Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients: a randomized controlled trial

Augmented versus non-augmented locking-plate fixation in proximal humeral fractures

Aims

Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures.

Methods

The search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles involving patients with complex proximal humeral fractures treated using open reduction with locking-plate fixation, with or without augmentation, were considered. A meta-analysis of comparative studies comparing locking-plate fixation with cement augmentation or with bone-graft augmentation versus locking-plate fixation without augmentation was performed.

Results

A total of 19 studies were included in the qualitative synthesis, and six comparative studies were included in the meta-analysis. Overall, 120 patients received locking-plate fixation with bone-graft augmentation, 179 patients received locking-plate fixation with cement augmentation, and 336 patients received locking-plate fixation without augmentation. No statistically relevant differences between the augmented and non-augmented cohorts were found in terms of the Disabilities of the Arm, Shoulder and Hand questionnaire score and Constant-Murley Score. The cement-augmented group had a significantly lower rate of complications compared to the non-augmented group.

Conclusion

While locking-plate fixation with cement augmentation appears to produce a lower complication rate compared to locking-plate fixation alone, functional outcomes seem comparable between augmented and non-augmented techniques.

Assessment of therapeutic clinical trials for proximal humeral fractures

Proximal humeral fractures (PHFs) are a common injury among the older population. An ideal therapeutic protocol has yet to be developed, and numerous clinical trials are being conducted to find the best therapeutic approach. The purpose of this study is to evaluate the current body of knowledge available via interventional clinical trials. In December 2022, interventional clinical trials relating to PHFs on Clinicaltrials.gov were screened. Trial characteristics included duration, status, intervention, phase, outcomes, location, and study design. Publications associated with each trial were searched on PubMed/Medline using the ClinicalTrials.gov registry number. The final dataset comprised 64 trials. The most common trial status was completed (36%). The majority did not have a Food and Drug Administration-defined phase (67%), was randomized (81%), involved a single facility (72%), used a parallel assignment intervention model (80%), and used an open-label approach (45%). Eleven trials were associated with a publication, and the publication rate was 17%. Average enrollment was 86 participants, and mean trial duration was 51.4 months. Europe/UK/Russia/Turkey participated in the most trials (70%). Most of the trials were initiated after 2010 (87.5%). Procedure-related interventions (55%) were most common. Disability/function was the most common primary outcome assessed (61%). The low publication rate and the multitude of trials conducted after 2010 highlight the urgency and need for trial results to be published to establish an ideal therapeutic protocol. Since the majority of the trials involved a single institution and an open-label approach, reinforcing blinding and establishing multi-centered trials can improve the validity of the clinical trial results.

Valgising angular stable plate fixation in the treatment of multifragmentary proximal humeral fractures in elderly patients

INTRODUCTION

The frequency of proximal humeral fractures shows an increasing tendency, especially in the elderly, who are frequently affected by osteoporosis. The adequate treatment of complex, displaced fractures poses a serious challenge. Among surgical treatment options, osteosynthesis with an angular stable plate is preferred, however, the implant-related complication rate may be exceptionally high. In our present study, we report the short-term outcomes of our new method of valgising angular stable plate fixation which we use for multifragmentary, displaced proximal humeral fractures in elderly patients.

MATERIALS AND METHODS

We retrospectively evaluated the clinical and radiological outcomes of 52 patients (46 female and 6 male, age: 71.9 ± 9.6) who suffered dislocated three- or four-part fractures and underwent valgising angular stable plate fixation.

RESULTS

Mean follow-up time was 17.3 months, while the functional outcomes were as following: excellent in 26, good in 18, moderate in 5 and poor in 3 patients. The mean Constant-Murley Score was 82.5 ± 11.2. Functional outcomes only showed significant correlation (p = 0.031) with age and were proven unrelated to fracture type, BMI and known primary diseases. The cumulative complication rate was 9.6% and revision rate was 5.8%. Neurological deficit, pseudoarthrosis or avascular humeral head necrosis did not occur during the follow-up period.

CONCLUSIONS

Valgising angular stable plate fixation that we apply for proximal humeral fractures provided favourable functional outcomes and a low postoperative complication rate due to the optimal head and plate placement. The method is especially effective for the treatment of displaced three- and four-part fractures with weakened, osteoporotic bone structure.

Surgery with locking plate or hemiarthroplasty versus nonoperative treatment of 3-4-part proximal humerus fractures in older patients (NITEP): An open-label randomized trial

BACKGROUND

Proximal humerus fractures (PHFs) are common fractures, especially in older female patients. These fractures are commonly treated surgically, but the consensus on the best treatment is still lacking.

METHODS AND FINDINGS

The primary aim of this multicenter, randomized 3-arm superiority, open-label trial was to assess the results of nonoperative treatment and operative treatment either with locking plate (LP) or hemiarthroplasty (HA) of 3- and 4-part PHF with the primary outcome of Disabilities of the Arm, Shoulder, and Hand (DASH) at 2-year follow-up. Between February 2011 and December 2019, 160 patients 60 years and older with 3- and 4-part PHFs were randomly assigned in 1:1:1 fashion in block size of 10 to undergo nonoperative treatment (control) or operative intervention with LP or HA. In total, 54 patients were assigned to the nonoperative group, 52 to the LP group, and 54 to the HA group. Five patients assigned to the LP group were reassigned to the HA group perioperatively due to high comminution, and all of these patients had 4-part fractures. In the intention-to-treat analysis, there were 42 patients in the nonoperative group, 44 in the LP group, and 37 in the HA group. The outcome assessors were blinded to the study group. The mean DASH score at 2-year follow-up was 30.4 (standard error (SE) 3.25), 31.4 (SE 3.11), and 26.6 (SE 3.23) points for the nonoperative, LP, and HA groups, respectively. At 2 years, the between-group differences were 1.07 points (95% CI [-9.5,11.7]; p = 0.97) between nonoperative and LP, 3.78 points (95% CI [-7.0,14.6]; p = 0.69) between nonoperative and HA, and 4.84 points (95% CI [-5.7,15.4]; p = 0.53) between LP and HA. No significant differences in primary or secondary outcomes were seen in stratified age groups (60 to 70 years and 71 years and over). At 2 years, we found 30 complications (3/52, 5.8% in nonoperative; 22/49, 45% in LP; and 5/49, 10% in HA group, p = 0.0004) and 16 severe pain-related adverse events. There was a revision rate of 22% in the LP group. The limitation of the trial was that the recruitment period was longer than expected due to a high number of exclusions after the assessment of eligibility and a larger exclusion rate than anticipated toward the end of the trial. Therefore, the trial was ended prematurely.

CONCLUSIONS

In this study, no benefit was observed between operative treatment with LP or HA and nonoperative treatment in displaced 3- and 4-part PHFs in patients aged 60 years and older. Further, we observed a high rate of complications related to operative treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01246167.

A network meta-analysis of multiple modalities for the treatment of complex proximal humeral fractures in older adults

OBJECTIVE

Four principal treatment modalities are applied to treat complex proximal humeral fractures in older adults: conservative treatment, open reduction internal fixation, hemiarthroplasty, and reverse shoulder arthroplasty. However, among these, the optimal treatment modality has yet to be determined. Therefore, a network meta-analysis was carried out to compare treatment modalities and assess their effectiveness.

METHODS

The databases PUBMED, EM-BASE, the Cochrane Central Register of Controlled Trials, Web of Science, and CNKI were searched for randomised controlled trials on complex proximal humeral fractures in older people, ranging from inception of each database to May 2023.

RESULTS

This meta-analysis included 14 randomised controlled trials, containing 791 patients aged over 60 years who were treated for complex proximal humeral fractures. Reverse shoulder arthroplasty and hemiarthroplasty yielded the highest Constant shoulder scores, whilst conservative treatment performed poorly. Hemiarthroplasty and open reduction internal fixation yielded the best performances on the visual analogue pain scale, whilst conservative treatment performed poorly. Reverse shoulder arthroplasty and open reduction internal fixation allowed for maximum forward flexion and outreach of range of motion, whilst hemiarthroplasty allowed for the least. Open reduction internal fixation and reverse shoulder arthroplasty allowed for maximum internal rotation of the range of motion, whilst conservative treatment allowed for the least. Hemiarthroplasty and conservative treatment allowed for maximum external rotation of the range of motion, whilst open reduction internal fixation allowed for the least.

CONCLUSION

Compared with open reduction internal fixation, reverse shoulder arthroplasty yields better Constant shoulder scores and allows for greater forward flexion and outreach of range of motion of the shoulder joint in complex proximal humerus fractures in older patients. Meanwhile, hemiarthroplasty yields the best visual analogue scale scores and allows for maximum external rotation of the range of motion. However, open reduction with internal fixation remains the preferred clinical treatment for complex proximal humeral fractures in older patients.

Why treatment of proximal humeral fractures remains unresolved despite randomized trials

Most proximal humeral fractures can be treated nonoperatively, but there are specific indications to perform surgery for some of these fractures. Optimal treatment remains subject to debate, since no consensus has been reached for the best therapy for these fractures. This review provides an overview of randomized controlled trials (RCTs) comparing treatment for proximal humeral fractures. Fourteen RCTs comparing different operative and nonoperative types of treatment for PHF are included. Different RCTs comparing the same interventions for PHF have drawn different conclusions. It also highlights reasons why consensus has not been reached based on these data, and how this could be addressed in future research. Previous RCTs have included different patient groups and fracture patterns, may have been prone to selection bias, often were underpowered for subgroup analysis, and showed inconsistency in the outcome measures used. Based on this, and appreciating that treatment may be tailored to specific fracture types and patient characteristic like age, a better way to move forward could be to use a (international) multicenter prospective cohort study. Such a registry-type study should use accurate patient selection and enrollment, well-defined fracture patterns, standardized surgical techniques performed according to the preferences of the surgeon, and with a standardized follow-up.

Plate Fixation of Proximal Humerus Fractures: How to Get It Right and Future Directions for Improvement

PURPOSE OF REVIEW

Open reduction and internal fixation with locking plates (ORIF-LP) has been used for decades for the surgical management of proximal humerus fractures. Despite good outcomes have been widely published in the literature, unacceptably high rates of complications (up to 40%), many of them yielding poor outcomes and requiring reoperation (up to 25%), have also been reported, especially in elderly patients. Most common complications are related to implant failure, with intra-articular screw penetration as the most frequent and devastating.

RECENT FINDINGS

Advances in patient selection and surgical technique, and implementation of bone or cement augmentation, have been developed to hopefully decrease complication rates. Mayo-FJD Classification offers prognostic information that can aid in the decision-making process for proximal humeral fractures. Displaced valgus impacted fractures seem to be associated with well over a 10% rate of avascular necrosis after ORIF-LP. A principle-based and stepwise surgical technique combining anatomic reduction and a short screw configuration can provide good outcome in most patients, even the elderly, decreasing implant failures to less than 10%. Acrylic cement augmentation has the potential to further decrease implant failure rate to 1%. Reoperation rates are higher partly due to the need to remove hardware for painful subacromial conflict. However, no studies to date definitively demonstrated the superiority of ORIF-LP compared to non-operative treatment, intramedullary nailing, or reverse shoulder arthroplasty. ORIF-LP can provide good results for the surgical management of displaced proximal humerus fractures even in elderly patients provided adequate patient selection and a principle based and stepwise surgical technique, supplemented with bone graft or acrylic cement when needed. Poor outcomes and high complication and reoperation rates should be expected when these recommendations are not followed.

Nonoperative Management of Humerus Fractures in Patients With Ispilateral Hemiparesis or Hemiplegia

BACKGROUND

Patients with upper limb dysfunction from a brain injury often have different goals of treatment and expectations following a fracture of the upper extremity. This study retrospectively reviewed outcomes of nonoperative management of acute humerus fractures in patients with severe ipsilateral hemiparesis or hemiplegia.

METHODS

Patients who had sustained an acute humerus fracture managed nonoperatively, greater than 1 year following an upper motor neuron (UMN) injury resulting in ipsilateral severe hemiparesis or hemiplegia at a single tertiary care center from 1988 to 2019, were reviewed. Fractures were classified using the AO-Müller/Orthopaedic Trauma Association and/or Neer classifications. Primary outcome measures included House classification level of function, pain, achievement of and time to radiographic union, and the need for subsequent surgical procedures.

RESULTS

Ten distinct nonoperatively managed humerus fractures-3 proximal (11A23), 5 mid-shaft (12A2b = 1, 12A2c = 2, 12A3a = 1, 12A2b = 1), and 2 distal (13A2 = 1, 13 C1 = 1)-were identified in 8 patients (6 women and 2 men) with ipsilateral hemiparesis or hemiplegia. The median radiographic follow-up was 20 months (range: 78 days to 12 years). The median clinical follow-up was 33.5 months (range: 100 days to 12 years). All patients presented with severe pain that was absent at final follow-up. Radiographic union was achieved in all patients with a mean time to union of 90.9 ± 39.3 days (range: 35-185 days). No patients required operative management.

CONCLUSIONS

Nonoperative management of humerus fractures in patients with an ipsilateral UMN injury might result in reliable pain relief and union without the need for further surgical intervention. Management of humerus fractures in this patient population should be individualized toward their goals of care.

Early Outcomes of Proximal Humerus Fractures in Adults Treated With Locked Plate Fixation Compared with Nonoperative Treatment: An Age-, Comorbidity-, and Fracture Morphology-Matched Analysis

OBJECTIVES

To compare patient-reported outcomes (PROs), range of motion (ROM), and complication rates for proximal humerus fractures managed nonoperatively or with open reduction internal fixation (ORIF).

DESIGN

Retrospective cohort.

SETTING

Academic level 1 trauma center.

PATIENTS/PARTICIPANTS

Four hundred thirty-one patients older than 55 years were identified retrospectively. 122 patients were excluded. 309 patients with proximal humerus fractures met inclusion criteria (234 nonoperative and 75 ORIF). After matching, 192 patients (121 nonoperative and 71 ORIF) were included in the analysis.

INTERVENTION

Nonoperative versus ORIF (locked plate) treatment of proximal humerus fracture.

MAIN OUTCOME MEASUREMENTS

Early Visual Analog Score (VAS), ROM, PROs, complications, and reoperation rates between groups.

RESULTS

At 2 weeks, ORIF showed lower VAS scores, better passive ROM, and patient-reported outcomes measurement information system (PROMIS) scores ( P < 0.05) compared with nonoperative treatment. At 6 weeks, open reduction internal fixation (ORIF) had lower VAS scores, better passive ROM, and PROMIS scores ( P < 0.05) compared with nonoperative treatment. At 3 months, ORIF showed similar PROMIS scores ( P > 0.05) but lower VAS scores and better passive ROM ( P < 0.05) compared with nonoperative treatment. At 6 months, ORIF showed similar VAS scores, ROM, and PROMIS scores ( P > 0.05) compared with nonoperative treatment. There was no difference in secondary operation rates between groups ( P > 0.05). ORIF patients trended toward a higher secondary reoperation rate (15.5% vs. 5.0%) than nonoperative patients ( P = 0.053).

CONCLUSIONS

In an age-, comorbidity-, and fracture morphology-matched analysis of proximal humerus fractures, ORIF led to decreased pain and improved passive ROM early in recovery curve compared with nonoperative treatment that normalized after 6 months between groups.

LEVEL OF EVIDENCE

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

Management of Proximal Humeral Fractures in Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

Differences in function, pain, and reoperation rates were compared between the following treatment options: (1) operative vs. nonoperative treatment and (2) various surgical treatments including open reduction internal fixation, intramedullary nail, hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA).

DATA SOURCES

MEDLINE, Embase, and Cochrane were searched through February 1, 2022. All English-language randomized trials comparing operative and nonoperative treatment of proximal humeral fractures with a control group in patients 18 years or older were included.

DATA EXTRACTION

Demographic data, functional and pain scores and re-operation rates were extracted. Study quality was determined with the Cochran risk of bias tool and the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE). Heterogeneity was determined with the I-squared statistic.

DATA SYNTHESIS

Meta-analysis of included studies using mean difference and odds ratios where appropriate.

CONCLUSIONS

Surgical treatment with either locked plates or HA results in similar functional scores and pain outcomes as nonoperative treatment, although plates were associated with higher reoperation rates in 3-part and 4-part fractures. In 3-part and 4-part fractures, RSA results in higher function and pain scores compared with HA. Further high-quality trials should focus on RSA, and further study is required to better define the role of open reduction internal fixation in the younger patient population.

LEVEL OF EVIDENCE

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

Risk factors for loss of reduction following locked plate fixation of proximal humerus fractures in older adults

PURPOSE

To identify characteristics associated with loss of reduction following open reduction and locked plate fixation (ORIF) of proximal humerus fractures in older adults and determine if loss of reduction affects patient reported outcomes (PROs), range of motion (ROM), and complication rates during the first postoperative year.

METHODS

Patients >55 years old who underwent proximal humerus ORIF were reviewed. Patient and fracture characteristics were recorded. Fixation characteristics were measured on the initial postoperative AP radiograph including humeral head height (HHH) relative to the greater tuberosity (GT), head shaft angle (HSA), screw-calcar distance, and screw tip-joint surface distance. Loss of reduction was defined as GT displacement >5 mm or HSA displacement >10° on final follow up radiographs. Patient, fracture, and fixation characteristics were tested for association with loss of reduction. Outcomes including ROM, visual analog scale pain and PROMIS scores, and complication/reoperation rates during the first postoperative year were compared between those with or without loss of reduction.

RESULTS

A total of 79 patients were identified, 23 (29.1%) of which had a loss of reduction. Calcar comminution (relative risk [RR]=2.5, 95% Confidence Interval [CI]=1.3-5.0, p<0.01), HHH <5 mm above GT (RR=2.0, CI=1.0-3.9, p = 0.048), and screw-calcar distance ≥12 mm (RR=2.1, CI=1.1-4.1, p = 0.03) were risk factors for loss of reduction. Upon multivariate analysis, calcar comminution was determined to be an independent risk factor for loss of reduction (RR=2.4, CI=1.2-4.7, p = 0.01). Loss of reduction led to higher complication (44% vs 13%, p<0.01) and reoperation rates (30% vs 7%, p<0.01), and decreased achievement of satisfactory ROM (>90° active forward flexion, 57% vs 82%, p = 0.02) compared to maintained reduction, but similar PROs.

CONCLUSIONS

Calcar comminution, decreased HHH, and increased screw-calcar distance are risk factors for loss of reduction following ORIF of proximal humerus fractures. These morphologic and technical factors are important considerations for prolonged reduction maintenance.

The Role of Intramedullary Nailing for Proximal Humerus Fractures: What Works and What Does Not

PURPOSE OF REVIEW

The evaluation of proximal humerus fractures (PHFs) should be aimed to answer the following four questions: (1) does the fracture need surgery in each particular patient? (2) if surgery is recommended, is it better to proceed with internal fixation or shoulder arthroplasty, (3) if internal fixation is recommended, what is the ideal fixation device strategy, and (4) how can outcomes be optimized? This review article tries to answer these questions and provides some clarity regarding what works and what does not in PHFs treated with intramedullary nailing.

RECENT FINDINGS

According to published articles on the treatment of PHFs with intramedullary nails, it is difficult to draw conclusions about outcomes and complications due to great variation in age, type of fracture, and nail designs included in the studies. However, the literature seems to support the use of modern nail designs for PHFs, especially in fractures of the surgical neck as well as varus posteromedial and valgus fractures with no tuberosity involvement. Although the results of IMN in PHF seem to be better in two-part fractures, in more complex fractures, the quality of the reduction achieved seems to influence functional outcomes. Tuberosity malreduction leads to poor clinical outcomes, high rate of complications, and an increased risk of avascular necrosis. Malreduction of the humeral head increases the risk of postoperative loss of reduction, especially for varus posteromedial impacted fractures. A medial nail entry point decreases the risk of postoperative varus malunion, preserves the rotator cuff tendon, and avoids iatrogenic fractures of the GT. To decrease the risk of postoperative stiffness, fracture fixation should be stable enough to allow early mobilization.

Traumatic brain injuries are ignored or discriminated in prospective clinical trials on shoulder fractures: a systematic review

PURPOSE

Current literature suggests a significant epidemiological association between traumatic brain injury (TBI) and proximal upper limb fractures in addition to major clinical consequences. A systematic review was conducted to assess how TBI is taken into consideration in interventional studies on shoulder fractures.

METHODS

The following data sources were used: MEDLINE, EMBASE, EBM Reviews, CINAHL, and OpenGrey databases. Study selection included interventional randomized clinical trials and prospective cohort studies on shoulder fractures published in English or French between 2008 and 2020. Studies on pathologic fractures, chronic fracture complications, nonhuman subjects, and biomechanics were excluded. Articles were reviewed by two independent authors according to the PRISMA guidelines. Baseline characteristics, exclusion criteria, and input relevant to TBI were recorded. Methodological quality was assessed with the Cochrane risk of bias tool for randomized clinical trials and the Newcastle-Ottawa Scale for cohort studies.

RESULTS

One-hundred-thirteen studies met the inclusion criteria. None discussed the possible impact of TBI on their results. Only three (2.7%) studies considered TBI relevant and included these patients in their cohort. Furthermore, 43/113 (38.1%) excluded patients with injuries or mechanisms strongly related to traumatic brain injuries: head injuries (4); moderate and/or severe TBI (7); high energy traumas (3); Polytrauma subjects (33).

CONCLUSION

TBI are ignored or discriminated in prospective clinical trials on shoulder fractures. The exclusion of these cases impacts generalizability as their prevalence is significant. Considering the major impact of TBI on important outcomes, its presence should always be assessed to ensure high quality evidence.

LEVEL OF EVIDENCE

Systematic Review, Therapeutic Level II.

Is arthroplasty necessary for three and four-part proximal humerus fractures in elderly?

Background/Aim: Proximal humerus fractures are common in elderly patients. Treatment of three and four-part fractures is especially controversial in these patients. In recent years, surgical options have been widely used, especially among shoulder surgeons. The purpose of this study was to compare clinical results of conservative and arthroplasty methods. Methods: Between 2016 and 2020, 30 patients who were treated for Neer type 3 and type 4 proximal humeral fractures were included in the study. Patient data were evaluated retrospectively and then divided into three groups. Group 1 was treated conservatively, group 2 underwent hemiarthroplasty; and group 3 underwent reverse total shoulder arthroplasty. CONSTANT and visual analog scale (VAS) scores and radiological results at six months were evaluated retrospectively from patient records. At the last control they have been evaluated with CONSTANT, University of California/Los Angeles. (UCLA), and VAS scores. Results: Twenty-three (76.7%) of the patients included in the study were females. The mean age was 73.5 (5.7) years. The mean follow-up period was 33 (2.5) months. The mean follow-up periods in groups 1–3 were 33.3 (2.9), 32.8 (2), and 32.2 (2.9) months, respectively. When the CONSTANT scores of the patients were compared at the sixth month, they were observed to be better in the reverse total shoulder arthroplasty group (P = 0.001). Final control CONSTANT scores in the hemiarthroplasty group were lower than in the other groups (P = 0.001) and similar in the reverse shoulder prosthesis and conservative treatment group (P = 1). When the UCLA scores of all groups were compared, the mean UCLA scores were found to be significantly higher in groups 1 and 3 compared to group 2 (P = 0.001). When the VAS scores of the patients were compared, a significant difference between all groups was detected (P < 0.05). The highest VAS scores were observed in group 2, the second highest in group 1, and the lowest in group 3. Conclusion: For treatment of proximal humerus fractures in the elderly, patients should be evaluated according to activity levels and expectations, and surgical treatment should be suggested rather than ordered.

Different treatments for 3- or 4-part proximal humeral fractures in the elderly patients: A Bayesian network meta-analysis of randomized controlled trials

Background

Proximal humeral fractures are the third most common fracture in the body, and their incidence is rising year by year as the population ages. However, the treatment of the proximal humerus in parts 3 and 4 is still debatable, necessitating a network meta-analysis to determine the best treatment for each treatment modality.

Methods

We searched PubMed, Embase, Cochrane Library for randomized controlled trials on proximal humeral fractures up to June 21, 2022. We performed data extraction and literature quality assessment by two independent authors and extracted constant score and reoperation rate as indicators for evaluation. Stata software, Revman software, JAGS software and the R-based BlandAltmanLeh package, gemtc package and riags package were used to perform this Bayesian network meta-analysis.

Results

Following screening, 11 papers with a total of 648 participants were included in the analysis. The SUCRA values for the constant score were in the following order: RSA, IMN, Conservative, HA, and LP, and the SUCRA values for the reoperation rate were LP, HA, IMN, Conservative, and RSA.

Conclusion

The elderly with 3- or 4-part proximal humeral fractures should consider RSA because it received the best evaluation ranking in terms of constant score and reoperation rate.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022341209, identifier: CRD42022341209.

Epidemiology and trends in management of acute proximal humeral fractures in adults: an observational study of 137,436 cases from the Danish National Patient Register, 1996-2018

BACKGROUND AND PURPOSE

Proximal humeral fractures (PHF) can be managed surgically or non-surgically. Locking plates have been the preferred head-preserving surgical technique while hemiarthroplasty (HA) or reverse shoulder arthroplasty (RSA) have been used in joint replacement surgery. We describe the epidemiology and trends in management of acute PHF in Denmark with a focus on (i) changes in the incidence of PHF; (ii) changes in the proportion of surgical cases; and (iii) changes in preferred surgical techniques.

PATIENTS AND METHODS

Data on diagnoses and interventions was retrieved from the Danish National Patient Register. Patients aged 18 years and above were included. Surgical treatment was defined as the diagnosis of PHF combined with a predefined surgical procedure code within 3 weeks of injury. Data on plate osteosynthesis, HA, RSA, and "other techniques" was retrieved. Non-surgical treatment was defined as no relevant surgical procedure code within 3 weeks.

RESULTS

We identified 137,436 PHF (72% women) in the Danish National Patient Register. The overall mean incidence was 138/100,000/year (500 for women 60 years or above). Non-surgical treatment accounted for 119,966 (87%). The 17,470 surgical procedures included 42% locking plates, 34% arthroplasties, and 25% other techniques. The rate of surgery declined from 17% in 2013 to 11% in 2018.

INTERPRETATION

The overall incidence of PHF remained stable between 1996 and 2018 but the absolute number increased. The approach to PHF remains predominantly non-surgical. The number of surgeries in Denmark have decreased since 2013, especially for locking plates and HA, while RSA is increasingly used.

How to assess applicability and methodological quality of comparative studies of operative interventions in orthopedic trauma surgery

PURPOSE

It is challenging to generate and subsequently implement high-quality evidence in surgical practice. A first step would be to grade the strengths and weaknesses of surgical evidence and appraise risk of bias and applicability. Here, we described items that are common to different risk-of-bias tools. We explained how these could be used to assess comparative operative intervention studies in orthopedic trauma surgery, and how these relate to applicability of results.

METHODS

We extracted information from the Cochrane risk-of-bias-2 (RoB-2) tool, Risk Of Bias In Non-randomised Studies-of Interventions tool (ROBINS-I), and Methodological Index for Non-Randomized Studies (MINORS) criteria and derived a concisely formulated set of items with signaling questions tailored to operative interventions in orthopedic trauma surgery.

RESULTS

The established set contained nine items: population, intervention, comparator, outcome, confounding, missing data and selection bias, intervention status, outcome assessment, and pre-specification of analysis. Each item can be assessed using signaling questions and was explained using good practice examples of operative intervention studies in orthopedic trauma surgery.

CONCLUSION

The set of items will be useful to form a first judgment on studies, for example when including them in a systematic review. Existing risk of bias tools can be used for further evaluation of methodological quality. Additionally, the proposed set of items and signaling questions might be a helpful starting point for peer reviewers and clinical readers.

Locking Plates With Computationally Enhanced Screw Trajectories Provide Superior Biomechanical Fixation Stability of Complex Proximal Humerus Fractures

Joint-preserving surgical treatment of complex unstable proximal humerus fractures remains challenging, with high failure rates even following state-of-the-art locked plating. Enhancement of implants could help improve outcomes. By overcoming limitations of conventional biomechanical testing, finite element (FE) analysis enables design optimization but requires stringent validation. This study aimed to computationally enhance the design of an existing locking plate to provide superior fixation stability and evaluate the benefit experimentally in a matched-pair fashion. Further aims were the evaluation of instrumentation accuracy and its potential influence on the specimen-specific predictive ability of FE. Screw trajectories of an existing commercial plate were adjusted to reduce the predicted cyclic cut-out failure risk and define the enhanced (EH) implant design based on results of a previous parametric FE study using 19 left proximal humerus models (Set A). Superiority of EH versus the original (OG) design was tested using nine pairs of human proximal humeri (N = 18, Set B). Specimen-specific CT-based virtual preoperative planning defined osteotomies replicating a complex 3-part fracture and fixation with a locking plate using six screws. Bone specimens were prepared, osteotomized and instrumented according to the preoperative plan via a standardized procedure utilizing 3D-printed guides. Cut-out failure of OG and EH implant designs was compared in paired groups with both FE analysis and cyclic biomechanical testing. The computationally enhanced implant configuration achieved significantly more cycles to cut-out failure compared to the standard OG design (p &lt; 0.01), confirming the significantly lower peri-implant bone strain predicted by FE for the EH versus OG groups (p &lt; 0.001). The magnitude of instrumentation inaccuracies was small but had a significant effect on the predicted failure risk (p &lt; 0.01). The sample-specific FE predictions strongly correlated with the experimental results (R2 = 0.70) when incorporating instrumentation inaccuracies. These findings demonstrate the power and validity of FE simulations in improving implant designs towards superior fixation stability of proximal humerus fractures. Computational optimization could be performed involving further implant features and help decrease failure rates. The results underline the importance of accurate surgical execution of implant fixations and the need for high consistency in validation studies.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely, including in the use of surgery. This is an update of a Cochrane Review first published in 2001 and last updated in 2015.

OBJECTIVES

To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registries, and bibliographies of trial reports and systematic reviews to September 2020. We updated this search in November 2021, but have not yet incorporated these results.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults.  DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. We prepared a brief economic commentary for one comparison.

MAIN RESULTS

We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. Six comparisons were tested by 2 to 10 trials, the others by small single-centre trials only. Twelve studies evaluated non-surgical treatments, 10 compared surgical with non-surgical treatments, 23 compared two methods of surgery, and two tested timing of mobilisation after surgery. Most trials were at high risk of bias, due mainly to lack of blinding. We summarise the findings for four key comparisons below. Early (usually one week post injury) versus delayed (after three or more weeks) mobilisation for non-surgically-treated fractures Five trials (350 participants) made this comparison; however, the available data are very limited. Due to very low-certainty evidence from single trials, we are uncertain of the findings of better shoulder function at one year in the early mobilisation group, or the findings of little or no between-group difference in function at 3 or 24 months. Likewise, there is very low-certainty evidence of no important between-group difference in quality of life at one year. There was one reported death and five serious shoulder complications (1.9% of 259 participants), spread between the two groups, that would have required substantive treatment. Surgical versus non-surgical treatment Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures). There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants). There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year (EQ-5D (0: dead to 1: best quality): mean difference (MD) 0.01, 95% CI -0.02 to 0.04; 6 studies, 502 participants). There is low-certainty evidence of little between-group difference in mortality: one of the 31 deaths was explicitly linked with surgery (risk ratio (RR) 1.35, 95% CI 0.70 to 2.62; 8 studies, 646 participants). There is low-certainty evidence of a higher risk of additional surgery in the surgery group (RR 2.06, 95% CI 1.21 to 3.51; 9 studies, 667 participants). Based on an illustrative risk of 35 subsequent operations per 1000 non-surgically-treated patients, this indicates an extra 38 subsequent operations per 1000 surgically-treated patients (95% CI 8 to 94 more). Although there was low-certainty evidence of a higher overall risk of adverse events after surgery, the 95% CI also includes a slightly increased risk of adverse events after non-surgical treatment (RR 1.46, 95% CI 0.92 to 2.31; 3 studies, 391 participants). Open reduction and internal fixation with a locking plate versus a locking intramedullary nail Four trials (270 participants) evaluated surgical intervention for displaced fractures (63% were two-part fractures). There is low-certainty evidence of no clinically important between-group difference in shoulder function at one year (SMD 0.15, 95% CI -0.12 to 0.41; 4 studies, 227 participants), six months (Disability of the Arm, Shoulder, and Hand questionnaire (0 to 100: worst disability): MD -0.39, 95% CI -4.14 to 3.36; 3 studies, 174 participants), or two years (American Shoulder and Elbow Surgeons score (ASES) (0 to 100: best outcome): MD 3.06, 95% CI -0.05 to 6.17; 2 studies, 101 participants). There is very low-certainty evidence of no between-group difference in quality of life (1 study), and of little difference in adverse events (4 studies, 250 participants) and additional surgery (3 studies, 193 participants). Reverse total shoulder arthroplasty (RTSA) versus hemiarthroplasty There is very low-certainty evidence from two trials (161 participants with either three- or four-part fractures) of no or minimal between-group differences in self-reported shoulder function at one year (1 study) or at two to three years' follow-up (2 studies); or in quality of life at one year or at two or more years' follow-up (1 study). Function at six months was not reported. Of 10 deaths reported by one trial (99 participants), one appeared to be surgery-related. There is very low-certainty evidence of a lower risk of complications after RTSA (2 studies). Ten people (6.2% of 161 participants) had a reoperation; all eight cases in the hemiarthroplasty group received a RTSA (very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery. The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures. There is insufficient evidence from randomised trials to inform the choices between different non-surgical, surgical or rehabilitation interventions for these fractures.

Operative Treatment of Proximal Humeral Fractures with Reverse Total Shoulder Arthroplasty in Patients ≥65 Years Old: A Critical Analysis Review

»

The majority of proximal humeral fractures (PHFs) in patients who are ≥65 years of age are treated nonoperatively, but certain complex fracture patterns benefit from surgical intervention. However, there continues to be debate regarding the indications for surgery and the optimal surgical treatment (repair versus replacement) in this population.

»

Reverse total shoulder arthroplasty (RTSA) has grown in popularity for surgical treatment of fracture-dislocations and displaced complex PHFs in patients who are ≥65 years of age; it has definite advantages over surgical repair and hemiarthroplasty, but this finding requires additional higher-quality evidence.

»

RTSA provides early pain relief and return of shoulder function as well as predictable elevation above shoulder level in the forward plane, but the indications for and understanding of the effect of timing on RTSA after a PHF continue to evolve.

»

RTSA for an acute PHF is indicated in patients who are ≥65 years of age with 3- and 4-part fracture-dislocations, head-split fractures, and severely displaced fractures, and is an option in patients who are not able to tolerate nonoperative treatment of severely displaced 3- and 4-part fractures.

»

RTSA is also indicated as a salvage operation for PHFs that have failed initial surgical repair (i.e., fixation failure, implant failure, rotator cuff failure, or osteonecrosis) and is an option for symptomatic nonunion or malunion after nonoperative treatment.

Reverse shoulder arthroplasty for treatment of proximal humerus complex fractures in elderly: A single institution experience

INTRODUCTION

Treatment of complex proximal humerus fractures (PHFs) in the elderly should provide early mobilization to maintain autonomy and self-care possibility, avoiding further surgery for complications. Nowadays, there is not a gold standard for treatment. Aim of our study was to review our experience with the use of Reverse Total Shoulder Arthroplasty (RTSA) for the treatment of these fractures in the elderly, evaluating complications and functional results.

MATERIALS AND METHODS

Ninety-one patients older than 65 were treated with RTSA at our Institute between June 2005 and December 2017: there were 14 males and 77 females, with a mean age of 76 years (range 65-87 years). There were 58 fractures (20 Neer 3, 38 Neer 4) and 33 fracture-dislocations (7 Neer 3, 26 Neer 4). Complications were recorded, and functional outcomes were evaluated using the DASH score and Constant score (CS).

RESULTS

Twenty-three complications occurred: 8 cases of scapular notching, 5 neurologic palsies, 4 dislocations, 3 intraoperative diaphyseal fractures, and subclavian artery damage, deep infection, and radiolucent line in one each. No aseptic loosening or breakage was observed. Further surgeries were necessary in 3 cases only, whereas all patients retained their implant at last follow-up. Functional results were satisfactory: mean abduction was 93°, mean flexion was 110°, mean active internal-rotation reached 35°, mean active external-rotation was 25°, mean CS was 54 points and mean DASH score was 45 points.

DISCUSSION

Surgical treatment of complex PHFs should be a "one-shot surgery," especially in the elderly, since further surgeries could compromise patient outcomes and survival. Additional surgery due to complications is less frequent after RTSA than other techniques. A stable reconstruction permitting early mobilization is fundamental in the elderly. Usually, a prolonged immobilization is recommended after ORIF, TSA, and hemiarthroplasty to provide a stable fixation, whereas RTSA allows early mobilization.

CONCLUSIONS

In elderly with inadequate bone stock and needing early recovery of autonomy in daily activities, RTSA effectively treats complex PHFs. The incidence of complications requiring revision surgery is low and functional results are satisfactory and predictable.

PHILOS Synthesis for Proximal Humerus Fractures Has High Complications and Reintervention Rates: A Systematic Review and Meta-Analysis

Purpose: The aim of this study was to quantify the rate of complications and reinterventions in patients treated with PHILOS plate for proximal humerus fractures (PHFs) synthesis. Methods: A comprehensive literature search was performed on the PubMed, Web of Science, Embase, and Cochrane databases up to 7 October 2021. Studies describing medium and long-term complications in PHF synthesis using the PHILOS plate were included. A systematic review and meta-analysis were performed on complications and causes of reinterventions. Assessment of risk of bias and quality of evidence was performed with the Downs and Black’s “Checklist for Measuring Quality”. Results: Seventy-six studies including 4200 patients met the inclusion criteria. The complication rate was 23.8%, and the main cause was screw cut-out (4.1%), followed by avascular necrosis (AVN) (3.1%) and subacromial impingement (1.5%). In patients over 55 years, the complication rate was 29.5%. In the deltopectoral (DP) approach the complication rate was 23.8%, and in the delto-split (DS) it was 17.5%, but no difference between the two approaches was seen when considering the type of fracture. The overall reintervention rate was 10.5% in the overall population and 19.0% in older patients. Conclusions: Proximal humerus synthesis with a PHILOS plate has high complications and reintervention rates. The most frequent complication was screw cut-out, followed by humeral head AVN and subacromial impingement. These results need to be further investigated to better understand both the type of patient and fracture that is more at risk of complications and reintervention and to compare pros and cons of the PHILOS plate with respect to the other solutions to manage PHFs.

Pegs not superior to screws for fixation of fractures of the proximal humerus

Background

Angular stable plates were introduced two decades ago as a promising treatment for fixation of displaced fractures of the proximal humerus (PHF). However, high rates of adverse events and reoperations have been reported. One frequent reason is secondary penetration of screws into the glenohumeral joint, due to sinking of the fracture or avascular head necrosis. To prevent joint penetrations angular stable plates with smooth locking pegs instead of locking screws have been developed. The aim of the present study was to investigate whether blunt pegs instead of pointed screws reduced the risk of secondary penetration into the glenohumeral joint during fracture healing after operatively treated PHFs.

Methods

From two different patient cohorts with displaced PHFs (60 treated with PHILOS plate with screws and 50 with ALPS-PHP plate with pegs), two groups were matched according to fracture type AO/OTA 11-B2 and 11-C2 and age (55–85 years). They were followed up at 3, 6 and 12 months. Primary outcome was radiographic signs of peg or screw penetrations into the glenohumeral joint at 12 months. Secondary outcomes were Oxford shoulder score (OSS) and Constant Score (CS) and radiographic signs of avascular humeral head necrosis (AVN).

Results

Eighteen PHILOS patients with B2 and C2 fractures could be matched with a corresponding group of 18 operated with ALPS-PHP with pegs. The number of penetrations of pegs and screws were equal between the two groups and the development of avascular head necrosis did not differ either. The functional outcomes for both OSS and CS at 12 months was clearly in favor of patients without joint penetrations in both groups.

Conclusion

We found no differences in the number of screw or peg penetrations in the PHILOS and ALPS-PHP group and the occurrence of AVN was equal. Joint penetrations led to inferior functional outcomes at 1 year.

The ClinicalTrials.gov identifier 20/11/12 prospectively for the Philos Group is NCT01737060, and for the ALPS group 11/03/20 retrospectively is NCT04622852.

Proximal humeral fractures in Finland : trends in the incidence and methods of treatment between 1997 and 2019

AIMS

Proximal humeral fractures (PHFs) are common. There is increasing evidence that most of these fractures should be treated conservatively. However, recent studies have shown an increase in use of operative treatment. The aim of this study was to identify the trends in the incidence and methods of treatment of PHFs in Finland.

METHODS

The study included all Finnish inhabitants aged ≥ 16 years between 1997 and 2019. All records, including diagnostic codes for PHFs and all surgical procedure codes for these fractures, were identified from two national registers. Data exclusion criteria were implemented in order to identify only acute PHFs, and the operations performed to treat them.

RESULTS

During the 23-year study period, 79,676 PHFs were identified, and 14,941 operations were performed to treat them. The incidence of PHFs steadily increased. In 2019, the overall incidence was 105 per 100,000 person-years (10⁵). The sex-adjusted incidence for females was 147.1 per 10⁵, and the age-adjusted incidence for patients aged ≥ 80 years was 407.1 per 10⁵. The incidence of operative treatment for PHFs rose during the first half of the study period and decreased during the second half. The use of plate osteosynthesis in particular decreased. In 2019, the incidence of operative treatment for PHFs was 13.2 per 10⁵, with 604 operations.

CONCLUSION

Although the incidence of PHFs is steadily increasing, particularly in elderly females, the incidence of operative treatment is now decreasing, which is in line with current literature regarding their treatment. Cite this article: Bone Joint J 2022;104-B(1):150-156.

Digital analysis of external fixation area of proximal humerus fractures in elderly patients

Introduction

The purpose is based on anatomical basis, combined with three-dimensional measurement, to guide the clinical repositioning of proximal humeral fractures, select the appropriate pin entry point and angle, and simulate surgery.

Methods

11 fresh cadaveric specimens were collected, the distance of the marked points around the shoulder joint was measured anatomically, and the vertical distance between the inferior border of the acromion and the superior border of the axillary nerve, the vertical distance between the apex of the humeral head and the superior border of the axillary nerve, the vertical distance between the inferior border of the acromion and the superior border of the anterior rotator humeral artery, and the vertical distance between the apex of the humeral head and the superior border of the anterior rotator humeral artery were marked on the 3D model based on the anatomical data to find the relative safety zone for pin placement.

Results

Contralateral data can be used to guide the repositioning and fixation of that side of the proximal humerus fracture, and uniform data cannot be used between male and female patients. For lateral pining, the distance of the inferior border of the acromion from the axillary nerve (5.90 ± 0.43) cm, range (5.3-6.9) cm, was selected for pining along the medial axis of the humeral head, close to the medial cervical cortex, and the pining angle was measured in the coronal plane (42.84 ± 2.45)°, range (37.02° ~ 46.31°), and in the sagittal plane (28.24 ± 2.25)°, range (19.22° ~ 28.51°). The pin was advanced laterally in front of the same level of the lateral approach point to form a cross-fixed support with the lateral pin, and the pin angle was measured in the coronal plane (36.14 ± 1.75)°, range (30.32° ~ 39.61°), and in the sagittal plane (28.64 ± 1.37)°, range (22.82° ~ 32.11°). Two pins were taken at the greater humeral tuberosity for fixation, with the proximal pin at an angle (159.26 ± 1.98) to the coronal surface of the humeral stem, range (155.79° ~ 165.08°), and the sagittal angle (161.76 ± 2.15)°, with the pin end between the superior surface of the humeral talus and the inferior surface of the humeral talus. The distal needle of the greater humeral tuberosity was parallel to the proximal approach trajectory, and the needle end was on the inferior surface of the humeral talus.

Conclusion

Based on the anatomical data, we can accurately identify the corresponding bony structures of the proximal humerus and mark the location of the pin on the 3D model for pin placement, which is simple and practical to meet the relevant individual parameters.

The methodological quality was low and conclusions discordant for meta-analyses comparing proximal humerus fracture treatments: a meta-epidemiological study

OBJECTIVE

To investigate the association between methodological quality and reported conclusions of meta-analyses comparing operative with non-operative treatments for proximal humerus fractures.

STUDY DESIGN AND SETTING

Cross-sectional meta-epidemiological study. We searched EMBASE, PubMed, The Cochrane Library, and Web of Science for systematic reviews with meta-analyses comparing non-operative with operative treatments for proximal humerus fractures. Methodological quality was assessed using AMSTAR2 and the reported conclusions were scored for three outcome domains (functional outcome, quality of life, and harm) on a scale from 1 to 6. The Mann-Whitney and Kruskal-Wallis tests were used to investigate the association between methodological quality and reported conclusions.

RESULTS

We included 21 systematic reviews: 19 pairwise meta-analyses and 2 network meta-analyses, although there are only 8 published randomized controlled trials. Most (n = 18) of the meta-analyses were rated as critically low quality, while the remaining 1 was rated as high quality. The conclusions were discordant for all three outcome domains, even for meta-analyses reporting similar inclusion criteria. We could not perform most of the statistical tests due to the predominantly critically low quality.

CONCLUSION

The methodological quality was so predominantly critically low that it was not possible to evaluate the association between methodological quality and reported conclusions.

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.

Comparison of Treatment Options of Three- and Four-Part Humerus Proximal Fractures in Patients Over 50 Years of Age

Introduction

Our aim was to evaluate different treatment methods including conservative treatment (CT), locking-plate osteosynthesis (OS) and hemiarthroplasty (HA) in three- and four-part humeral fractures in patients older than 50 years.

Methods

Forty-seven patients that have at least one year of follow-up were divided into three groups: 18 patients treated with OS, 14 patients treated conservatively and 15 patients treated with HA. For further evaluation, constant shoulder score, disabilities of the arm, shoulder and hand score (DASH), American Shoulder and Elbow Society (ASES) score had been used. Shoulder range of motion was also assessed.

Results

OS and CT groups had better scores than HA group. In OS group, average Constant score was 71.6 ± 16.2, DASH score was 12.1 (5.2-24.2) and ASES score was 77.5 (50.8-96.6). In CT group, average Constant score was 69.6 ± 19.2, DASH score was 16.4 (12.5-36.7) and ASES score was 76.6 (45.4-87.9). DASH scores (p = 0.032), Constant scores (p = 0.001), forward elevation (p < 0.001), abduction (p < 0.001), internal (p = 0.022) and external rotation (p = 0.048) were significantly improved in OS and CT groups than HA group.

Conclusions

HA should not be considered a priority in surgical planning in Neer three-part and four-part proximal humerus fractures. CT is superior for patients with additional morbidity and advanced age. But in patients who are younger and can tolerate the surgical procedure, the priority should be OS.

Use of different devices for surgical treatment of proximal humerus fractures in adults: a systematic review

Background and aim:

Proximal humeral fracture is one of the most common osteoporotic fractures in elderly people. The proper treatment choice is controversial. Open reduction and internal fixation (ORIF) with plate and screws is currently the most common treatment for the majority of displaced proximal humeral fractures. The aim of this systematic review is to investigate the surgical treatment outcomes of PHFs, focusing on main used devices and surgical approaches.

Methods:

From the earliest record up to 21 July 2020, two independent authors conducted a systematic review of two medical electronic database (PubMed and Science Direct). To achieve the maximum sensitivity of the search strategy, the following terms were combined: “(proximal NOT shaft NOT distal) AND humeral AND fracture AND (plate OR locking plate OR osteosynthesis NOT nail NOT arthroplasty)” as either key words or MeSH terms. The risk of bias of the included studies was assessed, agreeing to the Cochrane Handbook guidelines.

Results:

Thirty-four articles were initially noticed after the term string research in the two electronic databases. Finally, after full-text reading and analyzing the reference list, 8 studies were selected. The mean age recorded was 69.5 years (Range 67-72). All the studies included two-, three-, four-fragments fracture. Seven studies investigated PHILOS (Synthes, Bettlach, Switzerland) implants results, while one investigated CFR-PEEK plate (PEEK Power Humeral Fracture Plate; Arthrex, Naples, Florida, USA) outcomes or other plates. Deltopectoral and Transdeltoid approaches were the more common used.

Conclusions:

Both deltopectoral and transdeltoid approaches are valid approach in plating after proximal humerus fractures, for these reasons, the surgeon experience is crucial in the choice. The more valid implant is still unclear. The develop of prospective randomized comparative studies is strongly encourages. (www.actabiomedica.it)

Finite Element Analysis of Fracture Fixation

PURPOSE OF REVIEW

Fracture fixation aims to provide stability and promote healing, but remains challenging in unstable and osteoporotic fractures with increased risk of construct failure and nonunion. The first part of this article reviews the clinical motivation behind finite element analysis of fracture fixation, its strengths and weaknesses, how models are developed and validated, and how outputs are typically interpreted. The second part reviews recent modeling studies of the femur and proximal humerus, areas with particular relevance to fragility fractures.

RECENT FINDINGS

There is some consensus in the literature around how certain modeling aspects are pragmatically formulated, including bone and implant geometries, meshing, material properties, interactions, and loads and boundary conditions. Studies most often focus on predicted implant stress, bone strain surrounding screws, or interfragmentary displacements. However, most models are not rigorously validated. With refined modeling methods, improved validation efforts, and large-scale systematic analyses, finite element analysis is poised to advance the understanding of fracture fixation failure, enable optimization of implant designs, and improve surgical guidance.

Current Controversies in the Treatment of Geriatric Proximal Humeral Fractures

➤

Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes. Factors such as surgeon experience as well as the quality and maintenance of the reduction may influence operative outcomes, and their impact on these findings merits further investigation.

➤

In the treatment of 2 and 3-part fractures involving the surgical neck, intramedullary nailing has demonstrated functional outcomes that are comparable with those of open reduction and internal fixation (ORIF).

➤

In the geriatric population, reverse total shoulder arthroplasty has demonstrated improved functional outcomes, with a decreased rate of reoperation, compared with hemiarthroplasty. Tuberosity repair has been shown to improve functional outcomes and range of motion after both procedures and should be performed at the time of arthroplasty.

➤

Several authors have demonstrated the negative effect of osteopenia on outcomes after ORIF of proximal humeral fractures. Augmentative procedures, including cortical strut augmentation, are being investigated to address this issue; their role in the treatment of these fractures is unclear at this time.

Prediction of Nonunion After Nonoperative Treatment of a Proximal Humeral Fracture

BACKGROUND

The prevalence of nonunion after a proximal humeral fracture (PHF) and the risk factors for its occurrence are poorly defined. We aimed to estimate the rate of nonunion in nonoperatively treated patients and to produce a clinical model for its prediction.

METHODS

Two thousand two hundred and thirty adult patients (median age, 72 years [range, 18 to 103 years]; 75.5% were female) with a PHF underwent assessment of fracture union using standard clinical evaluation and conventional radiographs. We assessed the prevalence of nonunion and measured the effect of 19 parameters on healing. Best statistical practices were used to construct a multivariate logistic regression model. The PHF assessment of risk of nonunion model (PHARON) was externally validated in a subsequent prospectively collected population of 735 patients, treated by the same protocol in our institution.

RESULTS

Overall, 231 (10.4%) of 2,230 patients developed nonunion. Only 3 (0.8%) of 395 patients with a head-shaft angle (HSA) of >140° developed nonunion; in this cohort, none of the measured candidate variables were independently predictive of nonunion on multivariate logistic regression analysis. In the larger cohort of 1,835 patients with an HSA of ≤140°, 228 (12.4%) developed nonunion. Decreasing HSA, increasing head-shaft translation (HST), and smoking were independently predictive of nonunion on multivariate analysis. The prevalence of nonunion was very low (1%) in the majority with both an HSA of >90° and HST of <50%, whereas the risk was much higher (83.7%) in the 8.3% with an HSA of ≤90° and HST of ≥50%. In both groups, the prevalence of nonunion was much higher in smokers.

CONCLUSIONS

The prevalence of nonunion after PHF is higher than previously reported. Most patients have favorable risk-factor estimates and a very low risk of this complication, but a smaller subgroup is at much higher risk. The risk can be accurately estimated with PHARON, using standard clinical assessment tools.

LEVEL OF EVIDENCE

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

Are Arthroplasty Procedures Really Better in the Treatment of Complex Proximal Humerus Fractures? A Comprehensive Meta-Analysis and Systematic Review

OBJECTIVE

A meta-analysis and systematic review was performed to compare outcomes of open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (rTSA) for complex proximal humerus fractures. Data sources: MEDLINE, Embase, and Cochrane Library databases were screened. Search terms included reverse total shoulder arthroplasty, open reduction internal fixation, hemiarthroplasty, and proximal humerus fracture.

STUDY SELECTION

English-language studies published within the past 15 years evaluating outcomes of ORIF, rTSA, or HA for complex proximal humerus fractures with minimum of 1-year follow-up were included, resulting in 51 studies with 3064 total patients. Review articles, basic science studies, biomechanical studies, and cadaveric studies were excluded.

DATA EXTRACTION

The methodological quality of evidence was assessed using the Jadad scale and methodological index for nonrandomized studies.

DATA SYNTHESIS

Demographic data were compared using the χ2 test. Mean data were weighted by study size and used to calculate composite mean values and confidence intervals. Continuous data were compared using the Metan module with fixed effects. Count data were compared using the Kruskal-Wallis test. Alpha was set at 0.05 for all tests.

CONCLUSIONS

Patients undergoing rTSA had lower risks of complication (relative risk 0.41) and reoperation (relative risk 0.28) than HA patients. rTSA resulted in higher Constant scores (standard mean difference 0.63) and improved active forward flexion when compared with HA (standard mean difference 0.76). Pooled mean data demonstrated better outcome scores and active forward flexion of ORIF versus HA and rTSA, although the patients were younger and had more simple fracture patterns.

LEVEL OF EVIDENCE

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

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.

Arthroscopic treatment of a one-fourth anteroinferior glenoid comminuted fracture-dislocation with concomitant three-part complex proximal humerus fracture in a middle-aged man: a case report

INTRODUCTION

Proximal humeral fracture-dislocations can occur in high-energy traumas. This injury can be accompanied by a glenoid fracture; however, it is a rare type of complex injury in patients aged under 60 years.

MATERIALS AND METHODS

A 53-year-old man presented with a three-part fracture-dislocation of the proximal humerus and a severely comminuted glenoid fracture. For the glenohumeral dislocation and proximal humeral fracture, we performed closed reduction using a threaded Steinman pin and fixation with percutaneous cannulated screws. Using arthroscopy, while maintaining humeral traction with the Steinman pin, the intra-articular glenoid fragments were reduced and then fixed with a buttressing headless screw and one suture anchor. After a 6-week immobilization with a shoulder spica cast, rehabilitation was initiated.

RESULTS

We confirmed bony union of the fracture sites after 6 months post-surgery. The patient showed excellent clinical outcomes with a nearly full range of motion without instability CONCLUSIONS: We reported a successful outcome for a complex proximal humeral fracture involving the glenoid using closed reduction and fixation for the proximal humeral fracture and arthroscopic reduction and fixation for the comminuted anteroinferior glenoid fracture.

Surgical management of 2- or 3-part proximal humeral fractures: comparison of plate, nail and K-wires

Background

Proximal humeral fractures (PHFs) are fairly common injuries, and their treatment is a challenge. The aim of this study is to compare clinical and functional outcomes of different osteosynthesis techniques.

Materials and methods

We retrospectively reviewed patients’ files and the hospital’s digital database between March 2002 and April 2018. We treated surgically 148 patients with 2- and 3-part PHFs: 64 with plate and screws, 53 with intramedullary nailing and 31 with retrograde K-wires. We constituted three groups according to the type of treatment and two subgroups for each according to the number of fragments (Neer II or Neer III). Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-12 (SF-12) scores were recorded.

Results

Mean DASH and SF-12 scores both from the group treated with plate (Group I) and the one subjected to intramedullary nailing (Group II) were statistically superior to results from the patients treated by retrograde K-wires (Group III), while nails showed better functional results than the locking plates. In the first two groups, no difference was found between Neer II and III subgroups, while in Group III the DASH scores were significantly better in Neer II subgroup than those in Neer III subgroup. Avascular necrosis was the most frequent cause of revision surgery in Group I (4 cases) where we had 8 cases of reintervention (12.5%). In Group II, the subacromial impingement was the only cause for revision surgery with 3 cases (5.6%).

Conclusions

Intramedullary nails showed better functional results and a lower complication rate than the locking plates. Both techniques showed superior results compared to those available with retrograde K-wires. So the nail seems to be a more reliable and adequate method for treating 2- and 3-part proximal humeral fractures.

Three-dimensional models increase the interobserver agreement for the treatment of proximal humerus fractures

Background

The agreement for the treatment of proximal humerus fractures is low. Interpretation of exams used for diagnosis can be directly associated with this limitation. This study proposes to compare the agreement between experts and residents in orthopedics for treatment indication of proximal humerus fractures, utilizing 3D-models, holography (augmented reality), x-rays, and tomography as diagnostic methods.

Methods

Twenty orthopedists (ten experts in shoulder and elbow surgery and ten experts in traumatology) and thirty resident physicians in orthopedics evaluated nine fractures of the proximal humerus, randomly distributed as x-rays, tomography, 3D-models and holography, using the Neer and AO / OTA Classifications. After, we evaluated the interobserver agreement between treatment options (conservative, osteosynthesis and arthroplasty) and whether the experience of the evaluators interfered with the results.

Results

The interobserver agreement analysis showed the following kappa-values: κ = 0.362 and κ = 0.306 for experts and residents (3D-models); κ = 0.240 and κ = 0.221 (X-ray); κ = 0.233 and κ = 0.123 (Tomography) and κ = 0.321 and κ = 0.160 (Holography), for experts and residents respectively. Moreover, residents and specialists were discordant in the treatment indication using Tomography as a diagnostic method (p = 0.003). The same was not seen for the other diagnostic methods (p > 0.05).

Conclusions

Three-dimensional models showed, overall, the highest interobserver agreement (experts versus residents in orthopedics) for the choice of treatment of proximal humerus fractures compared to X-ray, Tomography, and Holography. Agreement in the choice of treatment among experts that used Tomography and Holography as diagnostic methods were two times higher compared to residents.

Trial registration

Registered in Brazil Platform under no. CAAE 12273519.7.0000.5505.

Arthroscopic Repair of a Displaced Tuberosity Fragment After Proximal Humerus Locking Plate Fixation: A Case Report

CASE

Locking plate fixation of proximal humerus fractures is known to have high complication rates. Even a technically well-performed surgery can be subject to loss of reduction, which can lead to an adverse functional outcome for the patient. In this case report, we describe a patient who underwent open reduction and internal fixation of a proximal humerus fracture complicated by delayed loss of reduction of a greater tuberosity fragment that was revised using arthroscopic techniques.

CONCLUSION

Arthroscopic repair of displaced greater tuberosity fragments after failed locking plate fixation of proximal humerus fractures can lead to good functional outcomes at 1-year follow-up.

ESTES recommendations on proximal humerus fractures in the elderly

PURPOSE

The section for the skeletal trauma and sport's injuries of the European Society for Trauma and Emergency Surgery (ESTES) appointed a task force group to reach a consensus among European countries on proximal humeral fractures.

MATERIAL/METHODS

The task force group organized several consensus meetings until a paper with final recommendations was confirmed during the ESTES Executive Board meeting in Berlin on 25 October 2018.

CONCLUSION

The Recommendations compare conservative and four possible operative treatment options (ORIF, nailing, hemi- and total reverse arthroplasty) and enable the smallest common denominator for the surgical treatment among ESTES members.

Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate

BACKGROUND

Locking plate technology has increased the frequency of open reduction and internal fixation (ORIF) of proximal humerus fractures (PHF). A number of technical pearls have been recommended to lower the complication rate of ORIF. These pearls are particularly relevant for patients aged >60 years, when nonoperative treatment and arthroplasty are alternatives commonly considered. There have been few large, single-center studies on the modern application of this technology.

METHODS

Between 2005 and 2015, a total of 173 PHFs in patients aged >60 years were treated at our institution with ORIF using locking plates. Failure was defined as reoperation or radiographic evidence of failure. Average follow-up was 6.1 years.

RESULTS

There was an overall complication rate of 44%. The overall failure rate was 34% and correlated with fracture type: 26% failure rate in 2-part fractures (16 failures), 39% in 3-part fractures (23 failures), and 45% in 4-part fractures (11 failures). There was no difference between the failure rate with and without fibular allograft (33% vs. 34%). Most patients with radiographic or clinical failure did not undergo reoperation. The overall reoperation rate was 11% (14 patients). Seven percent of 2-part fractures (4 shoulders), 14% of 3-part fractures (8 shoulders), and 18% of 4-part fractures (2 shoulders) required reoperation.

CONCLUSIONS

ORIF of PHFs with locking plates in patients aged >60 years resulted in a 44% complication and 34% failure rate. There was a trend toward higher complication and failure rates in older patients and more complex fractures. Refinement in fixation techniques and indications are necessary to optimize the surgical management of PHFs.

The plate fixation strategy of complex proximal humeral fractures

PURPOSE

For complex proximal humeral fractures, severe displacement and comminuted fragments lead to poor clinical outcomes. Despite considerable management, the locking plate fixation is still a preference and the proper selection of its strategy for each individual seems to be essential.

METHOD

The available classification system of the fracture, determination of surgical intervention, the common complications and related causes, and the latest critical surgical strategies with locking plate fixation were discussed in this review.

RESULTS

The frequent complications with complex proximal humeral fractures after operative treatment present a great challenge to orthopedic surgeons. In order to maintain the stability of locking plate fixation, several options including calcar screw, bone graft, bone cement augmentation, dual plate fixation, and fracture impaction were available for restoration of medial support.

CONCLUSION

Restoration of medial support seems of importance to provide solid stability and reduced complication for the complex fractures with fixation of locking plates.

Complication rate after operative treatment of three- and four-part fractures of the proximal humerus: locking plate osteosynthesis versus proximal humeral nail

PURPOSE

There is still disagreement regarding the optimal surgical treatment of three- and four-part fractures of the proximal humerus. The aim of this monocentric, retrospective study was to compare the complication rate of internal fixation with a locking plate versus proximal humeral nailing after a one-year follow-up.

METHODS

From 2005 to 2016, 292 patients suffered a fracture of the proximal humerus and were treated surgically at our level-I trauma center. According to the inclusion criteria, 50 patients were included in this study: 19 of these (11 three-part fractures and 8 four-part fractures) were treated with a proximal humeral nail (HN) and 31 (12 three-part fractures and 19 four-part fractures) with a locking plate (LP) osteosynthesis. Classification was performed according to the Hertel classification. At a 1-year follow-up, the complication rate of the two treatment methods was compared.

RESULTS

Twenty patients (40%) suffered at least one complication. Of these, six patients (12%) were treated with a HN and 14 (28%) with a LP (p = 0.39). The most frequent complication was screw perforation (22%), followed by non-union (16%). Humeral head necrosis (10%) occurred only in the LP cohort. One wound infection occurred in a patient treated with a HN. Four-part fractures were treated more frequently with a LP. However, the difference was non-significant in this sample (p = 0.186).

CONCLUSIONS

The results of our study provide some evidence that in terms of complication rate, both treatment options are comparable for internal fixation of three- and four-part fractures of the proximal humerus. The type of fracture seems to be decisive for the choice of implant.

Reverse Total Shoulder Arthroplasty for Treatment of 3- and 4-Part Proximal Humeral Fractures: Clinical and Radiological Analysis With Minimum Follow-Up of 2 Years

Background

Hemiarthroplasty has been associated with inferior and unpredictable outcomes when used in the treatment of complex proximal humeral fractures in elderly patients. In this age-group, reverse shoulder arthroplasty is gaining popularity due to the promising results presented in recent evidence. Our aim is to analyze the cases of complex proximal humeral fractures treated by reverse shoulder arthroplasty, regarding functional results and complications.

Materials and Methods

Thirty-five fractures from 33 patients with the mean age of 73.5 (65-81) years were treated with reverse shoulder arthroplasty for complex fractures of the proximal humerus. These patients were followed for a mean of 38.3 months (24-68) and analyzed regarding clinical outcomes and complications.

Results

The average Quick-Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons scores were 6.8 points and 78.3%, respectively. The mean Constant score on the affected side was 64.4 points, 19.5% less than the nonoperated side. The mean active elevation was 123°, abduction 109°, external rotation 38°, and internal rotation 41°. The radiographic tuberosity healing rate was 85.7%. There were no significant differences in outcomes, between patient with healed and reabsorbed tuberosities. Inferior scapular notching was seen in 8 patients. The global complication rate was 12.8%.

Conclusion

Reverse shoulder arthroplasty yields good and reproductive results with acceptable complication rates in selected elderly patients with complex proximal humeral fractures.

Reverse Shoulder Arthroplasty Is Superior to Plate Fixation at 2 Years for Displaced Proximal Humeral Fractures in the Elderly: A Multicenter Randomized Controlled Trial

BACKGROUND

Almost one-third of patients with proximal humeral fractures are treated surgically, and the number is increasing. When surgical treatment is chosen, there is sparse evidence on the optimum method. The DelPhi (Delta prosthesis-PHILOS plate) trial is a clinical trial comparing 2 surgical treatments. Our hypothesis was that reverse total shoulder arthroplasty (TSA) yields better clinical results compared with open reduction and internal fixation (ORIF) using an angular stable plate.

METHODS

The DelPhi trial is a randomized controlled trial comparing reverse TSA with ORIF for displaced proximal humeral fractures (OTA/AO types 11-B2 and 11-C2) in elderly patients (65 to 85 years of age). The primary outcome measure was the Constant score at a 2-year follow-up. The secondary outcome measures included the Oxford Shoulder Score and radiographic evaluation. Results were reported as the mean difference with 95% confidence interval (CI). The intention-to-treat principle was applied for crossover patients.

RESULTS

There were 124 patients included in the study. At 2 years, the mean Constant score was 68.0 points (95% CI, 63.7 to 72.4 points) for the reverse TSA group compared with 54.6 points (95% CI, 48.5 to 60.7 points) for the ORIF group, resulting in a significant mean difference of 13.4 points (95% CI, 6.2 to 20.6 points; p < 0.001) in favor of reverse TSA. When stratified for fracture classification, the mean score was 69.3 points (95% CI, 63.9 to 74.7 points) for the reverse TSA group and 50.6 points (95% CI, 41.9 to 59.2 points) for the ORIF group for type-C2 fractures, which yielded a significant mean difference of 18.7 points (95% CI, 9.3 to 28.2 points; p < 0.001). In the type-B2 fracture group, the mean score was 66.2 points (95% CI, 58.6 to 73.8 points) for the reverse TSA group and 58.5 points (95% CI, 49.6 to 67.4 points) for the ORIF group, resulting in a nonsignificant mean difference of 7.6 points (95% CI, -3.8 to 19.1 points; p = 0.19).

CONCLUSIONS

At a 2-year follow-up, the data suggested an advantage of reverse TSA over ORIF in the treatment of displaced OTA/AO type-B2 and C2 proximal humeral fractures in elderly patients.

LEVEL OF EVIDENCE

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

Outcomes of 188 Proximal Humeral Fractures Treated with a Dedicated External Fixator with Follow-up Ranging from 2 to 12 Years

BACKGROUND

The treatment of a displaced proximal humeral fracture is still a matter of controversy. Minimally invasive techniques are considered promising options. The purpose of this study was to report outcomes at medium to long-term follow-up after surgical treatment with pins stabilized with an external fixator.

METHODS

A total of 235 patients (average age, 64 years [95% confidence interval (CI), 62 to 65 years]) were treated with closed or open reduction and fixation with pins stabilized by an external fixator specifically designed for proximal humeral fractures. The pins were inserted using a "pins-crossing-fracture" or a "pins-bridging-fracture" technique. One hundred and eighty-eight patients had a minimum radiographic and clinical follow-up of 2 years. Outcomes were assessed using the Oxford Shoulder Score (OSS), the subjective shoulder value (SSV), a visual analog scale (VAS) for pain, and, for 155 patients, the Constant score.

RESULTS

Eighty-one (43%) of the 188 patients had a 2-part fracture, 60 (32%) had a 3-part fracture, and 47 (25%) had a 4-part fracture. The reduction was performed with percutaneous maneuvers in 120 shoulders or a deltopectoral approach, in 68. The external fixator was applied using a "pins-crossing-fracture" technique in 133 shoulders and using a "pins-bridging-fracture" technique in 55. At last follow-up, mean clinical scores were as follows: OSS, 42.6 (95% CI, 42 to 44); SSV, 85.5 (95% CI, 83 to 88); and VAS for pain, 1 (95% CI, 0.7 to 1.2). The complication rate at 3 months was 16% (37 of 235). The most frequent complication was pin-track infection (19 of 235, 8%). A total of 50 patients had ≥1 complication (50 of 188, 27%) and 6 (3%) underwent revision surgery. More complications were observed with the "pins-crossing-fracture" technique.

CONCLUSIONS

In our experience, the use of the external fixator has been a valuable option in the treatment of proximal humeral fractures. The complication and revision rates were acceptable. Most of the complications encountered were manageable without revision surgery.

LEVEL OF EVIDENCE

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

The influence of biplanar reduction and surgeon experience on proximal humerus fractures treated with ORIF

BACKGROUND

Treatment for proximal humerus fractures remains controversial. Studies of open reduction and internal fixation (ORIF) rarely account for reduction quality, while surgeon experience and sagittal plane reduction remain unstudied. In a retrospective case series analysis of AO/OTA C-type proximal humerus fractures treated with ORIF using a locking plate, we hypothesized that reduction quality would be associated with outcome, and reductions would improve with experience.

METHODS

We retrospectively identified 41 3- and 4-part proximal humerus fractures treated with ORIF by a single orthopaedic traumatologist. Two blinded traumatologists assessed injury and post-operative radiographs for medial calcar disruption and five measures of deformity. Major complications and functional outcome were assessed.

RESULTS

Outcome by ASES score was similar to previous reports (mean 73.6, std dev 22.5). Eleven of 35 patients (31.4%) with greater than six months follow-up experienced a complication. Post-reduction sagittal HSa<25° (RR = =9.44, p = =0.024) and medial calcar disruption (RR = =3.82, p = =0.009) were associated with complications. Post-reduction coronal and sagittal HSa improved with experience (p < 0.001 and p = =0.032, respectively) as did the likelihood of overall anatomic reduction (p = =0.006). ROC analysis found a threshold for superior reduction quality after 23 cases (AUC = =0.873, p < 0.001).

CONCLUSION

Sagittal reduction quality and medial calcar disruption were associated with complications. Additionally, reduction quality improved with experience. Future studies of proximal humerus ORIF should include multiplanar assessments of reduction while accounting for surgeon experience.

Does cement augmentation of the screws in angular stable plating for proximal humerus fractures influence the radiological outcome: a retrospective assessment

BACKGROUND

Screw-tip augmentation in angular stable plating offers new possibilities for the treatment of complex proximal humerus fractures. This retrospective analysis was performed to evaluate the radiological outcome of proximal humerus fractures treated with angular stable plates and additional screw-tip cement augmentation in patients over the age of 60.

MATERIALS AND METHODS

A retrospective single centre analysis was conducted from June 2013 to December 2016. The minimum follow-up time was set to 6 months after surgery. Anatomical reduction and fixation were evaluated in respect to reattached tuberosities to the head fragment and the adequate restoration of the calcar area not showing any valgus or varus malalignment. Complete fracture healing was determined 3 months after surgery. Any failures such as secondary displacement, primary screw perforation, intraarticular cement leakage and avascular necrosis of the humeral head with concomitant screw cut-out were assessed.

RESULTS

In total, 24 patients (21 females; 3 males) at a median age of 77.5 (62-96) years were included. Five 2-part, twelve 3-part and seven 4-part fractures were detected. The measured median BMD value of 23 patients was 78.4 mg/cm³ (38.8-136.9 mg/cm³). Anatomical reduction was achieved in 50% of the patients. In most cases, the A level screws and the B1 screw were augmented with bone cement by a median of 7 (5-9) head screws used. Postoperative varus displacement was not detected in any of the patients. One patient (4.2%) sustained an early secondary displacement. Intraarticular cement leakage was detected in 3 patients (2 head-split fractures). Avascular necrosis of the humeral head was observed in 4 patients (16.7%). Revision surgery was necessary in four cases, using hemiarthroplasty twice and reverse shoulder arthroplasty the other two times.

CONCLUSION

Screw-tip augmentation in angular stable plating for proximal humerus fracture treatment showed a low secondary displacement rate of 4.2% in patients suffering from poor bone quality. Nevertheless, the occurrence of avascular necrosis of the humeral head with mainly severe fracture patterns observed in this study was higher compared to previously reported results in the literature. Cement augmentation in head-split fractures is not recommended, considering the high risk of an intraarticular cement leakage.