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Challoumas D, Minhas H, Bagni S, Millar N. Early versus delayed mobilisation for non-surgically treated proximal humerus fractures: a systematic review and meta-analysis of randomised trials. BMC Musculoskelet Disord 2025; 26:203. [PMID: 40016664 PMCID: PMC11866563 DOI: 10.1186/s12891-025-08371-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2024] [Accepted: 01/29/2025] [Indexed: 03/01/2025] Open
Abstract
BACKGROUND Proximal humerus fractures (PHFs) are among the commonest bony injuries and the majority of them can be managed non-surgically. The aim of our systematic review and meta-analysis was to compare the effectiveness and safety of early versus delayed mobilisation in conservatively treated PHFs. METHODS A literature search was performed in Medline, EMBASE and clinicaltrials.gov in Januray 2025 aiming to identify all randomised controlled trials (RCTs) comparing early versus delayed (conventional) mobilisation as part of the non-surgical management of PHFs. Primary outcomes were patient-reported function and pain at short-term (3 months), mid-term (6 months) and long-term (12 months) follow-up, and secondary outcomes included secondary fracture displacement and total complications. Meta-analyses produced mean differences (MDs) or standardised MDs (SMDs) for continuous outcomes and odds ratios (ORs) for binary outcomes, with 95% confidence intervals (CI). Certainty of evidence was assessed using the GRADE tool. Recommendations for clinical practice were given only based on results of high or moderate certainty of evidence. RESULTS Six (6) RCTs were included that compared early mobilisation (EM; within one week from injury) to delayed mobilisation (DM; after 3 or 4 weeks of immobilisation) with a total of 470 patients with PHFs. There were no differences in patient-reported function (combined or Constant score) or pain between the EM and DM groups at any follow-up time points except for a significant difference in combined function scores favouring EM [SMD 0.4 CI (0.1,0.7), P = 0.006] at 3 months follow-up. There were no significant differences in the incidence of secondary fracture displacement and total complications in the two groups [OR 3.5 CI (0.7,18.2), P > 0.05, and OR 1.2 CI (0.5,2.9), P > 0.05, respectively]. All results were based on moderate or high strength of evidence. The most significant limitations of our study were the small number of pooled studies and inability to perform subgroup analyses for specific fracture types. CONCLUSIONS Our meta-analysis of RCTs showed that commencement of mobilisation within one week from injury for non-surgically managed PHFs is safe and may confer short-term functional benefits compared to delayed mobilisation.
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Affiliation(s)
- Dimitris Challoumas
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
| | - Haroon Minhas
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Stephanie Bagni
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Neal Millar
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Tille E, Lorenz F, Beyer F, Schlüßler A, Biewener A, Nowotny J. Early functional improvements using continuous passive motion therapy after angular-stable plate osteosynthesis of proximal humerus fractures - results of a prospective, randomized trial. J Orthop Surg Res 2024; 19:313. [PMID: 38802866 PMCID: PMC11131183 DOI: 10.1186/s13018-024-04804-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The use of continuous passive motion therapy (CPM) has led to promising results in the early phase of rehabilitation after surgical treatment of rotator cuff tears and arthrolysis of the elbow. However, its use has not been proven in other pathologies of the upper extremity. Therefore, the aim of the underlying study was to evaluate the use of CPM therapy after plate osteosynthesis of proximal humeral fractures. METHODS 95 patients with isolated proximal humerus fractures were enrolled in a prospective, randomized study. Patients were assigned to a treatment group with (n = 48, CPM) or without CPM therapy (n = 47, CG). Four patients (2 of each cohort) violated the study protocol and were excluded. CPM therapy was used for 6 weeks after surgery 2-3 times daily. Functional (range of motion) and patient reported outcomes (PROM, Constant Score [CSS], QuickDASH, subjective shoulder value [SSV], pain on visual analogue scale [VAS]) were evaluated at 6 weeks, 3 and 12months. 60 patients completed the 1-year follow-up. RESULTS The average patient age was 65.3 years (min: 27, max: 88, SD: ± 14.7). Seventy-two patients were female (79%). There was no difference regarding injury severity (2/3/4 part-fracture: 6/32/7 vs. 9/26/11, p = 0.867) and sex (p = 0.08). However, patients in the CPM group were significantly younger (CPM: 67 [min: 34, max: 82], CG: 74 [min: 27, max: 88], p = 0.032). After 6 weeks we observed a better range of motion for forward flexion (CPM: 90° [min: 50°, max: 180°] vs. CG: 80° [min: 20°, max: 170°] p = 0.035) and abduction (CPM: 80° [min: 40°, max: 180°] vs. CG: 70° [min: 20°, max: 180°], p = 0.048) in the CPM group. There was no difference regarding the further planes of motion or the assessed PROMs at 6 weeks. At 3 and 12 months the results between the treatment groups equalized with no further significant differences. CONCLUSION The treatment with CPM increases the range of motion after plate osteosynthesis of proximal humerus fractures in the first 6 weeks after surgery. This effect is not sustained after 3 and 12months. The evaluated PROMs are not being influenced by CPM therapy. Hence the results of this prospective randomized study suggest that CPM can be a beneficial asset in the early period of rehabilitation after proximal humerus plate osteosynthesis. TRIAL REGISTRATION The study protocol was registered in the US National Institutes of Health's database ( http://www. CLINICALTRIALS gov ) registry under NCT05952622.
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Affiliation(s)
- Eric Tille
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany.
| | - Franz Lorenz
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
| | - Franziska Beyer
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
| | - Antonia Schlüßler
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
| | - Achim Biewener
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
| | - Jörg Nowotny
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherst. 74, 01307, Dresden, Germany
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Martinez-Catalan N. Conservative Treatment of Proximal Humerus Fractures: When, How, and What to Expect. Curr Rev Musculoskelet Med 2022; 16:75-84. [PMID: 36562923 PMCID: PMC9889589 DOI: 10.1007/s12178-022-09817-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW The key question to answer during the decision-making process for proximal humerus fractures (PHF) is whether the amount of displacement of a specific fracture pattern will be acceptable taking into account the anticipated demands on the patient. The aim of this review article was to provide some clarity regarding the features that contribute to poor clinical outcomes when PHF are treated non-operatively and to review the reported outcomes of conservative treatment. RECENT FINDINGS Conservative treatment for non-displaced or minimally displaced fractures leads to good outcomes in 80% to 90% of patients. However, with increasing fracture complexity and displacement, functional outcomes tend to diminish. In active patients with significant functional demands, the challenge is to predict which fractures will do poorly when treated non-operatively. A better understanding of fracture patterns and fragment displacement may improve treatment indications. To avoid complications related to conservative treatment, surgery should be considered (1) in fractures in which the humeral head is severely compromised (due to fracture-dislocation, severe impaction, or a split of the head itself), (2) in non-impacted fractures with gross instability between the humeral shaft and humeral head, and (3) in those cases in which displacement of the tuberosities or the final shape of the proximal humerus after healing will lead to symptomatic malunion.
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Affiliation(s)
- Natalia Martinez-Catalan
- Department of Orthopaedics and Traumatology, Hospital Fundación Jimenez Diaz, Avenida de los Reyes Catolicos 2, 28040 Madrid, Spain
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Handoll HH, Elliott J, Thillemann TM, Aluko P, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2022; 6:CD000434. [PMID: 35727196 PMCID: PMC9211385 DOI: 10.1002/14651858.cd000434.pub5] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely, including in the use of surgery. This is an update of a Cochrane Review first published in 2001 and last updated in 2015. OBJECTIVES To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registries, and bibliographies of trial reports and systematic reviews to September 2020. We updated this search in November 2021, but have not yet incorporated these results. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults. DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. We prepared a brief economic commentary for one comparison. MAIN RESULTS We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. Six comparisons were tested by 2 to 10 trials, the others by small single-centre trials only. Twelve studies evaluated non-surgical treatments, 10 compared surgical with non-surgical treatments, 23 compared two methods of surgery, and two tested timing of mobilisation after surgery. Most trials were at high risk of bias, due mainly to lack of blinding. We summarise the findings for four key comparisons below. Early (usually one week post injury) versus delayed (after three or more weeks) mobilisation for non-surgically-treated fractures Five trials (350 participants) made this comparison; however, the available data are very limited. Due to very low-certainty evidence from single trials, we are uncertain of the findings of better shoulder function at one year in the early mobilisation group, or the findings of little or no between-group difference in function at 3 or 24 months. Likewise, there is very low-certainty evidence of no important between-group difference in quality of life at one year. There was one reported death and five serious shoulder complications (1.9% of 259 participants), spread between the two groups, that would have required substantive treatment. Surgical versus non-surgical treatment Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures). There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants). There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year (EQ-5D (0: dead to 1: best quality): mean difference (MD) 0.01, 95% CI -0.02 to 0.04; 6 studies, 502 participants). There is low-certainty evidence of little between-group difference in mortality: one of the 31 deaths was explicitly linked with surgery (risk ratio (RR) 1.35, 95% CI 0.70 to 2.62; 8 studies, 646 participants). There is low-certainty evidence of a higher risk of additional surgery in the surgery group (RR 2.06, 95% CI 1.21 to 3.51; 9 studies, 667 participants). Based on an illustrative risk of 35 subsequent operations per 1000 non-surgically-treated patients, this indicates an extra 38 subsequent operations per 1000 surgically-treated patients (95% CI 8 to 94 more). Although there was low-certainty evidence of a higher overall risk of adverse events after surgery, the 95% CI also includes a slightly increased risk of adverse events after non-surgical treatment (RR 1.46, 95% CI 0.92 to 2.31; 3 studies, 391 participants). Open reduction and internal fixation with a locking plate versus a locking intramedullary nail Four trials (270 participants) evaluated surgical intervention for displaced fractures (63% were two-part fractures). There is low-certainty evidence of no clinically important between-group difference in shoulder function at one year (SMD 0.15, 95% CI -0.12 to 0.41; 4 studies, 227 participants), six months (Disability of the Arm, Shoulder, and Hand questionnaire (0 to 100: worst disability): MD -0.39, 95% CI -4.14 to 3.36; 3 studies, 174 participants), or two years (American Shoulder and Elbow Surgeons score (ASES) (0 to 100: best outcome): MD 3.06, 95% CI -0.05 to 6.17; 2 studies, 101 participants). There is very low-certainty evidence of no between-group difference in quality of life (1 study), and of little difference in adverse events (4 studies, 250 participants) and additional surgery (3 studies, 193 participants). Reverse total shoulder arthroplasty (RTSA) versus hemiarthroplasty There is very low-certainty evidence from two trials (161 participants with either three- or four-part fractures) of no or minimal between-group differences in self-reported shoulder function at one year (1 study) or at two to three years' follow-up (2 studies); or in quality of life at one year or at two or more years' follow-up (1 study). Function at six months was not reported. Of 10 deaths reported by one trial (99 participants), one appeared to be surgery-related. There is very low-certainty evidence of a lower risk of complications after RTSA (2 studies). Ten people (6.2% of 161 participants) had a reoperation; all eight cases in the hemiarthroplasty group received a RTSA (very low-certainty evidence). AUTHORS' CONCLUSIONS There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery. The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures. There is insufficient evidence from randomised trials to inform the choices between different non-surgical, surgical or rehabilitation interventions for these fractures.
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Affiliation(s)
- Helen Hg Handoll
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, UK
- Department of Orthopaedics and Trauma, The University of Edinburgh, Edinburgh, UK
| | - Joanne Elliott
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, UK
| | - Theis M Thillemann
- Department of Orthopaedics, Shoulder and Elbow Unit, Aarhus University Hospital, Aarhus N, Denmark
| | - Patricia Aluko
- National Institute for Health Research (NIHR) Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Stig Brorson
- Centre for Evidence-Based Orthopaedics, Zealand University Hospital and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Thelen S, Grassmann JP, Schneider M, Jaekel C, Meier DM, Betsch M, Hakimi M, Wild M. The influence of fracture severity on postoperative outcome and quality of life after locking plate fixation of proximal humeral fractures. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2022; 11:Doc03. [PMID: 35692287 PMCID: PMC9178521 DOI: 10.3205/iprs000164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective: For proximal humeral fractures open reduction und internal fixation (ORIF) with a fixed-angle plate is considered the gold standard for surgical management. However, it can lead to poor functional outcomes and is associated with postoperative complications. Therefore, the purpose of this study was to investigate the influence of fracture severity by applying a new classification (simple versus complex) on clinical outcome and quality of life after ORIF of proximal humerus fractures. Methods: We conducted a prospective clinical study with an average follow-up period of 12 (SD 1) months after ORIF of proximal humeral fractures with a fixed-angle plate. The postoperative function and quality of life was measured using the Oxford Shoulder Score (OSS) and the Constant Score. Data was tested for statistical significance with the Mann-Whitney test and Fisher's exact test. Based on the findings of this study a simplified fracture classification system has been developed. Results: Seventy-two patients with a mean age of 65 years (SD 12) with 69% being males were included. According to the Neer classification, 35% (n=25) non-displaced (“one-part fractures”), 19% (n=14) two-part fractures, 15% (n=11) three-part fractures and 31% (n=22) four-part fractures were detected. Regarding the AO/OTA classification, 18% (n=13) were type A fractures, 43% (n=31) type B and 39% (n=28) type C fractures. From these criteria we derived our own fracture classification, including 50% (n=36) simple and 50% (n=36) severe fractures. Patients with simple fracture types achieved significantly higher total values in the Constant Score as well as the OSS (p=0.008; p=0.013). The cumulative incidence of complications in the entire patient collective was 14% (n=10) with humeral head necrosis (n=5) occurring only in the severe fracture group. Conclusions: The postoperative clinical outcome as well as the incidence of humeral head necrosis after ORIF of proximal humeral fractures with a fixed-angle plate correlates with the fracture type and severity. The newly derived fracture classification into simple and severe fractures is suitable with regard to clinical results and complication rate. However, prospective studies comparing ORIF vs. conservative treatment of proximal humeral fractures of the same severity are required. Level of Evidence: III
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Affiliation(s)
- Simon Thelen
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Jan P. Grassmann
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany,*To whom correspondence should be addressed: Jan P. Grassmann, Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany, Phone: +49 (0) 211-81-04400, Fax: +49 (0) 211-81-04902, E-mail:
| | - Madeleine Schneider
- Department of Orthopedics, Trauma and Hand Surgery, Klinikum Darmstadt, Darmstadt, Germany
| | - Carina Jaekel
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Dana M. Meier
- Department of Orthopedics and Trauma Surgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Marcel Betsch
- Department of Orthopedics and Trauma Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Mohssen Hakimi
- Vivantes Klinikum Am Urban, Department of Orthopedic, Trauma and Hand Surgery, Berlin, Germany
| | - Michael Wild
- Department of Orthopedics, Trauma and Hand Surgery, Klinikum Darmstadt, Darmstadt, Germany
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Patch DA, Reed LA, Hao KA, King JJ, Kaar SG, Horneff JG, Ahn J, Strelzow JA, Hebert-Davies J, Little MTM, Krause PC, Johnson JP, Spitler CA. Understanding postoperative rehabilitation preferences in operatively managed proximal humerus fractures: do trauma and shoulder surgeons differ? J Shoulder Elbow Surg 2022; 31:1106-1114. [PMID: 35143996 DOI: 10.1016/j.jse.2021.12.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 12/21/2021] [Accepted: 12/25/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal humerus fractures (PHFs) are common, and their incidence is increasing as the population ages. Despite this, postoperative rehabilitation remains unstandardized and little is known about surgeon preferences. The aim of this study was to assess differences in postoperative rehabilitation preferences and patient education between orthopedic trauma and shoulder surgeons. METHODS An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons to assess differences in postoperative rehabilitation preferences and patient counseling. Descriptive statistics were reported for all respondents, trauma surgeons, and shoulder surgeons. Chi-square and unpaired 2-sample t tests were used to compare responses. Multinomial regression was used to further elucidate the influence of fellowship training independent of confounding characteristics. RESULTS A total of 293 surgeons completed the survey, including 172 shoulder and 78 trauma surgeons. A greater proportion of trauma surgeons preferred an immediate weightbearing status after arthroplasty compared to shoulder surgeons (45% vs. 19%, P = .003), but not after open reduction and internal fixation (ORIF) (62% vs. 75%, P = .412). A greater proportion of shoulder surgeons preferred home exercise therapy taught by the physician or using a handout following reverse shoulder arthroplasty (RSA) (21% vs. 2%, P = .009). A greater proportion of trauma surgeons began passive range of motion (ROM) <2 weeks after 2-part fractures (70% vs. 41%, P < .001). Conversely, a greater proportion of shoulder surgeons began passive ROM between 2 and 6 weeks for 2-part (57% vs. 24%, P < .001) and 4-part fractures (65% vs. 43%, P = .020). On multinomial regression analysis, fellowship training in shoulder surgery was associated with preference for a nonweightbearing duration of >12 weeks vs. 6-12 weeks after ORIF. Similarly, fellowship training in shoulder surgery was associated with increased odds of preferring a nonweightbearing duration of <6 weeks vs. no restrictions and >12 weeks vs. 6-12 weeks after arthroplasty. Training in shoulder surgery was associated with greater odds of preferring a nonweightbearing duration prior to beginning passive ROM of 2-6 weeks vs. <2 weeks or >6 weeks for 2-part fractures, but not 4-part fractures. CONCLUSION Trauma surgeons have a more aggressive approach to rehabilitation following operative PHF repair compared to shoulder surgeons regarding time to weightbearing status and passive ROM. Given the increasing incidence of PHFs and substantial variations in reported treatment outcomes, differences in rehabilitation after PHF treatment should be further evaluated to determine the role it may play in the outcomes of treatment studies.
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Affiliation(s)
- David A Patch
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Logan A Reed
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Scott G Kaar
- Department of Orthopaedic Surgery, Saint Louis University, St Louis, MO, USA
| | - John G Horneff
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jason A Strelzow
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, USA
| | - Jonah Hebert-Davies
- Department of Orthopedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Milton T M Little
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Peter C Krause
- Department of Orthopaedic Surgery, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Joseph P Johnson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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Goudie EB, MacDonald DJ, Robinson CM. Functional Outcome After Nonoperative Treatment of a Proximal Humeral Fracture in Adults. J Bone Joint Surg Am 2022; 104:123-138. [PMID: 34878423 DOI: 10.2106/jbjs.20.02018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The functional outcome following nonoperative treatment of a proximal humeral fracture and the factors that influence it are poorly defined. We aimed to prospectively assess patient-reported outcome measures (PROMs) in a patient cohort at 1 year after the injury. METHODS In this study, 774 adult patients sustaining a proximal humeral fracture completed PROM assessments, including the Oxford Shoulder Score (OSS), the EuroQol-5 Dimensions-3 Levels (EQ-5D-3L), and visual analog scale (VAS) assessments of pain, health, and overall treatment satisfaction at 1 year. The mean patient age was 65.6 years, and 73.8% of patients were female. The influences of demographic and fracture measurements and complications on the OSS and EQ-5D-3L were assessed. RESULTS The 1-year mean scores were 33.2 points (95% confidence interval [CI], 32.1 to 34.2 points) for the OSS and 0.58 (95% CI, 0.55 to 0.61) for the EQ-5D-3L. There was considerable heterogeneity in the reported scores, and the 3 demographic variables of higher levels of dependency, higher levels of social deprivation, and a history of affective (mood) disorder were most consistently associated with poorer outcomes, accounting for between 37% and 43% of the score variation. The initial fracture translation potentially leading to nonunion accounted for 9% to 15% of the variation, and a displaced tuberosity fracture was also predictive of 1% to 4% of the outcome variation. There was evidence of a ceiling effect for the OSS, with 238 patients (30.8%) having a score of ≥47 points but a mean outcome satisfaction of only 72.9 points, and this effect was more pronounced in younger, active individuals. At the other end of the spectrum, 239 patients (30.9%) reported an OSS of ≤24 points, and 120 patients (15.5%) had a "worse-than-death" EQ-5D-3L score. CONCLUSIONS Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year, and a substantial proportion of patients have poor perceived functional outcomes. The outcome for the majority of less-displaced fractures is mainly influenced by preexisting patient-related psychosocial factors, although the fracture-related factors of displacement, nonunion, and tuberosity displacement account for a small but measurable proportion of the variation and the poorer outcomes in the minority with more severe injuries. LEVEL OF EVIDENCE Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ewan B Goudie
- The Edinburgh Shoulder Clinic, New Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Martínez R, Santana F, Pardo A, Torrens C. One Versus 3-Week Immobilization Period for Nonoperatively Treated Proximal Humeral Fractures: A Prospective Randomized Trial. J Bone Joint Surg Am 2021; 103:1491-1498. [PMID: 34101691 DOI: 10.2106/jbjs.20.02137] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is no consensus on the duration of immobilization for nonoperatively treated proximal humeral fractures (PHFs). The main objective of the study was to determine the differences in pain between PHFs that were treated nonoperatively with 3-week immobilization and those treated with 1-week immobilization. METHODS A prospective randomized trial was designed to evaluate whether the immobilization time frame (1-week immobilization [group I] versus 3-week immobilization [group II]) for nonoperatively treated PHFs had any influence on pain and functional outcomes. Pain was assessed using a 10-cm visual analog scale (VAS) that was administrated 1 week after the fracture, at 3 weeks, and then at the 3, 6, 12, and 24-month follow-up. The functional outcome was evaluated using the Constant score. To assess the functional disability of the shoulder, a self-reported shoulder-specific questionnaire, the Simple Shoulder Test (SST), was used. The Constant score and the SST were recorded at the 3, 6, 12, and 24-month follow-up. Complications and secondary displacement were also recorded. RESULTS One hundred and forty-three patients were randomized, and 111 (88 females and 23 males) who had been allocated to group I (55 patients) or group II (56 patients) were included in the final analysis. The mean age of the patients was 70.4 years (range, 42 to 94 years). No significant differences were found between the 2 groups in terms of pain as measured with the VAS at any time point (1 week [5.9 versus 5.6; p = 0.648], 3 weeks [4.8 versus 4.1; p = 0.059], 3 months [1.9 versus 2.4; p = 0.372], 6 months [1.0 versus 1.2; p = 0.605], 1 year [0.65 versus 0.66; p = 0.718], and 2 years [0.63 versus 0.31; p = 0.381]). No significant differences were found in the Constant score or SST score at any time point. No significant differences were noted in the complication rate. CONCLUSIONS Short and long periods of immobilization yield similar results for nonoperatively treated PHFs, independent of the fracture pattern. These fractures can be successfully managed with a short immobilization period of 1 week in order to not compromise patients' independence for an overly extended period. LEVEL OF EVIDENCE Randomized controlled trial Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Raquel Martínez
- Department of Orthopedics, Hospital d'Igualada, Consorci Sanitari de L'Anoia, Barcelona, Spain
| | - Fernando Santana
- Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Albert Pardo
- Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Carlos Torrens
- Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
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9
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Chang CJ, Su WR, Hsu KL, Hong CK, Kuan FC, Chang CH, Lin CL. Augmented cerclage wire improves the fixation strength of a two-screw construct for humerus split type greater tuberosity fracture: a biomechanical study. BMC Musculoskelet Disord 2021; 22:350. [PMID: 33845833 PMCID: PMC8042700 DOI: 10.1186/s12891-021-04215-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/31/2021] [Indexed: 11/17/2022] Open
Abstract
Background Poor functional outcome can result from humeral greater tuberosity (GT) fracture if not treated appropriately. A two-screw construct is commonly used for the surgical treatment of such injury. However, loss of reduction is still a major concern after surgery. To improve the biomechanical strength of screw fixation in GT fractures, we made a simple modification of the two-screw construct by adding a cerclage wire to the two-screw construct. The purpose of this biomechanical study was to analyze the effect of this modification for the fixation of GT fractures. Materials and methods Sixteen fresh-frozen human cadaveric shoulders were used in this study. The fracture models were arbitrarily assigned to one of two fixation methods. Group A (n = 8) was fixed with two threaded cancellous screws with washers. In group B (n = 8), all screws were set using methods identical to group A, with the addition of a cerclage wire. Horizontal traction was applied via a stainless steel cable fixed directly to the myotendinous junction of the supraspinatus muscle. Displacement of the fracture fixation under a pulling force of 100 N/200 N and loading force to construct failure were measured. Results The mean displacements under 100 N and 200 N traction force were both significantly decreased in group B than in group A. (100 N: 1.06 ± 0.12 mm vs. 2.26 ± 0.24 mm, p < 0.001; 200 N: 2.21 ± 0.25 mm vs. 4.94 ± 0.30 mm, p < 0.001) Moreover, the failure load was significantly higher in group B compared with group A. (415 ± 52 N vs.335 ± 47 N, p = 0.01), Conclusions The current biomechanical cadaveric study demonstrated that the two-screw fixation construct augmented with a cerclage wire has higher mechanical performance than the conventional two-screw configuration for the fixation of humeral GT fractures. Trial registration Retrospectively registered.
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Affiliation(s)
- Chao-Jui Chang
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Su
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Medical Device Innovation Center (MDIC), National Cheng Kung University Hospital, Tainan, Taiwan.,Musculoskeletal Research Center, Innovation Headquarter, National Cheng Kung University, Tainan, Taiwan
| | - Kai-Lan Hsu
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Musculoskeletal Research Center, Innovation Headquarter, National Cheng Kung University, Tainan, Taiwan.,Institute of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Kai Hong
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Fa-Chuan Kuan
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Musculoskeletal Research Center, Innovation Headquarter, National Cheng Kung University, Tainan, Taiwan.,Institute of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Hsun Chang
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Cheng-Li Lin
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan. .,Medical Device Innovation Center (MDIC), National Cheng Kung University Hospital, Tainan, Taiwan. .,Musculoskeletal Research Center, Innovation Headquarter, National Cheng Kung University, Tainan, Taiwan.
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The Benefits and Harms of Early Mobilization and Supervised Exercise Therapy after Non-surgically Treated Proximal Humerus or Distal Radius fracture: A systematic Review and Meta-analysis. Curr Rev Musculoskelet Med 2021; 14:107-129. [PMID: 33689149 DOI: 10.1007/s12178-021-09697-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Fractures of the proximal humerus (PHF) and distal radius (DRF) are among the most common upper extremity fractures in the elderly. Recent randomized controlled trials support non-surgical treatment. Evidence behind the best non-surgical treatment strategy has been sparse and raises questions as to when and how to initiate exercises. The purpose of this systematic review and meta-analysis was to assess the benefits and harms of early mobilization versus late mobilization and supervised versus non-supervised exercises therapy after PHF and DRF. RECENT FINDINGS 15 published and 5 unpublished trials were included. Early mobilization after PHF resulted in better function with a mean difference (MD) of 4.55 (95% CI 0.00-9.10) on the Constant Shoulder Score. However, the MD was not found to be clinically relevant. No clear evidence showed that early mobilization after PHF had a positive effect on range of motion or pain. Neither did it lead to more complications. Furthermore, no eligible evidence was found supporting early mobilization to be superior to late mobilization after DRF, or that supervised exercise therapy was superior to non-supervised exercise therapy after PHF and DRF. The quality of evidence on all outcomes was found to be low or very low. Early mobilization after PHF may have a beneficial effect on function. Due to the lack of clear evidence, there is an urgent need for future studies to determine the effect of early mobilization and supervised exercise therapy after PHF and DRF. Prospero ID number: CRD42020167656, date of registration 28.04.2020.
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11
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Some outcomes of patients treated operatively for distal humerus fractures are affected by hand dominance. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1507-1513. [PMID: 33660048 DOI: 10.1007/s00590-021-02915-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE This study sought to compare postoperative outcomes and complications between patients with distal humerus fractures treated with open reduction and internal fixation (ORIF) of their non-dominant versus dominant arm. METHODS A retrospective review of all patients who sustained a distal humerus fracture treated operatively with ORIF at one academic institution between 2011 and 2015 was performed. Measured outcomes included complications, time to fracture union, painful hardware, removal of hardware, Mayo Elbow Performance Index (MEPI), and elbow range of motion. Differences in outcomes between patients who underwent surgery of their dominant upper extremity and those who underwent surgery of their non-dominant extremity were assessed. RESULTS Sixty-nine patients met inclusion criteria. Forty (58.0%) underwent ORIF of a distal humerus fracture on their non-dominant arm and 29 (42.0%) on their dominant arm. Groups did not differ with respect to demographics, injury information, or surgical management. Mean overall follow-up was 14.1 ± 10.5 months, with all patients achieving at least 6 months follow-up. The non-dominant cohort experienced a higher proportion of postoperative complications (P = 0.048), painful hardware (P = 0.018), and removal of hardware (P = 0.002). At latest follow-up, the non-dominant cohort had lower MEPI scores (P = 0.037) but no difference in elbow arc of motion (P = 0.314). CONCLUSION Patients who sustained a distal humerus fracture of their non-dominant arm treated with ORIF experienced more postoperative complications, reported a greater incidence of painful hardware, underwent removal of hardware more often, and had worse functional recovery in this study. Physicians should emphasize the importance of physical therapy and maintaining arm movement especially when the non-dominant arm is involved following distal humerus fracture repair. LEVEL OF EVIDENCE Level III.
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12
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13
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Sun Q, Ge W, Li G, Wu JZ, Lu G, Li R, Zhao Z, Zhu Y, Xu Y, Wang L, Cai M. Plate Fixation versus Arthroscopic-Assisted Plate Fixation for Isolated Medium-Sized Fractures of the Greater Tuberosity: A Retrospective Study. Orthop Surg 2020; 12:1456-1463. [PMID: 33073535 PMCID: PMC7670132 DOI: 10.1111/os.12773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/03/2020] [Accepted: 07/09/2020] [Indexed: 12/15/2022] Open
Abstract
Objectives To compare the clinical outcomes of plate fixation and arthroscopic‐assisted plate fixation in patients with displaced isolated medium‐sized fractures of the greater tuberosity. Methods From July 2013 to October 2017, patients with displaced isolated medium‐sized fractures of the greater tuberosity who underwent arthroscopic‐assisted plate fixation (ASPF group) or open reduction and internal plate fixation (ORIF group) were retrospectively reviewed and analyzed. There were 19 patients in the ASPF group and 27 patients in the ORIF group, with comparable demographic characteristics. The average age of patients was 49.4 ± 12.1 years in the ASPF group and 46.9 ± 11.4 years in the ORIF group. The shoulder function reflected by the Constant–Murley (CS) scores, the American Shoulder and Elbow Surgeons (ASES) scores, and the range of motion (ROM) in the both groups at the last follow‐up were analyzed in the study. Surgery time, postoperative pain, and postoperative complications were also reviewed. Results A total of 46 eligible patients were included in this study. The mean follow‐up was similar for the ASPF (19.4 ± 3.7 months) and the ORIF (18.2 ± 3.2 months) groups (P = 0.372). All patients had achieved primary incision healing in both groups at the last follow‐up. The surgery time was 96.8 ± 11.7 min and 64.2 ± 8.3 min in the ASPF group and the ORIF group, respectively (P < 0.01). All the CS scores (P = 0.278), ASES scores (P = 0.426), and ROM were slightly better in the ASPF group than in the ORIF group, but they did not attain significant differences. In addition, there was no significant difference in the postoperative complication rate between the ASPF group (10.5%) and the ORIF group (18.5%) (P = 0.522). In the ASPF group, there was only one patient with postoperative shoulder stiffness and one case of fracture malunion. In the ORIF group, there were two cases of postoperative shoulder stiffness, two cases of fracture malunoin, and one case of subacromial impingement. Other major postoperative complications, such as fracture nonunion, pullout of the suture anchor, and screw penetration, were not observed in either group. Conclusion Arthroscopic‐assisted plate fixation is effective and may be an alternative in the treatment of displaced isolated medium‐sized fractures of the greater tuberosity.
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Affiliation(s)
- Qi Sun
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wei Ge
- Department of Orthopaedics, Yancheng City No. 1 People's Hospital, Yancheng, Jiangsu Province, China
| | - Gen Li
- Department of Orthopedics, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jie Zhou Wu
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Guanghua Lu
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Runmin Li
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Zhenyu Zhao
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yaru Zhu
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Youzhi Xu
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lei Wang
- Department of Orthopedics, Shanghai Institute of Traumatology and Orthopedics, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ming Cai
- Department of Orthopaedics, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
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14
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Stelter J, Malik S, Chiampas G. The Emergent Evaluation and Treatment of Shoulder, Clavicle, and Humerus Injuries. Emerg Med Clin North Am 2020; 38:103-124. [DOI: 10.1016/j.emc.2019.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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15
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Aguado HJ, Ariño B, Moreno-Mateo F, Bustinza EY, Simón-Pérez C, Martínez-Zarzuela M, García-Virto V, Ventura PS, Martín-Ferrero MÁ. Does an early mobilization and immediate home-based self-therapy exercise program displace proximal humeral fractures in conservative treatment? Observational study. J Shoulder Elbow Surg 2018; 27:2021-2029. [PMID: 29803503 DOI: 10.1016/j.jse.2018.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/26/2018] [Accepted: 04/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Nonoperative management of proximal humeral fractures (PHFs) is the most common treatment, but its functional outcome may improve with early mobilization. In frail osteoporotic patients, quick recovery of prefracture independency is mandatory. This study assessed fracture displacement in PHFs managed with conservative treatment after early mobilization and a home-based self-exercise program. METHODS We retrospectively analyzed the radiologic displacement of fracture fragments of PHFs treated conservatively with early mobilization and a home-based self-exercise program. RESULTS Included were 99 patients with 26 one-part, 32 two-part, 32 three-part, and 9 four-part PHFs managed conservatively, followed by early mobilization and a home-based self-exercise program. In the x-ray examinations, the head displaced from varus into valgus 55° ± 23° to 42° ± 22°, in the normal range of anatomic values. The medial hinge displaced from medial to the diaphysis (+1 ± 6 mm) to lateral to the head (-0.6 ± 6 mm). The greater tuberosity displaced cranially from -1 ± 7 mm to 2 ± 5 mm. The Constant score at the 1-year follow-up was 79.69 ± 16.3. DISCUSSION AND CONCLUSIONS The home-based self-exercise program for conservative treatment of PHFs displaces the head-diaphysis angle and the medial hinge toward anatomic reduction, but there is a risk of greater tuberosity cranial displacement. Functional results are fairly good, allowing frail patients to keep on with their independency and life style. Because a large number of patients might need further physiotherapy, the quality of the home-based self-exercises should be supervised.
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Affiliation(s)
- Héctor J Aguado
- Orthopedic and Trauma Surgery (Trauma Unit), Hospital Clínico Universitario, Valladolid, Spain; Medical School, University of Valladolid, Valladolid, Spain.
| | - Blanca Ariño
- Orthopedic and Trauma Surgery, Hospital Clínico Universitario, Valladolid, Spain
| | | | - Elías Y Bustinza
- Orthopedic and Trauma Surgery, Hospital Clínico Universitario, Valladolid, Spain
| | - Clarisa Simón-Pérez
- Medical School, University of Valladolid, Valladolid, Spain; Orthopedic and Trauma Surgery (Upper Limb Unit), Hospital Clínico Universitario, Valladolid, Spain
| | | | - Virginia García-Virto
- Orthopedic and Trauma Surgery (Trauma Unit), Hospital Clínico Universitario, Valladolid, Spain
| | | | - Miguel Ángel Martín-Ferrero
- Medical School, University of Valladolid, Valladolid, Spain; Orthopedic and Trauma Surgery, Hospital Clínico Universitario, Valladolid, Spain
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16
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Seppel G, Saier T, Martetschläger F, Plath JE, Guevara-Alvarez A, Henschel J, Winkler M, Augat P, Imhoff AB, Buchmann S. Single versus double row suture anchor fixation for greater tuberosity fractures - a biomechanical study. BMC Musculoskelet Disord 2017; 18:506. [PMID: 29191201 PMCID: PMC5710064 DOI: 10.1186/s12891-017-1868-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 11/20/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fractures of the humeral greater tuberosity (GT) are a frequent injury progressively treated with arthroscopic suture anchor repair. Yet, no biomechanical study has been performed comparing fixation strength of arthroscopic single- (SR) vs. double row (DR) fixation. METHODS Standardized fractures of the greater tuberosity were created in 12 fresh frozen proximal humeri. After random assignation to the SR or DR group the fixed humeri were tested applying cyclic loading to the supraspinatus and infraspinatus tendon. Load to failure and fragment displacement were assessed by means of an electrodynamic material testing machine using an optical tracking system. RESULTS Load to failure values were higher in the DR group (649 N; ±176) than in the SR group (490 N; ±145) however without statistical significance (p = .12). In greater tuberosity displacement of 3-5 mm surgical treatment is recommended. The fixing constructs in this study did not reach displacement landmarks of 3 or 5 mm before construct failure as shown in previous studies. Thus the applied traction force (N) at 1 mm displacement was analyzed. In the SR group the load at 1 mm displacement was 277 N; ±46 compared to 260 N; ±62 in the DR group (p = .65). CONCLUSION The results suggest that both techniques are viable options for refixation of greater tuberosity fractures. LEVEL OF EVIDENCE Laboratory study.
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Affiliation(s)
- Gernot Seppel
- Department of Orthopedic Sports Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany. .,Department of Orthopedics and Trauma Surgery, Krankenhaus Barmherzige Brüder, Munich, Germany.
| | - Tim Saier
- Department of Orthopedic Sports Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.,Department of Reconstructive Joint Surgery and Sportstraumatology, Berufsgenossenschaftliche Unfallklinik Murnau, Murnau, Germany
| | - Frank Martetschläger
- Department of Orthopedic Sports Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.,Center for Shoulder and Elbow Surgery, ATOS Clinic Munich, Munich, Germany
| | - Johannes E Plath
- Department of Orthopedic Sports Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.,Department of Trauma Surgery, Klinikum Augsburg, Augsburg, Germany
| | - Alberto Guevara-Alvarez
- Department of Orthopedic Sports Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Julia Henschel
- Institute of Biomechanics, Berufsgenossenschaftliche Unfallklinik Murnau, Murnau, Germany
| | - Martin Winkler
- Institute of Biomechanics, Berufsgenossenschaftliche Unfallklinik Murnau, Murnau, Germany
| | - Peter Augat
- Institute of Biomechanics, Berufsgenossenschaftliche Unfallklinik Murnau, Murnau, Germany.,Institute of Biomechanics, Paracelsus Medical University, Salzburg, Austria
| | - Andreas B Imhoff
- Department of Orthopedic Sports Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Stefan Buchmann
- Department of Orthopedic Sports Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.,Orthopädisches Fachzentrum, Weilheim, Germany
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17
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Gigis I, Nenopoulos A, Giannekas D, Heikenfeld R, Beslikas T, Hatzokos I. Reverse Shoulder Arthroplasty for the Treatment of 3 and 4- Part Fractures of the Humeral Head in the Elderly. Open Orthop J 2017; 11:108-118. [PMID: 28400879 PMCID: PMC5366383 DOI: 10.2174/1874325001711010108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 04/18/2016] [Accepted: 04/20/2016] [Indexed: 01/30/2023] Open
Abstract
Background: Proximal humeral fractures in elderly patients present with severe comminution and osteoporotic bone quality. Reverse shoulder arthroplasty has lately been proven beneficial in treating patients with complex proximal humeral fractures. The above technique is recommended and has better results in elderly than in younger individuals. Methods: We performed a literature search in the databases Pubmed, Medline, EMBASE and Cochrane Library for published articles between 1970 and 2016 using the terms: proximal humerus fractures and reverse shoulder arthroplasty. Results: Significant benefits with the use of reverse prosthesis, especially in patients older than 70 years with a proximal humeral fracture, include reduced rehabilitation time as well as conservation of a fixed fulcrum for deltoid action in case of rotator cuff failure. Compared with hemiarthroplasty and internal fixation, reverse prosthesis may be particularly useful and give superior outcomes in older patients, due to comminuted fractures in osteopenic bones. However, significant disadvantages of this technique are potential complications and a demanding learning curve.Therefore, trained surgeons should follow specific indications when applying the particular treatment of proximal humeral fractures and be familiar with the surgical technique. Conclusion: Although long-term results and randomized studies for reverse prosthesis are lacking, short and mid- term outcomes have given promising results encouraging more shoulder surgeons to use this type of prosthesis in proximal humeral fractures.
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Affiliation(s)
- Ioannis Gigis
- 2 Orthopedic Department, Aristotle University of Thessaloniki, "G. Gennimatas" General Hospital Thessaloniki, Thessaloniki, Greece
| | - Alexandros Nenopoulos
- 2 Orthopedic Department, Aristotle University of Thessaloniki, "G. Gennimatas" General Hospital Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Giannekas
- 2 Orthopedic Department, Aristotle University of Thessaloniki, "G. Gennimatas" General Hospital Thessaloniki, Thessaloniki, Greece
| | - Roderich Heikenfeld
- Center for Shoulder, Elbow and Hand Surgery, Center for Orthopaedics and Traumatology of the St. Elisabeth Group - Catholic Hospitals Rhein-Ruhr, St. Anna Hospital Herne, Marienhospital Herne University Hopsital, Marienhospital Witten, Germany
| | - Theodoros Beslikas
- 2 Orthopedic Department, Aristotle University of Thessaloniki, "G. Gennimatas" General Hospital Thessaloniki, Thessaloniki, Greece
| | - Ippokratis Hatzokos
- 2 Orthopedic Department, Aristotle University of Thessaloniki, "G. Gennimatas" General Hospital Thessaloniki, Thessaloniki, Greece
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Abstract
BACKGROUND Fracture of the proximal humerus, often termed shoulder fracture, is a common injury in older people. The management of these fractures varies widely. This is an update of a Cochrane Review first published in 2001 and last updated in 2012. OBJECTIVES To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and other databases, conference proceedings and bibliographies of trial reports. The full search ended in November 2014. SELECTION CRITERIA We considered all randomised controlled trials (RCTs) and quasi-randomised controlled trials pertinent to the management of proximal humeral fractures in adults. DATA COLLECTION AND ANALYSIS Both review authors performed independent study selection, risk of bias assessment and data extraction. Only limited meta-analysis was performed. MAIN RESULTS We included 31 heterogeneous RCTs (1941 participants). Most of the 18 separate treatment comparisons were tested by small single-centre trials. The main exception was the surgical versus non-surgical treatment comparison tested by eight trials. Except for a large multicentre trial, bias in these trials could not be ruled out. The quality of the evidence was either low or very low for all comparisons except the largest comparison.Nine trials evaluated non-surgical treatment in mainly minimally displaced fractures. Four trials compared early (usually one week) versus delayed (three or four weeks) mobilisation after fracture but only limited pooling was possible and most of the data were from one trial (86 participants). This found some evidence that early mobilisation resulted in better recovery and less pain in people with mainly minimally displaced fractures. There was evidence of little difference between the two groups in shoulder complications (2/127 early mobilisation versus 3/132 delayed mobilisation; 4 trials) and fracture displacement and non-union (2/52 versus 1/54; 2 trials).One quasi-randomised trial (28 participants) found the Gilchrist-type sling was generally more comfortable than the Desault-type sling (body bandage). One trial (48 participants) testing pulsed electromagnetic high-frequency energy provided no evidence. Two trials (62 participants) provided evidence indicating little difference in outcome between instruction for home exercises versus supervised physiotherapy. One trial (48 participants) reported, without presentable data, that home exercise alone gave better early and comparable long-term results than supervised exercise in a swimming pool plus home exercise.Eight trials, involving 567 older participants, evaluated surgical intervention for displaced fractures. There was high quality evidence of no clinically important difference in patient-reported shoulder and upper-limb function at one- or two-year follow-up between surgical (primarily locking plate fixation or hemiarthroplasty) and non-surgical treatment (sling immobilisation) for the majority of displaced proximal humeral fractures; and moderate quality evidence of no clinically important difference between the two groups in quality of life at two years (and at interim follow-ups at six and 12 months). There was moderate quality evidence of little difference between groups in mortality in the surgery group (17/248 versus 12/248; risk ratio (RR) 1.40 favouring non-surgical treatment, 95% confidence interval (CI) 0.69 to 2.83; P = 0.35; 6 trials); only one death was explicitly linked with the treatment. There was moderate quality evidence of a higher risk of additional surgery in the surgery group (34/262 versus 16/261; RR 2.06, 95% CI 1.18 to 3.60; P = 0.01; 7 trials). Although there was moderate evidence of a higher risk of adverse events after surgery, the 95% confidence intervals for adverse events also included the potential for a greater risk of adverse events after non-surgical treatment.Different methods of surgical management were tested in 12 trials. One trial (57 participants) comparing two types of locking plate versus a locking nail for treating two-part surgical neck fractures found some evidence of slightly better function after plate fixation but also of a higher rate of surgically-related complications. One trial (61 participants) comparing a locking plate versus minimally invasive fixation with distally inserted intramedullary K-wires found little difference between the two implants at two years. Compared with hemiarthroplasty, one trial (32 participants) found similar results with locking plate fixation in function and re-operation rates, whereas another trial (30 participants) reported all five re-operations occurred in the tension-band fixation group. One trial (62 participants) found better patient-rated (Quick DASH) and composite shoulder function scores at a minimum of two years follow-up and a lower incidence of re-operation and complications after reverse shoulder arthroplasty (RSA) compared with hemiarthroplasty.No important between-group differences were found in one trial (120 participants) comparing the deltoid-split approach versus deltopectoral approach for non-contact bridging plate fixation, and two trials (180 participants) comparing 'polyaxial' and 'monaxial' screws in locking plate fixation. One trial (68 participants) produced some preliminary evidence that tended to support the use of medial support locking screws in locking plate fixation. One trial (54 participants) found fewer adverse events, including re-operations, for the newer of two types of intramedullary nail. One trial (35 participants) found better functional results for one of two types of hemiarthroplasty. One trial (45 participants) found no important effects of tenodesis of the long head of the biceps for people undergoing hemiarthroplasty.Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial: 64 participants) or hemiarthroplasty (one trial: 49 participants). AUTHORS' CONCLUSIONS There is high or moderate quality evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures involving the humeral neck and is likely to result in a greater need for subsequent surgery. The evidence does not cover the treatment of two-part tuberosity fractures, fractures in young people, high energy trauma, nor the less common fractures such as fracture dislocations and head splitting fractures.There is insufficient evidence from RCTs to inform the choices between different non-surgical, surgical, or rehabilitation interventions for these fractures.
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Affiliation(s)
- Helen H G Handoll
- Health and Social Care Institute, Teesside University, Middlesbrough, Tees Valley, UK, TS1 3BA
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Handford C, Nathoo S, Porter K, Kalogrianitis S. A review of current concepts in the management of proximal humerus fractures. TRAUMA-ENGLAND 2015. [DOI: 10.1177/1460408614555069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Fracture of the proximal humerus is a common orthopaedic injury and is likely to increase in incidence. This fracture type is associated with a wide variety in fracture morphology and as a direct result there are many treatment options available. It is often not clear what treatment modality should be utilised. This article reviews the current literature on proximal humerus fractures offering evidence for care pathways and management strategies from presentation to rehabilitation.
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A prospective randomized study of operative treatment for noncomminuted humeral shaft fractures: conventional open plating versus minimal invasive plate osteosynthesis. J Orthop Trauma 2015; 29:189-94. [PMID: 25210833 DOI: 10.1097/bot.0000000000000232] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the clinical and radiologic results of conventional open plating (COP) and minimally invasive plate osteosynthesis (MIPO) in the treatment of noncomminuted humeral shaft fractures. DESIGN Randomized prospective study. SETTING Five level 1 trauma centers. PATIENTS Sixty-eight consecutive patients were randomized into 2 study groups: those treated by COP (COP group; n = 32) and those treated by MIPO (MIPO group; n = 36). INTERVENTION Simple humeral shaft fractures (AO/OTA classification types A and B) were reduced by open reduction or closed reduction and fixed with a narrow 4.5/5.0 locking compression plate, metaphyseal locking compression plate, or proximal humeral internal locking system plate to the anterior lateral aspect of the humerus. MAIN OUTCOME MEASUREMENTS Fracture healing time, operative time, radiation exposure time, and intraoperative nerve injury. To assess shoulder and elbow function, we used the University of California, Los Angeles (UCLA) scoring system and the Mayo elbow performance index, including the range of motion and pain. Radiographic measurements included fracture alignment, delayed union, and nonunion. RESULTS Thirty-one fractures (97%) healed in the COP group within 16 weeks, whereas 36 fractures (100%) were healed in the MIPO group by 15 weeks. No significant difference was observed in the operative time or complication rates. In both groups, all fractures achieved union without malunion and with excellent functional outcomes by definition of the Mayo elbow performance index and UCLA scoring system. CONCLUSIONS This study confirmed a high overall rate of union and excellent functional outcomes in both MIPO and COP groups. MIPO is equivalent to COP as a safe and effective method for simple types of humeral shaft fractures when surgery is indicated, and the surgeon is experienced in the technique. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Vachtsevanos L, Hayden L, Desai AS, Dramis A. Management of proximal humerus fractures in adults. World J Orthop 2014; 5:685-693. [PMID: 25405098 PMCID: PMC4133477 DOI: 10.5312/wjo.v5.i5.685] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/15/2014] [Accepted: 07/15/2014] [Indexed: 02/06/2023] Open
Abstract
The majority of proximal humerus fractures are low-energy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. Non-operative management has been associated with good functional outcomes in stable, minimally displaced and certain types of displaced fractures. Absolute indications for surgery are infrequent and comprise compound, pathological, multi-fragmentary head-splitting fractures and fracture dislocations, as well as those associated with neurovascular injury. A constantly expanding range of reconstructive and replacement options however has been extending the indications for surgical management of complex proximal humerus fractures. As a result, management decisions are becoming increasingly complicated, in an attempt to provide the best possible treatment for each individual patient, that will successfully address their specific fracture configuration, comorbidities and functional expectations. Our aim was to review the management options available for the full range of proximal humerus fractures in adults, along with their specific advantages, disadvantages and outcomes.
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Maier D, Jaeger M, Izadpanah K, Strohm PC, Suedkamp NP. Proximal humeral fracture treatment in adults. J Bone Joint Surg Am 2014; 96:251-61. [PMID: 24500588 DOI: 10.2106/jbjs.l.01293] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Most proximal humeral fractures affect elderly patients and can be treated nonoperatively with good functional outcomes.The treatment of displaced three and four-part fractures remains controversial and depends on a variety of underlying factors related to the patient (e.g., comorbidity, functional demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience).Throughout the literature, open reduction and locking plate osteosynthesis is associated with considerable complication rates, particularly in the presence of osteoporosis.Low local bone mineral density, humeral head ischemia, residual varus displacement, insufficient restoration of the medial column, and nonanatomic reduction promote failure of fixation and impair functional outcome.The outcome of hemiarthroplasty is closely related to tuberosity healing in an anatomic position to enable the restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with preexisting rotator cuff dysfunction or after the failure of first-line treatment.
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Affiliation(s)
- Dirk Maier
- Department of Orthopaedic and Trauma Surgery, University Medical Center Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany. E-mail address for D. Maier:
| | - Martin Jaeger
- Department of Orthopaedic and Trauma Surgery, University Medical Center Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany. E-mail address for D. Maier:
| | - Kaywan Izadpanah
- Department of Orthopaedic and Trauma Surgery, University Medical Center Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany. E-mail address for D. Maier:
| | - Peter C Strohm
- Department of Orthopaedic and Trauma Surgery, University Medical Center Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany. E-mail address for D. Maier:
| | - Norbert P Suedkamp
- Department of Orthopaedic and Trauma Surgery, University Medical Center Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany. E-mail address for D. Maier:
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23
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Rath E, Alkrinawi N, Levy O, Debbi R, Amar E, Atoun E. Minimally displaced fractures of the greater tuberosity: outcome of non-operative treatment. J Shoulder Elbow Surg 2013; 22:e8-e11. [PMID: 23639834 DOI: 10.1016/j.jse.2013.01.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Revised: 01/11/2013] [Accepted: 01/30/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Minimally displaced (<3 mm) and non-displaced fractures of the proximal humerus are a common source of disability; nevertheless, there is no agreement on the recommended rehabilitation program in these patients. The purpose of this study was to evaluate the outcome of this group of patients and describe the rehabilitation protocol we have used for the treatment of this injury. METHODS We retrospectively analyzed the records of patients diagnosed with minimally displaced (<3 mm) fractures of the greater tuberosity who were admitted to our institute between June 2007 and May 2008. Patients were treated with a three-phase protocol. In the first phase, patients were immobilized in a sling for 3 weeks. In the second phase, pendular and active assisted exercises were begun 3 to 6 weeks after the injury. In the third phase, active exercises were commenced starting 6 weeks after injury. RESULTS Sixty-nine patients matched our inclusion and exclusion criteria. At an average follow-up of 31 months (range, 26-41 months), the average Constant score improved from 40 points (range, 33-58 points) to 95 points (range, 75-100 points). Average satisfaction score improved from 4.2 of 10 (range, 2-6) to 9.5 of 10 (range, 7-10). The reported average duration of pain and decreased range of motion from the time of injury was 8.1 months (range, 1-24 months). CONCLUSIONS When the diagnosis of a minimally displaced fracture of the proximal humerus is made, the patient can be reassured that a favorable outcome is anticipated with a staged rehabilitation protocol. Nevertheless, clinicians and patients should be aware that full recovery from the injury may take an average of 8 months.
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Affiliation(s)
- Ehud Rath
- Orthopaedic Division, Tel Aviv Souraski Medical Center, Tel Aviv, Israel.
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24
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Widnall JC, Dheerendra SK, Malal JJG, Waseem M. Proximal humeral fractures: a review of current concepts. Open Orthop J 2013; 7:361-5. [PMID: 24082976 PMCID: PMC3785034 DOI: 10.2174/1874325001307010361] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Revised: 12/08/2012] [Accepted: 01/12/2013] [Indexed: 12/16/2022] Open
Abstract
The majority of proximal humerus fractures are sustained via low energy falls in the elderly population. These patients can attain an acceptable level of function via non-operative treatment. There is yet to be a clear consensus on treatment options suitable for those that fall outside of this majority group. Open reduction internal fixation, intra medullary nailing and arthroplasty surgery have all been used to varying effects. Good results are achievable if complications such as mal-union, non-union and avascular necrosis can be avoided. This review aims to clarify the options available to the current day trauma surgeon.
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Affiliation(s)
- James C Widnall
- Aintree University Hospitals NHS Trust, Longmoor Lane, Liverpool, L9 7AL, UK
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25
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Abstract
OBJECTIVES This study was performed to determine (1) the incidence of humeral shaft fractures within the Medicare noncancer population, (2) the trends in utilization of humeral shaft fixation techniques by plate-and-screw devices and intramedullary nails, (3) differences in procedure times, and (4) the outcomes of individuals as measured by rate of secondary operations and 1-year mortality. DESIGN/SETTING Retrospective comparative cohort analysis. A cancer-free Medicare part B claims sample derived from a 5% sample from the years 1993 to 2007 was analyzed. PATIENTS/INTERVENTION Our cohorts were generated by diagnostic and procedural codes for humeral shaft fractures. MAIN OUTCOME MEASUREMENT The incidence of humeral shaft fracture and trend in operative fixation were evaluated for all years of data. Surgical times were assessed by anesthesia Current Procedural Terminology codes. Outcomes and complications were assessed by Current Procedural Terminology codes. The proportion of individuals experiencing complications and 1-year mortality were compared by proportion hazards. RESULTS We identified 1385 claims for humeral shaft fractures over 15 years, with an adjusted rate of between 12.0 and 23.4 fractures per 100,000 beneficiaries. We identified 511 individuals who received surgical treatment for humeral shaft fractures, 451 of whom had complete 1-year follow-up data. Nail fixation was more prevalent than plate fixation most years and had shorter anesthesia time by 27.1 minutes (P < 0.0001). There were no significant differences in the complication rates between the 2 groups as measured by incidence of secondary operations and 1-year mortality. CONCLUSIONS Intramedullary nails are used for the majority of operative humeral shaft fractures among Medicare beneficiaries. Nailing has a shorter mean operative time. The 2 surgical techniques had no significant differences in terms of risk of secondary procedures and 1-year mortality. LEVEL OF EVIDENCE : Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Foster Chen
- National Institutes of Health, 10 Center Dr., Building 10, Mail Code 1468, Bethesda, MD 20892-1150
| | - Zhong Wang
- National Institutes of Health, 10 Center Dr., Building 10, Mail Code 1468, Bethesda, MD 20892-1150
| | - Timothy Bhattacharyya
- National Institutes of Health, 10 Center Dr., Building 10, Mail Code 1468, Bethesda, MD 20892-1150
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Abstract
BACKGROUND Fractures of the proximal humerus are common injuries. The management, including surgical intervention, of these fractures varies widely. This is an update of a Cochrane review first published in 2001 and last updated in 2010. OBJECTIVES To review the evidence supporting the various treatment and rehabilitation interventions for proximal humeral fractures. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, and bibliographies of trial reports. The full search ended in January 2012. SELECTION CRITERIA All randomised controlled trials pertinent to the management of proximal humeral fractures in adults were selected. DATA COLLECTION AND ANALYSIS Two people performed independent study selection, risk of bias assessment and data extraction. Only limited meta-analysis was performed. MAIN RESULTS Twenty-three small randomised trials with a total of 1238 participants were included. Bias in these trials could not be ruled out. Additionally there is a need for caution in interpreting the results of these small trials, which generally do not provide sufficient evidence to conclude that any non-statistically significant finding is 'evidence of no effect'.Eight trials evaluated conservative treatment. One trial found an arm sling was generally more comfortable than a less commonly used body bandage. There was some evidence that 'immediate' physiotherapy compared with that delayed until after three weeks of immobilisation resulted in less pain and potentially better recovery in people with undisplaced or other stable fractures. Similarly, there was evidence that mobilisation at one week instead of three weeks alleviated short term pain without compromising long term outcome. Two trials provided some evidence that unsupervised patients could generally achieve a satisfactory outcome when given sufficient instruction for an adequate self-directed exercise programme.Six heterogeneous trials, involving a total of 270 participants with displaced and/or complex fractures, compared surgical versus conservative treatment. Pooled results of patient-reported functional scores at one year from three trials (153 participants) showed no statistically significant difference between the two groups (standardised mean difference -0.10, 95% CI -0.42 to 0.22; negative results favour surgery). Quality of life based on the EuroQol results scores from three trials (153 participants) showed non-statistically significant differences between the two groups at three time points up to 12 months. However, the pooled EuroQol results at two years (101 participants) from two trials run concurrently from the same centre were significantly in favour of the surgical group. There was no significant difference between the two groups in mortality (8/98 versus 5/98; RR 1.55, 95% CI 0.55 to 4.36; 4 trials). Significantly more surgical group patients had additional or secondary surgery (18/112 versus 5/111; RR 3.36, 95% CI 1.33 to 8.49; 5 trials). This is equivalent to an extra operation in one of every nine surgically treated patients.Different methods of surgical management were tested in seven small trials. One trial comparing two types of locking plate versus a locking nail for treating two-part surgical neck fractures found some evidence of better function after plate fixation but also of a higher rate of surgically-related complications. One trial comparing a locking plate versus minimally invasive fixation with distally inserted intramedullary nails found some evidence of a short-term benefit for the nailing group. Compared with hemiarthroplasty, tension-band fixation of severe injuries using wires was associated with a higher re-operation rate in one trial. Two trials found no important differences between 'polyaxial' and 'monaxial' screws combined with locking plate fixation. One trial produced some preliminary evidence that tended to support the use of medial support locking screws in locking plate fixation. One trial found better functional results for one of two types of hemiarthroplasty.Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial) or hemiarthroplasty (one trial). AUTHORS' CONCLUSIONS There is insufficient evidence to inform the management of these fractures. Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It remains unclear whether surgery, even for specific fracture types, will produce consistently better long term outcomes but it is likely to be associated with a higher risk of surgery-related complications and requirement for further surgery.There is insufficient evidence to establish what is the best method of surgical treatment, either in terms of the use of different categories of surgical intervention (such as plate versus nail fixation, or hemiarthroplasty versus tension-wire fixation) or different methods of performing an intervention in the same category (such as different methods of plate fixation). There is insufficient evidence to say when to start mobilisation after either surgical fixation or hemiarthroplasty.
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Affiliation(s)
- Helen H G Handoll
- Health and Social Care Institute, Teesside University, Middlesbrough, UK.
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Wirbel R, Knorr V, Saur B, Dühr B, Mutschler W. [Not Available]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2012; 11:44-53. [PMID: 17004152 DOI: 10.1007/s00064-006-0082-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- R Wirbel
- Abteilung Unfall-, Hand und Wiederherstellungs-chirurgie, Chirurgische Universitätsklinik, Oscar-Orth-Straße, D-66421, Homburg/Saar
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29
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Abstract
Proximal humeral fractures are extremely common injuries, and are one of the true osteoporotic fractures. Most fractures can be effectively treated nonoperatively, as the rich vascularity and broad cancellous surfaces impart a high propensity for healing. Additionally, many fracture patterns result in adequate bone contact and minimal displacement with acceptable alignment. Open reduction and internal fixation of displaced fractures can improve outcomes, depending on the pre-injury functional status of the patient. If operative treatment is selected, unique treatment challenges must be overcome, including obtaining and maintaining reduction of small bone fragments with strong muscle forces, often in osteoporotic bone. Many options are feasible, including plates, nails, sutures, and other novel devices. Locking plates are the most common device used, but technical detail is critical to minimize the risk of implant failure, loss of reduction, and reoperation.
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Affiliation(s)
- Mark J Jo
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA,
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30
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Abstract
Proximal humeral fractures may present with many different configurations in patients with varying co-morbities and expectations. As a result, the treating physician must understand the fracture pattern, the quality of the bone, other patient-related factors, and the expanding range of reconstructive options to achieve the best functional outcome and to minimize complications. Current treatment options range from non-operative treatment with physical therapy to fracture fixation using percutaneous or open techniques to arthroplasty reconstructions. This article reviews the current literature on the classification and treatment options for proximal humeral fractures, while seeking to help the reader to define the most appropriate treatment plan for each individual patient with this type of fracture.
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Affiliation(s)
- Craig S Mauro
- Burke and Bradley Orthopedics, University of Pittsburgh Medical Center, UPMC St. Margaret 200 Delafield Rd. Suite 4010, Pittsburgh, PA, 15215, USA,
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31
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Abstract
Recent innovations have greatly increased the range of proximal humeral fractures that are amenable to open reduction and plate fixation.The optimum technique for some of the more complex fracture patterns is not yet fully refined.This article aims to describe the recent advances in the treatment of complex proximal humeral fractures by open reduction and locking plate fixation, focusing particularly on the indications for surgery, the operative techniques, and the expected outcomes after treatment.
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32
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Murray IR, Amin AK, White TO, Robinson CM. Proximal humeral fractures: current concepts in classification, treatment and outcomes. ACTA ACUST UNITED AC 2011; 93:1-11. [PMID: 21196536 DOI: 10.1302/0301-620x.93b1.25702] [Citation(s) in RCA: 130] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery. This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.
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Affiliation(s)
- I R Murray
- Edinburgh Shoulder Clinic, New Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Abstract
BACKGROUND Proximal humeral fractures are common injuries. The management, including surgical intervention, of these fractures varies widely. OBJECTIVES To review the evidence supporting the various treatment and rehabilitation interventions for proximal humeral fractures. SEARCH STRATEGY We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, and bibliographies of trial reports. The full search ended in March 2010. SELECTION CRITERIA All randomised controlled trials pertinent to the management of proximal humeral fractures in adults were selected. DATA COLLECTION AND ANALYSIS Two people performed independent study selection, risk of bias assessment and data extraction. Trial heterogeneity prevented meta-analysis. MAIN RESULTS Sixteen small randomised trials with 801 participants were included. Bias in these trials could not be ruled out.Eight trials evaluated conservative treatment. One trial found an arm sling was generally more comfortable than a less commonly used body bandage. There was some evidence that 'immediate' physiotherapy compared with that delayed until after three weeks of immobilisation resulted in less pain and potentially better recovery in people with undisplaced or other stable fractures. Similarly, there was evidence that mobilisation at one week instead of three weeks alleviated short term pain without compromising long term outcome. Two trials provided some evidence that unsupervised patients could generally achieve a satisfactory outcome when given sufficient instruction for an adequate physiotherapy programme.Surgery improved fracture alignment in two trials but was associated with more complications in one trial, and did not result in improved shoulder function. Preliminary data from another trial showed no significant difference in complications, quality of life or costs between plate fixation and conservative treatment. In one trial, hemiarthroplasty resulted in better short-term function with less pain and disability when compared with conservative treatment for severe injuries.Compared with hemiarthroplasty, tension-band fixation of severe injuries using wires was associated with a high re-operation rate in one trial. One trial found better functional results for one type of hemiarthroplasty.Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial) or hemiarthroplasty (one trial). AUTHORS' CONCLUSIONS There is insufficient evidence to inform the management of these fractures. Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It is unclear whether surgery, even for specific fracture types, will produce consistently better long term outcomes.
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Affiliation(s)
- Helen Hg Handoll
- Health and Social Care Institute, Teesside University, Middlesborough, Tees Valley, UK, TS1 3BA
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Malik S, Chiampas G, Leonard H. Emergent evaluation of injuries to the shoulder, clavicle, and humerus. Emerg Med Clin North Am 2010; 28:739-63. [PMID: 20971390 DOI: 10.1016/j.emc.2010.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This article provides a review of the evaluation and treatment of common injuries to the shoulder, humerus, and clavicle in the emergency department (ED) setting. In addition to a focused review of the shoulder's physical examination, topics include common emergent injuries such as glenohumeral dislocations, proximal humerus fractures, and acromioclavicular separations as well as less common, but important injuries including pectoralis and biceps tendon injuries and sternoclavicular dislocations. Accurate recognition and management of these injuries is essential in the optimal care of patients in the ED.
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Affiliation(s)
- Sanjeev Malik
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, 259 East Erie Street, Suite 100, Chicago, IL 60610, USA.
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Clinical and radiological evaluation of minimally displaced proximal humeral fractures. Arch Orthop Trauma Surg 2010; 130:673-9. [PMID: 19809828 DOI: 10.1007/s00402-009-0975-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The purpose of this prospective study was to assess the Constant score and radiographic outcome in 66 patients (mean age 58.7 years/mean follow-up 51 months) with a minimally displaced and/or impacted fracture of the proximal humerus treated with early mobilization. METHOD Special attention was paid to analyze the specific intrinsic parameters (age, gender, ASA grade and length of physiotherapy), injury-related parameters (classification, osteoporosis) and therapy-related parameters (initial fracture displacement, residual bony-deformity after healing, secondary fracture displacement during healing period, non-union, humeral head necrosis and omarthrosis) that may influence the final score. PATIENTS There were 31 A (47%), 22 B (33%) and 13 C-fractures (19%). The median Constant score for the fractured shoulder was 89 points. RESULTS All fractures healed without non-union. The radiological assessment showed in 80% a fracture-displacement with <15 degrees angulation and/or <5-mm displacement of the greater tuberosity. At time of follow-up, the residual bony-deformity was perfect and good in 88% of cases. There was a significant association between the final Constant score and the age, ASA classification, AO (ABC) classification and initial fracture displacement. CONCLUSION Early physiotherapy, with a short period of immobilization is a sufficient therapy for management of minimally displaced and/or impacted fractures of the proximal humerus.
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Internal Fixation of Unstable Proximal Humerus Fractures With an Anatomically Preshaped Interlocking Plate: A Clinical and Radiologic Evaluation. ACTA ACUST UNITED AC 2007; 63:1314-23. [DOI: 10.1097/01.ta.0000240457.64628.38] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lefevre-Colau MM, Babinet A, Fayad F, Fermanian J, Anract P, Roren A, Kansao J, Revel M, Poiraudeau S. Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial. J Bone Joint Surg Am 2007; 89:2582-90. [PMID: 18056488 DOI: 10.2106/jbjs.f.01419] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There have been few randomized controlled trials evaluating nonoperative treatment of proximal humeral fractures. To investigate shortening the period of dependence, we assessed the feasibility and efficacy of early mobilization of the shoulder (within three days after the fracture) in comparison with those of conventional three-week immobilization followed by physiotherapy. METHODS We randomly assigned seventy-four patients with an impacted proximal humeral fracture to receive early passive mobilization or conventional treatment. The primary outcome was the overall shoulder functional status (as measured with the Constant score) at three months. The secondary outcomes were the Constant score at six weeks and at six months, the change in pain (on a visual analog scale), and the active and passive range of motion. RESULTS At three months and at six weeks, the early mobilization group had a significantly better Constant score than did the conventional-treatment group (between-group difference, 9.9 [95% confidence interval, 1.9 to 17.8] [p = 0.02] and 10.1 [95% confidence interval, 2.0 to 18.1] [p = 0.02], respectively) and better active mobility in forward elevation (between-group difference, 12.0 [95% confidence interval, 1.7 to 22.4] [p = 0.02] and 28.1 [95% confidence interval, 7.1 to 49.1] [p = 0.01], respectively). At three months, the early mobilization group had significantly reduced pain compared with the conventional-treatment group (between-group difference, 15.7 [95% confidence interval, 0.52 to 30.8] [p = 0.04]). No complications in displacement or nonhealing were noted. CONCLUSIONS Early mobilization for impacted nonoperatively treated proximal humeral fractures is safe and is more effective for quickly restoring the physical capability and performance of the injured arm than is conventional immobilization followed by physiotherapy.
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Affiliation(s)
- M M Lefevre-Colau
- Department of Rehabilitation Medicine, Corentin-Celton Hospital, University Paris V, 4 Parvis Corentin Celton, BP66, 92133 Issy-les-Moulineaux Cedex, France.
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Dimakopoulos P, Panagopoulos A, Kasimatis G. Transosseous suture fixation of proximal humeral fractures. J Bone Joint Surg Am 2007; 89:1700-9. [PMID: 17671007 DOI: 10.2106/jbjs.f.00765] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The optimal treatment of displaced fractures of the proximal part of the humerus remains controversial. We evaluated the long-term functional and radiographic results of transosseous suture fixation in a series of selected displaced fractures of the proximal part of the humerus. METHODS Over an eleven-year period, a consecutive series of 188 patients with a specifically defined displaced fracture of the proximal part of the humerus underwent open reduction and internal fixation with transosseous sutures. Twenty patients were lost to follow-up and three died before the time of follow-up, leaving a cohort of 165 patients (ninety-four women and seventy-one men; mean age, fifty-four years) available for the study. Forty-five (27%) of the injuries were four-part fractures with valgus impaction; sixty-four (39%) were three-part fractures; and fifty-six (34%) were two-part fractures of the greater tuberosity, thirty-six (64%) of which were associated with anterior dislocation of the shoulder. All fractures were fixed with transosseous, nonabsorbable, number-5 Ethibond sutures. Associated rotator cuff tears detected in fifty-seven patients (35%) were also repaired. Over a mean follow-up period of 5.4 years, functional outcome was assessed with the Constant score. Follow-up radiographs were assessed for fracture consolidation, malunion, nonunion, heterotopic ossification, and signs of impingement, humeral head osteonecrosis, and degenerative osteoarthritis. RESULTS All fractures, except for two three-part fractures of the greater tuberosity, united within four months. The quality of fracture reduction as seen on the first postoperative radiograph was regarded as excellent/very good in 155 patients (94%), good in seven (4%), and poor in three (2%). Malunion was present in nine patients (5%) at the time of the last follow-up; six of the nine had had good or poor initial reduction and three, excellent/very good reduction. Humeral head osteonecrosis was seen in eleven (7%) of the 165 patients; four demonstrated total and seven, partial collapse. Fifteen patients had heterotopic ossification, but none had functional impairment. Four patients had signs of impingement syndrome, and two had arthritis. At the time of the final evaluation, the mean Constant score was 91 points, and the mean Constant score as a percentage of the score for the unaffected shoulder, unadjusted for age and gender, was 94%. CONCLUSIONS The clinical and radiographic results of this transosseous suture technique were found to be satisfactory at an average of 5.4 years postoperatively. Advantages of this technique include less surgical soft-tissue dissection, a low rate of humeral head osteonecrosis, fixation sufficient to allow early passive joint motion, and the avoidance of bulky and expensive implants.
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Affiliation(s)
- Panayiotis Dimakopoulos
- Shoulder and Elbow Unit, Orthopaedic Department, Patras University Hospital, Rio-Patras 26504, Greece.
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Rueger JM, Rücker A, Briem D, Grossterlinden L, Linhart W. Proximal Humeral Fractures: Nailing. Eur J Trauma Emerg Surg 2007; 33:357-66. [DOI: 10.1007/s00068-007-7098-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Accepted: 07/03/2007] [Indexed: 11/28/2022]
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Lögters TT, Briem D, Lohde C, Janssen A, Rueger JM, Windolf J, Linhart W. K-wire Arthrodesis and Coracoclavicular Augmentation of Complete Acromioclavicular Separations: Functional and Subjective Results. Eur J Trauma Emerg Surg 2007; 34:43-8. [PMID: 26815490 DOI: 10.1007/s00068-007-7901-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2007] [Accepted: 02/25/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND In recent years, there has been a trend from operative to conservative management of complete acromioclavicular separations. Despite this, surgical treatment is still recommended to manual workers and athletes, who account for a large part of the patients. The objective of this study was to evaluate the functional outcome of type III separations according to Tossy managed by temporary arthrodesis of the acromioclavicular joint combined with coracoclavicular augmentation. Special attention was paid to sport exercising patients. PATIENTS AND METHODS In this study, 32 patients (mean age 39 years) with a complete acromioclavicular separation were investigated. All of them underwent a surgical treatment managed by temporary acromioclavicular arthrodesis with two parallel k-wires and augmentation of the coracoclavicular ligaments with a biodegradable cord (PDS). Functional outcome was assessed after an average follow-up of 36 months by using the Constant-Murley-, Neer- and DASH-score. Additionally, incidence of complications and subjective results were observed. RESULTS Evaluation of the data, obtained from the scores, revealed an excellent result for the Constant-Murley- and DASH-score for 84% of the patients. Regarding the Neer-score, 78% had an excellent outcome. Eighty-four percent of the patients assessed revealed an excellent to fair subjective result. Cosmetic reasons were most frequently the cause for discontentedness. Minor complications occurred in three patients without severe sequelae. All patients returned back to former working and sport activity level. CONCLUSION Surgical treatment of complete acromioclavicular separations by temporary arthrodesis with two k-wires and coracoclavicualar PDS-augmentation results in good to excellent function. It is associated with a low complication rate and a high patient contentedness. Particularly for athletes in non-contact sports this surgical technique can still be recommended.
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Affiliation(s)
- Tim T Lögters
- Department of Trauma and Hand Surgery, University Hospital Düsseldorf, Düsseldorf, Germany. .,Department of Trauma and Hand Surgery, University Hospital Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Daniel Briem
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Lohde
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Arne Janssen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes M Rueger
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Joachim Windolf
- Department of Trauma and Hand Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Wolfgang Linhart
- Department of Trauma and Hand Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
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Braunstein V, Wiedemann E, Plitz W, Muensterer OJ, Mutschler W, Hinterwimmer S. Operative treatment of greater tuberosity fractures of the humerus--a biomechanical analysis. Clin Biomech (Bristol, Avon) 2007; 22:652-7. [PMID: 17466422 DOI: 10.1016/j.clinbiomech.2007.03.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2007] [Revised: 03/08/2007] [Accepted: 03/12/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fractures of the greater tuberosity of the humerus present with increasing frequency. However, no biomechanical data about the optimal fixation technique of greater tuberosity fractures is available. This biomechanical cadaver study compares the stability of three standard fixation techniques used for the treatment of greater tuberosity fractures of the proximal humerus. METHODS In 21 fresh frozen proximal humeri, standardized fractures of the greater tuberosity were created. The specimens were randomly assigned to one of three operation techniques: wire tension banding, two cancellous screws and transosseous sutures. These constructs were mechanically tested by applying an increasing force to the supraspinatus tendon. Load to 5mm displacement (load to 5mm yield point) and load to failure (maximum stretch strength) were measured in Newton (N). FINDINGS Load to 5mm yield point values showed no significant differences between tension banding (498 N, SD 153) and two cancellous screws (400 N, SD 174) (P>0.01). Both techniques showed significantly higher values than transosseous sutures (185 N, SD 132) (P<0.01). Load to failure values were significantly higher for tension banding (1054 N, SD 125) than screws (842 N, SD 140) and sutures (480 N SD 101) (P<0.01). The difference between screws and sutures was also significant (P<0.01). INTERPRETATION Tension banding and two cancellous screws provided the strongest fixation for isolated fractures of the greater tuberosity.
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Affiliation(s)
- V Braunstein
- Department of Surgery, Klinikum Innenstadt, Ludwig-Maximilians-Universitaet Muenchen, Muenchen, Germany.
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Linhart W, Ueblacker P, Grossterlinden L, Kschowak P, Briem D, Janssen A, Hassunizadeh B, Schinke M, Windolf J, Rueger JM. Antegrade nailing of humeral head fractures with captured interlocking screws. J Orthop Trauma 2007; 21:285-94. [PMID: 17485992 DOI: 10.1097/bot.0b013e318059b5a1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES/DESIGN To assess the functional outcome after treatment of proximal humeral fractures with a new antegrade nail that provides angular and sliding stability. INTERVENTION/PATIENTS: Ninety-seven patients were treated during a 4-year period between April 2000 and March 2004. All patients were followed for 6 months, 51 patients (53%) for 12 months, and 31 patients (32%) for 24 months. This study focuses mainly on the patients with a follow up of 1 year. Their mean age was 68 years (range: 33 to 90); 22% were more than 80 years of age. MAIN OUTCOME MEASUREMENTS All fractures were radiologically graded by the Neer and AO/ASIF classifications. Clinical assessment was performed at all follow-up visits using the Constant-Murley and Neer scores, and complications were recorded. RESULTS There were 26.8% 2-part, 66% 3-part, and 7.2% 4-part fractures. The relative Constant-Murley score improved significantly (P < 0.001) from 72% at 6 months to 82% at 12 months after operation. No further improvement regarding functional outcome was observed after 24 months. Patients younger than 60 years of age had better results. No significant functional differences were found among 2-, 3- or 4-part fractures. Complications included backing out of the proximal screws (9.8%), secondary dislocation (1.9%), complete osteonecrosis (1.9%), and partial osteonecrosis (5.8%). CONCLUSION Treatment with this nail provides sufficient fixation of the fragments to allow early mobilization. The good functional results in the majority of the patients indicate that this nail can be used, even in complex fractures and elderly patients.
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Affiliation(s)
- Wolfgang Linhart
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Laurencin CT, Khan Y, Kofron M, El-Amin S, Botchwey E, Yu X, Cooper JA. The ABJS Nicolas Andry Award: Tissue engineering of bone and ligament: a 15-year perspective. Clin Orthop Relat Res 2006; 447:221-36. [PMID: 16741478 DOI: 10.1097/01.blo.0000194677.02506.45] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Musculoskeletal repair is a major challenge for orthopaedic surgeons. The burden of repair is compounded by supply constraints and morbidity associated with autograft and allograft tissue. We report 15 years of research regarding tissue engineering and biological substitutes for bone and ligaments. Our approach has focused on biomaterial selection, scaffold development, cell selection, cell/material interaction, and growth factor delivery. We have extensively tested poly(ester), poly(anhydride), poly(phosphazene) derivatives, and composite materials using biocompatibility, degradation, and mechanical analyses for bone and ligament tissue engineering. We have developed novel three-dimensional matrices with a pore structure and mechanical properties similar to native tissue. We also have reported on the attachment, growth, proliferation, and differentiation of cells cultured on several scaffolds. Through extensive molecular analysis, in vitro culture condition analysis, and in vivo evaluation, our findings provide new methods of bone tissue regeneration using three-dimensional tissue engineered scaffolds, bioactive bone cement composite materials, and three-dimensional tissue engineered scaffolds for ligament regeneration.
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Affiliation(s)
- Cato T Laurencin
- Laurencin Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA.
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Martin C, Guillen M, Lopez G. Treatment of 2- and 3-part fractures of the proximal humerus using external fixation: a retrospective evaluation of 62 patients. Acta Orthop 2006; 77:275-8. [PMID: 16752290 DOI: 10.1080/17453670610046028] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Treatment of fractures of the humeral head remains controversial. We reviewed the outcome of our treatment of 2- and 3-part fractures of the proximal humerus using external fixation as a way of preventing damage to the vascularity of the humeral head and of reducing the risk of infection associated with open techniques. METHOD We retrospectively evaluated 2- and 3-part fractures of the humeral head, both clinically and radiographically, in 62 consecutive patients who were treated using external fixation. The mean follow-up time was 1.5 (1-2) years. RESULTS The reduction was considered to be good in 50 cases, and 8 cases were consolidated in varus and 4 cases in valgus. The fracture healed in all patients. Except for 1 case of superficial infection around the screws and 1 redisplacement after a new fall, there were no early complications. Necrosis of the humeral head was not observed. 2 of the patients underwent shoulder replacement because of severe pain. The mean Constant score was 84 points, with satisfactory results (>or=80 points) in 49 of the 62 patients. Sex, age, side, or type of fracture had no influence on the outcome. INTERPRETATION This procedure provides satisfactory early functional results, simplifies rehabilitation by limiting postoperative motion to a lesser degree than other techniques, is less aggressive than open reduction techniques and osteosynthesis, and leads to few complications.
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Affiliation(s)
- Carlos Martin
- Department of Orthopaedic Surgery, Obispo Polanco Hospital, Teruel, Spain.
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Tratamiento de las fracturas en dos y tres partes de la extremidad proximal del húmero mediante fijación externa. Rev Esp Cir Ortop Traumatol (Engl Ed) 2006. [DOI: 10.1016/s1888-4415(06)76409-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Hente R, Kampshoff J, Kinner B, Füchtmeier B, Nerlich M. Die Versorgung dislozierter 3- und 4-Fragmentfrakturen des proximalen Humerus mit einem winkelstabilen Plattenfixateur. Unfallchirurg 2004; 107:769-82. [PMID: 15292960 DOI: 10.1007/s00113-004-0818-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In the presented prospective study 35 consecutive patients with displaced 3- and 4-part fractures of the proximal humerus, including fracture dislocations, were treated with a fixator plate comprising angular stability between May 2001 and December 2002. After 18.5 (8-29) months 31 (89%) fractures were available for follow-up. Good and very good results were obtained in 64%. A poor result was documented in 23%. 64% of the patients had no or mild pain, 71% were able to abduct the arm over 90 degrees . Fracture classification according to Neer and AO had no influence on the outcome, with a mean Constant Score of 76 points. Partial avascular necrosis (AVN) of the humeral head was seen in 16% of all cases representing 4% of the fractures without dislocation and 80% of the fracture dislocations. Fracture dislocation (p=0.02) and AVN (p=0.005) had a negative effect on the Constant Score, with AVN being a predictor for a high level of pain (p=0.04). Secondary dislocation of the greater tuberosity was seen in two patients, loosening of screws in one patient and a fracture below the plate in another one. Secondary dislocation or loss of reduction of the head was not recorded. Angle stable plate fixation with tension band wiring of the tuberosities is an effective and safe option to treat this difficult fractures, also in elderly patients with osteoporotic bone. Because 40% of the 4-part fractures with fracture dislocation yielded a satisfactory or better result, the plate fixator with angular stability may be an alternative to prosthetic replacement in selected cases.
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Affiliation(s)
- R Hente
- Abteilung für Unfallchirurgie, Klinikum der Universität Regensburg.
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Abstract
BACKGROUND Proximal humeral fractures are common yet the management of these injuries varies widely. In particular, the role and timing of any surgical intervention have not been clearly defined. OBJECTIVES To collate and evaluate the scientific evidence supporting the various methods used for treating proximal humeral fractures. SEARCH STRATEGY We searched the Cochrane Musculoskeletal Injuries Group specialised register, the Cochrane Central Register of Controlled Trials, PEDro, MEDLINE (1966 to May week 4 2003), EMBASE (1980 to 2003 week 22), CINAHL (1982 to May week 3 2003), AMED (1985 to May 2003), the National Research Register (UK), Current Controlled Trials, and bibliographies of trial reports. The search was completed in May 2003. SELECTION CRITERIA All randomised studies pertinent to the treatment of proximal humeral fractures were selected. DATA COLLECTION AND ANALYSIS Independent quality assessment and data extraction were performed by two reviewers. Although quantitative data from trials are presented, trial heterogeneity prevented pooling of results. MAIN RESULTS Twelve randomised trials were included. All were small; the largest study involved only 86 patients. Bias in these trials could not be ruled out. Eight trials evaluated conservative treatment, three compared surgery with conservative treatment and one compared two surgical techniques. In the 'conservative' group there was very limited evidence indicating that the type of bandage used made any difference in terms of time to fracture union and the functional end result. However, an arm sling was generally more comfortable than a body bandage. There was some evidence that 'immediate' physiotherapy, without routine immobilisation, compared with that delayed until after three weeks immobilisation resulted in less pain and both faster and potentially better recovery in patients with undisplaced two-part fractures. Similarly, there was evidence that mobilisation at one week instead of three weeks alleviated pain in the short term without compromising long term outcome. Two trials provided some evidence that patients, when given sufficient instruction to pursue an adequate physiotherapy programme, could generally achieve a satisfactory outcome if allowed to exercise without supervision. Operative reduction improved fracture alignment in two trials. However, in one trial, surgery was associated with a greater risk of complication, and did not result in improved shoulder function. In one trial, hemi-arthroplasty resulted in better short-term function with less pain and less need for help with activities of daily living when compared with conservative treatment for severe injuries. Fracture fixation of severe injuries was associated with a high rate of re-operation in one trial, comparing tension-band wiring fixation with hemi-arthroplasty. There was very limited evidence that similar outcomes resulted from mobilisation at one week instead of three weeks after surgical fixation. REVIEWER'S CONCLUSIONS Only tentative conclusions can be drawn from the available randomised trials, which do not provide sufficient evidence for many of the decisions that need to be made in contemporary fracture management. Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It is unclear whether operative intervention, even for specific fracture types, will produce consistently better long term outcomes. There is a need for good quality evidence for the management of these fractures.
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Affiliation(s)
- H H G Handoll
- University Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, Little France, Old Dalkeith Road, Edinburgh, UK, EH16 4SU
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Williams GR, Wong KL. Two-part and three-part fractures: open reduction and internal fixation versus closed reduction and percutaneous pinning. Orthop Clin North Am 2000; 31:1-21. [PMID: 10629329 DOI: 10.1016/s0030-5898(05)70124-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Surgical management of two-part and three-part proximal humerus fractures is difficult and requires familiarity with more than one method of fixation. Poor bone quality, comminution, and the deforming forces of the rotator cuff on the tuberosities influence the choice of operative approach and fixation techniques. Closed reductions and percutaneous pinning offer the potential advantage of minimal soft-tissue dissection; however, good bone quality and minimal comminution are prerequisites. Selected two-part surgical neck fractures and valgus-impacted fractures lend themselves well to this technique. Open reduction and internal fixation is indicated in two-part surgical neck fractures with poor bone quality or extensive comminution, two-part greater tuberosity or lesser tuberosity fractures, and most three-part fractures. The choice of surgical approach is dictated by the fracture pattern and includes an extended deltopectoral approach and a superior deltoid-splitting approach. Fixation techniques are myriad and are dependent on the fracture pattern. Potential fixation methods include intramedullary rods, interfragmentary sutures or wires, and extramedullary plates and screws or blade plates. Successful results are predicated on obtaining adequate enough fixation to allow early passive motion. Results also are influenced by the quality of the reduction and patient compliance.
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Affiliation(s)
- G R Williams
- Shoulder and Elbow Service, Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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Koval KJ, Gallagher MA, Marsicano JG, Cuomo F, McShinawy A, Zuckerman JD. Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am 1997; 79:203-7. [PMID: 9052540 DOI: 10.2106/00004623-199702000-00006] [Citation(s) in RCA: 152] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
One hundred and four patients who had a minimally displaced fracture of the proximal part of the humerus (a so-called one-part fracture) were managed with a standardized therapy regimen and followed for more than one year. The clinical outcome was assessed on the basis of pain, function, and the range of motion of the shoulder. The duration of follow-up averaged forty-one months (range, twelve to 117 months). All fractures united without additional displacement. Eighty patients (77 per cent) had a good or excellent result, fourteen (13 per cent) had a fair result, and ten (10 per cent) had a poor result. Ninety four patients (90 per cent) had either no or mild pain in the shoulder, eight (8 per cent) had moderate pain, and two (2 per cent) had severe pain. Functional recovery averaged 94 per cent; forty-eight patients (46 per cent) had 100 per cent functional recovery. At the time of the most recent follow-up, forward elevation of the injured shoulder averaged 89 per cent; external rotation, 87 per cent; and internal rotation, 88 per cent that of the uninjured shoulder. The percentage of good and excellent results was significantly greater (p < 0.01) and external rotation was significantly better (p < 0.01) at the time of the latest follow-up for the patients who had started supervised physical therapy less than fourteen days after the injury than for the patients who had started such therapy at fourteen days or later.
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Affiliation(s)
- K J Koval
- Department of Orthopaedic Surgery, Hospital for Joint Diseases Orthopaedic Institute, New York City, N. Y. 10003, USA
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