-
Clinical Medicine & Research Jun 2009Proximal humeral fractures can restrict daily activities and, therefore, deserve efficient diagnoses that minimize complications and sequels. For good diagnosis and... (Review)
Review
Proximal humeral fractures can restrict daily activities and, therefore, deserve efficient diagnoses that minimize complications and sequels. For good diagnosis and treatment, patient characteristics, variability in the forms of the fractures presented, and the technical difficulties in achieving fair results with surgical treatment should all be taken into account. Current classification systems for these fractures are based on anatomical and pathological principles, and not on systematic image reading. These fractures can appear in many different forms, with many characteristics that must be identified. However, many current classification systems lack good reliability, both inter-observer and intra-observer for different image types. A new approach to image reading, following a well-designed set and sequence of variables to check, is needed. We previously reported such an image reading system. In the present study, we report a classification system based on this image reading system. Here we define 21 fracture characteristics and apply them along with classical Codman approaches to classify fractures. We base this novel classification system for classifying proximal humeral fractures on a review of scientific literature and improvements to our image reading protocol. Patient status, fracture characteristics and surgeon circumstances have been important issues in developing this system.
Topics: Aged; Aged, 80 and over; Algorithms; Decision Support Techniques; Female; Humans; Image Processing, Computer-Assisted; Male; Middle Aged; Orthopedics; Radiography; Reproducibility of Results; Shoulder Fractures
PubMed: 19574487
DOI: 10.3121/cmr.2009.779 -
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 -
Journal of Shoulder and Elbow Surgery May 2021The most appropriate treatment for displaced multiple-fragment proximal humeral fractures in elderly patients is currently unclear. Reverse total shoulder arthroplasty... (Randomized Controlled Trial)
Randomized Controlled Trial
Reverse total shoulder arthroplasty provides better shoulder function than hemiarthroplasty for displaced 3- and 4-part proximal humeral fractures in patients aged 70 years or older: a multicenter randomized controlled trial.
BACKGROUND
The most appropriate treatment for displaced multiple-fragment proximal humeral fractures in elderly patients is currently unclear. Reverse total shoulder arthroplasty (rTSA) is a promising treatment option that is being used increasingly. The purpose of this study was to compare the outcome of rTSA vs. hemiarthroplasty (HA) for the treatment of displaced 3- and 4-part fractures in elderly patients.
METHODS
This was a multicenter randomized controlled trial. We included patients aged ≥ 70 years with displaced 3- or 4-part proximal humeral fractures between September 2013 and May 2016. The minimum follow-up period was 2 years, with outcome measures including the Constant score (primary outcome), Western Ontario Osteoarthritis of the Shoulder index, EQ-5D (EuroQol 5 Dimensions) index, and range of motion, as well as pain and shoulder satisfaction assessed on a visual analog scale.
RESULTS
We randomized 99 patients to rTSA (48 patients) or HA (51 patients). Fifteen patients were lost to follow-up, leaving 41 rTSA and 43 HA patients for analysis. The mean age was 79.5 years, and there were 76 women (90%). The rTSA group had a mean Constant score of 58.7 points compared with 47.7 points in the HA group, with a mean difference of 11.1 points (95% CI, 3.0-18.9 points; P = .007). Compared with HA patients, rTSA patients had greater mean satisfaction with the shoulder (79 mm vs. 63 mm, P = .011), flexion (125° vs. 90°, P < .001), and abduction (112° vs. 83°, P < .001), but there was no difference in Western Ontario Osteoarthritis of the Shoulder index, pain, or EQ-5D index scores. We identified 3 and 4 adverse events in the rTSA and HA groups, respectively. Among patients aged ≥ 80 years (n = 38), there was no difference between rTSA treatment and HA treatment in pain (17 mm vs. 9 mm, P = .17) or shoulder satisfaction (77 mm vs. 74 mm, P = .73).
CONCLUSION
We found that rTSA provides better shoulder function than HA as measured with the Constant score, further emphasized by rTSA patients being more satisfied with their shoulder function. The difference appears to be mainly a result of better range of motion (abduction and flexion) in the rTSA group. The results also indicate that patients aged ≥ 80 years benefit less from rTSA than patients aged 70-79 years.
Topics: Aged; Arthroplasty, Replacement, Shoulder; Female; Hemiarthroplasty; Humans; Ontario; Range of Motion, Articular; Shoulder; Shoulder Fractures; Shoulder Joint; Treatment Outcome
PubMed: 33301926
DOI: 10.1016/j.jse.2020.10.037 -
Journal of Orthopaedic Surgery and... Feb 2022Angular stable plates were introduced two decades ago as a promising treatment for fixation of displaced fractures of the proximal humerus (PHF). However, high rates of...
BACKGROUND
Angular stable plates were introduced two decades ago as a promising treatment for fixation of displaced fractures of the proximal humerus (PHF). However, high rates of adverse events and reoperations have been reported. One frequent reason is secondary penetration of screws into the glenohumeral joint, due to sinking of the fracture or avascular head necrosis. To prevent joint penetrations angular stable plates with smooth locking pegs instead of locking screws have been developed. The aim of the present study was to investigate whether blunt pegs instead of pointed screws reduced the risk of secondary penetration into the glenohumeral joint during fracture healing after operatively treated PHFs.
METHODS
From two different patient cohorts with displaced PHFs (60 treated with PHILOS plate with screws and 50 with ALPS-PHP plate with pegs), two groups were matched according to fracture type AO/OTA 11-B2 and 11-C2 and age (55-85 years). They were followed up at 3, 6 and 12 months. Primary outcome was radiographic signs of peg or screw penetrations into the glenohumeral joint at 12 months. Secondary outcomes were Oxford shoulder score (OSS) and Constant Score (CS) and radiographic signs of avascular humeral head necrosis (AVN).
RESULTS
Eighteen PHILOS patients with B2 and C2 fractures could be matched with a corresponding group of 18 operated with ALPS-PHP with pegs. The number of penetrations of pegs and screws were equal between the two groups and the development of avascular head necrosis did not differ either. The functional outcomes for both OSS and CS at 12 months was clearly in favor of patients without joint penetrations in both groups.
CONCLUSION
We found no differences in the number of screw or peg penetrations in the PHILOS and ALPS-PHP group and the occurrence of AVN was equal. Joint penetrations led to inferior functional outcomes at 1 year. The ClinicalTrials.gov identifier 20/11/12 prospectively for the Philos Group is NCT01737060, and for the ALPS group 11/03/20 retrospectively is NCT04622852.
Topics: Aged; Aged, 80 and over; Bone Plates; Bone Screws; Fracture Fixation, Internal; Humans; Middle Aged; Necrosis; Postoperative Complications; Retrospective Studies; Shoulder; Shoulder Fractures; Treatment Outcome
PubMed: 35109905
DOI: 10.1186/s13018-022-02947-3 -
Orthopaedic Surgery Jul 2022To evaluate the efficacy of the double-row and double-pulley technique in treating anterior shoulder glenoid fracture (Ideberg type Ia) using shoulder arthroscopy.
OBJECTIVE
To evaluate the efficacy of the double-row and double-pulley technique in treating anterior shoulder glenoid fracture (Ideberg type Ia) using shoulder arthroscopy.
METHODS
Thirty-six patients with Ideberg type Ia admitted from March 1, 2017, to March 1, 2020, were retrospectively reviewed. Data of the patients' history included age, sex, side of the affected arm, the mean time from injury to surgery, the surgical duration, the average blood loss, and the average total duration of hospital stay. The double-row and double-pulley technique was used to repair the scapular glenoid fracture under arthroscopy. Computed tomography (CT) was used to evaluate fracture healing after surgery. The American Shoulder and Elbow Surgeons (ASES) score, the University of California at Los Angeles (UCLA) shoulder joint scoring system, and the Constant-Murley shoulder function score were used to assess the function of the affected shoulder.
RESULTS
The surgical duration was 90-150 min, with a mean of 127 min. The average blood loss was 90 mL (range, 60-120 mL), and the average total duration of hospital stay was 9.2 days (range, 3 to 14 days). At 9 months after surgery, the CT results showed that all fractures healed, and all patients returned to their previous levels of activity and regained an excellent range of motion. The visual analog scale (VAS) score was 7.55 ± 1.32 before surgery, and the VAS score significantly decreased to 1.24 ± 0.72 at 12 months after the operation (p < 0.05). The Constant, ASES, and UCLA shoulder function scores were 44.38 ± 2.16, 43.47 ± 12.76, and 21.80 ± 1.16 before the surgery, respectively, which improved to 93.52 ± 2.82, 91.34 ± 8.28, and 33.24 ± 1.64, respectively, in the following 12 months. One patient experienced fat liquefaction. However, no cases of deep venous thrombosis, iatrogenic neurovascular compromise, wound infection, or neurovascular injury were identified.
CONCLUSION
The double-row and double-pulley technique for treating Ideberg type Ia under shoulder arthroscopy has minor surgical trauma, reliable fracture reduction and fixation, less postoperative pain, and fewer postoperative complications and significantly improves the patient's shoulder joint function.
Topics: Arthroscopy; Humans; Range of Motion, Articular; Retrospective Studies; Rotator Cuff Injuries; Scapula; Shoulder Fractures; Shoulder Joint; Treatment Outcome
PubMed: 35638594
DOI: 10.1111/os.13305 -
BMC Musculoskeletal Disorders May 2015Proximal humerus fractures are a common fragility fracture that significantly affects the independence of older adults. The outcomes of these fractures are frequently... (Review)
Review
BACKGROUND
Proximal humerus fractures are a common fragility fracture that significantly affects the independence of older adults. The outcomes of these fractures are frequently disappointing and previous systematic reviews are unable to guide clinical practice. Through an integrated knowledge user collaboration, we sought to map the breadth of literature available to guide the management of proximal humerus fractures.
METHODS
We utilized a scoping review technique because of its novel ability to map research activity and identify knowledge gaps in fields with diverse treatments. Through multiple electronic database searches, we identified a comprehensive body of proximal humerus fracture literature that was classified into eight research themes. Meta-data from each study were abstracted and descriptive statistics were used to summarize the results.
RESULTS
1,051 studies met our inclusion criteria with the majority of research being performed in Europe (64%). The included literature consists primarily of surgical treatment studies (67%) and biomechanical fracture models (10%). Nearly half of all clinical studies are uncontrolled case series of a single treatment (48%). Non-randomized comparative studies represented 12% of the literature and only 3% of the studies were randomized controlled trials. Finally, studies with a primary outcome examining the effectiveness of non-operative treatment or using a prognostic study design were also uncommon (4% and 6%, respectively).
CONCLUSIONS
The current study provides a comprehensive summary of the existing proximal humerus fracture literature using a thematic framework developed by a multi-disciplinary collaboration. Several knowledge gaps have been identified and have generated a roadmap for future research priorities.
Topics: Age Factors; Aged; Aged, 80 and over; Bibliometrics; Biomechanical Phenomena; Biomedical Research; Fracture Healing; Frail Elderly; Humans; Humerus; Knowledge Bases; Middle Aged; Orthopedics; Risk Factors; Shoulder Fractures; Treatment Outcome
PubMed: 25958203
DOI: 10.1186/s12891-015-0564-8 -
Orthopaedic Surgery Oct 2020Based on the morphological characteristics of glenoid and greater tuberosity (GT) fractures and the relationship between them, we explored the injury mechanism of acute...
OBJECTIVE
Based on the morphological characteristics of glenoid and greater tuberosity (GT) fractures and the relationship between them, we explored the injury mechanism of acute anterior shoulder dislocation associated with glenoid and GT fractures.
METHODS
From December 2013 to December 2019, we retrospectively reviewed the clinical data of patients who were diagnosed with acute anterior shoulder dislocation associated with glenoid and GT fractures in our hospital. According to the fracture site, a glenoid fracture group and a greater tuberosity fracture (GT) group were established, and the morphological characteristics of both glenoid and GT fractures were measured and statistically analyzed.
RESULTS
A total of 41 patients (43 shoulders) met the inclusion criteria (39 unilateral shoulders and 2 bilateral shoulders). The mean age was 50.21 years (range, 22-71 years). A total of 27 shoulder injuries (62.8%) were split GT fractures and 33 shoulder injuries (76.7%) were combined with rotator cuff tears. The mean size of glenoid fragments was 30.16% and the mean displacement was 8.85 mm. The mean size of GT fragments was 28.43 mm. The mean superoinferior and anteroposterior displacements of the GT fragment were 6.77 mm and 4.96 mm, respectively. There was a negative correlation between the size of glenoid and GT fracture fragments (r = -0.64, P < 0.05). The glenoid fragments in the Ideberg type Ia glenoid fracture group were smaller than those in the Ideberg type II glenoid fracture group (28.41% and 40.95%, respectively), while the size of GT fragments in the type Ia group were larger than those in the type II group (29.77 mm and 20.21 mm, respectively) (P < 0.05). The GT fragments in the split GT fracture group were larger than those in the avulsion or depression GT fracture group (33.69 mm, 19.07 mm and 21.12 mm, respectively), while the size of glenoid fragments in the split GT fracture group were smaller than those in the avulsion or depression GT fracture group (23.57%, 41.37%, and 43.42%, respectively) (P < 0.05). As for the displacement direction of GT fragments, depression fractures were mainly inferior displacements, avulsion fractures were mainly anterosuperior displacements, while split fractures were mainly posteroinferior displacements (P < 0.05). Multiple regression analysis suggested that the type and the fragment size of GT fractures have a significant influence on the size of glenoid fragments.
CONCLUSION
Acute anterior shoulder dislocations associated with glenoid and GT fractures are often combined with rotator cuff tears. There is a negative correlation between the size of glenoid and GT fragments, and split GT fractures are most common. Such injuries are highly correlated to the relative spatial location between the GT and the glenoid when the shoulder dislocates.
Topics: Adult; Aged; Female; Humans; Male; Middle Aged; Retrospective Studies; Scapula; Shoulder Dislocation; Shoulder Fractures; Young Adult
PubMed: 32812705
DOI: 10.1111/os.12767 -
Orthopaedics & Traumatology, Surgery &... Feb 2013Three- and four-part fractures of the proximal humerus are usually treated surgically. Open reduction with internal fixation (ORIF) is the method of choice in younger... (Review)
Review
Three- and four-part fractures of the proximal humerus are usually treated surgically. Open reduction with internal fixation (ORIF) is the method of choice in younger patients. Anatomic reduction of the tuberosities is crucial to ensure that, in the event of poorly tolerated avascular necrosis of the humeral head, hemiarthroplasty can be performed under optimal conditions. Suboptimal outcomes may occur after ORIF, as less-than-perfect reduction and fixation is poorly tolerated at the shoulder. Preoperative computed tomography must be performed routinely to analyse fragment displacement and comminution, classify the fracture, assess humeral head vitality, and evaluate the mechanical properties of the underlying bone. Fracture reduction relies on principles that are shared by the various available techniques. Reduction of each fragment should be assessed separately. Reduction of the humeral head to the shaft should be performed before reduction of the tuberosities. The fixation technique should ensure stability of the anatomic reduction, with secure fixation of the tuberosities and a minimal risk of material migration into the joint. Here, we provide a detailed discussion of the various techniques, with their advantages and drawbacks, to help surgeons select the method that is most appropriate to each individual patient.
Topics: Fracture Fixation, Internal; Humans; Shoulder Fractures
PubMed: 23333125
DOI: 10.1016/j.otsr.2012.12.006 -
Acta Orthopaedica Jun 2020Background and purpose - When nonoperative treatment of proximal humerus fracture (PHF) fails, shoulder arthroplasty may be indicated. We investigated risk factors for...
Patients undergoing shoulder arthroplasty for failed nonoperative treatment of proximal humerus fracture have low implant survival and low patient-reported outcomes: 837 cases from the Danish Shoulder Arthroplasty Registry.
Background and purpose - When nonoperative treatment of proximal humerus fracture (PHF) fails, shoulder arthroplasty may be indicated. We investigated risk factors for revision and evaluated patient-reported outcome 1 year after treatment with either stemmed hemiarthroplasty (SHA) or reverse total shoulder arthroplasty (RTSA) after previous nonoperative treatment of PHF sequelae.Patients and methods - Data were derived from the Danish Shoulder Arthroplasty Registry and included 837 shoulder arthroplasties performed for PHF sequelae between 2006 and 2015. Type of arthroplasty, sex, age, and surgery period were investigated as risk factors. The Western Ontario Osteoarthritis of the Shoulder index (WOOS) was used to evaluate patient-reported outcome (0-100, 0 indicates worst outcome). Cox regression and linear regression models were used in the statistical analyses.Results - 644 patients undergoing SHA and 127 patients undergoing RTSA were included. During a mean follow-up of 3.7 years, 48 (7%) SHA and 14 (11%) RTSA were revised. Men undergoing RTSA had a higher revision rate than men undergoing SHA (hazard ratio [HR] 6, 95% confidence interval [CI] 2-19). 454 (62%) patients returned a complete WOOS questionnaire. The mean WOOS score was 53 for SHA and 53 for RTSA. Patients who were 65 years or older had a better WOOS score than younger patients (mean difference 7, CI 1-12). Half of patients had WOOS scores below 50.Interpretation - Shoulder arthroplasty for PHF sequelae was associated with a high risk of revision and a poor patient-reported outcome. Men treated with RTSA had a high risk of revision.
Topics: Aged; Arthroplasty, Replacement, Shoulder; Denmark; Female; Humans; Male; Middle Aged; Patient Reported Outcome Measures; Prosthesis Failure; Registries; Reoperation; Risk Factors; Shoulder Fractures; Shoulder Joint; Treatment Failure
PubMed: 32098560
DOI: 10.1080/17453674.2020.1730660 -
Bulletin of the NYU Hospital For Joint... 2012The recent increase in life expectancy is expected to bring about a concurrent rise in the number of proximal humerus fractures. Those presenting with significant... (Review)
Review
The recent increase in life expectancy is expected to bring about a concurrent rise in the number of proximal humerus fractures. Those presenting with significant displacement, osteoporosis, and comminution present distinct clinical challenges, and the optimal treatment of these injuries remains controversial. As implant technologies and treatment strategies continue to evolve, the role and appropriateness of certain operative and nonoperative treatment modalities are being debated. Prior concerns regarding humeral head viability forced many physicians to abandon operative management in favor of nonoperative modalities. However, with greater appreciation and understanding of the factors governing humeral head viability, operative intervention is increasingly used and investigated. Nevertheless, sub-optimal results with earlier implants continue to cloud the debate between nonoperative and operative treatment modalities. This paper will review historical considerations, biologic considerations, and implant considerations in the management of three-and four-part proximal humerus fractures.
Topics: Adult; Arthroplasty, Replacement; Biomechanical Phenomena; Female; Fracture Fixation; Hemiarthroplasty; History, 20th Century; History, 21st Century; Humans; Humeral Head; Male; Middle Aged; Radiography; Risk Assessment; Risk Factors; Shoulder Fractures; Treatment Outcome
PubMed: 22894692
DOI: No ID Found