Management of malunion of the proximal humerus: current concepts

Computed tomography improves the diagnostic accuracy but not the interobserver reliability of the Boileau classification of proximal humerus fracture sequelae

Background

The aim of this study was to investigate the impact of computed tomography on the reliability of Boileau classification for proximal humerus fracture sequelae.

Methods

A prospective study was designed using STARD guidelines. We included all patients diagnosed with proximal humerus fracture sequelae who underwent surgery at our institution between 2017 and 2021. Preoperative radiographs and computed tomography scans were reviewed by three independent observers. Intra- and inter-observer reliability and the diagnostic accuracy of radiographs and computed tomography scans in detecting chronic dislocation, nonunion, and severe greater tuberosity dislocation were assessed.

Results

Fifty-two patients were included in the study. The overall interobserver agreement was low on both radiographs and computed tomography scans. On radiographic images, we found a sensitivity of 97%, 88.9%, and 84.1%, and a specificity of 58.3%, 40%, and 53.3% to detect chronic dislocation, nonunion, and greater tuberosity dislocation, respectively. On computed tomography scans we reported a sensitivity of 100%, 96.8%, and 93.7%, and a specificity of 91.7%, 86.7%, and 93.3% to detect chronic dislocation, nonunion, and greater tuberosity dislocation, respectively.

Discussion

Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae. However, even using a three-dimensional evaluation of the deformity, the Boileau classification had a poor interobserver reliability.

Level of Evidence

I. Testing previously developed diagnostic criteria in a consecutive series of patients and a universally applied "gold standard."

Functional outcomes of reverse total shoulder arthroplasty in Boileau class 1 and class 2 proximal humeral fracture sequelae: A meta-analysis and systematic review

Background

Reverse total shoulder arthroplasty (RTSA) is an increasingly popular salvage treatment option for proximal humeral fracture (PHF) sequelae. This meta-analysis aimed to conduct a pooled analysis of functional outcomes of RTSA in PHF sequelae, with subgroup analysis comparing between intracapsular (Class 1) and extracapsular (Class 2) PHF sequelae.

Methods

A multi-database search (PubMed, OVID, EMBASE) was performed according to PRISMA guidelines on 27th July 2020. Data from all published literature meeting inclusion criteria were extracted and analysed.

Findings

Eleven studies were included, comprising 359 shoulders (167 Class 1 and 192 Class 2). The mean age was 68.2 years, and the mean time between injury and surgery was 49 months, (1-516 months). Constant score and forward flexion improved by 31.8 (95%CI: 30.5-33.1, p < 0.001) and 60o (95%CI: 58o-62o, p < 0.001) respectively between pre-operative and post-operative values for both groups. Constant scores were better in Class 1 patients (MD = 3.60, 95%CI: 1.0-6.2, p < 0.001) pre-operatively and post-operatively (MD = 7.4, 95%CI: 5.8-9.0, p < 0.001). Forward flexion was significantly better in Class 1 patients (MD = 13o, 95%CI: 7o-17o, p < 0.001) pre-operatively, but was slightly better in Class 2 patients post-operatively (MD = 7o, 95%CI: 4o-10o, p < 0.001). Overall complication rate was 16.8%.

Conclusion

Salvage RTSA is effective for PHF sequelae, with multiple factors contributing to the high complication rate.

Not All Proximal Humerus Fractures Do Well Without Surgery: Anterior Translation Predicts the Need for Surgery

OBJECTIVES

To evaluate the effect of translation on a large series of low-energy proximal humerus fractures initially treated nonoperatively.

DESIGN

Retrospective multicenter analysis.

SETTING

Five level-one trauma centers.

PATIENTS/PARTICIPANTS

Two hundred ten patients (152 F; 58 M), average age 64, with 112 left- and 98 right-sided low-energy proximal humerus fractures (OTA/AO 11-A-C).

INTERVENTION

All patients were initially treated nonoperatively and were followed for an average of 231 days. Radiographic translation in the sagittal and coronal planes was measured. Patients with anterior translation were compared with those with posterior or no translation. Patients with ≥80% anterior humeral translation were compared with those with <80% anterior translation, including those with no or posterior translation.

MAIN OUTCOMES

The primary outcome was failure of nonoperative treatment resulting in surgery and the secondary outcome was symptomatic malunion.

RESULTS

Nine patients (4%) had surgery, 8 for nonunion and 1 for malunion. All 9 patients (100%) had anterior translation. Anterior translation compared with posterior or no sagittal plane translation was associated with failure of nonoperative management requiring surgery ( P = 0.012). In addition, of those with anterior translation, having ≥80% anterior translation compared with <80% was also associated with surgery ( P = 0.001). Finally, 26 patients were diagnosed with symptomatic malunion, of whom translation was anterior in 24 and posterior in 2 ( P = 0.0001).

CONCLUSIONS

In a multicenter series of proximal humerus fractures, anterior translation of >80% was associated with failure of nonoperative care resulting in nonunion, symptomatic malunion, and potential surgery.

LEVEL OF EVIDENCE

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

Proximal humerus fracture sequelae: are corrective osteotomies still a taboo? The role of three-dimensional preoperative planning and patient-specific surgical guides for proximal humerus corrective osteotomy in combination with reverse shoulder arthroplasty

Background

Symptomatic proximal humeral fracture sequelae (PHFS) represent a surgical challenge due to the altered bone and soft tissue morphology. The purpose of this study was to report the outcome of Multiplanar Corrective Humeral Osteotomies (MCHOs) in combination with reverse total shoulder arthroplasty (rTSA) performed following a three-dimensional (3D) preoperative planning and using a 3D-printed patient-specific surgical instrumentation (PSI) in type 1C, 1D, and 4 PHFS.

Methods

In this prospective monocentric study, we enrolled patients affected by symptomatic PHFS type 1C, 1D, or 4 of Boileau's classification, treated between 2018 and 2019 with rTSA associated to MCHO and followed-up at 12 and 24 mo. The preoperative and postoperative Constant Score (CS), visual analog scale, and Disabilities of the Arm, Shoulder and Hand (DASH) score were recorded. All patients underwent a preoperative computed tomography, then a dedicated software was used to run a segmentation algorithm on computed tomography images. Metaphyseal bone cuts were virtually performed before surgery in all patients, and a 3D-printed PSI was used to reproduce the planned osteotomies in vivo.

Results

Twenty patients completed a 2-y follow-up. The mean (± standard deviation) CS, visual analog scale, and DASH values improve from 24.3 (± 8.8), 6.5 (± 1.3), 60.7 (± 9.6) preoperatively, to 67.7 (± 11.4), 1.6 (± 0.8), 24.1 (± 13.1) points after surgery, respectively. The minimally clinical important difference for CS and DASH score was achieved in 95% of patients. No major complication was observed. One patient showed an unexplained worsening of clinical scores between the 12 and the 24-mo follow-up, while in one patient bone resorption of the greater tuberosity was observed on radiographs at 2 y, with no clinical impact.

Conclusion

The combination of preoperative 3D planning and intraoperative use of 3D-printed PSI to perform MCHO as concurrent procedure in the context of rTSA in the treatment of Boileau type 1C, 1D, and 4 PHFS may lead to a satisfactory clinical outcome at 2 y of follow-up.

[Comparison of locking plate and intramedullary nail in treatment of Neer two- and three-part fractures of the proximal humerus in the elderly]

OBJECTIVE

To compare the effectiveness of locking plate and intramedullary nail in treatment of Neer two- and three-part fractures of the proximal humerus in the elderly.

METHODS

A retrospective analysis was conducted on 86 elderly patients with Neer two- and three-part fractures of the proximal humerus met the selection criteria between January 2015 and December 2018. Forty-six patients were treated with locking plate fixation (locking plate group), and 40 patients with intramedullary nail fixation (intramedullary nail group). There was no significant difference in gender, age, cause of injury, fracture side and type, time from injury to operation, and comorbidities between the two groups ( P>0.05). Visual analogue scale (VAS) score, American Shoulder and Elbow Surgery (ASES) score, Constant-Murley score, and shoulder range of motion (forward flexion, abduction, and external rotation) were compared between the two groups. X-ray films were taken to assess the fracture healing, and the neck-shaft angle was measured at 2 days after operation and at last follow-up, and the difference between the two time points was calculated.

RESULTS

Patients in both groups were followed up 18-40 months, with an average of 30.4 months. There was no significant difference in follow-up time between the two groups ( t=-0.986, P=0.327). X-ray films reexamination showed that the fractures of two groups healed, and the healing time was (11.3±2.1) weeks in locking plate group and (10.3±2.0) weeks in intramedullary nail group, which had significant difference between the two groups ( t=2.250, P=0.027). The difference of neck-shaft angle was (7.63±7.01)° in locking plate group and (2.85±2.82)° in intramedullary nail group, which had significant difference between the two groups ( t=4.032, P<0.001). There was no significant difference in Constant-Murley score, ASES score, VAS score, and shoulder range of motion between the two groups at last follow-up ( P>0.05). Complications occurred in 13 cases (28.3%) of locking plate group and in 4 cases (10.0%) of intramedullary nail group, and the difference between the two groups was significant ( χ ²=4.498, P=0.034).

CONCLUSION

Both locking plates and intramedullary nails can be used for the treatment of Neer two- and three-part fractures of the proximal humerus in the elderly. The intramedullary nail fixation surgery is more minimally invasive, which has fewer postoperative complications and faster fracture healing.

Management of Posttraumatic Avascular Necrosis of the Proximal Humerus

The etiology of avascular necrosis (AVN) of the proximal humerus can be classified as idiopathic or posttraumatic, the latter being mainly due to proximal humerus fractures. Evidence suggests that posttraumatic AVN may require surgical intervention more often than idiopathic AVN of the proximal humerus. This article provides a comprehensive review of the management of posttraumatic AVN of the proximal humerus. Early stage AVN (stages 1 to 3) is commonly treated with nonoperative intervention or core decompression of the humeral head, whereas later stage disease (stages 4 and 5) may require hemiarthroplasty or total shoulder arthroplasty to restore function. [Orthopedics. 2021;44(6):367-375.].

Patient risk factors for acromial stress fractures after reverse shoulder arthroplasty: a multicenter study

BACKGROUND

Despite the growing recognition of acromial stress fractures (ASFs) after reverse total shoulder arthroplasty (RTSA), most of the current data are derived from single-center studies with limited generalizability. This multicenter study investigated the incidence of ASFs after RTSA and identified preoperative patient characteristics associated with their occurrence.

METHODS

Using 2 institutional registries from different regions of the United States, we identified 1479 patients undergoing either primary or revision RTSA between 2013 and 2018 with minimum 3-month follow-up. ASFs were defined as radiographic evidence of an acromial or scapular spine fracture with clinical symptoms (eg, tenderness over the acromion or scapular spine). Multivariable logistic regression was performed to identify preoperative patient factors associated with the development of ASFs.

RESULTS

Overall, 54 (3.7%) patients were diagnosed with an ASF after RTSA. Patient-related factors independently associated with the development of an ASF included female sex (odds ratio [OR], 2.21 reference: male; 95% confidence interval [CI], 1.03-4.74; P < .05), rheumatoid arthritis (OR, 2.30; 95% CI, 1.02-5.16; P < .05), osteoporosis (OR, 2.55; 95% CI, 1.24-5.21; P < .05), a diagnosis of degenerative joint disease with rotator cuff tear (OR, 4.74 reference: degenerative joint disease without rotator cuff tear; 95% CI, 1.84-12.23; P < .05), and fracture malunion/nonunion (OR, 5.21; 95% CI, 1.20-22.76; P < .05).

CONCLUSIONS

The non-negligible percentage of ASFs that occur after RTSA is associated with the diagnoses of rotator cuff dysfunction and chronic fracture sequelae in female patients with suboptimal bone health. This information can be used to counsel patients and set expectations about potential setbacks in recovery.

Stemless Total Shoulder Arthroplasty for a 4-Part Proximal Humerus Malunion and Post-traumatic Arthritis: A Case Report

CASE

We present a 62-year-old left-hand-dominant woman with history of renal failure, osteoporosis, and 4-part proximal humerus fracture malunion with subsequent post-traumatic arthritis of the left glenohumeral joint. After conservative treatments failed to relieve her symptoms, the patient underwent stemless total shoulder arthroplasty (TSA) because of concerns that her proximal humerus could not accommodate a stemmed implant. At 2 and a half-years postoperative, the patient demonstrated significant improvement of symptoms without signs of radiographic loosening.

CONCLUSION

In the setting of proximal humerus malunion with post-traumatic arthritis, clinical improvement without implant loosening can be achieved with stemless TSA, even in the setting of compromised bone quality.

Ultrasound-guided Arthroscopic Tuberoplasty for Greater Tuberosity Malunion: A Case Report

Background:

Greater Tuberosity (GT) malunion can lead to impingement against the acromion, resulting in pain, stiffness, and weakness of the rotator cuff. For patients with lesser degrees of displacement, partial removal of the GT with rotator cuff repair (tuberoplasty) under fluoroscopic guidance is considered.

Case report:

A sixty-five year old female fell from a standing height and suffered a minimally displaced isolated GT fracture. She was conservatively managed for four months and referred to our institution due to persisting pain and stiffness. The shoulder motion was severely restricted (anterior elevation: 90°, lateral elevation: 45°, external rotation with the arm at side: 25°, hand behind back: 4th lumber vertebrae) and pain aggravated especially when laterally elevated. Plain radiography and computed tomography showed small superiorly malunited GT and magnetic resonance imaging showed no rotator cuff pathology. Ultrasound images showed impingement of the GT against the acromion when laterally elevated. Arthroscopic excision of the malunited GT and rotator cuff repair along with capsular release and acromioplasty was performed under ultrasound guidance. The ultrasound images were simultaneously delineated to the arthroscopic monitor. Dynamic evaluation of the reshaped GT passing under the acromion was possible.

Conclusion:

Intraoperative use of ultrasound during arthroscopic tuberoplasty offers advantages over fluoroscopic guidance concerning control of the amount of bone resection and dynamic evaluation between the GT and the acromion in addition to the problems of radiation and space-occupying devices.

SECEC Grammont Award 2017: the prejudicial effect of greater tuberosity osteotomy or excision in reverse shoulder arthroplasty for fracture sequelae

HYPOTHESIS

The aim was to evaluate risk factors for complications, revision, and mid- to long-term outcomes after reverse shoulder arthroplasty (RSA) implanted for proximal humeral fracture sequelae (PHFS).

METHODS

The radiographs of 98 patients (mean age, 68 years) who underwent RSA for the treatment of PHFS were reviewed at a minimum 5-year follow-up. PHFS were divided into 4 types according to the Boileau classification: type 1 (46 cases), type 2 (6 cases), type 3 (12 cases), and type 4 (34 cases). The tuberosities underwent osteotomy in 28 cases and excision in 12 (all type 3 or 4 PHFS). The mean follow-up period was 8.4 years (range, 5-14 years).

RESULTS

The functional results and rate of RSA survival without revision (85% vs. 100% at 10 years, P = .007) were significantly lower for types 3 and 4 vs. types 1 and 2. Overall, our findings showed that RSA for PHFS is not the panacea that surgeons once believed: At a mean follow-up of 8.5 years (range, 5-14 years), 59% of the patients in our series had fair or poor results. Patients who underwent tuberosity osteotomy or excision had lower functional results (adjusted Constant score, 69% vs. 88%; P < .001), more postoperative complications (32% vs. 9%, P = .003), and a higher revision rate (15% vs. 2%, P = .017). Patients who underwent tuberosity osteotomy or excision at the time of RSA were at risk of postoperative prosthetic instability and humeral stem loosening. The absence of the greater tuberosity at last radiographic follow-up was predictive of higher rates of complications and revisions, as well as a poorer final outcome. Previous fracture fixation was associated with a higher rate of complete tuberosity resorption (56% vs. 33%, P = .026) and with higher rates of postoperative complications (27% vs. 13%, P = .099) and reinterventions (17% vs. 2%, P = .018).

CONCLUSION

The functional results and rates of complications and revision depend on the type of fracture sequelae and tuberosity management. Patients with more severe (type 3 and 4) fracture sequelae who undergo tuberosity osteotomy or excision are at risk of having a poorer functional result and higher rates of complications and revision with lower survival. Previous fracture fixation is also a prejudicial factor.

Comparison between MIPO and the deltopectoral approach with allogenous fibular bone graft in proximal humeral fractures

BACKGROUND

The purpose of this study was to investigate the clinical differences between open reduction and plate fixation via a deltopectoral approach with allogenous fibular bone graft and a minimally invasive plate osteosynthesis (MIPO), in Neer's classification two-, three- part proximal humeral fractures.

METHODS

In this retrospective study, 77 patients with two-, three-part proximal humeral fractures were treated at two different institutions. Clinical and radiological evaluations were performed in 39 patients, who underwent MIPO at one institution (group A), and 38 patients, who underwent a deltopectoral approach with allo-fibular bone graft (group B) at another institution. The results between the groups were compared.

RESULTS

The MIPO technique was significantly less time consuming and caused less bleeding than the deltopectoral approach with allo-fibular bone graft (P<0.05). The duration of the fracture union was significantly reduced in group A (14.5±3.4; range, 10-22 weeks) compared to group B (16.4±4.3; range, 12-28) weeks (P<0.05). There were no statistically significant differences between the two groups when evaluating the visual analog scale and Constant scores between the two groups, 1 year postoperatively. In radiological evaluation, there was no difference in radiological outcomes between the two groups. There were no statistically significant differences in malunion between the two groups.

CONCLUSIONS

The MIPO technique and deltopectoral approach with allo-fibular bone graft for two-, three-part proximal humeral fractures, show similar clinical and radiological results. However, allogenous fibular grafts require longer surgery, cause more bleeding, and result in longer fracture healing time than MIPO technique.

Comparison between minimally invasive deltoid-split and extended deltoid-split approach for proximal humeral fractures: a case-control study

BACKGROUND

With the rapid aging of the population, the incidence of proximal humeral fracture (PHF) has increased. However, the optimal method for open reduction and internal fixation (ORIF) remains controversial.

METHODS

We performed a retrospective analysis of patients with PHF who underwent locking plate internal fixation at our institution from January 2016 to December 2018. Patients were divided into two groups based on the surgical approach used: an expanded deltoid-split approach group (ORIF group) and minimally invasive deltoid-split approach group (minimally invasive percutaneous plate osteosynthesis, [MIPPO] group). The groups were compared in terms of demographic and perioperative characteristics, and clinical outcomes.

RESULTS

A total of 115 cases of PHF were included in our study, of which 64 cases were treated using the minimally invasive deltoid-split approach and 51 using the extended deltoid-split approach. Fluoroscopy was performed significantly less frequently in the ORIF group and the surgical duration was shorter. However, the postoperative visual analogue scale (VAS) pain score and duration of postoperative hospital stay were significantly higher compared to the MIPPO group. Moreover, secondary loss was significantly less extensive in the ORIF group compared to the MIPPO group, while there was no significant group difference in fracture healing time, Constant shoulder score, or complications at the last follow-up visit.

CONCLUSIONS

The clinical outcomes associated with both the minimally invasive and extended deltoid-split approaches were satisfactory. The data presented here suggest that the extended deltoid-split approach was superior to the minimally invasive deltoid-split approach in terms of operational time, fluoroscopy, and secondary loss of reduction, while the minimally invasive approach was superior in terms of postoperative pain and hospital stay. Accordingly, neither procedure can be considered definitively superior; the optimal surgical procedure for PHF can only be determined after full consideration of the situation and requirements of the individual patient.

Comparison between minimally invasive plate osteosynthesis and open reduction-internal fixation for proximal humeral fractures: a meta-analysis based on 1050 individuals

BACKGROUND

This meta-analysis aimed to compare the clinical outcomes and complications of minimally invasive plate osteosynthesis (MIPO) and open reduction-internal fixation (ORIF) in patients with proximal humeral fractures.

METHODS

We searched PubMed, EMBASE, Ovid, and the Cochrane Library to identify all relevant studies from inception to April 2019. Cochrane Collaboration's Review Manage 5.3 was used for meta-analysis.

RESULTS

Sixteen studies involving 1050 patients (464 patients in the MIPO group and 586 patients in the ORIF group) were finally included. According to the meta-analysis, MIPO was superior to ORIF in operation time, blood loss, postoperative pain, fracture union time, and constant score. However, MIPO was associated with more exposure to radiation and axillary nerve injury. No significant differences were found in length of hospital stays and complication except for axillary nerve injury.

CONCLUSION

The present evidence indicates that compared to ORIF, MIPO had advantages in functional outcomes, operation time, blood loss, postoperative pain, and fracture union time for the treatment of PHFs. However, the MIPO technique had a higher rate of axillary nerve injury and longer radiation time compared to ORIF.

Functional improvement is sustained following anatomical and reverse shoulder arthroplasty for fracture sequelae: a registry-based analysis

INTRODUCTION

Shoulder arthroplasty for proximal humerus fracture sequelae is known to provide significant patient improvement, yet this outcome varies with time, prosthesis type, and fracture sequelae. We outline the expected course of postoperative shoulder pain and function in patients with anatomical (ASA) or reverse (RSA) shoulder arthroplasty following different fracture sequelae.

MATERIALS AND METHODS

Of 111 consecutive patients from our local shoulder arthroplasty registry, 32 underwent ASA for Boileau type 1 sequelae and 77 RSA patients were identified with Boileau types I, III, and IV. By 5 year post-surgery, there were 72 patients available. All patients underwent standardised ASA or RSA procedures with anatomical (Promos Standard; Lima SMR™; Arthrex Eclipse™; Univers™ II) or reverse prostheses (Promos Reverse^®; Lima SMR™ Reverse; Univers Revers™; Aequalis^® Reversed). Range of motion, Constant-Murley, Disability of the Arm, Shoulder and Hand (DASH), and Shoulder Pain and Disability Index (SPADI) scores were compared at 6, 12, 24, and 60 months postoperatively. We used generalised linear mixed models or random-effects ordered logistic regression to investigate postoperative changes of outcome parameters from baseline to follow-up time points for each group as well as for group comparisons.

RESULTS

Range of motion and clinical scores improved until 24 months postoperatively and did not deteriorate thereafter, except for internal rotation of Boileau type III and IV patients and external rotation of RSA patients with type I and IV sequelae. At all follow-ups, ASA patients with Boileau type I sequelae had significantly better internal and external rotation versus patients with RSA and/or other Boileau types (p < 0.001), while Constant, DASH, and SPADI scores were not significantly different between groups.

CONCLUSION

In humeral fracture sequelae, ASA and RSA lead to sustained clinical improvements. Surgeons may primarily consider implantation of ASA in type I sequelae.

Intramedullary nail versus locking plate for treatment of proximal humeral fractures: A meta-analysis based on 1384 individuals

Objective

The optimal surgical intervention on the treatment for proximal humeral fractures (PHFs) remains uncertain. The aim of this study was to evaluate clinical outcomes following fixation of PHFs by intramedullary nails or locking plates

Methods

The Cochrane Library, PubMed, EMBASE, China Knowledge Resource Integrated (CNKI), Chongqing VIP and Wanfang databases were systematically searched for studies published between January 01, 1996 and December 31, 2016 that investigated intramedullary nail vs. locking plate in the surgical treatment of PHFs. A meta-analysis examined incision length, blood loss, operation time, fracture healing time, Constant scores and post-operative complications. The methodological and evidence quality were also assessed by MINORS and GRADE system.

Results

From the original 1024 references, 20 studies involving 1384 patients met the eligibility criteria. Analyses showed that intramedullary nails were superior to locking plates in incision length, peri-operative bleeding time, operation time and fracture healing time. However, there were no differences between treatments in Constant score or post-operative complications.

Conclusion

Although the evidence quality was poor, the results suggest that compared with locking plates, intramedullary nails may be a better choice for the repair of PHFs.

Reverse total shoulder arthroplasty

Since the introduction of reverse total shoulder arthroplasty (RTSA) in 1987 (in Europe) and 2004 (in the United States), the number of RTSAs performed annually has increased.

Although the main indication for RTSA has been rotator cuff tears, indications have expanded to include several shoulder conditions, many of which involve dysfunction of the rotator cuff.

RTSA complications have been reported to affect 19% to 68% of patients and include acromial fracture, haematoma, infection, instability, mechanical baseplate failure, neurological injury, periprosthetic fracture and scapular notching.

Current controversies in RTSA include optimal baseplate positioning, humeral neck-shaft angle (135° versus 155°), glenosphere placement (medial, lateral or bony increased offset RTSA) and subscapularis repair.

Improvements in prosthesis design, surgeon experience and clinical results will need to occur to optimize this treatment for many shoulder conditions.

Cite this article: EFORT Open Rev 2018;3:58–69 DOI: 10.1302/2058-5241.3.170044