4-part Proximal Humerus Fractures Research Articles

Clinical and Radiographic Outcome of Open Reduction and Internal Fixation of 3- and 4-Part Proximal Humerus Fractures Augmented with Impaction Bone Grafting and A Magnesium-Based Bone Filler

BackgroundOpen reduction and internal fixation (ORIF) of proximal humerus fractures (PHF) is a challenging operation with high rates of loss of reduction, screw cut out, avascular necrosis, and subsequent unplanned reoperation. Augmentation of the repair with synthetic bone fillers and other alternatives has shown promise in decreasing adverse outcomes. Our aim is to report radiographic and clinical outcome of impaction grafting with cancellous allograft chips and injection of magnesium-based bone filler for ORIF augmentation of PHFs. MethodsAll patients that underwent ORIF for a 3- or 4-part PHF with the standardized protocol with a minimum of 6 months radiographic follow-up by a single surgeon (VE) were included. Radiographs were taken at standardized time points up to 6 months, followed by a final radiographic follow-up, to define radiographic healing or failure. Patient-reported outcome measures (PROMs) were collected at final follow-up. Patient characteristics, complications, reoperations and radiographic measures of reduction quality were also recorded. Results17 patients were identified with a mean 34.1 months of radiographic follow-up. Median Penn Shoulder Score was 89 (IQR 19), American Shoulder and Elbow Surgeons score was 92 (25), Veterans-Rand 12 (VR-12) Mental Component Score was 53.9 (11.9), VR-12 Physical Component Score was 51.6 (12.8), and Single Assessment Numerical Assessment was 85 (18.5).14 patients (82.3%) had routine radiographic healing. Two patients (11.8%) developed avascular necrosis (AVN) with screw cutout. Two patients (11.8%) had reoperation including one hardware removal and one conversion to reverse total shoulder arthroplasty for a subsequent rotator cuff tear. No signs of glenohumeral arthritis were present in 12/17 patients (70.6%), and no signs of cuff tear arthropathy were noted in 13/17 patients (76%). Seven out of nine (78%) patients who worked prior to injury returned to work at a mean of 14.7 weeks postoperatively. ConclusionAugmentation of 3- and 4-part proximal humeral fractures with a standardized protocol utilizing cancellous chips and a synthetic magnesium-based bone filler results in a high rate of maintenance of fracture reduction, radiographic healing, and satisfactory patient outcomes. Further comparative data is needed to evaluate the efficacy of this technique compared to alternative methods of augmentation.

Lateralization has minimal biomechanical impact on tuberosity fixation with the use of a stem-based repair and a 135o humeral implant in reverse shoulder arthroplasty for four-part proximal humerus fracture

IntroductionLateralization in reverse shoulder arthroplasty (RSA) has many proven and potential benefits. Concern over the increase in tension on the tuberosities imparted by glenoid lateralization and the subsequent effect on tuberosity healing may limit its use in the setting of RSA performed for fracture. This study evaluated whether glenoid lateralization increased tuberosity fracture gapping in a biomechanical model of a 4-part proximal humerus fracture with a stem-based tuberosity repair. We hypothesized that increased lateralization would increase fracture gapping. Materials and MethodsEight cadaveric shoulders (mean age, 62 +/- 2.4 years; range 52-70 years) were tested with a custom testing system that permits loading of rotator cuff muscles and humerothoracic muscles. A four-part proximal humerus fracture was simulated and then repaired with a stem-based tuberosity repair. The repaired tuberosities were cycled in internal and external rotation with 1.1Nm torque at 2 mm and 6 mm of glenoid lateralization. For the 6mm lateralization RSA, the torque was then increased to reach the range of motion values achieved with the 2mm lateralized RSA and cycled 10 times, followed by doubling the torque values for 10 cycles. Range of motion, muscle length and fracture gapping were assessed at 2 mm and 6 mm of glenoid lateralization. ResultsInternal rotation and total ROM demonstrated a significant decrease in the 6 mm RSA when compared to the 2 mm RSA (p < 0.05). The 6 mm lateralized RSA significantly increased rotator cuff muscle lengths when compared to the 2 mm lateralized RSA condition except for infraspinatus by an average of 2.7 ± 1.9mm (p < 0.05). There was no significant gapping of the proximal fracture for any condition. There was a significant increase in the gapping of the distal fracture gap in the 6 mm lateralized component condition only after 10 cycles of doubled rotational torque, which measured 1.9 ± 1.5mm (p = .031). DiscussionWe hypothesized that lateralization would increase fracture gapping. Fracture gapping did not occur proximally and only occurred at a slight amount distally after 10 cycles of doubled rotational torque. This may have implications on the choice of glenoid components when performing a RSA for fracture.

Predicting Proximal Humerus Fracture Mechanical Complications: Are Computed Tomography Hounsfield Units the Answer?

The purpose was to determine whether computed tomography (CT) Hounsfield units (HU) as a proxy for bone quality can predict postoperative complications following surgical treatment of proximal humerus fractures. Sixty-six patients with 2-, 3-, or 4-part proximal humerus fractures who underwent surgical fixation at single institution and had complete radiographic data available were included. Radiographic measurements included the deltoid tuberosity index (DTI) on preoperative anterior-posterior shoulder radiographs, and the HU value from the surgical proximal humerus was determined by measuring the humeral head at the midaxial/coronal/sagittal CT image using a circle-type region of interest (≥35 mm2). Postoperative complications recorded were implant failure, development of osteonecrosis, nonunion, and acute periprosthetic fracture. Patients with and without complications were statistically compared, and binary logistic regression was performed to determine whether preoperative proximal humerus CT HU were predictive of complications. Eight patients (12.1%) developed 11 overall complications, with three patients experiencing multiple complications each. Complications included osteonecrosis (4), implant failure (5), nonunion (1), and acute periprosthetic fracture (1). No difference was observed in demographics or Neer or AO/OTA classification between those with and without complications. Patients with complications had markedly lower DTI and overall HU as well as HU in the coronal and sagittal planes. Regression analysis for average DTI demonstrated a higher DTI and had a 10 times decreased risk of complication (P = 0.040, odds ratio = -10.5, 95% confidence interval, 0.000 to 0.616). Regression analysis for average total HU also found a higher HU associated with a decreased risk of complications (P = 0.034, odds ratio = -0.020, 95% confidence interval, 0.980 to 0.962). Logistic regression analysis, including age, age-adjusted Charlson Comorbidity Index, mean DTI, and mean total HU, only found mean total HU to be notable within the model. CT HU may identify patients with poorer bone quality and thus help predict postoperative complications. Diagnostic Level III.

Three- or four-part proximal humeral fractures in middle-aged and active elderly group of patients: a narrative review of treatment options.

Proximal humerus fractures (PHFs) occur in all age groups but more in elderly population with variety of treatment options. The choice of treatment of PHFs is rather controversial in the middle-aged and active elderly population. This review article highlights the current literature on the efficacy of treatment options for PHFs in middle-aged and active elderly patients which could help surgeons in decision making in clinical practice. PubMed and Scopus databases from January 1953 to February 2024 were searched and screened for studies, including systematic reviews, on the treatment of PHFs in middle-aged and elderly that served for narrative review of rationale behind such design. Patients with minimally displaced fractures should be treated nonoperatively. Internal fixation with intramedullary nailing is a viable option in cases of two-part surgical neck fractures, those with diaphyseal involvement and no significant displacement of the tuberosities, or pathologic fractures. Those elderly patients with displaced three- or four-part PHFs fractures with intact rotator cuff muscles should be treated with locking plate fixation if anatomical reduction of fracture fragments including tuberosity is possible, as the results after union despite avascular necrosis are favorable. Moreover, patients with failed fixation treated with salvage reverse shoulder arthroplasty (RSA) have similar outcomes to RSA for acute PHFs. Hemiarthroplasty should be reserved for select group of young active patients with unconstructable fracture, intact rotator cuff, and good tuberosity bone stock. RSA should be offered as first option for elderly patients with poor bone stock, rotator cuff insufficiency, fracture dislocations, head-split fractures, and severely displaced 3- and 4-part PHFs. The treatment of choice in middle-aged and active elderly patients with three- or four-part PHFs depends on several factors such as fracture pattern, bone quality, possibility of anatomical reduction, status of rotator cuff, and patient expectations. The success of treatment is based on patient selection while setting correct patient expectations.

Functional Outcome after Treatment of Three-Part Proximal Humerus Fractures Using Locking Plate vs. Conservative Treatment in the Elderly

Abstract Background Proximal humeral fractures (PHFs) are among the most common fractures in the elderly. The majority of proximal humeral fractures are treated conservatively, and up to 33% are treated surgically. Objective To compare functional outcome and quality of life after treatment of displaced 3-part proximal humerus fractures using the locking plates, as compared to nonoperative treatment in elderly patients. Methods This study performed a search for all published articles locking plates or nonoperative treatment in the management of displaced 3-part proximal humerus fractures. Results The pooled analysis of the included studies showed no significant difference between conservative treatment and operative treatment regarding the outcome of Constant score (MD = 0.04; 95% CI:[-0.2, 0.29]; P = 0.748). The pooled analysis of the included studies showed no significant difference in postoperative the DASH score between conservative treatment and operative treatment (MD = 0.05; 95% CI:[-0.35, 0.25]; P = 0.48). The pooled analysis of the included studies showed no significant difference in the outcome of VAS score between conservative treatment and operative treatment (MD = 0.38; 95% CI:[0.07, 0.69]; P = 0.748). The pooled analysis of the included studies showed no significant difference in ROM between conservative treatment and operative treatment (MD = 0.39; 95% CI:[-0.15, 0.94]; P = 0.425). The pooled analysis of the included studies showed no significant difference in postoperative complications between conservative treatment and operative treatment (RR = 1.148; 95% CI:[0.369 3.575]; P = 0.507). The pooled analysis of the included studies showed no significant difference in the outcome of non-union rate between conservative treatment and operative treatment (RR = 0.85; 95% CI: [0.72 – 2.28]; P = 0.158). Conclusion The results of this meta-analysis revealed no significant differences between conservative treatment and operative treatment as regard constant scores, DASH and VAS scores, range of movement, incidence of complications or non-union.

Non-union of the greater tuberosity in patients undergoing reverse total shoulder arthroplasty for proximal humerus fracture: Is it associated with worse outcomes?

4-part proximal humerus fractures are complex injuries that are often associated with comminution of the greater tuberosity. The purpose of this study is to evaluate the functional outcomes of 4-part humerus fractures that are treated with reverse total shoulder arthroplasty (rTSA) and correlate these outcomes with the healing status of the greater tuberosity. A retrospective observational study was performed including 65 patients who underwent rTSA following a 4-part proximal humerus fracture. These patients were categorized into 3 groups according to the healing status of the greater tuberosity: patients with healed greater tuberosity in an anatomical position (group A, n = 43), patients with non-union of the greater tuberosity but in anatomical position (group B, n = 14), and patients with resorption or non-union of the greater tuberosity not in anatomical position (group C, n = 8). The Constant-Murley score and range of motion were recorded for each patient at 12months postoperatively. The clinical and radiographical outcomes of the 3 groups were compared. Patients with healed greater tuberosity (group A) had higher range of motion compared to patients with greater tuberosity migration or reabsorption (group C) regarding forward flexion (130° vs 80°, p < 0.001), abduction (110° vs 65°, p < 0.001) and external rotation (20° vs 10°, p = 0.004). However, no significant changes regarding forward flexion (130° vs 125°, p = 0.67), abduction (110° vs 100°, p = 0.60) and external rotation (20° vs 25°, p = 0.37) were noted between patients with healed greater tuberosity (group A) and those with non-united greater tuberosity that remained attached to the humeral prosthesis (group B). Similarly, Constant- Murley score was similar between patients of group A and group B (65.0 vs 61.5, p = 0.53), while it was higher in patients of group A compared to those of group C (65.0 vs 39.0, p = 0.053). The outcomes of this study indicate that reliable recovery regarding range of motion and functional status can be achieved in patients who undergo rTSA due to 4-part proximal humerus fractures, as long as the greater tuberosity remains in close proximity to the humeral prosthesis, even if it has signs of non-union with no continuity to the adjacent humerus.

Clinical validation of artificial intelligence-based preoperative virtual reduction for Neer 3- or 4-part proximal humerus fractures

BackgroundIf reduction images of fractures can be provided in advance with artificial-intelligence (AI)-based technology, it can assist with preoperative surgical planning. Recently, we developed the AI-based preoperative virtual reduction model for orthopedic trauma, which can provide an automatic segmentation and reduction of fractured fragments. The purpose of this study was to validate a quality of reduction model of Neer 3- or 4-part proximal humerus fractures established by AI-based technology.MethodsTo develop the AI-based preoperative virtual reduction model, deep learning performed the segmentation of fracture fragments, and a Monte Carlo simulation completed the virtual reduction to determine the best model. A total of 20 pre/postoperative three-dimensional computed tomography (CT) scans of proximal humerus fracture were prepared. The preoperative CT scans were employed as the input of AI-based automated reduction (AI-R) to deduce the reduction models of fracture fragments, meanwhile, the manual reduction (MR) was conducted using the same CT images. Dice similarity coefficient (DSC) and intersection over union (IoU) between the reduction model from the AI-R/MR and postoperative CT scans were evaluated. Working times were compared between the two groups. Clinical validity agreement (CVA) and reduction quality score (RQS) were investigated for clinical validation outcomes by 20 orthopedic surgeons.ResultsThe mean DSC and IoU were better when using AI-R that when using MR (0.78 ± 0.13 vs. 0.69 ± 0.16, p < 0.001 and 0.65 ± 0.16 vs. 0.55 ± 0.18, p < 0.001, respectively). The working time of AI-R was, on average, 1.41% of that of MR. The mean CVA of all cases was 81%±14.7% (AI-R, 82.25%±14.27%; MR, 76.75%±14.17%, p = 0.06). The mean RQS was significantly higher when AI-R compared with MR was used (91.47 ± 1.12 vs. 89.30 ± 1.62, p = 0.045).ConclusionThe AI-based preoperative virtual reduction model showed good performance in the reduction model in proximal humerus fractures with faster working times. Beyond diagnosis, classification, and outcome prediction, the AI-based technology can change the paradigm of preoperative surgical planning in orthopedic surgery.Level of evidenceLevel IV.

Straight intramedullary MultiLoc nails for displaced proximal humeral fractures: health status, radiographic results, clinical outcome, and complications

BackgroundThe treatment of the displaced proximal humerus fractures (PHF) still facing a lot of unsolved problems. The aim of this study was to evaluate the clinical effect of MultiLoc nails for the treatment of PHF and present outcomes of patients with different Neer’s classification and reduction quality.MethodsAdult patients with PHFs were recruited and treated with MultiLoc nail. Intraoperative data, radiographic and functional outcomes, as well as occurrence of postoperative complications were assessed.Results48 patients met inclusion and exclusion criteria and were included in this study. The DASH Score were 32.2 ± 3.1 points at 12 months, and 37.3 ± 2.5 points at the final follow-up. The mean ASES score at 12 months and final follow-up were 74.4 ± 6.2 and 78.8 ± 5.1, respectively. The mean CM Score in all 48 patients reached 68 ± 6.4 points at the final follow-up, relative side related CM Score 75.2 ± 7.7% of contralateral extremity. The incidence rate of complications was 20.8%. Patients with fracture mal-union, adhesive capsulitis were observed but no secondary surgeries were performed. There was no significantly difference of DASH Score 12 months after surgery and at the last follow-up among patients with different Neer’s classification or reduction quality. However, functional outcomes such as ASES score and CM score were significantly influenced by severity of fracture and the quality of fracture reduction.ConclusionsOur study demonstrated that MultiLoc nails is well suited for proximal humeral fractures, with satisfactory health status recovery, good radiographic results, positive clinical outcomes and low rates of complications. The treatment for four part PHF still faces great challenges. Accurate fracture reduction was an important factor for good functional result.

Superior functional outcome following reverse shoulder arthroplasty compared to hemiarthroplasty for displaced three- and four-part fractures in patients 65 and older: results from a prospective multicenter randomized controlled trial - The shoulder hemiarthroplasty or reverse polarity arthoplasty (SHeRPA) trial

BackgroundAcute unreconstructible 3- or 4-part proximal humerus fractures can be treated with hemiarthroplasty or reverse polarity shoulder arthroplasty. Randomized trials using implants from multiple different companies or uncemented implants have found superior results with reverse polarity arthroplasty. AimsThis study aims to determine whether cemented reverse polarity arthroplasty produces a superior outcome compared to cemented hemiarthroplasty using one implant system in patients aged 65 years and over at 12 months follow-up as measured with the Constant score. MethodsA prospective patient and assessor blinded multicenter randomized controlled trial was conducted of shoulder hemiarthroplasty or reverse polarity arthroplasty in patients aged 65 years and older with acute 3- and 4-part proximal humerus fracture not amenable to osteosynthesis. The primary outcome was the Constant score at 12 months with total follow-up to 24 months. Block randomization by site was undertaken using random number generation and sealed envelopes. Power analysis indicated that 17 patients were required in each arm to achieve 80% power with an alpha-value of 5%. Secondary outcome measures were the difference in the mean Constant Score, Quick Disabilities of the Arm Shoulder and Hand Questionnaire (QuickDASH), Oxford Shoulder Score (OSS), American Shoulder and Elbow Surgeons (ASES) Score and EQ5D-5L up to two years; differences in complication rate at one and two years; differences in revision and implant failure at one and two years. Results18 patients were randomized to hemiarthroplasty and 18 to reverse polarity arthroplasty across 4 sites. The primary outcome as measured by the Constant score at 12 months was better in the reverse polarity shoulder arthroplasty (RSA) group (Mean 51.1, s.d. 14.9) compared to the hemiarthroplasty (HA) group (mean 35.0, s.d. 13.5) (p=0.004). No significant difference was reported at 24 months but this may be due to high rates of attrition (22%). The mean EQ-5D-5L patient rated health status score was significantly higher in the RSA group compared to the HA group at 12 months. One hemiarthroplasty was revised due to implant uncoupling and one reverse polarity shoulder replacement was revised due to instability. No other complications were recorded. DiscussionTreatment of unreconstructible 3- or 4-part proximal humerus fractures with reverse polarity shoulder arthroplasty results in a superior outcome compared to shoulder hemiarthroplasty at 12 months measured with the Constant score with no increased risk of failure up to 24 months in patients age 65 years and over. High attrition rates are observed in this older population due to cognitive decline and death from other causes.

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

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

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

Intramedullary nail fixation for proximal humerus fractures has been shown to provide satisfactory results. The quality of reduction correlates with clinical outcomes, the rate of complications, avascular necrosis, and postoperative loss of fixation. The purpose of this study was to evaluate the clinical outcomes and complications of 2-part proximal humerus fractures compared to 3- or 4-part proximal humerus fractures. A single-center retrospective review was carried out of patients who underwent an intramedullary nail for a proximal humerus fracture by one of three surgeons between the years of 2009 and 2022, and who had a minimum of 12-months follow-up. Fracture pattern, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, satisfaction, pain score, range of motion, and complications were recorded. The mechanism of injury (high energy vs. low energy), method of reduction (open vs. percutaneous), and evidence of radiographic healing were assessed. A P value of <.05 was considered to be statistically significant. The study included 78 patients (62 female, 16 male). The number of patients in each group (2-part, N=32 vs. 3- or 4-part, N=46), mean age (2-part, 64 vs. 3- or 4-part,61), follow-up (2-part, 42.5 months vs. 3- or 4-part, 34.5 months), injury type (2-part, 88% low energy vs. 3- or 4-part, 78% low energy), and method of reduction (2-part, 81% percutaneous vs. 3- or 4-part 72% percutaneous) were similar among the two groups. There was fracture union in all patients. All patients demonstrated satisfactory patient-reported outcome measures. However, 2-part fractures did have a significantly lower pain score, higher Single Assessment Numeric Evaluation score, and higher percentage of patients being satisfied or very satisfied when compared to 3- or 4-part fractures. The rate of subsequent procedures was 13% (n=4) in 2-part fractures compared to 19% (n=9) in 3- or 4-part fractures but was not statistically significant (P=.414). The overall rate of conversion to arthroplasty was 3.2% in 2-part fractures and 10.4% in 3- or 4-part fractures. Multipart proximal humerus fractures remain difficult to treat. However, this study demonstrates an overall acceptable outcome with improvement in range of motion, patient-reported outcomes, and similar complication rates between 2-part and 3- or 4-part proximal humerus fractures treated with an intramedullary nail. However, the improvement in certain parameters is not as marked in 3- or 4-part fractures as 2-part fractures.

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.

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

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

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.

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

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

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

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

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

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

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

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

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

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