Four-part Proximal Humerus Fractures Research Articles

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.

Factors influencing surgical outcomes of fixation with locking plate for three- and four-part proximal humerus fractures in patients aged 50 ​Years and older

BackgroundTreating complex three- and four-part proximal humerus fractures, especially in the elderly, remains contentious, with internal fixation using locking plates and shoulder arthroplasty being primary options. Although proximal humerus locking plates are more commonly used than shoulder replacements, they have a high complication rate. Factors like low bone density, advanced age, multiple fragment fractures, and medial cortical support loss negatively impact treatment outcomes. This study evaluates the functional and radiographic outcomes of using locking plates for treating these fractures in patients aged 50 and older, and the factors influencing outcomes and complication rates at the Ho Chi Minh City Hospital for Trauma and Orthopedics. MethodA descriptive case series study was conducted on 58 patients aged 50 and older (15 males, 43 females) with three- and four-part proximal humerus fractures. These patients underwent open reduction and internal fixation with Locking – compression plate (LCP) periarticular proximal humerus plates at the Ho Chi Minh City Hospital for Traumatology and Orthopedics (HTO) from April 2020 to April 2022. The minimum postoperative follow-up period was 12 months. ResultsThe average age of the patients was 62.78 ​± ​7.73 years, with a mean follow-up of 26.24 ​± ​5.93 months. Among them, 41 had three-part fractures (70.68 ​%) and 17 had four-part fractures (29.32 ​%). At the final follow-up (≥12 months), the mean Constant-Murley score was 70.81 ​± ​9.15, and the mean QDASH score was 8.33 ​± ​2.77. Complications occurred in 6 cases (10.34 ​%). Complex fractures, such as four-part fractures with displacement greater than 2 ​mm, had lower Constant-Murley scores and higher QDASH scores (p ​< ​0.05). Age, gender, bone density by deltoid tuberosity index (DTI), bone grafting, and rotator cuff sutures showed similar trends, but the differences were not statistically significant. ConclusionOpen reduction and internal fixation (ORIF) provides good bone healing and functional outcomes for three- and four-part proximal humerus fractures. Factors such as age, gender, bone density, bone grafting, and rotator cuff sutures do not significantly affect outcomes. Therefore, osteoporosis should not be a contraindication for ORIF with locking plates in these cases. Complex fractures, however, often lead to poorer outcomes and higher complication rates post-surgery.

Mid- to long-term outcomes of proximal humerus fractures treated with open reduction, plate fixation, and iliac bone autograft augmentation.

Open reduction and internal fixation (ORIF) using locking plates is a widely adopted treatment for displaced proximal humerus fractures. Various augmentation techniques have been developed to enhance the stability of plate fixation. Among these, iliac bone autograft is notable for its advantages over allografts, such as ready availability and the elimination of costs and risks associated with disease transmission. Despite its potential benefits, data on the outcomes of iliac bone autograft augmentation (IBAA) are still limited. This study aims to present the mid- to long-term results of treating proximal humerus fractures with ORIF using locking plates and IBAA. The study included 15 patients treated with ORIF and IBAA. We classified fracture patterns using the Neer classification and estimated local bone density via the deltoid tuberosity index. We measured the neck shaft angle (NSA) and humeral head height (HHH) on both immediate postoperative and most recent X-ray images to assess the maintenance of reduction. Clinical outcomes were evaluated using the DASH (Disabilities of the Arm, Shoulder, and Hand) and Constant scores. The average follow-up duration was 59.56 months, ranging from 24 to 93 months. A majority of fractures were classified as four-part (53%). The average immediate and late postoperative NSAs were 132.6±8.19 and 131.6±7.32 degrees, respectively. The average HHH on the immediate postoperative and latest follow-up images were 16.46±6.07 and 15.10±5.34, respectively. None of the patients exhibited any radiological signs of avascular necrosis or loss of reduction at the latest follow-up. The mean postoperative Constant and DASH scores at the latest follow-up were 79.6 and 11.5, respectively. Our findings suggest that ORIF with IBAA is an effective method for managing three- or four-part proximal humerus fractures, yielding excellent outcomes.

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.

Quality of life, functional and radiological outcomes of treatment of three-part and four-part proximal humerus fractures with locking plates and comparison in young versus older than 70years: a retrospective cohort study.

Verify if the use of locking plates in displaced three- and four-part proximal humerus fractures has meant an improvement even in patients over 70years of age. We performed surgery with locking plate fixation in 56 consecutive patients with three- and four-part proximal humerus fractures according to Neer's classification between 1/1/15 and 12/31/20 at our Hospital. Patient satisfaction, quality of life, functionality and radiological variables, as well as the comparison between patients older and younger than 70years were the main outcomes. Likewise, factors and complications that may have influenced these variables were analyzed as secondary outcomes. The analysis of all these variables was performed after a minimum follow-up time of 24months after surgery. 51 patients (92%) ended up satisfied or very satisfied according to the SF-36 test and with no disability or mild disability according to the DASH Score questionnaire. 46 patients (82%) obtained a satisfactory or excellent result according to the Neer scale modified by Cofield and 38 (68%) a good or excellent function according to the Constant Murley questionnaire. In 47 cases (84%) good radiological alignment was observed. Complications occurred in 20 patients (36%). The complications and the results of the SF-36, DASH Score, Neer scale modified by Cofield and Constant Murley tests depended on the radiological alignment (p = 0.009, p = 0.006, p = 0.025, p = 0.0008 and p = 0.0004). There were 37 patients younger than 70years and 19 older than 70years with no statistically significant differences when comparing the two groups. This study demonstrates that satisfactory results can be obtained with osteosynthesis with locking plates in displaced proximal humerus fractures even in patients older than 70years of age. Retrospective Cohort, Treatment Study.

Rehabilitation progress following reverse total shoulder replacement and internal fixation for geriatric three and four-part proximal humerus fractures – a propensity score matched comparison

BackgroundProximal humerus fracture is one of the most common fractures in the elderly population. However, in patients with complex fracture patterns, there is still no general consensus in the best treatment method. This study aims to evaluate the outcomes between those treated with reverse total shoulder arthroplasty (rTSA) and open reduction internal fixation (ORIF).MethodsAll geriatric patients (> 60 years of age) with proximal humerus fractures undergoing surgical treatment were analysed. There were 25 patients treated with rTSA and 75 with ORIF. Propensity score matching was used to select 25 matching patients from the ORIF group according to age and gender. All patients underwent surgical intervention within 7 days (mean 3.8 days). All patients followed a protocol-driven rehabilitation programme with outcome assessment at 3, 6, 12 and 24 months. Constant score, qDASH, range of motion, rate of complications and revision surgery were recorded and compared.ResultsTwenty-five rTSA were age and gender matched with 25 ORIF patients. The average age of patients in rTSA and ORIF groups were 77.0 years and 75.2 years respectively. At 3 months, mean Constant score was 37.7 (rTSA) vs 45.5 (ORIF) (p = 0.099). Mean qDASH score was 50.6 (rTSA) vs 29.4 (ORIF) (p = 0.003). Mean forward flexion range was 72.9° (rTSA) vs 94.4° (ORIF) (p = 0.007). Mean abduction range was 64.0° (rTSA) vs 88.6° (ORIF) (p = 0.001). At 2 years, mean Constant score was 72.8 (rTSA) vs 70.8 (ORIF) (p = 0.472). Mean qDASH score was 4.50 (rTSA) vs 11.0 (ORIF) (p = 0.025). Mean forward flexion range was 143° (rTSA) vs 109° (ORIF) (p < 0.001). Mean abduction range was 135° (rTSA) vs 110° (ORIF) (p = 0.025). There was a higher number of complications observed for ORIF (3) than rTSA (1) (p = 0.297) and a higher number of re-operations for ORIF (3) than rTSA (1) (p = 0.297), which was not statistically significant.ConclusionrTSA appears to yield a slower recovery at 3 months but a better outcome at 2 years. It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome.

Treatment of four-part proximal humerus fractures with depressed humeral head collapse using strut allograft with locking plates

To evaluate the clinical outcomes of allogeneic femoral head as strut allograft combined with proximal humeral internal locking system (PHILOS) in the treatment of proximal humeral Neer grade Ⅳ fracture with humeral head collapse. From January 2018 to November 2020, 18 patients with Neer grade Ⅳ fracture with humeral head collapse were treated with strut allograft with PHILOS, including 4 males and 14 females, aged from 55 to 78 years old, with an average of (68.11±7.20) years old. The operation time, intraoperative bleeding, postoperative drainage volume, fracture healing time, neck-shaft angle and the height of the humeral head, failure of internal fixation the shoulder function at the last follow-up was assessed using Neer's scoring system. All 18 patients were followed up, and the duration ranged from 10 to 12 months, with an average of (11.08±0.65) months. The operation time was (66.44±5.06) min, the intraoperative bleeding volume was (206.67±36.14) ml, the postoperative drainage volume was (76.11±9.63) ml, and the fracture healing time was (17.28±3.92) weeks. At the last follow-up, the degree of loss of neck-shaft angle was (5.44±0.86) ° and the loss of the height of humeral head was (1.43±0.27) mm. All 18 patients had healing without complications such as fracture, withdrawal, penetration of internal fixation and necrosis of humeral head. According to Neer's evaluation standard, the total score was (89.61±5.60), 10 cases got an excellent result, 6 good, 2 fair. Allogeneic femoral head combined with PHILOS is an appropriate treatment for the four-part proximal humerus fractures with humeral head collapse, exhibiting good clinic outcome.

Reverse shoulder arthroplasty for proximal humerus fractures: a comparison of the deltoid split and deltopectoral approaches.

Reverse shoulder arthroplasty (RSA) is a common treatment for three- and four-part proximal humerus fractures. RSA is commonly performed through a deltopectoral (DP) surgical approach; however, a deltoid split (DS) approach has been described. The purpose of this study was to compare the intraoperative and postoperative outcomes of patients undergoing RSA for proximal humerus fractures through a DP and DS approach. A retrospective study of patients who underwent RSA for proximal humerus fractures at our level 1 trauma center was performed. Patients were evaluated at a minimum 1-year follow-up. Intraoperative outcomes as well as patient-reported outcome measures (PROMs) were analyzed. Postoperative complications, reoperation rates, and radiographic outcomes were evaluated. Sixteen patients were included in the DP group and 13 patients in the DS group. The average follow-up was 28.6months in the DP group and 21.1months in the DS group. There were no significant differences in patient demographics or injury characteristics. Operative time was significantly shorter in the DS group (103min) compared to the DP group (123min). Tuberosity repair was performed in 81.3% of patients in the DP group and 92.3% of patients in the DS group. No significant differences were found in PROMs at final follow-up. There were no significant differences in postoperative complications. Three patients in the DP group and one patient in the DS group required reoperation. Lastly, 81.8% of patients achieved tuberosity union in the DS group and 66.7% in the DP group; however, this did not reach statistical significance. This study demonstrates that RSA for proximal humerus fractures performed through a DS or DP approach may result in similar intraoperative and postoperative outcomes, with no difference in reoperation or complication rates.

Isolated avulsion fracture of the lesser tuberosity of the humerus

Isolated lesser tuberosity fracture avulsion without an associated posterior shoulder dislocation or in the context of a three- or four-part proximal humerus fracture are extremely rare, with an estimated incidence rate of only 0.46 persons per 100,000. Diagnosis remains challenging, often leading to delayed treatment. In contrast with fractures of the greater tuberosity, there are no displacement guidelines to assist the surgeon in treatment decision-making for lesser tuberosity fractures. The aim of this study was to highlight diagnostic features as well as surgical treatment. We present a case of a 54-year-old male with an isolated lesser tuberosity fracture avulsion. We performed open reduction and osteosynthesis of the lesser tuberosity fragment with suture anchors and transosseous sutures. At 11-month follow-up the patient was able to normally perform his daily living and professional activities, had full, painless range of motion of the affected shoulder and regained almost full strength.

CORR Insights®: Reverse Total Shoulder Arthroplasty Demonstrates Better Outcomes Than Angular Stable Plate in the Treatment of Three-part and Four-part Proximal Humerus Fractures in Patients Older Than 70 Years.

1Assistant Professor, University of Minnesota Medical Center: University of Minnesota Health, Orthopaedic Surgery and Rehabilitation, Minneapolis, MN, USA M.P. Nguyen, University of Minnesota Medical Center, Orthopaedic Surgery and Rehabilitation, 2450 Riverside Avenue, Suite R200, Minneapolis, MN 55454, USA, Email: [email protected] This CORR Insights® is a commentary on the article “Reverse Total Shoulder Arthroplasty Demonstrates Better Outcomes Than Angular Stable Plate in the Treatment of Three-part and Four-part Proximal Humerus Fractures in Patients Older Than 70 Years” by Lanzetti and colleagues available at: DOI: 10.1097/CORR.0000000000002480. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

The N-brace trial: Does arm position during immobilisation of proximal humerus fractures influence outcome - A preliminary study.

Traditional initial management of proximal humerus fractures (PHF) involves arm immobilisation in a simple sling (SS) in an internally rotated position. We believe this risks fracture displacement and imbalance of soft tissues, encouraging malunion and stiffness. A neutral-rotation brace (NRB) maintains an arm position which may prevent this, leading to quicker and superior recovery. We randomised patients with two- to four-part PHF into 4 weeks of immobilisation with either a SS or NRB, independent of surgery. Range of motion (ROM), subjective shoulder value (SSV), DASH, Constant-Murley (CMS) and Oxford Shoulder (OSS) scores were assessed at 6-weeks, 3-months and 1-year post-injury. The SS group included 11 patients vs 9 in the NRB group. At final follow-up, the SS and NRB groups had mean DASH scores of 42 vs 35, OSS 42 vs 46, CMS 71 vs 86, SSV 84% vs 92%, respectively. ROM was superior with the NRB (elevation 159°, ER 47° and IR score 8 vs 140°, 37° and 7 with SS). Despite being a small series, our results demonstrate a trend towards NRB providing better outcomes. This feasibility study supports the need for a larger multi-centre randomised controlled trial comparing these immobilisation methods for PHF.

Reverse Total Shoulder Arthroplasty Demonstrates Better Outcomes Than Angular Stable Plate in the Treatment of Three-part and Four-part Proximal Humerus Fractures in Patients Older Than 70 Years.

Reverse Total Shoulder Arthroplasty Demonstrates Better Outcomes Than Angular Stable Plate in the Treatment of Three-part and Four-part Proximal Humerus Fractures in Patients Older Than 70 Years.

Fracture Line Morphology of Greater Tuberosity Fragments of Neer Three- and Four-Part Proximal Humerus Fractures.

In complicated Neer three- and four-part proximal humerus fracture (PHF), greater tuberosity (GT) fragments are often comminuted, and the currently widely used locking plate may not fix GT fragments effectively. A further understanding of morphological characteristics of the GT fragments may help explore new fixation devices. This study aimed to determine the fracture line morphology of the GT fragment of Neer three- or four-part PHF and analyze the location relationship between the locking plate and the GT fragment. Seventy-one three-dimensional computed tomography scans of Neer three- and four-part PHF were retrospectively reviewed between January 2014 and June 2019. Fracture fragments were reconstructed and virtually reduced in the Mimics software, and fracture lines of GT fragments were depicted on a humerus template in the 3-matic software and then were superimposed altogether. The common sites of the GT fracture were identified, and the location relationship between the locking plate and GT fragments was analyzed in a computer-simulated scenario. The fracture line morphology of GT fragments was similar between Neer three- and four-part PHF. The overall morphology of GT fragments was in a fan shape, which could be summarized as anterior, superior, posterior, and middle lines. Of these, we identified 51 split and 29 avulsion type GT fragments based on the Mutch classification, and they could occur simultaneously in a PHF. The overall morphology of split type fragments was in a fan shape, and avulsion type fragments showed a quite distinguishable distribution pattern. A GT fragment could be classified as anterior-split, posterior-split, complete-split, anterior -avulsion, and posterior-avulsion type based on its morphology and location. The median percentage of fragment area covered by the plate was 32.3% in all of the fragments, and it was 69.4%, 23.0%, 37.2%, 21.8%, 0.0% in anterior-split, posterior-split, complete-split, anterior-avulsion, and posterior-avulsion type GT fragments. We defined the posterior-split, anterior-avulsion, and posterior-avulsion type GT fragments as the risky GT fragments, and they occurred in 43 (60.6%) Neer three- and four-part PHFs. The fracture line morphology of GT fragments of Neer three- and four-part PHF was in a fan shape. GT fragments could be classified based on their location and morphology. The extent of GT fragment coverage provided by the locking plate differed in various fragment types, and we identified the anterior-avulsion, posterior-avulsion, and posterior-split type fragments as the risky GT fragments with a high incidence rate in Neer three- and four-part PHFs.

What Factors Are Associated With Poor Shoulder Function and Serious Complications After Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations?

What Factors Are Associated With Poor Shoulder Function and Serious Complications After Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations?

Functional Outcomes and Complication Analysis of Plate Osteosynthesis versus Hemiarthroplasty in Three-part and Four-part Proximal Humerus Fractures.

To compare the functional results and complications of open reduction-internal fixation and hemiarthroplasty performed in Neer three-part and four-part proximal humerus fractures. The retrospective study was conducted at the Istanbul Training and Research Hospital, Turkey, and comprised data of patients who were diagnosed with three-part or four-part fracture of the proximal humerus and underwent surgical procedure between January 2008 and April 2013. Those who had undergone open reduction-internal fixation using anatomical locking plates were placed in group A, and those who had undergone hemiarthroplasty were in group B. Constant-Murley shoulder outcome, University of California at Los Angeles shoulder and visual analogue scale scores were compared between the two groups. The degrees of forward flexion and abduction of the glenohumeral joint were recorded. Complications in both the groups were recorded. Data was analysed using SPSS 15.\. Of the 48 patients, 30(62.5%) were in group A; 16(53.3%) males and 14(46.7%) females, with an overall mean age of 60.0±9.4 years. The remaining 18(37.5%) were in group B; 7(39%) males and 11(61%) females, with an overall mean age of 67.3±10.1 years. The mean follow-up period was 18.7±16.4 months. The mean Constant-Murley and University of California at Los Angeles shoulder scores were not significantly different between the two groups (p>0.05). The mean visual analogue scale score was significantly higher in group A compared to group B (p=0.021). In group A, heterotropic ossification was observed in 1(3.4%) patient, avascular necrosis in 3(10%), screw penetration without avascular necrosis in 4(13.2%), and non-union in 1(3.4%), while in group B, shoulder subluxation was noted in 2(11.1%) patients and malunion of the greater tubercle in 6(33.3%). Although statistically non-significant, higher functional scores, forward flexion and abduction degrees were observed in patients who had undergone open reduction-internal fixation, while significantly lower visual analogue scale scores were recorded in the hemiarthroplasty group.

Assessment of Surgical Outcome in Three- and Four-Part Proximal Humerus Fracture Treated With Proximal Humerus Internal Locking System (PHILOS) Plate Versus Neer's Prosthesis in Elderly Patients.

Background: With an incidence of 50% of humerus fractures, proximal humerus fractures (PHFs) can significantly impact one’s quality of life. Moreover, management of highly comminuted or displaced PHFs poses a significant challenge amongst elderly population due to poor bone quality. Prosthetic replacement of humeral head or its stabilization using external plates is a commonly employed intervention for treating three- and four-part PHFs. Thus, these two methods were compared in this study to identify a preferable intervention.Methods: Patients were randomly divided into two groups to receive proximal humerus internal locking system (PHILOS®, Synthes, Switzerland) plating and Neer’s hemiarthroplasty. The deltopectoral approach was deployed as the surgical method. Their surgical outcome was assessed from functional range of motion (ROM) and Constant-Murley scores at regular intervals of three, six, twelve, and twenty-four weeks.Results: Twenty patients were divided into two groups who received PHILOS® plating and Neer’s hemiarthroplasty, averaged 67.2 years and 72.8 years. The ROM pertaining to flexion, extension, abduction, internal rotation, and external rotation for individuals with PHILOS® plating was 20%, 12.5%, 14.7%, 11.5%, and 18.5% higher than those who received Neer’s hemiarthroplasty. Moreover, the Murley score was also 8.7 units higher for individuals with PHILOS® plating.Conclusions: Prognosis following PHILOS® plate osteosynthesis had a better overall outcome than hemiarthroplasty with Neer’s prosthesis. Although hemiarthroplasty yielded a consistent functional outcome, PHILOS® plate osteosynthesis tends to restore a greater ROM. Thus, PHILOS® plating is recommended as the suitable method to manage three- and four-part PHF for people above fifty-five years of age.

CORR Insights®: 3D-printed Handheld Models Do Not Improve Recognition of Specific Characteristics and Patterns of Three-part and Four-part Proximal Humerus Fractures.

CORR Insights®: 3D-printed Handheld Models Do Not Improve Recognition of Specific Characteristics and Patterns of Three-part and Four-part Proximal Humerus Fractures.

Comparison of Treatment Options of Three- and Four-Part Humerus Proximal Fractures in Patients Over 50 Years of Age.

IntroductionOur aim was to evaluate different treatment methods including conservative treatment (CT), locking-plate osteosynthesis (OS) and hemiarthroplasty (HA) in three- and four-part humeral fractures in patients older than 50 years.MethodsForty-seven patients that have at least one year of follow-up were divided into three groups: 18 patients treated with OS, 14 patients treated conservatively and 15 patients treated with HA. For further evaluation, constant shoulder score, disabilities of the arm, shoulder and hand score (DASH), American Shoulder and Elbow Society (ASES) score had been used. Shoulder range of motion was also assessed.ResultsOS and CT groups had better scores than HA group. In OS group, average Constant score was 71.6 ± 16.2, DASH score was 12.1 (5.2-24.2) and ASES score was 77.5 (50.8-96.6). In CT group, average Constant score was 69.6 ± 19.2, DASH score was 16.4 (12.5-36.7) and ASES score was 76.6 (45.4-87.9). DASH scores (p = 0.032), Constant scores (p = 0.001), forward elevation (p < 0.001), abduction (p < 0.001), internal (p = 0.022) and external rotation (p = 0.048) were significantly improved in OS and CT groups than HA group.ConclusionsHA should not be considered a priority in surgical planning in Neer three-part and four-part proximal humerus fractures. CT is superior for patients with additional morbidity and advanced age. But in patients who are younger and can tolerate the surgical procedure, the priority should be OS.

3D-printed Handheld Models Do Not Improve Recognition of Specific Characteristics and Patterns of Three-part and Four-part Proximal Humerus Fractures.

Reliably recognizing the overall pattern and specific characteristics of proximal humerus fractures may aid in surgical decision-making. With conventional onscreen imaging modalities, there is considerable and undesired interobserver variability, even when observers receive training in the application of the classification systems used. It is unclear whether three-dimensional (3D) models, which now can be fabricated with desktop printers at relatively little cost, can decrease interobserver variability in fracture classification. Do 3D-printed handheld models of proximal humerus fractures improve agreement among residents and attending surgeons regarding (1) specific fracture characteristics and (2) patterns according to the Neer and Hertel classification systems? Plain radiographs, as well as two-dimensional (2D) and 3D CT images, were collected from 20 patients (aged 18 years or older) who sustained a three-part or four-part proximal humerus fracture treated at a Level I trauma center between 2015 and 2019. The included images were chosen to comprise images from patients whose fractures were considered as difficult-to-classify, displaced fractures. Consequently, the images were assessed for eight fracture characteristics and categorized according to the Neer and Hertel classifications by four orthopaedic residents and four attending orthopaedic surgeons during two separate sessions. In the first session, the assessment was performed with conventional onscreen imaging (radiographs and 2D and 3D CT images). In the second session, 3D-printed handheld models were used for assessment, while onscreen imaging was also available. Although proximal humerus classifications such as the Neer classification have, in the past, been shown to have low interobserver reliability, we theorized that by receiving direct tactile and visual feedback from 3D-printed handheld fracture models, clinicians would be able to recognize the complex 3D aspects of classification systems reliably. Interobserver agreement was determined with the multirater Fleiss kappa and scored according to the categorical rating by Landis and Koch. To determine whether there was a difference between the two sessions, we calculated the delta (difference in the) kappa value with 95% confidence intervals and a two-tailed p value. Post hoc power analysis revealed that with the current sample size, a delta kappa value of 0.40 could be detected with 80% power at alpha = 0.05. Using 3D-printed models in addition to conventional imaging did not improve interobserver agreement of the following fracture characteristics: more than 2 mm medial hinge displacement, more than 8 mm metaphyseal extension, surgical neck fracture, anatomic neck fracture, displacement of the humeral head, more than 10 mm lesser tuberosity displacement, and more than 10 mm greater tuberosity displacement. Agreement regarding the presence of a humeral head-splitting fracture was improved but only to a level that was insufficient for clinical or scientific use (fair to substantial, delta kappa = 0.33 [95% CI 0.02 to 0.64]). Assessing 3D-printed handheld models adjunct to onscreen conventional imaging did not improve the interobserver agreement for pattern recognition according to Neer (delta kappa = 0.02 [95% CI -0.11 to 0.07]) and Hertel (delta kappa = 0.01 [95% CI -0.11 to 0.08]). There were no differences between residents and attending surgeons in terms of whether 3D models helped them classify the fractures, but there were few differences to identify fracture characteristics. However, none of the identified differences improved to almost perfect agreement (kappa value above 0.80), so even those few differences are unlikely to be clinically useful. Using 3D-printed handheld fracture models in addition to conventional onscreen imaging of three-part and four-part proximal humerus fractures does not improve agreement among residents and attending surgeons on specific fracture characteristics and patterns. Therefore, we do not recommend that clinicians expend the time and costs needed to create these models if the goal is to classify or describe patients' fracture characteristics or pattern, since doing so is unlikely to improve clinicians' abilities to select treatment or estimate prognosis. Level III, diagnostic study.

Outcomes of plate osteosynthesis for displaced 3-part and 4-part proximal humerus fractures with deltopectoral vs. deltoid split approach.

Three part and four-part fractures of the proximal humerus offer challenges in reduction and plate fixation, with considerable debate about use of Deltoid splitting (DS) and Delto-pectoral (DP) approaches, especially when they involving the greater tuberosity. We prospectively compared the results using DS approach and DP approach in these cases, with special focus on functional outcomes, complications, and ease of tuberosity reduction. 84 patients with three- and four-part proximal humerus fracture were alternately allocated the DP approach or DS approach for proximal humerus locking plate fixation. The outcome analysis was done by evaluating relative Constant score and ease of surgical reduction of greater tuberosity; radiological malunion was evaluated using Beredjiklian classification and complications were noted. At mean follow-up of 23months (19-48months), the mean 'relative Constant score was 74.27 ± 8.19 in the DP group and 73.26 ± 8.02 in the DS group and the difference was statistically insignificant (p = 0.988). There was no significant difference with respect to shoulder ROM, abductor strength, radiological malunion or complications. However, the mean surgical time was significantly less (p value = 0.042) in DS group (65 ± 5min) in comparison to DP group (92 ± 4.3min); significantly less difficulties were documented by the surgeon in reducing the greater tuberosity in DS group(p value = 0.02). Although surgical time was reduced and greater tuberosity reduction was easier in DS group, the other outcomes were similar; either surgical approach can be used based, and can be based on the experience and comfort level of the surgeon.