Acute Proximal Humerus Fractures Research Articles

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.

Outcomes for reverse total shoulder arthroplasty after failed open reduction internal fixation versus primary reverse total shoulder arthroplasty for proximal humerus fractures

BackgroundThe purpose of this study is to determine the clinical and radiographic outcomes of reverse total shoulder arthroplasty (RTSA) after failed open reduction internal fixation (ORIF) for proximal humerus fracture (PHF) and compare them to outcomes of primary RTSA for PHF. MethodsWe performed a retrospective comparative study of patients who underwent RTSA between 2008 and 2015 at our institution by one of two fellowship-trained shoulder and elbow surgeons for an acute PHF or for continued pain or functional limitations following ORIF of a PHF. We compared the American Shoulder and Elbow Surgeons (ASES) scores, Simple Shoulder Test (SST) scores, range-of-motion, and radiographic measurements between cohorts. ResultsIn total, there were 20 patients treated with RTSA after failed ORIF and 30 patients treated acutely with RTSA for PHF. The average ASES score was significantly greater for primary RTSA (82.0 ± 13.5) than for delayed RTSA (64.0 ± 27.2, P = 0.016). The average SST score for primary RTSA (69.4%±19.1%) was significantly higher than the average for delayed RTSA (49.1%±8.9%, P = 0.020). Forward elevation achieved postoperatively was significantly greater for patients treated with primary RTSA versus those with delayed RTSA (130±31° vs 107±31°, P = 0.035). No difference was detected between groups in postoperative external rotation (P = 0.152) or internal rotation (P = 0.872). Radiographically, the tuberosities healed in an anatomic position in 70% of the primary cases versus the prior ORIF group in which the tuberosities were in an anatomic position in all cases (P = 0.007). ConclusionsIn an elderly population, primary RTSA for PHF resulted in better clinical outcomes compared to RTSA following failed ORIF in this retrospective cohort study. Level of EvidenceLevel III; Retrospective Comparative Study

ORIF vs. Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fracture: A Retrospective Review Comparing Two Treatment Options

Proximal humerus fractures are a frequent fragility fracture in the aging population and represent a challenge to the orthopedic surgeon. Open reduction internal fixation (ORIF) of these fractures is a viable but technically challenging with a high complication rate. In recent years, reverse shoulder arthroplasty (RTSA) has become a popular option for treating these fractures. The purpose of this study is to compare the outcomes between patients treated with ORIF versus RTSA for treatment for proximal humerus fractures.

Use and Cost of Reverse Shoulder Arthroplasty Versus Hemiarthroplasty for Acute Proximal Humerus Fractures.

Although reverse total shoulder arthroplasty (RTSA) may outperform hemiarthroplasty (HSA) for acute proximal humerus fractures (PHF), both the RTSA implant and the procedure are more expensive. The goal of this study was to compare the use and longitudinal cost of care for RTSA vs HSA for the treatment of PHF. Patients were selected from a private payer database with a surgical date between 2010 and 2015. The International Classification of Diseases, 9th Revision, Clinical Modification(ICD-9-CM), codes were used to identify patients who underwent RTSA and HSA for PHF. The 1-year cost follow-up was guaranteed. During the study period, a total of 1038 patients underwent RTSA and 1046 patients underwent HSA for the treatment of PHF. A total of 601 patients who underwent RTSA and 431 patients who underwent HSA with at least 1 year of follow-up were matched by age and sex. The average Charlson Comorbidity Index for the RTSA and HSA groups was 4, indicating similar health status. From 2010 to 2015, the use of RTSA increased linearly (R2=0.986), whereas the use of HSA decreased linearly (R2=0.796). The average index admission cost was higher for RTSA than for HSA ($15,263 vs $14,356, respectively; mean difference [MD], $907; 95% confidence interval [CI], $58-$1760; P=.04). At 1 year postoperatively, however, no statistically significant difference was noted in cost (P=.535). The 1-year physical and occupational therapy cost per patient was higher after HSA than after RTSA (MD, $723; CI, $718-$728; P<.001), but no difference was noted in discharge disposition or 1-year revision or readmission rates. The results of this study suggest that despite the higher initial cost of RTSA, the total cost of care in the year after RTSA and HSA is similar. Therefore, RTSA should be considered in the appropriate clinical setting. [Orthopedics. 2020;43(2):119-125.].

Primary reverse shoulder arthroplasty for acute proximal humerus fractures: A 5-year long term retrospective study of elderly patients

BackgroundReverse shoulder arthroplasty (RSA) in complex shoulder fractures is ever more frequently. This study compares clinical and radiologic results of patients with comminuted proximal humeral fractures (PHFs) treated with RSA, with and without tuberosities grafting. MethodsBetween January 2009 and June 2014, 55 patients aged ≥65 years with 3- and 4-part PHFs were treated surgically. Patients’ files and the hospital’s digital database were reviewed retrospectively with at least 5-year of follow up. We constituted three groups according to the tuberosity consolidation: patients in whom the tuberosities showed anatomic consolidation (Group I) and patients either with secondary displacement of the tuberosities (Group II) or without tuberosity repair (Group III). ResultsThe 74% of the repaired tuberosities consolidated in anatomic position. Among range of motion (ROM), we reported that forward elevation, abduction and external rotation were significantly better in Group I than those in Group II-III. Furthermore, quick Dash score and Constant score showed more satisfied results in Group I. Regarding complications, not infection or instability were found in group I. On the other hand, in group II, we reported one patient with deep infection, leading to two steps surgery. In group III, we recorded two patients with instability required implant revision and one with deep infection treated by revision. ConclusionRSA showed satisfied results even at 5 year follow up. Preservation of the tuberosities in anatomic position improves active forward elevation and external rotation as well as patient satisfaction with less complications.

How common are acromial and scapular spine fractures after reverse shoulder arthroplasty?: A systematic review.

Acromial fractures following reverse shoulder arthroplasty (RSA) have a wide range of incidences in reported case series. This study evaluates their incidence following RSA by systematically reviewing the current literature. A systematic review using the search terms "reverse shoulder", "reverse total shoulder", or "inverted shoulder" was performed using PubMed, Web of Science, and Cochrane databases between 1 January 2010 and 31 March 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Studies were included if they reported on RSA outcomes and the incidence rate of acromial and/or scapular spine fractures. The rate of these fractures was evaluated for primary RSA, revision RSA, RSA indications, and RSA implant design. The review included 90 articles out of 686 identified after exclusions. The incidence rate of acromial and/or scapular spine fractures was 2.8% (253/9048 RSAs). The fracture rate was similar for primary and revision RSA (2.8% vs 2.1%; p = 0.4). Acromial fractures were most common after RSA for inflammatory arthritis (10.9%) and massive rotator cuff tears (3.8%). The incidence was lowest in RSA for post-traumatic arthritis (2.1%) and acute proximal humerus fractures (0%). Lateralized glenosphere design had a significantly higher rate of acromial fractures compared with medial glenosphere designs. Based on current English literature, acromial and/or scapular spine fractures occur at a rate of 2.8% after RSA. The incidence is slightly more common after primary compared with revision arthroplasty. Also, higher rates of acromial fractures are reported in RSA performed for inflammatory arthritis and in the lateralized glenoid design. Cite this article: Bone Joint J 2019;101-B:627-634.

Outcomes of Uncemented Versus Cemented Reverse Shoulder Arthroplasty for Proximal Humerus Fractures.

Reverse shoulder arthroplasty (RSA) for proximal humerus fractures (PHFs) is traditionally performed with cemented humeral fixation. The purpose of this study was to compare the clinical and radiographic outcomes of cemented and cementless RSA for PHF. Between 2010 and 2014, 38 acute PHFs were treated with RSA and followed for a minimum of 2 years (mean, 37 months; range, 24-66 months). The mean time from fracture to RSA was 7 days (range, 1-30 days). Humeral stems were cemented in 19 shoulders and uncemented in 19 shoulders. Outcome measures included visual analog scale pain scores, range of motion, postoperative Quick Disabilities of the Arm, Shoulder and Hand scores, American Shoulder and Elbow Surgeons scores, and radiographic parameters. The 2 groups had similar visual analog scale pain scores, postoperative range of motion, and Quick Disabilities of the Arm, Shoulder and Hand scores (P>.05). American Shoulder and Elbow Surgeons scores and satisfaction scores were significantly higher with cemented humeral fixation (76.3 vs 48.0, P=.005; 1.2 vs 1.8, P=.04). Radiographically, there was no difference in terms of tuberosity healing, component loosening, or notching (P>.05). Reverse shoulder arthroplasty provides pain relief for PHF, regardless of humeral fixation. In this cohort, cementless fixation was associated with worse patient-reported outcomes, although no correlation could be established with pain, motion, or tuberosity healing. Further studies are required before cementless fixation can be recommended for RSA for fracture. [Orthopedics. 2019; 42(2):e236-e241.].

The increasing role of reverse total shoulder arthroplasty in the treatment of proximal humerus fractures

IntroductionHemiarthroplasty of the shoulder is a well established treatment for proximal humerus fractures not amenable to open reduction internal fixation. However, orthopedic surgeons have recently increased utilization of reverse total shoulder arthroplasty (RTSA) in the treatment of these injuries. The purpose of this study was to evaluate the use of hemiarthroplasty and RTSA between 2009 and 2016 for the treatment of proximal humerus fractures within a large United States integrated healthcare system. Materials and methodsA descriptive study was conducted using our integrated healthcare system’s Shoulder Arthroplasty Registry. Shoulder arthroplasty cases performed for an acute proximal humerus fracture between the years of 2009 and 2016 were identified. Revision rates were determined, as well as changes in age and gender distribution of the cohort during the study period. ResultsIn 2015, RTSA utilization surpassed that of hemiarthroplasty for the first time in the healthcare system. The utilization of RTSA in the treatment of proximal humerus fractures increased from 4.5% of all arthroplasties in 2009 to 67.4% of arthroplasties in 2016. During the study period, patients undergoing hemiarthroplasty were younger and less likely to be female. Crude revision rate was 4.0% for hemiarthroplasty and 3.2% for RTSA. ConclusionsRTSA is increasingly being utilized for the treatment of proximal humerus fractures and now appears to be the treatment of choice. While hemiarthroplasty appears to be falling out of favor in the treatment of fractures of the shoulder, surgeons may still be preferentially using the procedure in younger patients.

Decreased Reoperations and Improved Outcomes With Reverse Total Shoulder Arthroplasty in Comparison to Hemiarthroplasty for Geriatric Proximal Humerus Fractures: A Systematic Review and Meta-Analysis.

We sought to compare range of motion, clinical outcome scores, and complications after reverse total shoulder arthroplasty (RSA) and hemiarthroplasty (HA) in geriatric patients with acute proximal humerus fractures. We searched MEDLINE (1946-2017), EMBASE (1947-2017), the Cochrane Central Register of Controlled Trials (1898-2017) and ClinicalTrials.gov in October 2017. No limits were used in the database search. We also manually reviewed reference lists of included studies. We did not restrict studies based on language. We included all randomized controlled trials and cohort studies in which the study population had a mean age of 65 years or older, received RSA or HA to treat an acute proximal humerus fracture, and had a minimum follow-up of 6 months. Two independent reviewers used a standardized data collection form to extract relevant information from included studies. Discrepancies were resolved by a consensus or a third party if consensus could not be reached. Study authors were contacted for missing or incomplete data. Using a random effects model, we calculated mean differences (MD) and standardized mean differences (SMD) for continuous outcomes; we calculated relative risk for dichotomous outcomes. Fifteen studies were included in the meta-analysis, including 421 patients treated with RSA and 492 treated with HA for a total of 913 patients. Compared with HA, the RSA group had significantly improved pain scores (SMD = 0.74, P < 0.001), outcome scores (SMD = 0.63, P < 0.001), and forward flexion (MD = 24.3 degrees, P < 0.001). Compared with RSA, the HA group had a significantly increased risk of reoperation (relative risk = 2.8, P = 0.02). There were no differences between the groups with regard to external rotation (P = 0.31) or deep infection (P = 0.90). Aggregating available research suggests that RSA results in improved range of motion, clinical outcome scores, and rates of all-cause reoperation with no difference in infection rates. Using RSA for the treatment of acute proximal humerus fractures in the elderly population may result in improved short- and medium-term outcomes compared with HA. Future work should evaluate long-term outcomes to see if the benefits of RSA persist. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Mortality and Readmission After Shoulder Hemiarthroplasty for Fracture.

BackgroundLimited information exists regarding mortality and readmission following proximal humerus fracture. This study examines risk factors following hemiarthroplasty for these fractures.MethodsA retrospective analysis of prospectively collected data on 788 patients treated with hemiarthroplasty for acute proximal humerus fracture from January 2005 to December 2011 was conducted. One-year mortality and 30- and 90-day hospital readmission were evaluated. Patient risk factors included age, race, gender, diabetes, American Society of Anesthesiologists (ASA) score, and body mass index.ResultsOne-year mortality rate was 5.2%. Patients with ASA ≥3 had 2.37 times (95% confidence interval [CI]: 1.05–5.32) greater mortality risk versus patients with ASA1/2. The 30-day readmission rate was 8.4% and at 90 days was 12.6%. Females had 0.53 risk of readmission versus males (95% CI: 0.29–0.96). Patients with ASA ≥3 had 1.79 (95% CI: 1.04–3.09) risk of 90-day readmission versus patients with ASA1/2; females had 0.52 (95% CI: 0.31–0.85) risk of readmission versus males. Increased age increased all odds ratios.ConclusionsReadmission rate after hemiarthroplasty for proximal humerus fracture is significant both at 30 and 90 days and is higher in males. Age and ASA ≥3 correlate with this. Diabetes and obesity were not significant risk factors for readmission or mortality.

Bilateral Proximal Humerus Fracture - a Rare Combination with a High Complication Rate after Surgery.

Bilateral acute proximal humerus fractures are rare. There are no data available about these bilateral injuries. The aim of the study was to analyse bilateral proximal humerus fractures retrospectively in terms of incidence, complications and revisions. All bilateral proximal humerus fractures were evaluated retrospectively using the institution's database, with the focus on cause of the injury, fracture severity and the clinical course compared to published information on monolateral proximal humerus fractures. Bilateral posterior dislocation fractures were excluded, because these fractures are a separate entity. Between 2005 and 2016, n = 17 patients were primarily treated within our hospital for an acute proximal humerus fracture on both sides (n = 12 female, n = 5 male, average age: 68 years; overall 34 proximal humerus fractures). The general trauma mechanism was a fall on both arms (82% [18% polytrauma]). There were 65% displaced 3-/4-part proximal humerus fractures. Angle-stable plate osteosynthesis was performed predominantly (64%), followed by fracture prosthesis (18%; tension wiring: 3%; non-operatively: 15%). Overall, n = 10 patients (59%) or n = 18 (53%) proximal humerus fractures developed a complication, primarily with loss of reduction or implant loosening (44%). In n = 14 (78%) of the complications further operations were necessary. Alcohol abuse was increasingly found in 29% of the cases within the bilateral patient cohort compared to patients with monolateral fractures. Bilateral proximal humerus fractures are mainly associated with comminuted displaced fractures and a higher complication rate in comparison to monolateral fractures after surgical treatment.

Primary Hemiarthroplasty Following Severe Proximal Humerus Fracture Dislocations with Irretrievable Humeral Head in Young Patients

Neer first popularised the use of primary hemiarthroplasty to treat complex proximal humerus fractures, especially when the humeral head is nonviable or not reconstructable with internal fixations, and with younger patients. A 16-year-old boy had a motor vehicle accident and sustained a closed right proximal humerus fracture dislocation without neurovascular injury. Intraoperatively, due to difficulty retrieving the humeral head which dislocated and positioned behind the clavicle, hemiarthroplasty was done to avoid injuring the brachial plexus, vessels and lung. Mr Y, a 34-year-old man similarly sustained closed left proximal humerus fracture dislocation with an irretrievable head. He too underwent hemiarthroplasty. Both patients were followed up for a year with no pain and fairly good range of movement and muscle power. In complex proximal humerus fractures, there is still debate regarding primary hemiarthroplasty. There are risks of secondary displacement of fracture fragments and head necrosis after internal fixation. Neer and Cofield reported over 90% patients had relief of pain and 66% patients had free range of movement post hemiarthroplasty. Other authors described primary malposition and subsequent migration or deficient osseous integration as a complication after prosthesis. In a thirteen-year observational cohort study of 163 patients with hemiarthroplasty, the overall rate of prosthetic survival was 96.9% at one year, 95.3% at five years, and 93.9% at ten years. Of the factors that were assessed, the age is most important due to factors such as degenerative changes in the rotator cuff, osteoporosis, and motivation to achieve a good range of motion. Successful treatment of acute proximal humerus fractures with prosthetic replacement is challenging to orthopaedic surgeons as it requires proper patient evaluation, good surgical technique, especially in soft-tissue tensioning and stability, and meticulous rehabilitation. In young patients with good bone quality and irretrievable head, hemiarthroplasty is a choice.

Paper #22 - Are outcomes of uncemented reverse shoulder arthroplasty for acute proximal humerus fractures equivalent to cemented stems?

Paper #22 - Are outcomes of uncemented reverse shoulder arthroplasty for acute proximal humerus fractures equivalent to cemented stems?

Comparison of Reverse Total Shoulder Arthroplasty vs Hemiarthroplasty for Acute Fractures of the Proximal Humerus: Systematic Review

ABSTRACT The optimal treatment of proximal humerus fractures is debated; however, reverse total shoulder arthroplasty (RTSA) has become increasingly popular as the primary treatment. We systematically reviewed the PubMed, EMBASE, and Scopus databases to identify English-language clinical studies (evidence levels I through IV) comparing the results of RTSA with those of hemiarthroplasty (HA) for the treatment of acute proximal humerus fractures. We evaluated the following outcomes: Range of motion, patient-reported outcome measures (including pain relief), and complications. We identified eight published studies comparing RTSA with HA for treatment of acute proximal humerus fractures. The RTSA group (180 patients) showed significantly better postoperative pain relief, active anterior elevation, Constant-Murley scores, and American Shoulder and Elbow Surgeons (ASES) scores compared with the HA group (439 patients; all p &lt; 0.05). There were no significant differences between the two groups for overall complications (RTSA, 11.8% vs HA, 20.8%), infections (2% for both groups), dislocations (RTSA, 0% vs HA, 2.5%), or nerve injury (RTSA, 1% vs HA, 2.8%). Scapular notching occurred in 15.8% of RTSA cases (grade I, 53%; grade II, 32%; grade III, 16%; and grade IV, 0%). In the treatment of acute proximal humerus fractures, RTSA provided better pain relief, postoperative anterior elevation, and outcome scores after surgery compared with HA and had similar complication rates. Keywords Complications, Outcomes, Pain, Reverse total shoulder, Shoulder hemiarthroplasty, Surgery, Systematic review. How to cite this article Borade AU, Familiari F, Choi K, Joseph J, McFarland EG. Comparison of Reverse Total Shoulder Arthroplasty vs Hemiarthroplasty for Acute Fractures of the Proximal Humerus: Systematic Review. J Postgrad Med Edu Res 2017;51(4):182-187.

Outcomes of reverse total shoulder arthroplasty as primary versus revision procedure for proximal humerus fractures

Reverse total shoulder arthroplasty (RTSA) has been shown to be an effective treatment for proximal humerus fracture (PHF). This study evaluates outcomes of all patients with PHF treated with RTSA as a primary procedure for acute PHF, a delayed primary procedure for symptomatic PHF malunion or nonunion, a revision procedure for failed PHF hemiarthroplasty (HA), or a revision procedure for failed open reduction and internal fixation (ORIF). Patients who underwent RTSA for PHF were evaluated for active range of motion and Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test-12, American Shoulder and Elbow Surgeons (ASES), University of California-Los Angeles (UCLA) shoulder rating scale, Constant, and 12-Item Short Form Health Survey scores. Scaption and external rotation (ER) strength were also assessed. RTSA was performed in 49 patients with PHF; 13 patients underwent RTSA for acute PHF, 13 for malunion or nonunion, 12 for failed PHF HA, and 11 for failed PHF ORIF. ER range of motion, SPADI, ASES, UCLA, and Constant scores achieved significance. The acute fracture group significantly outperformed the failed HA group in SPADI, ASES, and UCLA scores. The malunion/nonunion group significantly outperformed the failed HA group in ASES and UCLA scores. The acute fracture and malunion/nonunion groups each had significantly greater ER than the failed HA group. RTSA is an effective treatment option for PHF as both a primary and a revision procedure. Primary RTSA outperformed RTSA done as a revision procedure. RTSA for acute PHF is comparable to RTSA for malunions and nonunions. Our outcomes of revision RTSA for failed HA and ORIF are more promising than previously published.

Le traitement des fractures de l’humérus proximal par prothèse totale d’épaule est plus coûteux en dépense hospitalière malgré une durée de séjour plus courte

BackgroundOperation choice is a complex decision in the surgical management of proximal humerus fractures. Recently, there has been an increase in the use of total shoulder arthroplasty (TSA) for complex fracture patterns. HypothesisPatients with proximal humerus fractures who receive TSA are more likely to have higher hospital charges and a prolonged length of stay relative to patients receiving hemiarthroplasty (HA), open reduction with internal fixation (ORIF) or closed reduction with internal fixation (CRIF). Materials and methodsA statewide electronic database was used to identify 13,316 hospital admissions from 2000–2011 where a proximal humerus fracture was surgically managed in an effort to determine the effect of operation choice on cost and length of stay. A univariate analysis was preformed to examine overall trends in surgical management. Additionally, a periodic, multivariate logistic regression analysis was used to determine how operation choice affected the odds of a high cost hospital stay or a prolonged length of stay after controlling for age, comorbidity burden, gender, and insurance type. ResultsAfter controlling for confounding factors, patients receiving total shoulder arthroplasty (TSA) were 2.25 times more likely to have high total hospital charges than patients receiving HA and 3.21 times more likely than patients receiving ORIF. Additionally, TSA was found to be a significant negative predictor of prolonged length of stay (pLOS). HA, ORIF and CRIF did not significantly predict pLOS. DiscussionThe use of TSA for acute proximal humerus fractures is associated with increased hospital costs despite a shorter length of stay when compared to other operative choices. As reverse total shoulder arthroplasty becomes more popular for treatment of this injury, it is important that functional outcomes be interpreted in the context of relative cost trade-offs. Level of evidenceLevel IV.

Expanding roles for reverse shoulder arthroplasty.

Since its introduction in the USA in 2003, reverse total shoulder arthroplasty (RTSA) has been used with increasingly frequency as surgeons have observed the remarkable improvement in pain, range of motion, and function associated with this implant. RTSA was initially used exclusively for elderly, low demand individuals with end-stage rotator cuff tear arthropathy. However, RTSA is now being increasingly successfully employed for the management of irreparable rotator cuff tears, glenohumeral osteoarthritis with an intact rotator cuff, acute proximal humerus fractures, the sequelae of proximal humerus fractures, neoplasms of the proximal humerus, inflammatory arthropathy, young patients and failed anatomic total shoulder arthroplasty and hemiarthroplasty. While long-term outcomes are pending, short- and mid-term follow-up results suggest that in experienced hands, RTSA may be a reasonable treatment for many previously difficult to treat pathologies within the shoulder.

Total shoulder arthroplasty for proximal humerus fracture is associated with increased hospital charges despite a shorter length of stay

BackgroundOperation choice is a complex decision in the surgical management of proximal humerus fractures. Recently, there has been an increase in the use of total shoulder arthroplasty (TSA) for complex fracture patterns. HypothesisPatients with proximal humerus fractures who receive TSA are more likely to have higher hospital charges and a prolonged length of stay relative to patients receiving hemiarthroplasty (HA), open reduction with internal fixation (ORIF) or closed reduction with internal fixation (CRIF). Materials and methodsA statewide electronic database was used to identify 13,316 hospital admissions from 2000–2011 were a proximal humerus fracture was surgically managed in an effort to determine the effect of operation choice on cost and length of stay. A univariate analysis was preformed to examine overall trends in surgical management. Additionally, a periodic, multivariate logistic regression analysis was used to determine how operation choice affected the odds of a high cost hospital stay or a prolonged length of stay after controlling for age, comorbidity burden, gender, and insurance type. ResultsAfter controlling for confounding factors, patients receiving total shoulder arthroplasty (TSA) were 2.25 times more likely to have high total hospital charges than patients receiving HA and 3.21 times more likely than patients receiving ORIF. Additionally, TSA was found to be a significant negative predictor of prolonged length of stay (pLOS). HA, ORIF and CRIF did not significantly predict pLOS. DiscussionThe use of TSA for acute proximal humerus fractures is associated with increased hospital costs despite a shorter length of stay when compared to other operative choices. As reverse total shoulder arthroplasty becomes more popular for treatment of this injury, it is important that functional outcomes be interpreted in the context of relative cost trade-offs. Level of evidenceLevel IV.

Influence of Early Bisphosphonate Administration for Fracture Healing in Patients with Osteoporotic Proximal Humerus Fractures.

BackgroundBisphosphonates are generally known to adversely affect fracture healing because they inhibit osteoclastic bone resorption. However, some authors argue that bisphosphonates have no adverse effect on the restoration of the mechanical integrity of long bones after fractures. It is unclear whether bisphosphonates can be initiated safely in patients with acute proximal humerus fractures. The aim of this study was to determine whether the early use of a bisphosphonate affects healing and outcomes of osteoporotic proximal humerus fractures treated with a locking compression plate.MethodsBetween August 2004 and June 2013, a total of 82 osteoporotic patients who underwent locking plate fixation of proximal humerus fractures were enrolled retrospectively. The patients were divided into two groups according to the timing of the commencement of treatment with alendronate after surgery: group A (n = 34, initiation of the bisphosphonate treatment within two weeks after surgery) and group B (n = 48, control group, initiation of the treatment three months after surgery). Patients were assessed for radiographic union at 2, 6, 10, and 16 weeks, 6 months, and 1 year after surgery. Clinical assessments were performed using the Constant score and American Shoulder and Elbow Surgeons (ASES) score at 1 year after surgery.ResultsNo significant differences were observed between the two groups with respect to radiographic and clinical outcomes after locking plate fixation. All patients obtained fracture union, and the mean time to radiographic union was similar in group A and group B (6.3 and 6.6 weeks, respectively; p = 0.67).ConclusionsThis study shows that the early initiation of bisphosphonate treatment does not affect bone union or clinical outcomes in patients with an osteoporotic proximal humerus fracture treated by locking compression plate fixation.