Proximal Humeral Fractures Research Articles

Preoperative chronic steroid use as a risk factor for complications following open reduction internal fixation for proximal humerus fracture.

The primary objective of this study was to investigate the association between preoperative chronic steroid use and postoperative complications following open reduction internal fixation(ORIF) for proximal humerus fractures(PHF). The American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was queried for all patients who underwent PHF ORIF between 2015 and 2021. A total of 6,273 patients were included in this study, of which 3.4% (n = 212) were in the chronic steroid use cohort. Patient characteristics including demographics, comorbidities, and 30-day postoperative complications after PHF ORIF were collected. Bivariate logistic regression and multivariate logistic regression analysis, adjusted for all significantly associated variables, was conducted to investigate the relationship between preoperative chronic steroid use and postoperative complications. Chronic steroid use was significantly associated with age ≥ 75 (p < 0.001), male gender (p =0.006), dependent functional status (p = 0.008), American Society of Anesthesiologist (ASA) ≥ 3 (p < 0.001), CHF (p = 0.007), hypertension (p < 0.001), COPD (p < 0.001), bleeding disorder (p = 0.007), ascites (p = 0.040), disseminated cancer (p< 0.001), and systemic sepsis (p < 0.001). After adjusting for all significantly associated variables, chronic steroid use was independently associated with major complication (OR 1.60, 95% CI 1.06-2.43; p = 0.026), and non-home discharge (OR 1.05, 95% CI 1.01-1.08; p = 0.014). Preoperative chronic steroid use is associated with increasing rate of postoperative complications following PHF ORIF. Better understanding and characterizing chronic steroid use as a preoperative risk factor can aid physicians in risk stratification to reduce rates of postoperative complications following PHF ORIF. III. Retrospective Cohort Comparison; Prognosis Study.

How does trauma secondary to unexpected extreme weather affect orthopaedic surgery departments? : An epidemiological study on the Filomena snowstorm

Trauma secondary to extreme weather events may heavily impact the normal activity of orthopaedic surgery departments, especially in places not prepared to deal with them. The Filomena snowstorm, which happened in January 2021, was one of the greatest snowstorms ever in Spain. During it, the constant influx of trauma patients caused Orthopaedic Emergencies Department (OED) to collapse. The primary objective of this study was to describe the orthopaedic injuries and changes in fracture's epidemiology observed during this exceptional period. Secondary objectives were to analyse the collected variables in order to minimize the future impact of these unexpected extreme weather events. A retrospective cohort study between patients that came to the OED during the snowstorm (Filomena group) and those who came on the same period of the previous year (Control group) was made. The following data were collected: age, sex, injury location, injury mechanism, diagnosis, AO/OTA fracture classification, treatment type (conservative vs surgical) and delay of surgical treatment. Atotal of 1237 patients were included, 655 patients from the Filomena group and 582 from the Control group. One in two patients in the Filomena group sustained afracture (50.7% vs 23.2%). The most frequent diagnosis on the Filomena group was distal radius fracture (16.2%), which was five times more frequent than in the Control group (3.4%). Asignificant increment was also observed in the incidence of ankle (21.7%) and proximal humerus (33%) fractures. In the Filomena group, surgically treated fractures increased by 168%, being more severe, as C‑type fractures were more prevalent (23% vs 13%). Mean delay to surgery was 6.78 days during the snowstorm. Unexpected snowstorms entail an exponential rise in orthopaedic care demand and OED pressures. Asignificant increment in orthopaedic trauma surgery, up to 168% more, particularly distal radius, proximal humerus and ankle fractures, is to be expected, which will imply elective surgery cancellation, hurting patients and increasing costs.

Proximal humeral fractures: association between displacement and fatty degeneration of the supraspinatus muscle.

To evaluate the relationship between initial displacement in proximal humeral fractures and fatty degeneration of the rotator cuff measured by CT according to the Goutallier classification. This cross-sectional observational study evaluated patients with proximal humeral fractures over a six-month period. The study included patients ≥ 18 years old with complete radiological views (anteroposterior, lateral, and Grashey) and a CT scan of the affected shoulder; previous fracture or ipsilateral shoulder surgery were excluded. Neer's classification system and Goutallier stages were used to evaluate the patients. Demographic data were collected and, two groups were analysed according to age (≤ 50 years and > 50 years). Sixty-two patients were included (m = 36, f = 26, ratio 1.3:1); seven patients were excluded. Male patients (36, 58.1%), patients older than 50 years (33, 53.2%) and a low-energy injury mechanism (36, 58.1%) were the most frequent cases. According to the Neer system, the most common proximal humerus fracture was fracture-dislocation in 17 (27.4%) cases. The most common stage in Goutallier's classification was I (some fatty streaks) in 22 (35.4%) cases. Younger patients (≤ 50 years) had more displaced fractures with low fatty degeneration (p = < 0.001) than older patients (> 50 years), who had minimally displaced fractures with greater fatty degeneration (p = 0.567). High-energy mechanisms are associated with younger patients and a more displaced fracture according to the Neer classification. Older patients had a more advanced Goutallier stage and lesser displaced fracture. We should consider a more aggressive approach in the treatment of non-displaced fractures in elderly patients, less conservative and more surgical management, to obtain a better clinical evolution after the treatment of these kinds of fractures. IV.

Retrospect?ve compar?son of cl?n?cal and rad?olog?cal results of conservat?ve and lock?ng anatom?cal plates for neer type 2 and type 3 prox?mal humerus fractures ?n pat?ents over 40 years of age

Proximal humerus fractures are one of the most common fractures in adults. Its incidence is increasing day by day with the increase in life expectancy in society. It was aimed to compare the radiological and functional results of patients over the age of 40 who were treated with conservative and anatomical locking plate (Philos) in our clinic due to Neer type 2 and type 3 proximal fractures. 82 patients who came to Bursa Uludağ University Hospital Orthopedics and Traumatology Clinic and Polyclinic with the diagnosis of Neer type 2 and type 3 proximal humerus fractures between January 2010 and December 2020, whose treatment was planned and completed, and who came for periodic control after discharge, were included in the study. For this purpose, X-ray radiographs, surgery notes and electronic file records in the PACS system were used. The functional results of the patients were evaluated according to the physical examinations at their last follow-up and Constant, ASES and DASH shoulder scoring. There was no significant difference in functional and radiological results between patients treated with conservative treatment and plate. In the measurements made at the last follow-up, the average head-neck angle was 136.2 (115-165) in the conservative group and 134.4 (113-165) in the surgical group. According to the Constant-Murley scoring in the evaluation made at the last follow-up of the patients, the median value out of a total of 100 points was 65.9 (10-98) in the conservative group and 73.9 (35-98) in the surgical group. ASES score is calculated out of a total of 100 points. The median value was 63.3(5-100) in the conservative group and 68.3(23.3-95) in the surgical group. DASH score is calculated from 0 at best to 100 at worst. The median value was 33.3(0-97.5) in the conservative group and 25(4.2-71.7) in the surgical group. In proximal humerus fractures, the fracture type and morphology should first be well defined and classified. When planning the treatment of patients, decisions should not only be made based on the type of fracture, but the treatment plan should also be taken into account by taking into account the patient's functional expectations and comorbidities.

A comparative study of functional outcome of percutaneous kirschner wire fixation versus philos plating of proximal humerus fractures

: Proximal humerus fractures, accounting for approximately 5% of all fractures, pose a significant challenge in orthopedic management due to their complex anatomy and diverse fracture patterns. Treatment options range from conservative methods to various surgical interventions, each with its pros and cons. This study specifically compares two commonly employed surgical techniques: Open reduction &amp; internal fixation with PHILOS plate and percutaneous k-wire fixation with/without external clamps. This study aims to address the effectiveness of each technique by evaluating functional outcomes using validated scoring systems like the Constant-Murley Score. To assess the functional outcomes of two surgical treatment methods (K-wire application and PHILOS plate fixation) for proximal humerus fractures. : A randomized prospective study was conducted on patients coming to the Orthopaedics outpatient department or casualty of tertiary care hospital for a duration of 1 year from Dec 2022 to Nov 2023. A total of 18 patients were included in the study. The mean Constant- Murley Score (CMS) was 81 +/- 6.13 for the PHILOS plating group and 76.88 +/- 7.37 for the K-wire treated group with a p-value of 0.08. The results for CMS were excellent in 22.2% of patients and good in 66.7% of patients in PHILOS treated group and excellent for 11.11%, good for 66.67% and satisfactory for 22.2% in the K-wire treated group. Both groups achieved satisfactory functional outcomes with CM Score at the final follow-up. Both techniques achieved favorable outcomes, with a majority of patients in both groups (88.89% for PHILOS and 77.78% for K-wire) achieving good to excellent results based on the CMS scores.

Conservative Versus Operative Treatment of Proximal Humerus Fractures in Older Individuals.

Little is known about the frequency and results of conservative treatment of proximal humerus fractures (PHF) in older individuals. Billing data of the BARMER health insurance carrier for all patients of age ≥ 65 for the years 2005-2021 were retrospectively analyzed with multivariable Cox regression models, taking account of the patients' age, sex, and individual comorbidity profiles. The defined primary endpoints were overall survival (OS), major adverse events (MAE), thromboembolic events (TE), and complications of surgery or of trauma. Multivariable p-values for the effect of treatment on all primary endpoints were jointly adjusted using the Bonferroni-Holm method. Of 81 909 patients, 54% were treated conservatively. Conservative treatment was more common in those who received their diagnosis as outpatients (79.5%, vs. 37.2% for inpatients). Operative treatment was associated with significantly longer overall survival (long-term hazard ratio [HR] 0.89, 95% confidence interval [0.86; 0.91]), fewer MAE (0.90 [0.88; 0.92]), and fewer TE (0.89 [0.87; 0.92]), but more complications due to surgery or trauma (1.66 [1,.4; 1.78]; all p < 0.001). By 6 months after diagnosis, 3.1% of the patients who were initially treated conservatively had undergone surgery. Risk factors for failure of conservative treatment were alcohol abuse, obesity, cancer, diabetes mellitus, Parkinson disease, and osteoporosis. The conservative treatment of PHF is associated with a lower overall rate of complications due to surgery or trauma, but also with more MAE, more TE, and higher mortality. These findings underline the need for individualized and risk-adjusted treatment recommendations.

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.

Construction and validation of a nomogram for blood transfusion after open reduction and internal fixation (ORIF) of proximal humeral fractures in the elderly: a cross-sectional study

PurposeFew studies have focused on the risk factors leading to postoperative blood transfusion after open reduction and internal fixation (ORIF) of proximal humeral fractures (PHFs) in the elderly. Therefore, we designed this study to explore potential risk factors of blood transfusion after ORIF for PHFs. We have also established a nomogram model to integrate and quantify our research results and give feedback.MethodsIn this study, we retrospectively analyzed the clinical data of elderly PHF patients undergoing ORIF from January 2020 to December 2021. We have established a multivariate regression model and nomograph. The prediction performance and consistency of the model were evaluated by the consistency coefficient and calibration curve, respectively.Results162 patients met our inclusion criteria and were included in the final study. The following factors are related to the increased risk of transfusion after ORIF: time to surgery, fibrinogen levels, intraoperative blood loss, and surgical duration.ConclusionsOur patient-specific transfusion risk calculator uses a robust multivariable model to predict transfusion risk.The resulting nomogram can be used as a screening tool to identify patients with high transfusion risk and provide necessary interventions for these patients (such as preoperative red blood cell mobilization, intraoperative autologous blood transfusion, etc.).

The Application of a Surgery Supporting Computer System Does Not Seem to Influence the Surgeons' Radiation Exposure: A Retrospective Analysis.

Since 2019, a surgery supporting system (SPM, surgical process manager; Johnson & Johnson, New Brunswick, New Jersey, Vereinigte Staaten) has been used in a Level I trauma center for common trauma surgery procedures (distal radius fractures, proximal femur fractures, ankle fractures, proximal humerus fractures, and spine fractures). The hypothesis of this study was that implementing standardized procedures (by using SPM) may reduce radiation exposure, especially for unexperienced surgeons.Workflows were developed for different surgical procedures (distal radius fractures, proximal femur fractures, ankle fractures, proximal humerus fractures, and spine fractures) and added into the SPM. Between October 2019 and June 2022, 90 surgeries using the SPM were included in the study. A control group was included with 107 surgeries using the same surgical technique. The values measured were the radiation exposure during the surgical procedure, the experience of the head surgeon, and whether or not the SPM was used. A statistical analysis was performed by using the chi square and Fischer exact tests, with significance set at a p value <0.05.SPM was applicated in 51 cases for the distal radius (control group 54 patients), 20 cases for distal fibula fractures (control group 21 patients), 9 cases for the proximal femur (control group 19 patients), 5 cases for vertebral fractures (control group 7 patients), and 5 cases for the proximal humerus (control group 6 patients). No difference concerning the median radiation exposure was observed by plating distal radius fractures with 5.7Gy/cm² in the SPM group and a median radiation exposure of 6.4Gy/cm² in the control group (p=0.96). The distal fibula fractures showed no significant difference in the intraoperative radiation (17.4Gy/cm² vs. 6.4Gy/cm², p value 0.53). Radiation exposure was lower when a consultant performed surgery without showing any significance, independent if SPM was used or not.In this study, no significant difference in the intraoperative radiation dose was observed when using a surgery supporting computer system. The experience of the surgeon showed no influence as well, regardless if SPM was used or not. Additional data should be collected questioning these findings.

Intraoperative Doppler flowmetry evaluation of humeral head perfusion after proximal humerus fracture

Understanding vascularity and assessing the risk of post-traumatic avascular necrosis are crucial for predicting outcomes and identifying optimal treatment options in proximal humerus fractures (PHFs). Until now, Hertel etal have been the only researchers to evaluate the intraoperative perfusion of the humeral head after fracture using Doppler flowmetry in a central single drill hole within the head. This pilot study aims to standardize the evaluation of intraoperative perfusion measurements in different areas of the humeral head in patients with PHF. In this prospective pilot study, intraoperative semiquantitative Doppler perfusion measurements were conducted during plate osteosynthesis for PHF treatment in our institution between July 2021 and May 2022. The fracture morphology was classified radiologically according to Resch's criteria. Quality of reduction was determined postoperatively to be either anatomical, minor malreduced, or major malreduced according to Peters etal in conventional and computed tomography examinations. Medial hinge integrity and medial metaphyseal extension were assessed radiographically according to Hertel etal. Intraoperatively, after drilling screw holes through the plate, a Doppler probe was inserted through all nine drill holes on the humeral head and at least one on the humeral shaft to successively measure the presence of a pulse to indicate if perfusion is present. A total of ten patients (mean age 59 years, range, 36-83) with a humeral head fracture (2× 2GL, 3× 3G, 2× 4G, 2× 4GL, 1× 5aG according to Resch) were included. Nine of the ten patients showed a pulse signal on the humeral shaft. Overall, pulse-synchronous perfusion was detected using Doppler sonography in at least one hole in the humeral head of all patients. In patients with an intact medial hinge (N=6), pulse-synchronous perfusion could be measured in almost twice as many humeral head holes on average (5.7 vs. 3.0 drill holes) compared to patients with a dislocated medial hinge (N=4). In patients with metaphyseal extension (N=3), pulse-synchronous perfusion was measured in an average of 6.7 humeral head holes compared to 3.7 holes in patients without metaphyseal extension (N=7). Semiquantitative, intraoperative Doppler flowmetry offers a noninvasive and rapid assessment of humeral perfusion which allows an understanding of humeral head perfusion, when used in a standardized fashion to measure flow in different areas of the humeral head.

Comparison between CFR-PEEK and titanium plate for proximal humeral fracture: A meta-analysis.

The aim of the present meta-analysis was to compare the efficacy and safety of the carbon fiber-reinforced polyetheretherketone (CFR-PEEK) and titanium plate for the treatment of proximal humeral fractures (PHFs) from clinical comparative trials. A comprehensive search of English databases was carried out, such as PubMed, Web of Science, ScienceDirect, Springer and Cochrane Library databases. The RevMan version 5.1 software was applied for statistical analysis, and the mean difference (MD) and risk difference (RD) as the combined variables, and "95%" as the confidence interval (CIs). One randomized-controlled trial and five retrospective controlled studies including 282 PHFs were considered eligible and finally included. Meta-analysis demonstrated that there were significant differences in Constant score (CS) (MD=9.23; 95% CI: 5.02, 13.44; p<0.0001), anterior elevation (MD=18.83; 95% CI: 6.27, 31.38; p=0.003), lateral elevation (MD=18.42; 95% CI: 3.64, 33.19; p=0.01) and adduction (MD=3.53; 95% CI: 0.22, 6.84; p=0.04). No significant differences were observed regarding Constant score compared to the contralateral shoulder, Oxford Shoulder Score, internal rotation, external rotation, screw perforation and cutout, varus/valgus malalignment, humeral head collapse/necrosis, implant removal, and revision surgery between the two groups. Compared to titanium plate, CFR-PEEK plate showed better Constant score, anterior elevation, lateral elevation and adduction in treating PHFs. The complications are comparable to those achieved with conventional titanium plates.

Finite element analysis and biomechanical study of "sandwich" fixation in the treatment of elderly proximal humerus fractures.

Proximal humerus fractures (PHFs) are common in the elderly and usually involve defects in the medial column.The current standard for medial column reconstruction is a lateral locking plate (LLP) in combination with either an intramedullary fibula support or an autogenous fibula graft. However, autogenous fibula graft can lead to additional trauma for patients and allogeneic fibular graft can increase patients' economic burden and pose risks of infection and disease transmission. The primary objective of this study was to introduce and assess a novel "Sandwich" fixation technique and compare its biomechanical properties to the traditional fixation methods for PHFs. In this study, we established finite element models of two different internal fixation methods: LLP-intramedullary reconstruction plate with bone cement (LLP-IRPBC) and LLP-intramedullary fibula segment (LLP-IFS). The biomechanical properties of the two fixation methods were evaluated by applying axial, adduction, abduction, torsional loads and screw extraction tests to the models. These FEA results were subsequently validated through a series of biomechanical experiments. Under various loading conditions such as axial, adduction, abduction, and rotation, the LLP-IRPBC group consistently demonstrated higher structural stiffness and less displacement compared to the LLP-IFS group, regardless of whether the bone was in a normal (Nor) or osteoporotic (Ost) state. Under axial, abduction and torsional loads, the maximum stress on LLPs of LLP-IRPBC group was lower than that of LLP-IFS group, while under adduction load, the maximum stress on LLPs of LLP-IRPBC group was higher than that of LLP-IFS group under Ost condition, and almost the same under Nor condition. The screw-pulling force in the LLP-IRPBC group was 1.85 times greater than that of the LLP-IFS group in Nor conditions and 1.36 times greater in Ost conditions. Importantly, the results of the biomechanical experiments closely mirrored those obtained through FEA, confirming the accuracy and reliability of FEA. The novel "Sandwich" fixation technique appears to offer stable medial support and rotational stability while significantly enhancing the strength of the fixation screws. This innovative approach represents a promising strategy for clinical treatment of PHFs.

Risk of Axillary Nerve Injury With Medial Support Screws in Intramedullary Nails: An Anatomical Study.

In recent years, intramedullary nails with medial support screws for proximal humeral fractures have become available. Although these devices have a potential risk of iatrogenic axillary nerve injury, no studies have investigated the anatomical relationship between the medial support screws in the modern intramedullary nail and the axillary nerve. This study aimed to clarify the anatomical relationship between the medial support screws in the intramedullary nail and the axillary nerve. In total, 29 cadaveric shoulders (mean age: 82.6 years old (range: 61-105); 15 males and 14 females) were included in this study. Shoulders within whole-body cadavers were used in all cases. A single proximal humeral nail with medial support screws (ARISTO Proximal Humeral Nail; MDM, Tokyo, Japan) was used. The distance of each medial support screw from the axillary nerve and its branches was measured. In two (6.90%) of 29 shoulders, the axillary nerves came into contact with the medial support screws. In the remaining 27 of 29 shoulders (93.1%), the nerves were located proximal to the medial support screws. Medial support screws in proximal humeral fracture nails had the potential to injure the axillary nerve and its branches.

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 &amp;lt;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 &amp;lt; 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.

Association between Deltoid Muscle Density and Proximal Humeral Fracture in Elderly Patients.

The potential role of deltoid muscle density in the occurrence of proximal humeral fractures remains uncertain. Therefore, the primary objective of this study was to examine the correlation between deltoid muscle density, as measured by CT attenuation value in Hounsfield units (HU), and the incidence of proximal humeral fractures in elderly patients. By investigating this association, we aim to shed light on the possible influence of deltoid muscle density on fracture risk in this specific population. A total of 68 patients with computed tomography (CT) images were retrospectively reviewed. Among them, 34 patients presented with fractures following low-energy injuries, while the remaining 34 patients served as controls and underwent CT scans after low-energy injuries without any fractures. The muscle density of the deltoid muscles was assessed at the approximate tubercle of humerus. We compared these parameters between the two groups and conducted analyses considering factors such as age, sex, laterality, and deltoid muscle density of the shoulders. The demographic factors related to the shoulder did not exhibit any significant association with proximal humeral fracture. However, we observed a noteworthy difference in deltoid muscle density between patients with fractures (40.85 ± 1.35) and the control group (47.08 ± 1.61) (p = 0.0042), indicating a lower muscle density in the fracture group. Based on the findings of this study, we can conclude that there exists a negative correlation between deltoid muscle density and the incidence of proximal humeral fractures. These results suggest that lower deltoid muscle density may be associated with an increased risk of proximal humeral fractures in the elderly population under investigation.

Transmediastinale migratie van een Kirschner-pin na fixatie van een proximale humerusfractuur: een casus

Transmediastinal migration of a Kirschner pin after fixation of a proximal humeral fracture: a case report Fractures of the proximal humerus are common lesions in the elderly population. In some cases, they are surgically stabilized via a minimally invasive technique, namely percutaneous osteosynthesis with fixation pins. Intrathoracic migration of these pins or wire is a rare complication after percutaneous osteosynthesis of a proximal humeral fracture. In this article, the authors describe an extremely rare transmediastinal migration of a Kirschner pin from the humeral head. The purpose of this case report is to call for awareness and to open a debate in which appropriate prevention can be freely discussed. The consideration of a conservative management, the choice of alternative osteosynthesis techniques, the use of a sling bandage to restrict the shoulder movement, the use of fixation pins with a threaded tip, bending of the external free end of the pin and an appropriate time to remove the pin are possible recommendations from the literature. Furthermore, it is important to provide additional information and awareness to health care providers in rehabilitation centers, geriatricians and orthopedists concerning the possibility of such a life-threatening postoperative complication. Thus, specific policies for clinical and radiographic monitoring of the position of fixation pins should be developed in hospitals and rehabilitation centers with the aim of prevention, early detection and prompt action when this life-threatening complication is suspected.

Short-Term Results after Reverse Total Shoulder Arthroplasty

Abstract Background: The loss of the shoulder’s center of rotation is caused by massive rotator cuff tears, which can occur with or without arthritis and proximal humerus fractures that are nonunion or malunion. Because anatomical total shoulder arthroplasty cannot provide a stable center of rotation, reverse total shoulder arthroplasty (RTSA) is the appropriate procedure for these indications and in older patients who have primary glenohumeral osteoarthritis. Anatomical total shoulder arthroplasty carries a risk of failure because of the loosening of the glenoid component or cuff tear. The purpose of this study was to determine the short-term outcomes following RTSA in patients who had primary glenohumeral osteoarthritis, acute proximal humerus fractures, malunited or nonunited proximal humerus fractures, and massive cuff tears. Materials and Methods: This single-arm clinical trial (interventional study) was done in Ain Shams University Hospitals; 16 patients were included who underwent RTSA. Constant score, American Shoulder and Elbow Surgeon score, Visual Analog Scale score, and range of motion (ROM) were the short-term outcomes. Patients with cuff tear arthropathy, irreparable cuff tear with or without glenohumeral arthritis, elderly patients with unreconstructable proximal humerus fracture, proximal humerus fracture malunion or nonunion, and patients with glenohumeral osteoarthritis were included. Patients under the age of 50, as well as those with deltoid muscle dysfunction or injuries to the axillary nerve, were excluded. Results: There were 16 patients in this study, 8 of whom were male and 8 of whom were female. The follow-up period lasted 2 years following surgery, with a mean age of 64.19 years. The study included 7 patients with irreparable cuff tears one of them had associated anterior shoulder instability and recurrent anterior shoulder dislocation. One patient had a neglected shoulder dislocation, two patients had proximal humerus fracture dislocation, two patients had a nonunited proximal humerus fracture, three patients had unreconstructable proximal humerus fracture, and two had glenohumeral osteoarthritis. Conclusion: Not only did RTSA provide good clinical and functional outcomes for the standard indication of a massive cuff tear, but it also proved beneficial for other disorders such as primary glenohumeral osteoarthritis, nonunited fracture, and acute proximal humerus fracture. Among all indications, irreparable cuff tears yielded the highest results; nonunited fractures displayed the least improvement regarding clinical outcomes. Enhancements in the design of prostheses, the expertise of surgeons, and clinical outcomes are crucial to maximize their effectiveness in treating various shoulder disorders.

Augmented versus non-augmented locking-plate fixation in proximal humeral fractures.

Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures. The search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles involving patients with complex proximal humeral fractures treated using open reduction with locking-plate fixation, with or without augmentation, were considered. A meta-analysis of comparative studies comparing locking-plate fixation with cement augmentation or with bone-graft augmentation versus locking-plate fixation without augmentation was performed. A total of 19 studies were included in the qualitative synthesis, and six comparative studies were included in the meta-analysis. Overall, 120 patients received locking-plate fixation with bone-graft augmentation, 179 patients received locking-plate fixation with cement augmentation, and 336 patients received locking-plate fixation without augmentation. No statistically relevant differences between the augmented and non-augmented cohorts were found in terms of the Disabilities of the Arm, Shoulder and Hand questionnaire score and Constant-Murley Score. The cement-augmented group had a significantly lower rate of complications compared to the non-augmented group. While locking-plate fixation with cement augmentation appears to produce a lower complication rate compared to locking-plate fixation alone, functional outcomes seem comparable between augmented and non-augmented techniques.

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.

Therapeutic Intervention for Osteoporosis of Surgical Cases With Non-Vertebral Fractures for Three Years in a Newly Established Rural Hospital in Japan.

Objectives Our hospital was newly opened in the spring of 2020 in a rural area of Japan, with a remarkably developing aging society and population decline. This study aimed to clarify and evaluate the practice of osteoporosis care in our hospital for three years since its establishment. We report a retrospective review of therapeutic interventions for osteoporosis for patients who underwent surgical treatment for non-vertebral fragility fractures in our hospital. Methods We evaluated the practice of osteoporosis intervention in patients who underwent surgery for proximal humerus fractures (PHFs), distal radius fractures (DRFs), or proximal femoral fractures (PFFs) from April 2020 to the end of March 2023. Results There were 115 surgical cases with non-vertebral fractures (10 patients with PHF, 41 patients with DRF, and 64 with PFF). Among the patients who had received osteoporosis treatment at other hospitals before the injury, only 15 (13.0%) patients had been administered therapeutic intervention for osteoporosis by other clinics or hospitals. Also, 82 (71.3%) patients were newly diagnosed with osteoporosis in our hospital after surgery according to the Japanese osteoporosis guideline. New postoperative osteoporosis interventions were administered to 39 (47.0%) patients, of which the rate was higher than the previous reports in Japan. While there was no significant difference between upper limb fracture and PFF in the percentage per young adult mean of spine areal bone marrow density (aBMD), the femoral neck aBMDs in the upper limb fracture group were significantly higher than in the PFF group. The serum total P1NP levels were significantly lower and the 25(OH)D levels were also greater in the upper limb fracture group than in the PFF group, whereas the serum TRACP-5b levels were not significantly different between the two groups. Two (1.7%) patients were affected with secondary fractures during the study period. Conclusions The rates of therapeutic intervention for osteoporosis of patients with non-vertebral fractures, especially in those with upper limb fractures, in our hospital were considered to be greater than those in the previous reports. However, the intervention rate for patients with PFFs was not much, and there was still room for improvement in our hospital concerning osteoporosis diagnosis and treatment.