Operative Management of Proximal Humerus Nonunions in Adults: A Systematic Review

Reverse Shoulder Megaprosthesis for Massive Proximal Humeral Bone Loss in Fracture Outcome Settings: A Report of Two Cases and Literature Review

In trauma settings, including the management of outcomes, there is no consensus on the most appropriate reconstructive method in the presence of severe bone loss of the proximal humerus. The objective of this report is to evaluate the short-term functional outcomes of two patients in whom reverse shoulder megaprosthesis was used to treat the failure of trauma surgery with severe bone loss. The secondary objective was to compare the results obtained with the literature regarding the use of megaprosthesis in shoulder trauma surgery. The patients showed a satisfying functional recovery and increased quality of life. At the 12-month follow-up, no complications occurred. Regarding the risk of complications, especially the risks of mobilization of the megaprosthesis, the CT-based intraoperative navigation system optimizes the configuration of the screw for the initial fixation of the glenoid component. Shoulder megaprosthesis appears to be a viable option not only in oncologic surgery but also in cases of failed trauma surgery. The functional results, considering functional score and range of motion, are encouraging and allow patients to improve their quality of life.

Reverse Total Shoulder Arthroplasty Demonstrates Better Outcomes Than Angular Stable Plate in the Treatment of Three-part and Four-part Proximal Humerus Fractures in Patients Older Than 70 Years

BACKGROUND

Proximal humeral fractures are traditionally treated with open reduction and internal fixation (ORIF), but reverse total shoulder arthroplasty (RTSA) has emerged as an increasingly popular treatment option. Although ORIF with angular locking plates is a common treatment for proximal humerus fractures, prior reports suggest high failure and complication rates. Although RTSA has become an increasingly popular option for complex proximal humeral head fractures given its low complication rates, there are concerns it may lead to limited postoperative ROM. Thus, the optimal treatment for patients older than 70 years from a functional and radiographic perspective remains unclear.

QUESTIONS/PURPOSES

(1) In patients older than 70 years with three-part and four-part proximal humerus fractures, does RTSA result in better functional outcome scores (Constant, American Shoulder and Elbow Surgeons [ASES], and DASH scores) than ORIF with a locking plate? (2) Does RTSA result in greater ROM than ORIF? (3) Does RTSA result in a lower risk of complications than ORIF? (4) In patients with either procedure, what are the rates of negative radiographic outcomes in those treated with ORIF (such as malunion, bone resorption, malalignment, or avascular necrosis) or those with RTSA (such as resorption, notching, and loosening)? (5) At a minimum of 2 years of follow-up, does ORIF result in a greater number of revision procedures than RTSA?

METHODS

Between January 1, 2013, and June 30, 2018, we treated 235 patients for a proximal humeral fracture. We considered only patients without previous ipsilateral fracture or surgery, other fractures, or radial nerve injuries; age older than 70 years; and patients without neurologic disease or cognitive dysfunction as potentially eligible. Sixty-nine percent (162 patients) of the patients were eligible; a further 31% (73 patients) were excluded because 18% (13 of 73 patients) did not meet the inclusion criteria, 62% (45 patients) underwent nonoperative treatment, and 21% (15 patients) declined to participate. Patients were nonrandomly allocated to receive RTSA if they had supraspinatus Goutallier/Fuchs Grade 3 or 4 atrophy or ORIF if they had supraspinatus Goutallier/Fuchs Grade 1 or 2 atrophy. This left 81 patients who were treated with RTSA and another 81 patients who were treated with ORIF. Among the 81 patients treated with RTSA, 11% (nine patients) were lost to the minimum study follow-up of 2 years or had incomplete datasets, leaving 89% (72 patients) for analysis. Among the 81 patients treated with ORIF, 19% (15 patients) were lost before the minimal study follow-up of 2 years or had incomplete datasets, leaving 82% (66 patients) for analysis. The median follow-up for both groups was 53 months (range 24 to 72 months). The mean age was 76 ± 2.9 years in the RTSA group and 73 ± 2.9 years in the ORIF group. In the RTSA group, 27 patients had a three-part fracture and 45 patients had a four-part fracture. In the ORIF group, 24 patients had three-part fractures and 42 patients had four-part fractures (p = 0.48). Shoulder function was assessed using functional outcome questionnaires (ASES, DASH, and Constant) and active ROM measurements. A surgical complication was defined as any instance of dislocations, fractures, adhesive capsulitis, nerve injuries, or surgical site infections. Radiographic outcomes after ORIF (malunion, tuberosity resorption, or avascular necrosis) and RTSA (notching and osteolysis) were assessed. In calculating the revision rate, we considered unplanned revision procedures only.

RESULTS

Compared with patients treated with ORIF, patients treated with RTSA had superior improvements in Constant (85.0 ± 7.0 versus 53.0 ± 5.0; mean difference 32 [95% CI 30 to 34]; p < 0.01), ASES (46.3 ± 3.7 versus 30.0 ± 3.5; mean difference 16 [95% CI 15 to 18]; p < 0.01), and DASH scores (40.5 ± 4.2 versus 30.5 ± 2.6; mean difference 10 [95% CI 9 to 11]; p < 0.01). The mean elevation was 135° ± 7° for patients with RTSA and 100° ± 6° for patients with ORIF (mean difference 35 o [95% CI 33 to 37]; p < 0.01). The mean abduction was 131° ± 7° for patients with RTSA and 104° ± 6° for those with ORIF (mean difference 27 o [95% CI 25° to 29°]; p < 0.01). The mean external rotation was 85° ± 5° for patients with RTSA and 64° ± 5° for those with ORIF (mean difference 21° [95% CI 19° to 23°]; p < 0.01). The mean internal rotation was 45° ± 6° for patients with RTSA and 40° ± 6° for those with ORIF (mean difference 5° [95% CI 3° to 7°]; p < 0.01). The risk of complications was not different between patients with ORIF and those with RTSA (5% [three of 66] versus 1% [one of 72]; relative risk 3.3 [95% CI 0.3 to 30.7]; p = 0.30). Among patients with ORIF, 8% had varus malunions (five of 66), 6% had resorption of the greater tuberosity (four of 66), and 2% had avascular necrosis of the humeral head (one of 66). In the RTSA group, 24% (17 of 72 patients) demonstrated reabsorption of periprosthetic bone and 79% of patients (57 of 72) exhibited no notching. The risk of revision was not different between the RTSA and ORIF groups (0% [0 of 72] versus 9% [six of 66]; relative risk 0.07 [95% CI 0.0 to 1.2]; p = 0.07).

CONCLUSION

In patients older than 70 years with three-part and four-part proximal humerus fractures, primary RTSA resulted in better patient-reported outcome scores and better ROM than ORIF with an angular stable locking plate. Our findings might help surgeons decide between internal fixation and arthroplasty to surgically treat these injuries in older patients. Although RTSA seems to be a preferable treatment modality in view of these findings, longer follow-up is required to evaluate its longevity compared with ORIF with an angular locking plate. Dissimilar to ORIF, which is generally stable once healed, arthroplasties are at a continued risk for loosening and infection even after healing is complete.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Increasing Rate of Shoulder Arthroplasty for Geriatric Proximal Humerus Fractures in the United States, 2010–2019

Introduction

The two historically dominant surgical options for displaced geriatric proximal humerus (PHFx) fractures are open reduction internal fixation (ORIF) and hemiarthroplasty (HA). However, shoulder arthroplasty (SA), predominantly in the form of reverse total shoulder arthroplasty (RTSA), has emerged as an attractive treatment option. We aim to compare the utilization trends, complications, and costs associated with surgical management of geriatric proximal humerus fractures (PHFs) between 2010 and 2019. We hypothesized that 1) the proportion of patients undergoing SA would increase over time, 2) the short-term complication rate in patients undergoing SA would decline over time, and 3) hospital related costs would decline for SA patients over time.

Patients and Methods

The National Inpatient Sample was queried from 2010 to 2019 to identify all PHFx in patients aged 65 or older that underwent ORIF, SA, or HA. Multivariable regression was used to evaluate differences between fixation methods regarding health care utilization metrics, hospital costs, and index hospital complications. The primary outcome of interest was the method of surgical management utilized in the treatment of geriatric PHFs, and secondary outcomes of interest included hospitalization cost, length of stay (LOS), discharge destination and index hospitalization complications.

Results

A total of 105 886 geriatric patients that underwent surgical management of PHFx were identified. While the proportion undergoing ORIF decreased from 59% to 29%, the proportion undergoing SA increased from 9% to 67%. Hospital costs decreased over time for patients treated with SA and increased for those treated with ORIF. Compared to ORIF, SA was associated with higher cost, decreased length of stay, and lower mortality and complication rates.

Conclusion

Over the last decade, SA has become the most common surgical treatment modality performed for geriatric PHFx. Index hospital complications are reduced in SA patients compared to ORIF patients, driven largely by a lower rate of blood transfusion. Although costs are decreasing and average length of stay is now lower in SA patients compared to ORIF patients, SA remains associated with higher hospital costs overall.

Decision-Making and Management of Proximal Humerus Nonunions

Proximal humerus fracture nonunions are heterogenous group of posttraumatic sequelae in both the operatively and nonoperatively treated proximal humerus fracture. The management of these fractures is largely based on the residual morphology. Understanding the relationship of the nonunited and malunited fragments, anatomic location of the fracture, and viability of the residual bone stock will allow for better surgical planning. Patient optimization with nonoperative care, open reduction internal fixation, intramedullary nailing, and shoulder arthroplasty, all have a role in the treatment of proximal humerus fracture nonunions.