Complex Proximal Humerus Fractures Research Articles

Development of a virtual surgical plan for reverse shoulder arthroplasty as a treatment for complex proximal humerus fracture in an elderly patient

IntroductionFracture reduction, implant selection and tuberosity reattachment propose significant challenges in reverse shoulder arthroplasty (RSA) for proximal humerus fractures (PHFs). It is hypothesised that preoperative virtual surgical planning (VSP) can improve implant positioning and tuberosity reattachment, resulting in better functional outcomes, reduced surgery time, and decreased complication risk. Therefore, this study aims to develop, implement, and evaluate a VSP protocol for RSA in complex PHFs. MethodsThe VSP protocol is developed using 3D medical image processing software based on CT scans from four previously treated patients with RSA for complex PHF. Next, the VSP was applied prospectively in a patient with a PHF planned for RSA. Evaluation was done using an expert opinion questionnaire evaluating surgical confidence, a comparison between implant positioning on postoperative radiographs and the VSP, functional outcomes and the Oxford Shoulder Score (OSS). ResultsThe study showed that VSP is a useful preoperative tool to optimize clinical outcome by digital fracture reduction, determination of surgical cuts, calculating implant size and height, and optimising tuberosity shape and reattachment. After two and six months, the patient showed good functional outcomes (OSS: 48/48 points), healing of tuberosities, and had minimal pain complaints. ConclusionVSP for RSA in PHF might create a more thorough preoperative understanding of the fracture pattern and implant and fracture fragment placement. Further investigative study would be required to demonstrate this.

Short-term clinical and radiographic outcomes with modular long stem for revision reverse total shoulder arthroplasty

BackgroundWhen performing reverse total shoulder arthroplasty with compromised proximal bone fixation, surgeons must consider using specialized stems with a distal press-fit design. In this study, the authors report on the clinical and radiographic outcomes of patients who underwent surgical management with modular diaphyseal press-fit stems. MethodsIn 2017-2021, patients who underwent revision reverse total shoulder arthroplasty reconstruction with diaphyseal press-fit stems (Aequalis Adjustable Stem [AS] or Aequalis Flex Revive Stem [RS]; Stryker, Kalamazoo, MI, USA) with minimum 1-year follow-up were identified. Patients with complex proximal humerus and scapula fractures, neurological injuries, and custom humeral replacements were excluded. Demographics and clinical follow-up data including range of motion, Visual Analog Scale (VAS), Simple Shoulder Test (SST), American Shoulder Elbow Surgeons (ASES) Score, and Single Assessment Numeric Evaluation were retrospectively reviewed. Postoperative radiographs were reviewed for aseptic humeral loosening, periprosthetic instability, stress shielding, periprosthetic fractures, and humeral stem failure. ResultsSixty-five patients (29 AS and 36 RS) had mean follow-up of 25 months (standard deviation ± 16). Mean anterior elevation improved from 57° ± 39 preoperative to 121° ± 31 postoperatively. Mean external rotation improved from 3° ± 17 to 34° ± 16. Mean internal rotation improved from 4° ± 13 to 35° ± 26. Mean VAS improved from 6.7 ± 2.2 to 2.9 ± 1.5. Mean SST improved from 13% ± 13% to 65% ± 22%. Mean ASES score improved from 19 ± 13 to 60 ± 18. Mean Single Assessment Numeric Evaluation improved from 25% ± 18% to 71% ± 17%. There were statistically significant differences in mean postoperative VAS (P = .0017), SST (P = .025), and ASES score (P = .0228) in favor of the RS group. There were no other notable differences between groups. The most common complications were aseptic humeral stem loosening (24% vs. 3%, P = .018) and periprosthetic instability (10% vs. 6%, P = .649) for the AS and RS cohorts, respectively. There was no statistically significant difference between surgical revision rates between the AS and RS cohorts (24% vs. 8%, respectively. P = .096). DiscussionDiaphyseal press-fit modular humeral stem can provide a viable surgical alternative in compromised proximal humeral bone. At short-term follow-up, the clinical and radiographic outcomes are comparable to other stem designs. Further studies are necessary to identify risks and causes of failure associated with modular diaphyseal press-fit stems.

Short-Term Results after Reversed Total Shoulder Arthroplasty

Abstract Purpose Massive rotator cuff tear, with or without arthritis and proximal humerus fracture non-union or malunion, lead to the loss of center of rotation of shoulder, while anatomical total shoulder arthroplasty does not provide a stable center of rotation, Therefor reversed total shoulder arthroplasty (RTSA) is the suitable method for these indications, as well as in elderly patients with primary glenohumeralosteoarthritis because anatomical total shoulder arthroplasty has the risk of failure either due to loosening of glenoid component or cuff tear. This study aimed to determine the short-term results after RTSA in patients a with massive cuff tear, acute proximal humerus fracture, proximal humerus fracture malunion or non- union, and primary glenohumeralosteoarthritis. Methods This one arm clinical trial (interventional study) conducted in Ain Shams University Hospitals included 16 patients who underwent RTSA. Short-term outcomes included constant score, American Shoulder and Elbow Surgeon (ASES) score, and range of motion (ROM). Patients with rotator cuff arthropathy, massive irreparable cuff tear with or without glenohumeralarthritis, elderly patients with acute complex proximal humerus fracture, malunited or nonunited proximal humerus fracture, and patients with glenohumeralosteoarthritis were included. Patients who were aged <50 years were excluded, as well as patients with axillary nerve injury or deltoid muscle dysfunction. Results This study included 16 patients, including 8 males and 8 females. The mean age was 64.19 years and the duration of follow up-was 1 year postoperatively. Seven Patients with massive irreparable cuff tear were included, of them, 1 had associated anterior shoulder instability and recurrent anterior dislocation, 3 had a four-part proximal humerus fracture, 2 had fracture dislocation, 2 had proximal humerus fracture non –union, 1had neglected dislocation, and 2 had glenohumeralosteoarthritis. Outcomes were followed using constant and ASES scoring systems, and ROM. The global postoperative gain was statistically significant (p < 0.001). Complication in the form of dislocation occurred in one case that had RTSA after fracture non-union. Conclusion Good clinical and functional outcomes were achieved after RTSA, not only for classic massive cuff tear indication, but for other disorders, such as acute proximal humerus fracture, fracture non-union, and primary glenohumeralosteoarthritis. However, the outcomes after irreparable cuff tear were the best among all indications, while fracture non-union had the least improvement in clinical outcomes. Improvements in prosthesis design, surgeon’s experience, and clinical results are necessary to optimize this treatment for many shoulder conditions.

Poster 150: Subscapularis CT Evaluation in Patients following Treatment for Proximal Humerus Fractures: Reverse versus Anatomical Total Shoulder Arthroplasty

Objectives: Hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RTSA) are both reliable treatment options for complex proximal humerus fractures. While the role of the subscapularis tendon is well defined in HA, its role in RTSA has not been clearly demonstrated. The purpose of our study is to evaluate the role of the subscapularis tendon in patients treated with HA and RTSA and investigate its association with clinical outcomes. Methods: Sixty-eight consecutive patients with proximal humeral fractures were prospectively enrolled in the study between June 2015 and May 2020 (RTSA = 36; HA = 32). Shoulder CT scans were performed pre- and postoperatively, and subscapularis muscle cross-sectional area (SMCSA) and supraspinatus fossa cross-sectional area (SFCSA) were measured. SMCSA/SFCSA ratio was employed to standardize values. Patient-reported outcomes (PROs) and range of motion (ROM) were evaluated at the final follow-up. Results: RTSA group demonstrated higher PROs compared to HA patients: Constant Score (p = .0001), Quick Dash (p = .0006), Simple Shoulder Test (p = .01). ROM was better in RTSA than HA: internal rotation (p = .0047 adduction and p = .026 abduction), external rotation (p = .001 adduction and p = .026 abduction) and forward flexion (p < .0001). Reduction of subscapularis size of >35% occurred in 20 RTSA and 8 HA (p = 0.01). The loss of subscapularis surface was greater in the RTSA patients (p = 0.018). Conclusions: RTSA demonstrated better results compared to HA, providing better PROs and ROM. Postoperative reduction in subscapularis size was significantly higher in RTSA compared to HA. Subscapularis condition demonstrated no correlation with functional outcomes in RTSA.

Poster 155: An Ultrasound and Clinical Evaluation in Patients Following Treatment for Proximal Humerus Fractures: Reverse Versus Anatomical Total Shoulder Arthroplasty

Objectives: Anatomic Total Shoulder Arthroplasty (ATSA) and Reverse Total Shoulder Arthroplasty (RTSA) are both viable treatment options for complex proximal humerus fractures. With its principal role as an abductor and internal rotator in a native joint, the subscapularis potentially plays an important functional and stability role postoperatively. Although less studied in RTSA, studies have found that failure of subscapularis repair is associated with anterior instability, and decreased range of motion (ROM), strength, and outcome scores following ATSA. The purpose of our study is to evaluate and compare the postoperative clinical, radiographic, and patient-reported outcomes following subscapularis reattachment in patients treated with either ATSA or RTSA. Methods: Sixty-eight consecutive patients with proximal humeral fractures were prospectively enrolled in the study between June 2015 and May 2020 (RTSA = 40; TSA = 28). Ultrasound scans of the subscapularis were performed postoperatively, and the subscapularis muscle cross-sectional area (iSMCSA) and contralateral subscapularis muscle cross-sectional area (cSMCSA) were measured. The ratio of the 2 values (iSMCSA/cSFCSA) was utilized to standardize values. Patient-reported outcomes (PROs) and ROM were evaluated at the final follow-up. Results: Demographically, there was no significant difference between age, arm dominance, surgical laterality, diabetes, or hypertension between the patient groups (Table 1). The RTSA group demonstrated higher PROs compared to TSA patients: Constant Score (p = .0007), Quick Dash (p = .0005), and ASES score (p = .09). ROM was better in the RTSA cohort, with statically significant values with internal rotation (p = .022 abduction), external rotation (p = .02 adduction and p = .01 abduction), abduction (p = 0.02), and forward flexion (p = .003). Radiographic ultrasound findings illustrated greater reduction in size of the subscapularis in the TSA cohort when compared to the contralateral, nonoperative subscapularis (40% vs 27%; p = 0.002). Reduction of subscapularis size of >35% occurred in 2 RTSA (7%) and 8 TSA patients (44%) (p = 0.01) (Table 2). Conclusions: Subscapularis repair following RTSA demonstrated better results compared to subscapularis repair following TSA, providing better PROs and ROM. Subscapularis muscle tissue decreased 50% more in the ATSA versus RTSA patients (40% vs 27%). Subscapularis condition demonstrated no correlation with functional outcome in RTSA.

Effectiveness over time of the reverse shoulder prosthesis for acute proximal humeral fracture

Reverse shoulder arthroplasty (RSA) has proven to be an effective surgical procedure for irreparable rotator cuff tears, comminuted fractures of the proximal humerus and shoulder arthroplasty revision surgeries. We know from the literature that the functional results are good in the short term, but not whether these results remain stable in the long term or, on the contrary, show a deterioration in functionality. This study aims to analyze the functionality, degree of satisfaction, complications, and prosthesis survival at different cut-off points in patients with complex proximal humerus fractures treated with RSA, with a minimum postoperative follow-up of 7 years. Analytical, longitudinal and prospective observational study of a cohort of patients treated for a fracture of the proximal humerus with PIH. Functional outcome was assessed using the Constant scale and the Constant adjusted for age and gender of the patients. Quality of life was measured using the University of California at Los Angeles Shoulder Assessment scale (UCLA) and the Disability of the Arm, Shoulder and Hand score scale (QuickDASH). In addition, range of motion, pain and radiological variables of loosening, scapular notching and tuberosity consolidation were assessed. Thirty-three patients were included with a mean postoperative follow-up of 8.3 years (range 7-12 years). There was a progressive and significant decrease in Constant score at 5and7years follow-up compared to the baseline assessment 2 years after surgery, although the effect size was not significant. The age- and sex-adjusted Constant as well as the UCLA scale did not show statistically significant variations at follow-up. Both shoulder abduction and anterior shoulder flexion correlated well with the final QuickDASH score. Radiological variables did not influence any of the study outcome variables. The functionality and quality of life of patients with complex proximal humerus fractures treated with RSA decreased significantly compared to the 2-year evaluation, although this change was not clinically relevant. Survival of RSA was satisfactory in the medium to long term with a low complication rate.

Reverse Shoulder Arthroplasty versus Non-Operative Treatment of Three-Part and Four-Part Proximal Humerus Fractures in the Elderly Patient: A Pooled Analysis and Systematic Review.

Background: The treatment of complex proximal humerus fractures in elderly patients is not yet fully elucidated. Of all treatment options, reverse shoulder arthroplasty (RSA) and non-operative treatment (NOT) appear to provide the best results. Evidence to guide the choice between the two is sparse. Therefore, this review provides an overview of the available evidence on RSA versus NOT. Methods: Studies comparing complex proximal humerus fractures in patients aged >65 years treated either with RSA or NOT were included for systematic review and direct comparison via pooled analysis of patient-rated outcome and range of motion. Indirect comparison of case series and non-comparative studies on either treatment was performed separately. Results: Three comparative studies including 77 patients treated with RSA and 81 treated non-operatively were analysed. The RSA group scored better for both the Constant-Murley score (mean difference 6 points) and DASH score (mean difference 8 points). No differences were detected in ASES, PENN score, pain scores, or range of motion between treatment groups. The most common complications for RSA were infection (3%), nerve injury (2%), and dislocation (2%). Reoperation was required in 5%. In the NOT group, common complications included malunion (42%), osteonecrosis (25%), and non-union (3%); no reoperation was required. Patient satisfaction was equal in both groups. Conclusions: The functional outcomes and range of motion after RSA seemed satisfactory and potentially superior to NOT in elderly patients. Patient satisfaction was comparable despite a high malunion and osteonecrosis rate in the non-operative treatment group, which did not require re-interventions.

Reverse Shoulder Prosthesis for Proximal Humeral Fractures: Primary Treatment vs. Salvage Procedure.

Background: The optimal treatment for complex proximal humerus fractures (PHFs) lacks consensus, with reverse total shoulder arthroplasty (RTSA) often being a final resort rather than a primary approach. This study aimed to compare outcomes and satisfaction rates of primary RTSA for PHFs versus salvage RTSA for previously unsuccessful treatments. We hypothesized that primary RTSA would yield superior clinical outcomes, functional scores, and patient satisfaction. Methods: A retrospective analysis of RSA procedures between 2011 and 2021 was conducted, focusing on primary RTSA for PHFs or salvage RTSA for failed osteosynthesis. Patients meeting inclusion criteria underwent clinical and radiological follow-up for at least two years. Demographic characteristics, outcomes scores, and range of motion (ROM) were assessed. Results: Of 63 patients, 42 underwent primary RTSA and 21 underwent salvage RTSA. The median follow-up was 50 months. Statistically significant differences favored primary RTSA in forward flexion, abduction, internal rotation, and Constant shoulder score. Patient satisfaction levels did not significantly differ between groups. Complications occurred in 7.15% of primary RTSA cases and 14.28% of salvage RTSA cases. Conclusions: Primary RTSA may yield slightly better outcomes and lower complication rates compared to salvage RTSA. Further prospective studies are necessary to validate these findings.

Converting to reverse shoulder arthroplasty from primary anatomic shoulder arthroplasty and fracture hemiarthroplasty: a radiographic and clinical outcome analysis at 8-years.

Revision shoulder arthroplasty can be challenging. One of the main considerations for surgeons is the type of implant that was placed in the initial surgery. Anatomic shoulder arthroplasty (ASA) is used for cases of osteoarthritis as well as for fractures of the humeral head. Hemiarthroplasty can be used for complex proximal humerus fractures. The purpose of this study is to determine whether there is a difference in clinical and radiographic outcomes between patients that failed primary fracture hemiarthroplasty (FHA), or ASA for osteoarthritis and then required reoperation with a conversion to reverse shoulder arthroplasty (RSA). Patients with failed anatomic shoulder replacement, who had undergone conversion to RSA, were enrolled after a mean follow-up of 107 (85-157) months. Two different groups, one with failed ASA implanted for osteoarthritis and one with failed FHA, were created. At follow-up patients were assessed with standard radiographs and clinical outcome scores. Twenty-nine patients (f = 17, m = 12; 51%) suffered from a failed ASA (Group A), while the remaining 28 patients (f = 21, m = 74; 49%) had been revised due to a failed FHA (Group B). Patients of Group B had a poorer Constant score (Group A: 60 vs. Group B: 46; p = 0.02). Abduction (Group A: 115° vs. Group B: 89°; p = 0.02) was worse after conversion of a failed FHA to RSA in comparison to conversions of failed ASA. The mean bone loss of the lateral metaphysis was higher in patients with failed FHA (Group A: 5mm vs. Group B: 20mm; p = 0.0). The initial indication for anatomic shoulder arthroplasty influences the clinical and radiological outcome after conversion to RSA. Conversion of failed FHA to RSA is related to an increased metaphyseal bone loss, decreased range of motion and poorer clinical outcomes when compared to conversions of failed ASA implanted for osteoarthritis. III Retrospective Cohort Comparison Study.

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.

Uncemented reverse shoulder arthroplasty in proximal humeral fractures: comparative study of two different press fit stems

BackgroundReverse shoulder arthroplasty (RSA) has extended its indications in recent years to include complex proximal humerus fractures (PHFs) in elderly patients. The traditional approach in cases of PHF has been to cement the stem but, as in orthopedic surgery, the current trend in PHF is to avoid cementing the humeral stem as well. MethodsWe evaluated 63 patients (representing 63 shoulders) who underwent RSA with uncemented stem after acute fracture of the proximal humerus. We analyzed the clinical and radiological outcomes, as well as medium-term complications, using two different prosthesis models. ResultsThe mean postoperative follow-up period was 21-23 months, and the mean age of the patients was 74.5 years. The average Constant Score was 56.94 points; there were no statistical significant differences in Constant Score depending on the prosthesis model used. No cases of aseptic loosening were observed. However, there was evidence of stress-shielding in prostheses with diaphyseal fixation, although this phenomenon did not appear to have functional or clinical consequences for the patients. Intraoperative complications occurred in 6.35% of cases, and postoperative complications were noted in 4.92%. ConclusionBased on the results of this study, we can affirm that the use of RSA with cementless stems in PHF can be a safe alternative, providing satisfactory clinical, functional, and radiographic results in the short term without the need to use cement in their fixation. The choice of prosthesis model may influence the occurrence of radiographic phenomena but does not seem to affect clinical outcome.

Advanced Preoperative Planning Techniques in the Management of Complex Proximal Humerus Fractures.

This review evaluates the current literature on the recent advances of preoperative planning in the management of complex proximal humerus fractures (PHF). PHFs canpose a considerable challenge for orthopaedic surgeons due to their diversity inpresentation and complexity. Poor preoperative planning can lead to prolongedoperations, increased blood loss, higher risk of complications, and increased stress on the surgical team. Recent advances have seen the evolution of preoperative planning from conventionalmethods to computer-assisted virtual surgical technology (CAVST) and three-dimensional (3D) printing, which have been highlighted as transformative tools for improvingpreoperative planning and postoperative outcomes. CAVST allows the creation of 3D renderings of patient-specific anatomy, clearlydemonstrating fracture patterns and facilitating detailed planning for arthroplasty orsurgical fixation. The early studies show promising outcomes however the literaturecalls for more high-quality randomised controlled trials. Using 3D printing for high-fidelity simulation involving patient-specific physicalmodels offers an immersive experience for surgical planning. Preoperative planningwith 3D printing reduces operative time, blood loss and use of fluoroscopy. Thetechnology's potential to produce customisable surgical implants further improves itsversatility. There is a need for a cost analysis for the use of these technologies within theorthopaedic field, particularly considering the high expense of 3D printing materials andextended hospital stays until the printed models are available. CAVST and 3D printing also show promising applications within high-fidelity simulationsurgical training, with CAVST offering possibilities in virtual reality and haptic-enhancedsimulations and 3D printing providing physical models for trainee surgeons to honetheir skills. Moving forward, a reduction in the cost of 3D printing and the advancement of CAVSTusing artificial intelligence would lead to future improvement. In conclusion,preoperative planning supported by these innovative technologies will play a pivotalrole in improving surgical outcomes and training for complex PHF cases.

Intramedullary Plating of Complex Proximal Humerus Fractures: A Case Series.

To assess fracture union rates using novel intramedullary plate technique. Post-operative humeral neck-shaft angles, patient range of motion and complication profile were secondary outcomes of interest. Single surgeon, retrospective case series of surgical technique at major trauma centre in Scotland. A 2.0mm mini-fragment plate was secured to the humeral head to act as an intramedullary strut during fixation in complex proximal humerus fractures. Fracture union and neck-shaft angle were assessed radiologically, whilst range of motion and complication profiles were assessed clinically. Twelve patients were followed up for an average of 10 months post-operatively. All achieved bony union with a mean neck-shaft angle of 128°. Mean range of motion values were 100° forward elevation, 83° abduction, 60° internal rotation and 37° external rotation. Four patients required further surgical intervention- two for hardware prominence, one for adhesive capsulitis and one for subsequent rotator cuff failure. There were no cases of avascular necrosis or infection. This novel technique addresses the established biomechanical propensity of proximal humerus fractures to fail in varus collapse and screw cut-out. This method provides an alternative to arthroplasty in the most severe proximal humerus fractures and is readily adopted via standard orthopaedic kit.

Outcome of Open Reduction and Internal Fixation versus Hemiarthroplasty in Proximal Humerus Complex Fractures

Abstract Background: This study compares open reduction and internal fixation (ORIF) versus hemiarthroplasty (HA) in the management of complex proximal humerus fractures. Materials and Methods: Neer three- and four-part fracture-dislocations, surgical neck fracture-dislocations with severe articular impaction, and any head-split fracture treated surgically at our institution were studied retrospectively. Constant–Murley scores, Disability of the Arm, Shoulder, and Hand (DASH), American Shoulder and Elbow Surgeons (ASES) Shoulder, and 36-item Short-Form Health Survey (SF-36) scores were obtained and compared between ORIF versus HA treatment. Results: Thirty patients were included in the analysis: 15 treated with ORIF were compared to 15 treated with HA with an average follow-up of 60 months. The mean Constant score (72 ± 15 vs. 54 ± 19; P = 0.005), DASH score (13 ± 17 vs. 29 ± 18; P = 0.006), ASES score (87 ± 13 vs. 66 ± 22; P = 0.003), and SF-36 physical composite score (PCS) (50 ± 11 vs. 40 ± 11; P = 0.02) all favored the ORIF group. Because of the potential confounding variable posed by including younger patients, we performed a subgroup analysis of patients older than 50 years. In this group, the Constant, DASH, ASES, and PCS scores remained significantly better in the ORIF group. Conclusion: Results of this retrospective study show improved patient-reported outcomes and quality of life scores in patients undergoing ORIF for complex proximal humerus fractures as compared to patients undergoing HA, despite a higher revision rate in the ORIF cohort. When considering patients older than 50 years, outcomes after ORIF were better than HA.

Locked Stem Reverse Total Shoulder Arthroplasty for Complex Proximal Humerus Fracture in the Elderly: Clinical and Radiological Short-Term Results.

To evaluate both the short-term clinical and radiological results of reverse shoulder arthroplasty (RSA) with uncemented locked stem in the management of a proximal humerus fracture (PHFs) in the elderly. Retrospective study including 40 consecutive 3-4 part proximal humerus fractures treated with reverse shoulder arthroplasty with a minimum of 24 months follow-up. In all the cases, the greater tuberosity (GT) was reattached with a standardized suture technique and a local horseshoe bone graft. All the patients were assessed at the 24-month follow-up with Constant-Murley Score (CMS) and Visual Analog Score (VAS). Radiographic healing of the greater tuberosity was noted in addition to stem locking screws radiographic changes. Complications and revision rates were reported. Mean final CMS for this cohort was 80 points. The greater tuberosity healed in the anatomic position in 90% of the cases (N = 36), obtaining an average CMS of 80 in these patients. Healing of the greater tuberosity did not occur in 10% of the cases (N = 4), obtaining an average CMS of 60. All patients scored above 100° in forward elevation with a mean of 140°. Mean active external rotation was 30°. Low-grade scapular notching was reported in <1% of the cases. Major complications were reported in one patient with an acromial fracture. No complications or loosening of stem locking screws were noted. There were no reoperations. In the elderly population, reverse shoulder arthroplasty utilizing a fracture-specific locking stem, low-profile metaphysis, suture-friendly groove, meticulous suture technique, and local bone grafting allows adequate fixation, variable prosthesis height adjustment, and enhances greater tuberosity healing. This approach yields positive short-term clinical outcomes without complications related to the stem's locking screws. Level IV Retrospective Case Series.

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.

Outcomes of Guided Personalized Surgery (GPS)-Navigated Reverse Polarity Total Shoulder Joint Replacement in a Low-Volume Hospital.

Introduction Reversepolarity shoulder arthroplasty (RSA) is an evolving surgery, and its indications have expanded over time. Apart from cuff tear arthropathy (CTA), it is recommended for complex proximal humerus fractures in the elderly, inflammatory arthritis, primary osteoarthritis in the elderly, and revision for failed hemiarthroplasty. Glenoid base plate placement and fixation are important to prevent complications, especially glenoid base plate loosening, dislocation, and scapular notching, and to improve longevity. Guided personalized surgery (GPS)-navigated RSA was devised to optimize the glenoid base plate position and fixation. Methodology A retrospective study was carried out in a low-volume district general hospital in England. All the patients who underwent GPS-navigated RSA were included. Their preoperative glenoid version, bone stock, glenoid base plate, and glenoid screw lengths were analysed. Preoperative and post-surgery patient-reported outcomes were gathered using the Oxford Shoulder Score (OSS) at six months and annually thereafter. Results Fourteen patients have undergone GPS-navigated RSA in our institute since 2018. Ten patients were female. All of them had a retroverted glenoid with a mean value of 13.6 degrees. Ten out of 14 patients had an augmented glenoid base plate. This included six eight-degree posterior augmentations, three 10-degree superior augmentations, and one extended cage peg. The follow-up period was six months to five years, depending on the date of surgery, and none of the patients dropped out of follow-up. The OSS revealed statistically significant improvement from preoperative values to six months postoperative, an improvement of 21.64±7.175. It also showed progressive improvement over time during postoperative follow-up, and the three-year mean was 47. The commonest complication was fractures, which happened in four cases. There were no infections or dislocations. Discussion Guided personalized surgery-navigated RSA was performed on selected patients at our institution when they were not suitable for conventional RSA due to distorted glenoid anatomy. Glenoid base plate positioning and fixation are important to optimize the outcome of RSA. Guided personalized surgery navigation is helpful in achieving optimum glenoid base placement, especially when the normal glenoid anatomy is distorted. There were no dislocations, glenoid base plate loosening, or scapular notching in the study group. There were four reported fractures, which was comparable with the published literature.

Translated article] Electromyographic axillary nerve injury in fractures of the proximal humerus: Prospective, observational study, analysing the fracture pattern

ObjectiveDescription and analysis of the relation between the proximal humerus fracture patterns and the traumatic injury of the axillary nerve. Material and methodProspective, observational study of a consecutive case series that analysed proximal humerus fractures. Radiographic evaluation was performed, and AO (Arbeitsgemeinshaft für Osteosynsthesefragen) system was used to classify the fractures. Electromyography was used to diagnose the axillary nerve injury. ResultsThirty-one patients on 105 who had a proximal humerus fracture met inclusion criteria. Eighty-six percent of the patients included were women and 14% men. The mean age was 71.8 years (30–96 years). Of the patients included in the study, 58% had normal or mild axonotmesis EMG, 23% had axillary nerve neuropathy without muscle denervation and 19% had injury with axillary nerve denervation. Patients who suffered complex fractures of the proximal humerus (AO11B and AO11C) had a higher risk of presenting axillary neuropathy type lesions with muscle denervation in the EMG, this relationship being statistically significant (p<0.001). ConclusionPatients who have more risk on presenting axillary nerve neuropathy with muscle denervation in electromyography are those who present complex proximal humerus fractures AO11B and AO11C (p<0.001).

Prediction of the Proximal Humerus Morphology Based on a Statistical Shape Model with Two Parameters: Comparison to Contralateral Registration Method.

(1) Background: Complex proximal humerus fractures often result in complications following surgical treatment. A better understanding of the full 3D displacement would provide insight into the fracture morphology. Repositioning of fracture elements is often conducted by using the contralateral side as a reconstruction template. However, this requires healthy contralateral anatomy. The purpose of this study was to create a Statistical Shape Model (SSM) and compare its effectiveness to the contralateral registration method for the prediction of the humeral proximal segment; (2) Methods: An SSM was created from 137 healthy humeri. A prediction for the proximal segment of the left humeri from eight healthy patients was made by combining the SSM with parameters. The predicted proximal segment was compared to the left proximal segment of the patients. Their left humerus was also compared to the contralateral (right) humerus; (3) Results: Eight modes explained 95% of the variation. Most deviations of the SSM prediction and the contralateral registration method were below the clinically relevant 2 mm distance threshold.; (4) Conclusions: An SSM combined with parameters is a suitable method to predict the proximal humeral segment when the contralateral CT scan is unavailable or the contralateral humerus is unhealthy, provided that the fracture pattern allows measurements of these parameters.

Comparison of Outcomes After Reverse Total Shoulder Arthroplasty in Patients With Proximal Humerus Fractures Versus Rotator Cuff Arthropathy.

Indications for reverse total shoulder arthroplasty (rTSA) has expanded to encompass complex proximal humerus fractures (PHFs) in recent years. The purpose of this study was to report and assess whether PHF patients treated with rTSA could achieve similar functional outcomes and short-term survivorship to patients who underwent rTSA for rotator cuff arthropathy (RTCA). All consecutive patients with a preoperative diagnosis of PHF or RTCA, 18 years or older, treated with rTSA at a single academic institution between 2018 and 2020 with a minimum 2-year follow-up were retrospectively reviewed. Primary outcomes were survivorship defined as revision surgery or implant failure analyzed using the Kaplan-Meier survival curve, and functional outcomes, which included Quick Disabilities of the Arm, Shoulder, and Hand, and range of motion (ROM) were compared at multiple follow-up time points up to 2 years. Secondary outcomes were patient demographics, comorbidities, surgical data, length of hospital stay, and discharge disposition. A total of 48 patients were included: 21 patients (44%) were diagnosed with PHF and 27 patients (56%) had RTCA. The Kaplan-Meier survival rate estimates at 3 years were 90.5% in the PHF group and 85.2% in the RTCA group. No differences in revision surgery rates between the two groups (P = 0.68) or survivorship (P = 0.63) were found. ROM was significantly lower at subsequent follow-up time points in multiple planes (P < 0.05). A greater proportion of patients in the PHF group received cement for humeral implant fixation compared with the RTCA group (48% versus 7%, P = 0.002). The mean length of hospital stay was longer in PHF patients compared with RTCA patients (2.9 ± 3.8 days versus 1.6 ± 1.8 days, P = 0.13), and a significantly lower proportion of PHF patients were discharged home (67% versus 96%, P = 0.015). The rTSA implant survivorship at 3 years for both PHF and RTCA patients show comparable results. At the 2-year follow-up, RTCA patients treated with rTSA were found to have better ROM compared with PHF patients.