Proximal humeral internal locking plate combined with a custom neutral-position shoulder and elbow sling for proximal humerus fractures: A randomized study

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.

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.

Efficacy of Intramedullary Nailing in the Treatment of Comminuted Proximal Humeral Fractures and Its Influence on Shoulder Joint Function Recovery

In this paper, we have aimed to elucidate the therapeutic effect of intramedullary nailing (IMN) in treating comminuted proximal humeral fractures (CPHFs) and its influence on the recovery of shoulder joint function. For this purpose, 60 cases with CPHFs were selected, particularly from January 2020 to October 2021. In these cases, 28 cases were treated with a locking proximal humeral plate (LPHP) and assigned to the control (Con) group and the remaining 32 patients were treated with IMN and included in the research (Res) group. The therapeutic effect, surgical indicators, total complications, visual analogue scale (VAS) score, and postoperative shoulder joint function score were compared between the two arms. We observed that compared with the Con group, the effective rate in the Res group was higher while the operation time, intraoperative blood loss, and fracture healing time were shorter, the overall complication rate and VAS score were lower, and the postoperative shoulder joint function score was higher, all with statistical significance. The above results indicate that IMN is effective and safe in the treatment of CPHFs, which can validly reduce the discomfort of patients and facilitate the recovery of shoulder joint function.

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.

The fragility and reverse fragility indices of proximal humerus fracture randomized controlled trials: a systematic review

BACKGROUND

The quality of evidence of the orthopedic literature has been often called into question. The fragility index (FI) has emerged as a means to evaluate the robustness of a significant result. Similarly, reverse fragility index (RFI) can be used for nonsignificant results to evaluate whether one can confidently conclude that there is no difference between groups. The analysis of FI and RFI in proximal humerus fracture (PHF) management is of particular interest, given ongoing controversy regarding optimal management and patient selection. The aim of this study was to report the FI, RFI and quality of the evidence in the proximal humerus fracture literature.

METHODS

A systematic review was conducted based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, which utilized EMBASE, MEDLINE and Cochrane Library databases. Inclusion criteria included randomized controlled clinical trials related to the management of proximal humerus fractures, published from 2000 to 2020 with dichotomous outcome measures and 1:1 allocation. The FI and RFI were calculated by successively changing one nonevent to an event for each outcome measure until the result was made nonsignificant or significant, respectively. The fragility quotient, (FQ), calculated by dividing the FI by the total sample size, was calculated as well.

RESULTS

There were 25 studies that met our criteria with 48 outcome measures recorded. A total of 21 studies had at least one fragile result, with ten studies including a fragile result in the conclusion of the abstract. A total of 31 outcome measures had nonsignificant results and the median RFI was found to be 4, with 71% greater than number of patients lost to follow up. Seventeen outcomes had significant results, with a median FI of 1, with 65% greater than or equal to the number patients lost to follow up. A total of 18 of 25 studies (72%) included a power analysis. In particular, ten studies reported a statistical analysis of complication rates, 90% of which were fragile. The median FQ was found to be 0.037.

CONCLUSIONS

The literature on PHF management is frequently fragile. Outcome measures are often fragile, particularly with regards to comparing complication rates and reoperation rates in treatment arms. Comparing to the studies in other subspecialties PHF RCTs are relatively more fragile and underpowered. Standardized reporting of FI, FQ and RFI can help the reader to reliably draw conclusions based on the fragility of outcome measures.

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

Hypothesis

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

Methods

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

Results

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

Conclusion

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

Comparison of locking plates and intramedullary nails in treatment of three-part or four-part proximal humeral neck fractures in elderly population: A randomized trial protocol

BACKGROUND

Locking plate and intramedullary nail are two commonly applied methods to fix proximal humeral fractures. There are limited randomized studies that specifically evaluate the results of proximal humeral neck fractures with three-part or four-part treated by locking plates or intramedullary nails. Our goal was to compare functional outcomes, complications, and imaging features between the two groups.

METHODS

This single-center, prospective, randomized controlled test will be conducted in Tengzhou Central People's Hospital. Patients with these conditions will be included: age between 55 and 80 years; are able to communicate normally and agree to participate in our study; with the radiological evidence of proximal humeral fractures with three-part or four-part; surgical treatment was performed within twenty-one days after the acute fracture. Consecutive patients with proximal humeral fractures will be stochastic to be dealt with a locking plate or a bone nail. The informed consent will be acquired in each patients. Two groups will use the same postoperative rehabilitation protocol. Clinical outcomes include Intraoperative blood loss, operation time, Constant-Murley score, Disability, Arm, Shoulder and Hand score, shoulder range of motion (such as external rotation), and postoperative complications. The significance level was defaulted as P < .05.

RESULTS

This study will provide a solid theoretical basis for exploring which technique is better in treatment of 3-part or 4-part proximal humeral neck fractures in elderly population.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (number: researchregistry6047).