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

Predicting Proximal Humerus Fracture Mechanical Complications: Are Computed Tomography Hounsfield Units the Answer?

INTRODUCTION

The purpose was to determine whether computed tomography (CT) Hounsfield units (HU) as a proxy for bone quality can predict postoperative complications following surgical treatment of proximal humerus fractures.

METHODS

Sixty-six patients with 2-, 3-, or 4-part proximal humerus fractures who underwent surgical fixation at single institution and had complete radiographic data available were included. Radiographic measurements included the deltoid tuberosity index (DTI) on preoperative anterior-posterior shoulder radiographs, and the HU value from the surgical proximal humerus was determined by measuring the humeral head at the midaxial/coronal/sagittal CT image using a circle-type region of interest (≥35 mm2). Postoperative complications recorded were implant failure, development of osteonecrosis, nonunion, and acute periprosthetic fracture. Patients with and without complications were statistically compared, and binary logistic regression was performed to determine whether preoperative proximal humerus CT HU were predictive of complications.

RESULTS

Eight patients (12.1%) developed 11 overall complications, with three patients experiencing multiple complications each. Complications included osteonecrosis (4), implant failure (5), nonunion (1), and acute periprosthetic fracture (1). No difference was observed in demographics or Neer or AO/OTA classification between those with and without complications. Patients with complications had markedly lower DTI and overall HU as well as HU in the coronal and sagittal planes. Regression analysis for average DTI demonstrated a higher DTI and had a 10 times decreased risk of complication (P = 0.040, odds ratio = -10.5, 95% confidence interval, 0.000 to 0.616). Regression analysis for average total HU also found a higher HU associated with a decreased risk of complications (P = 0.034, odds ratio = -0.020, 95% confidence interval, 0.980 to 0.962). Logistic regression analysis, including age, age-adjusted Charlson Comorbidity Index, mean DTI, and mean total HU, only found mean total HU to be notable within the model.

DISCUSSION

CT HU may identify patients with poorer bone quality and thus help predict postoperative complications.

LEVEL OF EVIDENCE

Diagnostic Level III.

Reverse shoulder arthroplasty or nothing for patients with displaced proximal humeral fractures: a randomized controlled trial

BACKGROUND

The benefits of reverse shoulder arthroplasty compared to nonoperative treatment for patients presenting with complex proximal fractures have been rarely explored. The aim of this prospective study was to compare the functional results of reverse shoulder arthroplasty with those of nonsurgical treatment in patients with displaced proximal humeral fractures.

METHODS

A multicentric prospective randomized control trial of patients older than 70 years who sustained an acute proximal humeral fracture (3 or 4 parts), with less than 3 weeks of evolution, and had no previous condition or surgery on the affected shoulder was conducted. Patients were randomly assigned to the intervention group (implantation of a reverse shoulder arthroplasty and tuberosities reattachment) or the control group (nonoperative treatment). Functional outcome was assessed using the Constant-Murley score (CMS) at the 1-year follow-up. Complications and reinterventions were considered secondary outcomes. The power of the study relied on the inclusion of 81 patients to recognize a statistically significant difference of 10 points between CMS scores in the groups. Analysis was performed based on the intention to treat principle.

RESULTS

Eighty-one patients were randomized to surgical treatment or nonoperative treatment, while 66 patients completed the 1-year follow-up evaluation. There was no significant difference between the groups in terms of age (76.1 yo vs. 77.43 yo, P = .43), sex (81.08% women in the surgical group vs. 84.09% in the nonoperative group, P = .72), or type of fracture according to Neer's classification system (P = .06). At the 1-year follow-up, the group assigned to undergo the intervention had better functional outcomes than the nonoperative treatment group (mean CMS; 61.24, SD: 13.33 vs. mean CMS: 52.44, SD: 16.22, P: .02), with a mean difference of 8.84 points, 95% CI (1.57, 16.11). Two patients in the intervention group (6.5%) suffered major complications (periprosthetic joint infection and axillary nerve palsy). No major complications were observed in the nonoperative group. One patient in the intervention group underwent secondary surgery for a periprosthetic joint infection.

CONCLUSIONS

Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture. The difference in CMS is close to the clinically significant thresholds, and some harms are associated with the operative treatment.

Reverse Shoulder Arthroplasty Is Superior to Plate Fixation for Displaced Proximal Humeral Fractures in the Elderly: Five-Year Follow-up of the DelPhi Randomized Controlled Trial

LEVEL OF EVIDENCE

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

Comparison between arthroplasty and non-operative treatment for proximal humeral fractures: a systematic review and meta-analysis

Background

The clinical efficacy of reverse shoulder arthroplasty (RSA), hemiarthroplasty (HA), and non-surgical management in the treatment of proximal humeral fractures (PHFs) is inconclusive. This systematic review and meta-analysis compared the clinical outcomes of arthroplasty and non-surgical management of PHFs.

Methods

The databases of PubMed, Embase, Web of Science, and Cochrane Library were searched on 5 May 2023 for studies comparing arthroplasty and non-surgical treatment of PHFs. Both randomized controlled trials (RCTs) and non-randomized controlled trials (nRCTs), were included. Standard methodological quality assessments were conducted for both types of studies. The primary outcome was the Constant-Murley Score (CMS) after surgical or non-surgical treatment. Secondary study outcomes included the visual analog scale (VAS), range of motion, and complications. All functional scores and complications were subjected to subgroup and sensitivity analyses.

Results

A total of four RCTs and six nRCTs were included in this study, which provided 508 patients in total for meta-analysis: 238 treated with arthroplasty and 270 treated non-surgically, of which 83 were treated with HA and 155 with RSA. All relevant information was collected, including functional scores, VAS, range of motion, and complications. The study found no significant difference in functional outcomes (mean difference, 2.82; 95% confidence interval, -0.49 to 6.14; P = 0.10; I 2 = 77%) and complications (mean difference, 1.08; 95% confidence interval, 0.51-2.25; P = 0.85; I 2 = 47%) between arthroplasty and non-surgical treatment. Both RCTs and nRCTs showed the same results. However, VAS scores were significantly lower in surgical treatment compared to non-surgical treatment. Subgroup and sensitivity analyses showed that RSA could achieve better functional scores than non-surgical treatment (mean difference, 6.00; 95% confidence interval, 1.97-10.03; P = 0.004; I 2 = 0%), while the results for HA were not significant (P > 0.05).

Conclusion

There were no significant differences in complications between arthroplasty and non-surgical treatment for PHFs. RSA could achieve better functional results than non-surgical treatment, while HA could only achieve better forward flexion.

Long-term survival of resurfacing humeral hemiarthroplasty

INTRODUCTION

The indication for shoulder resurfacing arthroplasty is controversial, and survival of these implants is somewhat inconsistent. This study aimed to evaluate the long-term survivorship of resurfacing humeral head implants (RHHIs) and determine risk factors for complications and revisions.

MATERIALS AND METHODS

This retrospective cohort study consisted of 275 cases and two types of RHHIs. The survival rate was evaluated using the Kaplan-Meier method and Cox regression for risk factor analysis. Demographic factors were studied, and the change in the humerus centre of rotation (COR) was measured.

RESULTS

The mean follow-up time was 8.7 years (SD 2.7 months, range 2.8-15.9 years). The mean age of the patients was 67.6 years (SD 9.6, range 33.5-84.9). Ten-year cumulative RHHI survival was 94.1%. The cumulative estimate without any complication was 98.9% at 5 years, 80.0% at 10 years and at 15 years it was 61.5%. The most common complication was persistent pain in 13.8% of the RHHIs. The risk factors for complications and revisions were implant type, preoperative conditions and change of COR > 5 mm.

CONCLUSIONS

RRHIs showed excellent long-term survival, but many complications were found. The most common complication was persistent pain, which seemed to be caused by a change of COR and was more related to one type of implant.

Time trends in proximal humeral fractures from 1944 to 2020 - A cohort study in Malmö, Sweden

BACKGROUND

Most studies infer increasing incidence of proximal humeral fractures (PHF) from the 1950´s until the 1990´s. Recent time trends are less clear.

OBJECTIVES

Our primary objective was to identify time trends in the age- and sex-adjusted adult incidence of PHF in Malmö, Sweden, from year 1944 until 2020. Our secondary objectives were to describe the variation in incidence according to age, the monthly distribution, and to compare data from the two most recent decades with earlier.

STUDY DESIGN AND METHODS

Malmö has one emergency hospital where acute fractures are treated. We identified PHF in adult patients (≥ 18 years) by reviewing relevant radiology examinations during 17 sample years from year 1944 to 2020. We used jointpoint analyses to estimate time trends.

RESULTS

We identified 3 031 PHF during the study period (3 231 161 person years), 73% were sustained by women with mean age of 69 years (mean age in men 59). Joinpoint analyses indicated an increase in the age- and sex-adjusted incidence of PHF from year 1944 (52 per 100 000 person years) until 1977 (120 per 100 000) and thereafter a decrease until 2020 (85 per 100 000). A seasonal variation with more fractures during winter months, was apparent in earlier but not recent decades.

CONCLUSIONS

The age- and sex-adjusted incidence of PHF increased in Malmö, Sweden, from the 1940´s until year 1977 and thereafter decreased until 2020. More fractures were seen during winter months in earlier but not recent decades.

Fibula allograft in complex three-part and four-part proximal humeral fractures in active patients, a matched case-control study

Background

About 20% of proximal humerus fractures (PHFs) are unstable and/or markedly displaced and therefore require surgery. Locking plate fixation after anatomical reduction has become the current treatment of choice for these fractures in the active population. However, studies have shown complication rates up to 36%, such as loss of reduction and avascular necrosis. To date, data from literature are inconclusive on outcomes following the use of an intramedullary fibula allograft in PHFs, possibly due to the case mix. It is hypothesized that the use of a fibula allograft is beneficial to prevent secondary displacement of the fracture in cases where the medial hinge is markedly displaced and unstable, resulting in better clinical and patient reported outcomes.

Methods

In this multicenter matched cohort study, patients with an unstable, displaced PHF, including anatomic neck fractures and significantly displaced surgical neck fractures, were included. Patients that were treated with a locking plate augmented with a fibula allograft were matched to patients who had undergone locking plate reconstruction without the allograft. The matches were made based on fracture characteristics, age, and performance status. Functional outcomes, Patient Reported Outcome Measures, complications, and radiographic results were compared.

Results

Twelve patients with fibula allograft augmented osteosyntheses were included and matched to 12 control patients. The mean age was 58 years in the fibula allograft group compared to 62 years in the control group. Minimum follow-up was 12 months. Disability of the Arm Shoulder and Hand score, Constant Shoulder score, abduction, and external rotation were significantly better in the fibula allograft group (17.4 ± 8.6 vs. 26.1 ± 19.2, P = .048; 16.5 ± 11.5 vs. 19.8 ± 16.5 P = .040; mean 127° ± 38° vs. mean 92° ± 49° P = -.045; 50° ± 21° vs. mean 26° ± 23°, P = .004). There was no statistically significant difference in the Oxford Shoulder score between groups (P = .105). The Visual Analog Scale was not significantly different between groups (3.1 ± 1.8 vs. 1.6 ± 1.9, P = .439). Radiographic union was reached in 11 patients of the fibula allograft group compared to 8 in the control group (P = .317). The complication rate was twice as high in the control group (3 vs. 7).

Conclusion

Additional support of the medial hinge in unstable PHFs with a locking plate in combination with a fibula allograft appears to create a more stable construct without compromising the viability of the articular surface of the head. The use of a fibula allograft in selected complex cases could therefore result in better clinical outcomes with lower complication rates.

Unchanged incidence but change in treatment trends from 1996 to 2018: 23,718 humeral shaft fractures from the Danish National Patient Registry

BACKGROUND AND PURPOSE

Humeral shaft fractures (HSF) can be treated surgically or non-surgically. National trends and distributions are sparsely reported. We present the temporal trends in epidemiology of adult HSF in Denmark, with the primary aim of reporting HSF incidences, and the secondary aim of reporting on the primary treatment management.

PATIENTS AND METHODS

The diagnosis (International Classification of Diseases Version 10 [ICD-10]: S42.3) and surgical procedure codes for HSF were obtained from the Danish National Patient Registry (DNPR) covering 1996-2018. The diagnosis code for HSF is validated in the DNPR with a positive predictive value of 89%. Patients aged 18 years and above were included. Surgical treatment was defined as a diagnosis of HSF combined with a surgical procedure within 3 weeks of injury. Cases without relevant registered procedures within 3 weeks were defined as nonsurgical treatment cases.

RESULTS

23,718 HSF (62% female) were identified in the DNPR. The overall mean incidence was 25/100,000/year and was stable over 23 years. The population above 50 years accounted for 78% of all HSF. Non-surgical treatment accounted for 87% of treatments and was stable during the study period. Temporal changes were observed regarding surgical procedures; intramedullary nailing decreased from 57% to 26% and plate osteosynthesis increased from 12% to 69%.

CONCLUSION

The overall incidence for HSF remained stable from 1996 to 2018. Most cases were females aged 50 years and above. The preferred primary treatment for HSF was non-surgical for all ages. Plate osteosynthesis became more popular than intramedullary nailing over the study period.

Double Plating for Complex Proximal Humeral Fractures: Clinical and Radiological Outcomes

Double plating for proximal humeral fractures (PHF) is an option to increase the primary fixation stability. Clinical data is missing for assessment of clinical and radiological outcome, as well as complications. We retrospectively examined 35 patients with unilateral PHF, who were treated with double plating for PHF between 2013 and 2019. The mean age was 59.5 ± 12 years and the leading fracture type was a varus dislocation (Resch type IV in 55.3%). A head-split was present in 22.9% of the cases. The primary outcome measurement was the radiological neck shaft angle (NSA). The radiological follow-up was 21 ± 16.6 months and the NSA did not differ between the intraoperative and follow-up time point (131.5 ± 6.9° vs. 136.6 ± 13.7°; p = 0.267). The clinical follow-up was 29.5 ± 15.3 months. The Constant-score was 78.5 ± 17 points, the simple-shoulder-test (SST) was 9.3 ± 3.2 points and the subjective shoulder value (SSV) was 78.8 ± 19.5%. The over-all complication rate was 31.4%, and without stiffness 14.3%. An avascular necrosis occurred in two patients (5.7%). In conclusion, this study shows good radiological and functional outcomes after double plating of highly complex proximal humeral fractures, while the complication rate is comparable to the literature. Double plating is a viable option especially for younger patients with complex fractures as a potential alternative to fracture arthroplasty.