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Ou Z, Feng Q, Peng L, Zhou M, Rai S, Tang X. Risk factors for osteonecrosis of the humeral head after internal fixation of proximal humeral fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2024; 144:31-40. [PMID: 37566131 DOI: 10.1007/s00402-023-05020-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/26/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Osteonecrosis of the humeral head (ONHH) is a severe complication after the internal fixation of proximal humeral fractures (IFPHF). The risk factors remain controversial though many studies have reported. In this research, meta-analysis was used to evaluate which surgeon-level factors can be modified to lower the risk and we hope to provide evidence-based support for preventing ONHH. METHODS Literature was retrieved from PubMed, Cochrane Library, Embase, Web of Science, and Scopus for eligible studies published up to January 2023. The pooled odds ratios (ORs) were calculated with their corresponding 95% confidence intervals (CIs) to evaluate. STATA 15.1 software was applied for data synthesis, sensitivity synthesis, and publication bias. RESULTS 45 articles were published between 2000 and 2022, and 2482 patients were finally included. All articles were observational research, with 7 case-control studies and 38 cohort studies, and the Newcastle Ottawa Scale (NOS) score ranged from 7 to 9. The pooled results suggested that age (OR 0.32, 95% CI 0.14-0.74, P = 0.01), reduction quality (OR 0.08, 95% CI 0.01-0.44, P = 0.00), fracture type (OR 0.44, 95% CI 0.25-0.78, P = 0.01), surgical approach (OR: 4.06, 95% CI 1.21-13.61, P = 0.02) and fixation implant (OR = 0.68, 95% CI = 0.34-1.33, P = 0.02) were risk factors for ONHH after IFPHF. According to sensitivity analysis, Begg (P = 0.42) and Egger (P = 0.68) tests, the results were stable and exhibited no publication bias. CONCLUSIONS The study showed that age, reduction quality, fracture type, surgical approach and fixation implant were risk factors for ONHH after IFPHF, while gender, varus or valgus, timely operation, injured side, and the existence of medial support have little influence on ONHH, as they could not be considered risk factors and still need further investigations.
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Affiliation(s)
- ZiXuan Ou
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - QiYuan Feng
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - LianQi Peng
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - MinQi Zhou
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Orthopaedics, Al Ahalia Hospital, Abu Dhabi, United Arab Emirates
| | - Xin Tang
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Jeong HJ, Park JW, Lee YK, Koo KH, Oh JH. Comparison between osteonecrosis of the humeral and femoral heads - epidemiological analysis of the surgical trend using the nationwide claims database of the republic of Korea. BMC Musculoskelet Disord 2023; 24:878. [PMID: 37951880 PMCID: PMC10638789 DOI: 10.1186/s12891-023-07022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUNDS The humeral head is the second most common site of osteonecrosis, after the femoral head. However, compared to osteonecrosis of the femoral head (ONFH), epidemiological information on osteonecrosis of the humeral head (ONHH) is scarce. We hypothesised that different biomechanical properties of the shoulder from the hip joint might present different epidemiological characteristics of ONHH from those of the ONFH. To evaluate epidemiological differences, we compared trends in the surgical treatment of ONHH and ONFH using the nationwide medical claims database of the Republic of Korea (ROK). METHODS We analysed epidemiological data from the Health Insurance Review and Assessment (HIRA) database of the ROK between 2008 and 2018. HIRA database contains almost all medical information in an anonymised form, including demographics, diagnoses, and types of surgical procedures, generated through healthcare practices in ROK. The annual incidence rates of ONHH and ONFH were calculated based on the total number of the general population. Demographics, annual incidence, and the proportion of post-traumatic osteonecrosis and surgical procedures were compared according to the anatomical site and the affected year. RESULTS The total number of patients treated for ONHH and ONFH during the study period was 1,028 and 66,260, respectively. Although the incidence of ONHH increased, it is a relatively rare disease compared to ONFH. ONHH occurred more frequently in females, while ONFH occurred predominantly in male patients (p < 0.001). Surgical treatment for ONHH was most frequently performed in older patients (63.7%), whereas middle-aged patients had the largest proportion of ONFH (48.9%, p < 0.001). The proportion of post-traumatic osteonecrosis was significantly higher in the ONHH (5.1%) than in the ONFH (1.9%, p < 0.001). Arthroplasty was performed more frequently in the ONHH (96.0%) than in the ONFH (92.9%, p < 0.001). CONCLUSION Despite the anatomical similarities between the hip and shoulder joints, the different biomechanical properties, such as weight-bearing functions, might cause epidemiological differences between ONHH and ONFH.
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Affiliation(s)
- Hyeon Jang Jeong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Jung-Wee Park
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Cheil Orthopedic Hospital, Seoul, Republic of Korea
| | - Joo Han Oh
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea.
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Avascular Necrosis and Posttraumatic Arthritis After Proximal Humerus Fracture Internal Fixation: Evaluation and Management. Curr Rev Musculoskelet Med 2023; 16:66-74. [PMID: 36637717 PMCID: PMC9889581 DOI: 10.1007/s12178-022-09818-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW Avascular necrosis (AVN) and posttraumatic arthritis (PTA) are common complications following both conservative treatment and open reduction and internal fixation (ORIF) of proximal humerus fractures (PHFs). Despite the frequent utilization of ORIF, information regarding these leading causes of failure is limited. This review includes a discussion of incidence, risk factors, and evaluation of AVN and PTA following PHF. The mechanisms of treatment options and associated outcomes are also reviewed. RECENT FINDINGS Recent best available evidence demonstrates significant rates of AVN and PTA following ORIF of PHF. This is particularly true of complex fracture patterns. A thorough workup is required in the setting of failure caused by AVN and PTA. This includes a careful patient history, clinical exam, plain film radiographs, and CT scans. EMG and/or aspiration may also be indicated. Special consideration is given to the examination of the deltoid muscle, neurovascular status, rotator cuff function, and the possibility of infection. Biological supplementation, anatomic total shoulder replacement (aTSA), and fusion are rarely employed in the treatment of AVN and/or PTA. Due to satisfactory patient outcomes, reverse total shoulder replacement (rTSA) has increased in popularity for the elderly population, while hemiarthroplasty (HA) may be appropriate for some young, active patients. With careful patient selection and meticulous surgical technique, AVN and PTA can be mitigated. Careful indications for ORIF may decrease the frequency of these complications. For most patients, rTSA is the optimal treatment option. Given the frequent utilization of ORIF and the higher than acceptable complication and failure rates, AVN and PTA warrant our attention.
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Tullio POD, Giordano V, Belangero WD, Pires RE, de Souza FS, Labronici PJ, Zamboni C, Malzac F, Belangero PS, Ikemoto RY, Rowinski S, Koch HA. Computed Tomography Does Not Improve Intra- and Interobserver Agreement of Hertel Radiographic Prognostic Criteria. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58101489. [PMID: 36295650 PMCID: PMC9612020 DOI: 10.3390/medicina58101489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/06/2022] [Accepted: 10/17/2022] [Indexed: 11/23/2022]
Abstract
Background and Objectives: Proximal humerus fractures are the second most frequent site of avascular necrosis (AVN), occurring in up to 16% of cases. The Hertel criteria have been used as a reference for the prediction of humerus head ischemia. However, these are based solely on the use of radiographs, which can make interpretation extremely difficult due to several reasons, such as the overlapping fragments, severity of the injury, and noncompliant acute pain patients. The objectives of the study were to evaluate the role of computed tomography (CT) in the interpretation of the Hertel criteria and to evaluate the intra- and interobserver agreement of orthopedic surgeons, comparing their area of expertise. Materials and Methods: The radiographs and CT scans of 20 skeletally mature patients who had fractures of the proximal humerus were converted to jpeg and mov, respectively. All images were evaluated by eight orthopedic surgeons (four trauma surgeons and four shoulder surgeons) in two different occasions. The intra- and interobserver agreement was assessed by using the Kappa coefficient. The level of significance was 5%. Results: There was a weak-to-moderate intraobserver agreement (κ < 0.59) for all examiners. Only the medial metaphyseal hinge greater than 2 mm was identified by 87.5% of evaluators both in the radiographic and CT examinations in the two rounds of the study (p < 0.05). There was no significant interobserver agreement (κ < 0.19), as it occurred only in some moments of the second round of evaluation. Conclusions: The prognostic criteria for humeral head ischemia evaluated in this study showed weak intra- and interobserver agreement in both the radiographic and tomographic evaluation. CT did not help surgeons in the primary interpretation of Hertel prognostic criteria used in this study when compared to the radiographic examination.
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Affiliation(s)
- Paulo Ottoni di Tullio
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro—Hospital Municipal Miguel Couto, Rio de Janeiro 22430-160, Brazil
| | - Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro—Hospital Municipal Miguel Couto, Rio de Janeiro 22430-160, Brazil
- Correspondence: ; Tel.: +55-(21)-99751-6859
| | - William Dias Belangero
- Departamento de Ortopedia, Reumatologia e Traumatologia—Universidade Estadual de Campinas (UNICAMP), Campinas 13083-970, Brazil
| | - Robinson Esteves Pires
- Departamento do Aparelho Locomotor—Universidade Federal de Minas Gerais (UFMG), Belo Horizonte 31270-901, Brazil
| | - Felipe Serrão de Souza
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro—Hospital Municipal Miguel Couto, Rio de Janeiro 22430-160, Brazil
| | - Pedro José Labronici
- Departamento de Cirurgia Geral e Especializada—Universidade Federal Fluminense (UFF), Niteroi 24220-900, Brazil
| | - Caio Zamboni
- Departamento de Ortopedia—Santa Casa de São Paulo, São Paulo 01221-020, Brazil
| | - Felipe Malzac
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro—Hospital Municipal Miguel Couto, Rio de Janeiro 22430-160, Brazil
| | - Paulo Santoro Belangero
- Departamento de Ortopedia e Traumatologia—Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo 04021-001, Brazil
| | - Roberto Yukio Ikemoto
- Grupo de Ombro e Cotovelo—Faculdade de Medicina do ABC, Santo André 09060-870, Brazil
| | | | - Hilton Augusto Koch
- Departamento de Radiologia—Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro 21941-901, Brazil
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Miltenberg B, Masood R, Katsiaunis A, Moverman MA, Puzzitiello RN, Pagani NR, Menendez ME, Salzler MJ, Drager J. Fracture dislocations of the proximal humerus treated with open reduction and internal fixation: a systematic review. J Shoulder Elbow Surg 2022; 31:e480-e489. [PMID: 35605847 DOI: 10.1016/j.jse.2022.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/11/2022] [Accepted: 04/18/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The treatment of proximal humerus fracture dislocations can be challenging given the extensive injury to the proximal humeral anatomy and increased risk of devascularization of the humeral head often seen in these injuries. The purpose of this study is to undertake a systematic review of the literature on the functional outcomes, rate of revision, and short- and long-term complications for proximal humerus fracture dislocations treated with open reduction and internal fixation (ORIF). METHODS The PubMed and OVID Embase databases were queried for literature reporting on proximal humerus fracture dislocations treated with ORIF. Data including study design, patient demographics, functional outcomes, and complications were recorded. RESULTS Twelve studies including 294 patients with Neer type 2-, 3-, or 4-part proximal humerus fracture dislocations met the criteria for inclusion. The mean patient age was 53.4 years (19-89 years) with an average follow-up of 2.9 years (1.15-4.9 years). At the final follow-up, the mean Constant score was 73.2 (52-87.3) and the mean Disabilities of the Arm Shoulder and Hand score was 26.6 (17.5-32). Avascular necrosis was observed in 20.0% (0%-82.3%) and nonunion was observed in 3.0% (0%-7.7%) of patients. Conversion to arthroplasty was observed in 10.7% (5%-20%) and a total reoperation was observed in 35.6% (11.8%-89.1%) of patients in studies explicitly reporting these outcomes. In addition to conversion to arthroplasty, common causes of reoperation were revision ORIF (5.2%) and hardware removal (22.2%). CONCLUSION Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates. This information can be used to counsel patients and set expectations about the potential for further surgeries.
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Affiliation(s)
| | - Raisa Masood
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, MA, USA
| | | | | | | | - Nicholas R Pagani
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, MA, USA
| | - Mariano E Menendez
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Matthew J Salzler
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, MA, USA
| | - Justin Drager
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, MA, USA.
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Wegner A, Wassenaar D, Busch A, Stanjek M, Mayer C, Jäger M. [Post-traumatic necrosis of the humeral head-Endoprosthesis or joint preservation]. ORTHOPADIE (HEIDELBERG, GERMANY) 2022; 51:822-828. [PMID: 36083347 DOI: 10.1007/s00132-022-04307-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Humerus fractures play a major role in daily clinical routine, and subsequent osteonecrosis is common after osteosyntheses. OBJECTIVES The current paper highlights the incidence and cause of osteonecrosis after proximal humerus fractures, with respect to presentation of anatomy and risk factors. METHODS Display of the literature and therapy options for humerus fracture and subsequent necrosis. RESULTS Humerus fractures are the seventh most frequent fractures in humans. The complication rate is 40%, and the described rate of necrosis is up to 34%. Accordingly, the surgical revision rate is at 19% according to recent literature. CONCLUSION The treatment of humerus head fracture must consider numerous variables. The individual type of fracture and the current individual situation of the patient must be included in the process of choosing the right treatment. Modern implants with screw locking features should be used, and for certain circumstances the direct implantation of a prosthesis should be considered. Thereby the expectations of the patient with respect to the postoperative activity level play a major role.
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Affiliation(s)
- A Wegner
- Lehrstuhl für Orthopädie und Unfallchirurgie, Universität Duisburg-Essen, Essen, Deutschland.
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Klinikum Wolfsburg, Sauerbruchstr. 7, 38440, Wolfsburg, Deutschland.
| | - D Wassenaar
- Klinik für Orthopädie, Unfall- und Wiederherstellungschirurgie, St. Marien-Hospital Mülheim an der Ruhr GmbH, Kaiserstr. 50, 45468, Mülheim/Ruhr, Deutschland
- Lehrstuhl für Orthopädie und Unfallchirurgie, Universität Duisburg-Essen, Essen, Deutschland
| | - A Busch
- Klinik für Orthopädie, Unfall- und Wiederherstellungschirurgie, St. Marien-Hospital Mülheim an der Ruhr GmbH, Kaiserstr. 50, 45468, Mülheim/Ruhr, Deutschland
- Lehrstuhl für Orthopädie und Unfallchirurgie, Universität Duisburg-Essen, Essen, Deutschland
| | - M Stanjek
- Klinik für Orthopädie, Unfall- und Wiederherstellungschirurgie, St. Marien-Hospital Mülheim an der Ruhr GmbH, Kaiserstr. 50, 45468, Mülheim/Ruhr, Deutschland
- Lehrstuhl für Orthopädie und Unfallchirurgie, Universität Duisburg-Essen, Essen, Deutschland
| | - C Mayer
- Klinik für Orthopädie, Unfall- und Wiederherstellungschirurgie, St. Marien-Hospital Mülheim an der Ruhr GmbH, Kaiserstr. 50, 45468, Mülheim/Ruhr, Deutschland
- Lehrstuhl für Orthopädie und Unfallchirurgie, Universität Duisburg-Essen, Essen, Deutschland
| | - M Jäger
- Klinik für Orthopädie, Unfall- und Wiederherstellungschirurgie, St. Marien-Hospital Mülheim an der Ruhr GmbH, Kaiserstr. 50, 45468, Mülheim/Ruhr, Deutschland
- Lehrstuhl für Orthopädie und Unfallchirurgie, Universität Duisburg-Essen, Essen, Deutschland
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Hernigou J, Bastard C, Dubory A, Zilber S, Flouzat Lachaniette CH, Rouard H, Hernigou P. Cell therapy for posttraumatic shoulder osteonecrosis. Morphologie 2020; 105:162-169. [PMID: 33309197 DOI: 10.1016/j.morpho.2020.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/05/2020] [Accepted: 11/12/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE This study compared the clinical and radiological results of bone marrow mesenchymal stem cell implantation with traditional simple core decompression (CD) using a matched pair case-control design for osteonecrosis of the humeral head (ONHH) after fracture of the proximal humerus. PATIENTS We retrospectively reviewed 64 patients who had surgery for ONHH. Thirty patients had been treated with cell therapy between 2010 and October 2015, with 18 patients at pre-collapse stage (8 stages-I, 10 stages-II), and 12 patients at post-collapse stages (7 stages-III and 5 stages-IV). Using a matched pair case-control design, these 30 study patients were compared to 34 other patients who were treated with simple core decompression (CD) without cells (control group). METHODS The cell therapy group was treated with percutaneous mesenchymal cell (MSCs) injection obtained from bone marrow (BM) concentration. During a mean follow-up duration of 7years (5 to 10years), radiographs performed each year were used to evaluate the radiological results; the Constant score and visual analogue scale were chosen to assess the clinical results. We assessed stage progression, collapse and arthroplasty conversion rate. Survivor rate analysis was performed using these parameters as the primary endpoints. RESULTS Among the 30 shoulders included in the cell therapy group, three (10%) humeral heads had collapsed at the most recent follow-up, versus 25 (74%) in 34 shoulders after simple core decompression (P<0.0001). As consequence, we observed statistically significant difference (P=0.0001) in the humeral head survival (absence of arthroplasty conversion) rate at the end time point between the cell therapy group (93% survival) and simple core decompression (26% survival). Better results were obtained for early stages (stages I and II) osteonecrosis without collapse at baseline. CONCLUSION Core decompression with cell therapy was a safe and effective procedure for treatment in the pre-collapse stages of posttraumatic shoulder osteonecrosis and improved the outcome of the disease as compared with simple core decompression without cells.
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Affiliation(s)
- J Hernigou
- Department of Orthopaedic and Traumatology Surgery, EpiCURA hospital, Baudour/Hornu, Belgium
| | - C Bastard
- Department of Orthopaedic and Traumatology Surgery, Hospital Henri-Mondor, University Paris East, Créteil, France
| | - A Dubory
- Department of Orthopaedic and Traumatology Surgery, Hospital Henri-Mondor, University Paris East, Créteil, France
| | - S Zilber
- Department of Orthopaedic and Traumatology Surgery, Hospital Henri-Mondor, University Paris East, Créteil, France
| | - C H Flouzat Lachaniette
- Department of Orthopaedic and Traumatology Surgery, Hospital Henri-Mondor, University Paris East, Créteil, France
| | - H Rouard
- Établissement Français du Sang (EFS) - Île-de-France, University Paris East, Créteil, France
| | - P Hernigou
- Department of Orthopaedic and Traumatology Surgery, Hospital Henri-Mondor, University Paris East, Créteil, France.
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Posttraumatic Avascular Necrosis After Proximal Femur, Proximal Humerus, Talar Neck, and Scaphoid Fractures. J Am Acad Orthop Surg 2019; 27:794-805. [PMID: 31149969 DOI: 10.5435/jaaos-d-18-00225] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Posttraumatic avascular necrosis (AVN) is osteonecrosis from vascular disruption, commonly encountered after fractures of the femoral neck, proximal humerus, talar neck, and scaphoid. These locations have a tenuous vascular supply; the diagnosis, risk factors, natural history, and treatment are reviewed. Fracture nonunion only correlates with AVN in the scaphoid. In the femoral head, the risk is increased for displaced fractures, but the time to surgery and open versus closed treatment do not seem to influence the risk. Patients with collapse are frequently symptomatic, and total hip arthroplasty is the most reliable treatment. In the humeral head, certain fracture patterns correlate with avascularity at the time of injury, but most do not go on to develop AVN due to head revascularization. Additionally, newer surgical approaches and improved construct stability appear to lessen the risk of AVN. The likelihood of AVN of the talar body rises with increased severity of talar injury. The development of AVN corresponds with a worse prognosis and increases the likelihood of secondary procedures. In proximal pole scaphoid fractures, delays in diagnosis and treatment elevate the risk of AVN, which is often seen in cases of nonunion. The need for vascularized versus nonvascularized bone grafting when repairing scaphoid nonunions with AVN remains unclear.
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Underlying Mental Illness and Psychosocial Factors Are Predictors of Poor Outcomes After Proximal Humerus Repair. J Orthop Trauma 2019; 33:e339-e344. [PMID: 31436713 DOI: 10.1097/bot.0000000000001494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES (1) To assess the correlation of psychosocial factors and long-term outcomes of proximal humerus fractures all in surgical repair; (2) to identify specific psychosocial factors with favorable and unfavorable outcomes; and (3) to assess the correlation between DSM-V mental health diagnoses and long-term Disabilities of Arm, Shoulder, and Hand (DASH) scores. DESIGN Prospective cohort study. SETTING Academic medical center. PATIENTS Patients were screened and identified on presentation to the emergency department or in the clinical office for inclusion in an institutional review board-approved registry. One hundred eighty-five proximal humerus fractures of 247 met inclusion criteria. INTERVENTION Surgical repair of proximal humerus fractures. MAIN OUTCOME MEASURE All patients were prospectively followed up and assessed for clinical and functional outcomes at latest follow-up visit (mean = 24.8 months) using the DASH questionnaires along with ranges of motion and pain level. Psychosocial factors at 3 months were obtained from the DASH survey. RESULTS Concomitant diagnosis of depressed mood (P = 0.001), anxiety (P < 0.0005), low energy level (P = 0.003), and fatigue (P = 0.001) correlated significantly with poorer outcome. All 6 psychosocial factors correlated directly and significantly with pain at latest follow-up (P < 0.0005). Multiple regression analysis revealed that the strongest predictor of the overall DASH score was the extent of interference with social life (P = 0.001). CONCLUSION Analysis demonstrated that psychological and social factors at 3 months postoperatively have a strong correlation with negative long-term (>1 year) outcomes after proximal humerus fixation. Clinicians may offer psychological support and encourage social support to these patients postoperatively to improve pain and treatment outcomes. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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