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European Journal of Orthopaedic Surgery... Aug 2021The optimal technique for the displaced greater tuberosity (GT) fractures remains unclear; those in favor of arthroscopic techniques emphasize on the feasibility of...
BACKGROUND
The optimal technique for the displaced greater tuberosity (GT) fractures remains unclear; those in favor of arthroscopic techniques emphasize on the feasibility of arthroscopic reduction and fixation, while others report that anatomic reduction and osteosynthesis of the fracture are optimal through open surgery. Therefore, we performed this study to evaluate the clinical results of arthroscopic fixation for displaced and/or comminuted GT fractures using a bridging arthroscopic technique.
MATERIALS AND METHODS
We studied the files of 11 patients (4 men, 7 women; mean age, 55 years; range, 28-74 years), with an isolated, displaced GT fracture treated with arthroscopic reduction and double-row suture anchor fixation technique from December 2016 to October 2018. All patients were operated at a mean time from their injury of 23 days (range, 1-85 days) using an arthroscopic technique. Any concomitant pathology that was arthroscopically identified was identified and repaired after arthroscopic fixation of the GT fracture. The mean follow-up was 12 months (range, 6-18 months). We evaluated pain using a 0-10 point visual analog scale (VAS), shoulder range of motion, fracture healing, Constant-Murley Shoulder Outcome Score, and patients' satisfaction from the operation.
RESULTS
Postoperative radiographs showed anatomic reduction without any displacement of the GT fracture in eight patients and residual displacement of < 3 mm in three patients. All patients significantly improved in VAS score from 8.4 points (range, 7-10 points) preoperatively to 0.9 points (range, 0-3 points) postoperatively. Range of motion was 153 degrees forward flexion (range, 130-170 degrees), 149 degrees abduction (range, 120-170 degrees), 42 degrees external rotation (range, 20-70), and internal rotation between T10 and L3 spinal level. The final mean Constant-Murley Shoulder Outcome Score was 85.8 points (range, 76-94 points); correlation analysis showed that the patients with the higher greater tuberosity fracture displacement had the worst postoperative score (Pearson correlation coefficient -0,85; p = 0.0009), and the patients with nonanatomic reduction had close to average score. All patients were very satisfied with the end result of the operation, even the 3 patients with residual fracture displacement. No patient experienced any postoperative complications.
CONCLUSIONS
Arthroscopic reduction and fixation of displaced GT fractures is a feasible minimally invasive procedure for optimal fracture healing and patients satisfaction.
Topics: Arthroscopy; Female; Fracture Fixation, Internal; Humans; Humerus; Male; Middle Aged; Range of Motion, Articular; Retrospective Studies; Shoulder Fractures; Treatment Outcome
PubMed: 33387054
DOI: 10.1007/s00590-020-02835-8 -
Acta Orthopaedica Et Traumatologica... Jul 2022The aim of this study was to propose a new classification of combined greater tuberosity (GT) fractures and anterior shoulder dislocation and studied the degree of...
OBJECTIVE
The aim of this study was to propose a new classification of combined greater tuberosity (GT) fractures and anterior shoulder dislocation and studied the degree of displacement, functional outcomes, and need for additional surgery after reduction.
METHODS
A cross-sectional study was conducted. We evaluated radiographs of patients treated for combined GT fractures and anterior shoulder dislocation. Three morphologies were proposed; type 1 (a small avulsion), type 2 (GT fractures without articular head involvement), and type 3 (GT associated with articular head fractures). Two orthopedic surgeons independently measured all radiographs and classified fractures into three types. Patients were interviewed by telephone to assess functional outcomes (the simple shoulder test (SST) and EQ-5D-5L), and additional shoulder surgery was also performed.
RESULTS
There were 52 eligible patients; 32 were male (61.5%) and the mean age was 57.3 · 17.1 years. Most cases were low-energy injuries (61.5%). Of all the cases, 32.7% were type I, 59.6% type II, and 7.7% type III cases. There were differences in the degree of displacement in each group at pre, post-reduction (both horizontal and vertical planes) and at two weeks post-reduction for HD (p < 0.05). Type III had more displacement than type I at pre- and post-reduction with a P value of less than 0.05. Type III also had higher rates of displacement than type II at post-reduction and at two-week postreduction (vertical plane). The intra and inter-rater reliabilities of measurement (ICC > 0.8) were in good to excellent agreement with the kappa value (>0.9). Three out of 52 cases (5.8%) required an additional surgery after closed reduction. Patients had good functional outcomes (SST score of 8) with an excellent utility index of EQ-5D-5L (0.9).
CONCLUSION
This new classification exhibited good-to-excellent intra-and inter-rater reliabilities, with an ability to determine injury type. Type III seems to be linked to higher risk of fracture displacement and may require additional surgery.
LEVEL OF EVIDENCE
Level IV, Diagnostic Study.
Topics: Cross-Sectional Studies; Female; Fracture Fixation, Internal; Humans; Male; Middle Aged; Retrospective Studies; Shoulder; Shoulder Dislocation; Shoulder Fractures
PubMed: 35943077
DOI: 10.5152/j.aott.2022.21316 -
Journal of Shoulder and Elbow Surgery Feb 2022The purposes of this study were (1) to compare postoperative range of motion (ROM) and functional outcomes in patients with proximal humeral fractures operated on with...
BACKGROUND
The purposes of this study were (1) to compare postoperative range of motion (ROM) and functional outcomes in patients with proximal humeral fractures operated on with cemented or uncemented reverse shoulder arthroplasty (RSA), (2) to compare the rate of tuberosity healing between cemented and uncemented stems, (3) to determine whether there are significant differences in functional outcomes between patients with healed tuberosities and those with unhealed tuberosities, and (4) to compare complications and revision rates in patients with cemented RSA and uncemented RSA.
METHODS
A cemented RSA was performed early in the study period, which represented a historical cohort (January 2015 to January 2017), followed by a transition to the uncemented RSA later in the study period (February 2017 to February 2019). We excluded 22 cases from postoperative evaluation because of fracture sequelae, age < 65 years, death, and institutionalization; 3 patients were lost to follow-up. The remaining 67 cases (32 cemented and 35 uncemented) underwent clinical and radiographic evaluation by 2 independent fellowship-trained shoulder surgeons. Patients were assessed regarding ROM and the visual analog scale for pain, American Shoulder and Elbow Surgeons score, Constant score, and Single Assessment Numeric Evaluation score. All intraoperative and postoperative complications were recorded.
RESULTS
The mean follow-up period was 41 months (range, 24-72 months), and the mean age was 74 years (range, 65-84 years). Mean postoperative active elevation, internal rotation, external rotation in abduction, and external rotation in adduction were 130° (±15°), 27° (±5°), 28° (±10°), and 16° (±6°), respectively. The mean postoperative visual analog scale, American Shoulder and Elbow Surgeons, Constant, and Single Assessment Numeric Evaluation scores were 1.8 (±0.8), 74 (±6), 58 (±11), and 74% (±8), respectively. There were no significant differences in final ROM and functional scores between the cemented and uncemented groups. The rate of tuberosity healing did not vary significantly in relation to whether the stem was cemented. The subgroup of patients with tuberosity healing presented significantly better active elevation, external rotation, and Constant scores than the subgroup without tuberosity healing. There were 5 complications (7%) and no cases of aseptic humeral stem loosening.
CONCLUSION
In the short term (mean, 41 months), there were no significant differences in postoperative ROM, functional outcomes, complications, and revisions between patients operated on with cemented RSA and those operated on with uncemented RSA for proximal humeral fractures. Patients with healed tuberosities presented significantly better ROM and functional scores than patients without tuberosity healing. The cementation of the stem did not significantly affect the rate of tuberosity healing.
Topics: Aged; Arthroplasty, Replacement, Shoulder; Humans; Range of Motion, Articular; Retrospective Studies; Shoulder Fractures; Shoulder Joint; Treatment Outcome
PubMed: 34358669
DOI: 10.1016/j.jse.2021.06.022 -
Journal of Orthopaedic Science :... Mar 2022Recent studies have reported the clinical effectiveness of tuberosity healing after reverse total shoulder arthroplasty in patients with proximal humeral fractures with...
BACKGROUND
Recent studies have reported the clinical effectiveness of tuberosity healing after reverse total shoulder arthroplasty in patients with proximal humeral fractures with respect to joint stability, long-term survival, and postoperative range of motion. However, it is challenging to achieve robust fixation of the fragile bone fragments in elderly patients. This study aimed to report on the radiographic and clinical outcomes of patients who underwent reverse total shoulder arthroplasty for acute proximal humeral fractures using a Turned stem Tension Band technique-a simple suture configuration that can apply a compressive force on both tuberosities at the same time.
METHODS
Eighteen patients who underwent reverse total shoulder arthroplasty for complex proximal humeral fractures (age 80.4 ± 4.7 years, range 70-87 years), using our Turned stem Tension Band technique, were included in this study and evaluated postoperatively for range of motion, American Shoulder and Elbow Surgeons score, Numerical Rating Scale, and tuberosity healing, with minimum 2-years follow-up (mean 34.5 months, range 24-60 months).
RESULTS
At the final follow-up, mean range of motion results were active flexion, 119 ± 34°; active abduction, 116 ± 35°; active external rotation, 27 ± 12°; and active internal rotation, L3. Six of 11 (55%) patients with 4-part dislocated fractures had neurological disorders from the time of injury; of these, three patients obtained shoulder elevation under 90° at the final follow-up. The mean American Shoulder and Elbow Surgeons score was 77.3 ± 10.7, and the mean Numerical Rating Scale was 1.2 ± 0.9. Fifteen of 18 (83%) patients were satisfied with the results. The tuberosity healing rate was 100% (18 of 18).
CONCLUSIONS
The Turned stem Tension Band technique in reverse total shoulder arthroplasty for proximal humeral fractures provides a robust fixation, regardless of the fracture pattern, which results in a high tuberosity healing rate.
Topics: Aged; Aged, 80 and over; Arthroplasty, Replacement, Shoulder; Humans; Range of Motion, Articular; Retrospective Studies; Shoulder Fractures; Shoulder Joint; Treatment Outcome
PubMed: 33551329
DOI: 10.1016/j.jos.2020.12.019 -
Archives of Orthopaedic and Trauma... Jan 2023The purpose of this study is to evaluate the effect of obesity on the outcome of operatively treated proximal humerus fractures.
PURPOSE
The purpose of this study is to evaluate the effect of obesity on the outcome of operatively treated proximal humerus fractures.
METHODS
Between December 2003 and October 2020, 240 patients with proximal humerus fractures requiring surgery were prospectively followed and classified according to the international AO/Orthopedic Trauma Association (AO/OTA) and Neer classifications. Patients' body mass indexes (BMI) were calculated and used to identify two groups, BMI ≥ 30 kg/cm (obese) and < 30 kg/cm (non-obese). Independent t tests were used for statistical analysis of continuous variables and χ tests for categorical variables. Regression analysis was performed to determine if BMI was a predictor of fracture pattern severity as determined by the AO/OTA classification.
RESULTS
Overall, 223 patients who sustained proximal humerus fractures were analyzed. Patient age at time of injury was 60.5 ± 13.7 years. There were 67 AO/OTA 11A, 79 AO/OTA 11B, and 77 AO/OTA 11C fracture types. Seventy-two patients (32.3%) were obese. No significant differences were seen between groups in regard to demographic variables, Neer classification, or functional and clinical outcomes as determined by DASH scores and shoulder ROM, respectively. Statistical analyses confirmed that obesity is associated with more severe fracture patterns of the proximal humerus as categorized by the AO/OTA classification. An independent t test confirmed that BMI was significantly higher in the complex fracture group based on the AO/OTA classification (p = 0.047). Regression analysis also demonstrated that age (p = 0.005) and CCI (p = 0.021) were predictors of more severe fractures, while BMI approached significance (p = 0.055) based on the AO/OTA classification.
CONCLUSION
A significantly higher incidence of complex proximal humerus fracture patterns is observed in patients with higher body mass indexes based on the AO/OTA classification. Age and CCI are also associated with more severe fracture patterns of the proximal humerus as determined by the AO/OTA classification. No differences were seen in outcomes or complication rates between obese patients and non-obese patients.
LEVEL OF EVIDENCE
Level III.
Topics: Humans; Middle Aged; Aged; Tomography, X-Ray Computed; Shoulder Fractures; Shoulder; Observer Variation; Humeral Fractures; Humerus; Retrospective Studies
PubMed: 35050410
DOI: 10.1007/s00402-022-04338-z -
Journal of Orthopaedic Science :... Nov 2022Our purpose was to evaluate the clinical and radiographic outcomes of proximal humeral fractures treated with a new generation plating system and compare results with a... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Our purpose was to evaluate the clinical and radiographic outcomes of proximal humeral fractures treated with a new generation plating system and compare results with a meta-analysis of recent literature.
METHODS
Between 2014 and 2017, 93 patients (18 males, 75 females) with proximal humerus fractures were treated with open reduction and internal fixation (ORIF) using a Pantera® Plate. These low-profile plates are anatomically shaped and include "cross-elements" that form a three-dimensional scaffold in bone to enhance fixation stability. According to Neer classification, there were 24 two-part fractures, 49 three-part fractures and 20 four-part fractures (4 with dislocated heads). X-rays and Constant Shoulder Scores (CSS) were used to evaluate healing, complications, and clinical outcomes. Results were compared with a meta-analysis of similar studies reported in literature over the last 10 years.
RESULTS
Eighty-three patients with a minimum follow-up of 2 years had a mean CSS of 72 (53-90) graded as excellent for 23 patients (28%), good for 35 (42%), fair for 14 (17%), and poor for 11 (13%). Fractures healed without complication in 75 (91%) patients. Eight (9%) complications were observed, i.e., three avascular necrosis of the humeral head, one case of implant loosening, two cases of subacromial impingement and two superficial infections. There was no significant correlation between Neer fracture stage and patient outcome (p = 0.257). Compared to the literature, this method had a lower complication grade (p = 0.03), though it did not significantly differ in its clinical outcomes (p = 0.08).
CONCLUSIONS
The investigated plating system includes design features that can potentially increase utility for ORIF of proximal humeral fractures. While the complication profile was signficantly less than reported in the literature for standard proximal humerus plates, clinical outcomes were similar. Further studies will be required to better understand the role of plate design on treatment of these challenging fractures.
LEVEL OF EVIDENCE
IV, therapeutic study.
Topics: Male; Female; Humans; Fracture Fixation, Internal; Shoulder Fractures; Bone Plates; Radiography; Humerus; Treatment Outcome; Retrospective Studies
PubMed: 34625328
DOI: 10.1016/j.jos.2021.08.008 -
Nederlands Tijdschrift Voor Geneeskunde Jan 2019There is an increasing incidence of proximal humerus fractures. Patients with proximal humerus fractures have traditionally been treated conservatively. During the past... (Review)
Review
There is an increasing incidence of proximal humerus fractures. Patients with proximal humerus fractures have traditionally been treated conservatively. During the past decades, however, various new osteosynthetic and prosthetic implants have been developed for the shoulder and surgical treatment of proximal humerus fractures has increased. However, recent literature in which conservative and surgical treatment of proximal humerus fractures is compared has shown no difference in functional outcome. The trend towards more frequent surgical treatment is thus not based on scientific evidence. In this article, we present the current state of affairs and attempt to give a nuanced picture of who will not, but also who might profit from surgical treatment of a proximal humerus fracture.
Topics: Conservative Treatment; Female; Fracture Fixation, Internal; Humans; Humerus; Male; Shoulder Fractures; Treatment Outcome
PubMed: 30638000
DOI: No ID Found -
Emergency Radiology Feb 2022The purpose of this study is to evaluate the prevalence of intimate partner violence (IPV)-related upper extremity fractures (UEF) in women presenting to US emergency...
PURPOSE
The purpose of this study is to evaluate the prevalence of intimate partner violence (IPV)-related upper extremity fractures (UEF) in women presenting to US emergency departments (ED) and compare their anatomic location to those due to accidental falls or strikes.
METHODS
An Institutional Review Board exempt, retrospective review of prospectively collected data was performed using the National Electronic Injury Surveillance System's All Injury Program data from 2005 through 2015 for all UEF sustained in women 15 to 54 years old. Injuries based on reported IPV versus accidental falls or strikes were analyzed accounting for the weighted, stratified nature of the data.
RESULTS
IPV-related UEF represented 1.7% of all UEF and 27.2% of all IPV fractures. The finger was the most common fracture site in IPV (34.3%) and accidental striking (53.3%) but accounted for only 10% of fall-related UEF. There was a higher proportion of shoulder fractures in IPV (9.2%) compared to accidental falls (7.4%) or strikes (2.9%). The odds of a finger fracture were 4.32 times greater in IPV than falling and of a shoulder fracture were 3.65 greater in IPV than accidental striking (p < 0.0001).
CONCLUSIONS
While the finger is the most common site for IPV UEF, it is also the most common location for accidental striking. A lower proportion of finger fractures in fall and of shoulder/forearm fractures in accidental striking should prompt the radiologist to discuss the possibility of IPV with the ED physician in any woman presenting with a finger fracture due to fall and a shoulder/forearm fracture with a vague history of accidental striking.
Topics: Adolescent; Adult; Arm Injuries; Female; Humans; Intimate Partner Violence; Middle Aged; Prevalence; Retrospective Studies; Shoulder Fractures; Upper Extremity; Young Adult
PubMed: 34626284
DOI: 10.1007/s10140-021-01972-9 -
Medical Image Analysis Jan 2018The optimal surgical treatment of complex fractures of the proximal humerus is controversial. It is proven that best results are obtained if an anatomical reduction of... (Review)
Review
The optimal surgical treatment of complex fractures of the proximal humerus is controversial. It is proven that best results are obtained if an anatomical reduction of the fragments is achieved and, therefore, computer-assisted methods have been proposed for the reconstruction of the fractures. However, complex fractures of the proximal humerus are commonly accompanied with a relevant displacement of the fragments and, therefore, algorithms relying on the initial position of the fragments might fail. The state-of-the-art algorithm for complex fractures of the proximal humerus requires the acquisition of a CT scan of the (healthy) contralateral anatomy as a reconstruction template to address the displacement of the fragments. Pose-invariant fracture line based reconstruction algorithms have been applied successful for reassembling broken vessels in archaeology. Nevertheless, the extraction of the fracture lines and the necessary computation of their curvature are susceptible to noise and make the application of previous approaches difficult or even impossible for bone fractures close to the joints, where the cortical layer is thin. We present a novel scale-space representation of the curvature, permitting to calculate the correct alignment between bone fragments solely based on corresponding regions of the fracture lines. The fractures of the proximal humerus are automatically reconstructed based on iterative pairwise reduction of the fragments. The validation of the presented method was performed on twelve clinical cases, surgically treated after complex proximal humeral fracture, and by cadaver experiments. The accuracy of our approach was compared to the state-of-the-art algorithm for complex fractures of the proximal humerus. All reconstructions of the clinical cases resulted in an accurate approximation of the pre-traumatic anatomy. The accuracy of the reconstructed cadaver cases outperformed the current state-of-the-art algorithm.
Topics: Algorithms; Cadaver; Humans; Models, Anatomic; Shoulder Fractures
PubMed: 29102769
DOI: 10.1016/j.media.2017.10.006 -
Injury Aug 2021Several surgical techniques of osteosynthesis have been described for treatment of proximal humeral fractures. There is evidence that the quality of reduction improves...
BACKGROUND
Several surgical techniques of osteosynthesis have been described for treatment of proximal humeral fractures. There is evidence that the quality of reduction improves the clinical outcome and decreases the number of complications. Reduction of the medial calcar is tricky when standard manoeuvres are performed. We have therefore augmented our standard surgical technique with a low-profile medial hinge plate which aims at better reconstructing the medial metaphysis without extensile soft tissue dissection in combination with proximal humerus locked plating.
OBJECTIVE
Evaluate the radiological and clinical outcome after application of an augmented fixation with a low-profile medial hinge plate. We questioned: (i) The quality of reduction, (ii) The rate of complications, (iii) The clinical function in terms of the Oxford Shoulder Score (OSS).
METHODS
A retrospective single-centre case series. Between 2016 and 2019, patients who had undergone open reduction and osteosynthesis by an anatomical locking plate associated with a 2.0 mm locking compression plate used as a hinge to support the medial metaphysis. Thirty-four patients, with an average age of 64 years had a clinical and/or radiological average follow-up of 36 months.
RESULTS
The preoperative imaging identified three fractures in two parts, 19 fractures in three parts and 12 fractures in four parts. Seven cases with fracture-dislocation were identified, one head-split fracture, and 14 cases with a metaphyseal head extension of less than 8 mm. After comparing head-shaft displacement, cranialisation of the greater tuberosity as well as head-shaft alignment in the preoperative and postoperative radiographs, overall anatomical or near-anatomical fracture reduction was achieved in 27 of the patients. Only two cases presented postoperative complications. The two cases were complicated with nonunion without screw perforation requiring surgical intervention by re-osteosynthesis. The clinical outcome assessed by the OSS showed an average of 45/48. The age of the group with anatomical or near anatomical reduction and the group with at least one parameter of malreduction was significantly different, 65 and 74 years respectively (p<0.05). No significant differences were found when comparing the sex, surgical time, time to operation or the number of fracture parts.
CONCLUSION
The technique described provides a surgical treatment option with lower complication rates and a quality of reduction consistent with the current literature as well as a satisfactory clinical outcome.
Topics: Aged; Bone Plates; Fracture Fixation, Internal; Fractures, Comminuted; Humans; Humeral Fractures; Middle Aged; Retrospective Studies; Shoulder Fractures; Treatment Outcome
PubMed: 34053774
DOI: 10.1016/j.injury.2021.05.005