Reverse total shoulder arthroplasty versus hemiarthroplasty for proximal humeral fractures: a systematic review

Mid- to long-term outcome of reverse total shoulder arthroplasty as revision procedure for failed hemiarthroplasty after proximal humerus fracture

BACKGROUND

Insufficient tuberosity healing is the most common reason for poor outcome after treatment of proximal humerus fractures (PHFs) using hemiarthroplasty (HA). In these cases, revision to reverse total shoulder arthroplasty (RTSA) can improve function and reduce pain in the short term, however, long-term results remain scarce. Aim of this study was to evaluate the clinical and radiological mid- to long-term results in patients with a revision RTSA after failed HA for PHF.

METHODS

In this retrospective study all patients that received a revision to RTSA after failed fracture HA between 2006 and 2018 were included. A total of 49 shoulders in 48 patients (38 female, 10 male; mean age 82 ± 9 years) were identified in our database. A total of 20 patients (17 female, 3 male; mean age was 79 ± 9 years) were available for follow-up examination after a mean time period of approximately eight years (3-14 years) after revision surgery. At final follow-up, patients were assessed using a subjective shoulder value (SSV), range of motion (ROM), visual analogue score (VAS), the Constant Score (CS) and the 12-Item Short Form Survey (SF-12).

RESULTS

At final follow-up, mean CS was 55 ± 19 (19-91), VAS averaged 3 ± 3 (0-8) and mean SSV was 61 ± 18% (18-90%). Mean SF-12 was 44 (28-57) with a mean physical component summary (PCS) of 38 (21-56) and a mean mental component summary (MCS) of 51 (29-67). On average active forward flexion (FF) was 104° (10-170°), active abduction (ABD) was 101° (50-170°), active external rotation (ER) was 19° (10-30°) and active internal rotation (IR) of the lumbosacral transition was reached. Three patients presented with a periprosthetic humeral fracture after RTSA implantation and underwent a reoperation (15%) during follow-up period.

CONCLUSIONS

Revision RTSA results in promising clinical results in patients after initial failed HA after PHF. A complication and reoperation rate of 15% is tolerable in consideration of satisfactory functional and psychological outcome.

TRIAL REGISTRATION

Retrospectively registered.

Comparison of Short Uncemented Metaphyseal Stem and Long-Stem Reverse Shoulder Arthroplasty in Proximal Humerus Fractures: Preliminary Study at 2-Year Follow-Up

Introduction: In the last few years, short metaphyseal-socket prosthetic humeral stems have been introduced for reverse shoulder arthroplasty (RSA). A short stem may have advantages in humeral force distribution, reducing shear stress and preserving bone stock, keeping in mind the need for possible future revision surgery. The main objective of our study was to validate the use of a short stem prosthesis in the surgical treatment of humeral fractures by comparing clinical and radiological outcomes of our studied implant with those obtained with the use of traditional long-stem implants. Methods: In this multicentric, controlled prospective study, 125 patients with proximal three- or four-fragment humerus fractures were selected and treated with RSA. A short stem was used in group A (n = 53, mean age: 75.6 ± 5.6 years old), and a long stem was used in group B (n = 72, mean age: 71.76 ± 3). Active range of motion (ROM), Constant score (CS), Quick DASH, American Shoulder and Elbow Surgeons Shoulder (ASES) score, and Visual Analog Scale (VAS) scores were collected and analyzed at 2 years mean follow-up, as well as humeral and glenoid bone resorption (sum Inoue scores and Sirveaux scores were used). Results: No statistically significant differences were observed between group A and B in ROM, Constant score (51.69 ± 15.8 vs. 53.46 ± 15.96, p > 0.05), Quick DASH (31.5 ± 21.81 vs. 28.79 ± 13.72, p = 0.85), ASES (82.53 ± 17.79 vs. 84.34 ± 15.24, p = 0.57), or the VAS (0.53 ± 1 vs. 0.56 ± 1.07, p = 0.14) at the final follow-up. No statistically significant differences were found in the radiographic parameters between the two groups. No statistically significant differences were found for the average degree of humeral and glenoid bone resorption either. Conclusions: The use of a short metaphyseal-socket stem can be considered a safe, effective, and feasible option in reverse shoulder arthroplasty for treating proximal humerus fractures. Our results are encouraging, with no statistically significant differences identified between the proposed treatment and traditional long stems.

Postoperative outcomes of third-generation shoulder hemiarthroplasties for three-and four-part proximal humeral fractures: A systematic review of published studies from 2012 to 2022

Background

The aim of this study was to provide up-to-date evidence on the outcomes for hemiarthroplasties (HAs) that were performed using modern third-generation prostheses (post-2004) for isolated (excluding head-splits and fracture-dislocations) three-and four-part proximal humerus fractures (PHFs).

Methods

PubMed, Medline, Embase and the Cochrane register were searched from January 1, 2012, to November 15, 2022, conforming to the PRISMA guidelines. The outcome measures were the complication rates, revision rates, surgery-related postoperative mortality, post-operative clinical outcome scores and radiological outcomes.

Results

432 hemiarthroplasties in 432 patients were performed across the 11 eligible studies (two prospective and 9 retrospective). Three studies compared HA versus reverse shoulder replacement (RSR); one study compared HA with locking plate fixation (LPF) and RSR; one study compared HA with LPF. 61.1 % and 19.4 % of hemiarthroplasties were performed using cemented and uncemented techniques respectively, while cementing data was ill-defined in 19.4 % of shoulders. The results for the outcome measures have been derived directly from the included studies and no statistical pooling was performed, due to heterogeneity in the different study designs and outcomes. Descriptive data synthesis from the included studies showed that third generation HAs have higher overall postoperative complication rates, with similar revision and mortality rates when compared to RSR and LPF for three-and four-part PHFs. RSR and LPF showed better statistically significant improvements than HA for the Constant-Murley score, Quick DASH, forward flexion and abduction. Mixed results were observed for the DASH score, ASES score and internal rotation ROM between RSR/LPF versus HA.

Conclusion

Low to moderate quality evidence from this review showed that even third-generation HA prostheses provided worse overall outcomes than RSR and LPF for three-and four-part PHFs.

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

Background

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

Methods

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

Results

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

Conclusion

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

How do surgeons decide when to treat proximal humerus fractures with operative versus nonoperative management?

PURPOSE

The objective of this study was to determine the underlying factors that drive the decision for surgeons to pursue operative versus nonoperative management for proximal humerus fractures (PHF) and if fellowship training had an impact on these decisions.

METHODS

An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons Society to assess differences in patient selection for operative versus nonoperative management of PHF. Descriptive statistics were reported for all respondents.

RESULTS

A total of 250 fellowship trained Orthopaedic Surgeons responded to the online survey. A greater proportion of trauma surgeons preferred nonoperative management for displaced PHF fractures in patients over the age of 70. Operative management was preferred for older patients with fracture dislocations (98%), limited humeral head bone subchondral bone (78%), and intraarticular head split (79%). Similar proportions of trauma surgeons and shoulder surgeons cited that acquiring a CT was crucial to distinguish between operative and nonoperative management.

CONCLUSION

We found that surgeons base their decisions on when to operate primarily on patient's comorbidities, age, and the amount of fracture displacement when treating younger patients. Further, we found a greater proportion of trauma surgeons elected to proceed with nonoperative management in patients older than the age of 70 years old as compared to shoulder surgeons.

Outcomes after salvage reverse shoulder arthroplasty for failed primary fixation or hemiarthroplasty for proximal humerus fractures: A systematic review

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.

Poor evidence is used to support commercial payers' coverage policies for shoulder arthroplasty

BACKGROUND

The incidence of shoulder arthroplasty has continued to increase over the past decade. In response, commercial payers have implemented strategies to control the medical requirement of these surgeries in attempt to contain the growing costs. For example, most payers require a prolonged trial of conservative management prior to shoulder arthroplasty for patients who may otherwise be surgical candidates. However, little is known regarding the evidence used to support these indications. The purpose of this study was to analyze the references used by commercial payers to substantiate their coverage policies for shoulder arthroplasty.

METHODS

Ten of the leading commercial payers for total shoulder arthroplasty were identified. Publicly available coverage policies were searched on the internet or requested directly from the payer via email or telephone. Cited references were reviewed independently by two authors for type of document, level of evidence, and mention of the efficacy of conservative management.

RESULTS

A total of 5 coverage policies were obtained with 118 references. The most common reference type was primary journal article (n = 70; 59.3%) followed by review or expert opinion articles (n = 35; 29.7%). Most references were of level IV evidence (n = 60; 52.2%), with only 6 (5.2%) of level I or II evidence. Only 4 (3.5%) references mentioned the efficacy of conservative management in patients who may be candidates for shoulder arthroplasty.

CONCLUSION

The majority of references used to substantiate the coverage policies for shoulder arthroplasty among major commercial payers within the United States are of low scientific evidence and fail to demonstrate the success of required nonoperative intervention strategies. Our study underscores the need for high-quality, comparative trials that evaluate the outcomes of conservative management vs. shoulder arthroplasty in end-stage glenohumeral osteoarthritis patients in order to determine the most cost-effective treatment algorithm.

Anatomic greater tuberosity healing does not influence the functional outcomes of reverse shoulder arthroplasty for acute proximal humerus fractures

Background

To investigate the functional outcomes of reverse shoulder arthroplasty (RSA) in acute complex proximal humerus fractures (PHF) in patients with an anatomic greater tuberosity union in comparison to patients with a displaced or resorbed tuberosity.

Method

It is a retrospective study with prospective data collection including 32 consecutive PHF with a minimum two-year follow-up treated with RSA. A radiological study and a CT scan were performed specifically for the study. Two shoulder surgeons and a musculoskeletal radiologist assessed the position and union of the greater tuberosity. The functional outcomes were assessed with the Constant-Murley, DASH, ASES and ADLER scores.

Results

The mean overall CS was 59.55. In 17 cases, the greater tuberosity healed in an anatomical position. In 15 cases, it was non-anatomical. In 53% of patients, greater tuberosity union was obtained. The CS was 62.76 in the anatomic union group and 55.9 in the non-anatomic union group. No significant differences were observed. No differences were observed in the ASES, DASH and ADLER scores.

Conclusion

After RSA for PHF, anatomic greater tuberosity healing was obtained in 53% of patients. The influence of the position and union of the greater tuberosity on the functional results could not be evidenced.

Brachial plexus deficits in patients undergoing shoulder arthroplasty

Background

Nerve deficit following shoulder arthroplasty can cause significant morbidity. We examined the incidence and pattern of nerve injury following shoulder arthroplasty in a University Hospital.

Methods

Retrospective review of all patients undergoing shoulder arthroplasty over a five-year period (September 2014 to August 2019). Patients were identified using clinical codes and relevant data extracted by review of patient records. We excluded patients with preoperative nerve injuries.

Results

220 arthroplasties were performed in 210 patients. The overall nerve deficit rate was 2.3% (5/220). Five nerve deficits occurred following reverse total shoulder arthroplasty (rTSA). In two patients, nerve recovery occurred within 12 months. Two patients had persistent deficits at 12 months. One patient had a deficit at seven months, but incomplete follow up. There was no clear documentation of discussions with clinicians specialising in nerve injury.

Conclusion

Nerve injury rates in our series for rTSA are low and comparable to systematic review data. We purport that for rTSA, adequate soft tissue releases, careful arm positioning and retraction alongside limiting over-lowering the centre of rotation may prevent nerve injuries. A postoperative nerve deficit should warrant an opinion from a specialist in nerve surgery with clear referral pathways to allow efficient access to services.

Reverse shoulder arthroplasty versus hemiarthroplasty versus non-surgical treatment for older adults with acute 3- or 4-part fractures of the proximal humerus: study protocol for a randomised controlled trial (PROFHER-2: PROximal Fracture of Humerus Evaluation by Randomisation - Trial Number 2)

BACKGROUND

Proximal humerus fractures (PHF) are common and painful injuries, with the majority resulting from falls from a standing height. As with other fragility fractures, its age-specific incidence is increasing. Surgical treatment with hemiarthroplasty (HA) and reverse shoulder arthroplasty (RSA) have been increasingly used for displaced 3- and 4-part fractures despite a lack of good quality evidence as to whether one type of arthroplasty is superior to the other, and whether surgery is better than non-surgical management. The PROFHER-2 trial has been designed as a pragmatic, multicentre randomised trial to compare the clinical and cost-effectiveness of RSA vs HA vs Non-Surgical (NS) treatment in patients with 3- and 4-part PHF.

METHODS

Adults over 65 years of age presenting with acute radiographically confirmed 3- or 4-part fractures, with or without associated glenohumeral joint dislocation, who consent for trial participation will be recruited from around 40 National Health Service (NHS) Hospitals in the UK. Patients with polytrauma, open fractures, presence of axillary nerve palsy, pathological (other than osteoporotic) fractures, and those who are unable to adhere to trial procedures will be excluded. We will aim to recruit 380 participants (152 RSA, 152 HA, 76 NS) using 2:2:1 (HA:RSA:NS) randomisation for 3- or 4-part fractures without joint dislocation, and 1:1 (HA:RSA) randomisation for 3- or 4-part fracture dislocations. The primary outcome is the Oxford Shoulder Score at 24 months. Secondary outcomes include quality of life (EQ-5D-5L), pain, range of shoulder motion, fracture healing and implant position on X-rays, further procedures, and complications. Independent Trial Steering Committee and Data Monitoring Committee will oversee the trial conduct, including the reporting of adverse events and harms.

DISCUSSION

The PROFHER-2 trial is designed to provide a robust answer to guide the treatment of patients aged 65 years or over who sustain 3- and 4-part proximal humeral fractures. The pragmatic design and recruitment from around 40 UK NHS hospitals will ensure immediate applicability and generalisability of the trial findings. The full trial results will be made available in a relevant open-access peer-reviewed journal.

TRIAL REGISTRATION

ISRCTN76296703. Prospectively registered on 5th April 2018.

30-Day Postoperative Complications After Surgical Treatment of Proximal Humerus Fractures: Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty

INTRODUCTION

The purpose of this study was to evaluate risk factors associated with complications after reverse total shoulder arthroplasty (TSA) and hemiarthroplasty for the treatment of proximal humerus fractures.

METHODS

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database was conducted. Current Procedural Terminology codes were used to identify patients treated for proximal humerus fracture with reverse TSA or hemiarthroplasty between 2005 and 2018.

RESULTS

One thousand five hundred sixty-three shoulder arthroplasties were conducted: 436 hemiarthroplasties and 1,127 reverse TSA. The overall complication rate was 15.4% (15.7% reverse TSA; 14.7% hemiarthroplasty) (P = 0.636). Most frequent complications included transfusion 11.1%, unplanned readmission 3.8%, and revision surgery 2.1%. A 1.1% incidence of thromboembolic events was noted. Complications occurred most frequently in patients older than 65 years; male; and patients with anemia, American Society of Anesthesiologists classification III-IV, inpatient procedure, bleeding disorders, duration of surgery >106 minutes, and length of stay >2.5 days. Patients with body mass index >36 kg/m2 had a decreased risk of 30-day postoperative complications.

DISCUSSION

There was a 15.4% complication rate in the early postoperative period. In addition, no notable difference was found in complication rates between groups (hemiarthroplasty: 14.7%; reverse TSA 15.7%). Future studies are needed to determine whether there is a difference between these groups in the long-term outcome and survivorship of these implants.

Is the Position and Union of the Tuberosities Assessable by Means of the Simple Radiograph After Reverse Shoulder Arthroplasty for Complex Proximal Humerus Fractures?

Background

The assessment of tuberosity position and union in reverse shoulder arthroplasty (RSA) for complex proximal humerus fractures (PHF) has been carried out by means of routine simple radiographs. To evaluate the interobserver agreement and intraobserver reproducibility of the simple radiograph in comparison to the CT scan.

Methods

The position and consolidation of the tuberosities in 2 radiographic projections and in a CT scan of 32 consecutive patients operated on a RSA for PHF was assessed by 5 observers. Interobserver agreement and intraobserver reproducibility in both imaging tests were also assessed.

Results

The interobserver agreement for the greater tuberosity position was 0.52 in the simple radiograph and 0.45 in the CT scan. For the greater tuberosity union, agreement was moderate in the simple radiograph (0.52), but fair in the CT scan (0.35). For the lesser tuberosity position and union, the agreement was fair in the radiograph and poor in the CT scan.

Conclusion

Only moderate agreement was observed in the assessment of the position and union of the tuberosities in the RSA for PHF in the simple radiograph and no improvement in it was seen for the 2D CT scan.

Reverse Total Shoulder Arthroplasty Is the Most Cost-effective Treatment Strategy for Proximal Humerus Fractures in Older Adults: A Cost-utility Analysis

BACKGROUND

Proximal humerus fractures are the second-most common fragility fracture in older adults. Although reverse total shoulder arthroplasty (RTSA) is a promising treatment strategy for proximal humerus fractures with favorable clinical and quality of life outcomes, it is associated with much higher, and possibly prohibitive, upfront costs relative to nonoperative treatment and other surgical alternatives.

QUESTIONS/PURPOSES

(1) What is the cost-effectiveness of open reduction internal fixation (ORIF), hemiarthroplasty, and RTSA compared with the nonoperative treatment of complex proximal humerus fractures in adults older than 65 years from the perspective of a single-payer Canadian healthcare system? (2) Which factors, if any, affect the cost-effectiveness of ORIF, hemiarthroplasty, and RTSA compared with nonoperative treatment of proximal humerus fractures including quality of life outcomes, cost, and complication rates after each treatment?

METHODS

This cost-utility analysis compared RTSA, hemiarthroplasty, and ORIF with the nonoperative management of complex proximal humerus fractures in adults older than 65 years over a lifetime time horizon from the perspective of a single-payer healthcare system. Short-term and intermediate-term complications in the 2-year postoperative period were modeled using a decision tree, with long-term outcomes estimated through a Markov model. The model was initiated with a cohort of 75-year-old patients who had a diagnosis of a comminuted (three- or four-part) proximal humerus fractures; 90% of the patients were women. The mean age and gender composition of the model's cohort was based on a systematic review conducted as part of this analysis. Patients were managed nonoperatively or surgically with either ORIF, hemiarthroplasty, or RTSA. The three initial surgical treatment options of ORIF, hemiarthroplasty, and RTSA resulted in uncomplicated healing or the development of a complication that would result in a subsequent surgical intervention. The model reflects the complications that result in repeat surgery and that are assumed to have the greatest impact on clinical outcomes and costs. Transition probabilities and health utilities were derived from published sources, with costs (2020 CAD) sourced from regional costing databases. The primary outcome was the incremental cost-utility ratio, which was calculated using expected quality-adjusted life years (QALYs) gained and costs. Sensitivity analyses were conducted to explore the impact of changing key model parameters.

RESULTS

Based on both pairwise and sequential analysis, RTSA was found to be the most cost-effective strategy for managing complex proximal humerus fractures in adults older than 65 years. Compared with nonoperative management, the pairwise incremental cost-utility ratios of hemiarthroplasty and RTSA were CAD 25,759/QALY and CAD 7476/QALY, respectively. ORIF was dominated by nonoperative management, meaning that it was both more costly and less effective. Sequential analysis, wherein interventions are compared from least to most expensive in a pairwise manner, demonstrated ORIF to be dominated by hemiarthroplasty, and hemiarthroplasty to be extendedly dominated by RTSA. Further, at a willingness-to-pay threshold of CAD 50,000/QALY, RTSA had 66% probability of being the most cost-effective treatment option. The results were sensitive to changes in the parameters for the probability of revision RTSA after RTSA, the treatment cost of RTSA, and the health utilities associated with the well state for all treatment options except ORIF, although none of these changes were found to be clinically realistic based on the existing evidence.

CONCLUSION

Based on this economic analysis, RTSA is the preferred treatment strategy for complex proximal humerus fractures in adults older than 65 years, despite high upfront costs. Based on the evidence to date, it is unlikely that the parameters this model was sensitive to would change to the degree necessary to alter the model's outcome. A major strength of this model is that it reflects the most recent randomized controlled trials evaluating the management of this condition. Therefore, clinicians should feel confident recommending RTSA for the management of proximal humerus fractures in adults older than 65 years, and they are encouraged to advocate for this intervention as being a cost-effective practice, especially in publicly funded healthcare systems wherein resource stewardship is a core principle. Future high-quality trials should continue to collect both clinical and quality of life outcomes using validated tools such as the EuroQOL-5D to reduce parameter uncertainty and support decision makers in understanding relevant interventions' value for money.

LEVEL OF EVIDENCE

Level III, economic and decision analysis.

Simultaneous Reverse Shoulder Arthroplasty and Open Reduction With Internal Fixation for Bilateral Proximal Humerus Fractures in the Elderly: A Report of Two Cases

Simultaneous bilateral proximal humerus fractures (PHFs) caused by a single trauma are considered rare. We herein report two patients with bilateral PHFs treated based on our treatment strategy: reverse shoulder arthroplasty (RSA) to obtain rigid stability for one shoulder and open reduction with internal fixation (ORIF) to regain the mobility of external and internal rotation for the other. By using Neer’s four-segment fracture classification, patients underwent RSA for one shoulder with the more advanced fracture type and ORIF for the other. In Case 1, a 74-year-old female presented with bilaterally comminuted PHFs and underwent surgical treatment with RSA and ORIF. In Case 2, a 78-year-old female with the comorbidity of rheumatoid arthritis and a history of total elbow arthroplasty for both elbows had bilateral PHFs and underwent surgical treatment with RSA and ORIF. Postoperatively, both patients were instructed to perform exercises including passive range of motion (ROM) for a week, active ROM exercises for two weeks, and muscle strengthening for six weeks after the surgery. At the follow-up, both patients were satisfied with the pain relief and functional recovery. Especially, increased ROM for external and internal rotation was obtained in shoulders with ORIF. These case reports describe a viable treatment option comprising simultaneous RSA and ORIF, and this surgical approach may restore shoulder functions in cases of bilateral PHFs.

[Current trends in reverse fracture arthroplasty]

The reliable results of reverse arthroplasty have made this the preferred treatment method for non-reconstructable proximal humeral fractures. The individual consideration of the patient and the morphological features of the fractures are essential. Computed tomography (CT) images provide crucial information on the perfusion of the humeral head relevant for the prognosis and treatment. In this context a differentiation must be made between hard and soft criteria against a reconstruction. Tuberosities should be reduced whenever possible, because reverse arthroplasty with healed tuberosities provides a better range of motion and more strength for external rotation and anteversion, less complications and longer survival rates. In recent years the trend has been towards anatomical designs of prostheses with a humeral inclination of 135°. Revision rates for primary fracture prostheses are overall low with instability as the main reason for revision surgery, followed by periprosthetic fractures and infections. Reverse fracture arthroplasty has comparable or better clinical results compared to conservative treatment, osteosynthesis for geriatric patients, hemiarthroplasty and prosthesis implantation by elective surgery. Reverse arthroplasties, which were implanted in conditions of fracture sequelae, did not achieve significantly poorer clinical outcome at mid-term follow-up and can significantly improve shoulder function.

Reverse shoulder replacement versus hemiarthroplasty for proximal humeral fracture in elderly patients: a systematic review

This systematic review of the literature aims to analyse current knowledge to inform choice between hemiarthroplasty (HA) and reverse total shoulder arthroplasty (rTSA) for managing proximal humerus fractures (PHF) in elderly patients; the aim is to understand if rTSA can be considered the gold standard for treating PHF in the elderly when surgical fixation or conservative treatment is not viable options. Studies reporting outcomes and complications of PHF treated with shoulder arthroplasty in the elderly were included. Studies were in English and published after 2008. Evidence levels I, II, III and IV were included. According to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PubMed search engines, as well as the Cochrane Central Register of Controlled Trials. General data collected were study design, number of patients treated with HA and rTSA, age of patients (mean, mean and SD, mean and range), length of follow-up, type of implant, and clinical outcomes. rTSA can be regarded as the gold standard for surgical management of displaced 3 and 4-part fractures in the elderly. However, the literature offers mostly low-quality studies, thereby requiring further work to achieve a full understanding of this important topic.

The Reliability and Reproducibility of a New Revised Edelson Classification

Objective

Edelson classification is a 3D classification of proximal humeral fractures, but there is a scarcity of application of this classification in large samples, and the accuracy of classification was also not testified. The objective of this research was to verify whether a revised Edelson classification produces satisfactory agreement for proximal humeral fracture classification in adult patients.

Methods

A total of 827 proximal humeral fractures (304 male and 520 female patients, 58.0 ± 16.2 years) were found retrospectively from January 2014 to December 2019, and classified according to the traditional and newly proposed Edelson classification. The three‐dimensional CT images were processed, rotated and visualized within software. Five shoulder surgeons classified each fracture. After data collection, radiographic classifications results were compared by inter‐ and intraobserver analysis with the method of weighted kappa coefficients. Fracture classification based on Edelson and revised Edelson classification was presented and compared.

Results

The mean k value for the interobserver reliability was 0.748 (range, 0.583 to 0.958) compared with Edelson classification (0.548, range, 0.48 to 0.635), indicating satisfactory agreement. The mean k value for intraobserver reliability was 0.906 (range, 0.823 to 0.943) compared with Edelson classification (0.762, range, 0.666 to 0.808), indicating excellent agreement when using the newly revised Edelson classification. The mechanism was categorized as the shoulder being in a position of forward flexion, abduction, and internal rotation in Edelson I‐IV and bicipital fractures. For the greater tuberosity fracture, the mechanism was classified into two mechanisms based on the presence of a combined dislocation. Bicipital groove fracture is a commonly observed fracture pattern, and included in the revised Edelson classification.

Conclusions

The revised Edelson classification proposed was more in line with the injury mechanism of the fracture, was beneficial in identifying more fracture types such as bicipital groove fracture, and verified to be a good proximal humeral fracture classification with good reliability compared with the traditional Edelson classification.

What Factors Are Associated With Poor Shoulder Function and Serious Complications After Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations?

BACKGROUND

Three-part and four-part fracture-dislocations of the proximal humerus are characterized by severe soft tissue disruptions that can compromise the viability of the humeral head. As a result, nonunion and avascular necrosis are more common in these injuries. In such injuries, surgical treatment (internal fixation or arthroplasty) is performed in most patients who are determined to be fit for surgery to potentially restore shoulder function. Although the decision to preserve or replace the humeral head is simple in young patients or those > 65 years, in most other patients, the decision can be complicated, and little is known about which patient-related and injury-related factors may be independently associated with poor shoulder function or complications like avascular necrosis.

QUESTIONS/PURPOSES

(1) What proportion of fractures united after internal fixation of a three-part or four-part fracture-dislocation of the proximal humerus, what is the mean Constant score at a minimum of 2 years after this injury, and what proportion had serious complications (such as loss of fixation, nonunion, reoperation, or avascular necrosis)? (2) After controlling for potential confounding variables, what factors are independently associated with poor shoulder function (defined as a Constant score < 55 out of 100) and occurrence of serious complications such as loss of fixation or reduction resulting in revision surgery, nonunion, or radiographic evidence of avascular necrosis of the humeral head?

METHODS

Between 2011 and 2017, the senior author of this study (ASG) treated 69 patients with three-part or four-part proximal humerus fracture dislocations. During this time, indications for internal fixation in these patients were adequate humeral bone quality as determined by the surgeon on radiographs, adequate bone stock and volume available for fixation in the humeral head as determined on CT images, and the absence of a head split component as assessed on preoperative radiographs and CT images. On this basis, 87% (60 patients) underwent internal fixation with a locked plate and suture fixation of the tuberosities through a deltopectoral approach. Thirteen percent (nine patients) underwent either a hemiarthroplasty or a reverse total shoulder arthroplasty. Of the 60 patients who underwent internal fixation, four declined to participate in the study and two with brachial plexus palsy were not considered for inclusion. This study focused on the remaining 54 patients who were considered potentially eligible. To be included, a minimum follow-up of 2 years was required; 11% (6 of 54) were lost before that time, and the remaining 48 patients were analyzed at a mean of 48 months ± 17 months in this retrospective study, which drew data from longitudinally maintained institutional databases. Fracture union was assessed by obliteration of fracture lines and the presence of bridging trabecular bone on plain radiographs. Shoulder function was assessed using the Constant score, which is scored from 0 to 100 points, with 0 indicating the most disability and 100 the least disability. The anchor-based minimal clinically important difference for the Constant score is 9.8 points. Twelve patient-related and injury-related factors were analyzed using a multivariate regression model to identify factors that are independently associated with poor results after internal fixation as measured by shoulder function and the occurrence of serious complications. We categorized results as poor if patients had one or more of the following: Constant score < 55 out of 100 at the last follow-up examination (for patients who underwent revision surgery, the Constant score immediately before revision was considered) and loss of fixation or reduction resulting in revision surgery, nonunion, or avascular necrosis of the humeral head. Patients were screened for avascular necrosis at 6 and 12 months after surgery, then annually for another 2 years. Further assessments were made only based on symptoms.

RESULTS

Seventy-nine percent of the fractures united within 18 weeks of surgery (38 of 48), and an additional 13% united by 24 weeks (6 of 48), while 8% did not unite (4 of 48). The mean Constant score at the last follow-up was 68 ± 12. Twenty-one percent (10 of 48) had a Constant score < 55, indicating poor shoulder function. Twenty-one percent (10 of 48) experienced avascular necrosis, and 15% (7 of 48) with either nonunion or avascular necrosis underwent revision shoulder arthroplasty. Two patients who underwent arthroplasty had both nonunion and avascular necrosis. After controlling for potentially confounding variables, we found that being a woman (odds ratio 1.7 [95% confidence interval 1.4 to 2.1]; p = 0.01), four-part fracture dislocations (OR 2.1 [95% CI 1.5 to 2.7]; p < 0.001), absence of a metaphyseal head extension (OR 2.4 [95% CI 1.8 to 3.3]; p < 0.001), absence of active back-bleeding from the humeral head (OR 3.4 [95% CI 2.3 to 5.1]; p < 0.001), height of the head segment < 2 cm (OR 2.3 [95% CI 1.8 to 2.8]; p < 0.001), and absence of capsular attachments to the head fragment (OR 2.2 [95% CI 1.6 to 2.9]; p < 0.001) were independently associated with poor shoulder function and the occurrence of complications such as nonunion and avascular necrosis.

CONCLUSION

Internal fixation of three-part and four-part proximal humerus fracture dislocations resulted in poor shoulder function and complications in a high number of patients, although fracture union was achieved in most patients. A nonunion proportion of 8%, 21% proportion of avascular necrosis, and 15% proportion of patients who underwent revision surgery suggests this is a fairly terrible injury. Being a woman and injury factors such as four-part fracture dislocation, absent metaphyseal head extension and back-bleeding from the head, height of the fractured head segment < 2 cm, and absence of capsular attachments to the head were independently associated with poor function and complications. Our findings can help surgeons decide between internal fixation and arthroplasty for the surgical treatment of these injuries in patients across different age groups and functional demands.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures: Current Concepts

Complex proximal humeral fractures, especially in elderly patients, often require arthroplastic surgical treatment. Traditionally, shoulder hemiarthroplasty (HA) is the method of choice, resulting in long implant survival and a painless shoulder; however, shoulder HA has heterogeneous clinical outcomes related to the correct position of the implant, both in terms of height and version, and the anatomical consolidation of tuberosities. Today, reverse shoulder arthroplasties are increasingly used to treat such fractures. These techniques result in better functional outcomes compared to HAs, especially regarding anterior flexion, but implant longevity has not been established. The development of specific prosthetic humeral components for the treatment of fractures, which were recently introduced in the clinical practice, led to better clinical outcomes.

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

BACKGROUND

Proximal humerus fractures (PHFs) are managed with open reduction and internal fixation (ORIF), hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), or nonoperatively. Given the mixed results in the literature, the optimal treatment is unclear to surgeons. The purpose of this study was to survey orthopedic shoulder and trauma surgeons to identify the patient- and fracture-related characteristics that influence surgical decision-making.

METHODS

We distributed a 23-question closed-response email survey to members of the American Shoulder and Elbow Surgeons and Orthopaedic Trauma Association. Questions posed to respondents included demographics, surgical planning, indications for ORIF and arthroplasty, and the use of surgical augmentation with ORIF. Numerical and multiple-choice responses were compared between shoulder and trauma surgeons using unpaired t-tests and χ² tests, respectively.

RESULTS

Respondents included 172 shoulder and 78 trauma surgeons. When surgery is indicated, most shoulder and trauma surgeons treat 2-part (69%) and 3-part (53%) PHFs with ORIF. Indications for managing PHFs with arthroplasty instead of ORIF include an intra-articular fracture (82%), bone quality (76%), age (72%), and previous rotator cuff dysfunction (70%). In patients older than 50 years, 90% of respondents cited a head-split fracture as an indication for arthroplasty. Both shoulder and trauma surgeons preferred RSA for treating PHFs presenting with a head-split fracture in an elderly patient (94%), pre-existing rotator cuff tear (84%), and pre-existing glenohumeral arthritis with an intact cuff (75%). Similarly, both groups preferred ORIF for PHFs in young patients with a fracture dislocation (94%). In contrast, although most trauma surgeons preferred to manage PHFs in low functioning patients with a significantly displaced fracture or nonreconstructable injury nonoperatively (84% and 86%, respectively), shoulder surgeons preferred either RSA (44% and 46%, respectively) or nonoperative treatment (54% and 49%, respectively) (P < .001). Similarly, although trauma surgeons preferred to manage PHFs in young patients with a head-split fracture or limited humeral head subchondral bone with ORIF (98% and 87%, respectively), shoulder surgeons preferred either ORIF (54% and 62%, respectively) or HA (43% and 34%, respectively) (P < .001).

CONCLUSIONS

ORIF and HA are preferred for treating simple PHFs in young patients with good bone quality or fracture dislocations, whereas RSA and nonoperative management are preferred for complex fractures in elderly patients with poor bone quality, rotator cuff dysfunction, or osteoarthritis. The preferred management differed between shoulder and trauma surgeons for half of the common PHF presentations, highlighting the need for future research.

Simultaneous Bilateral Proximal Humerus Fractures Treated with Single-Stage Bilateral Reverse Shoulder Arthroplasty

Introduction

Simultaneous bilateral fractures of the proximal humerus are infrequent, and simultaneous bilateral three- or four-part fractures are even rarer. Reverse shoulder arthroplasty (RSA) is being used increasingly for the treatment of three- and four-part fractures of the proximal humerus. However, treatment of simultaneous bilateral fractures of the proximal humerus is difficult because of concern about postoperative immobilization and rehabilitation. Case Presentation. A 75-year-old woman presented with bilateral shoulder pain subsequent to a fall on the street. Physical examination and radiographs showed simultaneous bilateral fractures of the proximal humerus. The right side fracture was classified as a four-part fracture and the left side fracture as a three-part fracture, according to Neer's classification. The right shoulder had a risk of avascular necrosis of the humeral head. For the left shoulder, the fracture type had caused ischemia of the humeral head. Single-stage bilateral RSA was performed 9 days after the injury. An abduction pillow was applied for 5 weeks postoperatively. Passive motion exercises were permitted starting at 4 weeks postoperatively, and active range of motion exercises were permitted at 6 weeks postoperatively. At the patient's most recent follow-up 30 months after surgery, the patient reported no restriction of the activities of daily living. Radiographs revealed no lucent line on the humerus and glenoid components, although bone resorption and superior retraction of the tuberosities on both sides were observed.

Conclusions

Single-stage bilateral RSA improved shoulder function, but healing of the greater tuberosity can affect the improvement in external rotation after the operation. Although a long-term follow-up is needed, single-stage bilateral RSA appears to be a viable treatment option.

Outcome of geriatric proximal humeral fractures: a comparison between reverse shoulder arthroplasty versus open reduction and internal fixation

Objectives:

In view of the increased attention to reverse shoulder arthroplasty (rTSA) as a treatment for complex proximal humeral fractures in the elderly, the present study analyzes in-hospital complications and the postoperative management of rTSA versus open reduction and internal fixation (ORIF).

Methods:

We retrospectively reviewed patients hospitalized from 2016 to 2018 for proximal humeral fractures (ICD-9 codes: S42.21), III- and IV-part, who underwent an ORIF with locking plates, rTSA or nonoperative treatment. In-hospital complications and postoperative management in both groups were included in the analysis.

Results:

We included n 190 patients (ORIF 90, rTSA 71, nonoperative 29), more likely to be female (82.1% vs 17.9%; P < .01) with an average age of 82years (min. 72, max. 99; SD 6.4). The ORIF and the rTSA groups showed comparable complication rates (15.6% vs 15%, P = .87) but with a significantly shorter hospital stay (8.6 vs 11.5days; P = .01) and shorter duration of surgery (72.9 vs 87.2 minutes; P = .01) in the ORIF group. Significantly more patients after ORIF achieved an independent life postoperatively (53.3% vs 40.8%; P = .013).

Conclusions:

In this retrospective analysis, ORIF is related to a shorter duration of surgery, a shorter hospital stay and a higher likelihood of independence. Despite the popularity of the rTSA, ORIF remains a reliable treatment option for proximal humeral fractures in the elderly.

Level of evidence: III

Treatment of rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

There is ongoing controversy regarding optimal treatment for full-thickness rotator cuff tears. Given that the evidence surrounding the use of various treatment options has expanded, an overall assessment is required.

OBJECTIVES

The following were compared to determine which resulted in improved patient-reported function, pain, and reoperation rates for each: (1) double-row (DR) fixation and single-row (SR) fixation in arthroscopic cuff repair; (2) latissimus dorsi transfer (LDT) with lower trapezius transfer (LTT), partial rotator cuff repair, and superior capsular reconstruction (SCR); and (3) early and late surgical intervention.

METHODS

Medline, Embase, and Cochrane were searched through to April 20, 2021. Additional studies were identified from reviews. The following were included: (1) All English-language randomized controlled trials (RCTs) in patients ≥18 years of age comparing SR and DR fixation, (2) observational studies comparing LDT with LTT, partial repair, and SCR, and (3) observational studies comparing early vs. late treatment of full-thickness rotator cuff tears.

RESULTS

A total of 15 RCTs (n = 1096 randomized patients) were included in the meta-analysis of SR vs. DR fixation. No significant standardized mean differences in function (0.08, 95% confidence interval [CI] -0.09, 0.24) or pain (-0.01, 95% CI -0.52, 0.49) were observed. There was a difference in retear rates in favor of DR compared with SR fixation (RR 1.56, 95% CI 1.06, 2.29). Four studies were included in the systematic review of LDT compared with a surgical control. LDT and partial repair did not reveal any differences in function (-1.12, 95% CI -4.02, 1.78) on comparison. A single study compared arthroscopically assisted LDT to LTT and observed a nonstatistical difference in the Constant score of 14.7 (95% CI -4.06, 33.46). A single RCT compared LDT with SCR and revealed a trend toward superiority for the Constant score with SCR with a mean difference of -9.6 (95% CI -19.82, 0.62). Comparison of early vs. late treatment revealed a paucity of comparative studies with varying definitions of "early" and "late" treatment, which made meaningful interpretation of the results difficult.

CONCLUSION

DR fixation leads to similar improvement in function and pain compared with SR fixation and results in a higher healing rate. LDT transfer yields results similar to those from partial repair, LTT, and SCR in functional outcomes. Further study is required to determine the optimal timing of treatment and to increase confidence in these findings. Future trials of high methodologic quality comparing LDT with LTT and SCR are required.

Imaging of traumatic shoulder injuries – Understanding the surgeon’s perspective

Imaging plays a key role in the assessment and management of traumatic shoulder injuries, and it is important to understand how the imaging details help guide orthopedic surgeons in determining the role for surgical treatment. Imaging is also crucial in preoperative planning, the longitudinal assessment after surgery and the identification of complications after treatment. This review discusses the mechanisms of injury, key imaging findings, therapeutic options and associated complications for the most common shoulder injuries, tailored to the orthopedic surgeon’s perspective.

Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty for the Treatment of Proximal Humerus Fractures: A Model-Based Cost-Effectiveness Analysis

INTRODUCTION

Compared with hemiarthroplasty (HA), reverse total shoulder arthroplasty (RTSA) may provide greater cost and health-related benefits for patients with complex three- and four-part proximal humeral fractures. This study set out to compare RTSA versus HA for the incremental cost per incremental improvement in quality adjusted life years (QALYs) for a hypothetical cohort of patients with proximal humerus fractures.

METHODS

Parameters and characteristics for a hypothetical cohort of elderly patients with proximal humerus fractures were collected through the literature. A cohort-level Markov decision model was constructed. Incremental cost-effectiveness ratios representing the difference in cost divided by the difference in QALYs were calculated, and scenario, one-way, and probabilistic analysis were conducted.

RESULTS

RTSA was associated with lower cost and greater effectiveness compared with HA. The predicted cost difference corresponded to a saving of $99,626 per 100 individuals treated, and the predicted difference in QALY was 16.8 per 100 individuals treated. Results were sensitive to the discount rate, the health-related quality of life assigned to health states, and the cost of the surgical procedures. In probabilistic analysis, 77.1% of iterations were cost-effective at a threshold willingness-to-pay for a QALY of $100,000 US dollars.

DISCUSSION

Findings suggest that RTSA may be a cost-effective alternative to HA for treating elderly patients requiring surgery for proximal humerus fractures.

DATA AVAILABILITY

The model and corresponding code are available on request to the corresponding author.

LEVEL OF EVIDENCE USING THE JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS GUIDANCE

Level III.

Subscapularis management in stemmed and stemless total shoulder arthroplasty: a surgeon decision-making analysis study

Background

Stemless total shoulder arthroplasty (TSA) continues to grow in popularity as an evolution of stemmed humeral implants. Proposed advantages include bone preservation and ease of potential revision. However, absence of a stem may necessitate a change in subscapularis takedown approach. Specifically, there is theoretical concern about violation of supportive bone with lesser tuberosity osteotomy when using a stemless device. Therefore, the goal of this study was to identify if surgeons change their subscapularis takedown preference when performing stemless vs. stemmed TSA.

Methods and materials

Data from a consecutive series of patients who underwent stemmed and stemless TSA at an academic institution were collected. The subscapularis management technique was documented. Subscapularis takedown techniques were divided into 2 groups: soft-tissue approach (subscapularis tenotomy or peel) and bony approach (lesser tuberosity osteotomy). Historical preference for each surgeon was determined by evaluating techniques employed using stemmed TSA. A Cramers V analysis was run to determine the strength of association between this historical preference and subscapularis management technique used for stemless TSA.

Results

One hundred and fifty-four patients were included in this analysis. There were 72 and 82 stemmed and stemless arthroplasty cases performed, respectively. Of the 154 patients, 50.6% were women. The average age of patients was 64.2 years. Four surgeons were included in this study. In all, there were 79 and 75 bony and soft-tissue subscapularis techniques, respectively. The historical preference for 3 of the surgeons was a subscapularis bony approach, and the historical preference for one of the surgeons was a soft-tissue approach. A Cramer's V analysis was used to measure the relative strength of association between patient factors, historical subscapularis management preference, and subscapularis takedown approach in stemless TSA. Our analysis yielded a value of 0.65 (P < .01), indicating a redundant association between subscapularis management approach used between stemmed and stemless implant per surgeon.

Conclusion

In determining subscapularis tendon management strategy, in surgeons who performed stemmed TSA before stemless TSA, the subscapularis takedown approach used for stemless TSA is strongly associated with surgeon's historical preference for stemmed TSA. Future research will be needed to determine the clinical ramifications of this finding.

Projections of Primary and Revision Shoulder Arthroplasty until 2040: Facing a Massive Rise in Fracture-Related Procedures

Although the demand for shoulder arthroplasties has reached its highest number worldwide, there remains a lack of epidemiologic data regarding recent and future trends. In this study, data for all shoulder arthroplasties (hemiarthroplasty, reverse/anatomic shoulder arthroplasty) from the nationwide inpatient statistics of Germany (2010–2019) and population forecasts until 2040 were gathered. A Poisson and a negative binomial approach using monotone B-splines were modeled for all types of prostheses to project the annual number and incidence of primary and revision arthroplasty. Additionally, trends in main indicators were also gathered and expected changes were calculated. Overall, the number of primary shoulder replacements is set to increase significantly by 2040, reaching at least 37,000 (95% CI 32,000–44,000) procedures per year. This trend is mainly attributable to an about 10-fold increased use of fracture-related reverse shoulder arthroplasty in patients over 80 years of age, although the number of procedures in younger patients will also rise substantially. In contrast, hemiarthroplasties will significantly decrease. The number of revision procedures is projected to increase subsequently, although the revision burden is forecast to decline. Using these country-specific projection approaches, a massive increase of primary and revision shoulder arthroplasties is expected by 2040, mainly due to a rising number of fracture-related procedures. These growth rates are substantially higher than those from hip or knee arthroplasty. As these trends are similar in most Western countries, this draws attention to the international issue, of: if healthcare systems will be able to allocate human and financial resources adequately, and if future research and fracture-prevention programs may help to temper this rising burden in the upcoming decades.

Outcomes of Management of Proximal Humeral Fractures with Patient-Specific, Evidence-Based Treatment Algorithms

BACKGROUND

Previous studies have identified risk factors for different types of treatment of proximal humeral fracture (PHF) and allowed the development of a patient-specific, evidence-based treatment algorithm with the potential of improving overall outcomes and reducing complications. The purpose of this study was to evaluate the results and complications of treating PHF using this algorithmic approach.

METHODS

All patients with isolated PHF between 2014 and 2017 were included and prospectively followed. The initial treatment algorithm (Version 1 [V1]) based on patients' functional needs, bone quality, and type of fracture was refined after 2 years (Version 2 [V2]). Adherence to protocol, clinical outcomes, and complications were analyzed at a 1-year follow-up.

RESULTS

The study included 334 patients (mean age, 66 years; 68% female): 226 were treated nonoperatively; 65, with open reduction and internal fixation (ORIF); 39, with reverse total shoulder arthroplasty (RTSA); and 4, with hemiarthroplasty. At 1 year, the preinjury EuroQol 5-Dimension (EQ-5D) values were regained (0.88 and 0.89, respectively) and the mean relative Constant Score (CS) and Subjective Shoulder Value (SSV) (and standard deviation [SD]) were 96% ± 21% and 85% ± 16%. Overall complications and revision rates were 19% and 13%. Treatment conforming to the algorithm outperformed non-conforming treatment with respect to relative CS (97% versus 88%, p = 0.016), complication rates (16.3% versus 30.8%, p = 0.014), and revision rates (10.6% versus 26.9%, p < 0.001).

CONCLUSIONS

Treating PHF using a patient-specific, evidence-based algorithm restored preinjury quality of life as measured with the EQ-5D and approximately 90% normal shoulders as measured with the relative CS and the SSV. Adherence to the treatment algorithm was associated with significantly better clinical outcomes and substantially reduced complication and revision rates.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute Versus Delayed Reverse Shoulder Arthroplasty for the Primary Treatment of Proximal Humeral Fractures

INTRODUCTION

Reverse total shoulder arthroplasty (rTSA) is gaining popularity as a treatment option for proximal humeral fractures in elderly patients. The impact of surgical timing on outcomes of primary rTSA is unclear. This study compared the rates of revision and complication, and surgery day cost of treatment between acute and delayed primary rTSA patients.

METHODS

Elderly patients with proximal humeral fracture who underwent primary rTSA within a year of fracture were identified in a national insurance database from 2005 to 2014. Patients were separated into acute (<4 weeks) or delayed (>4 weeks) cohorts based on the timing of rTSA. The univariate 1-year rates of revision and complication and surgery day cost of treatment were assessed. Multivariate logistic regression analysis was conducted, accounting for the factors of age, sex, obesity, diabetes comorbidity, and tobacco use.

RESULTS

Four thousand two hundred forty-five (82.6%) acute and 892 (17.4%) delayed primary rTSA patients were identified. Acute rTSA was associated with a higher surgery day cost (acute $15,770 ± $8,383, delayed $14,586 ± $7,271; P < 0.001). Delayed rTSA resulted in a higher 1-year revision rate (acute 1.7%, delayed 4.5%; P < 0.001) and surgical complication rates of dislocation (acute 2.8%, delayed 6.1%; P < 0.001) and mechanical complications (acute 1.9%, delayed 3.4%; P = 0.007). Multivariate analysis identified delayed primary treatment as independently associated with increased risk of revision (odds ratio: 2.29, 95% confidence interval 1.53 to 3.40; P < 0.001) and dislocation (OR: 2.05, 95% confidence interval 1.45 to 2.86; P < 0.001).

CONCLUSION

Delayed primary rTSA was associated with higher short-term rates of revision and dislocation compared with acute primary rTSA. Our results suggest that delaying rTSA, whether because of attempted nonsurgical treatment or patients' lack of access, may result in increased complication and additional surgery.

LEVEL OF EVIDENCE

Level III.

Reverse or Hemi Shoulder Arthroplasty in Proximal Humerus Fractures: A Single-Blinded Prospective Multicenter Randomized Clinical Trial

OBJECTIVES

To compare outcomes between hemiarthroplasty (HA) and reversed shoulder arthroplasty (RSA) as a treatment for dislocated 3-part and 4-part proximal humerus fractures in the elderly population.

DESIGN

Prospective multicenter randomized controlled trial.

SETTING

Three Level-1 trauma centers.

PATIENTS/PARTICIPANTS

This study included 31 patients of which 14 were randomized into the HA group and 17 into the RSA group.

INTERVENTION

Patients randomized to the HA group were treated with a cemented-stem Aequalis-fracture HA and patients randomized to the RSA group with a cemented-stem Aequalis-fracture RSA.

MAIN OUTCOME MEASUREMENTS

Primary outcomes consisted of range of motion and constant score. Secondary outcomes were the visual analog scale for pain, DASH score, SF-12 scores, and radiographic outcomes.

RESULTS

After 6 and 12 months of follow-up, RSA showed a significant higher anterior elevation (105 degrees vs. 80 degrees, P = 0.002 and 110 degrees vs. 90 degrees, P = 0.02, respectively) and constant score (60 vs. 41, P = 0.01 and 51 vs. 32, P = 0.05, respectively) compared with HA. There were no significant differences in external and internal rotation. Also, visual analog scale pain, DASH scores, SF-12 scores, and radiological healing of the tuberosities and heterotopic ossification did not show any significant differences between groups.

CONCLUSION

RSA showed significant superior functional outcomes for anterior elevation and constant score compared with HA for dislocated 3-part and 4-part proximal humerus fractures after short-term follow-up.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Clinical effect of using MultiLoc® nails to treat four-part proximal humeral fractures

Objective

This study was performed to evaluate the clinical effect of MultiLoc® nails (DePuy Synthes, Raynham, MA, USA) on the treatment of four-part proximal humeral fractures (PHFs).

Methods

From January 2014 to January 2018, 32 patients with four-part PHFs were treated with intramedullary MultiLoc® nails in our hospital. The operation time, bleeding volume, postoperative X-ray findings, and fracture healing status were recorded and analyzed. At the end of follow-up, the clinical outcome was evaluated based on the visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) shoulder score, Constant–Murley score (CMS), and occurrence of any complications.

Results

Among all patients, the average operation time was 124.5 minutes (range, 91–152 minutes), the average amount of bleeding was 90 mL (range, 55–150 mL), and the fracture healing rate was 100%. At the end of follow-up, the mean VAS score was 1.6 ± 0.4, mean ASES score was 84.4 ± 6.3, and mean CMS was 70.3 ± 6.1; no serious complications had occurred; and the patients exhibited good recovery of shoulder function.

Conclusions

MultiLoc nails® can be applied to the treatment of four-part PHFs. This surgical fixation method has no obvious complications and helps to restore shoulder function.

An update on reverse total shoulder arthroplasty: current indications, new designs, same old problems

Reverse total shoulder arthroplasty (RTSA) was originally developed because of unsatisfactory results with anatomic shoulder arthroplasty options for the majority of degenerative shoulder conditions and fractures.

After initial concerns about RTSA longevity, indications were extended to primary osteoarthritis with glenoid deficiency, massive cuff tears in younger patients, fracture, tumour and failed anatomic total shoulder replacement.

Traditional RTSA by Grammont has undergone a number of iterations such as glenoid lateralization, reduced neck-shaft angle, modular, stemless components and onlay systems.

The incidence of complications such as dislocation, notching and acromial fractures has also evolved.

Computer navigation, 3D planning and patient-specific implantation have been in use for several years and mixed-reality guided implantation is currently being trialled.

Controversies in RTSA include lateralization, stemless humeral components, subscapularis repair and treatment of acromial fractures.

Cite this article: EFORT Open Rev 2021;6:189-201. DOI: 10.1302/2058-5241.6.200085

Improved functional outcome and tuberosity healing in patients treated with fracture stems than nonfracture stems during shoulder arthroplasty for proximal humeral fracture: a meta-analysis and systematic review

BACKGROUND

Proximal humeral fractures are difficult injuries to treat and obtain satisfactory outcomes. For those treated with arthroplasty, humeral fracture stems have been popular due to better ability for reduction and fixation of tuberosities. This study aims to investigate the outcomes of fracture stems in shoulder arthroplasty for proximal humeral fracture and the comparison of outcomes between fracture vs. nonfracture stems.

METHODS

A meta-analysis was conducted with a multidatabase search (PubMed, OVID, EMBASE, Medline) according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines on May 19, 2020. Data from all published literature meeting inclusion criteria were extracted and analyzed.

FINDINGS

Eleven studies were included for analysis, including 383 hemiarthroplasties (HA) (294 fracture stems, 89 nonfracture stems) and 358 reverse total shoulder arthroplasties (RTSA) (309 fracture stems, 49 nonfracture stems). At the final follow-up, meta-analysis shows favorable overall ASES score in all fracture stem prosthesis (mean = 74.0, 95% confidence interval [CI]: 69.3-78.7), Constant-Murley score (mean = 67.2, 95% CI: 61.6-72.8), external rotation (mean difference [MD] = 7°, 95% CI: 3°-10°, P < .001), and forward flexion (MD = 17°, 95% CI: 10°-25°, P < .001). Pooled proportion (PP) of greater tuberosity healing (PP = 0.786, 95% CI: 0.686-0.886) was high, whereas all-cause revisions (PP = 0.034, 95% CI: 0.018-0.061) remained low. With the exception of RTSA scapular notching (PP = 0.109, 95% CI: 0.020-0.343), other complication metrics had PP of ≤0.023. In the 4 studies comparing fracture (138 HA, 54 RTSA) vs. nonfracture stems (89 HA, 49 RTSA), fracture stems had statistically significant better American Shoulder and Elbow Surgeons scores (MD = 14.29, 95% CI: 8.18-20.41, P < .001), external rotation (MD = 6°, 95% CI: 2°-9°, P = .003), forward flexion (MD = 16°, 95% CI: 7°-24°, P < .001), and greater tuberosity healing (odds ratio = 2.20, 95% CI: 1.28-3.77, P = .004). There was no statistically significant difference in complications.

CONCLUSION

Fracture stems showed promising overall clinical outcomes with low complication rates in treating proximal humeral fractures. The use of fracture stems is also associated with greater chance of tuberosity healing compared with nonfracture stems. There is increasing evidence to suggest the superiority of fracture stems over nonfracture stems in clinical outcomes, while maintaining similar complication rates.

The influence of reverse arthroplasty humeral component design features on scapular spine strain

BACKGROUND

Reverse shoulder arthroplasty (RSA) humeral implant parameters have been previously studied with respect to range of motion, deltoid function, and stability. However, limited literature exists on the influence of humeral design features on scapular spine strain. The purpose of this cadaveric biomechanical simulator study was to evaluate the role of humeral component lateralization and neck-shaft angle (NSA) on scapular spine strain.

METHODS

Eight fresh-frozen cadaveric shoulders were tested using an in vitro shoulder simulator. A custom-designed modular RSA system was implanted that allowed for the in situ adjustment of humeral lateralization and NSA. Scapular spine strain was measured by strain gauges placed along the acromion and scapular spine in clinically relevant positions representative of the Levy fracture zones. All testing was conducted in both abduction and forward elevation.

RESULTS

In Levy zones 2 and 3, increasing humeral lateralization caused significant incremental decreases in scapular spine strain at 0° and 90° abduction (P < .042). Strain decreases as high as 34% were noted with increases in humeral lateralization from -5 to 15 mm (P = .042). Changing NSA had no statistically significant effect on scapular spine strain (P > .14).

CONCLUSIONS

Some humeral implant design features in RSA have effects on scapular spine strain. Humeral component lateralization had significant effects, whereas adjusting NSA resulted in no substantial differences in scapular spine strain. Understanding humeral component variables is important to allow for design optimization of future RSA implants.

Humeral Head Fracture Dislocation with Displacement into the Mediastinum: A Case Report

CASE

A 70-year-old woman pedestrian struck by a motor vehicle presented with multiple orthopaedic injuries including a humeral head fracture dislocation with a large segment of humeral head located in the mediastinum. Thoracic surgery personnel performed a minimally-invasive video-assisted thoracoscopic extraction of the humeral head, and the patient underwent subsequent reverse total shoulder arthroplasty.

CONCLUSION

Intramediastinal displacement of the humeral head is a rare, yet serious traumatic injury that necessitates early recognition and comanagement with cardiothoracic or thoracic surgery. Early thoracic intervention to extract the humeral head and replacement arthroplasty is an effective treatment modality.

Intrathoracic migration of a K-wire after percutaneous fixation of a proximal humerus fracture

Proximal humerus fractures are common in elderly patients. Not all patient are fit for major surgery. Percutaneous fixation can be a suitable option though surgeons should be aware of the risks and complications. This case is about a 90-year-old woman with a proximal humerus fracture. After closed anatomical reduction we performed percutaneous K-wire fixation of the humerus fracture with a single K-wire. Five days postoperatively the patient experienced increased pain and dyspnea due to a pneumothorax caused by intrathoracic migration of the K-wire. Percutaneous fixation can be a suitable treatment for low-maintenance and fragile patients but surgeons should act with caution. Multiple threaded K-wires with a bend-free end should be used to reduce the risk for loss of repositioning or migration of the K-wire.

Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of proximal humerus fractures

Hypothesis

We hypothesized that the modified Fragility Index (mFI) would predict complications in patients older than 50 years who underwent operative intervention for a proximal humerus fracture.

Methods

We retrospectively reviewed the American College of Surgeons National Surgery Quality Improvement Program database, including patients older than 50 years who underwent open reduction and internal fixation of a proximal humerus fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates as well as length of stay (LOS) were recorded. Univariate as well as multivariable statistical analyses were performed, controlling for age, sex, body mass index, LOS, and operative time.

Results

We identified 2,004 patients (median age, 66 years; interquartile range: 59-74), of which 76.2% were female. As mFI increased from 0 to 2 or greater, 30-day readmission rate increased from 2.8% to 6.7% (P-value = .005), rate of discharge to rehabilitation facility increased from 7.1% to 25.3% (P-value < .001), and rates of any complication increased from 6.5% to 13.9% (P-value < .001). Specifically, the rates of renal and hematologic complications increased significantly in patients with mFI of 2 or greater (P-value = .042 and P-value < .001, respectively). Compared with patients with mFI of 0, patients with mFI of 2 or greater were 2 times more likely to be readmitted within 30 days (odds ratio = 2.2, P-value .026). In addition, patients with mFI of 2 or greater had an increased odds of discharge to a rehabilitation center (odds ratio = 2.3, P-value < .001). However, increased fragility was not significantly associated with an increased odds of 30-day reoperation or any complication after controlling for demographic data, LOS, and operative time.

Conclusion

An increasing level of fragility is predictive of readmission and discharge to a rehabilitation center after open reduction and internal fixation of proximal humerus fractures. Our data suggest that a simple fragility evaluation can help inform surgical decision-making and counseling in patients older than 50 years with proximal humerus fractures.

High-Energy Proximal Humerus Fractures in Geriatric Patients: A Review

High-energy proximal humerus fractures in elderly patients can occur through a variety of mechanisms, with falls and MVCs being common mechanisms of injury in this age group. Even classically low-energy mechanisms can result in elevated ISS scores, which are associated with higher mortality in both falls and MVCs. These injuries result in proximal humerus fractures which are commonly communicated via Neer’s classification scheme. There are many treatment options in the armamentarium of the treating surgeon. Nonoperative management is widely supported by systematic review as compared to almost all other treatment methods. ORIF is particularly useful for complex patterns and fracture dislocations in healthy patients. Hemiarthroplasty can be of utility in patients with fracture patterns with high risk of AVN and poor bone quality risking screw cut-out. Reverse total shoulder arthroplasty is a popular method of treatment for geriatric patients also, with literature now showing that even late conversion from nonoperative management or ORIF to rTSA can lead to good clinical outcomes. Prevention is possible and important for geriatric patients. Optimizing medical care including hearing, vision, strength, and bone quality, in coordination with primary care and geriatricians, is of great importance in preventing fractures and decreasing injury when falls do occur. Involving geriatricians on dedicated trauma teams will also likely be of benefit.

Reverse total shoulder arthroplasty compared to stemmed hemiarthroplasty for proximal humeral fractures: a registry analysis of 5946 patients

BACKGROUND

There is an increasing trend toward the use of reverse total shoulder arthroplasty (RTSA) over stemmed hemiarthroplasty (HA) for the management of proximal humeral fractures. There are limited data available comparing the revision rates for RTSA and HA in the setting of a fracture. The aim of this study was to compare the revision rates for RTSA and HA when used for the treatment of a fracture and to analyze the effect of demographics and prosthesis fixation on these revision rates.

METHODS

Data obtained from the Australian Orthopaedic Association National Joint Replacement Registry from April 16, 2004, to December 31, 2017, included all procedures for primary diagnosis proximal humeral fracture. The analyses were performed using Kaplan-Meier estimates of survivorship and hazard ratios from Cox proportional hazards models.

RESULTS

Over the study period, there were 3049 (51%) RTSA and 2897 (49%) HA procedures. The cumulative percent revision rate at 9 years was lower for the RTSA than for the HA: 7.0% (95% confidence interval [CI], 4.8-10.1) compared with 11.7% (95% CI, 10.3-13.2). Between 0 and 6 months, the HA had a significantly lower revision rate than the RTSA (hazard ratio, 0.50; 95% CI, 0.34-0.72; P < .001). Between 6 month and 3 years, the HA had a significantly higher revision rate. For the RTSA, males have a significantly higher rate of revision compared with females. There is a higher rate of early revision due to instability in younger persons (55-64) and males. For both RTSA and HA, cemented prostheses have lower revision rates compared with cementless prostheses.

CONCLUSIONS

RTSA has a significantly lower revision rate compared with HA for the treatment of proximal humeral fractures in females. Younger patients (<65) and males are at risk of early revision secondary to instability. In these patient groups, either alternatives to RTSA or further attention to fixation of tuberosities and shoulder rehabilitation may be indicated.

Tratamento não operatório de fraturas desviadas da extremidade proximal do úmero em idosos: Correlação entre os desvios e os resultados clínicos

Objetivos Descrever o resultado funcional do tratamento não operatório de fraturas desviadas da extremidade proximal do úmero (FEPU) pela escala da American Shoulder and Elbow Surgeons (ASES, na sigla em inglês) após 12 meses e avaliar se as diferentes classificações e medidas radiográficas iniciais têm correlação com os resultados clínicos.

Métodos Foram avaliados em tempos padronizados (3, 6 e 12 meses), 40 pacientes > 60 anos com FEPU submetidos ao tratamento não operatório. Foram utilizadas as escalas da ASES, Constant-Murley e Single Assessment Numeric Evaluation (SANE, na sigla em inglês). As variáveis radiográficas incluíram as classificações de Neer e Resch, a presença de fratura e desvio dos tubérculos, cominuição metafisária, lesão periosteal medial, desvios angulares e translacionais da cabeça no plano coronal e sagital e desvio dos tubérculos.

Resultados Observamos resultados pela escala de ASES de 77,7 ± 23,2 para toda a amostra, pela de Constant-Murley de 68,7 ± 16 e de 82,6% para a escala em relação ao lado contralateral. A escala de SANE aos 12 meses foi de 84,8 ± 19. Os critérios radiográficos que apresentaram influência negativa no resultado clínico pela escala de ASES aos 12 meses foram a gravidade pela classificação de Neer e pelo desvio angular no plano coronal (mensurado pelo ângulo cabeça-diáfise) e a presença de fratura dos tubérculos.

Conclusão O tratamento não operatório de fraturas desviadas da extremidade proximal do úmero em pacientes idosos resulta em bons resultados clínicos. Os resultados clínicos são influenciados negativamente pelo desvio angular da cabeça do úmero e pela presença de fratura dos tubérculos maior e menor, assim como pela classificação de Neer.

Treatment of Complex Proximal Humeral Fractures in the Elderly with Reverse Shoulder Arthroplasty

OBJECTIVE

To assess the short-term efficacy of reverse shoulder arthroplasty in the treatment of complex proximal humeral fractures in the elderly.

METHODS

Forty-three elderly patients treated operatively for complex proximal humeral fractures with reverse shoulder arthroplasty from July 2017 to January 2019 were retrospectively reviewed. To be specific, 12 males and 31 females were reviewed with an average age of 72.0 years (range, 66-78 years). All fractures were attributed to trauma and treated for 8.0 days on average (range, 6-11 days). As suggested from Neer classification, 21 cases (48.8%, 21/43) were three-part fractures, and 22 (51.2%, 22/43) were four-part fractures. To assess the postoperative efficacy, Visual Analog Scale (VAS), American Society of Shoulder and Elbow Surgery Shoulder Joint Score (ASES), Constant-Murley score and radiological examination were adopted. The Neer three-part fracture group and the Neer four-part fracture group were compared.

RESULTS

There was no significant difference in age, gender, operation time, and follow-up period between Neer three-part fracture group and Neer four-part fracture group. All operations were successfully performed, and the average operation time was 120-170 min, with an average of 141.3 min. Besides, the mean blood loss was 407.0 mL (250-700 mL), and the average intraoperative blood transfusion reached 446.5 mL (400-800 mL). All patients received the follow-up for 6 to 16 months, that is for 10.9 months on average. All patients were discharged in 7 days after operation, and no wound-related complications were identified. In 8 weeks, the greater and lesser tuberosities of all patients healed completely. During the last follow-up, no loosening or dislocation of prosthesis was detected, and the forward elevation of 133.0 (100°- 165°), the external rotation of 29.5° (20°-35°), the internal rotation of 46.7°(30°-60°), the VAS score of 0.8(0-3), the ASES score of 89.1(78.8-100.0) were achieved. Constant-Murley score reached 88.7 (range, 70-98). There was no significant difference between Neer three-part fracture group and Neer four-part fracture group (P > 0.05). A 71-year-old patient developed the symptoms of axillary nerve injury after operation; he recovered completely at 6 weeks after the operation, which had not adversely affected the functional rehabilitation exercise or the stability of the prosthesis. At the follow-up, no other complications (e.g., infection, acromial stress fracture, and scapular notching) were identified in all patients.

CONCLUSION

The short-term efficacy of one-stage reverse shoulder arthroplasty to treat complex proximal humeral fractures in the elderly is satisfactory.

Outcome measures reported for the management of proximal humeral fractures: a systematic review

BACKGROUND

The American Shoulder and Elbow Surgeons multicenter taskforce studying proximal humerus fractures reached no consensus on which outcome measures to include in future studies, and currently no gold standard exists. Knowledge of commonly used outcome measures will allow standardization, enabling more consistent proximal humerus fracture treatment comparison. This study identifies the most commonly reported outcome measures for proximal humerus fracture management in recent literature.

METHODS

A systematic review identified all English-language articles assessing proximal humerus fractures from 2008 to 2018 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Review articles, meta-analyses, revision surgery, chronic injuries, studies with <15 patients, studies with <12 month follow-up, anatomic/biomechanical studies, and technique articles were excluded. Included studies were assessed for patient demographics and outcome scores, patient satisfaction, complications, range of motion, and strength.

RESULTS

Of 655 articles, 74 met inclusion criteria. The number of proximal humerus fractures averaged 74.2 per study (mean patient age, 65.6 years). Mean follow-up was 30.7 months. Neer type 1, 2, 3, and 4 fractures were included in 8%, 51%, 81%, and 88% of studies, respectively. Twenty-two patient-reported outcome instruments were used including the Constant-Murley score (65%), Disabilities of the Arm, Shoulder, and Hand score (31%), visual analog scale pain (27%), and American Shoulder and Elbow Surgeons score (18%). An average of 2.2 measures per study were reported.

CONCLUSION

Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging. We recommend that future literature on proximal humerus fractures use at least 3 outcomes measures and 1 general health score until the optimal scores are determined.

Progression and projection for shoulder surgery in France, 2012-2070: Epidemiologic study with trend and projection analysis

INTRODUCTION

Shoulder surgery has been rapidly expanding over the past 20 years and now makes up a large share of orthopedic surgery practice. Data on how this activity has changed is not available in France due to a lack of registries. The study objectives were to: (1) quantify the number of shoulder surgeries in France, (2) predict how this activity will change over the next 50 years based on extreme scenarios.

METHODS

This study involved an analysis of shoulder surgery data taken from the French hospital discharge database (PMSI). Two mathematical scenarios were applied to define the change over time: the first only considered the evolution in the population and changes in the age brackets over time; the second extrapolated the trends observed over the past few years (2012 to 2018).

RESULTS

In 2018, there were 234,612 procedures coded as primary shoulder surgery procedures in France. This activity increased 24.5% between 2012 and 2018 and is projected to increase 18% to 161% from now to 2050, depending on the scenario (p<0.0001). Rotator cuff surgery procedures were done 173,799 times - of which 61,055 were tendon repair - representing 74% of all shoulder procedures. The scenarios point to an increase of 13.6% to more than 300% (p<0.0001). Primary shoulder arthroplasty corresponded to 17,043 procedures in 2018 (7.3% of all procedures), with a 47% increase between 2012 and 2018. Between 2018 and 2050, the number of total shoulder arthroplasty procedures is expected to increase 31% to 322% (p<0.0001). The total number of revision arthroplasty procedures was 1508, increasing by 39% from 2012 to 2018. There were 14,229 procedures done for anterior or posterior instability in 2018 (6% of total). Bone block procedures made up 53% of these cases. This increased 17% between 2012 and 2018, with a projected increase of 5% to 82% up to 2050 (p<0.01).

DISCUSSION

Shoulder surgery is the third largest activity in the orthopedic realm after hip and knee surgery, although it has seen the largest increases in recent years. This growth in shoulder procedures should continue over the next decades.

LEVEL OF EVIDENCE

IV, descriptive epidemiology study.

How to improve the outcomes of surgically treated proximal humeral osteoporotic fractures? A narrative review

Proximal humeral fractures (PHF) are the third most common non-vertebral fragility fractures after hip and distal radius. It still controversial which treatment might be more appropriate, and surgically treated outcomes depends also on an appropriate technique. In order to clarify surgical indications, tips and pitfall a narrative review was conducted. Pinning, external fixation, plating and internal fixators has each one its advantages and disadvantages. During the procedure an appropriate use of the fixation device and handling of the soft tissue might be associated with better outcomes. Calcar comminution, varus angulation, medial dislocation of the shaft, fracture-dislocation are factors that could lead to choose a replacement. Hemiarthroplasty and reverse total shoulder arthroplasty are the most common prosthesis used in PHF. The restoration of humeral length and tuberosities might lead to an improvement in clinical outcomes and prosthesis survivorship.

Cost-Minimization Analysis and Treatment Trends of Surgical and Nonsurgical Treatment of Proximal Humerus Fractures

PURPOSE

Recent evidence demonstrated similar outcomes between nonsurgical and surgical management of displaced proximal humerus fractures. We analyzed treatment trends and performed a cost-minimization analysis comparing nonsurgical treatment, open reduction and internal fixation, reverse total shoulder arthroplasty, and hemiarthroplasty. We hypothesized that rates of surgical treatment have increased and that the costs associated with surgery are greater compared with nonsurgical management of proximal humerus fractures.

METHODS

We used a US private-payer claims database of 22 million patient records from 2007 to 2016 to compare (1) cost for the episode of care from the payer perspective between each surgical group and nonsurgical treatment of proximal humerus fractures, and (2) annual trends and complication rates of each group. Cost data, including facility fees, physician fees, physical therapy, and clinic visits, were used to complete a cost-minimization analysis.

RESULTS

Nonsurgical treatment was associated with lower average total costs compared with surgical intervention. Facility and physician fees accounted for most of this difference. Physical therapy costs and number of physical therapy visits were higher in each surgical group compared with nonsurgical treatment. Surgical treatment was associated with higher complications, revision rates, and length of stay. There was a small but statistically significant decrease in nonsurgical management of proximal humerus fractures between 2007 and 2016. No change was observed in rates of open reduction and internal fixation, whereas rates of reverse total shoulder arthroplasty increased and rates of hemiarthroplasty decreased.

CONCLUSIONS

Nonsurgical management of proximal humerus fractures decreased during the study period. In the setting of treatment equipoise, cost-minimization analysis favors nonsurgical management of proximal humerus fractures. Surgical management is associated with higher complication rates, revision rates, and length of stay.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic Decision Analysis IV.

Single-stage bilateral reverse total shoulder arthroplasty for bilateral posterior shoulder fracture-dislocation following seizure: A case report

INTRODUCTION

Posterior shoulder dislocations comprise a small percentage of shoulder dislocations. Even more uncommon are posterior shoulder fracture-dislocations, which are commonly associated with trauma, seizures, and electrical shock.

PRESENTATION OF CASE

We present the case of a 64-year-old right-hand dominant male who sustained bilateral shoulder posterior fracture-dislocations after a hypoglycemia-induced seizure. The patient was treated with bilateral reverse total shoulder arthroplasties in a single-stage. He recovered well and continues to have excellent function and range of motion at 4-year follow-up.

DISCUSSION

Treatment options for proximal humerus fracture-dislocations include open reduction internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder arthroplasty (RTSA). The indications for reverse total shoulder arthroplasty continue to expand.

CONCLUSION

This is a rare case of bilateral posterior shoulder fracture-dislocations. In similar cases, simultaneous reverse total shoulder arthroplasties can be considered as a viable treatment option.

Low arthroplasty survival after treatment for proximal humerus fracture sequelae: 3,245 shoulder replacements from the Nordic Arthroplasty Register Association

Background and purpose - Proximal humerus fractures (PHF) may result in sequelae indicating arthroplasty. We report cumulative survival rates and reasons for revision after arthroplasty for proximal humerus fracture sequelae (PHFS).Patients and methods - Data were derived from the Nordic Arthroplasty Register Association. The Kaplan-Meier method was used to illustrate survival rates. A scaled Schoenfeld residual plot was used to report the risk of revision for men relative to women in patients who were treated with reverse shoulder arthroplasty (RSA). Revision was defined as removal or exchange of any component or the addition of a glenoid component.Results - 30,190 primary arthroplasties were reported from 2004 to 2016, of which 3,245 were for PHFS. The estimated 1-, 5-, and 10-year cumulative survival rates (95% CI) were 96% (95-97), 90% (89-92), and 86% (83-88) for stemmed hemiarthroplasty and 94% (92-95), 89% (87-91), and 86% (82-90) for RSA with a median time to revision of 18 months (IQR 9-44) and 3 months (IQR 0-17). The risk of revision for men relative to women in patients who were treated with RSA was 3.2 (1.9-5.1) 0-1 year after surgery and 1.9 (0.9-4.1) 1-8 years after surgery. The estimated 1-, 5-, and 10-year cumulative survival rates (95% CI) were 94% (92-96), 88% (85-90), and 80% (75-86) for men and 95% (94-96), 86% (84-89), and 81% (77-84) for young patients.Interpretation - Shoulder arthroplasty for PHFS was associated with lower survival rates, compared with previously published results of shoulder arthroplasty for acute PHF. The low arthroplasty survival rates for men and young patients especially are worrying.