4-part Proximal Humerus Fractures Research Articles

Comparison of Conservative and Arthroplasty Treatment for 3- or 4-Part Proximal Humerus Fractures in the Elderly

Background/Purpose: Proximal humerus fractures are common injuries in the elderly population. The hypothesis of this study is that arthroplasty is not superior to conservative treatment in the management of multi-part proximal humerus fractures in elderly patients. Methods: Patients aged 65 and above with 3-4 part proximal humerus fractures, treated either conservatively or with arthroplasty, were included in the study. The minimum follow-up period was set at 12 months. Clinical evaluations of the patients were performed using the Q-DASH scoring system. Statistical analysis comparing the two groups was conducted using the SPSS software. The mean values of numerical data were analyzed using the Mann Whitney U test, while categorical data were compared using the Chi-square test. A significance level of 0.05 was considered. Results: A total of 67 patients who received adequate clinical follow-up were included in the study (50 conservative 17 arthroplasty). The average age of the patients was 76.12 years, with 9 male and 58 female patients. The average follow-up period was 22.61 months (range: 12-82). There were no statistically significant differences in age, gender, side, follow-up period, and fracture type distribution between the two groups. However, a significant difference in Q-DASH scores was observed (p

A technique for passing tuberosity-implant cerclage ribbons in fracture-inverse total shoulder arthroplasty

Complex proximal humerus fractures are difficult to treat particularly in patients above 65 years with osteoporotic bone and disturbed anatomical landmarks. Fracture-inverse total shoulder arthroplasty has shown a good treatment option for these injuries. However, better results are associated with meticulous reduction and fixation of the tuberosities around the implant. The purpose of this study is to describe a simple technique to pass cerclage ribbons to fix the tuberosities together around the inverse total shoulder arthroplasty. MethodsThis is a retrospective cohort study that was performed from January 2019 to January 2021. Thirty-five shoulders with 3- & 4-part proximal humerus fractures had undergone fracture-inverse total shoulder arthroplasty with a special technique for tuberosities repair. Follow-up was a minimum of 24 months. ResultsThe tuberosity healing rate was 86%. Complete resorption of one or more tuberosities occurred in 8%, and tuberosity migration and nonunion were present in 6%. ConclusionThis surgical technique offers a simple way for passing cerclage ribbons in fracture-inverse total shoulder arthroplasty for fixing the tuberosities together and to the implant. It has been shown to encourage tuberosity healing which improves shoulder stability and results in more optimal restoration of shoulder function.

Comparison of clinical outcomes and complications in 2-part vs. 3- or 4-part proximal humerus fractures treated using an intramedullary nail designed to capture the tuberosities

Comparison of clinical outcomes and complications in 2-part vs. 3- or 4-part proximal humerus fractures treated using an intramedullary nail designed to capture the tuberosities

Application of Intramedullary Calcar Support Plate and Lateral Locking Plate in Elderly Patients with Neer 3 and 4-Part Fractures of Proximal Humerus Through a Deltoid Splitting Approach

BackgroundThe reduction and fixation of Medial humeral calcar is difficult in the treatment of elderly proximal humerus Neer 3 and 4-part fractures with a single lateral locking plate. Our study investigated the efficacy of an intramedullary calcar supporting plate combined with a lateral locking plate for the treatment of 3- and 4-part fractures of the proximal humerus in the elderly through a deltoid splitting approach.MethodsFrom June 2022 to December 2022, we treated six elderly patients with Neer 3 and 4-part fractures using proximal humeral intramedullary calcar support plate in combination with lateral locking plate through a deltoid splitting approach. Follow-up time was 6–12 months. Assessment indicators included fracture union, quality of reduction, and complication rate. The Constant-Murley score was used to record shoulder function at 6 months postoperatively.ResultsAll 6 patients showed fracture union and anatomic reduction. Constant-Murley score was 79.5 (70–90) at 6 months postoperatively. There was no incision non-healing, internal fixation failure, bone non-union or surgical site infection, secondary surgery, or death. Shoulder impingement occurred in 1 case.ConclusionProximal humeral intramedullary calcar support plate combined with lateral locking plate fixation through a deltoid splitting approach can effectively maintain fracture reduction, prevent inversion collapse of humeral head and internal fixation failure, and provide satisfactory clinical results at an early stage.

Treatment of 2-part, 3-part, and 4-part proximal humerus fractures from 2016 to 2020: A nationally-representative database

IntroductionComplex proximal humerus fractures pose challenges in elderly patients, as this common scenario can lead to unpredictable outcomes, regardless of treatment method. Given the evolving nature of the treatment for 3-and-4-part proximal humerus fractures, an epidemiological analysis offers a way to minimize the gap between appropriate understanding and effective intervention. As such, we aimed to i) evaluate the trends of nonoperative and operative management; and ii) compare the complication rates of ORIF to conversion ORIF (to RTSA). MethodsWe utilized a national, all-payer database to include patients who underwent open reduction and internal fixation for 2-part (n = 2783), 3-part (n = 2170), 4-part (n = 1087) proximal humerus fractures between April 2016 to December 2022. Patients who failed ORIF to RTSA included n = 108 for 2-part fractures, n = 123 for 3-part fractures, and n = 128 for 4-part fractures. We collected demographic and postoperative medical and surgical complications at 90-days, in addition to time-interval between ORIF and RTSA. ResultsThe malunion and nonunion rates for ORIF between different types of proximal humerus fractures were similar (2-part fractures: 1.8 %, 4.7 %; 3-part fractures: 1.8 %, 3.5 %; 4-part fractures: 2.4 %, 3.7 %). The conversion rates of failed ORIF to RTSA were 1.9 %, 2.8 %, and 5.9 % for 2-part, 3-part, and 4-part fractures, respectively. The time interval from failed ORIF to RTSA was 190 days for 2-part fractures, 169 days for 3-part fractures, and 129 for 4-part fractures. ConclusionAn epidemiological analysis of proximal humerus fractures by fracture type demonstrated an increase in RTSA for 2-part, 3-part, and 4-part fractures while nonoperative treatment showed no change from 2016 to 2020. Additional research is needed to determine which fractures are best treated operatively while maximizing outcomes. In the setting of complex proximal humerus fractures, several options seem feasible depending on patient demographic characteristics.

Pectoralis major pedicle bone grafting vs. tricortical iliac grafting for Neer 4-part proximal humerus fractures: a randomized controlled trial

The risk of avascular necrosis, nonunion, or malunion is high in osteoporosis-related 4-part fractures. We tried to evaluate the results of patients who underwent plate osteosynthesis with vascularized pectoralis major graft comparing with tricortical iliac grafting to treat 4-part proximal humerus fractures. Thirty-four patients aged 50-75 with Neer 4-part proximal humerus fractures were studied. Group A (n=17) underwent osteotomy of a 2.5cm±1cm pectoralis major pedicle bone graft and plate application, while Group B (n=17) underwent plate osteosynthesis using iliac autogenous grafts. Final follow-up assessments included evaluation using Constant and American Shoulder and Elbow Surgeons scoring systems, Humeral Neck-Shaft Angle (HNSA), humeral head height (Humeral Head Height) and humeral head avascular necrosis. Although reduction loss was observed in 3 patients (17.6%) in Group A patients, reduction loss was observed in 10 patients (58.8%) in Group B., p= 0.013. Humeral head avascular necrosis was 1 (5.8%) in Group A, while it was 5 (29.4%) in the other group (p= 0.071). The HNSA was normal in 12 (70.5%) of Group A patients, while it was normal in 6 (35.2%) of Group B patients. The HNSA was weak or bad (<1200) in 29.4% of Group A patients, while this rate was 64.7% in Group B patients. HHH was 2.64±1.45 mm in Group A and 3.66±1.65 mm in Group B. There were no statistically significant differences between the two groups in terms of Constant and American Shoulder and Elbow Surgeons scoring systems. Pectoralis major bone pedicle graft in Neer 4-part proximal humerus fractures reduces the risk of avascular necrosis and nonunion rates. Our technique yielded excellent clinical and radiological results. We achieved recovery without creating additional donor site morbidity.

Comparison of outcomes of internal fixation and non-operative management of 2-part and 3-part proximal humerus fractures in younger adults

Aims This study aimed to compare outcomes of internal fixation and non-operative management in younger adults. Methods A retrospective cohort study was undertaken in patients aged 18–55 with 2-part or 3-part proximal humerus fractures at a Level 1 trauma centre from January 2010 to December 2018. Outcome measures were the Oxford shoulder score (OSS), EQ-5D-5L, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, and non-union/malunion. Statistical analysis included univariable analysis and multivariable analysis performed using binary logistic regression and linear regression. Results A total of 184 eligible patients were included; 99 underwent operative fixation and 85 were managed with sling immobilisation. The mean (SD) age in the operative group was 39.3 ± 10.6 and in the non-operative group was 43.2 ± 10.8 ( p = 0.02). Seventy-seven percent completed a minimum 12-month follow-up (median 3.2 years, IQR 2–6.5 years). Most 3-part fractures were treated surgically (78%), as opposed to 44% of 2-part fractures. All open fractures, all segmental fractures, eight head split fractures (89%), and 12 fracture-dislocations (80%) were treated surgically. There was no difference in mean OSS (43.7 operative vs 42.1 non-operative, p = 0.27), mean EQ-5D-5L utility score (0.81 vs 0.78, p = 0.32) or proportion returned to work (83% vs 75%, p = 0.34). Adjusted for case-mix, there was no difference in OSS (adjusted mean difference 0.24, 95%CI −2.73 to 3.22, p = 0.87) or EQ-5D-5L utility score (adjusted mean difference 0.00, 95%CI −0.06 to 0.07, p = 0.96). The complication rate was high (36% non-operative, 27% operative, p = 0.24). A higher rate of varus malunion was observed in the non-operative group (24.0% vs 41.4%, p &lt; 0.001). Following operative management, 23% underwent subsequent surgery compared with 7% of the non-operative group ( p = 0.002). Conclusion In younger adults with proximal humerus fractures no differences in patient reported outcome measures were observed between groups. Operative management was associated with improved radiological outcomes, but a higher rate of subsequent surgery.

Avascular necrosis of humeral head after proximal humerus fracture: comparison between classification systems in predicting necrosis risk.

Avascular necrosis (AVN) of the humeral head is a relatively frequent complication after proximal humerus fractures (PHF). There are many factors related to the risk of developing AVN, with fracture complexity being one of the most relevant. Aim of the present study is to evaluate the correlation between different classification systems and the risk of post-operative AVN in patients treated with locking plate fixation for Neer 3 and 4-part PHFs. The study population included 44 patients (F:M 2:1, mean age 62) treated between December 2014 and April 2019. Fractures were classified according to Neer, Russo and Lego classifications and Hertel's criteria. AVN was established on postoperative radiographs after a minimum follow-up of 6 months. The odds ratio (OR) for AVN for each classification subtype was calculated. The incidence of necrosis was 11%. Significant association with AVN was found for Neer 4 part (OR=8), Russo IVB (OR=4), Lego pattern 12 (OR=8) and in presence of 3 mayor Hertel's criteria (OR=15,5). There is a significant association between AVN and Neer 4 part, Russo type IVB and Lego pattern 12 fractures. AVN risk is also significantly higher in presence of 3 major Hertel's criteria.

Thermal analysis of tendon, cartilage and bone samples from shoulder joint replacement patients using differential scanning calorimetry (DSC) and thermogravimetry (DTA/TG)

AbstractDespite advanced imaging techniques, more information on the extent of joint degeneration and modifications in tendon collagen content is required for selecting the appropriate type of shoulder prosthesis. The goal of this study was to compare the thermal parameters of various tissue samples from patients who had shoulder arthroplasty and to correlate the thermal shifts with the outcomes of radiological and histopathological assessments. Rotator cuff (ROC) tendon, hyaline cartilage, and subchondral bone samples were obtained throughout surgery for a comminuted 4-part proximal humerus fracture or cuff tear arthropathy. Thermal parameters were measured using differential scanning calorimetry and thermogravimetry (DTA/TG). ROC: The effect of advanced collagen damage was visible in denaturation curves of osteoarthritis samples. Only moderately increased thermal enthalpy and melting temperature were found in the tissue of the trauma patients. Cartilage: Thermal parameters revealed that structural change generated by pathologic conditions exceeded the effects of trauma. Bone: Thermal parameters from degenerative samples revealed more structural damage and calcification decrease than thermal parameters from trauma samples. Correlation: A statistically significant relationship between the extent of osteoarthritis and the thermal variables of cartilage and subchondral bone was discovered. Authors suggest that thermal analysis may be useful in the diagnostic process of orthopedic and posttraumatic shoulder diseases.

2-year clinical and radiographic outcomes following uncemented reverse shoulder replacements for proximal humerus fractures.

Uncertainty remains regarding the role and long-term outcomes following uncemented reverse shoulder replacements (RSR) in managing displaced proximal humerus fractures (PHF). While RSRs for trauma have traditionally undergone cemented fixation of the humeral component, there is increasing interest in uncemented RSRs. Our primary aim was to evaluate 2-year outcomes following uncemented RSR fixation for 3 and 4-part PHFs in the elderly. A secondary aim was to evaluate if timing of surgery affected outcomes. This cohort series evaluated 2-year outcomes for 42 patients with Neer 3 and 4-part PHFs treated with uncemented RSRs between October 2016 to December 2019. 38 patients (90%) had clinical and radiological follow-up at a minimum of two years. The primary outcomes compared postoperative range of movement (ROM), radiographic outcomes and patient reported outcome measures (PROMs). The PROMs collected included Oxford Shoulder Scores (OSS), satisfaction scores and the Friends and Family Test. The secondary outcome involved a sub analysis to see if outcomes were affected by treatment timing - within 2 weeks, 2-12 weeks and >12 weeks. The mean age of patients was 74.1 (range 58-89). There were 11 males and 31 females. No intra-operative fractures were sustained. There was one transient axillary neurapraxia, which fully resolved by 4 months. Three patients required postoperative transfusions. During the study follow-up period, no patients developed deep infections requiring a washout, dislocation, or underwent further surgery. At two-year follow-up, radiological follow-up demonstrated tuberosity union in 29/38 cases (76%). 8/38 patients (21%) demonstrated some glenoid notching (Sirveuax 1-2 only) on radiographic follow-up. There was no evidence of loosening. The mean OSS was 38 (range 15-48°). Mean range of movement achieved at 2-years was, forward flexion 122° (50-180°); abduction 116° (46-180°) and external rotation 25° (range 5-60°). 18 (47%) patients described their result as excellent, 17 (45%) as good and 3 (8%) as poor. When comparing the time form injury to treatment, there was no statistically significant difference in complications, or radiographic outcomes between the groups. Patients had a reduced forward flexion when treated between 2 and 12 weeks compared to the other groups (p=0.019) CONCLUSION: Uncemented RSR is a safe treatment option for the management of complex PHFs in the elderly. We report low complication rates, high patient satisfaction and good outcomes at 2-year follow-up.

Subgroups and differences of fixation in 3-part proximal humerus fractures.

This study aimed to determine the morphological differences of three-part proximal humerus fractures, the group in which plate screw fixation is most frequently used, and to evaluate the functional and radiological results of the methods applied for different subgroups. Twenty-nine patients (6 males and 23 females) with three-part proximal humerus fractures were in the study, with an average age of 64. The patients were in three groups according to their fracture types. Group 1 included eight patients with valgus impaction fracture. Group 2 included eleven patients with easily achieved stability after reduction. Group 3 consisted of ten patients with procurvatum varus angulation, a significant displacement between fragments, and in whom medial cortical continuity was not maintained without fixation. All patients underwent surgery with a minimally invasive deltoid split approach method and locked ana-tomic plate screw osteosynthesis. In group 1 patients, the space in the area where valgization is present in the head was filled with cortico-cancellous allografts. No grafting or metaphyseal compression took place in Group 2 patients. In group 3 patients, the metaphyseal compression technique was applied to the bone defect area. Cephalodiaphyseal angles (CDA) were measured at the postoperative and final follow-up. The constant Murley score made the functional evaluation. The patients were followed for an average of 27.6 months, and the union was present in all patients for an average of 3.6 months. Early screw migration was present in three patients, and late screw migration was in one patient. There were twenty-four excellent and 5 good results. CDA decreased from 139.42° to 136.13°. A statistically significant difference was present between the values of Groups 2 and 3 in the final control CDA of the groups. In this study, the functional scores of grafting stable valgus-impacted fractures and metaphyseal compression of unstable fractures with insufficient medial support were as good as stable 3-part fractures. Considering neer type 3 fractures should be evaluated with their subgroups, and fixation and stability-enhancing solutions specific to the groups are essential.

Impact of Age on Functional Outcome After Reverse Shoulder Arthroplasty Performed for Proximal Humerus Fractures or Their Sequelae.

The use of reverse shoulder arthroplasty (RSA) to treat displaced, unstable 3- and 4-part proximal humerus fractures (PHFs) has traditionally been reserved for patients over 70 years old. However, recent data suggest that nearly one-third of all patients treated with RSA for PHF are between 55-69 years old. The purpose of this study was to compare outcomes for patients younger than 70 versus patients older than 70 years of age treated with RSA for a PHF or fracture sequelae. All patients who underwent primary RSA for acute PHF or fracture sequelae (nonunion, malunion) between 2004 and 2016 were identified. A retrospective cohort study was performed comparing outcomes for patients younger than 70 versus older than 70. Bivariate and survival analyses were performed to evaluate for survival complications, functional outcomes, and implant survival differences. A total of 115 patients were identified, including 39 patients in the young group and 76 cases in the older group. In addition, 40 patients (43.5%) returned functional outcomes surveys at an average of 5.51 years (average age range: 3.04-11.0 years). There were no significant differences in complications, reoperation, implant survival, range of motion, DASH (27.9 vs 23.8, P=0.46), PROMIS (43.3 vs 43.6, P=0.93), or EQ5D (0.75 vs 0.80, P=0.36) scores between the two age cohorts. At a minimum of 3 years after RSA for a complex PHF or fracture sequelae, we found no significant difference in complications, reoperation rates, or functional outcomes between younger patients with an average age of 64 years and older patients with an average age of 78 years. To our knowledge, this is the first study to specifically examine the impact of age on outcome after RSA for the treatment of a proximal humerus fracture. These findings indicate that functional outcomes are acceptable to patients younger than 70 in the short term, but more studies are needed. Patients should be counseled that the long-term durability of RSA performed for fractures in young, active patients remains unknown.

Reverse total shoulder arthroplasty for complex proximal humerus fracture in the elderly: clinical and radiological results

The use of reverse total shoulder arthroplasty (RSA) for the treatment of proximal humeral fractures (PHFs) is steadily increasing. Better clinical outcomes of RSA have been correlated with tuberosity reattachment and healing. The purpose of this study was to evaluate both the clinical and radiological results of reverse shoulder arthroplasty in the management of a proximal humerus fracture in the elderly. Retrospective study including 400 consecutive 3-4 part proximal humerus fractures treated with reverse shoulder arthroplasty with a minimum of 12-month follow-up. In all the cases, the greater tuberosity was reattached with a standardized suture technique and a local bone graft. All the patients were assessed at the 12-month follow-up with Constant-Murley Score (CMS). Radiographic healing of the greater tuberosity was noted. Complications and revision rates were reported. Mean final CMS for this cohort was 82 points. The greater tuberosity healed in anatomic position in 85% of the cases (N= 340), obtaining an average CMS of 85 in these patients. Healing of the greater tuberosity did not occur in 13% of the cases (N= 52) and displacement more than 5 mm occurred in 2% (N= 8) of the patients for an average CMS of 60. All patients scored above 120° in forward elevation with a mean of 150°. Mean active external rotation was 35°. The lateralization shoulder angle had a mean of 91° and the distalization shoulder angle had a mean of 54°. Low-grade scapular notching was reported in <1% of the cases. A total of 60 patients presented failure of healing or displacement of the greater tuberosity. Major complications were reported in nine patients. Of these nine patients, two acquired superficial wound infections, while two had deep shoulder prosthetic infection. Two other patients developed hematomas, one sustained an acromial stress fracture, and two had a stem loosening. There were 4 reoperations. Reverse shoulder arthroplasty, with the use of a fracture-specific stem, allows an improved rate of greater tuberosity healing and short-term clinical outcomes in the elderly population.

Effect of tuberosity repair on functional outcome of reverse shoulder arthroplasty in proximal humerus fractures

PurposeUnsatisfactory results of hemiarthroplasty in Neer's 3- and 4-part proximal humerus fractures in elderly, have led to the shift towards reverse shoulder arthroplasty (RSA). The objective of our study was to repair the tuberosities that are generally overlooked during RSA and observe its impact on the functional outcome and shoulder scores. MethodsWe include elderly patients with acutely displaced or dislocated 3- or 4-part proximal humerus fractures from July 2013 to November 2019 who were treated with RSA along with tuberosity repair by non-absorbable sutures and bone grafting harvested from the humeral head. Open injuries and cases with neuro-muscular involvement of the deltoid muscle were excluded. According to the tuberosity healing on radiographs of the shoulder at 9th postoperative month, the patients were divided into 2 groups, as the group with successful tuberosity repair and the other with failed tuberosity repair. Statistical analysis of the functional outcome and shoulder scores between the 2 groups were done by independent t-test for normally distributed parameters and Mann-Whitney test for the parameters, where data was not normally distributed. ResultsOf 41 patients, tuberosity healing was achieved in 28 (68.3%) and failed in 13 (31.7%) cases. Lysis of the tuberosity occurred in 5 patients, tuberosity displacement in 2, and nonunion in 2. Mean age was 70.4 years (range 65 – 79 years) and mean follow-up was 58.7 months (range 18 – 93 months). There were no major complications. Group with successful tuberosity repair showed improvement in mean active range of movements, like anterior elevation (165.1° ± 4.9° vs. 144.6° ± 9.4°, p < 0.000), lateral elevation (158.9° ± 7.2° vs. 138.4° ± 9.6°, p < 0.000), external rotation (30.5° ± 6.9° vs. 35.0° ± 6.3°, p = 0.367), internal rotation (33.7° ± 7.5° vs. 32.6° ± 6.9°, p = 0.671) and in mean shoulder scores including Constant score (70.7 ± 4.1 vs. 55.5 ± 5.7, p < 0.000), American shoulder and elbow surgeons score (90.3 ± 2.4 vs. 69.0 ± 5.7, p < 0.000), disability of arm shoulder and hand score (22.1 ± 2.3 vs. 37.6 ± 2.6, p < 0.000). ConclusionSuccessful repair and tuberosity healing around the RSA prosthesis is associated with statistically significant improvement in postoperative range of motion, strength and shoulder scores. Standardized repair technique and interposition of cancellous bone grafts, harvested from the humeral head can improve the rate of tuberosity healing.

Non-Operative Treatment of 3-Part and 4-Part Proximal Humerus Fractures and its Related Functional Aftermath

Objective: To assess the functional outcomes of noninvasive treatment for proximal humerus three parts and four parts fracture. Study Design: Prospective-cohort study Place and Duration of Study: Department of Orthopaedics, Sialkot Medical College, Sialkot from 1st January 2021 to 31st March 2022. Methodology: Fifty patients between 56-65 years and radiograpically both anterior and lateral views were taken. There was a follow up plan in each patient at half month, three months, six months and a year with repeated imaging. Oxford-Shoulder Score and EuroQol-5 Dimensions-3 Levels was used for finding primary functional results while secondary functional outcomes were score through Visual Analog Scoring and University of California at Los Angeles Shoulder Score. Results: The mean of the patients was 62.3±5.6 years with more females (70%) than males. Majority of the cases had a high incidence of fall due to feeling low in energy. The comparison of Oxford-Shoulder Score (OSS) and EQ 5D 3L method showed a high significance within each variable. Comparative imaging at follow ups have showed timely fixation of the humerus with non-invasive procedure with improved OSS values. One-year scores for Oxford-Shoulder Score were 33.1 with 95% confidence of interval while it was 0.59 for EQ-5D-3L. Considering the secondary outcomes it was noticed that mean outcomes score of treatment was 32.1 while visual analogue scale (VAS) pain score was 32.1 with 59.2 as VAS satisfaction score. Conclusion: Good functional outcome of displaced 3-part and 4-part fracture of proximal humerus. Keywords: Noninvasive treatment, Proximal humerus fractures, Osteoporosis Neers classification, Related functional aftermath, Functional outcome

Fracture dislocations of the proximal humerus treated with open reduction and internal fixation: a systematic review.

The treatment of proximal humerus fracture dislocations can be challenging given the extensive injury to the proximal humeral anatomy and increased risk of devascularization of the humeral head often seen in these injuries. The purpose of this study is to undertake a systematic review of the literature on the functional outcomes, rate of revision, and short- and long-term complications for proximal humerus fracture dislocations treated with open reduction and internal fixation (ORIF). The PubMed and OVID Embase databases were queried for literature reporting on proximal humerus fracture dislocations treated with ORIF. Data including study design, patient demographics, functional outcomes, and complications were recorded. Twelve studies including 294 patients with Neer type 2-, 3-, or 4-part proximal humerus fracture dislocations met the criteria for inclusion. The mean patient age was 53.4 years (19-89 years) with an average follow-up of 2.9 years (1.15-4.9 years). At the final follow-up, the mean Constant score was 73.2 (52-87.3) and the mean Disabilities of the Arm Shoulder and Hand score was 26.6 (17.5-32). Avascular necrosis was observed in 20.0% (0%-82.3%) and nonunion was observed in 3.0% (0%-7.7%) of patients. Conversion to arthroplasty was observed in 10.7% (5%-20%) and a total reoperation was observed in 35.6% (11.8%-89.1%) of patients in studies explicitly reporting these outcomes. In addition to conversion to arthroplasty, common causes of reoperation were revision ORIF (5.2%) and hardware removal (22.2%). Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates. This information can be used to counsel patients and set expectations about the potential for further surgeries.

Thermal analysis of the biceps tendon samples obtained from patients underwent reversed shoulder arthroplasty for comminuted proximal humerus fractures

Most commonly occurring in elderly patients, the comminuted 4-part or Neer VI type proximal humerus fractures frequently necessitate complete shoulder replacement. Despite the recent advances in imaging technologies, there is still a need for more information about the degree of joint degeneration and changes of the collagen content of tendons to select the proper implant type. It is known that human long head biceps tendon subjected to synovial inflammation and mechanical wear could result in tear and structural damage. Differential scanning calorimetry has already been demonstrated to be a dependable in the assessment of collagen in degenerative tendon conditions. The purpose of the study was to determine whether variations in thermal parameters detected by DSC are related to the degenerative changes of LHBT samples. LHBT tendons were collected from patients who had reversed shoulder arthroplasty because of trauma. DSC was utilized to measure the thermodynamic changes. Macroscopical, radiological and histological assessment were also performed. Based on the thermal parameters and denaturation curves, LHBT samples collected of patients underwent reversed shoulder arthroplasty due to comminuted proximal humerus fracture have shown minimal or mild degenerative injuries. These data were supported by preoperative radiological examination and histological analysis. The authors suggest that DSC could be a useful investigative tool in the clinical evaluation of tendon injuries.

Evaluation of functional outcome following ORIF of complex proximal humerus fractures with PHILOS plating

Background: Neers 3 and 4 part proximal humerus fractures are often difficult to treat due to the complex nature of the fracture patterns. The aim of this study was to evaluate the functional outcome of these fractures following ORIF (Open reduction and internal fixation) with PHILOS plate. Methods: 30 patients with fractures of the proximal humerus who presented between June 2013 to June 2016 were managed by ORIF with PHILOS plating and were followed up for a period of 3 years. Functional assessment was done using the DASH (Disabilities of arm, shoulder and hand) and Constant and Murley scores. Results: There was a male preponderance seen in our study with the right side being more commonly affected. The mean time to fracture union was 11.9 weeks. The average DASH score at 1 year was 8.9±6.4 and the Constant and Murley score was 64.5±7.2. All patients were satisfied with the functional outcome achieved. Conclusion: PHILOS plating is a good treatment option for complex proximal humerus fractures. It provides multiple divergent screw options for securing purchase in osteoporotic bone and requires less soft tissue stripping and aids in preserving the blood supply to the bone. It provides good union rates and better functional outcomes.

Endosteal plating in proximal humerus fractures: a novel technique and alternative to fibular strut allograft for medial column support

The purpose of this retrospective study is to investigate the clinical and radiographic outcomes associated with the use of a standard metal plate as an endosteal implant in combination with a lateral locking plate to treat 4 patients with displaced proximal humerus fractures. A retrospective case series study design was utilized, and the medical records of 4 patients with displaced, 3-part proximal humerus fractures treated using this technique between January 2019 and July 2021 were reviewed for this study. The mean age was 52 years (range, 44-57 years). The radiographic outcome of interest was humeral neck-shaft angle preoperatively, intraoperatively, and at the latest follow-up. The average follow-up duration was 62 weeks (range, 12-161 weeks). All fractures healed without loss of reduction or neurovascular deficits. Avascular necrosis was not observed in the 2 patients with sufficient follow-up time to make such an evaluation. The average neck-shaft angles preoperatively, intraoperatively, and at the latest follow-up were 104.8°, 139.8°, and 137°, respectively. Locking plate technology augmented with an endosteal plate provided stable reduction and restoration of physiologic alignment in a small number of patients with displaced proximal humerus fractures. This construct creates a second column of fixation, providing medial column support, and could be removed in the event of a future revision to a reverse shoulder arthroplasty.

A retrospective analysis of complex proximal humerus fractures managed with reverse shoulder arthroplasty in a level 1 trauma center

BackgroundThe treatment of complex 3- and 4-part proximal humerus fractures (PHFs) in the elderly poses significant challenges because of osteoporosis and fracture comminution. The wide range of surgical options available is evidence of the complex nature of the injury. At present, reverse shoulder replacement is gaining popularity among shoulder surgeons for treating these difficult fractures, and the literature has shown equivalent or superior outcomes with reverse shoulder arthroplasty (RSA). We aimed to analyze the long-term results of these complex PHF treated with reverse shoulder replacement. MethodsFor this study, fractures from 39 patients with a mean age of 63.18 years who were treated with RSA for acute complex fractures of the proximal humerus in our institution between 2013 and 2019 were analyzed (n = 31, acute 4-part fractures; n = 4, acute fracture–dislocation; n = 3, fracture with irreparable cuff tear; n = 1, osteoporotic 2-part fracture). All patients had a standard reverse shoulder replacement (cemented humeral stem n = 37 and uncemented stem n = 2) surgery in a level 1 trauma center. The mean follow-up duration was 60 months (24-111 months). The clinical outcomes (Oxford Shoulder Score and Constant Shoulder Score) and the complications at 6 months, 12 months, and 24 months were analyzed. ResultsOur study found a relatively younger population, with 21 patients (53.84%) aged <66 years. Spearman's correlation showed that younger patients had better signs of improvement in Oxford Shoulder Scores at 2 years (P = .008). The average Oxford Shoulder Score was 39.12 ± 4.327, and the average Constant Shoulder Score was 67.67 on the operated side. The mean active forward elevation was 142.56 ± 22.29º, abduction was 136.538 ± 24.31º, external rotation was 27 ± 9.011º, and internal rotation was 33 ± 20.41º. The overall complication rate of 17.94% (periprosthetic infection n = 2, periprosthetic humerus fracture n = 1, and hematoma evacuation n = 4) in our study was similar to those of recent studies in the literature. ConclusionRSA provides a reliable option for PHFs and offers good results in the form of pain relief and good functional outcomes at 2 years even in a younger age group. Thus, it is fast becoming an important option in treating complex PHF, but we must be wary of the steep learning curve and the complications pertinent to this procedure.