Factors predicting complication and reoperation rates following surgical fixation of proximal humeral fractures

Construction and validation of a nomogram for blood transfusion after open reduction and internal fixation (ORIF) of proximal humeral fractures in the elderly: a cross-sectional study

PURPOSE

Few studies have focused on the risk factors leading to postoperative blood transfusion after open reduction and internal fixation (ORIF) of proximal humeral fractures (PHFs) in the elderly. Therefore, we designed this study to explore potential risk factors of blood transfusion after ORIF for PHFs. We have also established a nomogram model to integrate and quantify our research results and give feedback.

METHODS

In this study, we retrospectively analyzed the clinical data of elderly PHF patients undergoing ORIF from January 2020 to December 2021. We have established a multivariate regression model and nomograph. The prediction performance and consistency of the model were evaluated by the consistency coefficient and calibration curve, respectively.

RESULTS

162 patients met our inclusion criteria and were included in the final study. The following factors are related to the increased risk of transfusion after ORIF: time to surgery, fibrinogen levels, intraoperative blood loss, and surgical duration.

CONCLUSIONS

Our patient-specific transfusion risk calculator uses a robust multivariable model to predict transfusion risk.The resulting nomogram can be used as a screening tool to identify patients with high transfusion risk and provide necessary interventions for these patients (such as preoperative red blood cell mobilization, intraoperative autologous blood transfusion, etc.).

Preoperative factors predict prolonged length of stay, serious adverse complications, and readmission following operative intervention of proximal humerus fractures: a machine learning analysis of a national database

Background

Proximal humerus fractures are a common injury, predominantly affecting older adults. This study aimed to develop risk-prediction models for prolonged length of hospital stay (LOS), serious adverse complications, and readmission within 30 days of surgically treated proximal humerus fractures using machine learning (ML) techniques.

Methods

Adult patients (age >18) who underwent open reduction internal fixation (ORIF), hemiarthroplasty, or total shoulder arthroplasty for proximal humerus fracture between 2016 and 2021 were included. Preoperative demographic and clinical variables were collected for all patients and used to establish ML-based algorithms. The model with optimal performance was selected according to area under the curve (AUC) on the receiver operating curve (ROC) curve and overall accuracy, and the specific predictive features most important to model derivation were identified.

Results

A total of 7473 patients were included (72.1% male, mean age 66.2 ± 13.7 years). Models produced via gradient boosting performed best for predicting prolonged LOS and complications. The model predicting prolonged LOS demonstrated good discrimination and performance, as indicated by (Mean: 0.700, SE: 0.017), recall (Mean: 0.551, SE: 0.017), accuracy (Mean: 0.717, SE: 0.010), F1-score (Mean: 0.616, SE: 0.014), AUC (Mean: 0.779, SE: 0.010), and Brier score (Mean: 0.283, SE: 0.010) Preoperative hematocrit, preoperative platelet count, and patient age were considered the strongest predictive features. The model predicting serious adverse complications exhibited comparable discrimination [precision (Mean: 0.226, SE: 0.024), recall (Mean: 0.697, SE: 0.048), accuracy (Mean: 0.811, SE: 0.010), F1-score (Mean: 0.341, SE: 0.031)] and superior performance relative to the LOS model [AUC (Mean: 0.806, SE: 0.024), Brier score (Mean: 0.189, SE: 0.010), noting preoperative hematocrit, operative time, and patient age to be most influential. However, the 30-day readmission model achieved the weakest relative performance, displaying low measures of precision (Mean: 0.070, SE: 0.012) and recall (Mean: 0.389, SE: 0.053), despite good accuracy (Mean: 0.791, SE: 0.009).

Conclusion

Predictive models constructed using ML techniques demonstrated favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged LOS and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture. Modifiable preoperative factors such as hematocrit and platelet count were identified as significant predictive features, suggesting that clinicians could address these factors during preoperative patient optimization to enhance outcomes. Overall, these findings highlight the potential for ML techniques to enhance preoperative management, facilitate shared decision-making, and enable more effective and personalized orthopedic care by exploring alternative approaches to risk stratification.

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.

Venous thromboembolism following surgical management of proximal humerus fractures: a systematic review

Background

Currently, there is limited information on the incidence of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE) after surgical treatment of proximal humerus fractures (PHFs). Therefore, the purpose of this systematic review is to evaluate the incidence of VTE, DVT, and PE following surgery for PHFs.

Methods

A comprehensive search of several databases was performed from inception to May 27, 2022. Studies were screened and evaluated by 2 reviewers independently utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Only original, English studies that evaluated the incidences of VTE following surgical management of PHFs were included. Surgical procedures consisted of shoulder arthroplasty (SA) including both hemiarthroplasty (Hemi) and reverse shoulder arthroplasty (RSA) in addition to open reduction and internal fixation (ORIF). A pooled incidence for postoperative DVT, PE, and overall VTE was reported.

Results

Twelve studies met the inclusion and exclusion criteria, encompassing a total of 18,238 patients. The overall DVT, PE, and VTE rates were 0.14%, 0.59%, and 0.7%, respectively. VTE was more frequently reported after SA than ORIF, (1.27% vs. 0.53%, respectively). Among SA patients, a higher rate of DVT was seen with RSA (1.2%) with the lowest DVT rate was observed for ORIF with 0.03%.

Conclusions

Symptomatic VTEs following surgical treatment of PHFs, are rare, yet still relevant as a worrisome postoperative complication. Among the various procedures, VTE was the most frequently reported after SA when compared to ORIF, with RSA having the highest VTE rate.

Short-Term Outcomes and Long-Term Implant Survival After Inpatient Surgical Management of Geriatric Proximal Humerus Fractures

Introduction

The most common surgical options for geriatric proximal humerus fractures are open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty. We used a longitudinal inpatient discharge database to determine the cumulative incidence of conversion to arthroplasty after ORIF of geriatric proximal humerus fractures. The rates of short-term complications and all-cause reoperation were also compared.

Patients and Methods

All patients 65 or older who sustained a proximal humerus fracture and underwent either ORIF, HA, or shoulder arthroplasty (SA) as an inpatient from 2000 through 2017 were identified. Survival analysis was performed with ORIF conversion to arthroplasty and all-cause reoperation as the endpoints of interest. Rates of 30-day readmission and short-term complications were compared. Trends in procedure choice and outcomes over the study period were analyzed.

Results

A total of 27 102 geriatric patients that underwent inpatient surgical management of proximal humerus fractures were identified. Among geriatric patients undergoing ORIF, the cumulative incidence of conversion to arthroplasty within 10 years was 8.2%. The 10-year cumulative incidence of all-cause reoperation was 12.1% for ORIF patients and less than 4% for both HA and SA patients. Female sex was associated with increased risk of ORIF conversion and younger age was associated with higher all-cause reoperation. ORIF was associated with higher 30-day readmission and short-term complication rates. Over the study period, the proportion of patients treated with ORIF or SA increased while the proportion of patients treated with HA decreased. Short-term complication rates were similar between arthroplasty and ORIF patients in the later cohort (2015-2017).

Conclusion

The 10-year cumulative incidence of conversion to arthroplasty for geriatric patients undergoing proximal humerus ORIF as an inpatient was found to be 8.2%. All-cause reoperations, short-term complications, and 30-day readmissions were all significantly lower among patients undergoing arthroplasty, but the difference in complication rate between arthroplasty and ORIF was attenuated in more recent years. Younger age was a risk factor for reoperation and female sex was associated with increased risk of requiring conversion to arthroplasty after ORIF.

Nonanatomic healing of the greater tuberosity after plating in proximal humeral fractures: a case control study

BACKGROUND

Open reduction and plate internal fixation (ORIF) is one of the most common treatment methods for proximal humeral fractures. Complications associated with the greater tuberosity (GT) are rarely reported, therefore, the purpose of this study was to analyze the complications associated with the GT and the risk factors after locked-plate internal fixation.

METHODS

We retrospectively analyzed the medical and radiographic data of patients with proximal humeral fractures involving the GT treated with locking plates between January 2016 and July 2019. We divided all patients into two groups, the anatomic GT healing group and the nonanatomic GT healing group, depending on the radiographic outcomes of the GT. Clinical outcome was assessed by the Constant scoring system. Potential risk factors included preoperative and intraoperative factors. Preoperative factors included sex, age, body mass index, fracture type, fracture-dislocation, proximal humeral bone mineral density, humeral head extension, hinge integrity, comminuted GT, volume and surface area of the main GT fragment, and displacement of the main GT fragment. Intraoperative factors were adequate medial support, residual head-shaft displacement, head-shaft angle and residual GT displacement. Univariate logistic regression and multivariate logistic regression were used to identify risk factors.

RESULTS

There were 207 patients (130 women and 77 men; mean age, 55 years). GT anatomic healing was observed in 139 (67.1%) patients and nonanatomic healing in 68 (32.9%). Patients with GT nonanatomic healing had significantly inferior Constant scores than those with GT anatomic healing (75.0 ± 13.9 vs. 83.9 ± 11.8, P < 0.001). Patients with high GT malposition had worse Constant scores than patients with low GT malposition (73.3 ± 12.7 vs. 81.1 ± 11.4, P = 0.039). The multivariate logistic model showed that GT fracture characteristics were not risk factors for nonanatomic GT healing, while residual GT displacement was.

CONCLUSIONS

Nonanatomic healing of the GT is a high-rate complication of proximal humeral fractures, resulting in inferior clinical outcomes, especially for high GT malposition. Fracture characteristics of the GT are not risk factors for GT nonanatomic healing and GT comminution should not be regarded as a contraindication to ORIF for proximal humeral fractures.

Proximal humerus fractures - epidemiology, comparison of mortality rates after surgical versus non-surgical treatment, and analysis of risk factors based on Medicare registry data

AIMS

The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate?

METHODS

PHFs occurring between 1 January 2009 and 31 December 2019 were identified from the Medicare physician service records. Incidence rates were determined, mortality rates were calculated, and semiparametric Cox regression was applied, incorporating 23 demographic, clinical, and socioeconomic covariates, to compare the mortality risk between treatments.

RESULTS

From 2009 to 2019, the incidence decreased by 11.85% from 300.4 cases/100,000 enrollees to 266.3 cases/100,000 enrollees, although this was not statistically significant (z = -1.47, p = 0.142). In comparison to matched Medicare patients without a PHF, but of the same five-year age group and sex, a mean survival difference of -17.3% was observed. The one-year mortality rate was higher after nonoperative treatment with 16.4% compared to surgical treatment with 9.3% (hazard ratio (HR) = 1.29, 95% confidence interval (CI) 1.23 to 1.36; p < 0.001) and to shoulder arthroplasty with 7.4% (HR = 1.45, 95% CI 1.33 to 1.58; p < 0.001). Statistically significant mortality risk factors after operative treatment included age older than 75 years, male sex, chronic obstructive pulmonary disease (COPD), cerebrovascular disease, chronic kidney disease, a concomitant fracture, congestive heart failure, and osteoporotic fracture.

CONCLUSION

Mortality risk factors for distinct treatment modes after PHF in elderly patients could be identified, which may guide clinical decision-making.Cite this article: Bone Joint Res 2023;12(2):103-112.

Development and Internal Validation of Novel Risk Tools to Predict Subsequent Shoulder Surgery After Proximal Humerus Fractures

OBJECTIVE

To (1) identify predictors of subsequent surgery after initial treatment of proximal humerus fractures (PHFs) and (2) generate valid risk prediction tools to predict subsequent surgery.

METHODS

We identified patients ≥50 years with PHF from 2004 to 2015 using health data sets in Ontario, Canada. We used procedural codes to classify patients into treatment groups of (1) surgical fixation, (2) shoulder replacement, and (3) conservative. We used procedural and diagnosis codes to capture subsequent surgery within 2 years after fracture. We developed regression models for two-thirds of each group to identify predictors of subsequent surgery and the regression equations to develop risk tools to predict subsequent surgery. We used the final third of each cohort to evaluate the discriminative ability of the risk tools using c-statistics.

RESULTS

We identified 20,897 patients with PHF, 2414 treated with fixation, 1065 with replacement, and 17,418 treated conservatively. Predictors of reoperation after fixation included bone grafting and nail or wire fixation versus plate fixation, whereas poor bone quality was associated with reoperation after initial replacement. In conservatively treated patients, more comorbidities were associated with subsequent surgery, whereas age 70+ and discharge home after presentation lowered the odds of subsequent surgery. The risk tools were able to discriminate with c-statistics of 0.75-0.88 (derivation) and 0.51-0.79 (validation).

CONCLUSIONS

Our risk tools showed good to strong discriminative ability for patients treated conservatively and with fixation. These data may be used as the foundation to develop a clinically informative tool.

LEVEL OF EVIDENCE

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

Outcomes associated with secondary implant removal and arthrolysis in patients with a painful stiff shoulder after proximal humeral fracture fixation

AIMS

Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome.

METHODS

Between 1998 and 2018, 424 consecutive patients were treated with primary ORPF for proximal humerus fracture. ADROM was offered to symptomatic patients with a healed fracture at six months postoperatively. Patients were followed up retrospectively with demographic data, fracture characteristics, and complications recorded. Active range of motion (aROM), Oxford Shoulder Score (OSS), and EuroQol five-dimension three-level questionnaire (EQ-5D-3L) were recorded preoperatively and postoperatively.

RESULTS

A total of 138 patients underwent ADROM; 111 patients were available for long-term follow-up at a mean of 10.9 years (range 1 to 20). Mean age was 50.8 years (18 to 75);79 (57.2%) were female. Mean time from primary ORPF to ADROM was 11.9 months (6 to 19). Five patients developed superficial wound infection; ten developed symptomatic osteonecrosis/post-traumatic arthrosis (ON/PTA); four underwent revision arthrolysis. Median OSS improved from 17 (interquartile range (IQR) 12.0 to 22.0) preoperatively to 40.0 (IQR 31.5 to 48.0) postoperatively, and 39.0 (IQR 31.5 to 46.5) at long-term follow-up (p < 0.001). Median EQ-5D-3L improved from 0.079 (IQR -0.057 to 0.215) to 0.691 (IQR 0.441 to 0.941) postoperatively, and 0.701 (IQR 0.570 to 0.832) at long-term follow-up (p < 0.001). We found that aROM improved in all planes (p < 0.001). Among the variables assessed on multivariable analysis, a manual occupation, worsening Charlson Comorbidity Index and increasing socioeconomic deprivation were most consistently predictive of worse patient-reported outcome scores. Patients who subsequently developed ON/PTA reported significantly worse one-year and late OSS.

CONCLUSION

ADROM in patients with persistent symptomatic stiffness following ORPF can achieve excellent short- and long-term outcomes. More deprived patients, those in a manual occupation, and those with worsening comorbidities have worse outcomes following ADROM. Cite this article: Bone Joint J 2022;104-B(1):157-167.

Comorbidities, substance abuse, weight and age are independent risk factors for postoperative complications following operation for proximal humerus fractures: a retrospective analysis of 1109 patients

INTRODUCTION

This study aimed to investigate the influence of epidemiologic parameters on complications that needed operative revision of operatively treated proximal humerus fractures.

METHODS

We performed a retrospective single-center study in a level 1 trauma center. We included all patients with operatively treated proximal humerus fractures from January 1 2005 to December 31 2015. We characterized our cohort and subgroup using descriptive statistics. The primary outcome was postoperative complications. For this purpose, postoperative complications were defined in advance, an operative revision was necessary on a general rule. The secondary outcome was a model of the risk factors for complications created with multiple logistic regression.

RESULTS

We included 1109 patients. The average age was 67.2 years (± 16.4), and 71.4% of the fractures occurred in women. A total of 644 patients (58.1%) had between one to three comorbidities, and 27.8% had four or more. The fracture morphology was as follows: 3 part 41.8%, 4 part 26.9%, 2 part 24.3%, and dislocation fracture 6.7%. Complications occurred in 150 patients (13.5%). The number of comorbidities [odds ratio (OR) 2.85, p < 0.01], body weight (OR 1.15, p = 0.02), and substance abuse (OR 1.82, p = 0.04) significantly correlated with the risk of complications. We achieved a sensitivity of 48% and a specificity of 74% for the variables body weight, substance abuse, age, and comorbidities CONCLUSION: The epidemiologic parameters, comorbidities, substance abuse, weight, and age are independent risk factors for complications. If these factors are present, one can predict a postoperative complication requiring surgical revision with low sensitivity and moderate specificity. Therefore, concerning the high number of multi-morbid patients with proximal humerus fractures, an increased postoperative complication rate can be expected.

LEVEL OF EVIDENCE

Level of evidence IV.

No change in reoperation rates despite shifting treatment trends: a population-based study of 4,070 proximal humeral fractures

Background and purpose - Clear and acknowledged treatment algorithms for proximal humeral fractures (PHFs) are lacking. Nevertheless, a change in treatment trends, including a change towards more reversed shoulder arthroplasties (RSA), has been observed during recent years. We examined the effect of these changes on reoperation rates.Patients and methods - Between 2011 and 2017, 4,070 PHFs treated at Sahlgrenska University Hospital were registered prospectively in the Swedish Fracture Register (SFR) and followed up until 2019 (mean follow-up of 4.5 years). Data on all reoperations were gathered from the SFR and from medical records.Results - The majority of PHFs were treated non-surgically and the proportion increased slightly, but not statistically significantly, during the study period (from 76% to 79%). Of the surgically treated fractures, the proportion fixed with a plate decreased from 47% to 25%, while the use of RSA increased 9-fold (from 2.0% to 19%). 221 patients underwent 302 reoperations. For those primarily treated surgically, the reoperation rate was 17%. Among treatment modalities, plate fixation was associated with the highest reoperation rate (21%). Rate of reoperations remained constant during the study period, both for the entire study cohort and for the surgically treated patientsInterpretation - During the study period, treatment changes that are in accordance with recently published treatment recommendations were observed. However, these treatment changes did not affect the reoperation rate. Treatment with a plate, intramedullary nail, or hemiarthroplasty was associated with the highest reoperation rates. The fact that almost every 4th surgical procedure was a reoperation indicates a need for further improvement of modern treatment concepts for PHFs.

Rate of venous thromboembolism after surgical treatment of proximal humerus fractures

INTRODUCTION

The rate of venous thromboembolism following surgical treatment of proximal humerus fractures is not well established.

METHODS

A retrospective review of all patients undergoing surgical treatment for proximal humerus fractures from September 2011 to May 2017 was performed. Included patients received only mechanoprophylaxis using sequential compression devises. All patients had at least 6 months follow-up. The primary outcome of interest was the rate of postoperative DVT and PE.

RESULTS

131 patients underwent 139 surgeries for proximal humerus fracture. After exclusion criteria were applied, 92 patients who underwent 92 surgeries were included. There were 47 females and 45 males. Five (5.4%) were taking Aspirin 81 mg preoperatively. There were 76 cases of open reduction and internal fixation (ORIF), 8 cases of reverse total shoulder arthroplasty, 4 cases of hemiarthroplasty, 3 cases of closed reduction percutaneous pinning (CRPP), 1 case of open reduction without fixation. 53.3% of patients had one or more risk factors for VTE. There were no cases of fatal PE or DVT. There were two cases of symptomatic PE (2.2%) following one ORIF and one CRPP. There was one additional case of asymptomatic PE found incidentally after ORIF. Overall VTE rate was 3.3%. Fisher's exact test yielded that there was no significant association between the presence of VTE risk factors and prevalence of VTE postoperatively (p = 0.245).

CONCLUSIONS

The incidence of symptomatic VTE after surgery for proximal humerus fractures is low. Chemical VTE prophylaxis in patients after surgical fixation for proximal humerus fractures is not universally indicated. Selective prophylaxis for patients with systemic risk factors may be warranted.

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

OBJECTIVE

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

ORIF versus arthroplasty for open proximal humerus fractures: Nationwide Inpatient Sample data between 1998 and 2013

BACKGROUND

Limited data exists in analyzing open reduction and internal fixation (ORIF) and arthroplasty in the management of open proximal humerus fractures. We analyzed differences in hospital course between these procedures, patient demographics, complication rate, length of stay, hospital charges, and mortality rate.

MATERIALS AND METHODS

This is a retrospective review of the Nationwide Inpatient Sample database. ICD-9 codes identified patients hospitalized for open proximal humerus fractures from 1998 to 2013 who underwent ORIF or shoulder arthroplasty (hemi-, total, or reverse). Demographics and in-hospital complications were compared. Logistic regression controlling for age, gender, and Deyo index tested the impact of ORIF vs ARTH on any complications.

RESULTS

Seven hundred thirty patients were included (ORIF, n = 662 vs ARTH, n = 68). ORIF patients were younger (p < 0.001), more likely to be males (p < 0.001), and had a lower Deyo score (p = 0.012). Both groups had comparable complication rates (21.4% vs 18.0%, p = 0.535), lengths of stay (7.86 days vs 7.44 days, p = 0.833), hospital charges ($76,998 vs $64,133, p = 0.360), and mortality rates (0.2% vs 0%, p = 0.761). Type of surgery was not a predictor of any complications (OR = 0.67 [95% CI 0.33-1.35], p = 0.266), extended length of stay (OR = 1.01 [95% CI 0.58-1.78], p = 0.967), or high hospital charges (OR = 1.39 [95% CI 0.68-2.86], p = 0.366).

CONCLUSION

We revealed no differences in hospital course between ORIF and arthroplasty for management of open proximal humerus fractures. Although differences in demographics existed, no differences in complication rates, length of stay, hospital charges and mortality rates were noted. Future studies can evaluate the long-term outcomes of these procedures.

LEVEL OF EVIDENCE

Level III.

High risk for revision after shoulder arthroplasty for failed osteosynthesis of proximal humeral fractures

Background and purpose - It is unclear whether previous osteosynthesis is a risk factor for inferior outcome following shoulder arthroplasty for a proximal humeral fracture. We used data from the Danish Shoulder Arthroplasty Registry (DSR) to examine this question. Patients and methods - All 285 patients treated with a shoulder arthroplasty after failed osteosynthesis of a proximal humeral fracture reported to DSR from 2006 to 2013 were included. Each case was matched with 2 controls (570) treated with a primary shoulder arthroplasty for an acute proximal humeral fracture. Patient reported outcome was assessed using the Western Ontario Osteoarthritis of the Shoulder index (WOOS) and the relative risk of revision was reported. Results - The mean WOOS was 46 (SD 25) for a shoulder arthroplasty after failed osteosynthesis and 52 (27) after a primary shoulder arthroplasty. The relative risk of revision for a shoulder arthroplasty after failed osteosynthesis was 2 with a primary arthroplasty for fracture as reference. In a separate analysis of patients treated by locking plate the mean WOOS was 46 (24), with a relative risk of revision at 1.5 with a primary arthroplasty as reference. Interpretation - Compared with primary arthroplasty for proximal humeral fracture, we found an inferior patient-reported outcome and a substantial risk of revision for patients treated with a shoulder arthroplasty after failed osteosynthesis for a proximal humeral fracture. The risk and burdens of additional surgery should be accounted for when deciding on the primary surgical procedure.

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.

Failure and revision rates of proximal humeral fracture treatment with the use of a standardized treatment algorithm at a level-1 trauma center

BACKGROUND

The aims of this study were to evaluate treatment failure and revision rates of proximal humeral fracture (PHF) treatment with a standardized treatment algorithm within the reality of a level-1 trauma center and to identify predictors of subsequent surgery.

MATERIALS AND METHODS

The medical database of a level-1 trauma center was screened for all primary treatments of PHFs between January 2009 and June 2012. Medical records and imaging were analyzed to identify the fracture morphology, pre-existing diseases, revision surgeries and treatment failures (conversion to another treatment). The patients were asked about subsequent surgeries by phone. A functional outcome questionnaire was mailed to participating patients.

RESULTS

Follow-up data were available for 423 of 521 patients (312 females, 111 males). The mean age at the time of primary treatment was 68.3 years; mean follow-up was 24.6 ± 12.3 months. The overall rate of mandatory re-operations was 15.6%, including a failure rate of 8.3%; another 7.6% of patients had additional arthroscopic surgeries. Treatment with anatomic hemi-prostheses was associated with the highest re-operation rates, and lowest outcomes. Involvement of the medial calcar region, complex fracture morphologies, cigarette smoking and alcohol-abuse were predictors for subsequent surgery. Patients without subsequent surgery had significantly higher functional outcome scores than patients with additional surgery.

CONCLUSIONS

With the use of a standardized treatment algorithm no treatment modality was at significantly higher risk for having additional surgery. Complex fracture types, involvement of the medial calcar, cigarette-smoking and alcohol-abuse were associated with subsequent surgeries.

LEVEL OF EVIDENCE

Level IV case series.

Locking intramedullary nails versus locking plates for the treatment of proximal humerus fractures

INTRODUCTION

Proximal humerus fractures (PHF) are common fractures and are the third most common type of fractures among older adults. The most commonly used implants include the locking plate and the locking intramedullary nail. Areas covered: The aim of this study is to perform a literature review of biomechanical and clinical studies that compare the locking plate and intramedullary nail for PHF osteosynthesis. Expert commentary: Twelve clinical studies and seven biomechanical studies were identified that met this criterion. The findings of this review showed that intramedullary nailing and locking plate fixation yielded similar functional results, but with contrasting complication rates. The biomechanical studies showed controversial results, with most of the studies demonstrating better biomechanical properties for the intramedullary nail. Different types of intramedullary nail for PHF have different characteristics, with curvilinear nails presenting a higher risk of complications.

Early Hospital Readmission and Mortality Risk after Surgical Treatment of Proximal Humerus Fractures in a Community-Based Health Care Organization

CONTEXT

Surgical treatment for proximal humerus fractures has increased exponentially. Recent health care policies incentivize centers to reduce hospital readmission rates. Better understanding of risk factors for readmission and early mortality in this population will assist in identifying favorable risk-benefit patient profiles.

OBJECTIVE

To identify incidence and risk factors of 30-day hospital readmission rate and 1-year mortality rate after open surgery of proximal humerus fractures.

DESIGN

Retrospective cohort analysis from Kaiser Permanente Southern California Region database.

METHODS

Using International Classification of Diseases, Ninth Revision, diagnosis and procedure codes, all operative proximal humerus fractures were validated. Hospital readmission, one-year mortality, and demographic and medical data were collected. A logistic regression test was performed to assess potential risk factors for outcomes.

RESULTS

From 1387 surgical patients, the 30-day all-cause readmission rate was 5.6%. Forty percent of hospital read-missions were due to surgery-related reasons. Severe liver disease (odds ratio [OR], 3.48, 95% confidence interval [CI] = 1.42-8.55) and LACE (length of stay, acuity of admission, comorbidities, and number of Emergency Department visits in the previous 6 months) index score ≥ 10 (OR, 4.47, 95% CI = 2.54-7.86) were independent risk factors of readmission on multivariate analysis. The 1-year mortality rate was 4.86%. Multivariate analysis showed length of hospital stay (OR 1.11, 95% CI = 1.05-1.19), cancer (OR 3.38, 95% CI = 1.61-7.10), 30-day readmission (OR 3.31, 95% CI = 1.34-8.21), and Charlson comorbidity index greater than or equal to 4 (OR 13.94, 95% CI = 4.40-44.17) predicted higher mortality risk.

CONCLUSION

After open treatment of proximal humerus fractures, there was a 5.6% all-cause 30-day hospital readmission rate. Surgical complications accounted for 40% of read-missions. Severe liver disease and LACE score correlated best with postoperative 30-day readmission risk. Length of hospital stay, preexisting cancer, 30-day readmission, and Charlson comorbidity index were predictive of 1-year mortality.

Hemiarthroplasty versus reverse shoulder arthroplasty in 4-part displaced fractures of the proximal humerus: Multicenter retrospective study

INTRODUCTION

Complex 4-part fractures of the proximal humerus are one of the most difficult fractures to manage. For several years, reverse total arthroplasty (RSA) has been proposed as an alternative to hemiarthroplasty (HA) when internal fixation is insufficient. The goal of this study was to compare the short and intermediate term results of these 2 different types of arthroplasty.

MATERIALS AND METHODS

In a retrospective, multicenter study, 57 HA and 41 RSA were reviewed after a follow-up of at least 2 years. The clinical evaluation was based on the absolute and adjusted Constant scores, Simple shoulder value (SSV) and the quick-DASH scores. The radiological assessment included standard radiological tests.

RESULTS

After a mean follow-up of 39 months, the RSA group had a significantly higher adjusted Constant score than the HA group (83% vs 73%, respectively P=0.02). However, there was no significant difference in the absolute Constant score, the quick-DASH or the SSV scores. Active anterior elevation was better in the RSA group, while internal rotation was better in the HA group (130° vs 112°, P=0.01; sacrum vs L3, P=0.03). There was no significant difference in external rotation (28° vs 23°, P=0.31). The rate of complications was higher in the HA group than in the RSA group (24% vs 10%, P=0.01). The radiological rate of union of the greater tuberosity was similar in both groups (70%) and scapular notching was found in 23% of the RSA group.

CONCLUSION

The short and intermediate term clinical outcomes are better with RSA than with HA. The complication rate is higher with HA. Nevertheless, scapular notching occurred in more than 20% of patients with RSA, suggesting that care should be taken when using this prosthesis in young, active patients.

Open reduction internal fixation has fewer short-term complications than shoulder arthroplasty for proximal humeral fractures

BACKGROUND

Open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and anatomic or reverse total shoulder arthroplasty (TSA/RTSA) are surgical treatment options for proximal humeral fractures (PHFx). Little is known about comparative complication rates. We aimed to determine whether ORIF for PHFx has fewer 30-day complications than HA and TSA/RTSA and to define independent risk factors for 30-day complications.

METHODS

Patients who underwent ORIF, HA, or TSA/RTSA for PHFx between 2006 and 2013 were identified from the National Surgical Quality Improvement Program database. Potential patient and surgical risk factors and 30-day postoperative complications were extracted. Univariate and multivariate analyses were conducted.

RESULTS

We identified 1791 patients (1262 ORIF, 404 HA, and 125 TSA/RTSA). The overall complication rate was 13.0% in ORIF, 22.0% in HA, and 23.2% in TSA/RTSA (P < .001), driven primarily by rates of blood transfusion. Multivariate analyses demonstrated ORIF was an independent protective factor against minor complications (P = .009) and overall complications (P = .028) but not against major complications (P = .351). Risk factors for overall complications included preoperative sepsis (P < .001), higher American Society of Anesthesiologists Physical Status Classification (P < .001), dependent functional status (P = .002), transfusion of at least 5 units in the 72 hours before surgery (P = .002), longer operative time (P = .003), and a history of chronic obstructive pulmonary disease (P = .028).

CONCLUSIONS

After adjusting for patient factors, ORIF for PHFx remains an independent protective factor against overall complications and minor complications compared with HA and TSA/RTSA, primarily due to lower rates of blood transfusion. Patient comorbidities play a larger role than the procedure selected in predicting short-term complications.

A Population-Based 16-Year Study on the Risk Factors of Surgical Site Infection in Patients after Bone Grafting: A Cross-Sectional Study in Taiwan

Bone grafting is a commonly used orthopedic surgical procedure that will provide bone formation in bone defects or regions of defective bone healing. A major complication following bone grafting is a postoperative recipient graft site infection that is associated with substantial mortality and increased use of medical resources. The purpose of the study was to identify the risk factors associated with infection after bone-grafting surgery.Data from 1,303,347 patients listed in the Taiwan National Health Insurance Research Database (NHIRD) and admitted to hospitals from 1997 through 2012 who underwent primary bone grafting (mean age: 46.57 years old; mean length of hospital stay: 8.04 days) were analyzed. The incidence of infection by age, hospital stay, gender, income, chronic disease (tuberculosis [TB]; diabetes mellitus [DM]; acquired immunodeficiency syndrome [AIDS]), fracture complications (nonunion; delayed union fracture), types of graft and hospital was evaluated.Three percent of the patients developed a postoperative recipient graft site infection. Multivariable analysis revealed that patients were more likely to develop a post bone-grafting surgery infection if they were older, had a longer hospital stay, were male, had a lower income, or had comorbid TB, DM, or AIDS. Patients were more likely to develop an infection if they had a nonunion, an alloplast graft, or treated in a local clinic.Our findings should provide a clinically relevant reference for surgeons who perform bone grafting. Patients should be informed of the potential risks.

A Comparison of the Charlson and Elixhauser Comorbidity Measures to Predict Inpatient Mortality After Proximal Humerus Fracture

OBJECTIVES

Proximal humerus fractures are very common in infirm elderly patients and are associated with appreciable inpatient mortality. We sought to compare the discriminative ability of the Charlson and Elixhauser comorbidity measures for predicting inpatient mortality after proximal humerus fractures.

METHODS

Data from the Nationwide Inpatient Sample (2002-2011) were obtained. We constructed 2 main multivariable logistic regression models, with inpatient mortality as the dependent variable and 1 of the 2 comorbidity scores, as well as age and sex, as independent variables. A base model that contained only age and sex was also evaluated. The predictive performance of the Charlson and Elixhauser comorbidity measures was assessed and compared using the area under the receiver operating characteristic curve (AUC) derived from these regression models.

RESULTS

Elixhauser comorbidity adjustment provided better discrimination of inpatient mortality [AUC = 0.840, 95% confidence interval (CI), 0.828-0.853] than the Charlson model (AUC = 0.786, 95% CI, 0.771-0.801) and the base model without comorbidity adjustment (AUC = 0.722, 95% CI, 0.705-0.740). In terms of relative improvement in predictive ability, the Elixhauser score performed 46% better than the Charlson score.

CONCLUSIONS

Given that inadequate comorbidity risk adjustment can unfairly penalize hospitals and surgeons that care for a disproportionate share of infirm and sick patients, wider adoption of the Elixhauser measure for mortality prediction after proximal humerus fracture-and perhaps other musculoskeletal injuries-merits to be considered.