Proximal Humerus Research Articles

The effect of tuberosity healing on functional outcomes after reverse shoulder arthroplasty for proximal humerus fractures: a systematic review and meta-analysis.

This systematic review and meta-analysis compared clinical outcome measures in patients undergoing reverse shoulder arthroplasty (RSA) for proximal humerus fracture (PHF) with healed versus non-healed greater tuberosity (GT). We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines querying PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane for studies that stratified results by the GT healing status. Studies that did not attempt to repair the GT were excluded. We extracted and compared clinical outcomes including postoperative forward flexion (FF), external rotation (ER), internal rotation (IR), Constant score, and complications and revision rates. Of the included patients, 295 (78.5%) demonstrated GT healing while 81 did not (21.5%). The healed GT cohort exhibited increased postoperative FF (P < .001), ER (P < .001), IR (P = .006), and Constant score (P = .006) compared to the non-healed GT cohort. The overall dislocation rate was 0.8% with no study differentiating GT status of dislocation cases. Healing of the GT after RSA for PHF yields improved postoperative range of motion and strength, whereas patient-reported pain and function were largely not affected by GT healing indicating merit to RSA for PHF regardless of the likelihood of the GT healing.

Development of the humeral head offset index for control of humeral torsion

BackgroundControl of humeral torsion can present a challenge, especially intraoperatively during closed reduction and fixation of humeral shaft fractures or 2-part surgical neck fractures of the proximal humerus. The objective of this study is to develop and validate an indirect method for the assessment of humeral torsion using an index that is linearly correlated with rotational arm position and can be derived from only a single plain radiographic image of the proximal humerus.MethodsThe Humeral Head Offset Index (HHOI) is calculated as the ratio of the medial and lateral offset of the humeral head measured from the outer cortices of the shaft on a plain radiographic or fluoroscopic image. The relationship of HHOI with humeral torsion was first verified on a sawbone model with radiopaque characteristics under fluoroscopic control. Different degrees of retroversion were simulated through manual rotation of the humerus with a digital protractor in 5° increments until 40° internally rotated and then in 5° increments until 40° externally rotated from the neutral position. The same procedure was subsequently performed digitally on Digitally Reconstructed Radiographs (DRRs) from computed tomography (CT) dataset of the sawbone. Next, the HHOI index was applied to eight randomly selected patients with total humerus CT using the same method. Spearman’s rho was calculated for the bivariate analysis of correlation between the simulated degree of retroversion and the HHOI. Strength of correlation was classified according to Koo and Li. Interrater and intrarater reliability of three blinded observers with repetition of measurement after three months were analyzed by assessing the intraclass correlation coefficient (ICC).ResultsBoth in the sawbone model and in DRRs, we demonstrated a high to very high significant linear correlation between simulated retroversion and the HHOI. ICC values demonstrated excellent interrater reliability and excellent intrarater reliability for measurement of the HHOI.ConclusionsThe HHOI is a new, simple, reliable index that has a linear relationship to the rotation of the humerus and can therefore allow an indirect control of humeral torsion in comparison to the contralateral side.

Free functional gracilis transfer for reconstruction of isolated anterior deltoid atrophy following surgical proximal humerus fixation

BackgroundPalsy of the clavicular head of the deltoid is a complication after surgical fixation of proximal humerus fractures. Flexion of the shoulder joint may be impaired as a result. Additionally, patients may complain of joint instability, visible atrophy and pain. Where nerve reconstruction is not possible, muscle transfers remain as secondary reconstructive procedures. MethodsThree patients suffering from anterior deltoid palsy after proximal humerus fixation received a free functional gracilis transfer to the shoulder. Postoperatively, patients underwent biofeedback-based rehabilitation. Before and after the intervention, subjective complaints, pain level and active range of motion (ROM) were recorded. At the final follow-up patients completed a Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. ResultsThe surgery was successful in all patients with first muscle signals registered through sEMG approximately four months postoperatively. At the latest follow-up (> 3 years), the patients showed improved shoulder stability and pain scores. In two patients with preoperative restrictions, active ROM improved. The DASH score showed minimal to no disability in two patients and moderate disability in the third. Two patients voiced satisfaction with the restoration of the ventral bulk of the shoulder. ConclusionsThe free functional gracilis muscle transfer is a novel approach for secondary reconstruction in patients with anterior deltoid atrophy who don’t qualify for nerve intervention. It addresses shoulder instability and pain and may improve active ROM. The addition of fresh muscle tissue to the ventral shoulder can improve its natural contour and prevent protrusion of the humeral head.

Reverse Allograft Prosthetic-Composite Versus Endoprosthesis Reconstruction for Massive Proximal Humerus Bone Loss: A Systematic Review and Meta-analysis of Outcomes and Complications.

This systematic review and meta-analysis sought to compare the clinical outcomes after proximal humerus reconstruction with a reverse allograft-prosthetic composite (APC) versus reverse endoprosthesis. Per PRISMA guidelines, we queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of reverse APC or reverse endoprosthesis reconstruction of the proximal humerus for massive bone loss secondary to tumor, fracture, or failed arthroplasty. We compared postoperative range of motion, outcome scores, and the incidence of complications and revision surgery. Of 259 unique articles, 18 articles were included (267 APC, 260 endoprosthesis). There were no significant differences between the APC and endoprosthesis cohort for postoperative forward elevation (P = .231), external rotation (P = .634), ASES score (P = .420), Constant score (P = .414), MSTS (P = .815), SST (P = .367), or VAS (P = .714). Rate of complications was 15% (31/213) in the APC cohort and 19% (27/144) in the endoprosthesis cohort. The rate of revision surgery was 12% after APC cohort and 7% after endoprosthesis. APC-specific complications included a 10% APC nonunion/malunion/resorption rate and 6% APC fracture/fragmentation rate. Reverse APC and endoprosthesis are reasonable options for proximal humerus reconstruction. APC carries additional risks for complications, warranting evaluation of patients' healing capacity and surgeon experience. Level IV; Systematic Review. The online version contains supplementary material available at 10.1007/s43465-024-01248-7.

A Study Examining the Functional Outcomes of Conservative and Surgical Management of Three- and Four-Part Proximal Humerus Fractures in Individuals Aged Over 50 Years.

Proximal humerus fractures are common in elderly patients and are often associated with osteoporosis. The management of these fractures, particularly three-part and four-part fractures, remains controversial, with conservative and surgical treatments both employed. This study compared conservative and surgical management's functional outcomes in subjects over 50 years. This prospective observational study was conducted at Father Muller Medical College from December 2018 to June 2020. A total of 48 patients aged over 50 years with three-part and four-part proximal humerus fractures were included. Patients were divided into two groups: group A (conservative treatment with U-slab immobilization) and group B (surgical treatment with proximal humerus internal locking system plate fixation). Functional outcomes were assessed using the constant score at one-, three-, and 6-month intervals. Of the 48 patients, 25 (52.1%) had three-part fractures, and 23 (47.9%) had four-part fractures. At six months, the mean constant score for conservatively managed patients was significantly higher in both three-part fractures (77.23 vs. 52.58, p < 0.001) and four-part fractures (75.73 vs. 53.58, p < 0.001) compared to the surgically managed group. The conservative group also demonstrated better pain relief, range of motion, and shoulder strength. Complications were more common in the surgical group, with two cases of surgical site infection and one case of wound dehiscence, while no complications were observed in the conservative group. Conservative treatment of three-part and four-part proximal humerus fractures in patients over 50 years provides better functional outcomes than surgical intervention. Conservative management should be considered the preferred treatment approach, especially in elderly patients with low-demand lifestyles.

Surgical Applications for Bone Marrow Aspirate Concentrate

Bone marrow aspirate concentrate (BMAC) is an autologous orthobiologic agent that may be of benefit in specific surgical scenarios. Composed of elements isolated from bone marrow, including mesenchymal stromal cells, bone marrow–derived platelets, red and white blood cells, and hematopoietic precursors, BMAC has gained appeal for its potential to slow the progression of chondral degeneration, improve function, and provide symptomatic relief. BMAC is typically prepared during the final stages of a surgical procedure, beginning with bone marrow aspirate harvested from the iliac crest, distal femur, body of the ilium, or proximal humerus and then centrifuged to yield concentrated marrow cells. In a published technique for BMAC use in arthroscopic acetabular labral repair, 120 mL of BMA is harvested from the body of the ilium and then centrifuged to yield approximately 4 to 6 mL of BMAC. The biologic activity of BMAC is 2-fold: (1) mesenchymal stromal cells are pluripotent stem cells that stimulate a robust tissue response for cartilage repair through their potential to differentiate into chondrocytes that induce chondrogenesis, and (2) bone marrow–derived platelets produce growth factors, cytokines, and chemokines that promote collagen synthesis, wound healing, and suppression of proinflammatory cytokines. To date, BMAC has shown promise as an efficacious adjuvant therapy. When comparing patient outcomes, studies have found that patients receiving BMAC achieved lower rates of revision rotator cuff repair, higher functional outcome scores following arthroscopic acetabular labral repair, and significant reductions in pain levels in the context of knee cartilage defects. These findings, however, must be interpreted with caution, as there remains a paucity of randomized controlled trials investigating the mid- and long-term efficacy of BMAC. Overall, as treatments for patients with both progressive chondral degeneration and acute orthopaedic injuries continue to evolve, BMAC serves as promising orthobiologic therapy to improve outcomes.

Effect of birth type and sex on growth performance, wither height, humerus-radius bone dimensions, humerus-ulna growth plate width and selected hormone profile in growing Gurcu goat kids.

In this study, the effects of sex and birth type on growth performance, withers height (WH), radiographic measurements and selected hormone profiles in Gurcu goat kids were investigated. Twenty kids (single female=5, single male=5, twin female=5, twin male=5) were included in the study. Body weight (BW), WH, radiographic measurements (humerus length [HL], radius length [RL], proximal humerus epiphyseal plate width [HEP] and distal ulna epiphyseal plate width [UEP]) and biochemical analysis (for serum calcitonin, free triiodothyronine [FT3], free thyroxine [FT4], growth hormone [GH] and insulin-like growth factor-I [IGF-I]) were performed at 1, 3, 5, 7, 9 and 12 months of age. BW was significantly higher in males starting from the seventh month compared to females (p<0.05). HL was higher in males at seventh (p=0.009) and ninth (p=0.033) months, whereas RL was lower in twins at the third month (p=0.021). UEP was wider in males at seventh (p=0.008) and ninth (p=0.036) months. Closure of HEP was observed in 65% of kids by the 12th month. Calcitonin was lower in twins at third (p=0.045) and fifth (p=0.006) months, with changes observed due to group and time effects (p<0.05), whereas other hormones only changed with time (p<0.05). Positive correlations were observed between BW, WH, HL, RL and IGF-I. There was a negative correlation between BW, WH, HL, RL, IGF-I and HEP, UEP, calcitonin, FT3, FT4, GH. Sex and birth type in Gurcu goat kids may have an impact on growth performance, radiographic measurements and certain hormonal profiles.

Radiologic evaluation of the healing of the greater tubercle after humeral hemiarthroplasty with Aequalis-fracture-implants for proximal humeral fracture: a retrospective cohort study in 45 shoulders

IntroductionDevelopment and use of specific anatomic prosthesis for shoulder’s fracture aimed to reach the best rate of consolidation of the greater tubercle, which means a cuff restitution to improve functional results. The lack of bone healing of the tubercles suggested the use of a fenestrated humeral implant with interposition of a bone graft in the metaphyseal part of the prosthesis. This characteristic of specific implant, have few reports in the literature, leading us to the current retrospective study aiming: 1) to evaluate the healing rate of the greater tubercle after implantation of fracture dedicated anatomic implant, which includes a fenestration in the prosthetic metaphysis for the addition of a cortico cancellous graft, 2) to asses on patients with proximal humerus fractures, the bone healing of the greater tubercle close to the intraprosthetic bone graft. HypothesisThe specific “implant-fracture” can achieve a high rate of bone healing of the humeral greater tubercle Patients and methodsBetween January 2001 and December 2020, fifty-one patients were operated on by implantation of fracture dedicated implant for proximal humerus fracture. Six were excluded (2 operated for revision, 2 operated after 3 weeks, 1 died, 1 without follow-up). In total 45 patients were included in radiological analysis, clinical analysis had been performed on 23/45 patients at the longest follow up, the other 22/45 were only analyzed on radiographies. Mean-aged 66 years (range, 47 years -88 years), 25/45 (56%) of women, with 3-4-parts fractures according to Neer’s classification. The techniques of tubercle fixation were isolated cerclages of combined horizontal cerclages and vertical sutures. Position and healing of the greater tubercle was controlled through antero-posterior and lateral X-Rays views at the longest follow-up (mean 50 months, range 3 to 193 months). Peroperative techniques of fixation, clinical and functional outcomes were noted and correlated to the radiologic position of the greater tubercle and the graft evolution. Factors associated with healing and anatomic position had been investigated. ResultsThe rate of greater tubercle healing was 32/45 (73%). Factors significantly associated with greater tuberosity consolidation were higher age (p = 0.04) and the addition of a vertical osteosuture to the horizontal suture of the greater tubercle (p = 0.01). The rate of anatomic position of the greater tubercle was 15/45 (33%) of cases. When the fixation of the tuberosity was made with vertical suture, good position of the tuberosity was observed in 68% (17/24) at the longest follow-up. DiscussionOur results were in accordance with the literature, but the current study underlined there were two types of factors influencing tubercle healing in the literature: the technique of fixation of the tubercle and the patient’s age. Level of evidencelevel IV cohort study without control group.

Evaluation and Management of Glenohumeral Instability in Adolescent Patients: An Expert Consensus Statement.

Management of glenohumeral instability in the adolescent population can be both challenging and controversial. There are no current guidelines for optimal management of glenohumeral instability in this population (unidirectional or multidirectional), and the cutoff ages for transition to adult treatment are not known. To develop consensus-based guidelines for the management of glenohumeral instability in adolescents. Consensus statement. A 26-question, multiple-choice survey was developed after 2 rounds of iterations and was submitted to the orthopaedic surgeons of the Pediatric Research in Sports Medicine (PRiSM) Society. The survey comprised 3 sections-demographics, practice setting, and decision-making-and included cutoff ages and management in 5 specific case scenarios. Consensus-based guidelines were generated with 66% response agreement. An indication score was then applied to each response related to more aggressive management to determine if variables related to consensus (or lack thereof) could be identified. A total of 54 responses were returned. Of the respondents, 59% were from academic practice, 84% were pediatric orthopaedic fellowship trained, and 46% performed >25 shoulder instability cases per year. In the setting of first-time anterior shoulder dislocation, nonoperative treatment was preferred for boys aged <14 years and girls aged <13 years. Besides age, proximal humerus physeal status, injury mechanism, sport, and presence of bony injury affected treatment selection. The presence of a Bankart lesion was an indication for stabilization in first-time dislocations for contact athletes with a closing or closed physis, but not in patients with an open physis or noncontact injury mechanisms. For recurrent anterior shoulder dislocation, stabilization was preferred irrespective of physis status. Initial nonoperative treatment was preferred for multidirectional instability. In the setting of first-time anterior shoulder dislocation in patients with open physes, nonoperative treatment was preferred for boys <14 years and girls <13 years. Future multicenter prospective studies focusing on outcomes would help to validate current practice patterns, especially in scenarios for which no consensus was reached.

Surgeon-related Factors in the Surgical Treatment of Proximal Humerus Fractures.

In this study, we reviewed proximal humeral fractures surgically treated with open reduction and internal fixation (ORIF) to test the null hypothesis that there is no association between fracture characteristics and surgeon characteristics in outcomes after surgical management of displaced proximal humeral fractures with ORIF. A retrospective review of surgically treated proximal humeral fractures was done at a tertiary-level hospital. The data were organized into two categories: fracture characteristics and surgeon characteristics. There were 314 proximal humeral fractures treated with ORIF. In total, there were 112 failures (36%). Bivariate Pearson correlations demonstrated that the number of proximal humerus fixation surgeries performed by an individual surgeon was associated with adequate calcar reduction (r = 0.995, P < 0.001) and greater tuberosity reduction (r = 0.994, P < 0.001). Years of experience was positively associated with adequate calcar reduction (r = 0.594, P = 0.012) and greater tuberosity reduction (r = 0.589, P = 0.013). Regression analysis of two surgeons versus the rest of the cohort demonstrated significantly lower failure rates (P = 0.001). Complex proximal humeral fractures (3-part and 4-part) have better calcar reduction and tuberosity reduction when treated by surgeons with greater volume of proximal humeral fracture surgery. Among surgeons with high volume, there may be individuals who have the unique ability to provide markedly better results.

Low-value surgical innovation under peer-review: A sham study of abstracts on proximal humerus fractures submitted to scientific meetings.

Innovation has in common the promise of benefit for patients; however, past experience has shown that this promise is not always delivered. Instead, low-value innovation might encourage treatment variation and dilute the available body of evidence. This study aims to investigate (1) whether the peer-review process is capable of filtering out low-value innovation appropriately, and (2) whether low-value surgical innovation would be preferred more often than nonoperative innovation by peer-reviewers in the treatment of proximal humeral fractures in the elderly. Two duplicated sham scientific abstracts, respectively introducing a low-value surgical innovation and a valuable nonsurgical innovation, were submitted to nineteen peer-reviewed scientific meetings worldwide for orthopedic trauma surgery with submission deadlines between 01/01/2022 and 31/12/2022. Decision regarding abstract acceptance was compared. There was a high acceptance rate for the abstract introducing low-value surgical innovation (12 out of 19 (63.2 %)), which was higher than that of a nonoperative duplicate (10 out of 19 (52.6 %)), but this difference was not statistically significant (p = 0.5). The majority of the ten meetings that accepted both abstracts placed both in equivalent programmatic tiers (oral presentation (4) and poster presentation (2)). In three meetings, the surgical abstract received superior program placement (oral presentation). In one case, it was the opposite. There is a high acceptance rate for low-value surgical innovation among peer-reviewed scientific meetings. However, we can not conclude that low-value surgical innovation is preferred more often than nonoperative innovation by peer-reviewers as the differences in acceptance rate were small and not statistically significant. The peer-review process may be suitable as value-based medicine emerges. Scientists should be encouraged to pursue value-based innovation.

United States opioid prescribing trends after shoulder surgery and their correlation with opioid misuse

BACKGROUNDOrthopedic surgery has been highlighted as a contributor to the opioid epidemic. There is a paucity of literature focused specifically on opioid prescribing trends following shoulder surgery. Our aims were to describe national and regional trends in opioid prescribing following total shoulder arthroplasty (TSA), proximal humerus fracture fixation, and rotator cuff repair (RCR), and to correlate opioid prescribing trends after shoulder surgery with regional heroin use and new opioid misuse diagnoses. METHODSThis is a retrospective study of 218,577 patients from a commercial insurance dataset who had undergone orthopedic shoulder procedures from 2014-2020. Opioid prescription data within 90-day postop were converted to morphine milligram equivalents (MME). Multivariate modelling was used to evaluate independent associations between MME’s prescribed and subsequent new postoperative diagnosis of opioid dependence. Additionally, longitudinal mixed effects modeling was employed to understand aggregated prescriber habits by state over time and the subsequent effects on estimates of state heroin use and drug overdose deaths. RESULTSFrom 2014 to 2020, the mean number of MMEs prescribed nationally decreased by over 50% for TSA, proximal humerus fracture fixation, and RCR. Over the study period, most states demonstrated an overall downtrend of 90-day opioid prescribing for these procedures.Individuals with a new opioid misuse diagnosis following shoulder surgery were found to be younger (SMD=0.27, p<0.001), have increased comorbidities (SMD=0.38, p<0.001), and increased MME’s prescribed (SMD=0.94, p<0.001). Increased comorbidity score (OR=3.28, p<0.001) and increased 90-day MME’s prescribed (OR=1.05, p<0.001) were all found to increase the odds ratio of a postoperative opioid misuse diagnosis in patient’s undergoing shoulder surgery, while increased age (OR=0.97, p<0.001) and patient’s undergoing RCR (OR=0.79, p=0.001) were found to have a decreased odds ratio of developing a new opioid misuse diagnosis.The predictors of regional heroin use included the within-state 90-day MMEs prescribed (p=0.002). The predictors of drug overdose death included year (p<0.001), but did not include type of surgery or 90-day MMEs. CONCLUSIONOrthopedic surgeons successfully reduced the number of opioids prescribed nationally after shoulder surgeries by over 50% during our study period with similar trends seen at the state level. Our data indicate a relationship between increased opioid prescribing after shoulder surgery and heroin use. This study highlights that while progress has been made, there is evidence that opioid prescribing following shoulder surgery is associated with the more widespread opioid epidemic, and that more research is needed to further lower postoperative opioid misuse in the future.

Radiographic assessment of incidental bone lesions of the proximal humerus: a prevalence study.

An increased prevalence of benign lesions has been associated with the increased use of radiological tools in orthopedic practice. To investigate the inter-observer reliability of the radiographic detection of lesions on the proximal humerus between different observers. X-ray radiological examinations of 17,243 patients were performed by an orthopedic surgeon to assess the presence of proximal humeral bone lesions. After this initial screening, 201 patients with lesions were identified and these 201 scans were assessed by three different physicians: an orthopedic oncologist, an orthopedic surgeon, and a musculoskeletal radiologist. Of the 201 patients with lesions, 80 had magnetic resonance imaging in addition to X-rays and were assessed. The diagnosis of the lesions was determined by each participant according to their radiological appearance to assess inter-observer reliability. The prevalence of proximal humeral lesions was determined by the orthopedic surgeon to be 1.165% (201 of 17,243 patients). In 201 patients with a lesion, the mean age was 48 ± 17 years (range = 18-91 years). According to the assessments of the orthopedic oncologist, orthopedic surgeon, and musculoskeletal radiologist, the most common bone lesion identified was enostosis, with prevalence percentages of 53.7%, 59.7%, and 64.7%, respectively. A noteworthy consensus exists in the collective diagnosis of bone lesions among the three investigators, demonstrated by a substantial agreement with Fleiss' κ at 0.74 (P < 0.001). There was remarkable agreement between the three investigators on the collective diagnosis of bone lesions. Enostosis was the most common bone lesion at the proximal humerus in our series.

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.

Locking Plate Fixation with Calcium Phosphate Bone Cement Augmentation for Elderly Proximal Humerus Fractures-A Single-Center Experience and Literature Review.

Proximal humerus fractures (PHFs) are among the most common upper-extremity fractures, with a rising incidence linked to the growing elderly population. Treatment options include non-surgical and surgical methods, but the best approach for geriatric PHFs remains debated. Patient selection for treatment must consider clinical and functional outcomes and the potential complications of surgery. Osteoporosis, a key factor in elderly PHFs, meaning those in patients over 65 years old, often results from low-energy trauma and necessitates treatments that enhance bone healing. Bone cement, such as calcium phosphate, is widely used to improve fracture stability and healing. However, the benefits of surgical fixation with bone cement augmentation (BCA) for elderly PHF patients remain controversial. Hence, in this article, we searched databases including MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science to analyze the evidence on locking plate fixation (LPF) with BCA for proximal humeral fractures. We aim to provide readers with updates concerning the above issues.

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.

Head-Shaft Angle Influences Isometric Shoulder Strength Levels after Intramedullary Nailing of Proximal Humerus Fractures: A Pilot Study.

Proximal humerus fractures are common fractures of the elderly population which can lead to long-term compromise of a patient's shoulder function. Closed reduction and internal fixation with intramedullary nailing is a well-established surgical technique yielding good outcomes, as perceived by patients, obtained via Patient-Reported Outcome Measures, and objectified by clinical shoulder testing. Apart from conventional range-of-motion testing and clinical shoulder tests, strength testing of the shoulder is a yet-neglected but meaningful and standardizable outcome parameter. In this study, isometric shoulder strength is evaluated in relation to fracture morphology/postoperative reduction quality as well as with patient-reported outcomes. 25 patients (mean age 73.2 ± 10.5 years) underwent isometrics strength-testing of the shoulder joint in the scapular plane (abduction) as well as in the sagittal plane (flexion) as well as hand-grip strength-testing at 4.5 ± 1.88 years follow-up. Pre- and postoperative radiographs were analysed. Patients completed ASES and CMS questionnaires. Patients exhibited a decrease in abduction and flexion force (-24.47% and -25.30%, respectively, p < 0.001) using the contralateral, uninjured arm as reference. Abduction force tended to be decreased in three- and four-part fractures. Patient satisfaction correlated negatively with the relatively reduced force of the affected arm. Varus-angulated humeral heads produced significantly lower abduction force output than valgus- or physiologic angulation (p = 0.014), whereas flexion force was unaffected (p = 0.468). The anatomical reduction had no influence on shoulder strength. Proximal humerus fractures may cause a significant reduction in shoulder function, both reported by patients and objectified by shoulder strength testing. Varus head angulation demonstrated the greatest loss of shoulder strength and should be avoided to ensure proper functioning. Further, strength testing seems a valuable outcome parameter for a thorough shoulder examination with easy obtainability.

Enhanced Outcomes and Safety of Reverse Shoulder Arthroplasty in Rotator Cuff Deficiency and Proximal Humerus Fractures: A 22-Patient Retrospective Analysis.

BACKGROUND Reverse shoulder arthroplasty (RSA) is an accepted treatment that provides reproducible results in the treatment of rotator cuff deficiency and proximal humerus fractures. This single-center study aimed to evaluate the outcomes from reverse shoulder arthroplasty for rotator cuff ınsufficiency and proximal humerus fractures in 22 patients from a single center. MATERIAL AND METHODS Twenty-two patients were included in the study. The median age of the patients was 66 years (Range: 58-95). Proximal humerus fractures were diagnosed using X-ray and CT, while rotator cuff tears were diagnosed using MRI. For the assessment of joint function, the Constant-Murley score, the American Shoulder and Elbow Surgeons (ASES), and the Disabilities of Arm, Shoulder, and Hand (DASH) scores were used as patient-reported outcome measures. Kaplan-Meier analysis was conducted to evaluate implant survival. RESULTS The mean follow-up duration was 4.05±1.2 years. Significant improvements were observed: ASES Score: Increased from 35.8±2.8 to 81.3±5.4 (p<0.001). VAS Pain Score: Decreased from 7.3±1 to 2.9±0.9 (p<0.001). DASH Score: Improved from 66.3±4.3 to 32.5±3.6 (p<0.001). Constant-Murley Score: Increased from 48.3±3.5 to 74.6±7.7 (p<0.001). Kaplan-Meier analysis estimated implant survival at 6.7 years (95% CI, 6.3-7.2). CONCLUSIONS When performed with appropriate indications, RSA yields positive results, as seen in the literature and our study. Interscalene block anesthesia, advancements in implant technology, and adherence to surgical procedures can reduce RSA complications and ensure its safe application.

Management of traumatic fracture-dislocation of the shoulder in children: A systematic review of published case reports

Proximal humerus fracture with simultaneous shoulder dislocation in children is a rare occurrence, with few reported cases. This systematic review of case reports aimed to document the outcomes of different treatment methods. A comprehensive literature search from 1980 to 2024 included case reports on traumatic shoulder fracture-dislocation in children. Eighteen studies were included, with a mean follow-up of 1.5 years. The cases comprised 7 boys and 11 girls, aged between 11 months and 16 years (median 6 years). The cases were divided into two groups based on epiphyseal involvement. Group A had 11 cases (61%) with epiphyseal involvement, while Group B had 7 cases (38%) with metaphyseal fractures without epiphyseal involvement. Treatments included closed or open reduction, with or without internal fixation. All fractures healed in an average of 7 weeks, with full function restored in an average of 21.58 weeks. The review suggests that open reduction with K-wire fixation is optimal for Group A, whereas closed reduction with intramedullary fixation is more effective for Group B, offering satisfactory clinical and radiological results in a shorter time efficiently.

Metastatic cancer in a medieval skeleton from the Principality of Liechtenstein.

We present a presumptive case of metastatic carcinoma in an individual from the 11th/12th century CE from Vaduz, Principality of Liechtenstein. The skeleton exhibits extensive new bone formation in the axial skeleton and the proximal humerus and femur. Radiological examinations revealed further sclerotic lesions in the clavicles, the manubrium, the sternum, the femoral diaphysis, and possibly the frontal. The pelvic bones and the sacrum, as well as the spine, are the most heavily affected skeletal regions. The newly formed bone in some lesions has a "sun-burst" appearance. The sex and age at death of the individual, the distribution and the osteoblastic nature of the lesions suggest that prostate carcinoma is the most likely primary tumor.