Acute Proximal Humerus Fractures Research Articles

Achieving satisfactory functional outcomes in conservatively treated proximal humerus fractures: relationship between shoulder range of motion and patient-reported clinical outcome scores

Proximal humerus fractures are common osteoporotic fractures. Postinjury outcome measures include objective clinician-measured range of motion (ROM) and subjective patient-reported outcome measures (PROMs), but the relationship between both has not been established. This study aimed to determine the relationship between shoulder ROM and PROMs and establish which ROMs correlated most with PROMs. A prospective cohort study was conducted on patients with acute proximal humerus fractures. Surgical intervention, open or pathological fractures, neurovascular compromise, polytrauma, or delayed presentations were excluded. Correlation and regression analyses between active ROM and PROMs (Quick Disabilities of Arm, Shoulder and Hand [QuickDASH] and Oxford Shoulder Score [OSS]) at 1-year postinjury were explored. ROM cutoffs predicting satisfactory PROM scores were established. Fifty-five patients were recruited. Moderate correlations were observed between PROMs and flexion, extension, and abduction, but not internal and external rotation. Multivariate analysis showed significant relationships between PROMs and flexion [QuickDASH: adjusted coefficient (AC):-0.135, P=.013, OSS: AC: 0.072, P=.002], abduction [QuickDASH: AC:-0.115, P=.021, OSS: AC: 0.059, P=.005], and extension [QuickDASH: AC:-0.304, P=.020] adjusting for age, gender, Neer classification, injury on dominant side, and employment. Achieving 130° flexion, 59° extension, and 124° abduction were correlated with satisfactory OSS/QuickDASH scores, respectively. Overall, holistic assessment of outcomes with both subjective and objective outcomes are necessary, as shoulder flexion, extension, and abduction are only moderately correlated with PROMs. Attaining 130° flexion, 59° extension, and 124° abduction corresponded with satisfactory functional outcomes measured by OSS/QuickDASH and can guide rehabilitation.

State transition and intercellular communication of synovial fibroblasts in response to chronic and acute shoulder injuries unveiled by single-cell transcriptomic analyses

ABSTRACT Purpose We aimed to investigate the heterogeneity of synovial fibroblasts and their potential to undergo cell state transitions at the resolution of single cells. Materials and Methods We employed the single-cell RNA sequencing (scRNA-seq) approach to comprehensively map the cellular landscape of the shoulder synovium in individuals with chronic rotator cuff tears (RCTs) and acute proximal humerus fractures (PHFs). Utilizing unbiased clustering analysis, we successfully identified distinct subpopulations of fibroblasts within the synovial environment. We utilized Monocle 3 to delineate the trajectory of synovial fibroblast state transition. And we used CellPhone DB v2.1.0 to predict cell-cell communication patterns within the synovial microenvironment. Results We identified eight main cell clusters in the shoulder synovium. Unbiased clustering analysis identified four synovial fibroblast subpopulations, with diverse biological functions associated with protein secretion, ECM remodeling, inflammation regulation and cell division. Lining, mesenchymal, pro-inflammatory and proliferative fibroblasts subsets were identified. Combining the results from StemID and characteristic gene features, mesenchymal fibroblasts exhibited characteristics of fibroblast progenitor cells. The trajectory of synovial fibroblast state transition showed a transition from mesenchymal to pro-inflammatory and lining phenotypes. In addition, the cross talk between fibroblast subclusters increased in degenerative shoulder diseases compared to acute trauma. Conclusion We successfully generated the scRNA-seq transcriptomic atlas of the shoulder synovium, which provides a comprehensive understanding of the heterogeneity of synovial fibroblasts, their potential to undergo state transitions, and their intercellular communication in the context of chronic degenerative and acute traumatic shoulder diseases.

Fracture vs. standard stem for proximal humerus fractures using reverse total shoulder arthroplasty

BackgroundReverse total shoulder arthroplasty (rTSA) and hemiarthroplasty are recognized treatment options for significantly displaced proximal humerus fractures. Repair of the tuberosities and preservation of rotator cuff function is a principle of treatment to enhance function and prevent instability. Humeral fracture stems were developed to improve tuberosity union with hemiarthroplasty, and similarly fracture stems are used with rTSA with promising results. However, there are conflicting studies on the use of fracture stems in improving outcomes in rTSA for proximal humerus fracture. The purpose of this study is to determine the clinical and radiographic outcomes, complication and revision rates, and patient satisfaction for fracture vs. standard stems for acute proximal humerus fracture treated with rTSA. MethodsA prospective multi-institutional institutional review board approved registry with a minimum two-year follow-up was queried and identified 231 patients that underwent rTSA for acute proximal humerus fracture, 187 of which received a fracture stem and 44 that received a standard stem. Patients were excluded if there was a previous fracture repair, malunion, or nonunion. Patient demographics, clinical and radiographic outcomes, complications, revision surgery, and patient reported outcome measures were collected preoperatively and at latest follow-up postoperatively. ResultsThe mean follow-up was 48 ± 24 and 54 ± 34 months, mean age was 74 ± 7.9 and 72 ± 8.6 years, and mean body mass index was 28 ± 6.1 and 30 ± 5.3 kg/m2 for fracture and standard stems, respectively. Both fracture and standard stem groups showed significant improvements in patient reported clinical outcomes preoperative to postoperatively. Postoperatively, patients with fracture and standard stems had comparable abduction, forward elevation, internal rotation, external rotation, Visual Analog Scale pain, Global Shoulder Function scale, Simple Shoulder Test scale, American Shoulder and Elbow Surgeons scale, University of California Los Angeles Shoulder score, and Shoulder Arthroplasty Smart score. Patient satisfaction was high and did not differ between the two groups. Similar rates of humeral radiolucent lines, scapular notching, complications, and revision rates occurred between the fracture vs. standard stem groups. ConclusionThere were no significant differences in postoperative clinical outcomes, radiographic outcomes, complication rate, revision rate, and patient satisfaction between the fracture and standard stem groups for the treatment of acute proximal humerus fracture using rTSA. Both stems significantly improved clinical outcomes postoperatively. Either a fracture or standard stem may be used to achieve improved clinical outcomes for acute proximal humerus fracture using rTSA.

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

BackgroundThe aim of this study was to investigate (1) whether fracture pattern and age are associated with local bone quality (LBQ), and (2) whether a scoring system based on these variables is able to predict LBQ in proximal humerus fractures (PHF).Materials and methodsA retrospective study was performed of all acute PHF at a Level 2 trauma center with plain radiographs and CT between June 2009 and March 2022. Local bone quality was measured by using the deltoid tuberosity index (DTI). In addition to age and gender, fracture morphology was categorized using the following classification systems: Neer, Resch, AO Foundation/Orthopaedic Trauma Association (AO/OTA), and Hertel/LEGO. Additionally, coronal head alignment was calculated by measuring the head-shaft angle.ResultsOnly the Resch classification system revealed a significant relationship between fracture type and bone quality, as there was a significant association between coronal head alignment and DTI (p = 0.001). Valgus head alignment was observed significantly more frequent in patients with low bone quality (p = 0.002). Multinomial logistic regression analysis revealed a significant relative risk ratio for age (RRR = 0.97, [95% CI, 0.94-1], p = 0.039) and a non-significant trend for DTI (RRR = 1.26, [95% CI, 0.96–1.64], p = 0.092) for occurrence of anatomic relative to valgus head alignment. Using a DTI cut-off value of 1.3 instead of 1.4, age and also varus head alignment were identified as significant predictors of LBQ (OR = 1.12, [95% CI, 1.1–1.15], p < 0.001; OR = 0.54, [95% CI, 0.3–0.96], p = 0.037). A scoring system called the LBQ-PHF score (local bone quality in proximal humerus fractures), developed based on these two variables was able to predict LBQ with a sensitivity of 79.2% and a specificity of 86.7%.ConclusionAge and coronal humeral head alignment are independent predictors of LBQ in PHF. A simple scoring system developed based on these variables is able to assess BQ with solid predictive characteristics.

Trends in prevalence and implant types in the Nova Scotia Joint Database Registry between 2005 and 2021.

The aim of this study is to evaluate the change in incidence rate of shoulder arthroplasty, indications, and surgeon volume trends associated with these procedures between January 2003 and April 2021 in the province of Nova Scotia, Canada. A total of 1,545 patients between 2005 and 2021 were analyzed. Patients operated on between 2003 and 2004 were excluded due to a lack of electronic records. Overall, 84.1% of the surgeries (n = 1,299) were performed by two fellowship-trained upper limb surgeons, with the remainder performed by one of the 14 orthopaedic surgeons working in the province. Total shoulder arthroplasty (TSA) was the most frequent procedure (32.17%; n = 497), followed by stemmed hemiarthroplasty (SHA) (27.7%; n = 428). The most frequent indication for primary shoulder arthroplasty was degenerative osteoarthritis (58.1%; n = 882), followed by acute proximal humerus fracture in 15.11% (n = 245), and rotator cuff arthropathy in 14.18% (n = 220). The overall rate of revision was 7.7% (2.8% to 11.2%). The number of TSAs and reverse shoulder arthroplasties (RSAs) has been increasing since 2016. The amount of revision cases is proportional to the number of operations performed in the same year throughout the study period. The incidence of shoulder arthroplasty in the Maritime Provinces has increased over the last 16 years. Revision rates are similar the those found in other large database registries. Reverse shoulder arthroplasty prevalence has increased since 2016.

Primary versus conversion reverse total shoulder arthroplasty for complex proximal humeral fractures in elderly patients: a retrospective comparative study.

The purpose of this study was to compare clinical, implant-related, and patient-reported outcomes of shoulders undergoing conversion to reverse total shoulder arthroplasty (rTSA) following previous open reduction-internal fixation vs. shoulders undergoing rTSA as a primary treatment modality for acute proximal humeral fractures (PHFs) in patients aged ≥65 years. We performed a retrospective analysis of a prospectively collected cohort of patients who underwent primary rTSA for PHFs vs. a cohort who underwent conversion arthroplasty with rTSA following fracture repair between 2009 and 2020. Outcomes were assessed preoperatively and at latest follow-up. Demographic characteristics and outcomes were analyzed between cohorts using conventional statistics, as well as stratification by minimal clinically important difference and substantial clinical benefit thresholds where applicable. In total, 406 patients met the study criteria, of whom 322 underwent primary rTSA for PHF and 84 underwent conversion rTSA after failed PHF open reduction-internal fixation. The conversion rTSA cohort was, on average, 7 years younger than the primary rTSA cohort (65±10 years vs. 72±9 years, P<.001). The follow-up periods were similar between the cohorts, with an average of 47.1 months (range, 24-138 months). The percentages of Neer 3-part (41.9% vs. 45.2%) and 4-part (49.1% vs. 46.4%) PHFs were similar (P>.99). The primary rTSA cohort achieved higher forward elevation, external rotation, and patient-reported outcome measurements including Simple Shoulder Test, American Shoulder and Elbow Surgeons, University of California-Los Angeles, Constant, Shoulder Arthroplasty Smart, and Shoulder Pain and Disability Index scores at a minimum of 24 months postoperatively (P<.05 for all). Patient satisfaction was higher in the primary rTSA group than in the conversion rTSA cohort (P=.002). Patient-reported outcome measures uniformly favored the primary rTSA cohort, rising to the level of statistical significance for forward elevation, American Shoulder and Elbow Surgeons score, and Shoulder Pain and Disability Index score (P<.05) relative to substantial clinical benefit. The adverse event rate and revision rate in the conversion rTSA cohort were higher than those in the primary rTSA cohort (26.2% vs. 2.5% [P<.001] and 8.3% vs. 1.6% [P=.001], respectively). At 10 years postoperatively, the revision-free implant survival rate was significantly lower in the conversion cohort compared with the primary cohort (66% vs. 94%, P=.012). Finally, the hazard ratio of revision was 3.69 in the conversion rTSA cohort compared with only 1.0 in the primary rTSA cohort. This study demonstrates that elderly patients who undergo rTSA as a conversion procedure following previous osteosynthesis do not fare as well as those treated with rTSA for acute displaced PHFs. Conversion rTSA patients report lower patient satisfaction and have significantly restricted range of shoulder motion, a higher risk of complications, a higher risk of revision, poorer patient-reported outcomes, and a shorter implant survival rate at 10 years compared with patients undergoing acute rTSA.

Inferior surgical outcomes following reverse total shoulder arthroplasty for nonunion and malunion compared to acute arthroplasty: a nationwide matched cohort analysis

BackgroundReverse total shoulder arthroplasty (rTSA) has become popularized in the management of acute proximal humerus fractures (PHFs). Limited evidence exists to compare the outcomes of acute rTSA to management following failed open reduction and internal fixation. We aimed to analyze the differences between acute rTSA for PHF compared to subsequent rTSA for nonunion/malunion. MethodsPatients who underwent primary rTSA from 2016 to 2020 were identified in the Premier Healthcare Database. Nonunion, malunion, and hardware complication patients were identified using International Classification of Diseases Tenth Revision diagnosis codes and compared to acute PHF controls. Patients were matched in a 1:1 fashion to acute fracture based on age (±3 years), sex, race, and presence of pertinent comorbidities. Patient demographics, hospital factors, patient comorbidities, and 90-day complications were assessed and compared between the two cohorts. Descriptive statistics and regression analysis were employed with significance set at P < .05. ResultsPrior to matching, 8561 nonunion/malunion cases and 11,134 acute rTSA controls were identified. Patients undergoing acute rTSA for PHF were older, had longer length of stay, and higher total costs (P < .0001). When compared to acute rTSA for fracture, nonunion/malunion patients were at increased risk of multiple surgical complications including periprosthetic joint infection (odds ratio [OR]: 4.56; 95% confidence interval [CI]: 2.95-7.04; P < .0001), periprosthetic fracture (OR: 2.86; 95% CI: 2.09-3.93), stiffness (OR: 2.01; 95% CI: 1.17-3.44; P = .01), and dislocation (OR: 2.37; 95% CI: 1.80-3.12; P < .0001). However, patients undergoing acute rTSA had higher rates of all medical complications investigated, including deep vein thrombosis, pulmonary embolism, pneumonia, myocardial infarction, acute kidney infection, and sepsis (P < .001). ConclusionrTSA after nonunion/malunion of PHFs is associated with increased risk of surgical complications compared to acute rTSA. Initial rTSA for PHFs may mitigate subsequent increased risk of surgical complication and should be considered as the initial treatment option in patients with PHFs. However, the increased risk of medical complications seen in acute PHF warrants attention and diligent medical optimization from providers.

Dual plate fixation of proximal humerus fractures: Retrospective review and surgical technique.

Recent interest has been directed towards dual plate fixation for comminuted proximal humerus fractures, with an aim to improve construct stability and thus improve patient outcomes while decreasing the risk of fracture-associated complications. We present our experience with this technique in a case series of patients with proximal humerus fractures and describe our surgical technique. This was a single-center retrospective case series of patients presenting with an acute (<6 weeks) proximal humerus fracture who underwent ORIF with dual plating fixation. Patient, fracture, and surgical data were collected. All patient outcomes were evaluated using Constant-Murley shoulder score and Single Assessment Numeric Evaluation. Our series included nine patients with a mean age of 46.2 years (range: 27-70 years old). All fractures healed within 4 months and no complications were encountered. At 1 year follow-up, the mean SANE score was 69.4% and the mean Constant Murley shoulder score was 78.9 (range: 70-96). Our current series shows that applying the dual plating technique in severely comminuted proximal humerus fractures provides adequate fixation and thus good patient outcomes. Further research is required before this technique can be strongly recommended for management of these complex fractures. Level 5.

Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fractures Treated With Trabecular Metal Prosthesis: Medium-Term Results.

Introduction Reverse shoulder arthroplasty (RSA) is becoming increasingly popular as a primary procedure for complex proximal humeral fractures (PHF) in acute trauma due to more emerging evidence and better patient outcomes. Methods This study is a retrospective case series of 51 patients who underwent a trabecular metal RSA for non-reconstructable, acute three or four-part PHF performed by a single surgeon between 2013 and 2019 with a minimum follow-up of three years. This included 44 females and seven males. Mean age was 76 years (range: 61-91 years). Oxford shoulder score (OSS) along with relevant patient information relating to demographics and functional outcomes were collected at regular intervals in outpatient clinic follow-ups. Complications were addressed accordingly during treatment and follow-up. Results The mean follow-up duration was 5.08 years. Two patients were lost to follow-up and nine patients died due to other causes. Four of them had developed severe dementia and were excluded as an outcome score from them could not be acquired. Two patients who had surgery beyond four weeks post-injury were excluded. Thirty-four patients in total were followed up. Patients had good range of motion and mean OSS of 40.28 post-operatively. The overall complication rate was 11.7%, and none of the patients had deep infections, scapular notching, or acromial fractures. Revision rate was 5.8% at mean follow-up of five years and one month (range: three years to nine years two months).Greater tuberosity union following intra-operative repair was evident on radiographs in 61.7% of the patients. Conclusion RSA is certainly a rewarding surgery in patients with complex PHF and was associated with good post-operative OSS along with patient satisfaction, and positive radiological outcomes at minimum three-year follow-up.

DOES HEALTHCARE SETTING INFLUENCE OUTCOMES FOLLOWING SHOULDER ARTHROPLASTY?

In Australia nearly two-thirds of arthroplasty procedures are performed in the private setting, which is disproportionate to the dimensioning 43.5% of the population with private health cover. The rapid growth of shoulder arthroplasty surgery will be absorbed by both private and public sectors. This study aimed to assess the influence of healthcare setting on elective shoulder arthroplasty outcomes, defined by revision rate, and functional measures.Data was collected on all primary procedures performed from 2004 – 2019 within a regional area of Victoria, Australia. Patients were categorised into private or public settings. Trauma cases for acute proximal humerus fractures were excluded. The primary outcome of revision surgery was recorded as a cumulative percentage, and survival analysis conducted to calculate a hazard ratio (HR). Functional outcomes were measured through range-of-motion (ROM) and multiple validated patient-reported-outcome-measures (PROMs).458 patients were identified in the study: 290 private and 168 public. There was no difference in the revision rate (3.8% private, 4.8% public), with an adjusted HR of 1.25 (p=0.66) for public compared to private. Baseline and post-operative functional measures were significantly greater in the private setting for ROMs and PROMs analysis, in particular post-operative QuickDASH (15.9±14.7 to 32.7±23.5; p&lt;0.001) and Oxford Shoulder Score (42.6±6.3 to 35.7±11.2; p&lt;0.001). However, there was no significant difference for any of the functional measures in the amount of change from baseline to 12-months between settings.Although healthcare setting does not appear to influence revision rate for shoulder arthroplasty, clear differences were demonstrated for functional measures both pre and post operatively. This may be attributed to factors such as access to perioperative rehabilitation and should be an area to target future investigations.

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.

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

The role of hemiarthroplasty (HA) in the management of proximal humerus fractures (PHFs) and their sequalae has evolved with the development of contemporary internal fixation techniques and the widespread use of the reverse total shoulder arthroplasty. However, HA may still have a role in certain acute PHFs as well as select fracture sequalae. The aim of this investigation was to evaluate the outcomes of HA when used in acute fractures and fracture sequelae. Over a 16-year period (2000 - 2016), 122 primary HA performed for either acute PHFs or fracture sequelae were identified. Of these, 70 (57.4%) HA were performed within 4 weeks of the injury, whereas 52 (42.6%) underwent HA for fracture nonunion, malunion, or avascular necrosis. The minimum follow-up period was 2 years. Outcomes included the visual analog scale for pain, range of motion, American Shoulder and Elbow Surgeons (ASES) score, complications, and reoperations inclusive of revision surgery. Cumulative incidence analysis was used to report implant survivorship with death as a competing risk. The mean follow-up time after HA was 4.8 years (range, 2-15 years) with no differences between groups (P=.102). Cohort comparisons demonstrated an older age (67.8 vs. 60.1; P=.004), lower rate of previous procedure (4.3% vs. 51.9%; P<.001), lower bone graft use (28.6% vs. 59.6%; P<.001), and a longer length of stay (5.9 vs. 3.0 days; P<.001) in the acute HA group. Additionally, no differences were observed between the acute and sequalae cohort in pain (2.0 vs. 2.5; P=.523), forward elevation (98° vs. 93°; P=.627), external rotation (30° vs. 23°; P=.215), internal rotation score (4.0 vs. 4.5; P=.589), satisfaction (P=.592), ASES scores (64.4 vs. 57.1; P=.168), complications (27.1% vs. 28.8%; P=.836), or reoperations (11.4% vs. 19.2%; P=.229). When comparing acute fractures and sequalae, the 15-year complication rates were 32.4% and 43.3%, respectively (P=.172), with 15-year reoperation rates of 13.7% and 24%, respectively (P=.098). HA, whether performed acutely for a PHF or in a delayed fashion for fracture sequalae, demonstrated no statistically significant differences in outcomes for all examined parameters. HA in this setting may provide reasonable pain relief. However, limited motion, marginal ASES scores, and elevated rates of complications and reoperations can be expected up to 15 years postoperatively.

Self-Reduction in Proximal Humerus Fractures through Upright Patient Positioning: Is It up to Gravity?

Background: The self-reduction in proximal humerus fractures (PHFs) remains a poorly explored myth, and it was rarely investigated in the past. One of the oldest hypotheses suggests that gravity and the weight of the affected arm alone are driving forces, which facilitate a self-reducing potential in PHFs. However, thus far, clear radiographic evidence for this theory is missing in the literature. This study aimed to investigate the immediate effect of upright patient positioning on self-reducing of PHFs. Methods: Between November 2019 and November 2020, seven consecutively bedridden but mentally competent patients were admitted to our emergency department with an acute proximal humerus fracture. Within routinely attempts of closed reductions under the control of an image converter (C-arm), immobile patients were mobilized into an upright sitting position on a stretcher while the affected arm was immobilized in a sling. Fluoroscopic controls were performed before and after upright positioning. Changes in the head-shaft angle (HSA), as well as the medial hinge index (MHI), were determined on plain true anteroposterior (AP) fluoroscopic images. Results: In all cases, upright patient positioning had an immediate self-reducing effect. This effect could be seen in five out of seven cases for both HSA and MHI. Changes in HSA and MHI averaged 21.2° and 0.25, respectively. Mean deviation from an ideal, anatomic HSA of 135° decreased through upright positioning from 25.5° to 13.8°. Mean deviation from an ideal, anatomic MHI of 1 decreased through upright positioning from 0.28 to 0.19. Conclusions: Upright patient positioning might contribute immediately to the self-reduction in PHF through the force of gravity. This underlines the importance of being aware of patients’ position when interpreting X-ray images within treatment decision-making processes.

Anatomic greater tuberosity healing does not influence the functional outcomes of reverse shoulder arthroplasty for acute proximal humerus fractures.

To investigate the functional outcomes of reverse shoulder arthroplasty (RSA) in acute complex proximal humerus fractures (PHF) in patients with an anatomic greater tuberosity union in comparison to patients with a displaced or resorbed tuberosity. It is a retrospective study with prospective data collection including 32 consecutive PHF with a minimum two-year follow-up treated with RSA. A radiological study and a CT scan were performed specifically for the study. Two shoulder surgeons and a musculoskeletal radiologist assessed the position and union of the greater tuberosity. The functional outcomes were assessed with the Constant-Murley, DASH, ASES and ADLER scores. The mean overall CS was 59.55. In 17 cases, the greater tuberosity healed in an anatomical position. In 15 cases, it was non-anatomical. In 53% of patients, greater tuberosity union was obtained. The CS was 62.76 in the anatomic union group and 55.9 in the non-anatomic union group. No significant differences were observed. No differences were observed in the ASES, DASH and ADLER scores. After RSA for PHF, anatomic greater tuberosity healing was obtained in 53% of patients. The influence of the position and union of the greater tuberosity on the functional results could not be evidenced.

Incidence and risk factors for pseudosubluxation of the humeral head following proximal humerus fracture.

BackgroundHumeral head pseudosubluxation (HHPS) in relation to the glenohumeral joint is a common finding following fractures of the proximal humerus. The temporary inferior subluxation of the humeral head may be secondary to a transient axillary nerve neuropraxia, pain inhibition of the deltoid, or hemarthrosis or capsular disruption that alters the physiologically negative pressure in the glenohumeral joint. Despite the frequency of this finding, it is not well described in the literature. This study sought to describe the incidence, risk factors, and rate of resolution of HHPS following proximal humerus fracture.MethodsThe practice of two fellowship-trained shoulder and elbow surgeons was queried for proximal humerus fractures. Patient radiographs were reviewed at the time of injury and all subsequent follow-ups through one year after injury. Data collection included the presence of HHPS, type of fracture based on the Neer classification, operative vs. nonoperative management, and resolution of HHPS. Exclusion criteria included skeletally immature patients, fracture-dislocations, patients treated with reverse shoulder arthroplasty, inadequate follow-up, or those patients with incorrect International Classification of Diseases coding.ResultsThe incidence of HHPS was 20.0% (103 out of 515 patients) overall. Patients who required surgical intervention were more likely to develop pseudosubluxation than those who were treated conservatively (P < .001). There was an increasing incidence of pseudosubluxation based on the Neer classification, with 0-part fractures demonstrating a 2.56% (2/78) rate, whereas 4-part fractures were found to have HHPS in 35.1% (20/57) of cases (P < .001). All patients were found to have resolution of their HHPS at the final follow-up or one year after injury. None of age, sex, obesity, or injury to the dominant arm was associated with the occurrence of HHPS. There was, however, a statistically significant difference in the body mass index of those who developed HHPS (28.4, ± 5.77) vs. those who did not (26.2, ± 5.32, P < .01).ConclusionThis retrospective radiographic study is the largest to date investigating the incidence of HHPS following proximal humerus fracture and first to correlate with Neer classification and operative intervention. We found that HHPS occurs in one-fifth of acute proximal humerus fractures and resolves regardless of intervention. More complex fractures, including those with increasing Neer parts or requiring operative intervention, developed HHPS at higher rates than simpler fracture patterns. This study will help both general orthopedists as well as shoulder surgeons understand the epidemiology of HHPS and provide reassurance to patients that PS is a benign finding with expected spontaneous resolution by one year.

Outcomes of acute but not delayed reverse total shoulder arthroplasty for proximal humerus fracture are equal to those for rotator cuff arthropathy

BackgroundThe utilization of reverse total shoulder arthroplasty (RTSA) for the treatment of proximal humerus fractures in the elderly is increasing. Recent results support the use of RTSA for this indication over hemiarthroplasty or open reduction internal fixation (ORIF). However, there are limited data on the outcomes of RTSA for fracture or fracture sequelae as compared to RTSA for cuff tear arthropathy (CTA). We hypothesized that patients undergoing RTSA for fracture or fracture sequelae would have worse outcomes compared to patients undergoing RTSA for CTA. MethodsThis was a retrospective analysis of a prospectively collected outcomes database of all patients undergoing shoulder arthroplasty at a single institution between 2008 and 2019. Patients were included if they underwent primary RTSA for a diagnosis of acute fracture, fracture nonunion or malunion, failed hemiarthroplasty or ORIF for proximal humerus fracture, or rotator cuff arthropathy. The primary outcome was American Shoulder and Elbow Surgeons (ASES) score at the most recent follow-up, with minimum 1-year follow-up. Secondary outcomes included range of motion (ROM) at most recent follow-up, patient satisfaction with surgery, and revision or reoperation rates. Analysis of variance was used to compare continuous variables between the groups, while chi-square or Fisher's exact test were used to compare categorical variables. Linear regression analysis was used to perform multivariable analysis. Prosthesis survival rates were calculated using Kaplan-Meier survival analysis. Significance was defined as P< .05. ResultsThere were 287 patients included in the final cohort, including 62 with fracture and 225 with CTA. Sex, diagnosis, increasing patient comorbidities, and diagnosis (malunion/nonunion and failed prior surgery) were associated with worse ASES scores on univariate analysis (P < .05). On multivariate analysis, there was no difference in outcomes (ASES and ROM) between the acute fracture and CTA cohorts (P > .05). Outcomes of delayed RTSA for malunion/nonunion and hemiarthroplasty/ORIF were significantly worse than those for acute fracture/CTA (P < .01). Three-year prosthesis survival was 95% for CTA, 97% for acute fracture, 97% for malunion/nonunion, and 78% for failed prior surgery. ConclusionTreatment of acute proximal humerus fractures with RTSA leads to similar improvements in patient outcomes compared to elective treatment for CTA, but outcomes of delayed RTSA for fracture are considerably worse. These findings provide further guidance to clinicians counselling patients on treatment options and outcomes for proximal humerus fractures. Level of evidenceLevel III; Retrospective comparative study

Repair of proximal humerus fracture nonunions using a standardized treatment algorithm: a case series.

Nonunion of fractures about the proximal humerus represents a rare and complex problem. The purpose of this study was to evaluate the clinical and functional outcomes following proximal humerus fracture (PHF) nonunion repair using a plate and screw construct with a direct comparison to those experienced following operative fixation of acute PHF using a plate and screw construct. Two separate patient cohorts were included in this study. The first consisted of 16 patients diagnosed with a non-united PHF who underwent operative nonunion repair treated with a standard algorithmic approach. The comparison group consisted of 173 patients who achieved union following initial open reduction and internal fixation of an acute PHF treated with a proximal humerus locking plate construct. All patients had at least 12months of postoperative follow-up. Outcomes were assessed for both groups using American Shoulder and Elbow Surgeons (ASES) scores, visual analog scale (VAS) pain scores, and postoperative shoulder range of motion (ROM). Statistical analyses were used to compare these outcome measures between the two cohorts. The nonunion repair cohort consisted of eleven surgical neck nonunions and five nonunions of both the surgical neck and greater tuberosity. Ten patients had undergone surgical treatment for their original fracture, while six were initially treated non-operatively. All patients had Boileau type 3 sequelae of their proximal humerus fracture. Union was achieved in all patients at a mean of 5.4months following nonunion repair. Complications included hardware failure requiring revision in two patients (12.5%) and avascular necrosis requiring conversion to anatomic total shoulder arthroplasty following union in one patient (6.3%). The nonunion repair and acute fracture cohorts did not differ with respect to mean ASES scores, VAS pain scores, or active shoulder ROM at any postoperative time point. Surgical repair of PHF nonunion is a viable treatment strategy that can lead to consistent bony healing with outcomes comparable to those of patients who achieve fracture union following initial surgical repair of an acute proximal humerus fracture. Surgeons should be cognizant of mechanical considerations that may lead to early failure.

Fracture-Specific and Conventional Stem Designs in Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fractures-A Retrospective, Observational Study.

Tuberosity healing and stem design can be outcome-dependent parameters in hemiarthroplasty for proximal humerus fractures (PHF). The relevance of fracture-specific stem design in reverse shoulder arthroplasty (RSA) is still a matter of debate. This retrospective study evaluates tuberosity healing and function for fracture specific stems (A) compared to conventional stems (B) in RSA for complex PHF in 26 patients (w = 21, mean age 73.5 years). Clinically, range of motion (ROM), Constant-Murley-Score (CS), Subjective Shoulder Value (SSV), and external rotation lag signs (ERLS) were evaluated. Healing of greater tuberosity (GT) and lesser tuberosity (LT), scapular notching, and loosening were examined radiologically. There were no statistical significant differences with regards to CS (A: 73 ± 11; B: 77 ± 9 points), SSV (A: 78% ± 11%; B: 84% ± 11%), external rotation (A: 18° ± 20°; B: 24° ± 19°), or internal rotation (A: 5.7 ± 2.2; B: 6.7 ± 2.8 CS-points) (p > 0.05). Mean forward flexion was superior for group A (p = 0.036). Consolidation of GT (82%) and LT (73%) was similar in both groups. Anatomical healing was slightly higher in group B (p > 0.05). Scapular notching was found in 27% (A) and 55% (B) (p > 0.05). RSA for PHF provides good to excellent clinical results. The quantitative and qualitative union rate for both cohorts was similar, indicating that fracture stems with open metaphyseal designs to allow for bone ingrowth do not improve tuberosity healing. ERLS correlates with a worse function in CS and ROM in all planes.

Tuberosity union in patients with proximal humerus fractures treated with reverse shoulder arthroplasty: a technical note and exploratory analysis.

The use of reverse shoulder arthroplasty (RSA) to treat complex humerus fractures is increasing, especially in older, osteoporotic patients. Refixation and tuberosity healing are needed to achieve an optimal range of motion (ROM), external rotation, active forward elevation, and patient satisfaction. Proper healing has been reported, however, in only 40-84% of cases. Our study's aim was to describe a simple, reproducible fixation technique designed to improve tuberosity healing. We included 30 patients with acute proximal humerus fractures undergoing RSA (Global Unite Reverse Fracture, DePuy Synthes, Warsaw, IN, USA) with tuberosity reattachment. The humerus stem was cemented in 24 cases. A standardized suture technique with two fiber tapes was used to reattach tuberosities. Clinical and radiological parameters, which were collected one year post-operatively, included ROM, pain level, Constant scores, subjective shoulder value (SSV), and tuberosity healing. The mean age of the patients was 79.3years (± 7; range 65-92), and the tuberosity healing rate was 90.0% (27 of 30). Two patients showed migration (one nonunion, one malunion), and another had complete resorption after an initial period of proper healing. Radiolucent lines around the humerus stem occurred in one case, and three patients had scapular notching. The mean SSV was 86% (± 11; range 60-100), the Constant score was 72 (± 10.3; range 48-92), the active forward flexion was 140° (± 14.3; range 115-165), and external rotation was 23° (± 16.5; range 0-50). This reattachment technique, which is simple and reproducible, achieved a higher tuberosity healing rate than previously published rates.

Low arthroplasty survival after treatment for proximal humerus fracture sequelae: 3,245 shoulder replacements from the Nordic Arthroplasty Register Association

Background and purpose — Proximal humerus fractures (PHF) may result in sequelae indicating arthroplasty. We report cumulative survival rates and reasons for revision after arthroplasty for proximal humerus fracture sequelae (PHFS).Patients and methods — Data were derived from the Nordic Arthroplasty Register Association. The Kaplan–Meier method was used to illustrate survival rates. A scaled Schoenfeld residual plot was used to report the risk of revision for men relative to women in patients who were treated with reverse shoulder arthroplasty (RSA). Revision was defined as removal or exchange of any component or the addition of a glenoid component.Results — 30,190 primary arthroplasties were reported from 2004 to 2016, of which 3,245 were for PHFS. The estimated 1-, 5-, and 10-year cumulative survival rates (95% CI) were 96% (95–97), 90% (89–92), and 86% (83–88) for stemmed hemiarthroplasty and 94% (92–95), 89% (87–91), and 86% (82–90) for RSA with a median time to revision of 18 months (IQR 9–44) and 3 months (IQR 0–17). The risk of revision for men relative to women in patients who were treated with RSA was 3.2 (1.9–5.1) 0–1 year after surgery and 1.9 (0.9–4.1) 1–8 years after surgery. The estimated 1-, 5-, and 10-year cumulative survival rates (95% CI) were 94% (92–96), 88% (85–90), and 80% (75–86) for men and 95% (94–96), 86% (84–89), and 81% (77–84) for young patients.Interpretation — Shoulder arthroplasty for PHFS was associated with lower survival rates, compared with previously published results of shoulder arthroplasty for acute PHF. The low arthroplasty survival rates for men and young patients especially are worrying.