Complication rates and outcomes stratified by treatment modalities in proximal humeral fractures: a systematic literature review from 1970-2009

Comparative analysis of proximal humerus fracture management in elderly patients: complications of open reduction and internal fixation by shoulder surgeons and non-shoulder surgeons-a retrospective study

BACKGROUND

Open reduction and internal fixation (ORIF) with a locking plate is a popular surgical treatment for proximal humeral fractures (PHF). This study aimed to assess the occurrence of complications in elderly patients with PHF treated surgically using ORIF with a locking plate and to investigate the potential differences between patients treated by shoulder surgeons and non-shoulder surgeons.

METHODS

A retrospective study was conducted using a single-center database to identify patients aged ≥70 years who underwent ORIF for PHF between January 1, 2011, and December 31, 2021. Data on the Neer classification, follow-up, occurrence of avascular necrosis of the humeral head, implant failure, and revision surgery were also collected. Statistical analyses were performed to calculate the overall frequency of complications according to the Neer classification.

RESULTS

The rates of implant failure, avascular osteonecrosis, and revision surgery were 15.7%, 4.8%, and 15.7%, respectively. Complications were more common in patients with Neer three- and four-part fractures. Although the difference between surgeries performed by shoulder surgeons and non-shoulder surgeons did not reach statistical significance, the rate of complications and the need for revision surgery were nearly two-fold higher in the latter group.

CONCLUSIONS

PHF are highly prevalent in the elderly population. However, the ORIF surgical approach, as demonstrated in this study, is associated with a considerable rate of complications. Surgeries performed by non-shoulder surgeons had a higher rate of complications and a more frequent need for revision surgery. Future studies comparing surgical treatments and their respective complication rates are crucial to determine the optimal therapeutic options. Level of evidence: III.

Position statement: management of proximal humerus fractures

We sought to compare outcomes and reoperation rates for the surgical treatment of proximal humerus fractures (excluding head-splitting fractures, fracture-dislocations, and isolated greater-tuberosity fractures) in men and women older than 60 years. We searched MEDLINE, Embase, and Cochrane through to Feb. 1, 2022, and included all English-language randomized trials comparing operative versus nonoperative treatment; open reduction and internal fixation (ORIF) with locking plate versus intramedullary nail; arthroplasty versus ORIF; and reverse shoulder arthroplasty versus hemiarthroplasty. Outcomes of interest were functional outcomes (e.g., Constant score), pain outcomes (visual analogue scale scores), and reoperation rates for the interventions of interest when available. We rated the quality of the evidence and strength of recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. This guideline will benefit patients considering surgical intervention for fractures of the proximal humerus by improving counselling on surgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making.Nous avons cherché à comparer les résultats et les taux de réintervention à la suite d'un traitement chirurgical pour une fracture de l'humérus proximal (excluant les fractures de la tête humérale, les fractures-luxations et les fractures isolées de la grande tubérosité) chez les hommes et les femmes âgés de plus de 60 ans. Nous avons effectué des recherches dans les bases de données MEDLINE, Embase, et Cochrane jusqu'au 1er février 2022 et avons inclus tous les essais randomisés publiés en anglais comparant différents duos d'interventions : traitements chirurgicaux ou non chirurgicaux; réductions ouvertes avec fixation interne (ROFI) réalisées à l'aide d'une plaque verrouillée ou enclouages centromédullaires; arthroplasties ou ROFI; et arthroplasties inversées de l'épaule ou hémiarthroplasties. Les paramètres d'intérêt étaient la capacité fonctionnelle (p. ex., score de Constant), la douleur (p. ex., échelle analogique visuelle) et le taux de réintervention pour les interventions d'intérêt, selon les données disponibles. Nous avons évalué la qualité des données probantes et la solidité des recommandations à l'aide de l'approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Cette ligne directrice profitera aux patients qui envisagent une intervention chirurgicale après une fracture de l'humérus proximal en améliorant les consultations sur les options de traitement chirurgical et les résultats escomptés. Elle aidera aussi les chirurgiens en améliorant leurs connaissances sur différentes approches chirurgicales. Les données présentées pourraient servir à mettre au point des cadres et des outils pour une prise de décision partagée.

Advanced Preoperative Planning Techniques in the Management of Complex Proximal Humerus Fractures

This review evaluates the current literature on the recent advances of preoperative planning in the management of complex proximal humerus fractures (PHF). PHFs can pose a considerable challenge for orthopaedic surgeons due to their diversity in presentation and complexity. Poor preoperative planning can lead to prolonged operations, increased blood loss, higher risk of complications, and increased stress on the surgical team. Recent advances have seen the evolution of preoperative planning from conventional methods to computer-assisted virtual surgical technology (CAVST) and three-dimensional (3D) printing, which have been highlighted as transformative tools for improving preoperative planning and postoperative outcomes. CAVST allows the creation of 3D renderings of patient-specific anatomy, clearly demonstrating fracture patterns and facilitating detailed planning for arthroplasty or surgical fixation. The early studies show promising outcomes however the literature calls for more high-quality randomised controlled trials. Using 3D printing for high-fidelity simulation involving patient-specific physical models offers an immersive experience for surgical planning. Preoperative planning with 3D printing reduces operative time, blood loss and use of fluoroscopy. The technology's potential to produce customisable surgical implants further improves its versatility. There is a need for a cost analysis for the use of these technologies within the orthopaedic field, particularly considering the high expense of 3D printing materials and extended hospital stays until the printed models are available. CAVST and 3D printing also show promising applications within high-fidelity simulation surgical training, with CAVST offering possibilities in virtual reality and haptic-enhanced simulations and 3D printing providing physical models for trainee surgeons to hone their skills. Moving forward, a reduction in the cost of 3D printing and the advancement of CAVST using artificial intelligence would lead to future improvement. In conclusion, preoperative planning supported by these innovative technologies will play a pivotal role in improving surgical outcomes and training for complex PHF cases.

Erich arch bars vs intermaxillary fixation screws for mandibular fracture reduction during ORIF: a randomized clinical trial

OBJECTIVE

This randomized clinical trial aimed to compare the efficacy of Erich arch bars (EAB) and intermaxillary fixation (IMF) screws in reducing mandibular fractures during open reduction and internal fixation (ORIF).

METHODS

A total of 28 patients with mandibular fractures were randomly allocated to either the EAB group or the IMF screws group. The study evaluated various parameters including occlusal stability, complications, duration of application, oral hygiene status, quality of life, and patient characteristics.

RESULTS

The study found no significant differences in occlusal stability between the EAB and IMF screw groups. However, the application and removal times were longer for EAB compared to IMF screws. The EAB group showed a higher presence of biofilm on teeth, indicating poorer oral hygiene status compared to the IMF screws group. In terms of quality of life, patients in the EAB group reported worse results in the "handicap" domain at the 15th postoperative day. No significant differences were observed in other quality-of-life parameters. Patient characteristics were well distributed between the two groups, enhancing the reliability of the results.

CONCLUSION

Both EAB and IMF screws demonstrated comparable occlusal stability for minimally displaced mandibular fractures. However, IMF screws offered advantages such as shorter application and removal times, better oral hygiene maintenance, and potentially improved quality of life in the "handicap" domain. Further studies with larger sample sizes are necessary to validate these findings and explore the stability of IMF methods in cases requiring postoperative malocclusion correction or prolonged IMF.

Risk Factors and Clinical Outcomes after Antegrade Intramedullary Nailing in Proximal Humeral Fractures: Insights and Implications for Patient Satisfaction

BACKGROUND

Proximal humeral fractures (PHFs) are common injuries that can lead to significant functional impairment. This retrospective cohort study aimed to evaluate the clinical outcomes and complications associated with the use of the Targon PH+ (Fa. Aesculap, Germany) intramedullary nail for the treatment of PHFs.

METHODS

A subgroup consisting of 70 patients with a mean follow-up of 4.91 years out of 479 patients who underwent treatment with the Targon PH+ intramedullary nail for PHFs at a single center between 2014 and 2021 were included. Patient-reported outcome measures (PROMs) and health-related quality of life (HRQoL) were assessed using validated German versions of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and EuroQol 5-Dimension 5-Level (EQ-5D-5L). Radiographic assessment was performed using pre- and postoperative imaging.

RESULTS

Among the 70 patients of the subgroup who completed follow-up, 21.4% experienced complications, including major complications in 15.7% of cases, all of which were revised (revision rate of 15.7%). Anatomical reduction was achieved in 48,5% of cases. The mean DASH, ASES, and OSS scores were 25.4 ± 22.0, 76.2 ± 21.1, and 38.8 ± 10.3, respectively. Significant correlations were observed among the PROMs, indicating their convergent validity. Additionally, a significant correlation of all used PROMs and patient well-being (HRQoL) was observed. Severe complications and revisions were associated with significantly lower ASES scores (-11.1%, p = 0.013). There was a tendency for PROM scores to slightly decline with increasing fracture complexity, although this trend did not reach statistical significance. Our findings indicate that patients over the age of 65 years tend to exhibit lower scores in PROMs and HRQoL measures.

CONCLUSION

The use of the Targon PH+ intramedullary nail for the treatment of PHFs resulted in satisfactory clinical outcomes and acceptable complication and revision rates. The PROMs and HRQoL measures indicated varying levels of disability and symptoms, with major complications, revision surgery, and age negatively impacting shoulder function after midterm follow-up.

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.

A Comprehensive Radiologic Review of Shoulder Girdle Trauma

Radiologic knowledge of different fracture patterns involving the shoulder girdle is an important tool to generate clinically relevant reports, identify concomitant injuries, guide management decisions, and predict and minimize complications, such as nonunion, osteoarthritis, osteonecrosis, and hardware failure. Complex unstable injuries like scapulothoracic dissociation can also occur because of shoulder girdle trauma. Management options may vary from conservative to surgical, depending on the fracture type and patient factors. Injuries around the shoulder girdle can involve the glenohumeral articulation, scapula, superior shoulder suspensory complex, acromioclavicular joints, and scapulothoracic articulation.

Proximal humerus fractures: anatomy, diagnosis and management

Proximal humeral fractures are common with a bimodal distribution and sex discrepancy, affecting younger men and older women. The presentation of a proximal humeral fracture can vary greatly because of this bimodal distribution and the associated differences in mechanism of injury.

Initial management should involve assessment of life- and limb-threatening injuries as outlined by the British Orthopaedic Association Standards for Trauma, with particular attention paid to axillary nerve function and vascular status. Initial imaging should involve orthogonal X-rays in three planes to determine fracture characteristics and exclude glenohumeral dislocation. Computed tomography imaging improves interobserver agreement and is the gold standard in determining fracture management.

Management depends on fracture pattern, patient functionality and bone stock. Most patients with proximal humeral fractures achieve good functional outcomes via conservative methods (sling support and early, graded mobilisation), although there is a lack of evidence in certain populations, including younger patients. Surgery is required for open fractures and more complex fracture patterns where there is a risk of avascular necrosis of the humeral head, unacceptable impairment of functionality or neurovascular compromise. Surgical techniques can be head-sparing or involve replacement of the humeral head. There are several head-sparing techniques, each with different cost–benefit and complication profiles with no one technique superior to any other. However, improvements in plate technology may render open reduction internal fixation a more suitable technique, particularly in younger patients. Head replacement techniques (hemiarthroplasty and reverse shoulder arthroplasty) are indicated when the risk of avascular necrosis is too high or in older patients with osteoporotic bone. In these patients, reverse shoulder arthroplasty is preferred as it achieves better functional results than hemiarthroplasty. Complication rates vary depending on the fracture configuration and the course of management undertaken.

The effect of different pin configurations on cyclic stability in pediatric proximal humerus fracture fixation: A Sawbones model study

BACKGROUND

In sawbones with proximal humerus fracture model, three different fixation configurations, Parallel-Straight K-wires, Cross-Straight K-wires and Palm-Tree Method, were biomechanically compared.

METHODS

A total of 36 anatomical pediatric humerus sawbones models were used. They were divided into three equal groups; parallel fixation with straight K-wires (Group PS), cross fixation with straight K-wires (Group CS), and Palm-Tree Method (Group PT). Models were tested in abduction and torsional at a speed of 0.5 mm/s and a 0-5 mm displacement range. Loading (N) and Stiffness (N/mm) data were calculated and compared statistically.

RESULTS

Group PS was significantly higher than the other two groups in abduction bending cyclic load values (P<0.001). It was also significantly higher in Group CS than in Group PT (P < 0.001). No significant differences were detected between the three different fixation groups' cyclic torsional load values (p < 0.05).

CONCLUSION

The parallel configuration with straight K-wires will provide a more stable fixation than the cross configuration with straight or Palm-Tree Method in pediatric proximal humeral sawbones fracture modeling.

Angular stable plate versus reverse shoulder arthroplasty for proximal humeral fractures in elderly patient

BACKGROUND

Treatment of complex proximal humeral fractures in the elderly is a challenge and reverse shoulder arthroplasty (RTSA) is now an important alternative to open reduction internal fixation (ORIF) with angular stable plate. The purpose of this study is to compare clinical and radiological outcomes of RTSA and ORIF in the elderly.

METHODS

We retrospectively analyzed patients treated for three- or four-part displaced fractures of the proximal humerus. Range of motion, disabilities of the arm, shoulder and hand (DASH) and Constant scores were recorded. X-ray exam in three projections completed the clinical observation at follow-up.

RESULTS

Forty-eight patients were enrolled after a mean follow-up of 37 months: 22 RTSA and 26 ORIF. Mean age at trauma was 74 years. Compared with RTSA patients, ORIF patients had significantly higher mean external rotation (28° vs. 14°) and better results in modal internal rotation (hand at D7 vs. hand at L5-S1). No significant differences were seen in DASH and Constant scores. Avascular necrosis and loss of reduction with varus dislocation of the humeral head were the most frequent causes of revision surgery in ORIF (34.6%) while the revision rate of the RTSA was 9.1%.

CONCLUSION

In this study, both treatments showed good clinical outcomes, but RTSA resulted in lower revision rate than ORIF. Even if external and internal rotation in RTSA patients were worse than ORIF, they did not affect the patient's quality of life. So, the reverse arthroplasty seems to be a more reliable treatment.

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.

Age-Independent Clinical Outcome in Proximal Humeral Fractures: 2-Year Results Using the Example of a Precontoured Locking Plate

INTRODUCTION

The optimal treatment strategy for the proximal humeral fracture (PHF) remains controversial. The debate is centered around the correct treatment strategy in the elderly patient population. The present study investigated whether age predicts the functional outcome of locking plate osteosynthesis for this fracture entity.

METHODS

A consecutive series of patients with surgically treated displaced PHF between 01/2017 and 01/2018 was retrospectively analyzed. Patients were treated by locking plate osteosynthesis. The cohort was divided into two groups: Group 1 (≥65 years) and Group 2 (<65 years). At the follow-up examination, the SSV, CMS, ASES, and Oxford Shoulder Score (OS), as well as a radiological follow-up, was obtained. The quality of fracture reduction is evaluated according to Schnetzke et al. Results: Of the 95 patients, 79 were followed up (83.1%). Group 1 consists of 42 patients (age range: 65-89 years, FU: 25 months) and Group 2 of 37 patients (28-64 years, FU: 24 months). The clinical results showed no significant differences between both groups: SSV 73.4 ± 23.4% (Group 1) vs. 80.5 ± 189% (Group 2). CMS: 79.4 ± 21 vs. 81.9 ± 16, ASES: 77.2 ± 20.4 vs. 77.5 ± 23.1, OS: 39.5 ± 9.1 vs. 40.8 ± 8.2; OS: 39.5 ± 9.1 vs. 40.8 ± 8.2. In the radiological follow-up, fractures healed in all cases. Furthermore, the quality of fracture reduction in both groups is comparable without significant differences. The revision rate was 9.5% in Group 1 vs. 16.2% in Group 2.

DISCUSSION

Both age groups show comparable functional outcomes and complication rates. Thus, the locking plate osteosynthesis can be used irrespective of patient age; the treatment decision should instead be based on fracture morphology and individual patient factors.

Proximal humeral nail for treatment of 3- and 4-part proximal humerus fractures in the elderly population: effective and safe in experienced hands

BACKGROUND

Optimal treatment of 3- and 4-part proximal humerus fractures (PHFs) remains controversial. Although commonly recommended for less comminuted PHFs, the outcomes of treatment with proximal humerus nailing (PHN) are more equivocal. The purpose of this study was to report on radiographic and clinical outcomes of patients undergoing PHN fixation of 3- and 4-part PHFs at minimum one-year follow-up. Our hypothesis was that the findings would demonstrate satisfactory radiographic and clinical outcomes, with low rates of complications and revision surgeries.

METHODS

Between 2008 and 2016, 121 patients with comminuted, low-energy, osteoporotic, PHFs underwent fixation via Targon PHN (Aesculap, Tuttlingen, Germany). Of these, 60 patients met inclusion and exclusion criteria and were included in this analysis (mean age 72; range 65-85). All completed a minimum 1-year follow-up (range 12.5-82 months). Patients with 3-part PHFs were compared to patients with 4-part PHFs. Clinical, radiographic, and functional outcomes were assessed at postoperative visits. Patient reported outcomes included pain, the American Shoulder and Elbow Surgeons (ASES) score and the Simple Shoulder Test (SST). Radiographic union and revision and complication rates were assessed.

RESULTS

Overall, 37 (62%) fractures were classified as Neer 3 and 23 (38%) were classified as Neer 4. Both groups achieved similar postoperative range of motion. Patients with 3-part fractures reported significantly lower postoperative pain (0.76 ± 1.8 vs. 1.65 ± 2.2, p = 0.0047). Patients with 3-part fractures reported significantly better ASES scores (82.4 ± 19.2 vs. 70.8 ± 21.9, p = 0.02) and non-statistically significant higher SST scores (8.4 ± 3.2 vs. 7.43 ± 3.8, p = 0.14). Adequate fracture union was achieved in 53 fractures (88.3%). Three patients (5%) had varus malunion or greater tuberosity displacement, one (1.7%) had mechanical failure, and three (5%) had radiographic evidence of avascular necrosis. Between groups, there was no difference in failure rates.

CONCLUSION

Proximal humeral nails can successfully be used by experienced surgeons in fixation of comminuted and displaced proximal humeral fractures in selected patients with osteoporosis. While patients with both 3- and 4-part fractures demonstrate fracture union with satisfactory outcomes, patients with 3-part fractures demonstrate significantly higher postoperative functional scores.

Comparability of Patient-reported Outcome Measures and Clinical Assessment Tools for Shoulder Function in Patients with Proximal Humeral Fracture

BACKGROUND

Patient-reported outcome measures (PROMs) are gaining increasing importance in the context of quality management. Different PROMs and scoring tools are available to assess shoulder function after proximal humeral fracture (PHFx). In Europe, these include the Constant-Murley Score (CS), Neer Score (NS), Oxford Shoulder Score (OSS), University of California at Los Angeles Score (UCLA) and Disabilities of the Arm, Shoulder and Hands Score (DASH). In addition, the health-related quality of life can be assessed by the PROMs Short Form 36 (SF-36) and EuroQol (EQ-5D). Although all these test instruments assess shoulder function, the components to be answered objectively and subjectively vary and thus the possibility of independent assessment. The aim of the present study is to compare the correlation between the results of the different PROMs and the clinical screening tools in patients with PHFx.

METHODS

76 patients who were treated with angular stable plate osteosynthesis for a proximal humeral fracture between 01/2001 and 12/2005 were included in this trial. The outcome was measured with PROMs or clinical scoring tools such as CS, NS, OSS, UCLA, DASH, SF-36 and EQ-5D and a correlation coefficient between those evaluation tools was calculated. In addition, a distinction was made between the two force measurement methods (wrist [HG] vs. deltoid muscle [DM]) for CS.

RESULTS

The correlation of the results of CS and NS (HG: r = 0.85; p < 0.001/DM: r = 0.93; p < 0.001), CS and UCLA (HG: r = 0.83; p < 0.001/DM: r = 0.86; p < 0.001), NS and UCLA (r = 0.91; p < 0.001) as well as DASH and OSS (r = 0.88; p < 0.001) was strongly expressed. A good comparability of the results was demonstrated between CS and OSS (HG: r = 0.63; p < 0.001/DM: r = 0.66; p < 0.001) and between CS and DASH (HG: r = 0.62; p < 0.001/DM: r = 0.61; p < 0.001). The correlation of CS (HG/DM) and UCLA with the EQ-5D index was also good. Assessment of the physical components of SF-36 with CS, NS, OSS, UCLA and DASH showed a moderate to good association, while the mental components of SF-36 showed a low correlation (p > 0.05).

CONCLUSION

The assessment of shoulder function after proximal humerus fracture showed a very strong correlation within the clinical questionnaires (CS/NS/UCLA) and the PROMs (OSS/DASH). A strong correlation also exists between the clinical questionnaires and the PROMs. There was only a moderate correlation with the EQ-5D. The moderate to strong correlation between the physical components of SF-36, with almost no correlation between the mental components of SF-36, indicates that the quality of life restriction is based on a physical, but not on a mental impairment.

A Biomechanical Study of Tuberosity-Based Locked Plate Fixation Compared with Standard Proximal Humeral Locking Plate Fixation for 3-Part Proximal Humeral Fractures

BACKGROUND

One of the main shortcomings of current proximal humeral plate designs is their inability to reliably secure the greater tuberosity (GT) or lesser tuberosity, leading to fixation failure, nonunion, and rotator cuff dysfunction. Traditional proximal humeral locking plates (PHLPs) rely on isolated screw fixation or suture repair to maintain reduction of the greater and/or lesser tuberosities. This study evaluates a tuberosity-based plate (TBP) specifically designed to improve tuberosity fixation, which may decrease tuberosity displacement and related clinical sequelae.

METHODS

Five cadaveric specimens (10 shoulders) were randomized to receive either standard PHLP or TBP fixation. The specimens were skeletonized except for the rotator cuff insertion on the GT. A reproducible 3-part osteotomy was performed for each cadaver, creating head, shaft, and GT segments. Anatomic reduction and plate fixation were performed according to the surgical technique guide for each plate system, with an equal number of screws placed in each plate both proximally and distally. GT fixation was enhanced with standardized suture augmentation through the rotator cuff in every specimen in both groups. In each trial, fracture displacement, load to failure, number of cycles endured, and mechanism of failure were noted.

RESULTS

The mean load to tuberosity fixation failure for the PHLP and TBP groups was 220 and 502 N (P = 0.005), respectively.

CONCLUSIONS

The TBP had a significantly higher load to failure and significantly lower mean fracture displacement compared with the PHLP.

Acute Presentation of a Pseudoaneurysm After a Proximal Humerus Shaft Fracture: A Case Report

CASE

A 69-year-old woman presented with a brachial artery pseudoaneurysm causing median, ulnar, and radial nerve compressive neuropathies 8 weeks after a proximal humerus shaft fracture treated with intramedullary nailing. She underwent a brachial artery bypass with a reverse cephalic vein interposition graft and neurolysis after decompression of a large pseudoaneurysm. Postoperatively, the patient had a normal vascular examination with recovering neurological function.

CONCLUSIONS

A high index of suspicion for a brachial artery pseudoaneurysm should be maintained in patients with a displaced proximal humerus shaft fracture, particularly when an abnormal neurovascular examination is present.

Clinical and Radiographic Outcomes After Surgical Treatment of Proximal Humeral Fractures with Head-Split Component

BACKGROUND

Head-split fractures are a subgroup of proximal humeral fractures in which the fracture line affects the articular surface. Limited data are available regarding outcomes and risk factors for failure following surgical treatment of this rare fracture type.

METHODS

Of 45 patients with head-split fractures identified, a total of 30 (67%) were included in this retrospective study, with a mean follow-up of 49 ± 18 months (range, 12 to 83 months). Of those 30, 24 were treated with open reduction and internal fixation (ORIF), 4 with reverse total shoulder arthroplasty (RTSA), and 2 with hemiarthroplasty. Subjective Shoulder Value, Simple Shoulder Test, Constant score, and biplanar radiographs were assessed. Fracture pattern, quality of reduction, eventual complications, revision procedures, and clinical failure (adjusted Constant score < 40) were analyzed, and risk factors for failure were calculated.

RESULTS

The overall complication rate was 83% (ORIF: 21 of 24 [88%]; RTSA: 3 of 4 [75%]; and hemiarthroplasty: 1 of 2 [50%]). The most common complications following ORIF were humeral head osteonecrosis (42%), malunion of the lesser tuberosity (33%), and screw protrusion (29%), whereas all complications following RTSA were related to tuberosity problems. Revision was performed in 7 of 24 (29%) of initial ORIF patients, and no revisions were performed in RTSA or hemiarthroplasty patients. Four patients (17%) who underwent primary ORIF underwent conversion to RTSA, and 3 patients (12.5%) had screw removal due to penetration. The overall clinical failure rate was 50% (ORIF: 12 of 24 [50%]; RTSA: 1 of 4 [25%]; and hemiarthroplasty: 2 of 2 [100%]). No significant association was found between preoperative factors and clinical failure. ORIF and primary RTSA showed higher average clinical outcome scores than primary hemiarthroplasty and secondary RTSA. In general, patients who required revision had worse Subjective Shoulder Value (p = 0.014), Simple Shoulder Test (p = 0.028), and adjusted Constant scores (p = 0.069).

CONCLUSIONS

Head-split fractures of the humerus treated with ORIF showed high complication and revision rates. RTSA resulted in comparable clinical outcomes and complication rates; however, the complications associated with RTSA were mostly related to tuberosity problems, which in this small series did not require revision. Therefore, RTSA may be the most predictable treatment option for head-split fractures in elderly patients.

LEVEL OF EVIDENCE

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

A higher reoperation rate following arthroplasty for failed fixation versus primary arthroplasty for the treatment of proximal humeral fractures

Aims

To compare complication-related reoperation rates following primary arthroplasty for proximal humerus fractures (PHFs) versus secondary arthroplasty for failed open reduction and internal fixation (ORIF).

Patients and Methods

We identified patients aged 50 years and over, who sustained a PHF between 2004 and 2015, from linkable datasets. We used intervention codes to identify patients treated with initial ORIF or arthroplasty, and those treated with ORIF who returned for revision arthroplasty within two years. We used multilevel logistic regression to compare reoperations between groups.

Results

We identified 1624 patients who underwent initial arthroplasty for PHF, and 98 patients who underwent secondary arthroplasty following failed ORIF. In total, 72 patients (4.4%) in the primary arthroplasty group had a reoperation within two years following arthroplasty, compared with 19 patients (19.4%) in the revision arthroplasty group. This difference was significantly different (p < 0.001) after covariable adjustment.

Conclusion

The number of reoperations following arthroplasty for failed ORIF of PHF is significantly higher compared with primary arthroplasty. This suggests that primary arthroplasty may be a better choice for patients whose prognostic factors suggest a high reoperation rate following ORIF. Prospective clinical studies are required to confirm these findings. Cite this article: Bone Joint J 2019;101-B:1272–1279

Open reduction internal fixation vs non-operative management in proximal humerus fractures: a prospective, randomized controlled trial protocol

BACKGROUND

Proximal humerus fractures are the third most common fracture in the elderly population and are expected to increase due to the aging population. Surgical fixation with locking plate technology has increased over the last decade despite a lack of proven superiority in the literature. Three previous randomized controlled trials have not shown a difference in patient-centered outcomes when comparing non-operative treatment with open reduction and internal fixation. Low patient enrollment and other methodological concerns however limit the generalizability of these conclusions and as a result, management of these fractures remains a controversy. By comparing the functional outcomes of locked plate surgical fixation versus non-operative treatment of displaced three and four-part proximal humerus fractures in the elderly population with a large scale, prospective, multi-centered randomized controlled trial, the optimal management strategy for this common injury may be determined.

METHODS

We will conduct a prospective, single blind randomized controlled parallel arm trial to compare non-operative management of proximal humerus fractures with open reduction and internal fixation using locked plating technology. One-hundred and sixty patients > age 60 with acute 3- or 4- part proximal humerus fractures will be randomized to either open reduction and internal fixation with locked plating technology or non-operative management treatment arms. The primary outcome measure is the Constant Score at 24 months post-operative. Secondary outcome measures include the American Shoulder and Elbow Surgeon's Score (ASES), EuroQol EQ-5D-5 L Health Questionnaire Score, short form PROMIS upper extremity score and IPAQ for the elderly score. Further outcome measures include assessment of the initial classification, displacement and angulation and the quality of surgical reduction via a standard computed tomography (CT) scan; rates of non-union, malunion, arthrosis, osteopenia or other complications including infection, nerve injury, intra-articular screw penetration, reoperation rates and hospital re-admission rates.

DISCUSSION

The results of this trial will provide Level 1 evidence to guide decision-making in the treatment of proximal humerus fractures in the elderly population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02362100 . Registered 5 Feb 2015.

Plate fixation for management of humerus fractures

Proximal humerus, humeral shaft, and distal humerus fractures are all common adult fractures, and often occur in older patients. While the treatment of proximal humerus fractures remains controversial, certain fractures benefit from plate fixation such as fracture-dislocations and head-split fractures. When plate fixation is chosen, anatomic reduction and restoration of the medial calcar are important for successful results. Further research is required to minimize complications and determine the optimal surgical candidates for plate fixation. Humeral shaft fractures are generally treated non-operatively. However, certain shaft fractures warrant plate fixation, such as open fractures, those with associated forearm fractures, and those in poly-trauma patients. Choice of surgical approach and plate depends on the location and type of the fracture. The majority of intra-articular distal humerus fractures should be treated with plate fixation. Dual plating is generally accepted as the gold standard treatment, while the optimal surgical approach and plate configuration requires more research.

Complications Associated with Locking Plate of Proximal Humerus Fractures

Proximal humerus fractures constitute a significant percentage of fragility fractures. The growing use of locking plate has helped treat this problem, but at the same time has brought about complications. Past systematic reviews have documented these complications, however a large number of recent studies have been published since, reporting their own complication rates with different techniques. This study reviews the current complications associated with locking plate of proximal humerus fractures as well as methods to reduce them. A systematic review, following the PRISMA guidelines, was conducted in November 2013 and repeated in March 2015, using PubMed, Scopus, and Cochrane databases, to evaluate locking plate fixation (and complications) of traumatic proximal humerus fractures. Inclusion criteria included adults (>18 years), minimum of 12-month postoperative followup, articles within the last 5 years, and studies with >10 participants. Exclusion criteria included pathologic fractures, cadaveric studies, and nonhuman subjects. Eligible studies were graded using a quality scoring system. Articles with a minimum of 7/10 score were included and assessed regarding their level of evidence per the Journal of Bone and Joint Surgery and Centre for Evidence-Based Medicine guidelines. The initial query identified 51,206 articles from multiple databases. These records were thoroughly screened and resulted in 57 articles, consisting of seven Level 1, three Level 2, 10 Level 3, and 37 Level 4 studies, totaling 3422 proximal humerus fractures treated with locking plates. Intraarticular screw penetration was the most reported complication (9.5%), followed by varus collapse (6.8%), subacromial impingement (5.0%), avascular necrosis (4.6%), adhesive capsulitis (4.0%), nonunion (1.5%), and deep infection (1.4%). Reoperation occurred at a rate of 13.8%. Collapse at the fracture site contributed to a majority of the implant-related complications, which in turn were the main reasons for reoperation. The authors of these studies discussed different techniques that could be used to address these issues. Expanding use of locking plate in the proximal humerus fractures leads to improvements and advancements in surgical technique. Further research is necessary to outline indications to decrease complications, further.

The Applications of Finite Element Analysis in Proximal Humeral Fractures

Proximal humeral fractures are common and most challenging, due to the complexity of the glenohumeral joint, especially in the geriatric population with impacted fractures, that the development of implants continues because currently the problems with their fixation are not solved. Pre-, intra-, and postoperative assessments are crucial in management of those patients. Finite element analysis, as one of the valuable tools, has been implemented as an effective and noninvasive method to analyze proximal humeral fractures, providing solid evidence for management of troublesome patients. However, no review article about the applications and effects of finite element analysis in assessing proximal humeral fractures has been reported yet. This review article summarized the applications, contribution, and clinical significance of finite element analysis in assessing proximal humeral fractures. Furthermore, the limitations of finite element analysis, the difficulties of more realistic simulation, and the validation and also the creation of validated FE models were discussed. We concluded that although some advancements in proximal humeral fractures researches have been made by using finite element analysis, utility of this powerful tool for routine clinical management and adequate simulation requires more state-of-the-art studies to provide evidence and bases.

Surgical management of complex proximal humeral fractures: pinning, locked plate and arthroplasty : Clinical results and functional outcome on retrospective series of patients

PURPOSE

The aim of the study was to compare the clinical results and related complications of four different surgical treatments of complex proximal humeral fractures according to their classification and features of patients.

METHODS

Between 2007 and 2011, 92 consecutive patients with diagnosis of three-four-part displaced fractures, fractures with head dislocation and head-splitting fractures were evaluated postoperatively with Constant-Murley score, disability of arm, shoulder and hand score and simple shoulder test.

RESULTS

All the treatment modalities showed from optimal to good mean functional results. The statistical analysis comparing each treatment group showed better outcomes scores (p < 0.05) for: locked plating versus HA, locked plating versus RSA and RSA versus HA. No differences between postoperative range of motion, complication rate and overall revision rate of the treatment groups were found at the end of follow-up (p > 0.05). Overall complication rate of surgical treatment of complex PHF was 31.5% (29 patients) with overall revision rate of 14.1%. Among patients with complications 77.8% of HA (7 of 9) required revision surgery (p < 0.05).

CONCLUSIONS

The treatment of complex PHF is nowadays a challenge even for skilled shoulder surgeons. The several viable operative options give good results whenever used for the correct indication. The range of reported complications from 18.2 to 37.5% remains concerning, but most of them did not affect clinical outcome in this series. Accurate preoperative characterization of the fracture pattern is necessary, and high surgical skills of the different operative techniques, including arthroplasty, are recommended to meet the increased functional expectations of patients.

LEVEL OF EVIDENCE

Therapeutic series, Level IV.

Multifragmentary dislocated humeral head fracture-A case report of a successful head preserving treatment strategy despite delayed presentation

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Case report of multifragmentary and luxated humeral head fracture treated headpreserving despite delayed surgery (120 h).

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“Avoiding arthroplasty inspite of extrmely high risk of avascular necrosis due to compromised blood supply in luxation oft he humeral head.

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The headpreserving treatment showed excellent functional and radiologic results keeping a high “quality of life level”.

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Divergent from the recommended standard−treatment (trauma arthroplasty) of luxated humeral headsplit fractures in a “delayed situation” a head preserving option should be taken into consideration.

Introduction

Head preserving, delayed osteosynthesis five days after a luxated, multifragmentary humeral head fracture is rarely seen and a challenge for the surgeon.

Presentation of case

This case history describes the case of a 69-year-old female with delayed head preserving treatment of a dislocated multifragmentary humeral head fracture using intramedullary nailing, avoiding a primary trauma arthroplasty after strict refusal of the patient despite poor prognosis and high risk of avascular humeral head necrosis.

Discussion

The treatment of the humeral head fracture is still a matter of debate, the “golden standard” does not exist, especially in the deferred luxated situation. With the use of modern implants head preserving treatment is reasonable and possible. It should therefore always be taken into account as an alternative for arthroplasty.

Conclusion

Excellent postoperative outcome can be achieved by joint reconstruction eliminating the possible side effects of shoulder endoprosthesis.

Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial

BACKGROUND

Previous studies have shown good clinical results in patients with proximal humeral fractures (PHFs) treated with locking intramedullary nails or locking plates. Our study compared the clinical and radiographic outcomes in patients with 2- and 3-part surgical neck fractures.

METHODS

In this prospective, randomized controlled trial, 72 patients with 2- or 3-part surgical neck PHFs were randomly assigned to receive fixation with locking intramedullary nails (nail group) or locking plates (plate group). The primary outcome was the 12-month Constant-Murley score. The secondary outcomes included the Disabilities of the Arm, Shoulder and Hand score, the visual analog scale pain score, the shoulder passive range of motion, the neck-shaft angle, and complication rates.

RESULTS

There was no significant mean treatment group difference in the Constant-Murley score at 12 months (70.3 points for the nail group vs. 71.5 points for the plate group; P = .750) or at individual follow-up assessments. There were no differences in the 3-, 6- and 12-month Disabilities of the Arm, Shoulder and Hand scores, visual analog scale scores, and range of motion, except for the medial rotation at 6 months. The neck-shaft angle was equivalent between the groups at 12 months. There were significant differences over 12 months in total complication rates (P = .002) and reoperation rates (P = .041). There were no significant differences for the rotator cuff tear rate (P = .672).

CONCLUSION

Fixation of PHFs with locking plates or locking intramedullary nails produces similar clinical and radiologic results. Nevertheless, the complication and reoperation rates were higher in the nail group.

A scoping review of biomechanical testing for proximal humerus fracture implants

Background

Fixation failure is a relatively common sequela of surgical management of proximal humerus fractures (PHF). The purpose of this study is to understand the current state of the literature with regard to the biomechanical testing of proximal humerus fracture implants.

Methods

A scoping review of the proximal humerus fracture literature was performed, and studies testing the mechanical properties of a PHF treatment were included in this review. Descriptive statistics were used to summarize the characteristics and methods of the included studies.

Results

1,051 proximal humerus fracture studies were reviewed; 67 studies met our inclusion criteria. The most common specimen used was cadaver bone (87 %), followed by sawbones (7 %) and animal bones (4 %). A two-part fracture pattern was tested most frequently (68 %), followed by three-part (23 %), and four-part (8 %). Implants tested included locking plates (52 %), intramedullary devices (25 %), and non-locking plates (25 %). Hemi-arthroplasty was tested in 5 studies (7 %), with no studies using reverse total shoulder arthroplasty (RTSA) implants. Torque was the most common mode of force applied (51 %), followed by axial loading (45 %), and cantilever bending (34 %). Substantial testing diversity was observed across all studies.

Conclusions

The biomechanical literature was found to be both diverse and heterogeneous. More complex fracture patterns and RTSA implants have not been adequately tested. These gaps in the current literature will need to be addressed to ensure that future biomechanical research is clinically relevant and capable of improving the outcomes of challenging proximal humerus fracture patterns.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0627-x) contains supplementary material, which is available to authorized users.

Plate osteosynthesis versus hemiarthroplasty in proximal humerus fractures--does routine screening of systemic inflammatory biomarkers makes sense?

Background

Increases in C-reactive protein (CRP) and white blood cell (WBC) counts after orthopedic surgical procedures can give evidence of postoperative infection. However, there is a lack of knowledge about the kinetics of these biomarkers in cases with an uneventful clinical course after osteosynthesis of upper limb fractures. This study investigated CRP and WBC serum levels after osteosynthesis or hemiarthroplasty of humeral head fractures.

Methods

A retrospective study on patients with humeral head fractures who had open reduction and internal fixation via plate osteosynthesis (PO) (n = 64) or hemiarthroplasty (HA) (n = 28) without any complications in the postoperative clinical course. C-reactive protein serum levels (mg/l) and leukocyte counts (g/l) were assayed at several time points. Multiple regression analysis was performed to evaluate the influence of several confounding variables (the surgical procedure, duration of surgery, patient’s health status, and comorbidities) on the kinetics of CRP and WBC.

Results

Our data showed that CRP levels were statistically significantly higher in the HA cohort when compared to the PO cohort (p = 0.003). Moreover, daily measurement of CRP levels during the postoperative course showed that CRP peaked on the 2nd and 3rd days postoperatively in both cohorts and started to decrease afterward, reaching normal values on day 8 to 10. However, WBCs did not show any significant differences between the HA and PO cohorts. Finally, the choice of surgical procedure and the patient’s health status were associated with higher peak levels of CRP.

Conclusions

After osteosynthesis or hemiarthroplasty of humeral head fractures, CRP is a responsive serum parameter in the postoperative course of an uneventful inflammatory response. Abnormalities from these values should be interpreted carefully as they may give a hint as to postoperative complications such as infection.

Treatment of fracture sequelae of the proximal humerus: comparison of hemiarthroplasty and reverse total shoulder arthroplasty

INTRODUCTION

Fracture sequelae (FS) of the proximal humerus is a challenging scenario in shoulder surgery. Despite they have been traditionally treated with hemiarthroplasty (HA), the use of reverse shoulder arthroplasty (RSA) has been recently introduced. However, there are no studies comparing the results of HA and RSA in FS. The purpose of this study was to compare the functional and quality of life-related outcomes, and complications in the treatment of proximal humeral FS between HA and RSA.

MATERIALS AND METHODS

A therapeutic prospective non-randomized comparative study was conducted. All consecutive patients with diagnosis of FS after non-operative treatment of proximal humeral fractures and no previous shoulder surgery were considered for this study. A total of 32 patients (24 females, 8 males) with a mean (SD) age at the time of surgery of 80.1 (4.9) years were finally included: 12 in the HA group, and 20 in the RSA group. FS were treated with shoulder arthroplasty by the implantation of either HA or RSA. Constant score (total and specific items), quality of life (assessed through SF-36), and complications requiring revision surgery were compared between groups.

RESULTS

All parameters of the Constant score significantly improved in the postoperative compared to preoperative period when considering the entire sample. The RSA group demonstrated a higher improvement in total Constant score (p = 0.06) and Constant activity level (p = 0.02) compared to the HA group. The HA demonstrated a higher number of complications compared to the RSA (p = 0.05). There were no differences in SF-36 scores between both groups.

CONCLUSIONS

The shoulder arthroplasty is an effective treatment for FS with significant improvement in pain and function. The RSA may be a better option than HA for FS given the trend towards better total Constant score and a significantly lower number of complications requiring revision surgery.

LEVEL OF EVIDENCE

Therapeutic level II evidence.

Brachial artery pseudoaneurysm

We describe a case of an elderly man who presented with an upper arm swelling that had developed following a humeral fracture 8 months previously. The swelling was painless but associated with significantly diminished motor function of his right hand and concurrent paraesthaesia. On examination, a large pulsatile mass was identified and CT angiography confirmed the presence of an 11×7 cm brachial artery pseudoaneurysm. The patient underwent surgical repair in which a fragment of the humerus was found to have punctured the brachial artery resulting in a pseudoaneurysm. The patient had an uncomplicated postoperative period and was discharged 2 days later having regained some motor function in his right hand.