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Peña-Martínez V, Meza-Camacho J, Tamez-Mata Y, Simental-Mendía M, Villarreal-Villarreal G, Salinas-Garza R, Acosta-Olivo C. Proximal humeral fractures: association between displacement and fatty degeneration of the supraspinatus muscle. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05458-4. [PMID: 39008080 DOI: 10.1007/s00402-024-05458-4] [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: 03/04/2024] [Accepted: 07/03/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION To evaluate the relationship between initial displacement in proximal humeral fractures and fatty degeneration of the rotator cuff measured by CT according to the Goutallier classification. MATERIAL AND METHODS This cross-sectional observational study evaluated patients with proximal humeral fractures over a six-month period. The study included patients ≥ 18 years old with complete radiological views (anteroposterior, lateral, and Grashey) and a CT scan of the affected shoulder; previous fracture or ipsilateral shoulder surgery were excluded. Neer's classification system and Goutallier stages were used to evaluate the patients. Demographic data were collected and, two groups were analysed according to age (≤ 50 years and > 50 years). RESULTS Sixty-two patients were included (m = 36, f = 26, ratio 1.3:1); seven patients were excluded. Male patients (36, 58.1%), patients older than 50 years (33, 53.2%) and a low-energy injury mechanism (36, 58.1%) were the most frequent cases. According to the Neer system, the most common proximal humerus fracture was fracture-dislocation in 17 (27.4%) cases. The most common stage in Goutallier's classification was I (some fatty streaks) in 22 (35.4%) cases. Younger patients (≤ 50 years) had more displaced fractures with low fatty degeneration (p = < 0.001) than older patients (> 50 years), who had minimally displaced fractures with greater fatty degeneration (p = 0.567). CONCLUSIONS High-energy mechanisms are associated with younger patients and a more displaced fracture according to the Neer classification. Older patients had a more advanced Goutallier stage and lesser displaced fracture. We should consider a more aggressive approach in the treatment of non-displaced fractures in elderly patients, less conservative and more surgical management, to obtain a better clinical evolution after the treatment of these kinds of fractures. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Victor Peña-Martínez
- Orthopaedics and Traumatology, Universidad Autónoma de Nuevo León. Hospital Universitario "Dr. José E. González", Ave Madero and Gonzalitos, S/N, Mitras centro, Monterrey, Nuevo León, Mexico
| | - Jorge Meza-Camacho
- Orthopaedics and Traumatology, Universidad Autónoma de Nuevo León. Hospital Universitario "Dr. José E. González", Ave Madero and Gonzalitos, S/N, Mitras centro, Monterrey, Nuevo León, Mexico
| | - Yadira Tamez-Mata
- Orthopaedics and Traumatology, Universidad Autónoma de Nuevo León. Hospital Universitario "Dr. José E. González", Ave Madero and Gonzalitos, S/N, Mitras centro, Monterrey, Nuevo León, Mexico
| | - Mario Simental-Mendía
- Orthopaedics and Traumatology, Universidad Autónoma de Nuevo León. Hospital Universitario "Dr. José E. González", Ave Madero and Gonzalitos, S/N, Mitras centro, Monterrey, Nuevo León, Mexico
| | - Gregorio Villarreal-Villarreal
- Orthopaedics and Traumatology, Universidad Autónoma de Nuevo León. Hospital Universitario "Dr. José E. González", Ave Madero and Gonzalitos, S/N, Mitras centro, Monterrey, Nuevo León, Mexico
| | - Ricardo Salinas-Garza
- Orthopaedics and Traumatology, Universidad Autónoma de Nuevo León. Hospital Universitario "Dr. José E. González", Ave Madero and Gonzalitos, S/N, Mitras centro, Monterrey, Nuevo León, Mexico
| | - Carlos Acosta-Olivo
- Orthopaedics and Traumatology, Universidad Autónoma de Nuevo León. Hospital Universitario "Dr. José E. González", Ave Madero and Gonzalitos, S/N, Mitras centro, Monterrey, Nuevo León, Mexico.
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Longo UG, Gulotta LV, De Salvatore S, Lalli A, Bandini B, Giannarelli D, Denaro V. Augmented versus non-augmented locking-plate fixation in proximal humeral fractures. Bone Joint J 2024; 106-B:646-655. [PMID: 38945543 DOI: 10.1302/0301-620x.106b7.bjj-2023-1113.r1] [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] [Indexed: 07/02/2024]
Abstract
Aims Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures. Methods The search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles involving patients with complex proximal humeral fractures treated using open reduction with locking-plate fixation, with or without augmentation, were considered. A meta-analysis of comparative studies comparing locking-plate fixation with cement augmentation or with bone-graft augmentation versus locking-plate fixation without augmentation was performed. Results A total of 19 studies were included in the qualitative synthesis, and six comparative studies were included in the meta-analysis. Overall, 120 patients received locking-plate fixation with bone-graft augmentation, 179 patients received locking-plate fixation with cement augmentation, and 336 patients received locking-plate fixation without augmentation. No statistically relevant differences between the augmented and non-augmented cohorts were found in terms of the Disabilities of the Arm, Shoulder and Hand questionnaire score and Constant-Murley Score. The cement-augmented group had a significantly lower rate of complications compared to the non-augmented group. Conclusion While locking-plate fixation with cement augmentation appears to produce a lower complication rate compared to locking-plate fixation alone, functional outcomes seem comparable between augmented and non-augmented techniques.
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Affiliation(s)
- Umile G Longo
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Lawrence V Gulotta
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Sergio De Salvatore
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
- IRCCS Istituto Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Alberto Lalli
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Benedetta Bandini
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Diana Giannarelli
- IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Vincenzo Denaro
- Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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Kodandapani K, Sangani K, Chakrapani A, Vedapriya AK. Optimising safe margins in shoulder surgeries: a cadaveric study on brachial plexus nerves with anthropometric and movement correlation. INTERNATIONAL ORTHOPAEDICS 2024; 48:1809-1813. [PMID: 38558193 DOI: 10.1007/s00264-024-06163-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: 01/17/2024] [Accepted: 03/24/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE Shoulder surgeries, vital for diverse pathologies, pose a risk of iatrogenic nerve damage. Existing literature lacks diverse bone landmark-specific nerve position data. The purpose of this study is to address this gap by investigating such relationships. METHOD This cadaveric study examines axillary, radial and suprascapular nerves' relation with acromion, coracoid and greater tuberosity of the humerus (GT). It also correlates this data with humeral lengths and explores nerve dynamics in relation to arm positions. RESULTS The mean distance from the axillary nerve to (i) GT was 4.38 cm (range 3.32-5.44, SD 0.53), (ii) acromion was 6.42 cm (range 5.03-7.8, SD 0.694) and (iii) coracoid process was 4.3 cm (range 2.76-5.84, SD 0.769). Abduction brought the nerve closer by 0.36 cm, 0.35 cm and 0.53 cm, respectively. The mean distance from radial nerve to (i) GT was 5.46 cm (range 3.78-7.14, SD 0.839), (ii) acromion was 7.82 cm (range 5.4-10.24, SD 1.21) and (iii) tip of the coracoid process was 6.09 cm (range 4.07-8.11 cm, SD 1.01). The mean distance from the suprascapular nerve to the acromion was 4.2 cm (range 3.1-5.4, SD 0.575). The mean humeral length was noted to be 27.83 cm (range 25.3-30.7, SD 1.13). There was no significant correlation between these distances and humeral lengths. CONCLUSION It is essential to exercise caution to avoid axillary nerve damage during the abduction manoeuvre, as its distance from the greater tuberosity and tip of the coracoid process has shown a significant reduction. The safe margins, in relation to the length of the humerus and consequently the patient's stature, exhibit no significant variation. In situations where the greater tuberosity (GT) and the border of the acromion are inaccessible due to reasons such as trauma, the tip of the coracoid process can serve as a dependable bone landmark for establishing a secure surgical margin.
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Affiliation(s)
- K Kodandapani
- Orthopaedic Dept., Osmania General Hospital, Hyderabad, 500012, India
| | - Karthik Sangani
- Orthopaedic Dept., Osmania General Hospital, Hyderabad, 500012, India.
| | - Arjun Chakrapani
- Orthopaedic Dept., Osmania General Hospital, Hyderabad, 500012, India
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Cederwall A, Karlsson MK, Rosengren BE. Time trends in proximal humeral fractures from 1944 to 2020 - A cohort study in Malmö, Sweden. BMC Musculoskelet Disord 2024; 25:491. [PMID: 38914972 PMCID: PMC11194865 DOI: 10.1186/s12891-024-07602-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 06/14/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Most studies infer increasing incidence of proximal humeral fractures (PHF) from the 1950´s until the 1990´s. Recent time trends are less clear. OBJECTIVES Our primary objective was to identify time trends in the age- and sex-adjusted adult incidence of PHF in Malmö, Sweden, from year 1944 until 2020. Our secondary objectives were to describe the variation in incidence according to age, the monthly distribution, and to compare data from the two most recent decades with earlier. STUDY DESIGN AND METHODS Malmö has one emergency hospital where acute fractures are treated. We identified PHF in adult patients (≥ 18 years) by reviewing relevant radiology examinations during 17 sample years from year 1944 to 2020. We used jointpoint analyses to estimate time trends. RESULTS We identified 3 031 PHF during the study period (3 231 161 person years), 73% were sustained by women with mean age of 69 years (mean age in men 59). Joinpoint analyses indicated an increase in the age- and sex-adjusted incidence of PHF from year 1944 (52 per 100 000 person years) until 1977 (120 per 100 000) and thereafter a decrease until 2020 (85 per 100 000). A seasonal variation with more fractures during winter months, was apparent in earlier but not recent decades. CONCLUSIONS The age- and sex-adjusted incidence of PHF increased in Malmö, Sweden, from the 1940´s until year 1977 and thereafter decreased until 2020. More fractures were seen during winter months in earlier but not recent decades.
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Affiliation(s)
- Anton Cederwall
- Clinical and Molecular Osteoporosis Research Unit, Departments of Orthopedics and Clinical Sciences, Skåne University Hospital Malmo and Lund University, Malmö, 205 02, Sweden.
| | - Magnus K Karlsson
- Clinical and Molecular Osteoporosis Research Unit, Departments of Orthopedics and Clinical Sciences, Skåne University Hospital Malmo and Lund University, Malmö, 205 02, Sweden
| | - Björn E Rosengren
- Clinical and Molecular Osteoporosis Research Unit, Departments of Orthopedics and Clinical Sciences, Skåne University Hospital Malmo and Lund University, Malmö, 205 02, Sweden
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Jin S, Lim JR, Yoon TH, Choi YR, Chun YM. Optimal immobilization position for conservative treatment of proximal humerus fractures by fracture type: a biomechanical cadaveric study. Sci Rep 2024; 14:13460. [PMID: 38862648 PMCID: PMC11166630 DOI: 10.1038/s41598-024-64326-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 06/07/2024] [Indexed: 06/13/2024] Open
Abstract
In conservative treatment for proximal humerus fractures (PHFs), the immobilization position of the affected arm should not be determined uniformly. The aim of this study is to investigate the optimal immobilization position for conservative treatment of different types of PHFs. We hypothesized that the optimal position minimizing the deforming force in PHFs depends on the fracture components involved. PHF models involving either the surgical neck (SN) or greater tuberosity (GT) were created using 12 fresh-frozen cadaveric shoulders. In the SN model, the deforming forces on the pectoralis major muscle were measured in full adduction by increasing external rotation. In the GT model, the deforming force of the supraspinatus muscle was measured in neutral rotation by decreasing abduction, and the deforming force of the infraspinatus muscle was measured in full adduction by increasing internal rotation, respectively. In the SN model, the deforming force of the pectoralis major muscle increased significantly with external rotation from full internal rotation to neutral rotation (P = 0.006), indicating that the arm should be placed in full internal rotation. In the GT model, the deforming force of the supraspinatus muscle increased significantly with adduction from 45° of abduction to full adduction (P = 0.006); the deforming force of the infraspinatus muscle increased significantly with internal rotation from neutral rotation to full internal rotation (P = 0.006). These findings should be considered when placing the arm in abduction and neutral rotation so as to minimize the deforming force by either the supra or infraspinatus muscle. In conservative treatment for PHFs, the affected arm should be placed in a position that minimizes the deforming force on the fracture components involved.
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Affiliation(s)
- Seokhwan Jin
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Joon-Ryul Lim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Tae-Hwan Yoon
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Yun-Rak Choi
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Korea.
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Koa J, Fares MY, Daher M, Abboud JA. Assessment of therapeutic clinical trials for proximal humeral fractures. Clin Shoulder Elb 2024; 27:237-246. [PMID: 38556914 PMCID: PMC11181066 DOI: 10.5397/cise.2023.00521] [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: 06/24/2023] [Revised: 09/30/2023] [Accepted: 10/22/2023] [Indexed: 04/02/2024] Open
Abstract
Proximal humeral fractures (PHFs) are a common injury among the older population. An ideal therapeutic protocol has yet to be developed, and numerous clinical trials are being conducted to find the best therapeutic approach. The purpose of this study is to evaluate the current body of knowledge available via interventional clinical trials. In December 2022, interventional clinical trials relating to PHFs on Clinicaltrials.gov were screened. Trial characteristics included duration, status, intervention, phase, outcomes, location, and study design. Publications associated with each trial were searched on PubMed/Medline using the ClinicalTrials.gov registry number. The final dataset comprised 64 trials. The most common trial status was completed (36%). The majority did not have a Food and Drug Administration-defined phase (67%), was randomized (81%), involved a single facility (72%), used a parallel assignment intervention model (80%), and used an open-label approach (45%). Eleven trials were associated with a publication, and the publication rate was 17%. Average enrollment was 86 participants, and mean trial duration was 51.4 months. Europe/UK/Russia/Turkey participated in the most trials (70%). Most of the trials were initiated after 2010 (87.5%). Procedure-related interventions (55%) were most common. Disability/function was the most common primary outcome assessed (61%). The low publication rate and the multitude of trials conducted after 2010 highlight the urgency and need for trial results to be published to establish an ideal therapeutic protocol. Since the majority of the trials involved a single institution and an open-label approach, reinforcing blinding and establishing multi-centered trials can improve the validity of the clinical trial results.
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Affiliation(s)
- Jonathan Koa
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Mohamad Y. Fares
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Mohammad Daher
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Joseph A. Abboud
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Matheron G, Mahoney M, Domos P. Conservative treatment of 3- and 4-part proximal humeral fractures: Can poor outcomes be predicted? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2031-2040. [PMID: 38517527 DOI: 10.1007/s00590-024-03890-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/28/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE 3- and 4-part proximal humeral fractures are frequently treated conservatively. This study aims to combine radiographic, and patient reported outcome data to identify factors leading to poor outcomes following conservative treatment. METHODS A retrospective local database analysis identified 3- and 4-part fractures. Radiographic and functional outcomes including Oxford Shoulder Score (OSS), QuickDash (QD), Subjective Shoulder Score (SSV) and VAS pain scores were collected. RESULTS 104 patients were included at mean follow-up of 55 months. Analysis highlighted significant OSS differences in 3- versus 4-part (p = 0.027), dominant arm injury (p = 0.046), age > 65 (p = 0.006), varus coronal neck-shaft angle < 115 versus 115-155 degrees (p = 0.008), posterior head tilt > 155 degrees (p = 0.005), greater tuberosity (GT) displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.032). According to QD scores; age > 65 (p = 0.012), varus neck-shaft angle (p = 0.01), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.006). SSV varied significantly with 3- versus 4-part fractures (p = 0.005), age > 65 (p = 0.04), varus neck-shaft angle (p = 0.001), posterior head tilt (p = 0.005), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.003), and medial calcar hinge displacement > 2 mm (p = 0.001). CONCLUSION We highlight risk factors for unfavourable outcomes following conservative management, aiding surgeons in shared decision-making and patient expectation management.
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Affiliation(s)
- George Matheron
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK.
| | - Melissa Mahoney
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK
| | - Peter Domos
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK
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Østergaard HK, Launonen AP, Toft M, Fjalestad T, Sumrein BO, Døssing KV, Axelsen MH, Noe SS, Wagle T, Engebretsen KB, Laitinen MK, Mattila VM, Mechlenburg I. Physiotherapist-supervised exercises versus unsupervised home-based exercises after nonsurgically treated proximal humerus fracture: a multicenter randomized controlled trial. J Shoulder Elbow Surg 2024; 33:994-1003. [PMID: 38311103 DOI: 10.1016/j.jse.2023.12.002] [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: 07/13/2023] [Revised: 11/21/2023] [Accepted: 12/04/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Proximal humerus fracture (PHF) is a common fragility fracture in older adults and can have a substantial impact on upper limb function. Although most patients with PHF can be treated nonsurgically, it is unknown whether older adults benefit from supervised exercise therapy after PHF. Therefore, the objective of this trial was to investigate whether 10 weeks of physiotherapist-supervised exercises once a week were superior to 10 weeks of unsupervised home-based exercises in older adults with a nonsurgically treated displaced 2-part PHF. METHODS This was designed as an assessor-blinded, prospective, randomized controlled trial and took place in 3 Nordic countries. In total, 72 patients (≥60 years) with nonsurgically treated displaced 2-part PHF were randomized to either physiotherapist-supervised exercises once a week for 10 weeks, combined with daily home-based exercises, or to 10 weeks of daily unsupervised home-based exercises. The primary outcome measure was the Disability of the Arm, Shoulder, and Hand (DASH) with a primary endpoint at 3 months. Secondary outcomes were DASH (at 12 months), Constant-Murley Score, the 15D-instrument, Visual Analog Scale, General Self-Efficacy Scale, and Pain Catastrophizing Scale, with follow-up visits after 3 and 12 months. Non-union and patient death within 3 months were counted as complications. RESULTS The mean age of the patients in both groups was 72 years. At 3 months follow-up, the mean DASH score in the supervised group was 25.9 (SD 16.0) compared to 22.4 (SD 18.9) in the unsupervised group. The mean between-group difference (3.5, 95% CI -5.0 to 12.5) was not clinically relevant. None of the secondary outcome measures presented any clinically relevant or statistically significant between-group differences at 3 or 12 months follow-up. One patient in the supervised group and 3 in the unsupervised group were diagnosed with non-union. One patient from each group died before 3 months follow-up. CONCLUSIONS This trial provides no evidence that supervised exercises are superior to unsupervised home-based exercises in improving functional outcome or health-related quality of life in older patients with a nonsurgically treated 2-part PHF. Further, our results suggest that most older adults with a nonsurgically treated 2-part PHF can perform home-based exercises without the supervision of a physiotherapist.
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Affiliation(s)
- Helle K Østergaard
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Antti P Launonen
- Department of Orthopaedics, Tampere University Hospital, Tampere, Finland
| | - Marianne Toft
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark
| | - Tore Fjalestad
- Department of Orthopaedics, Oslo University Hospital, Oslo, Norway
| | - Bakir O Sumrein
- Department of Orthopaedics, Tampere University Hospital, Tampere, Finland
| | - Kaj V Døssing
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark
| | - Mette H Axelsen
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark
| | - Sidsel S Noe
- Department of Orthopaedics, Viborg Regional Hospital, Viborg, Denmark
| | - Tone Wagle
- Department of Orthopaedics, Oslo University Hospital, Oslo, Norway
| | - Kaia B Engebretsen
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Minna K Laitinen
- Department of Orthopaedics, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Ville M Mattila
- Department of Orthopaedics, Tampere University Hospital, Tampere, Finland
| | - Inger Mechlenburg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Orthopaedics, Aarhus University Hospital, Aarhus, Denmark
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Fares MY, Boufadel P, Koa J, Vadhera AS, Singh J, Abboud JA. Top fifty cited articles on humeral fractures. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:153-160. [PMID: 38706674 PMCID: PMC11065750 DOI: 10.1016/j.xrrt.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Background Humeral fractures (HF) are common orthopedic pathologies. Reviewing the content and quality of influential literature over time is important to advance scientific research regarding a specific topic. This study aims to explore and appraise the fifty most cited HF studies that had been published in orthopedic literature. Methods The Web of Science database was used to conduct a systematic search for articles pertaining to HF. Articles were sorted out in descending order of citations and were included based on their relevance to HF. Data and metrics of the included studies were recorded. The methodological quality of the studies was assessed using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies criteria. Statistical analysis was conducted to explore any significant relationships between the date of publication and other relevant variables. Results Included articles (N = 50) were published between 1959 and 2015, with a total of 14,864 accumulated citations. Europe and North America contributed to all but one of the included studies. The Journal of Bone and Joint Surgery contributed to the highest number of included articles with 27 articles (54%). The proximal humerus was the most commonly explored HF location in our study (72%). The average MCMS and Methodological Index for Non-randomized Studies scores were reported to be 64.6 and 10.4, respectively, and the majority of articles (52%) were considered level four case series. Year of publication was found to have a positive correlation with increasing level of evidence(r = -0.301, P = .044), citation density (r = 0.734, P < .001), and MCMS score (r = 0.41, P = .01). Conclusion The level of evidence, MCMS scores, and citation density of influential HF literature has been increasing with time, reflecting the increasing effort and work being put in that field. While the findings seem encouraging, additional high-quality research is needed to help achieve better treatment strategies and outcomes.
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Affiliation(s)
- Mohamad Y. Fares
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Peter Boufadel
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Jonathan Koa
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Amar S. Vadhera
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Jaspal Singh
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Joseph A. Abboud
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Nóbrega Catelas D, Correia L, Adan E Silva F, Ribau A, Claro R, Barros LH. Greater tuberosity fractures of the humerus: complications and long-term outcomes after surgical treatment. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-03969-9. [PMID: 38684532 DOI: 10.1007/s00590-024-03969-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/16/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Isolated greater tuberosity (GT) fractures typically occur in younger patients following high-energy trauma compared to humeral neck fractures. Surgical treatment is indicated when superior displacement is > 5 mm. This study aimed to assess the complications and long-term outcomes of surgically-treated GT fractures. METHODS A retrospective review of 39 patients who underwent surgery from 2010 to 2014 was conducted. The cohort comprised 54.6% females, with an average age of 56.74 years and a median follow-up of 6.71 years. Only 25 patients returned for reevaluation, with functional outcomes assessed using Constant-Murley score. RESULTS Women were older than men (63.00 ± 12.15 vs. 48.65 ± 16.93, p = 0.006). 18/39 patients (46.1%) sustained avulsion-type, 1 patient out of 39 (2.6%) depression-type, and 20/39 patients (51.3%) split-type fractures. The mean Constant-Murley score was 84.08 ± 18.36, with higher scores observed in men (p = 0.021). Avulsion-type fractures were related to higher postoperative scores compared to split fractures (p = 0.069). Post-surgical complications occurred in 20.5% of patients, with no differences noted between sexes, fracture types, or procedures. CONCLUSION This study enhances understanding of the long-term outcomes of surgically-treated GT fractures, aiding in treatment selection. Interfragmentary screws may be preferable in younger male patients, but are associated with the higher risk of reintervention, particularly in fragile bone. Prospective multicentric studies are warranted to further elucidate long-term results and treatment strategies.
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Affiliation(s)
- Diogo Nóbrega Catelas
- Department of Orthopedic Surgery, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal.
- School of Medicine and Biomedical Sciences - University of Porto (ICBAS-UP), Porto, Portugal.
| | - Lucinda Correia
- Department of Orthopedic Surgery, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
- School of Medicine and Biomedical Sciences - University of Porto (ICBAS-UP), Porto, Portugal
| | - Filipa Adan E Silva
- Department of Orthopedic Surgery, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
- School of Medicine and Biomedical Sciences - University of Porto (ICBAS-UP), Porto, Portugal
| | - Ana Ribau
- Department of Orthopedic Surgery, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
| | - Rui Claro
- Department of Orthopedic Surgery, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
- Shoulder Unit, Department of Orthopedic Surgery, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- School of Medicine and Biomedical Sciences - University of Porto (ICBAS-UP), Porto, Portugal
| | - Luís Henrique Barros
- Department of Orthopedic Surgery, Centro Hospitalar Universitário de Santo António, 4099-001, Porto, Portugal
- Shoulder Unit, Department of Orthopedic Surgery, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- School of Medicine and Biomedical Sciences - University of Porto (ICBAS-UP), Porto, Portugal
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11
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Nguyen Manh K, Nguyen Van H, Cao Dinh B, Le Xuan H. OUTCOME OF SHOULDER HEMIARTHROPLASTY FOR COMPLEX PROXIMAL HUMERAL FRACTURE IN VIETDUC UNIVERSITY HOSPITAL. Orthop Rev (Pavia) 2024; 16:115587. [PMID: 38586246 PMCID: PMC10994828 DOI: 10.52965/001c.115587] [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: 11/24/2023] [Accepted: 02/05/2024] [Indexed: 04/09/2024] Open
Abstract
ABSTRACTS Translational Study Introduction: The proximal humeral fracture accounts for 4-5% of all fractures1 and traffic accidents are often the main cause of this injury in Vietnam. Shoulder hemiarthroplasty is a suitable option in treating a complex proximal humeral fracture, especially in the elderly, and improves quality of life. This study describes clinical and radiographic characteristics of complex proximal humerus fractures and evaluates the results of shoulder hemiarthroplasty for this type of fracture at Viet Duc University Hospital Materials and methods: A retrospective study of 78 cases with complex proximal humeral fractures underwent shoulder hemiarthroplasty in Viet Duc University Hospital from January 2017 to December 2021. RESULTS Traffic accidents (42 cases, 53.8%); daily-life accidents (34 cases, 43.6%), other causes were less common (2 cases, 2.6%). 74.4% of the patients had no pain, 17.4% mild pain, 7.7% moderate pain, and no patients suffered from severe pain that required regular narcotic analgesics. The mean postoperative Constant score was 67.45 ± 13.20. CONCLUSION In Viet Nam, the most common cause of injury was a traffic accident, primarily occurring in young males with complex proximal humerus fractures, shoulder hemiarthroplasty for complex proximal humerus fractures improves postoperative pain and shoulder function.
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Affiliation(s)
- Khanh Nguyen Manh
- Department of Upper limb surgery and sports medicine Viet Duc Hospital
| | - Hoc Nguyen Van
- Department of Upper limb surgery and sports medicine Viet Duc Hospital
| | - Bang Cao Dinh
- Department of Upper limb surgery and sports medicine Viet Duc Hospital
| | - Hoang Le Xuan
- Department of Upper limb surgery and sports medicine Viet Duc Hospital
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Hameleers A, Boonen B, Most J, Dremmen M, Schotanus MGM, Van Vugt R. Permissive Weight Bearing in Proximal Humeral Fracture Management: A Survey-Based Inquiry in the Netherlands. Cureus 2024; 16:e57670. [PMID: 38707136 PMCID: PMC11070209 DOI: 10.7759/cureus.57670] [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] [Accepted: 04/04/2024] [Indexed: 05/07/2024] Open
Abstract
Purpose Proximal humeral fractures (PHF) are common, particularly among the elderly due to low-energy trauma. Adequate rehabilitation is essential for functional recovery, whether through conservative or surgical treatment. Permissive weight bearing (PWB) is a relatively new rehabilitation concept, characterized by earlier mobilization of the affected limb/joint after trauma. Multiple studies demonstrated the value of PWB for the lower extremities, but this has not been translated to the upper extremity (i.e. PHF). Therefore, our aim was to investigate the current state and variability of rehabilitation of PHF and the role of implementing PWB principles in aftercare. Materials and methods An online survey, comprising 23 questions about the treatment of PHF, was distributed amongst an estimated 800 Dutch orthopaedic and trauma surgeons via the Dutch Orthopaedic and Dutch Trauma Society newsletter from May 2021 until July 2021. Results Among 88 respondents (n=69 orthopaedic, n=17 trauma surgeons, and n=2 other), most recommended early post-trauma mobilization (<6 weeks). Additionally, 53.4% (n=49) advised starting load bearing after six weeks for conservatively treated patients and 59.8% (n=52) for operative treatment. A wide variation of exercises used after immobilization was found in both groups. The usage of a sling after operative treatment was advised by 86% (n=74) of all 86 respondents. Conclusions The present study found limited consensus about PHF aftercare and the implementation of weight-bearing principles. The majority recommended early mobilization and advised the usage of a sling. A protocol capable of accommodating the diversity in aftercare (e.g. fracture type) is essential for maintaining structured rehabilitation, with PWB emerging as a promising example. More prospective studies are needed to form an evidence-based protocol focusing on the aftercare of PHF.
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Affiliation(s)
- Amber Hameleers
- Department of Orthopedic Surgery, Zuyderland Medical Center, Sittard-Geleen, NLD
- Department of Surgery, Maastricht University Medical Center+, Maastricht, NLD
| | - Bert Boonen
- Department of Orthopedic Surgery, Zuyderland Medical Center, Sittard-Geleen, NLD
| | - Jasper Most
- Department of Orthopedic Surgery, Zuyderland Medical Center, Sittard-Geleen, NLD
| | - Martijn Dremmen
- Department of Rehabilitation Medicine, Zuyderland Medical Center, Heerlen, NLD
| | | | - Raoul Van Vugt
- Department of Surgery, Zuyderland Medical Center, Heerlen, NLD
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13
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Goyal S, Ambade R, Singh R, Lohiya A, Patel H, Patel SK, Kanani K. A Comprehensive Review of Proximal Humerus Fractures: From Epidemiology to Treatment Strategies. Cureus 2024; 16:e57691. [PMID: 38711710 PMCID: PMC11070885 DOI: 10.7759/cureus.57691] [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: 12/20/2023] [Accepted: 04/03/2024] [Indexed: 05/08/2024] Open
Abstract
This comprehensive review delves into the intricate landscape of proximal humerus fractures (PHFs), exploring their epidemiology, historical evolution, contemporary classification systems, treatment strategies, and outcome measures. PHFs present a complex orthopedic challenge, necessitating a nuanced understanding of their multifaceted dimensions. Despite their clinical significance, PHFs remain relatively understudied in population-based epidemiology. This review critically examines existing literature to uncover the incidence, prevalence, and demographic patterns associated with these fractures. A foundational understanding of the epidemiological landscape is crucial for effective preventive strategies and optimized fracture management. Tracing back to historical records, the review explores the evolution of diagnostic and therapeutic approaches for PHFs. From ancient treatment modalities documented on the Edwin Smith papyrus to contemporary X-ray-based classifications such as Neer and AO/OTA, a historical context is provided to understand the journey of managing these fractures. Navigating through a spectrum of treatment strategies, the review contrasts nonoperative approaches with various surgical interventions. The challenges and outcomes associated with conservative management are juxtaposed against methods like open reduction internal fixation and tension band osteosynthesis. Evidence synthesis guides clinicians in making informed decisions based on patient characteristics and fracture complexities. Central to assessing PHF management are patient-reported outcome measures. The review explores the significance of instruments such as the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Constant-Murley score in evaluating treatment success. The shift toward subjective measures is discussed, considering their correlation with patient experiences and the concept of minimal clinically important difference. The impact of demographic factors, including age and gender, on PHFs is scrutinized. The association between these fractures and osteoporosis is highlighted, emphasizing the crucial role of bone health in fracture prevention and management. Through this comprehensive exploration, the review provides a robust foundation for understanding, evaluating, and advancing the management strategies for PHFs. The synthesis of historical perspectives, contemporary classifications, and treatment modalities serves as a valuable resource for the orthopedic community, fostering improved clinical decision-making and patient outcomes.
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Affiliation(s)
- Saksham Goyal
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Ratnakar Ambade
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Rahul Singh
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Ashutosh Lohiya
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Hardik Patel
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Siddharth K Patel
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Kashyap Kanani
- Orthopaedics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Hasler A, Ker A, Grubhofer F, El Nashar R, Ernstbrunner L, Gerber C, Wieser K. Clinical and radiographic long-term outcomes of hemiarthroplasty for complex proximal humeral fractures. J Shoulder Elbow Surg 2024; 33:698-706. [PMID: 37611843 DOI: 10.1016/j.jse.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 07/15/2023] [Accepted: 07/21/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Hemiarthroplasty (HA) is a treatment option for complex proximal humeral fractures not suitable for conservative treatment or open reduction-internal fixation. Long-term outcomes using a large-metaphyseal volume prosthesis in the management of proximal humeral fractures have not been reported thus far. METHODS Between 2006 and 2010, 41 patients with proximal humeral fractures were treated with HA at our institution (average age, 62 years; age range, 38-85 years). Nine patients underwent revision surgery, 3 were lost to follow-up, and 7 died unrelated to the index surgical procedure. Twenty-two patients were reviewed clinically and radiographically after a mean period of 10.4 years (range, 9-13 years). RESULTS Of the 9 HA failures, 7 occurred within the first 2 postoperative years: 2 patients had infections and 5 had greater tuberosity nonunions or malunions. The other 2 patients underwent revision for rotator cuff deficiency >5 years after initial surgery. Among the patients available for final follow-up, the implant survival rate was 71% (22 of 31 patients). At final follow-up, these patients showed a mean relative Constant score of 76% (range, 49%-96%), mean active elevation of 116° (range, 60°-170°), and mean external rotation of 28° (range, 0°-55°). The majority had good or excellent internal rotation, with internal rotation to the 12th thoracic vertebra in 13 patients (59%) and to the eighth thoracic vertebra in 7 (31%). The mean Subjective Shoulder Value was 76% (range, 40%-100%). Clinical outcomes did not significantly deteriorate over a period of 10 years, except for flexion (P < .001) and internal rotation (P = .002). On analysis of greater tuberosity healing, 1 patient had a nonunion and 10 patients (45%) had a malunion, whereas the greater tuberosity had healed in an anatomic position in 12 patients (55%). Patients with a displaced malunion of the greater tuberosity did not have inferior clinical results at last follow-up. Only 2 patients showed glenoid erosion, and in no patients could stem loosening be identified at final follow-up. CONCLUSION The revision rate following large-metaphyseal volume HA to treat a proximal humeral fracture was 29% after 10 years postoperatively, with failure within 2 years largely related to greater tuberosity nonunion or malunion and failure later related to rotator cuff insufficiency. Patients with a retained implant showed good clinical and radiographic long-term results, without relevant deterioration over time even when the greater tuberosity healed in a nonanatomic position.
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Affiliation(s)
- Anita Hasler
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Andrew Ker
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.
| | - Florian Grubhofer
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Rany El Nashar
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Lukas Ernstbrunner
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christian Gerber
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopaedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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15
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Claro R, Barros B, Ferreira C, Ribau A, Barros LH. Comparative analysis of proximal humerus fracture management in elderly patients: complications of open reduction and internal fixation by shoulder surgeons and non-shoulder surgeons-a retrospective study. Clin Shoulder Elb 2024; 27:32-38. [PMID: 38268320 PMCID: PMC10938022 DOI: 10.5397/cise.2023.00626] [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: 07/16/2023] [Revised: 09/12/2023] [Accepted: 09/24/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Open reduction and internal fixation (ORIF) with a locking plate is a popular surgical treatment for proximal humeral fractures (PHF). This study aimed to assess the occurrence of complications in elderly patients with PHF treated surgically using ORIF with a locking plate and to investigate the potential differences between patients treated by shoulder surgeons and non-shoulder surgeons. METHODS A retrospective study was conducted using a single-center database to identify patients aged ≥70 years who underwent ORIF for PHF between January 1, 2011, and December 31, 2021. Data on the Neer classification, follow-up, occurrence of avascular necrosis of the humeral head, implant failure, and revision surgery were also collected. Statistical analyses were performed to calculate the overall frequency of complications according to the Neer classification. RESULTS The rates of implant failure, avascular osteonecrosis, and revision surgery were 15.7%, 4.8%, and 15.7%, respectively. Complications were more common in patients with Neer three- and four-part fractures. Although the difference between surgeries performed by shoulder surgeons and non-shoulder surgeons did not reach statistical significance, the rate of complications and the need for revision surgery were nearly two-fold higher in the latter group. CONCLUSIONS PHF are highly prevalent in the elderly population. However, the ORIF surgical approach, as demonstrated in this study, is associated with a considerable rate of complications. Surgeries performed by non-shoulder surgeons had a higher rate of complications and a more frequent need for revision surgery. Future studies comparing surgical treatments and their respective complication rates are crucial to determine the optimal therapeutic options. Level of evidence: III.
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Affiliation(s)
- Rui Claro
- Department of Orthopaedics, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Shoulder Unit, Department of Orthopaedics, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto, Porto, Portugal
| | - Bianca Barros
- Department of Orthopaedics, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Carlos Ferreira
- Department of Orthopaedics, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Department of Orthopaedics, Centro Hospitalar de Leiria, Hospital de Santo André, Leiria, Portugal
| | - Ana Ribau
- Department of Orthopaedics, Centro Hospitalar do Médio Ave, Famalicão, Portugal
| | - Luis Henrique Barros
- Department of Orthopaedics, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Shoulder Unit, Department of Orthopaedics, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar da Universidade do Porto, Porto, Portugal
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16
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Demir Y, Vuorinen A, Gordon M, Nordqvist A, Salomonsson B. Timing of Surgery for Proximal Humeral Fracture Treated with Shoulder Hemiarthroplasty, Best Results with Surgery Within 2 Weeks. Indian J Orthop 2024; 58:162-168. [PMID: 38312897 PMCID: PMC10830992 DOI: 10.1007/s43465-023-01079-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 12/01/2023] [Indexed: 02/06/2024]
Abstract
Background Preoperative delay may affect the outcome of proximal humerus fractures treated with shoulder hemiarthroplasty. There is currently no consensus for the recommended preoperative time interval. The aim was to examine how the time to surgery with shoulder hemiarthroplasty after a proximal humerus fracture affected the patient-reported outcome. Methods 380 patients with proximal humerus fractures treated with shoulder hemiarthroplasty recorded from the Swedish Shoulder Arthroplasty Registry were included. Three self-reporting outcome instruments were used at follow-up after 1-5 years: a shoulder-specific score, the Western Ontario Osteoarthritis of the Shoulder index (WOOS), the EuroQol-5 Dimension index (EQ-5D), and subjective patient satisfaction assessment. Results The preoperative delay had a negative impact on the WOOS, EQ-5D, and patient satisfaction level (p < 0.01). The best result, measured with WOOS at a minimum 1-year follow-up, was found when surgery was performed 6-10 days after the reported date of fracture. WOOS% 8-14 days was 69.4% (± 24.2). A delay of more than 10 days was shown to be correlated with poorer outcomes. WOOS% 15-60 days was 55.8% (± 25.0) and continued to decrease. Conclusion The current recommendation in Sweden to perform shoulder hemiarthroplasty within 2 weeks after sustaining a proximal humerus fracture is considered valid.
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Affiliation(s)
- Yilmaz Demir
- Orthopedic Department, Danderyd Hospital, 182 88 Stockholm, Sweden
- Karolinska Institutet, Stockholm, Sweden
| | | | - Max Gordon
- Orthopedic Department, Danderyd Hospital, 182 88 Stockholm, Sweden
- Karolinska Institutet, Stockholm, Sweden
| | | | - Björn Salomonsson
- Orthopedic Department, Danderyd Hospital, 182 88 Stockholm, Sweden
- Karolinska Institutet, Stockholm, Sweden
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D'Almeida SS, Cannon R, Vu NT, Ponce BA, Redden D. Comparing Intramedullary Nails and Locking Plates in Displaced Proximal Humerus Fracture Management: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e54235. [PMID: 38496197 PMCID: PMC10944142 DOI: 10.7759/cureus.54235] [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] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
This study aims to provide an updated review comparing the complication rates and clinical outcomes of intramedullary nails and locking plates (LPs) in displaced proximal humerus fracture (PHF) management. We performed a systematic review of the Cochrane Central Register of Controlled Trials, Clinical Trials Registry, EMBASE, and PubMed. Studies with level III evidence or higher comparing intramedullary nails and LPs used for internal fixation of displaced PHFs were included. The Methodological Index for Nonrandomized Studies (MINORS) criteria and Cochrane Handbook for Systematic Reviews of Interventions 5.2.0 were used to assess the risk of bias. Our meta-analysis included a comparison of method-related complications, pain scores, range of motion (ROM), and functional scores. A total of 13 comparative studies were included: five randomized controlled trials, three prospective cohort studies, and five retrospective cohort studies. The total number of patients included was 1,253 (677 in the LP group and 576 in the intramedullary nail group). Superior Constant-Murley scores and external rotation ROM were found in the LP group during the early postoperative period. However, long-term functional scores and complication rates were comparable between the two groups. We conclude that intramedullary nailing and LP fixation are both equally effective for the treatment of displaced PHFs. Neither treatment appears superior at this time, and more large-scale randomized controlled trials should be conducted to further evaluate the potential benefit of LPs in the early postoperative period.
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Affiliation(s)
| | - Reily Cannon
- Medicine, Touro College of Osteopathic Medicine, Henderson, USA
| | - Nguyen T Vu
- Medicine, Edward Via College of Osteopathic Medicine, Auburn, USA
| | | | - David Redden
- Research and Biostats, Edward Via College of Osteopathic Medicine, Auburn, USA
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Papalia AG, Romeo PV, Kingery MT, Alben MG, Lin CC, Simcox TG, Zuckerman JD, Virk MS. Trends in the treatment of proximal humerus fractures from 2010 to 2020. J Shoulder Elbow Surg 2024; 33:e49-e57. [PMID: 37659703 DOI: 10.1016/j.jse.2023.07.038] [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: 05/12/2023] [Revised: 07/24/2023] [Accepted: 07/29/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND The incidence of proximal humerus fractures (PHF) is continuing to rise due to shifts towards a more aged population as well as advancements in surgical treatment options. The purpose of this study is to examine and compare trends in the treatment of PHFs (nonoperative vs. operative; different surgical treatments) across different age groups over the last decade (2010-2020). METHODS The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried using International Classification of Diseases and Current Procedural Terminology codes to identify all patients presenting with or undergoing surgery for PHF between 2010 and 2020. Treatment trends, demographics, and insurance information were analyzed during the study period. Comparisons were made between operative and nonoperative trends with respect to the number and type of surgeries performed among 3 age groups: ≤49 years, 50-64 years, and ≥65 years. The rate of postoperative complications and reoperations was evaluated and compared among different surgical treatments for patients with a minimum 1-year postoperative follow-up. RESULTS A total of 92,308 patients with a mean age of 67.8 ± 16.8 years were included. Over the last decade, there was no significant increase in the percentage of PHFs treated with surgery. A total of 15,523 PHFs (16.82%) were treated operatively, and these patients, compared with the nonoperative cohort, were younger (64.9 years vs. 68.4 years, P < .001), more likely to be White (80.2% vs. 74.7%, P < .001), and more likely to have private insurance (41.4% vs. 32.0%, P < .001). For patients ≤49 years old, trends in operative treatment have remained stable with internal fixation (IF) as the most used surgical modality. For patients 50-64 years old, we observed a gradual decline in the use of hemiarthroplasty (HA), with a corresponding increase in the use of reverse total shoulder arthroplasty (rTSA), but IF continued to be the most used operative modality. In patients over 65 years, a steep decline in the use of IF and HA was noted during the first half of the decade along with a significant exponential increase in the use of rTSA, which surpassed the use of IF in 2019. Despite the increase in the use of rTSA, no differences in rate of surgical complications were noted between rTSA and IF (χ2 = 0.245, P = .621) or reoperations (χ2 = 0.112, P = .730). CONCLUSION Nonsurgical treatment remains the mainstay treatment of PHFs. Although there is no increase in the prevalence of operative treatment in patients ≥50 years in the last decade, there is an exponential increase in the use of rTSA with a corresponding decrease in HA and IF, a trend more substantial in patients ≥65 years compared with patients between 50 and 64 years.
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Affiliation(s)
- Aidan G Papalia
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Paul V Romeo
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Matthew T Kingery
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Matthew G Alben
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Charles C Lin
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Trevor G Simcox
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Joseph D Zuckerman
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Mandeep S Virk
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA.
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19
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Kimmeyer M, Schmalzl J, Schmidt E, Graf A, Rentschler V, Gerhardt C, Lehmann LJ. Surgical treatment of fracture sequelae of the proximal humerus according to a pathology-based modification of the Boileau classification results in improved clinical outcome after shoulder arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:757-769. [PMID: 37690026 PMCID: PMC10858156 DOI: 10.1007/s00590-023-03721-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/27/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Fracture sequelae of the proximal humerus were classified by Boileau into four types. Since there are pathomorphological differences and specific characteristics within the four types, we have developed a subclassification. For elderly patients, shoulder arthroplasty is mostly recommended. Based on the available literature and clinical trial results, a subclassification could be created that suggests a specific therapy for each subgroup. The aim of this study was to evaluate the endoprosthetic therapy according to the proposed subclassification and to provide an overview of the clinical and radiological results after endoprosthetic treatment of proximal humerus fracture sequelae. METHODS Patients with fracture sequelae of the proximal humerus who underwent arthroplasty according to the suggestion of the subclassification were included. Minimum time to follow-up was twelve months. General condition and several specific shoulder scores as the Constant-Murley Score (CS) were recorded at the follow-up examination. Complication and revision rates were analyzed. RESULTS In total, 59 patients (72.6 ± 10.0 years, 47 females, 12 males) were included. Mean follow-up time was 31.3 ± 17.0 months. Reverse shoulder arthroplasty was performed in 49 patients and anatomic shoulder arthroplasty was performed in ten patients. The CS increased by 47.3 points from preoperative (15.0) to postoperative (62.3). Good or very good clinical results were seen in 61% of the patients. Complications were observed in twelve (20%) patients and revision surgery was performed in nine (15%) patients. CONCLUSION Due to of the variety of fracture sequelae of the proximal humerus, a modification of the Boileau classification seems necessary. This study shows that endoprosthetic treatment for fracture sequelae can significantly improve the shoulder function in elderly patients. Good clinical results can be achieved with a comparatively low revision rate following the treatment suggestions of the proposed subclassification of the Boileau classification. LEVEL OF EVIDENCE IV Case series.
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Affiliation(s)
- Michael Kimmeyer
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany.
- Alps Surgery Institute, Clinique Générale Annecy, 4 Chemin de La Tour la Reine, 74000, Annecy, France.
| | - Jonas Schmalzl
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, Oberduerrbacher Str. 6, 97080, Würzburg, Germany
| | - Evelin Schmidt
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
- University of Jena, Bachstr. 18, 07743, Jena, Germany
| | - Annika Graf
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Verena Rentschler
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Christian Gerhardt
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Lars-Johannes Lehmann
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
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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.
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Affiliation(s)
| | | | - Christos K Yiannakopoulos
- Department of Orthopaedic Surgery, National and Kapodistrian University of Athens, Athens 11527, Greece
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Kim YJ, Ji JH, Park SE, Parikh D, Lee WJ. Comparison between arthroscopic suture anchor fixation and open plate fixation in the greater tuberosity fracture of the proximal humerus. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:621-631. [PMID: 37668752 DOI: 10.1007/s00590-023-03684-x] [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: 04/16/2023] [Accepted: 08/13/2023] [Indexed: 09/06/2023]
Abstract
INTRODUCTION The purpose of this study is to compare the clinical and radiological outcomes of patients undergoing open reduction and internal fixation (OR/IF) using a plate or patients undergoing an arthroscopic suture anchor fixation for the greater tuberosity (GT) fracture of the proximal humerus. The purpose of this study is to compare the clinical and radiological outcomes of patients undergoing OR/IF or an arthroscopic suture anchor fixation for the GT fracture. MATERIALS AND METHODS Between January, 2010 and December, 2020, 122 patients with GT fracture underwent operative fixation. Either OR/IF using proximal humeral locking plate (50 patients) or arthroscopic suture anchor (72 patients) fixation was performed. Fourteen patients were lost to follow-up and finally, 108 patients were enrolled in this study. We divided these patients into two groups: (1) OR/IF group (Group I: 44 patients) and arthroscopic anchor fixation group (Group II: 64 patients). The primary outcome was subjective shoulder function (shoulder functional scale). Secondary outcomes were range of motion, and complications including GT fixation failure, fracture migration, or neurologic complication. Also, age, sex, BMI, operation time, shoulder dislocation, fracture comminution, AP (anteroposterior), SI (superoinferior) size and displacement were evaluated and compared between two groups. RESULTS Both groups showed satisfactory clinical and radiological outcomes at mid-term follow-up. Between 2 groups, there were no significant differences in age, sex, BMI, presence of shoulder dislocation or comminution. Group II showed higher clinical scores except VAS score (p < 0.05) and longer surgical times (95.3 vs. 61.5 min). Largest fracture displacement (Group I vs. II: SI displacement: 40 vs. 13 mm, and AP displacement: 49 vs. 11 mm) and higher complication rate (p = 0.049) was found in Group I. CONCLUSIONS Both arthroscopic anchor fixation and open plate fixation methods showed satisfactory outcomes at mid-term follow-up. Among them, OR/IF is preferred for larger fracture displacement (> 5 mm) and shorter operation time However, arthroscopic anchor fixation group showed better clinical outcomes and less complications than the OR/IF group. LEVEL OF EVIDENCE Level 4, Case series with subgroup analysis.
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Affiliation(s)
- Young-Jun Kim
- Department of Orthopedic Surgery, Incheon Sejong Hospital, Incheon, South Korea
| | - Jong-Hun Ji
- Department of Orthopedic Surgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 520-2, Daeheung-Dong, Jung-Gu, Daejeon, 301-723, South Korea.
| | - Sang-Eun Park
- Department of Orthopedic Surgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 520-2, Daeheung-Dong, Jung-Gu, Daejeon, 301-723, South Korea
| | - Darshil Parikh
- Department of Orthopedic Surgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 520-2, Daeheung-Dong, Jung-Gu, Daejeon, 301-723, South Korea
| | - Woo-Jin Lee
- Department of Orthopedic Surgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 520-2, Daeheung-Dong, Jung-Gu, Daejeon, 301-723, South Korea
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Lee CH, Kim SY. Effectiveness of locking compression plate for proximal humeral fracture in elderly patients without structural bone grafting: age group of 65-79 compared to 80 and above. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3461-3467. [PMID: 37191886 DOI: 10.1007/s00590-023-03569-z] [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: 03/21/2023] [Accepted: 04/27/2023] [Indexed: 05/17/2023]
Abstract
PURPOSE This study shows the effectiveness of locking compression plate for proximal humeral fractures in elderly patients over 80 years old without structural bone grafting compared age group of 65-79 (Group 1) with 80 and above (Group 2). METHODS This study included sixty-one patients who underwent using locking compression plate for proximal humeral fractures between April 2016 and November 2021. The patients were divided into two groups. The neck shaft angle (NSA) was checked at immediately after surgery, at 1 month and the final follow-up visit. The NSA changes in the two groups were compared using the independent t-test. In addition, multiple regression analysis was used to find out which factors affect NSA changes. RESULTS In group 1, the mean difference between NSA immediately after surgery and 1 month after surgery was 2.74°, and group 2 was 2.89°. In group 1, the mean difference in NSA for 1 month after surgery and at the last follow-up was 1.43°, and group 2 was 1.75°. No significant difference was observed in the NSA changes between two groups (p = 0.59, 0.173). Bone marrow density and four-part fracture type were significant difference in NSA changes (p = 0.003, 0.035). The disabilities of the arm, shoulder and hand scale (DASH scale), age, medical support, diabetes and three-part fracture type were no significant in NSA changes. CONCLUSIONS Using locking compression plate without structural bone grafting is a good option in elderly patients over 80 years old and can help achieve radiological results similar to patients which age group of 67-79.
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Affiliation(s)
- Chul Hyung Lee
- Department of Orthopedics, Daejeon Sun Hospital, 29 Mok-Dong, Jung-gu, Daejeon, 34811, South Korea.
| | - Seo Yul Kim
- Department of Orthopedics, Daejeon Sun Hospital, 29 Mok-Dong, Jung-gu, Daejeon, 34811, South Korea
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Levy HA, Szeto S, O Starks A, Davis DE. Outcomes after salvage reverse shoulder arthroplasty for failed primary fixation or hemiarthroplasty for proximal humerus fractures: A systematic review. Shoulder Elbow 2023; 15:6-18. [PMID: 37974637 PMCID: PMC10649504 DOI: 10.1177/17585732221099200] [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: 12/14/2021] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 11/19/2023]
Abstract
Background Salvage reverse shoulder arthroplasty (RSA) for failed proximal humerus fractures (PHFs) fixation and hemiarthroplasty (HA) may maximize outcomes in the absence of tuberosity healing or a chronically torn rotator cuff. The purpose of this systematic review was to examine the improvement in clinical outcomes for patients after revision RSA was performed for failed PHFs fixation or HA. Methods An electronic database search of SCOPUS, PubMed, Embase, MEDLINE, SPORTDiscus, CINAHL, and ClinicalTrials.gov was performed. A meta-analysis was carried out to determine weighted mean outcome differences between two primary intervention cohorts (failed fixation: open reduction and internal fixation, intramedullary nail, or K-wire vs. failed HA). Results Fifteen studies were included (primary fixation: 208 patients; HA: 162 patients). Patients improved meaningfully in all clinical outcomes after revision surgery (constant: 18.5-48.3; abduction: 44-95; forward flexion: 47-107; external rotation: 5-10), with a 16.2% complication and 9.4% revision rate. The failed fixation group performed significantly better than the failed HA group in postoperative constant (fixation: 53.3 vs. HA: 45.1, p = 0.016) and shoulder abduction (fixation: 102 vs. HA: 87, p = 0.026). Conclusions RSA is a successful revision intervention for primary PHF operative failures with the greatest benefit for failures of primary fixation versus HA.
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Affiliation(s)
- Hannah A Levy
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stanley Szeto
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexandria O Starks
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel E Davis
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
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van Schaardenburgh FE, Nguyen HC, Magré J, Willemsen K, van Rietbergen B, Nijs S. Prediction of the Proximal Humerus Morphology Based on a Statistical Shape Model with Two Parameters: Comparison to Contralateral Registration Method. Bioengineering (Basel) 2023; 10:1185. [PMID: 37892915 PMCID: PMC10604326 DOI: 10.3390/bioengineering10101185] [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: 09/06/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
(1) Background: Complex proximal humerus fractures often result in complications following surgical treatment. A better understanding of the full 3D displacement would provide insight into the fracture morphology. Repositioning of fracture elements is often conducted by using the contralateral side as a reconstruction template. However, this requires healthy contralateral anatomy. The purpose of this study was to create a Statistical Shape Model (SSM) and compare its effectiveness to the contralateral registration method for the prediction of the humeral proximal segment; (2) Methods: An SSM was created from 137 healthy humeri. A prediction for the proximal segment of the left humeri from eight healthy patients was made by combining the SSM with parameters. The predicted proximal segment was compared to the left proximal segment of the patients. Their left humerus was also compared to the contralateral (right) humerus; (3) Results: Eight modes explained 95% of the variation. Most deviations of the SSM prediction and the contralateral registration method were below the clinically relevant 2 mm distance threshold.; (4) Conclusions: An SSM combined with parameters is a suitable method to predict the proximal humeral segment when the contralateral CT scan is unavailable or the contralateral humerus is unhealthy, provided that the fracture pattern allows measurements of these parameters.
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Affiliation(s)
- Florianne E. van Schaardenburgh
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - H. Chien Nguyen
- Department of Orthopaedics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- 3D Lab, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Joëll Magré
- Department of Orthopaedics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- 3D Lab, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Koen Willemsen
- 3D Lab, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Bert van Rietbergen
- Orthopaedic Biomechanics, Department of Biomedical Engineering, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
| | - Stefaan Nijs
- Division Surgical Specialties, Department Trauma Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
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Kimmeyer M, Schmalzl J, Rentschler V, Schieffer C, Macken A, Gerhardt C, Lehmann LJ. Correct positioning of the calcar screw leads to superior results in proximal humerus fractures treated with carbon-fibre-reinforced polyetheretherketone plate osteosynthesis with polyaxial locking screws. J Orthop Traumatol 2023; 24:54. [PMID: 37816859 PMCID: PMC10564686 DOI: 10.1186/s10195-023-00733-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/29/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Plate osteosynthesis with implants made of carbon-fibre-reinforced polyetheretherketone (CFR-PEEK) has recently been introduced for the treatment of fractures of the proximal humerus (PHFs). The advantages of the CFR-PEEK plate are considered to be its radiolucency, its favourable modulus of elasticity, and the polyaxial placement of the screws with high variability of the angle. The primary aim of this study is to investigate the influence of calcar screw positioning on the complication and revision rates after CFR-PEEK plating of PHFs. The secondary aim is to assess its influence on functional outcome. MATERIAL AND METHODS Patients were identified retrospectively. Minimum follow-up was 12 months. The cohort was divided into two groups depending on the distance of the calcar screw to the calcar (group I: < 12 mm, group II: ≥ 12 mm). The range of motion (ROM), Subjective Shoulder Value Score (SSV) and Constant-Murley Score (CS) were analysed at follow-up examination. Subjective complaints, complications (e.g. humeral head necrosis, varus dislocation) and the revision rate were evaluated. RESULTS 51 patients (33 female, 18 male) with an average age of 68.6 years were included after a period of 26.6 months (group I: 32 patients, group II: 19 patients). Apart from the gender distribution, no significant differences were seen in the patient characteristics. The outcome scores showed significantly better clinical results in group I: SSV 83.4 vs 71.2, p = 0.007; CS 79.1 vs 67.8, p = 0.013. Complications were seen less frequently in group I (18.8 % vs 47.4 %, p = 0.030). CONCLUSION This study shows that the positioning of the calcar screw is relevant for CFR-PEEK plate osteosynthesis in PHFs with a good reduction of the fracture. Optimal positioning of the calcar screw close to the calcar (< 12 mm) is associated with a lower rate of complications, resulting in significantly superior functional outcomes. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Michael Kimmeyer
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany.
- Alps Surgery Institute, Clinque Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France.
| | - Jonas Schmalzl
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, Oberduerrbacher Str. 6, 97080, Wuerzburg, Germany
| | - Verena Rentschler
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Christian Schieffer
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Arno Macken
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Alps Surgery Institute, Clinque Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
| | - Christian Gerhardt
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Lars-Johannes Lehmann
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
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Varahra A, MacDermid JC, Szekeres M. A systematic review of biopsychosocial prognostic factors of recovery after a proximal humerus fracture. J Hand Ther 2023; 36:825-844. [PMID: 37481367 DOI: 10.1016/j.jht.2023.06.005] [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: 01/12/2023] [Accepted: 06/02/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Proximal humerus fracture (PHF) is a common upper extremity injury. PHF often causes prolonged disability and interferes with independent function. PURPOSE This study reviewed and summarized prognostic factors of recovery following PHF and classified them within the International Classification of Functioning, Disability and Health (ICF) with each domain sub-categorized by modifiability. STUDY DESIGN Systematic review. METHODS We searched MEDLINE, CINAHL, EMBASE, and PsychINFO from the date of database inception to March 2019 and updated searches in December 2021. Studies included examining an association between prognostic factors and recovery with at least a 6-month follow-up. Two independent reviewers used the Quality in Prognosis Studies tool for methodological bias and levels of evidence. Designs showed wide variability in terms of characteristics of the included population, definition of recovery, assessment of prognostic factors, and outcome measures used. This prevented pooled estimates from being produced. Prognostic factors linked to ICF domains were possible. RESULTS Twenty-three studies including 4323 participants aged ≥18 met inclusion criteria. The risk of bias was low (35%), moderate (30%), and high (35%) across the included studies. Moderate evidence showed a significant association between pre-fracture functional independence and post-fracture complications with recovery. Fracture type, structural deformity, medication use, age, and gender were prognostic factors with inconclusive evidence. We assigned a weak level of evidence to the remaining 20 factors due to limited data. Immediate rehabilitation, compliance to post-fracture rehabilitation exercise, task-oriented exercise, and pain self-efficacy (i.e., coping behavior) are modifiable and are tapped into the ICF contextual factors. CONCLUSIONS An array of factors that fit within an ICF biopsychosocial framework have been investigated as potential mediators of outcomes after PHF. The evidence is incomplete conceptually and in terms of research design quality. Preoperative functional status is predictive of functional recovery emphasizing the importance of healthy aging.
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Affiliation(s)
- Azar Varahra
- Health and Rehabilitation Sciences, Faculty of Health Sciences, Western University, London, Ontario, Canada.
| | - Joy C MacDermid
- Department of Physical Therapy, Faculty of Health Sciences, Western University, London, Ontario, Canada; School of Rehabilitation Science, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
| | - Mike Szekeres
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada; School of Occupational Therapy, Faculty of Health Sciences, Western University, London, Ontario, Canada
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Alzobi OZ, Salman LA, Derbas J, Abudalou A, Hantouly AT, Ahmed G. Epidemiology of proximal humerus fractures in Qatar. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3119-3124. [PMID: 37038016 PMCID: PMC10504139 DOI: 10.1007/s00590-023-03539-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 03/27/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE This study aimed to investigate the epidemiological characteristics and treatment options of proximal humerus fractures at a level one trauma center and to compare our data with the current literature. METHODS A retrospective review was conducted on all patients diagnosed and treated for proximal humerus fractures at Hamad General Hospital, a level one trauma center, between January 2018 and December 2019. Age, gender, mechanism of injury, fracture classification, mode of treatment, implant type, length of hospital stay, associated injuries and complications were analyzed. RESULTS A total of 190 patients with a mean age of 52.4 years were included; 56.8% were males. The incidence of proximal humerus fracture was 4.1/100,000 per year. Falling from a standing height was the most common cause of injury (50.5%). Additionally, Neer's two-part fracture was found to be the most common type (n = 132, 69%). Forty-one patients (21.3%) had other associated injuries. Most fractures were treated nonoperatively with an arm sling (n = 138, 72.6%). CONCLUSION In summary, the incidence of proximal humerus fractures during the two-year study period was found to be 4.1 per 100,000 persons per year. Our results showed a lower incidence of proximal humerus fractures with a predominance of males and younger patients in Qatar's population compared to females and older patients in the developed countries. Our results may contribute to the development of effective strategies for preventing and treating proximal humerus fractures, and can provide important data for further high-level clinical research. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Osama Z Alzobi
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Loay A Salman
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Jawad Derbas
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Abedallah Abudalou
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Ashraf T Hantouly
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar
| | - Ghalib Ahmed
- Department of Orthopaedic Surgery, Surgical Speciality Center, Hamad Medical Corporation, Doha, Qatar.
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Hammes A, Smektala R, Halbach D, Müller-Mai C. [One-year outcomes after proximal humeral fractures : A risk-adjusted regression analysis of routine data based on 17,322 cases]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:870-876. [PMID: 37608117 DOI: 10.1007/s00104-023-01942-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Proximal humeral fractures (PHF) are the third most common fracture in geriatric traumatology. No standard evidence-based treatment has been established so far. The epidemiology and economic burden highlight the importance of a targeted treatment strategy. OBJECTIVE Epidemiology of PHF and analysis of the influence of preoperative length of stay, comorbidities and quality of patient life. Additionally, a comparison to the more frequently studied proximal femoral fractures. MATERIAL AND METHODS A routine data analysis of 17,322 cases admitted for inpatient treatment with an observational period of 1 year was performed following an established model. Descriptive statistics included comorbidities, treatment procedures and mortality. Analytical statistics using logistic regression with the primary endpoints of early revision, mortality and decubitus within 1 year. RESULTS In the investigated PHFs there was a mortality of 13% within 1 year, which is increased three-fold in patients with comorbidities such as cancer. There was an increase of 57% in patients who first received a care level following PHF. A preoperative care level in general significantly decreased survival. The most frequently used surgical procedure was fixation via stable-angle plate (used in 43%). The preoperative length of stay did not impact survival. DISCUSSION Intrinsic factors such as preoperative comorbidities are crucial for the mortality after PHF. The PHF affects patients' lives less than proximal femoral fractures. With comparable comorbidity profiles, possible reasons are the lower levels of immobilization and less dependency on care before the fracture in comparison to proximal femoral fractures.
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Affiliation(s)
- A Hammes
- Klinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland.
| | - R Smektala
- Klinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland
| | - D Halbach
- Knappschaft, Knappschaftstr. 1, 44799, Bochum, Deutschland
| | - C Müller-Mai
- Klinik für Unfallchirurgie und Orthopädie, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland
- Klinik für Unfallchirurgie, Orthopädie und Sportmedizin, St. Marien Hospital, Altstadtstraße 23, 44534, Lünen, Deutschland
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Varahra A, MacDermid JC, Szekeres M, Walton D, Faber KJ. Understanding individuals' perspectives and experiences of recovery following a proximal humerus fracture: an interpretive description. Disabil Rehabil 2023; 45:3476-3483. [PMID: 36250673 DOI: 10.1080/09638288.2022.2134469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 09/17/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Proximal humerus fractures are common in older adults and optimizing their outcomes following this injury can be challenging. This study explored recovery from the perspective of individuals who experience proximal humerus fracture. MATERIALS AND METHODS We conducted in-depth semi-structured interviews (n = 14) with participants (aged 45 and over) recruited from a hand clinic in London, Ontario using a purposive sampling technique. The exploratory interviews were audio-recorded, transcribed, and analyzed using interpretive description approach. RESULTS Four themes emerged from the narratives of individuals: challenges of day-to-day activities, coping as you go, recapturing valued life roles, and support matters. CONCLUSIONS Recovery after PHF seems relative to contexts and manifests within numerous scenarios. Based on individuals' narratives, the context produces a mosaic that contributes to unique recovery perception and experience. Awareness of the context emphasizes the complexity inherent in recovery and may guide healthcare professionals' efforts toward care for their patients.IMPLICATIONS FOR REHABILITATIONIndividuals with proximal humerus fracture experience recovery as a personal and dynamic process occurring in their diverse contexts.Healthcare professionals need to recognize the significant impact of context on individuals' physical, emotional, and social life following proximal humerus fracture (PHF).A multidisciplinary treatment plan might be desirable where people with PHF and health care professionals collaborate as a whole.Building a multidisciplinary health team including healthcare professionals, peer support, and case management may remove some barriers and facilitate the transition to recovery.
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Affiliation(s)
- Azar Varahra
- Bruyère Research Institute, Ottawa, Canada
- Health and Rehabilitation Sciences, University of Western Ontario, London, Canada
| | - Joy C MacDermid
- Physical Therapy and Surgery, Western University, London, Canada
- Hand and Upper Limb Centre, St. Joseph's Health Centre, London, Canada
- Rehabilitation Science McMaster University, Hamilton, Canada
| | - Mike Szekeres
- Lawson Health Research Institute, St. Joseph's Health Centre, London, Canada
- Hand Therapy Canada, London, Canada
| | - David Walton
- School of Physical Therapy, Western University, London, Canada
| | - Kenneth J Faber
- Department of Surgery, Western University, Roth ‖ McFarlane Hand & Upper Limb Center, St. Joseph's Health Care, London, Canada
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Foruria AM. Plate Fixation of Proximal Humerus Fractures: How to Get It Right and Future Directions for Improvement. Curr Rev Musculoskelet Med 2023; 16:457-469. [PMID: 37572239 PMCID: PMC10497484 DOI: 10.1007/s12178-023-09853-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE OF REVIEW Open reduction and internal fixation with locking plates (ORIF-LP) has been used for decades for the surgical management of proximal humerus fractures. Despite good outcomes have been widely published in the literature, unacceptably high rates of complications (up to 40%), many of them yielding poor outcomes and requiring reoperation (up to 25%), have also been reported, especially in elderly patients. Most common complications are related to implant failure, with intra-articular screw penetration as the most frequent and devastating. RECENT FINDINGS Advances in patient selection and surgical technique, and implementation of bone or cement augmentation, have been developed to hopefully decrease complication rates. Mayo-FJD Classification offers prognostic information that can aid in the decision-making process for proximal humeral fractures. Displaced valgus impacted fractures seem to be associated with well over a 10% rate of avascular necrosis after ORIF-LP. A principle-based and stepwise surgical technique combining anatomic reduction and a short screw configuration can provide good outcome in most patients, even the elderly, decreasing implant failures to less than 10%. Acrylic cement augmentation has the potential to further decrease implant failure rate to 1%. Reoperation rates are higher partly due to the need to remove hardware for painful subacromial conflict. However, no studies to date definitively demonstrated the superiority of ORIF-LP compared to non-operative treatment, intramedullary nailing, or reverse shoulder arthroplasty. ORIF-LP can provide good results for the surgical management of displaced proximal humerus fractures even in elderly patients provided adequate patient selection and a principle based and stepwise surgical technique, supplemented with bone graft or acrylic cement when needed. Poor outcomes and high complication and reoperation rates should be expected when these recommendations are not followed.
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Affiliation(s)
- Antonio M Foruria
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery, Autónoma University, Fundación Jiménez Díaz University Hospital, Avenida Reyes Católicos 2, Madrid, Spain.
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Zhelev D, Hristov S, Zderic I, Ivanov S, Visscher L, Baltov A, Ribagin S, Stoffel K, Kralinger F, Winkler J, Richards RG, Varga P, Gueorguiev B. Treatment of Metaphyseal Defects in Plated Proximal Humerus Fractures with a New Augmentation Technique-A Biomechanical Cadaveric Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1604. [PMID: 37763723 PMCID: PMC10536689 DOI: 10.3390/medicina59091604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/25/2023] [Accepted: 08/31/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Unstable proximal humerus fractures (PHFs) with metaphyseal defects-weakening the osteosynthesis construct-are challenging to treat. A new augmentation technique of plated complex PHFs with metaphyseal defects was recently introduced in the clinical practice. This biomechanical study aimed to analyze the stability of plated unstable PHFs augmented via implementation of this technique versus no augmentation. Materials and Methods: Three-part AO/OTA 11-B1.1 unstable PHFs with metaphyseal defects were created in sixteen paired human cadaveric humeri (average donor age 76 years, range 66-92 years), pairwise assigned to two groups for locked plate fixation with identical implant configuration. In one of the groups, six-milliliter polymethylmethacrylate bone cement with medium viscosity (seven minutes after mixing) was placed manually through the lateral window in the defect of the humerus head after its anatomical reduction to the shaft and prior to the anatomical reduction of the greater tuberosity fragment. All specimens were tested biomechanically in a 25° adduction, applying progressively increasing cyclic loading at 2 Hz until failure. Interfragmentary movements were monitored by motion tracking and X-ray imaging. Results: Initial stiffness was not significantly different between the groups, p = 0.467. Varus deformation of the humerus head fragment, fracture displacement at the medial humerus head aspect, and proximal screw migration and cut-out were significantly smaller in the augmented group after 2000, 4000, 6000, 8000 and 10,000 cycles, p ≤ 0.019. Cycles to 5° varus deformation of the humerus head fragment-set as a clinically relevant failure criterion-and failure load were significantly higher in the augmented group, p = 0.018. Conclusions: From a biomechanical standpoint, augmentation with polymethylmethacrylate bone cement placed in the metaphyseal humerus head defect of plated unstable PHFs considerably enhances fixation stability and can reduce the risk of postoperative complications.
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Affiliation(s)
- Daniel Zhelev
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
- Department of Orthopedics and Traumatology, University Hospital for Active Treatment, 8018 Burgas, Bulgaria;
| | - Stoyan Hristov
- Department of Orthopedics and Traumatology, University Hospital for Active Treatment, 8018 Burgas, Bulgaria;
| | - Ivan Zderic
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
| | - Stoyan Ivanov
- Department of Orthopaedics and Traumatology, Medical University of Varna, 9002 Varna, Bulgaria;
| | - Luke Visscher
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
- School of Medicine, Queensland University of Technology, Brisbane 4000, Australia
| | - Asen Baltov
- Department of Trauma Surgery, University Multiprofile Hospital for Active Treatment and Emergency Medicine ‘N. I. Pirogov’, 1606 Sofia, Bulgaria;
| | - Simeon Ribagin
- Department of Health Pharmaceutical Care, Medical College, University ‘Prof. Dr. Asen Zlatarov’, 8010 Burgas, Bulgaria;
| | - Karl Stoffel
- Department of Orthopaedics and Traumatology, University Hospital Basel, 4031 Basel, Switzerland;
| | - Franz Kralinger
- Department of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria;
- Trauma and Sports Department, Ottakring Clinic, Teaching Hospital, Medical University of Vienna, 1160 Vienna, Austria
| | - Jörg Winkler
- Cantonal Hospital Graubuenden, 7000 Chur, Switzerland;
| | - R. Geoff Richards
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
| | - Peter Varga
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
| | - Boyko Gueorguiev
- AO Research Institute Davos, 7270 Davos, Switzerland; (D.Z.); (I.Z.); (L.V.); (R.G.R.); (P.V.)
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Cheng T, Galicia K, Patel PP, Anstadt MJ, Gonzalez RP, Kubasiak J. A nationwide analysis of geriatric proximal humerus fractures: trends, outcomes, and cost. Trauma Surg Acute Care Open 2023; 8:e001055. [PMID: 37533777 PMCID: PMC10391795 DOI: 10.1136/tsaco-2022-001055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 06/16/2023] [Indexed: 08/04/2023] Open
Abstract
Background In the USA, proximal humerus fractures (PHF) are the third most common fracture among the elderly. Although most geriatric PHF are treated conservatively, surgical management remains an option. This retrospective study compares annual trends, patient outcomes, and hospital costs between operatively and non-operatively managed geriatric PHF. Methods The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was queried from 2012 to 2015. Geriatric patients with PHF were identified and those who underwent operative or non-operative management were compared in trends, outcomes and costs. Results In total, 137 810 patients met inclusion criteria, of which 51 795 (37.6%) underwent operative management. The operative cohort was younger (76.6 vs 80.9, p<0.001) with a greater proportion of females (81.8% vs 77.6%, p<0.001). The operative cohort demonstrated less frailty and lower Elixhauser Comorbidity Scores (both p<0.001). The operative cohort was also more likely to be discharged home (30.4% vs 13.9%, p<0.001). There was no significant linear trend in age-adjusted and sex-adjusted proportions of operative versus non-operative geriatric PHF (p=0.071), but a positive linear trend was statistically significant for total cost of operative geriatric PHF (p<0.001). Multivariable analyses demonstrated similar overall complication rates between cohorts (OR 0.95, 95% CI 0.89 to 1.00; p=0.06), although surgical intervention increased length of stay (LOS) by 0.15 days (95% CI 0.03 to 0.27; p<0.001) and median cost of hospitalization by US$10 684 (95% CI US$10 384 to US$10 984; p<0.001). Conclusions This study identifies a positive linear trend in total cost of operatively managed geriatric PHF from 2012 to 2015. Operative management of geriatric PHF is associated with a similar overall complication rate and greater likelihood of being discharged home. Although non-operative management is associated with decreased LOS and hospital expenses, providers should consider surgical PHF treatment options when available and appropriate in the context of patient-focused outcomes, particularly long-term disposition after intervention. Level of Evidence This level IV retrospective study identifies.
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Affiliation(s)
- Teresa Cheng
- Department of Surgery, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA
| | - Kevin Galicia
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA
- Burn and Shock Trauma Research Institute, Loyola University Medical Center, Maywood, Illinois, USA
| | - Purvi P Patel
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Michael J Anstadt
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Richard P Gonzalez
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA
- Burn and Shock Trauma Research Institute, Loyola University Medical Center, Maywood, Illinois, USA
| | - John Kubasiak
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois, USA
- Burn and Shock Trauma Research Institute, Loyola University Medical Center, Maywood, Illinois, USA
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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.
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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
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Barati H, Afzal S. Successful treatment of a multifocal comminuted open fracture of humerus with severe soft tissue defect: a case report. J Med Case Rep 2023; 17:261. [PMID: 37357304 DOI: 10.1186/s13256-023-03989-9] [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: 03/09/2023] [Accepted: 05/17/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Choosing the appropriate treatment approach for a multifocal comminuted open fracture of humerus with severe soft tissue defect is a challenging issue, which could be interesting for every orthopedic surgeon especially for those working in the trauma centers. CASE PRESENTATION This study described an innovative approach using titanium elastic nailing to treat a multifocal comminuted open fracture of humerus with severe soft tissue defect. In this study, we report a 40-year-old Persian female patient in whom the treatment achieved complete fracture union and skin graft healing by elastic medullary nailing, vacuum dressing, and skin grafting. CONCLUSIONS Elastic medullary nailing is a viable option for reconstruction of simultaneous comminuted fracture and soft tissue defect.
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Affiliation(s)
- Hasan Barati
- Department of Orthopedic surgery, School of Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sina Afzal
- Department of Orthopedic surgery, School of Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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35
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Baker HP, Gutbrod J, Cahill M, Shi L. Optimal Treatment of Proximal Humeral Fractures in the Elderly: Risks and Management Challenges. Orthop Res Rev 2023; 15:129-137. [PMID: 37396822 PMCID: PMC10312335 DOI: 10.2147/orr.s340536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/20/2023] [Indexed: 07/04/2023] Open
Abstract
Proximal humeral fractures (PHFs) are a common type of fracture, particularly in older adults, accounting for approximately 5-6% of all fractures. This article provides a comprehensive review of PHFs, focusing on epidemiology, injury mechanism, clinical and radiographic assessment, classification systems, and treatment options. The incidence of PHFs varies across regions, with rates ranging from 45.7 to 60.1 per 100,000 person-years. Females are more susceptible to PHFs than males, and the incidence is highest in women over the age of 85. The injury mechanism of PHFs is typically bimodal, with high-energy injuries predominant in younger individuals and low-energy injuries in the elderly. Clinical assessment of PHFs involves obtaining a thorough history, physical examination, and evaluation of associated injuries, particularly neurovascular injuries. Radiographic imaging helps assess fracture displacement and plan for treatment. The Neer classification system is the most commonly used classification for PHFs, although other systems, such as AO/OTA, Codman-Hertel, and Resch classifications, also exist. The choice of treatment depends on factors such as patient age, activity level, fracture pattern, and surgeon expertise. Nonoperative management is typically preferred for elderly patients with minimal displacement, while operative fixation is considered for more complex fractures. Nonoperative treatment involves sling immobilization followed by physiotherapy, with good outcomes reported for certain fracture patterns. Operative management options include closed reduction and percutaneous pinning (CRPP), open reduction and internal fixation (ORIF), or arthroplasty. CRPP is suitable for specific fracture patterns, but the quality of reduction is crucial for favorable outcomes. ORIF is used when CRPP is not feasible, and various surgical approaches are available, each with its advantages and potential complications. PHFs are a significant clinical challenge due to their prevalence and complexity. Treatment decisions should be patient centered based on patient factors and fracture severity.
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Joseph Gutbrod
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Michael Cahill
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
| | - Lewis Shi
- Department of Orthopaedic Surgery, the University of Chicago, Chicago, IL, USA
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Demir Y, Sjöberg H, Stark A, Salomonsson B. Western Ontario Osteoarthritis of the Shoulder Index (WOOS) - a validation for use in proximal humerus fractures treated with arthroplasty. BMC Musculoskelet Disord 2023; 24:450. [PMID: 37268955 DOI: 10.1186/s12891-023-06578-5] [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: 03/13/2023] [Accepted: 05/29/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND The Swedish shoulder and Arthroplasty Registry (SSAR) use the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) as their shoulder-specific score in the follow-up. WOOS is not yet validated for use as the Patient Reported Outcome Measurement (PROM) for proximal humerus fractures (PHF) treated with shoulder hemiarthroplasty (SHA) in the Swedish registry. The aim of this study was to examine the validity, the reliability and the responsiveness of WOOS as a PROM for proximal humerus fractures treated with shoulder arthroplasty. METHODS Data was collected from the SSAR from the 1st of January 2008 to the 31st of June 2011. A total of 72 subjects were identified with at least 1 year of follow-up. Of these 43 completed all the shoulder-specific PROM together with a clinical examination, including a WOOS retest and general health scores. A group of 29 did not undergo any clinical examination, but they completed all the questionnaires not requiring a clinical examination. The validity was assessed with WOOS compared to satisfaction level, and the Spearman rank coefficient was used for the correlation between WOOS and the shoulder-specific scores (Constant-Murley Score, Oxford Shoulder Score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form and EQ-5D. For reliability, Intra Class Correlation (ICC) was used for the test-retest assessment and Cronbach´s alpha for the construct reliability. RESULTS The validity for WOOS had an excellent correlation (> 0.75) with all the shoulder-specific scores and a good correlation (> 0.6) with EQ-5D. The reliability with the test-retest of the total WOOS score and the subgroups had an excellent correlation. Cronbach´s alpha also supports the construct of WOOS. There were no floor or ceiling effects. CONCLUSIONS We found that WOOS is a reliable tool for evaluating patients with SHA after PHF. Based on our study, we recommend the continued use of WOOS in shoulder arthroplasty registries and observational studies.
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Sheng N, Shi T, Wang Q, Wang L, Chen Y. Nonanatomic healing of the greater tuberosity after plating in proximal humeral fractures: a case control study. J Orthop Surg Res 2023; 18:374. [PMID: 37208767 DOI: 10.1186/s13018-023-03811-8] [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: 06/25/2022] [Accepted: 04/23/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Open reduction and plate internal fixation (ORIF) is one of the most common treatment methods for proximal humeral fractures. Complications associated with the greater tuberosity (GT) are rarely reported, therefore, the purpose of this study was to analyze the complications associated with the GT and the risk factors after locked-plate internal fixation. METHODS We retrospectively analyzed the medical and radiographic data of patients with proximal humeral fractures involving the GT treated with locking plates between January 2016 and July 2019. We divided all patients into two groups, the anatomic GT healing group and the nonanatomic GT healing group, depending on the radiographic outcomes of the GT. Clinical outcome was assessed by the Constant scoring system. Potential risk factors included preoperative and intraoperative factors. Preoperative factors included sex, age, body mass index, fracture type, fracture-dislocation, proximal humeral bone mineral density, humeral head extension, hinge integrity, comminuted GT, volume and surface area of the main GT fragment, and displacement of the main GT fragment. Intraoperative factors were adequate medial support, residual head-shaft displacement, head-shaft angle and residual GT displacement. Univariate logistic regression and multivariate logistic regression were used to identify risk factors. RESULTS There were 207 patients (130 women and 77 men; mean age, 55 years). GT anatomic healing was observed in 139 (67.1%) patients and nonanatomic healing in 68 (32.9%). Patients with GT nonanatomic healing had significantly inferior Constant scores than those with GT anatomic healing (75.0 ± 13.9 vs. 83.9 ± 11.8, P < 0.001). Patients with high GT malposition had worse Constant scores than patients with low GT malposition (73.3 ± 12.7 vs. 81.1 ± 11.4, P = 0.039). The multivariate logistic model showed that GT fracture characteristics were not risk factors for nonanatomic GT healing, while residual GT displacement was. CONCLUSIONS Nonanatomic healing of the GT is a high-rate complication of proximal humeral fractures, resulting in inferior clinical outcomes, especially for high GT malposition. Fracture characteristics of the GT are not risk factors for GT nonanatomic healing and GT comminution should not be regarded as a contraindication to ORIF for proximal humeral fractures.
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Affiliation(s)
- Ning Sheng
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, People's Republic of China
| | - Tingwang Shi
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, People's Republic of China
| | - Qiuke Wang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, People's Republic of China
| | - Lei Wang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, People's Republic of China.
| | - Yunfeng Chen
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, People's Republic of China.
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Dewarrat A, Terrier A, Barimani B, Vauclair F. Comparison of the ALPS and PHILOS plating systems in proximal humeral fracture fixation - a retrospective study. BMC Musculoskelet Disord 2023; 24:371. [PMID: 37165381 PMCID: PMC10170861 DOI: 10.1186/s12891-023-06477-9] [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: 06/17/2022] [Accepted: 04/29/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Open reduction and plate osteosynthesis are considered as a successful technique for the treatment of proximal humerus fracture (PHF) despite high complication rates. The objective of our study was to review the clinical outcome and complications of the Anatomic Locking Plate System (ALPS) and compare it to the Proximal Humeral Internal Locking System (PHILOS). Our hypothesis was that ranges of motion (ROM) were superior and complication rates were lower with ALPS. METHODS Twenty patients treated with ALPS for PHF were retrospectively compared to 27 patients treated with PHILOS. Union, ROM and complications were clinically and radiologically assessed at 6 weeks, 3, 6, 12 and 18-24 months post-operatively. RESULTS Mean age was 52 ± 14 in the ALPS group and 58 ± 13 in the PHILOS group. Last follow-ups were conducted at a mean of 20.6 ± 4.8 months. Mean shoulder abduction was superior with ALPS by 14° (p-value = 0.036), 15° (p-value = 0.049), and 15° (p-value = 0.049) at 3, 6, and 12 months respectively. Mean shoulder external rotation was superior with ALPS by 11° (p-value = 0.032), 15° (p-value = 0.010) and 12° (p-value = 0.016) at 6 weeks, 3 and 6 months respectively. At the end of the follow-up, ROM remained better with ALPS, but not significantly. Complication rates over 21 months reached 20% with ALPS and 48% with PHILOS (p-value = 0.045). Implant removal rates reached 10% with ALPS and 37% with PHILOS (p-value = 0.036). Avascular necrosis was the only cause for hardware removal in the ALPS group. CONCLUSION The ALPS group showed better clinical outcomes with faster recovery in abduction and external rotation, although no difference in ROM remained after 21 months. Additionally, the complications rate was lower at last follow up. In our experience, the ALPS plating system is an effective management option in some PHF.
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Affiliation(s)
| | - Alexandre Terrier
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
- Laboratory of Biomechanical Orthopedics, Ecole Polytechnique Fédérale de Lausanne (EPFL), Station 9, 1015, Lausanne, Switzerland
| | - Bardia Barimani
- Division of Orthopedic Surgery, McGill University, Montreal, QC, Canada
- University of Toronto, Toronto, Canada
| | - Frédéric Vauclair
- University of Lausanne, Lausanne, Switzerland
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
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Chang HH, Lim JR, Lee KH, An H, Yoon TH, Chun YM. The biomechanical effect of fibular strut grafts on humeral surgical neck fractures with lateral wall comminution. Sci Rep 2023; 13:3744. [PMID: 36879028 PMCID: PMC9988971 DOI: 10.1038/s41598-023-30935-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 03/03/2023] [Indexed: 03/08/2023] Open
Abstract
No studies have evaluated the effect of fibular strut augmentation on the stability of locking plate fixation for osteoporotic proximal humeral fractures with lateral wall comminution. The purpose of this study was to evaluate the stability of locking plate fixation with a fibular strut graft compared with locking plate alone in an osteoporotic two-part surgical neck fracture model with lateral cortex comminution. Ten paired fresh-frozen cadaveric humeri were randomly allocated into two groups, either the locking plate alone (LP group) or locking plate with fibular strut graft augmentation (LPFSG group), with an equal number of right and left osteoporotic surgical neck fractures with lateral wall comminution of the greater tuberosity. Varus, internal/external torsion, and axial compression stiffness as well as single load to failure were measured in plate-bone constructs, and the LPFSG group showed significantly greater values in all metrics. In conclusion, this biomechanical study shows that fibular strut augmentation significantly enhances varus stiffness, internal torsion stiffness, external torsion stiffness, and maximum failure load of a construct compared to locking plate fixation alone in proximal humeral fractures with lateral wall comminution.
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Affiliation(s)
- Hsien-Hao Chang
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Sinchon-dong, Seodaemun-gu, Seoul, 03722, Korea
| | - Joon-Ryul Lim
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Sinchon-dong, Seodaemun-gu, Seoul, 03722, Korea
| | - Kil-Han Lee
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Sinchon-dong, Seodaemun-gu, Seoul, 03722, Korea
| | - Haemosu An
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Sinchon-dong, Seodaemun-gu, Seoul, 03722, Korea
| | - Tae-Hwan Yoon
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Sinchon-dong, Seodaemun-gu, Seoul, 03722, Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Sinchon-dong, Seodaemun-gu, Seoul, 03722, Korea.
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Tuberculum-majus-Frakturen. ARTHROSKOPIE 2023. [DOI: 10.1007/s00142-023-00598-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Early Outcomes of Proximal Humerus Fractures in Adults Treated With Locked Plate Fixation Compared with Nonoperative Treatment: An Age-, Comorbidity-, and Fracture Morphology-Matched Analysis. J Orthop Trauma 2023; 37:142-148. [PMID: 36730947 DOI: 10.1097/bot.0000000000002511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To compare patient-reported outcomes (PROs), range of motion (ROM), and complication rates for proximal humerus fractures managed nonoperatively or with open reduction internal fixation (ORIF). DESIGN Retrospective cohort. SETTING Academic level 1 trauma center. PATIENTS/PARTICIPANTS Four hundred thirty-one patients older than 55 years were identified retrospectively. 122 patients were excluded. 309 patients with proximal humerus fractures met inclusion criteria (234 nonoperative and 75 ORIF). After matching, 192 patients (121 nonoperative and 71 ORIF) were included in the analysis. INTERVENTION Nonoperative versus ORIF (locked plate) treatment of proximal humerus fracture. MAIN OUTCOME MEASUREMENTS Early Visual Analog Score (VAS), ROM, PROs, complications, and reoperation rates between groups. RESULTS At 2 weeks, ORIF showed lower VAS scores, better passive ROM, and patient-reported outcomes measurement information system (PROMIS) scores ( P < 0.05) compared with nonoperative treatment. At 6 weeks, open reduction internal fixation (ORIF) had lower VAS scores, better passive ROM, and PROMIS scores ( P < 0.05) compared with nonoperative treatment. At 3 months, ORIF showed similar PROMIS scores ( P > 0.05) but lower VAS scores and better passive ROM ( P < 0.05) compared with nonoperative treatment. At 6 months, ORIF showed similar VAS scores, ROM, and PROMIS scores ( P > 0.05) compared with nonoperative treatment. There was no difference in secondary operation rates between groups ( P > 0.05). ORIF patients trended toward a higher secondary reoperation rate (15.5% vs. 5.0%) than nonoperative patients ( P = 0.053). CONCLUSIONS In an age-, comorbidity-, and fracture morphology-matched analysis of proximal humerus fractures, ORIF led to decreased pain and improved passive ROM early in recovery curve compared with nonoperative treatment that normalized after 6 months between groups. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Mys K, Visscher L, van Knegsel KP, Gehweiler D, Pastor T, Bashardoust A, Knill AS, Danker C, Dauwe J, Mechkarska R, Raykov G, Karwacki GM, Knobe M, Gueorguiev B, Windolf M, Lambert S, Nijs S, Varga P. Statistical Morphology and Fragment Mapping of Complex Proximal Humeral Fractures. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020370. [PMID: 36837571 PMCID: PMC9966327 DOI: 10.3390/medicina59020370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 02/17/2023]
Abstract
Background and Objectives: Proximal humerus fractures (PHFs) are common in the elderly, but the treatment results are often poor. A clear understanding of fracture morphology and distribution of cortical bone loss is important for improved surgical decision making, operative considerations, and new implant designs. The aim of this study was to develop a 3D segmentation fracture mapping technique to create a statistical description of the spatial pattern and cortical bone loss of complex PHFs. Materials and Methods: Fifty clinical computed tomography (CT) scans of complex PHFs and their contralateral intact shoulders were collected. In-house software was developed for semi-automated segmentation and fracture line detection and was combined with manual fracture reduction to the contralateral template in a commercial software. A statistical mean model of these cases was built and used to describe probability maps of the fracture lines and cortical fragments. Results: The fracture lines predominantly passed through the surgical neck and between the tuberosities and tendon insertions. The superior aspects of the tuberosities were constant fragments where comminution was less likely. Some fracture lines passed through the bicipital sulcus, but predominantly at its edges and curving around the tuberosities proximally and distally. Conclusions: A comprehensive and systematic approach was developed for processing clinical CT images of complex fractures into fracture morphology and fragment probability maps and applied on PHFs. This information creates an important basis for better understanding of fracture morphology that could be utilized in future studies for surgical training and implant design.
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Affiliation(s)
- Karen Mys
- AO Research Institute Davos, 7270 Davos, Switzerland
| | - Luke Visscher
- AO Research Institute Davos, 7270 Davos, Switzerland
- Royal Brisbane and Women’s Hospital, 4029 Brisbane, Australia
- Centre for Biomedical Technologies, Queensland University of Technology, 4000 Brisbane, Australia
| | - Kenneth Petrus van Knegsel
- AO Research Institute Davos, 7270 Davos, Switzerland
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Luzerne, Switzerland
| | | | - Torsten Pastor
- AO Research Institute Davos, 7270 Davos, Switzerland
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Luzerne, Switzerland
| | | | | | | | - Jan Dauwe
- AO Research Institute Davos, 7270 Davos, Switzerland
- Department of Trauma Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Rayna Mechkarska
- AO Research Institute Davos, 7270 Davos, Switzerland
- University Multiprofile Hospital for Active Treatment and Emergency Medicine “N. I. Pirogov”, 1606 Sofia, Bulgaria
| | - Georgi Raykov
- AO Research Institute Davos, 7270 Davos, Switzerland
- Medical University of Varna ‘‘Prof. Dr. Paraskev Stoyanov’’, 9002 Varna, Bulgaria
| | - Grzegorz Marek Karwacki
- Department of Radiology and Nuclear Medicine, Lucerne Cantonal Hospital, 6000 Luzerne, Switzerland
| | - Matthias Knobe
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Luzerne, Switzerland
| | | | | | - Simon Lambert
- University College London Hospital, London NW1 2BU, UK
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
- University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Peter Varga
- AO Research Institute Davos, 7270 Davos, Switzerland
- Correspondence:
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Walter N, Szymski D, Kurtz SM, Lowenberg DW, Alt V, Lau E, Rupp M. Proximal humerus fractures - epidemiology, comparison of mortality rates after surgical versus non-surgical treatment, and analysis of risk factors based on Medicare registry data. Bone Joint Res 2023; 12:103-112. [PMID: 36718643 PMCID: PMC9950668 DOI: 10.1302/2046-3758.122.bjr-2022-0275.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
AIMS The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate? METHODS PHFs occurring between 1 January 2009 and 31 December 2019 were identified from the Medicare physician service records. Incidence rates were determined, mortality rates were calculated, and semiparametric Cox regression was applied, incorporating 23 demographic, clinical, and socioeconomic covariates, to compare the mortality risk between treatments. RESULTS From 2009 to 2019, the incidence decreased by 11.85% from 300.4 cases/100,000 enrollees to 266.3 cases/100,000 enrollees, although this was not statistically significant (z = -1.47, p = 0.142). In comparison to matched Medicare patients without a PHF, but of the same five-year age group and sex, a mean survival difference of -17.3% was observed. The one-year mortality rate was higher after nonoperative treatment with 16.4% compared to surgical treatment with 9.3% (hazard ratio (HR) = 1.29, 95% confidence interval (CI) 1.23 to 1.36; p < 0.001) and to shoulder arthroplasty with 7.4% (HR = 1.45, 95% CI 1.33 to 1.58; p < 0.001). Statistically significant mortality risk factors after operative treatment included age older than 75 years, male sex, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, chronic kidney disease, a concomitant fracture, congestive heart failure, and osteoporotic fracture. CONCLUSION Mortality risk factors for distinct treatment modes after PHF in elderly patients could be identified, which may guide clinical decision-making.Cite this article: Bone Joint Res 2023;12(2):103-112.
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Affiliation(s)
- Nike Walter
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Dominik Szymski
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Steven M. Kurtz
- Implant Research Center, Drexel University, Philadelphia, Pennsylvania, USA
| | - David W. Lowenberg
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Edmund Lau
- Exponent Inc, Menlo Park, California, USA
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Regensburg, Germany, Markus Rupp. E-mail:
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Kimmeyer M, Schmalzl J, Rentschler V, Jessen M, Gerhardt C, Lehmann LJ. Functional results and unfavorable events after treatment of proximal humerus fractures using a new locking plate system. BMC Musculoskelet Disord 2023; 24:63. [PMID: 36694169 PMCID: PMC9872058 DOI: 10.1186/s12891-023-06176-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/18/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Proximal humerus fractures are often treated with a fixed-angle titanium plate osteosynthesis. Recently, plates made of alternative materials such as carbon fibre-reinforced polyetheretherketone (CFR-PEEK) have been introduced. This study presents the postoperative results of patients treated with a CFR-PEEK plate. METHODS Patients with proximal humerus fractures treated with a CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) were included. In follow-up examination, age and gender adjusted Constant-Murley Score (ACS), Subjective Shoulder Value (SSV), Quick Disabilities of the Arm, Shoulder and Hand Score (QDASH) and pain score (Visual Analog Scale (VAS)) were analyzed. General condition at follow-up was measured by European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L). Range of motion was recorded. In addition, radiographs at follow-up, unfavorable events and revision rate were analyzed. RESULTS In total, 98 patients (66.0 ± 13.2 years, 74 females, 24 males) were reexamined. Mean follow-up was 27.6 ± 13.2 months. There were 15 2-part, 28 3-part and 55 4-part fractures. The functional scores showed good results: SSV 83.3 ± 15.6%, QDASH 13.1 ± 17.0 and ACS 80.4 ± 16.0. A 4-part-fracture, head split component, nonanatomic head shaft reposition and preoperative radiological signs of osteoarthritis were significant negative predictors for poorer clinical scores. Unfavourable events were observed in 27 patients (27.6%). Revision surgery was performed in 8 (8.2%) patients. Risk factors for an unfavourable event were female gender, age of 50 years and older, diabetes, affected dominant hand, 4-part fracture, head split and preoperative radiological signs of osteoarthritis. CONCLUSION There are several advantages of the CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) such as the polyaxial screw placement and higher stability of locking screws. In summary, the CFR-PEEK plate osteosynthesis is a good alternative with comparable clinical results and some biomechanical advantages. Proximal humerus fractures show good clinical results after treatment with a CFR-PEEK plate. The revision rate and the risk of unfavorable events are not increased compared to conventional titanium plate osteosynthesis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Michael Kimmeyer
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeuserstr. 18, 76135 Karlsruhe, Germany
| | - Jonas Schmalzl
- grid.411760.50000 0001 1378 7891Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, Oberduerrbacher Str. 6, 97080 Wuerzburg, Germany
| | - Verena Rentschler
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeuserstr. 18, 76135 Karlsruhe, Germany
| | - Malik Jessen
- grid.6936.a0000000123222966Department of Trauma Surgery, University Clinic Rechts Der Isar, Technical University Munich, Ismaninger Str. 22, D-81675 Munich, Germany
| | - Christian Gerhardt
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeuserstr. 18, 76135 Karlsruhe, Germany
| | - Lars-Johannes Lehmann
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeuserstr. 18, 76135 Karlsruhe, Germany
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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.
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Patel R, Brown JR, Miles JW, Dornan GJ, Bartolomei C, Dey Hazra RO, Vidal LB, Millett PJ. Preventing varus collapse in proximal humerus fracture fixation: 90-90 dual plating versus endosteal fibular allograft strut. Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04738-1. [PMID: 36598604 DOI: 10.1007/s00402-022-04738-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/13/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Screw cut out and varus collapse are the most common complication of locked plate fixation of proximal humerus fractures. The purpose of this study was to compare dual plating and endosteal fibular allograft struts as augmentation strategies to prevent varus collapse. MATERIALS AND METHODS A trapezoidal osteotomy was created at the metaphysis to create a 2-part proximal humerus model in 18 paired shoulder specimens. Each specimen was assigned to group A, B, or C and was fixed with either a lateral locking plate, a lateral locking plate and anterior one-third tubular plate in an orthogonal 90/90 configuration, or a lateral locking plate with intramedullary fibular strut, respectively. The specimens were stressed in axial compression to failure. Displacement, elastic limit, ultimate load, and stiffness were recorded and calculated. RESULTS There was no difference in mean cyclic displacement between the three groups (0.71 mm vs 0.89 mm vs 0.61 mm for Group A, B, C, respectively). Lateral plating demonstrated the greatest absolute and relative displacement at the elastic limit (5.3 mm ± 1.5 and 4.4 mm ± 1.3) without significance. The elastic limit or yield point was greatest for fibular allograft, Group C (1223 N ± 501 vs 1048 N ± 367 for Group B and 951 N ± 249 for Group A) without significance. CONCLUSIONS Dual plating of proximal humerus fractures in a 90-90 configuration demonstrates similar biomechanical properties as endosteal fibular strut allograft. Both strategies demonstrate superior stiffness to isolated lateral locked plating.
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Affiliation(s)
- Ravi Patel
- Steadman Philippon Research Institute, 181 W. Meadow Dr. Ste 1000, Vail, CO, 81657, USA
| | - Justin R Brown
- Steadman Philippon Research Institute, 181 W. Meadow Dr. Ste 1000, Vail, CO, 81657, USA
| | - Jon W Miles
- Steadman Philippon Research Institute, 181 W. Meadow Dr. Ste 1000, Vail, CO, 81657, USA
| | - Grant J Dornan
- Steadman Philippon Research Institute, 181 W. Meadow Dr. Ste 1000, Vail, CO, 81657, USA
| | | | - Rony-Orijit Dey Hazra
- Steadman Philippon Research Institute, 181 W. Meadow Dr. Ste 1000, Vail, CO, 81657, USA
| | - Leslie B Vidal
- Steadman Philippon Research Institute, 181 W. Meadow Dr. Ste 1000, Vail, CO, 81657, USA
| | - Peter J Millett
- Steadman Philippon Research Institute, 181 W. Meadow Dr. Ste 1000, Vail, CO, 81657, USA.
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Schuette HB, Starcher NJ, Goubeaux CC, DeGenova DT, Triplet JJ, Mehta S, Taylor BC. Reverse shoulder arthroplasty for proximal humerus fractures: a comparison of the deltoid split and deltopectoral approaches. Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04746-1. [PMID: 36596991 DOI: 10.1007/s00402-022-04746-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 12/23/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Reverse shoulder arthroplasty (RSA) is a common treatment for three- and four-part proximal humerus fractures. RSA is commonly performed through a deltopectoral (DP) surgical approach; however, a deltoid split (DS) approach has been described. The purpose of this study was to compare the intraoperative and postoperative outcomes of patients undergoing RSA for proximal humerus fractures through a DP and DS approach. MATERIALS AND METHODS A retrospective study of patients who underwent RSA for proximal humerus fractures at our level 1 trauma center was performed. Patients were evaluated at a minimum 1-year follow-up. Intraoperative outcomes as well as patient-reported outcome measures (PROMs) were analyzed. Postoperative complications, reoperation rates, and radiographic outcomes were evaluated. RESULTS Sixteen patients were included in the DP group and 13 patients in the DS group. The average follow-up was 28.6 months in the DP group and 21.1 months in the DS group. There were no significant differences in patient demographics or injury characteristics. Operative time was significantly shorter in the DS group (103 min) compared to the DP group (123 min). Tuberosity repair was performed in 81.3% of patients in the DP group and 92.3% of patients in the DS group. No significant differences were found in PROMs at final follow-up. There were no significant differences in postoperative complications. Three patients in the DP group and one patient in the DS group required reoperation. Lastly, 81.8% of patients achieved tuberosity union in the DS group and 66.7% in the DP group; however, this did not reach statistical significance. CONCLUSION This study demonstrates that RSA for proximal humerus fractures performed through a DS or DP approach may result in similar intraoperative and postoperative outcomes, with no difference in reoperation or complication rates.
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Affiliation(s)
- Hayden B Schuette
- Department of Orthopedic Surgery, OhioHealth/Doctors Hospital, 5100 West Broad Street, Columbus, OH, 43228, USA.
| | - Nathaniel J Starcher
- Department of Orthopedic Trauma, OhioHealth/Grant Medical Center, Columbus, OH, USA
| | - Craig C Goubeaux
- Department of Orthopedic Surgery, OhioHealth/Doctors Hospital, 5100 West Broad Street, Columbus, OH, 43228, USA
| | - Daniel T DeGenova
- Department of Orthopedic Surgery, OhioHealth/Doctors Hospital, 5100 West Broad Street, Columbus, OH, 43228, USA
| | - Jacob J Triplet
- Department of Orthopedic Surgery, Indiana University Health, Muncie, IN, USA
| | - Sanjay Mehta
- Department of Orthopedic Trauma, OhioHealth/Grant Medical Center, Columbus, OH, USA
| | - Benjamin C Taylor
- Department of Orthopedic Trauma, OhioHealth/Grant Medical Center, Columbus, OH, USA
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Martinez-Catalan N. Conservative Treatment of Proximal Humerus Fractures: When, How, and What to Expect. Curr Rev Musculoskelet Med 2022; 16:75-84. [PMID: 36562923 PMCID: PMC9889589 DOI: 10.1007/s12178-022-09817-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW The key question to answer during the decision-making process for proximal humerus fractures (PHF) is whether the amount of displacement of a specific fracture pattern will be acceptable taking into account the anticipated demands on the patient. The aim of this review article was to provide some clarity regarding the features that contribute to poor clinical outcomes when PHF are treated non-operatively and to review the reported outcomes of conservative treatment. RECENT FINDINGS Conservative treatment for non-displaced or minimally displaced fractures leads to good outcomes in 80% to 90% of patients. However, with increasing fracture complexity and displacement, functional outcomes tend to diminish. In active patients with significant functional demands, the challenge is to predict which fractures will do poorly when treated non-operatively. A better understanding of fracture patterns and fragment displacement may improve treatment indications. To avoid complications related to conservative treatment, surgery should be considered (1) in fractures in which the humeral head is severely compromised (due to fracture-dislocation, severe impaction, or a split of the head itself), (2) in non-impacted fractures with gross instability between the humeral shaft and humeral head, and (3) in those cases in which displacement of the tuberosities or the final shape of the proximal humerus after healing will lead to symptomatic malunion.
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Affiliation(s)
- Natalia Martinez-Catalan
- Department of Orthopaedics and Traumatology, Hospital Fundación Jimenez Diaz, Avenida de los Reyes Catolicos 2, 28040 Madrid, Spain
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Pisitwattanaporn P, Saengpetch N, Thamyongkit S, Wanitchanont T, Sa-Ngasoongsong P, Aroonjarattham P. Additional cuff suture provides mechanical advantage for fixation of split-type greater tuberosity fracture of humerus. Injury 2022; 53:4033-4037. [PMID: 36424688 DOI: 10.1016/j.injury.2022.10.016] [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: 07/16/2022] [Revised: 10/07/2022] [Accepted: 10/14/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Split type of greater tuberosity fracture has variety of surgical treatment options. This study aimed to compare the biomechanics property of additional cuff suture and other fracture fixation techniques. METHODS Fifteen porcine humeri were categorized into three groups of fixation techniques those were proximal humeral internal locking system (PHILOS) plate with 2 cuff sutures, nonlocking (conventional, 3.5 mm) T-plate with 2 cuff sutures and T-plate with washer that had additional cuff suture (novel technique). Fracture was created by greater tuberosity osteotomy with 50˚ inclination to the line of surgical neck and then fixed with different prescribed techniques. Displacement of fracture site was measured with universal testing machine. The maximum forces to produce 3 mm, 5 mm of displacement and load to failure were recorded. RESULTS The average loads to reach 3 mm, 5 mm displacement and failure were 30.8 N, 45.4 N and 161 N for nonlocking T-plate; 76.6 N, 99.2 N and 144 N for PHILOS plate; 95.8 N, 120 N and 197 N for novel technique. The differences among three groups were significant in load to displacement at 3 and 5 mm (but not significant in load to failure). For load to reach 3- and 5-mm displacement, PHILOS plate and novel technique were significantly stronger than nonlocking T-plate (P < 0.05). For load to reach 3 and 5 mm displacement, novel technique was stronger than PHILOS plate but not significant (P > 0.05). For load to failure, novel technique was stronger than nonlocking plate and PHILOS plate but not significant (P < 0.05). CONCLUSION The important factors affecting the strength of fracture fixation are type of plate and numbers of suture augmentation that tie to the plate. Fixation with additional cuff suture showed the superior biomechanics of load to reach 3 mm, 5 mm displacement with better load to failure compared with PHILOS plate and conventional T-plate alone.
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Affiliation(s)
- Pathomchat Pisitwattanaporn
- Department of Orthopedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.
| | - Nadhaporn Saengpetch
- Department of Orthopedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.
| | - Sorawut Thamyongkit
- Department of Orthopedics, Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10540, Thailand.
| | - Thitiphol Wanitchanont
- Department of Orthopedics, Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan 10540, Thailand.
| | - Paphon Sa-Ngasoongsong
- Department of Orthopedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.
| | - Panya Aroonjarattham
- Department of Mechanical Engineering, Faculty of Engineering, Mahidol University, Nakornpathom 73170, Thailand.
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Spek RWA, Kim L. What is the interobserver agreement of displaced humeral surgical neck fracture patterns? Clin Shoulder Elb 2022; 25:304-310. [PMID: 36330721 PMCID: PMC9727487 DOI: 10.5397/cise.2022.01025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/06/2022] [Indexed: 12/04/2022] Open
Abstract
Background: The Boileau classification distinguishes three surgical neck fracture patterns: types A, B, and C. However, the reproducibility of this classification on plain radiographs is unclear. Therefore, we questioned what the interobserver agreement and accuracy of displaced surgical neck fracture patterns is categorized according to the modified Boileau classification. Does the reliability to recognize these fracture patterns differ between orthopedic residents and attending surgeons?Methods: This interobserver study consisted of a randomly retrieved series of 30 plain radiographs representing clinical practice in a level 1 and a level 2 trauma center. Radiographs were included from patients (≥18 years) who sustained an isolated displaced surgical neck fracture if they were taken ≤1 week after initial injury. A ground truth was established by consensus among three senior orthopedic surgeons. All images were assessed by 17 orthopedic residents and 17 attending orthopedic trauma surgeons.Results: Agreement for the modified Boileau classification was fair (κ=0.37; 95% confidence interval [CI], 0.36–0.38) with an accuracy of 62% (95% CI, 57%–66%). Comparison of interobserver variability between residents and attending surgeons revealed a significant but clinically irrelevant difference in favor of attending surgeons (0.34 vs. 0.39, respectively, Δ κ=0.05, 95% CI, 0.02–0.07).Conclusions: The modified Boileau classification yields a low interobserver agreement with an unsatisfactory accuracy in a panel of orthopedic residents and attending surgeons. This supports the hypothesis that surgical neck fractures are challenging to categorize and that this classification should not be used to determine prognosis if only plain radiographs are available.
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