Treatment Of Proximal Humeral Fractures Research Articles

Posttraumatische Schultersteife

Posttraumatic stiffness of the shoulder joint is a frequent and socioeconomically relevant result of injury; however, prior to making the diagnosis as the only cause of a persisting impairment of motion, it is necessary to rule out other sequelae of trauma. Even intensive conservative treatment is mostly accompanied by the stagnation of the impairments of movement. In many cases the treatment of choice is early arthroscopic arthrolysis with a standardized approach and intensive follow-up treatment. In the surgical treatment of proximal humeral fractures with humeral head preservation, arthroscopic arthrolysis with simultaneous implant removal is a form of planned second intervention for improvement of shoulder function in cases of persisting motion deficits after bony consolidation. Despite sometimes substantial limitations of movement, a clinically relevant and lasting improvement of shoulder function can be achieved with arthroscopic arthrolysis in posttraumatic shoulder stiffness.

Application of suspensory external fixation technique in treatment of proximal humeral fracture

To investigate the effectiveness of suspensory external fixation technique in treatment of proximal humeral fractures. Between August 2013 and October 2018, 14 patients with proximal humeral fractures were treated with suspensory external fixation technique. There were 10 males and 4 females with an average age of 55.9 years (range, 43-76 years). There were 10 cases of falling injury and 4 cases of traffic accident injury. Among them, there were 9 cases of Neer type Ⅲ and 5 cases of Neer type Ⅳ. The time from injury to operation was 3-7 days (mean, 4.6 days). Nine cases were complicated with osteoporosis. The preoperative visual analogue scale (VAS) score was 6.1±1.2. The effectiveness was comprehensively evaluated by hospital stay, fracture healing time, removal time of external fixator, postoperative complications, VAS score, and Neer score of shoulder joint function. All operations were successfully completed, and the hospital stay was 6-14 days, with an average of 9.4 days. All the incisions healed by first intention, and no infection or other complications occurred. All patients were followed up 16-60 months (mean, 35.4 months). X-ray films examination showed that all fractures healed, the healing time was 4-7 months (mean, 4.9 months). The removal time of external fixator was 5-8 months (mean, 6.3 months). VAS scores were 1.5±0.8 at 1 month after operation and 1.0±0.9 at last follow-up, both of which were significantly improved when compared with preoperative score, the differences were significant between different time points ( P<0.05). Neer score of shoulder joint function was 75-100 (mean, 91.1); 9 cases were excellent, 4 cases were good, and 1 case was fair. The excellent and good rate was 92.9%. During follow-up, there was no adverse events such as acromion impingement, nonunion, or pseudoarthrosis. For proximal humeral fractures, the suspensory external fixation technique is a simple and reliable treatment method that can significantly improve joint function.

Latest Trends in the Current Treatment of Proximal Humeral Fractures - an Analysis of 1162 Cases at a Level-1 Trauma Centre with a Special Focus on Shoulder Surgery.

The management of proximal humeral fracture (PHF) is not only complex but ever changing. Published epidemiological data are often dated and do not factor in demographic changes or the latest developments in implant material and surgical techniques. The primary aim of this study was to evaluate changes in the epidemiology and actual treatment of PHF at a level-1 trauma centre, with a special focus on shoulder surgery. 1. Between 2009 to 2012 and 2014 to 2017, an increase in complex PHF entities can be observed. 2. In correlation with fracture complexity, an increasing number of comorbidities, especially osteoporosis, can be observed. Between 2014 and 2017, a total of 589 patients (73% female; mean age: 68.96 ± 14.9 years) with 593 PHFs were treated. Patient records and imaging (XRs and CTs) of all patients were analysed. Fractures with ad latus displacement of a maximum of 0,5 cm and/or humeral head angulation of less than 20° were classified as non-displaced. Patients with displaced fractures were included in the analysis of the therapeutic algorithm. These results were compared to those of a cohort 2009 to 2012 (566 patients, 569 PHFs), which used the same inclusion criteria. The two cohorts showed comparable patient numbers, as well as gender and age distributions. Between 2009 to 2012 and 2014 to 2017, a decrease in 2-part fractures (13.9 to 8.6%) and a simultaneous increase in 4-part fractures (20.4 to 30%), and thus fracture complexity was observed. Further decreases were observed in conservative therapy (27.8 to 20.6%), nail osteosynthesis (10.7 to 2.7%) and anatomic shoulder arthroplasty (5,4 to 1%). Furthermore, there was an increase in the use of locking plate osteosynthesis (43.2 to 56.7%) and reverse shoulder arthroplasty (9 to 18.4%). The general trend shows an increase in surgical therapy between the years (72.2 to 79.4%), as well as an increase in osteoporosis incidence (13 to 20.6%). The greatest numbers of comorbidities were found in 3- and 4-part fractures. There is an increase in both the complexity of fractures and the number of surgically treated fractures between 2009 and 2012. Furthermore, an increase in osteoporosis numbers can be observed. New implants (PEEK, fenestrated screws for cement augmentation) and new surgical techniques (double plating osteosynthesis) were used as a result of increasing fracture complexity. Moreover, reverse total shoulder arthroplasty was used more commonly.

Evaluation of spin in the abstracts of systematic reviews and meta-analyses related to the treatment of proximal humerus fractures.

Research has shown that many physicians rely solely on abstracts to make clinical decisions. However, many abstracts have been shown to be misleading. The primary objective of this study was to identify the prevalence of spin - bias towards particular results - within the abstracts of systematic reviews and meta-analyses pertaining to the treatment of proximal humerus fractures, one of the most common osteoporotic fractures among elderly patients. We systematically searched MEDLINE and Embase databases to identify systematic reviews and meta-analyses examining the treatment of proximal humerus fractures. Screening and data extraction occurred in a masked, duplicate fashion. The nine most severe types of spin that occur within abstracts were extracted along with study characteristics, including journal recommendations to adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and year in which the review was performed, to identify potential associations. We subsequently explored the association between spin and the methodological quality of a systematic review using the revised A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2) appraisal instrument. Our search retrieved 505 articles, of which 73 systematic reviews met inclusion criteria. We found that 34.2% (25/73) of the included systematic reviews contained spin. Spin type 3 (selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention) was the most common type identified (12/73, 16.4%). Three spin types were not identified in any of the abstracts. Spin was 3.2 (OR 3.2; 95% CI, 1.02-10.02) times more likely to be present in systematic reviews published in journals recommending adherence to PRISMA. Furthermore, the odds of an abstract containing spin was 1.25 (OR 1.25; 95% CI, 1.02-1.52) times more likely to be present in systematic reviews for each year after 2000. No other study characteristics were associated with spin. The methodological quality of 24 studies were rated as "critically low" (32.9%), 14 were "low" (19.2%), 28 were "moderate" (38.4%), and 7 were "high" (9.6%), but these findings were not associated with spin. Spin was present in systematic review abstracts regarding treatment of proximal humerus fractures. Measures such as education on the subject of spin and improved reporting standards should be implemented to increase awareness and reduce incidence of spin in abstracts. Basic Science Study; Research Methodology.

A prospective study of outcome of fracture of proximal humerus treated with PHILOS plating

Background: PHILOS plating is used for two to four fragmented dislocated fractures of the proximal humerus, including fractures involving osteopenic bone, pseudarthroses and osteotomies in the proximal humerus. Various studies have been conducted regarding outcome of fracture of proximal humerus treated with PHILOS plating with variable outcome. Present study was designed to determine the efficacy and functional outcome of PHILOS locking plate in proximal humerus fractures.Method: As per study criteria 40 patients with fracture of shoulder was included in this study. After admission of patients a detailed careful history was taken to know the mechanism of injury. Patient was assessed clinically to evaluate general condition, vitals were recorded and examination o fracture site was done to know the Swelling, deformity, loss of function and nerve injury, distal vascularity. Radiological assessment was done and fracture was classified and preoperative routine haematological investigation was done.Result: Regarding complications of surgery postoperative infection was found in 2(5%) patients, stiffness of shoulder was present in 2(5%) patients, one patients developed malunion and Osteonecrosis was present in one patients. Constant score was excellent in 20 (50%) patients; it was good in 18(45%) patients and fair in 2(5%) patients.Discussion and conclusion: From present study we can conclude that PHILOS platting provides good fracture stabilization in the treatment of proximal humeral fractures. Stiffness of shoulder was common complication but present in 5% patients. Postoperative outcome was excellent in most of the patients.

Patient Satisfaction Using a Home-Based Rehabilitation Protocol for the Non-Surgical Treatment of Proximal Humeral Fractures: A Prospective Longitudinal Cohort Study.

Supervised, center-based, daily physiotherapy presents limitations: transport, need for an accompanying person, or risk of infection. Home-based rehabilitation protocols (HBRP) can be effective alternatives. We use a HBRP for the non-surgically treated proximal humeral fractures (PHF) in older patients.ObjectivesTo assess patient satisfaction and preferences of using a booklet, videos, or an app to guide physiotherapy.Patients and methodsProspective, single-center observational study of patients ≥55 years old who sustained a non-surgically treated PHF. The HBRP consisted of immediate mobilization, followed by 5 physiotherapist-guided, weekly sessions of rehabilitation and standard physiotherapy after 3 months, if needed. A booklet with images, videos, or a smartphone application were offered to guide the patients.ResultsMean degree of satisfaction (1-5) was 4.66 ± .9: 84 patients (82.4%) were very satisfied, 11 patients (10.8%) were satisfied, and 5 patients (4.9%) were not satisfied at all. Mean Oxford Shoulder Score achieved was 40.5 ± 6.6. 59.8% patients preferred the booklet and 29.4% the videos. Exercise compliance was considered very high in 87.3% of patients, while 4% hardly never followed the HBRP. Only 17.7% patients needed center-based physiotherapy after the HBRP.DiscussionReasons for satisfaction were good final functional outcome, no need for transportation, being away from hospital, immediate rehabilitation availability and being capable of maintaining independence. Adherence is a major concern. Videos are more didactic explaining the exercises.ConclusionIf standard physiotherapy is not available, the HBRP can be a valid treatment option for PHF management in older patients, with a high degree of patient satisfaction. Older patients preferred the booklet to guide physiotherapy.

Could direct transdeltoid approach to severely displaced proximal humerus fracture be advantageous for a better reduction?

Background and aim:Surgical treatment of proximal humeral fractures (PHF) is a challenge for orthopaedic surgeons. Despite the wide application of open reduction and internal fixation with locking plates, the optimal surgical approach of PHF is still debated. This study aims to evaluate the radiological outcomes, defined as anatomical restoration of the greater tuberosity and humeral head-shaft angle, of the deltopectoral (DPA) and the lateral transdeltoid (LTA) approaches in three- and four-part PHF, treated with locking plate.Materials and methods:This retrospective series review identifies 74 PHF surgically treated between January 2012 and December 2019. Patients were divided into two groups according to the surgical approach (DPA vs LTA). Demographic data, duration of surgery, radiological pre- and post-surgery parameters (greater tuberosity displacement and humeral head-shaft angle) were collected. The association between the surgical approach and the quality of fractures reduction was assessed.Results:The use of LTA approach correlates with a better reduction of greater tuberosity displacements compare to DPA (63% in DPA vs 100% LTA). No significant association was found with the humeral head-shaft angle (restored in 89% of the patients in DPA and 86% in LTA group), and surgical times (range 40 - 210 minutes ± DS 33,56 for the DPA; range 45 - 170 minutes ± 29,60 for LTA). Conclusions: The results of this radiological study suggest that PHF with significant displacement of the grater tuberosity could benefit from the adoption of a lateral transdeltoid approach for the ORIF procedure. Further studies are needed to confirm these findings. (www.actabiomedica.it)

Clinical effect of using MultiLoc® nails to treat four-part proximal humeral fractures.

ObjectiveThis study was performed to evaluate the clinical effect of MultiLoc® nails (DePuy Synthes, Raynham, MA, USA) on the treatment of four-part proximal humeral fractures (PHFs).MethodsFrom January 2014 to January 2018, 32 patients with four-part PHFs were treated with intramedullary MultiLoc® nails in our hospital. The operation time, bleeding volume, postoperative X-ray findings, and fracture healing status were recorded and analyzed. At the end of follow-up, the clinical outcome was evaluated based on the visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) shoulder score, Constant–Murley score (CMS), and occurrence of any complications.ResultsAmong all patients, the average operation time was 124.5 minutes (range, 91–152 minutes), the average amount of bleeding was 90 mL (range, 55–150 mL), and the fracture healing rate was 100%. At the end of follow-up, the mean VAS score was 1.6 ± 0.4, mean ASES score was 84.4 ± 6.3, and mean CMS was 70.3 ± 6.1; no serious complications had occurred; and the patients exhibited good recovery of shoulder function.ConclusionsMultiLoc nails® can be applied to the treatment of four-part PHFs. This surgical fixation method has no obvious complications and helps to restore shoulder function.

Treatment of proximal humeral fractures in elderly patients with intramedullary nail and locking plate

Objective: To compare the effect of intramedullary nail and locking plate in the treatment of proximal humeral fractures in the elderly. Methods: A total of 37 elderly patients with proximal humeral fractures were selected from April 2016 to June 2018 in Tianjin Hospital, including 13 males and 24 females, aged (66±5) years. The patients were divided into observation group (17 cases) and control group (20 cases) according to the random number table, and were treated with multiloc intramedullary nail and locking plate respectively. The operation time, blood loss, healing time of fractures, visual analogue scale of pain, Neer shoulder function score were recored and compared between the two groups. The data were compared with t test between the two groups. Results: The operation time of the observation group was shorter than that of the control group ((72±7) min vs (89±9) min, t=6.365, P<0.05); the intraoperative bleeding volume was lower than that of the control group ((56±6) ml vs (74±8) ml, t=7.923, P<0.05). The superior rate of shoulder function was 94.1%(16/17) in the observation group and 90.0%(18/20) in the control group (χ(2)=0.209, P>0.05). The VAS score of the observation group was lower than that of the control group on the first day after operation (t=4.706, P<0.05); the Neer shoulder function score of the observation group was higher than that of the control group on the sixth month after operation (81±8 vs 76±8, t=2.156, P<0.05). Six months after the operation, the valgus angle (19.21°±2.88°) of the observation group was larger than that of the control group (16.32°±2.63°, t=3.189, P<0.05), the humeral head varus angle (3.57°±0.47°), the humeral neck stem angle (139°±10°) was smaller than that of the others (5.24°±1.26°), (146°±13°) (t=5.159, 2.258, both P<0.05). There was no significant difference in shoulder function score and complication rate 12 months after operation between the two groups (both P>0.05). Conclusion: Both intramedullary nailing and locking plate can achieve better results in the treatment of proximal humeral fractures in the elderly, but the operation time of intramedullary nailing is shorter, the pain after operation is lighter and the recovery is faster.

Onlay Uncemented Lateralized Reverse Shoulder Arthroplasty for Fracture Sequelae Type 1 with Valgus/Varus Malunion: Deltoid Lengthening and Outcomes.

The successful treatment of proximal humeral fractures remains challenging for shoulder surgeons, and failure rates are high, regardless of initial treatment. This study aimed to analyze the clinical and radiographic midterm results of onlay lateralized cementless stem reverse shoulder arthroplasty (RSA) in patients with valgus/varus malunion proximal humerus fracture sequelae without metaphyseal osteotomy. We retrospectively studied 35 cases with the diagnosis of fracture sequelae of the proximal part of the humerus with valgus/varus malunion. The mean duration of follow-up was 4.6 years (range, 2 to 7 years), and the mean time between fracture and arthroplasty was 6 years (1 to 32 years). Seventeen patients (48.6%) had initially been treated nonoperatively. The Constant score (CS), active range of motion, and radiographs of the affected shoulders, as well as the acromion to greater tuberosity (AGT) distance and deltoid length (DL), were analyzed before surgery and at their latest follow-up. A total of thirty-three patients (94.3%) rated their outcome as very good or good. Mean CS, forward flexion, and external rotation improved significantly (p < 0.0001), as did internal rotation and pain (p < 0.05). AGT distance significantly increased postoperatively from 14.7 to 43.3 mm, as did DL from 143 to 170 mm (p < 0.05). There was no correlation between the outcomes and valgus/varus deformity, previous surgeries, or AGT distance/DL. A total of four complications occurred (11.4%): two dislocations were detected (5.7%) and successfully revised with a longer cemented stem. Onlay lateralized uncemented stem RSA improves clinical outcomes and decreases complications when treating valgus/varus malunion fracture sequelae, avoiding intraoperative technical challenges, such as tuberosities osteotomy conscious of bone loss and proper deltoid tensioning.

Effect of surgical approaches on deltoid innervation and clinical outcomes in the treatment of proximal humeral fractures.

Objectives This study aims to investigate the effects of deltopectoral and anterolateral acromial approaches commonly used in open reduction-internal fixation of proximal humeral fractures on the clinical outcomes, and axillary nerve damage through electrophysiological assessment.Patients and methods Forty-eight patients (22 males, 26 females; mean age 47.9±13.2 years; range, 22 to 73 years) diagnosed with Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) type 11 proximal humeral fractures who underwent osteosynthesis with anatomical locking plates in our hospital between January 2015 and June 2016 were prospectively examined. The patients were divided into two groups according to either the deltopectoral or anterolateral deltoid-split surgical approach used. Clinical outcomes were evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH) scores and Constant-Murley scores (CMS) obtained at three- and 12-month follow-up visits. Needle electromyography (EMG) was performed for the electrophysiological assessment of the deltoid muscle.Results There were no significant differences between the groups in terms of demographic data, follow-up times, and complications. DASH scores and CMS obtained postoperatively at three months (p=0.327 and p=0.531, respectively) and 12 months (p=0.324 and p=0.648, respectively) revealed no significant differences. In addition, the two groups did not significantly differ with respect to the presence of EMG abnormalities (p=0.792). Avascular necrosis of the humeral head was detected in only two patients from the deltopectoral group.ConclusionDeltopectoral and anterolateral approaches do not differ regarding the presence of postoperative EMG abnormalities and functional outcomes. Surgeons can thus adopt either approach. However, dissection without damaging the soft tissue should be performed in both approaches.

Operative Treatment of Proximal Humeral Fracture-dislocations Through an Anterolateral Deltoid Split Approach.

Proximal humeral fracture-dislocations (PHFD) are a special entity in proximal humeral fracture treatment. The aim of this study is to present our minimally invasive plate osteosynthesis (MIPO) technique through an anterolateral deltoid split approach. In addition, we performed a retrospective cohort study analyzing the patient reported functional outcome and complications. A single center cohort study was performed. All patients operated through a deltoid split approach for PHFD between 2009 and 2016 were eligible for inclusion. The primary endpoint was subjective shoulder function measured with QuickDASH and subjective shoulder value (SSV). Secondary endpoints were complications and implant-related irritation. 28 patients were included. The mean age was 49 (SD ± 10.3). The mean follow-up was 48 months (SD ± 23.7). The mean QuickDASH score was 6.8 (SD ±7.8) and the mean SSV was 86 (SD ±14.6). Four patients had a conversion into a reversed arthroplasty (14%), one patient (4%) a shortening of secondary perforated screws, four patients an early re-osteosynthesis (14%), four patients (14%) developed an AVN and in one patient damage of the axillary nerve was observed. 21 patients (75%) had their implant removed. Patient reported functional results after humeral head preservation and internal fixation of PHFDs through an anterolateral deltoid spilt approach are promising. However, there is a high rate of re-operations either because of complications or for implant removal. Comparing our data to literature these rates are not depending on the approach chosen.

Shoulder arthroplasty for proximal humerus fractures in the elderly: The path from Neer to Grammont.

Shoulder replacement is indicated for the surgical treatment of proximal humeral fractures in elderly patients, when severe comminution and osteoporosis jeopardize the chances of success of any fixation technique. Two different implants are available for this purpose: anatomical hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RTSA). HA for fractures was popularized by Charles Neer in the ‘50s and for several decades remained the only reliable implant for these injuries. However, many authors reported inconsistent results with HA as a consequence of the high rate of tuberosity and rotator cuff failure. In 1987, Paul Grammont designed the first successful RTSA, which was the end result of a long thought process on functional surgery of the shoulder. This implant was initially used to treat cuff tear arthropathy and shoulder pseudoparalysis, but indications have gradually expanded with time. Since RTSA does not rely on a functional cuff for shoulder elevation, it was felt that results in fractures could be improved by this prosthesis. In this study, the salient features of these implants are described to understand the rationale behind both approaches and highlight their pros and cons. Several clinical studies comparing HA vs RTSA for proximal humeral fractures have been published during the last two decades. A literature review is carried out to analyze and compare outcomes of both implants, analyzing clinical results, radiographic findings and complications. The final goal is to provide an overview of the different factors to consider for making a choice between these two prostheses.

Randomized prospective evaluation of the use of tranexamic acid and effects on blood loss for proximal humeral fracture surgery

Tranexamic acid (TXA) is an antifibrinolytic agent that has been used to reduce blood loss in orthopedic surgery. It has been shown to decrease blood loss in upper- and lower-extremity arthroplasty, as well as lower-extremity fracture surgery. The use of TXA for proximal humeral fracture surgery has yet to be evaluated. The purpose of this study was to examine the effects of TXA on blood loss in patients undergoing open reduction-internal fixation (ORIF) or arthroplasty for the treatment of proximal humeral fractures. A total of 101 patients were randomized to receive either a single preoperative dose of intravenous TXA (53 patients) or a control dose of saline solution (48 patients) at the time of proximal humeral fracture surgery. On the basis of patient age and fracture pattern, ORIF was performed in 57 patients (30 TXA and 27 control patients) and reverse shoulder arthroplasty (RSA) was performed in the other 44 patients (23 TXA and 21 control patients). Intraoperative blood loss plus 24-hour drain output was used to calculate total blood loss for each procedure. The preoperative-to-postoperative change in hemoglobin level was also evaluated for each patient. Further stratification of blood loss and change in hemoglobin level based on procedure (ORIF or RSA) was performed as well. Compared with the control group, the TXA group had less average intraoperative blood loss (178 mL vs. 129 mL, P < .0001), less postoperative drain output (103 mL vs. 62 mL, P < .0001), and less total blood loss (280 mL vs. 188 mL, P < .0001). Compared with the control group, the TXA group had a smaller average preoperative-to-postoperative change in hemoglobin level(-2.6 g/dL vs. -1.5 g/dL, P < .0001). Further stratification based on procedure showed that among patients undergoing ORIF and patients undergoing RSA, those receiving TXA had less average total blood loss and a smaller decrease in hemoglobin level than the control group. No identifiable intraoperative or postoperative complications associated with the use of TXA occurred in any patient. TXA was effective in reducing total blood loss and led to a smaller preoperative-to-postoperative decrease in hemoglobin levelcompared with control in patients undergoing surgery for proximal humeral fractures. This effect was consistent in patients treated with either ORIF or arthroplasty as the surgical procedure. TXA can be used to decrease blood loss in the surgical treatment of proximal humeral fractures.

“Suspension bridge” external fixation technique for the treatment of proximal humeral fractures

The purpose of this study was to investigate the clinical efficacy of the "suspension bridge" external fixation technique for the treatment of proximal humeral fractures with or without soft tissue defects and infection, as well as postoperative revision. From August 2013 to June 2018, 9 patients with proximal humeral fractures were selected. There were 5 males and 4 females, with an average age of 55.2 years (range: 32-74 years). Five patients were diagnosed with acute fractures (soft tissue defects in 2 patients). Of these patients, 1 patient was diagnosed with a fracture of the anatomic neck, 2 patients with 3-part fractures, and 2 patients with 4-part fractures. Internal fixation failure occurred in 4 patients, who needed revision surgery. Of these 4 patients, 1 patient was diagnosed with an anatomic neck fracture and 3 patients with 4-part fractures before surgery. Postoperative plate and screw fixation failure was the main cause of revision. One patient had an accompanying skin defect, and 1 had an infection. The "suspension bridge" external fixation technique was used to treat the fractures in the revision surgeries. The operative time was 84.1 minutes (range: 63-120 minutes), and the blood loss was 224.4 mL (range: 140-320 mL). The follow-up period was 35.1 months (range: 16-72 months). All fractures unioned, with an average unioning time of 12.7 weeks (range: 8-16 weeks). At the final follow-up, the flexion was 131.8° (range 108°-152°), extension 39.9° (range 32°-47°), abduction 128.6° (range 110°-150°), internal rotation 43.9° (range 34°-55°), and external rotation 60.7° (range 46°-72°); the mean visual analog scalescore for pain was 1.3 (range 0-3), and the mean Neer score was 87.4 points (range 75-98 points). Efficacy was assessed as excellent in 4 patients, good in 3 patients, and acceptable in 2 patients; the excellent or good rate was 77.8%. No adverse events, such as postoperative infection, fixation failure, and nonunion, occurred during the follow-up. The "suspension bridge" external fixation technique is an effective method for the treatment of proximal humerus fractures, and it can also be used for the treatment of skin defects and infections.

Reverse total shoulder arthroplasty compared to stemmed hemiarthroplasty for proximal humeral fractures: a registry analysis of 5946 patients

There is an increasing trend towardthe use of reverse total shoulder arthroplasty (RTSA) over stemmed hemiarthroplasty (HA) for the management of proximal humeral fractures. There are limited data available comparing the revision rates for RTSA and HA in the setting of a fracture. The aim of this study was to compare the revision rates for RTSA and HA when used for the treatment of a fracture and to analyze the effect of demographics and prosthesis fixation on these revision rates. Data obtained from the Australian Orthopaedic Association National Joint Replacement Registryfrom April 16, 2004, to December 31, 2017, included all procedures for primary diagnosis proximal humeral fracture. The analyses were performed using Kaplan-Meier estimates of survivorship and hazard ratiosfrom Cox proportional hazards models. Over the study period, there were 3049 (51%) RTSA and 2897 (49%) HA procedures. The cumulative percent revisionrate at 9 years was lower for the RTSA than for the HA: 7.0% (95% confidence interval [CI], 4.8-10.1) compared with 11.7% (95% CI, 10.3-13.2). Between 0 and 6 months, the HA had a significantly lower revision rate than the RTSA (hazard ratio, 0.50; 95% CI, 0.34-0.72; P < .001). Between 6 month and 3 years, the HA had a significantly higher revision rate. For the RTSA, males have a significantly higher rate of revision compared with females. There is a higher rate of early revision due to instability in younger persons (55-64) and males. For both RTSA and HA, cemented prostheses have lower revision rates compared with cementless prostheses. RTSA has a significantly lower revision rate compared with HA for the treatment of proximal humeral fractures in females. Younger patients (<65) and males are at risk of early revision secondary to instability. In these patient groups, either alternatives to RTSAor further attention to fixation of tuberosities and shoulder rehabilitationmay be indicated.

The Current State of the Problem of Treatment of Patients with Proximal Humeral Fractures against the Background of Osteoporosis

This study focuses on problems of treatment of proximal humeral fractures occurring against the background of osteoporosis. It presents statistics on osteoporosis and lower energy trauma among patients in the Russian Federation and abroad. The high susceptibility to osteoporotic changes in the bone structure of the male population of Russia compared to the global statistics of osteoporosis among men was emphasized. The main classifications used in the clinical practice of orthopedists and traumatologists allow to identify the type of fracture by clinical and anatomical basis and to structure the existing patient management tactics to achieve the most optimal result of treatment and restoration of limb function. There is an analysis of publications representing various methods of fracture treatment, which helps to use the most optimal methods of relevant fractures treatment.

Complications after surgical management of proximal humeral fractures: a systematic review of event terms and definitions

BackgroundThe most frequently used surgical procedures for treating a proximal humeral fracture (PHF) are plate osteosynthesis, nail osteosynthesis and arthroplasty. Evidence-based recommendations for an appropriate surgical procedure after PHF requires transparent and valid safety data. We performed a systematic review to examine reported terms and definitions of complications after surgically-treated PHFs.MethodsA literature search was conducted on PubMed, Cochrane Library, EMBASE, Scopus and WorldCat to identify clinical articles and book chapters on complications of PHF published from 2010 to 2017. Complication terms and definitions were extracted from each selected article independently by two reviewers and grouped according to a predefined scheme.ResultsFrom 1376 initial references, we selected 470 articles, of which 103 were reviewed in reverse chronological order until no further information was gained. Twelve book chapters were reviewed. We found 667 local event terms associated with complications after surgical treatment of PHFs. The most frequently used event terms were infection (52 references), nonunion (n = 42), malunion (n = 35), avascular necrosis (n = 27) and pain (n = 25). Overall, 345, 177, 257 and 102 local event terms were related to plating, nailing, arthroplasty and other surgical techniques, respectively. Radiological assessment was the basis for the majority of event terms and complication definitions. Thirty-six event definitions were extracted, mostly defining the terms “secondary fracture displacement”, “screw perforation/cutout”, “malunion”, “delayed healing” and “notching”.ConclusionScientific literature on surgically-managed PHF uses different terms to describe complications and without approved definitions, which highlights a lack of agreement on adverse event terminology for PHFs. Defined event terms are mostly based on radiological observations. Consensus among shoulder surgeons on a core event set is indispensable to support the standardization of safety reporting for surgically-treated PHFs.

Synthetic Bone Substitutes and Mechanical Devices for the Augmentation of Osteoporotic Proximal Humeral Fractures: A Systematic Review of Clinical Studies.

Background: Different augmentation techniques have been described in the literature in addition to the surgical treatment of proximal humeral fractures. The aim of this systematic review was to analyze the use of cements, bone substitutes, and other devices for the augmentation of proximal humeral fractures. Methods: A systematic review was conducted by using PubMed/MEDLINE, ISI Web of Knowledge, Cochrane Library, Scopus/EMBASE, and Google Scholar databases according the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines over the years 1966 to 2019. The search term “humeral fracture proximal” was combined with “augmentation”; “polymethylmethacrylate, PMMA”; “cement”; “bone substitutes”; “hydroxyapatite”; “calcium phosphates”; “calcium sulfate”; “cell therapies”, and “tissue engineering” to find the literature relevant to the topic under review. Results: A total of 10 clinical studies considered eligible for the review, with a total of 308 patients, were included. Mean age at the time of injury was 68.8 years (range of 58–92). The most commonly described techniques were reinforcing the screw–bone interface with bone PMMA cement (three studies), filling the metaphyseal void with synthetic bone substitutes (five studies), and enhancing structural support with metallic devices (two studies). Conclusion: PMMA cementation could improve screw-tip fixation. Calcium phosphate and calcium sulfate injectable composites provided good biocompatibility, osteoconductivity, and lower mechanical failure rate when compared to non-augmented fractures. Mechanical devices currently have a limited role. However, the available evidence is provided mainly by level III to IV studies, and none of the proposed techniques have been sufficiently studied.

Treatment options for proximal humeral fractures in the older adults and their implication on personal independence.

No consensus exists on the optimal treatment of proximal humeral fractures (PHFx). Uncertainty about surgical treatment in the older adults using locking plates (e.g., PHILOS) has emerged, due to a high number of complications. This study aimed to assess the impact of non-operative versus operative treatment of a PHFx on the level of self-dependence in our older population. We included patients aged over 65years with some level of self-dependence, treated at our hospital between 5/2011 and 4/2013 for isolated PHFx of AO subtypes A2, A3, and B1 for which either non-operative or surgical treatment using a PHILOS plate had been applied. The patients were questioned, examined, or interviewed via phone; AO fracture patterns and treatment were documented as well as level of self-dependence, complications, constant score (CSM), subjective shoulder value (SSV), quality of life (EQ-5D), and shoulder pain and disability index (SPADI). Patients with PHFx of AO subtypes A2, A3, or B1 that were either treated non-operative (n = 50) or operative by insertion of the PHILOS plate (n = 63) were included. Operative-treated patients were 3.3 times as likely to lose some level of independence (95% CI 0.39-28, p = 0.271). Shoulder motion, strength, and functional outcomes tended to be lower in operative-treated patients, with adjusted differences of, - 11 CMS points (95% CI - 23 to 2), - 9 SPADI points (95% CI - 18 to 0), and - 6% in SSV (95% CI - 17 to 5). Quality-of-life EQ-5D utility index was similar in both groups (mean - 0.04; 95% CI - 0.18 to 0.10). In our study population, non-operatively treated older adults with an AO type A2, A3, B1 fracture of the proximal humerus tended to have a high chance to return to their premorbid level of independence, compared to patients treated with a locking plate. A change in the treatment algorithm for these PHFx may be carefully considered and further investigated in clinical practice.