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Spoden M, Dröge P, Günster C, Datzmann T, Helfen T, Schaser KD, Schmitt J, Schuler E, Christoph Katthagen J, Nowotny J. A high hospital frailty risk score indicates an increased risk for complications following surgical treatment of proximal humerus fractures. Arch Gerontol Geriatr 2024; 128:105598. [PMID: 39182348 DOI: 10.1016/j.archger.2024.105598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 08/01/2024] [Accepted: 08/04/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Approximately 70 % of proximal humerus fractures (PHF) occur after the age of 60. High complication rates have been described in correlation with the treatment of PHF. Major risk factors for the outcome might be frailty, mobility and comorbidities of patients at the time of hospital admission. The aim of this study was to create risk adjusted quality indicators for surgical treatment of proximal humerus fractures based on German claims data and to evaluate the impact of the Hospital Frailty Risk Score (HFRS) on risk adjustment. METHODS Retrospective claims data (2015-2021) were used to create risk adjusted quality indicators for eight outcomes by clustered multivariable logistic regression. The comparison of different risk adjustment model performances was done by ROC-AUC and Standardized Mortality/Morbidity Ratios. RESULTS In total, N = 34,912 patients (median age 75 years, 80.3 % female) were included. The most common surgical procedure was open reduction and internal fixation with plate osteosynthesis with 39.7 %, followed by reverse shoulder arthroplasty with 25.3 %. The most influential risk factor for all outcomes was a high HFRS with an Odds Ratio of 2.0 (95 %-Confidence Interval 1.8-2.3) for any secondary surgery (365 days) up to an Odds Ratio of 17.6 (95 %-Confidence Interval 14.9-20.8) for general complications during the index stay. CONCLUSION Comparative quality reporting for the surgical treatment of PHF appears feasible with the developed models for risk adjustment using claims data. Preoperative evaluation of HFRS in PHF can contribute to risk assessment, and individual patient management. It therefore enables personalized treatment decisions.
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Affiliation(s)
| | | | | | - Thomas Datzmann
- Center for Evidence-based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Tobias Helfen
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal UniversityCenter Munich (MUM), LMU University Hospital, LMU Munich, Germany
| | - Klaus-Dieter Schaser
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital, Technische Universität Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - J Christoph Katthagen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Munster, Munster, Germany
| | - Jörg Nowotny
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital, Technische Universität Dresden, Germany
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Tille E, Lorenz F, Beyer F, Schlüßler A, Biewener A, Nowotny J. Early functional improvements using continuous passive motion therapy after angular-stable plate osteosynthesis of proximal humerus fractures - results of a prospective, randomized trial. J Orthop Surg Res 2024; 19:313. [PMID: 38802866 PMCID: PMC11131183 DOI: 10.1186/s13018-024-04804-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The use of continuous passive motion therapy (CPM) has led to promising results in the early phase of rehabilitation after surgical treatment of rotator cuff tears and arthrolysis of the elbow. However, its use has not been proven in other pathologies of the upper extremity. Therefore, the aim of the underlying study was to evaluate the use of CPM therapy after plate osteosynthesis of proximal humeral fractures. METHODS 95 patients with isolated proximal humerus fractures were enrolled in a prospective, randomized study. Patients were assigned to a treatment group with (n = 48, CPM) or without CPM therapy (n = 47, CG). Four patients (2 of each cohort) violated the study protocol and were excluded. CPM therapy was used for 6 weeks after surgery 2-3 times daily. Functional (range of motion) and patient reported outcomes (PROM, Constant Score [CSS], QuickDASH, subjective shoulder value [SSV], pain on visual analogue scale [VAS]) were evaluated at 6 weeks, 3 and 12months. 60 patients completed the 1-year follow-up. RESULTS The average patient age was 65.3 years (min: 27, max: 88, SD: ± 14.7). Seventy-two patients were female (79%). There was no difference regarding injury severity (2/3/4 part-fracture: 6/32/7 vs. 9/26/11, p = 0.867) and sex (p = 0.08). However, patients in the CPM group were significantly younger (CPM: 67 [min: 34, max: 82], CG: 74 [min: 27, max: 88], p = 0.032). After 6 weeks we observed a better range of motion for forward flexion (CPM: 90° [min: 50°, max: 180°] vs. CG: 80° [min: 20°, max: 170°] p = 0.035) and abduction (CPM: 80° [min: 40°, max: 180°] vs. CG: 70° [min: 20°, max: 180°], p = 0.048) in the CPM group. There was no difference regarding the further planes of motion or the assessed PROMs at 6 weeks. At 3 and 12 months the results between the treatment groups equalized with no further significant differences. CONCLUSION The treatment with CPM increases the range of motion after plate osteosynthesis of proximal humerus fractures in the first 6 weeks after surgery. This effect is not sustained after 3 and 12months. The evaluated PROMs are not being influenced by CPM therapy. Hence the results of this prospective randomized study suggest that CPM can be a beneficial asset in the early period of rehabilitation after proximal humerus plate osteosynthesis. TRIAL REGISTRATION The study protocol was registered in the US National Institutes of Health's database ( http://www. CLINICALTRIALS gov ) registry under NCT05952622.
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Affiliation(s)
- Eric Tille
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany.
| | - Franz Lorenz
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
| | - Franziska Beyer
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
| | - Antonia Schlüßler
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
| | - Achim Biewener
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
| | - Jörg Nowotny
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
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Miquel J, Cassart E, Santana F, Martínez R, Valls L, Salomó-Domènech M, Torrens C. Reverse shoulder arthroplasty or nothing for patients with displaced proximal humeral fractures: a randomized controlled trial. J Shoulder Elbow Surg 2024:S1058-2746(24)00224-6. [PMID: 38548095 DOI: 10.1016/j.jse.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/03/2024] [Accepted: 02/12/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND The benefits of reverse shoulder arthroplasty compared to nonoperative treatment for patients presenting with complex proximal fractures have been rarely explored. The aim of this prospective study was to compare the functional results of reverse shoulder arthroplasty with those of nonsurgical treatment in patients with displaced proximal humeral fractures. METHODS A multicentric prospective randomized control trial of patients older than 70 years who sustained an acute proximal humeral fracture (3 or 4 parts), with less than 3 weeks of evolution, and had no previous condition or surgery on the affected shoulder was conducted. Patients were randomly assigned to the intervention group (implantation of a reverse shoulder arthroplasty and tuberosities reattachment) or the control group (nonoperative treatment). Functional outcome was assessed using the Constant-Murley score (CMS) at the 1-year follow-up. Complications and reinterventions were considered secondary outcomes. The power of the study relied on the inclusion of 81 patients to recognize a statistically significant difference of 10 points between CMS scores in the groups. Analysis was performed based on the intention to treat principle. RESULTS Eighty-one patients were randomized to surgical treatment or nonoperative treatment, while 66 patients completed the 1-year follow-up evaluation. There was no significant difference between the groups in terms of age (76.1 yo vs. 77.43 yo, P = .43), sex (81.08% women in the surgical group vs. 84.09% in the nonoperative group, P = .72), or type of fracture according to Neer's classification system (P = .06). At the 1-year follow-up, the group assigned to undergo the intervention had better functional outcomes than the nonoperative treatment group (mean CMS; 61.24, SD: 13.33 vs. mean CMS: 52.44, SD: 16.22, P: .02), with a mean difference of 8.84 points, 95% CI (1.57, 16.11). Two patients in the intervention group (6.5%) suffered major complications (periprosthetic joint infection and axillary nerve palsy). No major complications were observed in the nonoperative group. One patient in the intervention group underwent secondary surgery for a periprosthetic joint infection. CONCLUSIONS Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture. The difference in CMS is close to the clinically significant thresholds, and some harms are associated with the operative treatment.
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Affiliation(s)
- Joan Miquel
- Orthopaedics & Trauma Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain.
| | - Elisa Cassart
- Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Fernando Santana
- Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Raquel Martínez
- Department of Orthopedics, Althaia Xarxa Assistencial Universitària de Manresa, Manresa, Spain; Department of Orthopedics, Hospital d'Igualada, Consorci Sanitari de L'Anoia, Barcelona, Spain
| | - Laura Valls
- Department of Orthopedics, Hospital d'Igualada, Consorci Sanitari de L'Anoia, Barcelona, Spain
| | - Mònica Salomó-Domènech
- Orthopaedics & Trauma Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Carlos Torrens
- Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
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D'Almeida SS, Cannon R, Vu NT, Ponce BA, Redden D. Comparing Intramedullary Nails and Locking Plates in Displaced Proximal Humerus Fracture Management: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e54235. [PMID: 38496197 PMCID: PMC10944142 DOI: 10.7759/cureus.54235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
This study aims to provide an updated review comparing the complication rates and clinical outcomes of intramedullary nails and locking plates (LPs) in displaced proximal humerus fracture (PHF) management. We performed a systematic review of the Cochrane Central Register of Controlled Trials, Clinical Trials Registry, EMBASE, and PubMed. Studies with level III evidence or higher comparing intramedullary nails and LPs used for internal fixation of displaced PHFs were included. The Methodological Index for Nonrandomized Studies (MINORS) criteria and Cochrane Handbook for Systematic Reviews of Interventions 5.2.0 were used to assess the risk of bias. Our meta-analysis included a comparison of method-related complications, pain scores, range of motion (ROM), and functional scores. A total of 13 comparative studies were included: five randomized controlled trials, three prospective cohort studies, and five retrospective cohort studies. The total number of patients included was 1,253 (677 in the LP group and 576 in the intramedullary nail group). Superior Constant-Murley scores and external rotation ROM were found in the LP group during the early postoperative period. However, long-term functional scores and complication rates were comparable between the two groups. We conclude that intramedullary nailing and LP fixation are both equally effective for the treatment of displaced PHFs. Neither treatment appears superior at this time, and more large-scale randomized controlled trials should be conducted to further evaluate the potential benefit of LPs in the early postoperative period.
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Affiliation(s)
| | - Reily Cannon
- Medicine, Touro College of Osteopathic Medicine, Henderson, USA
| | - Nguyen T Vu
- Medicine, Edward Via College of Osteopathic Medicine, Auburn, USA
| | | | - David Redden
- Research and Biostats, Edward Via College of Osteopathic Medicine, Auburn, USA
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Henkelmann R, Hepp P, Mester B, Dudda M, Braun PJ, Kleen S, Zellner J, Galler M, Koenigshausen M, Schildhauer TA, Saier T, Trulson I, Dey Hazra RO, Lill H, Glaab R, Bolt B, Wagner M, Raschke MJ, Katthagen JC. Assessment of Complication Risk in the Treatment of Proximal Humerus Fractures: A Retrospective Analysis of 4019 Patients. J Clin Med 2023; 12:jcm12051844. [PMID: 36902631 PMCID: PMC10003238 DOI: 10.3390/jcm12051844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/22/2023] [Accepted: 02/21/2023] [Indexed: 03/03/2023] Open
Abstract
(1) Background: The treatment of proximal humeral fractures (PHFs) is debated controversially. Current clinical knowledge is mainly based on small single-center cohorts. The goal of this study was to evaluate the predictability of risk factors for complications after the treatment of a PHF in a large clinical cohort in a multicentric setting. (2) Methods: Clinical data of 4019 patients with PHFs were retrospectively collected from 9 participating hospitals. Risk factors for local complications of the affected shoulder were assessed using bi- and multivariate analyses. (3) Results: Fracture complexity with n = 3 or more fragments, cigarette smoking, age over 65 years, and female sex were identified as predictable individual risk factors for local complications after surgical therapy as well as the combination of female sex and smoking and the combination of age 65 years or older and ASA class 2 or higher. (4) Conclusion: Humeral head preserving reconstructive surgical therapy should critically be evaluated for patients with the risk factors abovementioned.
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Affiliation(s)
- Ralf Henkelmann
- Department of Orthopedics, Trauma and Plastic Surgery, Division of Arthroscopic and Special Joint Surgery/Sports Injuries, University of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
- Correspondence: ; Tel.: +49-341-9717300
| | - Pierre Hepp
- Department of Orthopedics, Trauma and Plastic Surgery, Division of Arthroscopic and Special Joint Surgery/Sports Injuries, University of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Bastian Mester
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Marcel Dudda
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Philipp-Johannes Braun
- Department of Trauma and Orthopaedic Surger, BG Hospital Unfallkrankenhaus Berlin gGmbH, Warener Straße 7, 12683 Berlin, Germany
| | - Sebastian Kleen
- Department of Trauma and Orthopaedic Surger, BG Hospital Unfallkrankenhaus Berlin gGmbH, Warener Straße 7, 12683 Berlin, Germany
| | | | - Michael Galler
- Department of Trauma Surgery, Caritas Hospital St. Josef, Landshuter Strasse 65, 93053 Regensburg, Germany
| | - Matthias Koenigshausen
- Department of General and Trauma Surgery, University Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | - Thomas A. Schildhauer
- Department of General and Trauma Surgery, University Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | - Tim Saier
- Department of Trauma Surgery, BG Trauma Center Murnau, 82418 Murnau, Germany
| | - Inga Trulson
- Institute for Laboratory Medicine, German Heart Center, Technical University of Munich, Lazarettstraße 36, 80636 Munich, Germany
| | - Rony-Orijit Dey Hazra
- Department for Orthopaedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169 Hannover, Germany
| | - Helmut Lill
- Department for Orthopaedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169 Hannover, Germany
| | - Richard Glaab
- Department of Traumatology, Cantonal Hospital Aarau, 5001 Aarau, Switzerland
| | - Basil Bolt
- Department of Traumatology, Cantonal Hospital Aarau, 5001 Aarau, Switzerland
| | - Marcus Wagner
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), Leipzig University, Härtelstraße 16-18, 04107 Leipzig, Germany
| | - Michael J. Raschke
- Department for Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Jan Christoph Katthagen
- Department for Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
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Double Plating for Complex Proximal Humeral Fractures: Clinical and Radiological Outcomes. J Clin Med 2023; 12:jcm12020696. [PMID: 36675625 PMCID: PMC9860712 DOI: 10.3390/jcm12020696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/19/2022] [Accepted: 01/09/2023] [Indexed: 01/17/2023] Open
Abstract
Double plating for proximal humeral fractures (PHF) is an option to increase the primary fixation stability. Clinical data is missing for assessment of clinical and radiological outcome, as well as complications. We retrospectively examined 35 patients with unilateral PHF, who were treated with double plating for PHF between 2013 and 2019. The mean age was 59.5 ± 12 years and the leading fracture type was a varus dislocation (Resch type IV in 55.3%). A head-split was present in 22.9% of the cases. The primary outcome measurement was the radiological neck shaft angle (NSA). The radiological follow-up was 21 ± 16.6 months and the NSA did not differ between the intraoperative and follow-up time point (131.5 ± 6.9° vs. 136.6 ± 13.7°; p = 0.267). The clinical follow-up was 29.5 ± 15.3 months. The Constant-score was 78.5 ± 17 points, the simple-shoulder-test (SST) was 9.3 ± 3.2 points and the subjective shoulder value (SSV) was 78.8 ± 19.5%. The over-all complication rate was 31.4%, and without stiffness 14.3%. An avascular necrosis occurred in two patients (5.7%). In conclusion, this study shows good radiological and functional outcomes after double plating of highly complex proximal humeral fractures, while the complication rate is comparable to the literature. Double plating is a viable option especially for younger patients with complex fractures as a potential alternative to fracture arthroplasty.
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