Outcomes of Management of Proximal Humeral Fractures with Patient-Specific, Evidence-Based Treatment Algorithms

Intramedullary nailing of proximal humerus fractures does not achieve superior functional results to non-operative treatment in the long term

INTRODUCTION

Non-operative treatment (NOT) of proximal humerus fractures (PHF) has regained significance due to recent evidence. Additionally, positive outcomes of plate osteosynthesis and fracture arthroplasty prompt a reassessment of the role of intramedullary nailing (IMN). While favorable short and medium-term results have been documented following IMN, little is known regarding functional outcomes and quality of life in the long-term.

METHODS

Data from 180 patients with dislocated PHF of Neer types III, IV and V, treated at our level-I trauma center between 2004 and 2014 using IMN or NOT therapy, were scanned. Patients were re-evaluated after a minimum of 5 years to assess functional outcomes (age- and sex-adapted Constant Score, QuickDASH), quality of life (SF12), and complications or reoperations.

RESULTS

Out of the initially identified 180 patients, 51 were unavailable for follow-up (FU) and 71 had deceased during the FU period. Functional outcomes and quality of life was, therefore, assessed in 58 patients (30 IMN, 28 NOT) with an average age at injury of 68 years after a mean FU time of 10.3 ± 3.4 years. Epidemiological patient characteristics did not exhibit significant differences between the two groups (p > .05). The functional outcome assessed by age- and sex-adapted Constant Score (NOT: 74 ± 28; IMN: 68 ± 24; p = .438), QuickDASH (NOT: 25 ± 27; IMN: 31 ± 23; p = .374) or quality of life using the SF12 (p > .05) revealed no significant disparities in long-term outcomes between the treatment groups. 10 of 30 patients in the IMN group underwent surgical revision to address complications, exceeding mere implant removal. Conversely, no patient in the NOT group underwent a revision surgery during the FU period.

CONCLUSIONS

In the long-term, functional and quality of life-related outcomes of IMN did not diverge significantly from those of NOT, while causing a higher incidence of follow-up interventions.

What Are the Long-term Outcomes of Locking Plates for Nonosteoporotic Three-part and Four-part Proximal Humeral Fractures With a Minimum 10-year Follow-up Period?

BACKGROUND

Proximal humeral fractures (PHFs) often occur in elderly individuals who experience low-energy falls. Open reduction and internal fixation (ORIF) of the proximal humerus is typically performed in young, active patients because of their good bone quality and high functional demands. Although good short-term results have been reported after ORIF in young patients, few studies have specifically evaluated long-term outcomes.

QUESTIONS/PURPOSES

(1) What are the long-term clinical outcomes scores and (2) radiologic outcomes of nonosteoporotic three-part and four-part PHFs treated with locking plates? (3) What complications occurred after treatment, and what factors are associated with poor postoperative functional outcomes scores and avascular necrosis (AVN) of the humeral head after ORIF?

METHODS

Between June 2005 and December 2012, we surgically treated 774 patients for displaced two-, three-, and four-part PHFs. Approximately 75% (581 of 774) underwent ORIF, 10% (77 of 774) underwent hemiarthroplasty, 7% (54 of 774) underwent intramedullary nailing, 5% (39 of 774) underwent reverse shoulder arthroplasty, and the remaining 3% (23 of 774) underwent other surgical treatments. We considered those who had ORIF as potentially eligible. Based on that criterion, 75% (581) were eligible. However, only patients with nonosteoporotic three- and four-part PHFs (cortical thickness of the proximal humeral diaphysis greater than 6 mm on a preoperative AP radiograph of the affected shoulder) and a minimum of 10 years of follow-up were included. Sixty-four percent (498 of 774) of the patients were excluded because of simple or osteoporotic fractures, 1% (7 of 774) were excluded because of ipsilateral limb multiple fractures, 0.3% (2 of 774) were excluded because of pathologic PHFs, and another 2% (13 of 774) were lost before the minimum study follow-up of 10 years, leaving 8% (61 of 774) for analysis here. The mean age at surgery was 45 ± 12 years, with a mean follow-up of 13 years. Fifty-seven percent (35 of 61) of the patients were men. Patient-reported outcomes were evaluated using the University of California Loas Angeles (UCLA) score (range 0 to 35; higher scores represent better shoulder function) and Constant score (range 0 to 100; higher scores represent better shoulder function) at least 10 years postoperatively. Postoperative radiographs were reviewed to assess the cortical bone thickness of the proximal humerus, neck-shaft angle, head-to-tuberosity distance, and radiologically confirmable complications. Logistic regression analysis was performed to evaluate factors associated with poor postoperative functional scores (UCLA score ≤ 27 or Constant score ≤ 70) and AVN of the humeral head; the association between AVN and postoperative functional outcomes was also assessed.

RESULTS

At the most-recent follow-up, these patients had a mean UCLA score of 31 ± 3 and a Constant score of 88 ± 10. The mean neck-shaft angle was 133° ± 10°, and 23% (14 of 61) of patients experienced AVN of the humeral head during follow-up. Twenty-nine complications in 30% (18 of 61) of patients were reported. After controlling for potentially confounding variables such as age and gender, we found that the presence of greater tuberosity malposition (odds ratio 18 [95% confidence interval 2 to 167]; p = 0.01) and immediate postoperative neck-shaft angle less than 130° (OR 19 [95% CI 3 to 127]; p = 0.002) were associated with poor postoperative functional scores. Four-part PHFs (OR 13 [95% CI 2 to 82]; p = 0.008) and metaphyseal extension less than 8 mm (OR 7 [95% CI 1 to 35]; p = 0.03) were associated with AVN of the humeral head. For patients who met the criteria for anatomic reduction (achievement of all of the following three criteria: neck-shaft angle ≥ 130°, head-shaft displacement < 5 mm, and head-to-tuberosity distance greater than or equal to 3 mm and less than or equal to 20 mm), there were no differences in postoperative functional scores between patients with AVN and those without.

CONCLUSION

ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up. When encountering complex PHFs in patients with good bone quality, every effort must be made to achieve an anatomic reduction of the fracture as far as possible, which may not reduce the risk of AVN (this occurred in nearly one-fourth of patients). However, good outcomes can usually be expected, even in patients with AVN. Because this was a retrospective study with a high risk of bias owing to sparse data, the factors associated with poor postoperative functional outcomes must be further investigated in large prospective studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

[Reverse Shoulder Arthroplasty - Current Concepts]

Due to first promising long term outcome data, reverse shoulder arthroplasty experienced an immense increase of usage during the past decade. Moreover, the initial Grammont concept has constantly been refined and adapted to current scientific findings. Therefore, clinical and radiological problems like scapular notching and postoperative instability were constantly addressed but do still remain an area of concern.This article summarises current concepts in reverse shoulder arthroplasty and gives an overview of actual indications like cuff tear arthropathy, severe osteoarthritis, proximal humerus fractures, tumours, fracture sequelae as well as revision surgery and their corresponding clinical and radiological results.

Predicting the deltoid tuberosity index in proximal humerus fractures using fracture characteristics and patient age: development of the LBQ-PHF score

BACKGROUND

The aim of this study was to investigate (1) whether fracture pattern and age are associated with local bone quality (LBQ), and (2) whether a scoring system based on these variables is able to predict LBQ in proximal humerus fractures (PHF).

MATERIALS AND METHODS

A retrospective study was performed of all acute PHF at a Level 2 trauma center with plain radiographs and CT between June 2009 and March 2022. Local bone quality was measured by using the deltoid tuberosity index (DTI). In addition to age and gender, fracture morphology was categorized using the following classification systems: Neer, Resch, AO Foundation/Orthopaedic Trauma Association (AO/OTA), and Hertel/LEGO. Additionally, coronal head alignment was calculated by measuring the head-shaft angle.

RESULTS

Only the Resch classification system revealed a significant relationship between fracture type and bone quality, as there was a significant association between coronal head alignment and DTI (p = 0.001). Valgus head alignment was observed significantly more frequent in patients with low bone quality (p = 0.002). Multinomial logistic regression analysis revealed a significant relative risk ratio for age (RRR = 0.97, [95% CI, 0.94-1], p = 0.039) and a non-significant trend for DTI (RRR = 1.26, [95% CI, 0.96-1.64], p = 0.092) for occurrence of anatomic relative to valgus head alignment. Using a DTI cut-off value of 1.3 instead of 1.4, age and also varus head alignment were identified as significant predictors of LBQ (OR = 1.12, [95% CI, 1.1-1.15], p < 0.001; OR = 0.54, [95% CI, 0.3-0.96], p = 0.037). A scoring system called the LBQ-PHF score (local bone quality in proximal humerus fractures), developed based on these two variables was able to predict LBQ with a sensitivity of 79.2% and a specificity of 86.7%.

CONCLUSION

Age and coronal humeral head alignment are independent predictors of LBQ in PHF. A simple scoring system developed based on these variables is able to assess BQ with solid predictive characteristics.

Impact of aberrant beam paths on antero-posterior shoulder radiographs in proximal humeral fractures

INTRODUCTION

Accurate radiographic assessment of proximal humeral fractures (PHF) is important as it influences clinical decision-making and predicts clinical outcome. Since aberrant radiographic views might influence the assessment of fracture displacement, it was the goal of this study to investigate the impact of aberrant beam paths on radiographic assessment of PHF.

MATERIALS AND METHODS

Ten consecutive patients with a displaced PHF, bilateral computed tomography (CT) scan, and a true clinical AP radiograph were included. Digitally reconstructed radiographs (DRRs) were generated and aberrant beam paths were simulated by rotation of ± 30° around the horizontal (flexion and extension) and vertical axis (internal and external rotation) by increments of 10°. Measurement of the neck-shaft-angle (NSA) and eccentric head index (EHI) addressed humeral angulation and offset, respectively. Paired comparisons determined the influence of aberrant beam paths on both measurements between incremental altered views, and between clinical and digital true AP views. Descriptive statistics assessed the change in Neer classification and recommended treatment.

RESULTS

True AP DRRs approximated the clinical true AP view by a mean difference of 2° for NSA, and a mean difference of 0.12 for EHI. NSA in injured shoulders was most susceptible to malrotation around the vertical axis (p < 0.03), with largest differences seen for internal rotation. Aberrant projections in extension had no influence on NSA (p > 0.70), whereas flexion of ≥ 20° and 30° demonstrated differences in injured and uninjured shoulders, respectively (p < 0.05). EHI was only influenced by malrotation in internal rotation in uninjured shoulders (p < 0.03). Alterations in Neer type occurred at 30° of malrotation in 5 cases, with a change in recommended treatment in 2.

CONCLUSIONS

Humeral angulation and offset measurements on AP radiographs are more susceptible to aberrant beam paths in fractured humeri. Altered radiographic beam paths around the vertical axis showed the most substantial influence on the assessment of PHF, with angular measurements demonstrating larger differences then offset measurements. Beam path alterations of 30° can influence the Neer classification, and might influence fracture displacement-based decisions.

Proximal humerus fracture management and outcomes are distinctly different for individuals 60 years of age or younger: a systematic review

Background

Proximal humerus fractures (PHFs) occur most commonly in an elderly and osteoporotic population, but a considerable proportion of these injuries occur in relatively younger individuals. Differences in treatment principles and outcomes in this younger population remain poorly understood. The purpose of this review was to characterize the treatment algorithms and outcomes for patients less than or equal to 60 years of age with PHFs.

Methods

A comprehensive search of the Medline, Pubmed, Embase, and Cochrane databases for articles published between January 2005 and December 2020 was performed in January 2021. Levels of evidence I-IV analyzing outcomes (patient reported outcomes and/or complications) following PHFs in adult patients less than or equal to 60 years of age were included. The search was carried out in accordance with the preferred reported items for systematic reviews and meta-analyses guidelines. The risk of bias 2 tool and methodological index for nonrandomized studies score were utilized to evaluate included studies.

Results

Fourteen studies met the inclusion criteria (open reduction internal fixation: 5, intramedullary nail: 4, hemiarthroplasty: 2, nonoperative: 1, and reverse total shoulder arthroplasty (RTSA): 1). Seven studies reported differences in outcomes between younger and older patient populations, with three studies noting separate management algorithms for those 60 years of age or younger. There were no studies comparing different treatments modalities in those less than 60 years of age, and the lone study on RTSA did not include patient-reported outcomes.

Conclusion

Treatment algorithms and outcomes following PHFs in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population. However, evidence-based treatment recommendations for this younger population are limited by the lack of studies comparing treatment modalities and the absence of patient-reported outcomes for individuals undergoing RTSA.

Complications of Locked Plating for Proximal Humeral Fractures in Active Patients in a Level One Trauma Center

Background

The incidence of complications associated with locked plating of proximal humerus fractures (PHF) has been reported in up to 40% of surgeries. This study aimed to analyze the incidence and risk factors of complications and re-intervention associated with locked plating of PHF in a an young active working population.

Methods

This retrospective cohort study included patients indicated for locked plating of displaced PHF at a dedicated workers' accident trauma center. The variables analyzed were patient comorbidities, fracture characteristics, and immediate radiologic surgical outcomes. Postoperative complications and risk factors were determined.

Results

A total of 127 patients with a median follow-up of 31 months and a median age of 52 years were included. The complication and reintervention rates were 13.4% and 12.6%, respectively. The main cause of reintervention was post-traumatic stiffness. The incidence of other complications was 4% screw protrusion, 1.6% avascular necrosis, 1.6% varus collapse. Complications were not associated with age, comorbidity, fracture classification, bone mineral density, Hertel's risk factors, presence of calcar comminution, reduction quality, and calcar screw position.

Discussion

The incidence of complications and reintervention was low. The main cause of reintervention was persistent stiffness, and no risk factors for complications were found in this study.

Hemiarthroplasty for proximal humerus fractures and for fracture sequelae: did not differ in their outcomes

Background

The role of hemiarthroplasty (HA) in the management of proximal humerus fractures (PHFs) and their sequalae has evolved with the development of contemporary internal fixation techniques and the widespread use of the reverse total shoulder arthroplasty. However, HA may still have a role in certain acute PHFs as well as select fracture sequalae. The aim of this investigation was to evaluate the outcomes of HA when used in acute fractures and fracture sequelae.

Methods

Over a 16-year period (2000 - 2016), 122 primary HA performed for either acute PHFs or fracture sequelae were identified. Of these, 70 (57.4%) HA were performed within 4 weeks of the injury, whereas 52 (42.6%) underwent HA for fracture nonunion, malunion, or avascular necrosis. The minimum follow-up period was 2 years. Outcomes included the visual analog scale for pain, range of motion, American Shoulder and Elbow Surgeons (ASES) score, complications, and reoperations inclusive of revision surgery. Cumulative incidence analysis was used to report implant survivorship with death as a competing risk.

Results

The mean follow-up time after HA was 4.8 years (range, 2-15 years) with no differences between groups (P = .102). Cohort comparisons demonstrated an older age (67.8 vs. 60.1; P = .004), lower rate of previous procedure (4.3% vs. 51.9%; P < .001), lower bone graft use (28.6% vs. 59.6%; P < .001), and a longer length of stay (5.9 vs. 3.0 days; P < .001) in the acute HA group. Additionally, no differences were observed between the acute and sequalae cohort in pain (2.0 vs. 2.5; P = .523), forward elevation (98° vs. 93°; P = .627), external rotation (30° vs. 23°; P = .215), internal rotation score (4.0 vs. 4.5; P = .589), satisfaction (P = .592), ASES scores (64.4 vs. 57.1; P = .168), complications (27.1% vs. 28.8%; P = .836), or reoperations (11.4% vs. 19.2%; P = .229). When comparing acute fractures and sequalae, the 15-year complication rates were 32.4% and 43.3%, respectively (P = .172), with 15-year reoperation rates of 13.7% and 24%, respectively (P = .098).

Conclusions

HA, whether performed acutely for a PHF or in a delayed fashion for fracture sequalae, demonstrated no statistically significant differences in outcomes for all examined parameters. HA in this setting may provide reasonable pain relief. However, limited motion, marginal ASES scores, and elevated rates of complications and reoperations can be expected up to 15 years postoperatively.

Cemented vs. uncemented reverse total shoulder arthroplasty for the primary treatment of proximal humerus fractures in the elderly-a retrospective case-control study

BACKGROUND

Uncemented reverse total shoulder arthroplasty (RTSA) for the primary treatment of proximal humerus fractures (PHF) in elderly patients was introduced at our institution in 2017. Recent reports have raised concerns about increased rates of early bone resorption at the proximal humerus with uncemented fracture stems. The aim of this study was to find out whether there was any difference in functional or radiographic outcomes between cemented and uncemented RTSA for PHF.

METHODS

Seventeen consecutive patients who underwent uncemented RTSA (group nC) in 2017 and 2018 were age and sex matched (propensity score matching 1:2) to 34 patients with cemented RTSA implanted between 2011 and 2016 (group C) for the primary treatment of PHF. These two groups were compared in terms of clinical and radiographic outcomes at 2 years after the index surgery.

RESULTS

The mean bone quality was low in both groups: in group nC the deltoid tuberosity index (DTI) was 1.43 (1.22-1.72) and in group C 1.42 (1.22-1.67). At the final 2 year follow-up, the relative CS was 98.3% (71-118) in group nC and 97.9% (36-125) in group C (p = 0.927); the absolute CS was 70.2 (49-89) in group nC and 68.0 (30-94) in group C (p = 0.509). Lucent lines at the humeral site were seen in 8 cases (47%) in group nC and in 13 cases (38%) in group C (p = 0.056). Compared to 3% in group C, all patients in group nC showed at least grade 1 and 65% showed grade 3 bone resorption at the proximal humerus (p < 0.001).

CONCLUSION

Compared to cemented RTSA bone resorption at the proximal humerus was significantly more frequent in patients with uncemented RTSA for PHF. So far, this is rather a radiographic than a clinical finding, because both groups showed very satisfying functional outcomes and low revision rates at the 2 year follow-up.

LEVEL OF EVIDENCE III

A retrospective case-control study.

Shoulder arthroplasty for proximal humeral fracture treatment: a retrospective functional outcome analysis

PURPOSE

Following proximal humeral fractures hemiarthroplasty (HA) or reversed total shoulder arthroplasty (rTSA) are performed if osteosynthesis or conservative treatment is not possible. HA has been reported to result in decreased functional outcomes compared with rTSA. Secondary shoulder arthroplasty, performed after a different initial treatment, has also been associated with inferior outcomes.

METHODS

Patients recieving a shoulder arthroplasty related to a proximal humeral fracture from 2010 to 2019 were included. A retrospective analysis of functional outcomes was performed using QuickDASH and subjective shoulder value (SSV).

RESULTS

The mean [standard deviation (SD)] follow-up time among the 82 included patients was 48 (28) months. The mean age was 70 (10) years. The mean age for HA was significantly different from rTSA [57 (9) and 72 (21) years; p < .001]. The mean QuickDASH score for primary arthroplasty was 11 (2) versus 12 (16) for secondary arthroplasty (p = .313). The mean SSV for primary arthroplasty was 84 (22) versus 82 (17) for secondary arthroplasty (p = .578). The mean QuickDASH score for HA was 24 (36) versus 9 (15) for rTSA (p = .346). The mean SSV for HA was 70 (34) versus 86 (17) for rTSA (p = .578).

CONCLUSION

Functional outcomes after fracture-related shoulder arthroplasty were excellent in an older population, even when performed secondarily after failed primary osteosynthesis or conservative treatment. No significant differences in shoulder function were identified between rTSA and HA, likely due to restrictive indications for HA.