. Results: 17 patients were enrolled. Mean age was 69.7 years. Fractures were classified according to Neer as type III in 10 cases and type IV in 7 cases. The mean operating time was 22 minutes. Mean Constant score value at follow up was 74 ± 11,52 at 2 months, 82 ± 11,16 at 6 months and 85 ± 9,86 at 12 months. Conclusion: These preliminary results show that the studied system is easy to use, minimally invasive, effective in reducing surgical and hospitalization time. The results in terms of functional recovery are encouraging, showing a reduced number of complications. (www.actabiomedica.it)
Collapse
|
35
|
Walters JM, Ahmadi S. High-Energy Proximal Humerus Fractures in Geriatric Patients: A Review. Geriatr Orthop Surg Rehabil 2020; 11:2151459320971568. [PMID: 33354380 PMCID: PMC7734485 DOI: 10.1177/2151459320971568] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 08/29/2020] [Accepted: 10/06/2020] [Indexed: 01/01/2023] Open
Abstract
High-energy proximal humerus fractures in elderly patients can occur through a variety of mechanisms, with falls and MVCs being common mechanisms of injury in this age group. Even classically low-energy mechanisms can result in elevated ISS scores, which are associated with higher mortality in both falls and MVCs. These injuries result in proximal humerus fractures which are commonly communicated via Neer’s classification scheme. There are many treatment options in the armamentarium of the treating surgeon. Nonoperative management is widely supported by systematic review as compared to almost all other treatment methods. ORIF is particularly useful for complex patterns and fracture dislocations in healthy patients. Hemiarthroplasty can be of utility in patients with fracture patterns with high risk of AVN and poor bone quality risking screw cut-out. Reverse total shoulder arthroplasty is a popular method of treatment for geriatric patients also, with literature now showing that even late conversion from nonoperative management or ORIF to rTSA can lead to good clinical outcomes. Prevention is possible and important for geriatric patients. Optimizing medical care including hearing, vision, strength, and bone quality, in coordination with primary care and geriatricians, is of great importance in preventing fractures and decreasing injury when falls do occur. Involving geriatricians on dedicated trauma teams will also likely be of benefit.
Collapse
Affiliation(s)
- Jordan M Walters
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Shahryar Ahmadi
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| |
Collapse
|
36
|
Gracitelli MEC, Yamamoto GJ, Malavolta EA, Andrade-Silva FB, Kojima KE, Ferreira Neto AA. Tratamento não operatório de fraturas desviadas da extremidade proximal do úmero em idosos: Correlação entre os desvios e os resultados clínicos. Rev Bras Ortop 2020; 57:273-281. [PMID: 35652030 PMCID: PMC9142268 DOI: 10.1055/s-0040-1716760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 07/06/2020] [Indexed: 10/24/2022] Open
Abstract
Resumo
Objetivos Descrever o resultado funcional do tratamento não operatório de fraturas desviadas da extremidade proximal do úmero (FEPU) pela escala da American Shoulder and Elbow Surgeons (ASES, na sigla em inglês) após 12 meses e avaliar se as diferentes classificações e medidas radiográficas iniciais têm correlação com os resultados clínicos.
Métodos Foram avaliados em tempos padronizados (3, 6 e 12 meses), 40 pacientes > 60 anos com FEPU submetidos ao tratamento não operatório. Foram utilizadas as escalas da ASES, Constant-Murley e Single Assessment Numeric Evaluation (SANE, na sigla em inglês). As variáveis radiográficas incluíram as classificações de Neer e Resch, a presença de fratura e desvio dos tubérculos, cominuição metafisária, lesão periosteal medial, desvios angulares e translacionais da cabeça no plano coronal e sagital e desvio dos tubérculos.
Resultados Observamos resultados pela escala de ASES de 77,7 ± 23,2 para toda a amostra, pela de Constant-Murley de 68,7 ± 16 e de 82,6% para a escala em relação ao lado contralateral. A escala de SANE aos 12 meses foi de 84,8 ± 19. Os critérios radiográficos que apresentaram influência negativa no resultado clínico pela escala de ASES aos 12 meses foram a gravidade pela classificação de Neer e pelo desvio angular no plano coronal (mensurado pelo ângulo cabeça-diáfise) e a presença de fratura dos tubérculos.
Conclusão O tratamento não operatório de fraturas desviadas da extremidade proximal do úmero em pacientes idosos resulta em bons resultados clínicos. Os resultados clínicos são influenciados negativamente pelo desvio angular da cabeça do úmero e pela presença de fratura dos tubérculos maior e menor, assim como pela classificação de Neer.
Collapse
Affiliation(s)
- Mauro Emilio Conforto Gracitelli
- Grupo de Ombro e Cotovelo, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Gustavo Jum Yamamoto
- Grupo de Ombro e Cotovelo, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Eduardo Angeli Malavolta
- Grupo de Ombro e Cotovelo, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Fernando Brandão Andrade-Silva
- Grupo de Ombro e Cotovelo, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Kodi Edson Kojima
- Grupo de Ombro e Cotovelo, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Arnaldo Amado Ferreira Neto
- Grupo de Ombro e Cotovelo, Instituto de Ortopedia e Traumatologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| |
Collapse
|
37
|
Scheer JH, Tillander BM, Dånmark I, Björnsson Hallgren HC. Solely sutures is a reliable fixation for valgus-impacted proximal humeral fractures. J Clin Orthop Trauma 2020; 15:130-135. [PMID: 33717927 PMCID: PMC7920155 DOI: 10.1016/j.jcot.2020.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Valgus impacted proximal humeral fractures with substantial displacement may severely compromise shoulder function and open reduction can therefore be considered. Internal fixation hardware may eventually however constitute problems. In a small subset of these fractures, in which there is no medial comminution and intact blood supply it is possible to use a least possible fixation method with solely sutures through the tendons of the rotator cuff and the shaft as described by Bigliani 1990. The aim of the present study was to investigate the outcome of this fixation method in a retrospective series of patients. METHODS Twenty-seven patients, 23 women and 4 men, with a mean age of 66 years (53-83) and minimum follow-up time of 2 years (2-11 years) accepted follow-up with standard shoulder radiographs and 22 were examined with Oxford Shoulder Score (OSS), Constant-Murley (CM) shoulder score and Numeric Rating Scale for pain (NRS). Reoperations or adverse events were recorded. RESULTS The median OSS was 45 (range 5-48) and CM 63 (range 21-98). The relative CM score was 81% of the uninjured side and median NRS 0 (range 0-5). No reoperations were undertaken. One patient had a complete avascular necrosis (AVN), 3 patients had a partial AVN of the humeral head and two a partial resorption of the greater tuberosity. CONCLUSION The use of sutures only for fixation of displaced valgus-impacted proximal humeral fractures provided a relatively reliable outcome with good functional scores and no reoperations. There appears to be no need for the use of hardware for fixation of this rare subset of fractures.
Collapse
Affiliation(s)
- Johan H. Scheer
- Corresponding author. Department of Orthopedics, Linköping University Hospital, Linköping S-581 85, Sweden.
| | | | | | | |
Collapse
|
38
|
Russo R, Guastafierro A, Rotonda GD, Viglione S, Ciccarelli M, Mortellaro M, Minopoli P, Fiorentino F, Pietroluongo LR. A new classification of impacted proximal humerus fractures based on the morpho-volumetric evaluation of humeral head bone loss with a 3D model. J Shoulder Elbow Surg 2020; 29:e374-e385. [PMID: 32573449 DOI: 10.1016/j.jse.2020.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/13/2020] [Accepted: 02/20/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study aimed to classify the pathomorphology of impacted proximal humeral fractures according to the control volume theory, with the intention to introduce a severity index to support surgeons in decision making. METHODS In total, 50 proximal humeral fractures were randomly selected from 200 medical records of adult patients treated from 2009 to 2016. Four nonindependent observers used 2 different imaging modalities (computed tomography scans plus volume rendering; 3D model) to test the classification reliability. A fracture classification system was created according to the control volume theory to provide simple and understandable patterns that would help surgeons make quick assessments. The impacted fractures table was generated based on an evaluation of the calcar condition, determined by the impairment of a defined volumetric area under the cephalic cup and the humeral head malposition. In addition to the main fracture pattern, the comminution degree (low, medium, high), providing important information on fracture severity, could also be evaluated. RESULTS From 3D imaging, the inter- and intraobserver reliability revealed a k value (95% confidence interval) of 0.55 (0.50-0.60) and 0.91 (0.79-1.00), respectively, for the pattern code, and 0.52 (0.43-0.76) and 0.91 (0.56-0.96), respectively, for the comminution degree. CONCLUSIONS The new classification provides a useful synoptic framework for identifying complex fracture patterns. It can provide the surgeon with useful information for fracture analysis and may represent a good starting point for an automated system.
Collapse
Affiliation(s)
- Raffaele Russo
- Department of Orthopedic Surgery, Pineta Grande Hospital, Caserta, Italy.
| | | | | | - Stefano Viglione
- Department of Orthopedic Surgery, Pineta Grande Hospital, Caserta, Italy
| | - Michele Ciccarelli
- Department of Orthopedic Surgery, Pineta Grande Hospital, Caserta, Italy
| | | | | | | | | |
Collapse
|
39
|
Matsumura N, Furuhata R, Seto T, Takada Y, Shirasawa H, Oki S, Kawano Y, Shiono S. Reproducibility of the modified Neer classification defining displacement with respect to the humeral head fragment for proximal humeral fractures. J Orthop Surg Res 2020; 15:438. [PMID: 32967709 PMCID: PMC7509915 DOI: 10.1186/s13018-020-01966-2] [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: 08/01/2020] [Accepted: 09/14/2020] [Indexed: 11/10/2022] Open
Abstract
Background Although the Neer classification is widely used for the assessment of proximal humeral fractures, its reproducibility has been challenged. The purpose of this study was to evaluate the reproducibility of the conventional Neer classification and a modified classification that defined fracture displacement with respect to the humeral head fragment. Methods The fracture patterns in 80 cases of proximal humeral fractures were independently assessed by 6 observers. The cases were grouped according to the conventional Neer classification using radiographs followed by computed tomography (CT) scans by each examiner twice with a 1-month interval. The fractures were then classified with the modified Neer classification, which defined displacement of the fragment as separation of more than 1 cm or angulation of more than 45° from the humeral head fragment, twice with a 1-month interval. Kappa coefficients of the conventional and modified Neer classifications were compared. Results The modified classification showed significantly higher intra-observer agreement than the conventional classification, both for radiographs (P = .028) and for CT scans (P = .043). Intra-observer agreement was also significantly higher for the modified classification than for the conventional classification, both for radiographs (P = .001) and for CT scans (P < .001). Conclusions The present study showed that agreement for the Neer classification could be improved when fracture displacement was defined as separation or angulation from the humeral head. Considering vascularity to the humeral head, furthermore, the modified method might be more helpful for predicting patients’ prognosis than the conventional Neer classification.
Collapse
Affiliation(s)
- Noboru Matsumura
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Ryogo Furuhata
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Takayuki Seto
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yuhei Takada
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hideyuki Shirasawa
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Satoshi Oki
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yusuke Kawano
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Shohei Shiono
- Department of Orthopedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| |
Collapse
|
40
|
Does the magnitude of injuries affect the outcome of proximal humerus fractures treated by locked plating (PHILOS)? Eur J Trauma Emerg Surg 2020; 48:4515-4522. [PMID: 32778927 DOI: 10.1007/s00068-020-01451-9] [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: 05/11/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Health-related quality of life (HRQoL) becomes increasingly relevant in an aging society. Functional outcome (FO) and the patient-reported outcome (PRO) after surgical treatment of proximal humerus fractures (PHF) depends on numerous factors, including patient- and injury-specific factors. There is little evidence on how the FO and the PRO vary in different settings such as monotrauma or multiple injuries, even though the PHF is one of the more frequent fractures. In addition, to a previous study, on multiple injured patients and upper extremity injuries, the aim of the current study was to investigate the impact of multiple injuries, quantified by the ISS, on the FO and PRO after surgically treated PHF by PHILOS. METHODS A retrospective cohort-study was conducted with an additional follow-up by a questionnaire. HRQoL tools such as range of motion (ROM), the Quick-Disability of Arm Shoulder and Hand score (DASH), EuroQol Five Dimension Three Levels (EQ-5D-3L), and EuroQol VAS (EQ-VAS) were used. The study-population was stratified according to ISS obtained based on information at discharge into Group I/M-H (ISS < 16 points) and Group PT-H (ISS ≥ 16). Median outcome scores were calculated and presented. INCLUSION CRITERIA adult patients (> 18 years) with PHF treated at one academic Level 1 trauma center between 2007 and 2017 with Proximal Humeral Inter-Locking System (PHILOS) and preoperative CT-scan. Group stratification according Injury Severity Score (ISS): Group PT-H (ISS ≥ 16 points) and Group I/M-H (ISS < 16 points). EXCLUSION CRITERIA oncology patients, genetic disorders affecting the musculoskeletal system, paralysis or inability to move upper extremity prior or after injury, additional ipsilateral upper limb fractures, open injuries, associated vascular injuries as well brachial plexus injuries and nerve damages. Follow-up 5-10 years including PRO: EQ-5D-3L and EQ-VAS. FO, including DASH and ROM. The ROM was measured 1 year after PHILOS. RESULTS Inclusion of 75 patients, mean age at injury was 49.9 (± 17.6) years. The average follow-up period in Group I/M-H was 6.18 years (± 3.5), and in Group PT-H 5.58 years (± 3.1). The ISS in the Group I/M-H was 6.89 (± 2.5) points, compared to 21.7 (± 5.3) points in Group PT-H (p ≤ 0.001). The DASH-score in Group I/M-H was 9.86 (± 13.12 and in Group PT-H 12.43 (± 15.51, n.s.). The EQ-VAS in Group I/M-H was 78.13 (± 19.77) points compared with 74.13 (± 19.43, n.s.) in Group PT-H. DASH, EQ-VAS as well as ROM were comparable in Groups I/M-H and PT-H (9.9 ± 13.1 versus 12.4 ± 15.5, n.s.). The EQ-5D-3L in Group I/M-H was 0.86 (± 0.23) points compared to Group PT-H 0.72 (± 0.26, p ≤ 0.017). No significant differences could be found in Group I/M-H and PT-H in the severity of traumatic brain injury (TBI). A multivariable regression analyses was performed for DASH, EQ-5D-3L and EQ-VAS. All three outcome metrics were correlated. There was a significant difference between the EQ-5D-3L and the ISS (Beta-Coefficient was 0.86, 95% low was 0.75, 95% high was 0.99, p ≤ 0.041). No significant correlation could be found comparing DASH, EQ-5D-3L and EQ-VAS to age, gender and TBIs. CONCLUSION Multiple injuries did not affect the DASH, ROM or EQ-VAS after PHILOS; but a higher ISS negatively affected the EQ-5D-EL. While the ROM and DASH aim to be objective measurements of functionality, EQ-5D-3L and EQ-VAS represent the patients' PRO. The FO and PRO outcomes are not substitutable, and both should be taken into consideration during follow-up visits of multiple injured patients. Future research should prospectively explore whether the findings of this study can be recreated using a larger study population and investigate if different FO and PRO parameters come to similar conclusions. The gained information could be used for an enhanced long-term evaluation of patients who suffered a PHF from multiple injuries to meet their multifarious conditions. LEVEL OF EVIDENCE II.
Collapse
|
41
|
Hosseinzadeh S, DeAngelis JP, Komarraju A, Wu AC, Wu JS. Imaging of Acute Shoulder Trauma. Semin Roentgenol 2020; 56:5-21. [PMID: 33422184 DOI: 10.1053/j.ro.2020.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Acute injuries to the shoulder girdle are common and frequently encountered by the practicing radiologist. The type of injury is highly dependent on the age of the patient and mechanism of trauma with injuries occurring at the site of greatest mechanical weakness. In this review, we discuss the main clinical features and key imaging findings for the most common shoulder injuries. For each injury, we also provide a section on the important features that the orthopedic surgeon needs to know in order to guide surgical versus nonsurgical management.
Collapse
Affiliation(s)
- Shayan Hosseinzadeh
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Joseph P DeAngelis
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Aparna Komarraju
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Allison C Wu
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jim S Wu
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| |
Collapse
|
42
|
Open reduction and internal fixation of three- and four-part proximal humeral fractures by intrafocal distraction: a clinical and radiographic study of thirty-two cases with five to ten years of follow-up. INTERNATIONAL ORTHOPAEDICS 2020; 44:2101-2112. [PMID: 32564175 DOI: 10.1007/s00264-020-04657-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The disadvantage of ORIF of proximal humerus fracture (PHF) by intrafocal distraction is that once the device is inserted, it cannot be removed. This study was designed to evaluate the tolerance of such a titanium alloy device at five years of minimal follow-up (FU) and secondarily to assess the relevance of the osteosynthesis of these fractures. METHOD Thirty-two patients operated for PHF and implanted with a titanium alloy device between 2009 and 2011 were reviewed: fifteen three-part fracture (3-PF) with mean age 65.2 ± seven years and mean FU at 86 months, and seventeen four-part (4-PF) with mean age 62.9 ± 12 years and mean FU at 88 months. RESULTS There were no signs of clinical or radiological incompatibility to the metal. The lateral cortex of the humeral shaft at the wedge component level of the device was thinner than pre-operatively in half of the cases. For the fifteen 3-PF, the median raw and weighted constant score (CS) were 75 and 100, respectively. Only one case presented avascular necrosis (AVN). For the seventeen 4-PF, the median raw and weighted CS were 64 and 88, respectively. Seven cases presented AVN and none of them seven had initially a dorsomedial metaphyseal extension of the humeral head. Kaplan-Meier survivorship analysis, with 95% confidence interval, was calculated at 89.7% (79.7-100%) survivorship at 7.18 years of follow-up. CONCLUSIONS This study shows no incompatibility of the titanium alloy device, radiological signs of localized stress shielding in half of the cases with no functional impact, excellent clinical and radiological evolution of the 3-PF, and AVN in all 4-PF without dorsomedial metaphyseal extension of the humeral head whereas most of cases without AVN had dorsomedial metaphyseal extension.
Collapse
|
43
|
Murena L, Canton G, Ratti C, Hoxhaj B, Giraldi G, Surace MF, Grassi FA. Indications and results of osteosynthesis for proximal humerus fragility fractures in elderly patients. Orthop Rev (Pavia) 2020; 12:8559. [PMID: 32391138 PMCID: PMC7206366 DOI: 10.4081/or.2020.8559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/13/2020] [Indexed: 02/08/2023] Open
Abstract
Proximal humerus fractures (PHF) are common injuries in the elderly population. Conservative treatment is indicated for undisplaced and stable fractures, which account for almost 80% of the cases. More complex fracture patterns might need surgery, with a wide variety of indication criteria and surgical techniques described in the literature. Surgical treatment should be reserved for patients in good clinical conditions, autonomous in daily living activities and able to adhere to postoperative rehabilitation protocols. In the elderly population with severe osteoporosis, cognitive impairment and clinical comorbidities, the risk of surgical failures is high. In these patients, the choice between surgical and conservative treatment, as well as for the type of procedure, is even more difficult, with no general consensus in the literature. Final indication is usually conditioned by surgeon’s experience and preference. Two independent reviewers (B.H and G.G) independently extracted studies on proximal humeral fractures. All selected studies were screened independently (B.H and G.G) based on title and abstract. Then the full text of any article that either judged potentially eligible was acquired and reviewed again. Any disagreement was resolved by discussing the full text manuscripts. Aim of the present paper is to review the literature about indications and results of osteosynthesis for proximal humerus fragility fractures in the elderly population.
Collapse
Affiliation(s)
- Luigi Murena
- Orthopedics and Trauma Unit - ASUGI, Department of Medicine, Surgery and Health Sciences, University of Trieste
| | - Gianluca Canton
- Orthopedics and Trauma Unit - ASUGI, Department of Medicine, Surgery and Health Sciences, University of Trieste
| | - Chiara Ratti
- Orthopedics and Trauma Unit - ASUGI, Department of Medicine, Surgery and Health Sciences, University of Trieste
| | - Bramir Hoxhaj
- Orthopedics and Trauma Unit - ASUGI, Department of Medicine, Surgery and Health Sciences, University of Trieste
| | - Gioia Giraldi
- Orthopedics and Trauma Unit - ASUGI, Department of Medicine, Surgery and Health Sciences, University of Trieste
| | - Michele Francesco Surace
- Interdisciplinary Research Centre for Pathology and Surgery of the Musculoskeletal System, Department of Biotechnology and Life Sciences, University of Insubria, Varese
| | - Federico Alberto Grassi
- Orthopedic and Trauma Unit, University Hospital "Maggiore della Carità", Department of Health Sciences, University of East Piedmont, Novara, Italy
| |
Collapse
|
44
|
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).
Collapse
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.
| |
Collapse
|
45
|
Chen H, Cui X, Rui Y, Ma B, Li H. Indirect Reduction and Strut Support of Proximal Humerus Fractures Using a Titanium Mesh in Elderly Patients: A Novel Technique. J Orthop Trauma 2020; 34:e142-e147. [PMID: 31738236 DOI: 10.1097/bot.0000000000001699] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Surgical treatment of unstable proximal humeral fractures is challenging in elderly patients. The locking plate technique has been advocated for the management of these fractures in recent years; however, it is still difficult to achieve stable fixation and maintain intra-operative reduction in patients with low bone mineral density. It is generally accepted that a critical step to enhance clinical results and reduce complications is re-creation of the medial column support. Here, we introduce a novel technique using titanium mesh in the treatment of proximal humerus fractures. Although preliminary results have been encouraging, further study with a larger number of patients and longer follow-up is needed to fully validate this technique.
Collapse
Affiliation(s)
- Hui Chen
- Department of Orthopaedics, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Trauma Center, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China; and.,Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Xueliang Cui
- Department of Orthopaedics, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Trauma Center, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China; and.,Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Yunfeng Rui
- Department of Orthopaedics, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Trauma Center, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China; and.,Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - Binbin Ma
- Department of Orthopaedics, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Trauma Center, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China; and.,Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China
| | - He Li
- Department of Orthopaedics, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China.,Trauma Center, Zhongda Hospital, Southeast University, Nanjing, Jiangsu, People's Republic of China; and.,Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, People's Republic of China
| |
Collapse
|
46
|
Marongiu G, Leinardi L, Congia S, Frigau L, Mola F, Capone A. Reliability and reproducibility of the new AO/OTA 2018 classification system for proximal humeral fractures: a comparison of three different classification systems. J Orthop Traumatol 2020; 21:4. [PMID: 32166457 PMCID: PMC7067934 DOI: 10.1186/s10195-020-0543-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 01/09/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The classification systems for proximal humeral fractures routinely used in clinical practice include the Neer and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 2007 systems. Currently used systems have low inter- and intraobserver reliability. In 2018, AO/OTA introduced a new classification system with the aim of simplifying the coding process, in which the Neer four-part classification was integrated into the fracture description. The aim of the present work is to assess the inter- and intraobserver agreement of the new AO/OTA 2018 compared with the Neer and AO/OTA 2007 classifications. MATERIALS AND METHODS A total of 116 radiographs of consecutive patients with proximal humeral fracture were selected and classified by three observers with different levels of experience. All three observers independently reviewed and classified the images according to the Neer, AO/OTA 2007, and new AO/OTA 2018 systems. To determine the intraobserver agreement, the observers reviewed the same set of radiographs after an interval of 8 weeks. The inter- and intraobserver agreement were determined through Cohen's kappa coefficient analysis. RESULTS The new AO/OTA 2018 classification showed substantial mean inter- (k = 0.67) and intraobserver (k = 0.75) agreement. These results are similar to the reliability observed for the Neer classification (interobserver, k = 0.67; intraobserver, k = 0.85) but better than those found for the AO/OTA 2007 system, which showed only moderate inter- (k = 0.57) and intraobserver (k = 0.58) agreement. The two more experienced observers showed better overall agreement, but no statistically significant difference was found. No differences were found between surgical experience and agreement regarding specific fracture types or groups. CONCLUSIONS The results showed that the Neer system still represents the more reliable and reproducible classification. However, the new AO/OTA 2018 classification improved the agreement among observers compared with the AO/OTA 2007 system, while still maintaining substantial descriptive power and simplifying the coding process. The universal modifiers and qualifications, despite their possible complexity, allowed a more comprehensive fracture definition without negatively affecting the reliability or reproducibility of the classification system. LEVEL OF EVIDENCE Level III, diagnostic studies.
Collapse
Affiliation(s)
- Giuseppe Marongiu
- Orthopaedic Clinic, Department of Surgical Sciences, Cagliari State University, Lungomare Poetto 12, 09126, Cagliari, Italy.
| | - Lorenzo Leinardi
- Orthopaedic Clinic, Department of Surgical Sciences, Cagliari State University, Lungomare Poetto 12, 09126, Cagliari, Italy
| | - Stefano Congia
- Orthopaedic Clinic, Department of Surgical Sciences, Cagliari State University, Lungomare Poetto 12, 09126, Cagliari, Italy
| | - Luca Frigau
- Department Economics and Business Science, Cagliari State University, Cagliari, Italy
| | - Francesco Mola
- Department Economics and Business Science, Cagliari State University, Cagliari, Italy
| | - Antonio Capone
- Orthopaedic Clinic, Department of Surgical Sciences, Cagliari State University, Lungomare Poetto 12, 09126, Cagliari, Italy
| |
Collapse
|
47
|
Imaging to improve agreement for proximal humeral fracture classification in adult patient: A systematic review of quantitative studies. J Clin Orthop Trauma 2020; 11:S16-S24. [PMID: 31992911 PMCID: PMC6977161 DOI: 10.1016/j.jcot.2019.06.019] [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: 05/25/2019] [Revised: 06/23/2019] [Accepted: 06/24/2019] [Indexed: 11/20/2022] Open
Abstract
Proximal humeral fracture classification has low reproducibility. Many studies have tried to increase inter- and intra-observer agreement with more sophisticated imaging. The aim of this review was to determine which imaging modality produces the best inter- and intra-observer agreement for proximal humeral fracture classification in adults and to determine if this varies with observer experience or fracture complexity. OvidMEDLINE, The Cochrane Library, EBSCO CINAHL and Elsevier Scopus were searched on July 22nd, 2018. Quantitative studies comparing at least two imaging modalities for inter- or intra-observer agreement of proximal humeral fracture classification in adults were eligible for inclusion in this systematic literature review. Two reviewers independently screened and extracted data. Study quality was appraised using a modified Downs and Black checklist. The search strategy identified 1987 studies, of which 15 met the eligibility criteria. All included studies addressed inter-observer agreement and 8 provided results for intra-observer agreement. A narrative synthesis was performed. Trends were compared between studies as clinical heterogeneity and the statistical measures used by included studies prevented meta-analysis. Inter- and intra-observer agreement was found to increase from radiographs (x-ray) to two-dimensional (2D) computed tomography (CT) to three-dimensional (3D) CT. 2D and 3D CT may improve inter-observer agreement to a greater extent in less experienced observers and in more complex fractures. Future studies should compare 2D and 3D CT with subgroups categorising surgeon experience and fracture complexity. X-ray should be used for initial assessment; however doctors should have a low threshold for ordering CT. PROSPERO number: CRD42018094307.
Collapse
|
48
|
Stirma GA, Secundino AR, Gonzalez GFG, Sola Junior WC, Souza GALD, Dau L. INTER/INTRA-OBSERVER EVALUATION BETWEEN RADIOGRAPHS AND TOMOGRAPHIES FOR PROXIMAL HUMERUS FRACTURE. ACTA ORTOPEDICA BRASILEIRA 2020; 28:36-39. [PMID: 32095111 PMCID: PMC7006533 DOI: 10.1590/1413-785220202801215063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The use of images in 3D reconstruction is an instrument that facilitates the interpretation of the fracture, observations of deviations, rotations and articular surface. OBJECTIVE To evaluate the inter-observer and intra-observer reliability of the Neer x AO proximal humerus fracture classification on radiographs versus computed tomography with three-dimensional reconstruction (3D). METHODS We evaluated the digital radiographs (anteroposterior and profile) and computerized tomography with 3D reconstruction of patients presenting with a proximal humerus fracture, surgically treated at an Orthopedics and Traumatology Service. All radiographs and computed tomography were classified (Neer and AO) by eight (8) orthopedic surgeons, specialists in the upper limb and sent, following the pre-established numeration by the author, in a spreadsheet to the author of the study. RESULTS The Neer and AO scores were more reproducible when determined by computed tomography with 3D reconstruction, mainly in fractures of greater complexity (Neer 4 parts and AO group C). However, in absolute values, inter and intra-observer reproducibility and concordance still remain low. CONCLUSION Computed tomography with 3D reconstruction allows a better analysis of fractures of group C and Neer 4 parts. However, the inter and intra-observer agreement does not increase significantly in comparison to the radiographs. Level of evidence III, Study of non-consecutive patients, without gold standard, applied uniformly.
Collapse
|
49
|
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.
Collapse
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.
| | -
- Société française de chirurgie orthopédique et traumatologique, 56, rue Boissonade, 75014 Paris, France
| |
Collapse
|
50
|
Zhao L, Qi YM, Yang L, Wang GR, Zheng SN, Wang Q, Liang B, Jiang CZ. Comparison of the Effects of Proximal Humeral Internal Locking System (PHILOS) Alone and PHILOS Combined with Fibular Allograft in the Treatment of Neer Three- or Four-part Proximal Humerus Fractures in the Elderly. Orthop Surg 2019; 11:1003-1012. [PMID: 31762222 PMCID: PMC6904636 DOI: 10.1111/os.12564] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/16/2019] [Accepted: 10/08/2019] [Indexed: 01/28/2023] Open
Abstract
Objective To compare and analyze the clinical outcomes of the proximal humeral internal locking system (PHILOS) alone and the PHILOS combined with fibular allograft in the treatment of Neer three‐ and four‐part proximal humerus fractures (PHF) in the elderly. Methods From January 2014 to January 2018, a total of 42 elderly patients with Neer three‐ or four‐part PHF admitted to our hospital were randomly divided into observation group and control group, with 21 patients in each group. The observation group was treated with the PHILOS combined with fibular allograft. The control group was treated with the PHILOS alone. Perioperative parameters and fracture classification were recorded in the two groups. Function results were assessed by Visual Analog Scale (VAS), Constant‐Murley score (CMS), American Shoulder and Elbow Surgeons (ASES) score, and the Disability of Arm‐Shoulder‐Hand (DASH) score. Radiological results were evaluated using the neck‐shaft angle (NSA) and humeral head height (HHH), and complications were also recorded in each group. Results There were no significant differences between the two groups in terms of preoperative status, age, gender, cause of trauma, fracture site, and fracture classification. The average follow‐up time was 12 months. At the last follow‐up, the VAS and DASH observation groups were lower than the control group, and there was significant difference between the two groups (P < 0.05). The CMS and ASES were higher in the observation group than the control group, and there was significant difference between the two groups (P < 0.05). The mean difference in the NSA and HHH were lower in the observation group than the control group, and there was a significant difference between the two groups (P < 0.05). There was one postoperative complication in the observation group, which was humeral head avascular necrosis (AVN). There were seven postoperative complications in the control group, including three cases of humeral head collapse and three cases of screw cutout and one case of humeral head AVN. The incidence of postoperative complications in the observation group was significantly lower than the control group (P < 0.05), there was a significant difference between the two groups. Conclusions For Neer three‐ or four‐part PHF in the elderly patients, PHILOS fixation with fibular allograft shows satisfactory short‐term results with respect to humeral head support and maintenance of reduction, and may reduce the incidence of complications associated with fixation using a PHILOS alone.
Collapse
Affiliation(s)
- Lei Zhao
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yi-Min Qi
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Lei Yang
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Gang-Rui Wang
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Sheng-Nai Zheng
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Qiang Wang
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Bin Liang
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chun-Zhi Jiang
- Department of Orthopaedic Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| |
Collapse
|