Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial

doi:10.1016/j.jse.2010.12.018

Journal of Shoulder and Elbow Surgery

Volume 20, Issue 5, July 2011, Pages 747-755

https://doi.org/10.1016/j.jse.2010.12.018 Get rights and content

Background

The aim of the study was to report the 2-year outcome after a displaced 3-part fracture of the proximal humerus in elderly patients randomized to treatment with a locking plate or nonoperative treatment.

Patients and methods

We included 60 patients, mean age 74 years (range, 56-92), 81% being women. The main outcome measures were the Constant and Disabilities of the Arm, Shoulder and Hand (DASH) scores and the health-related quality of life (HRQoL) according to the EQ-5D.

Results

At the final 2-year follow-up, the results for range of motion (ROM), function and HRQoL were all in favor of the locking plate group. The mean flexion in the locking plate group was 120° compared to 111° in the nonoperative group (P = .36) and the mean abduction was 114° compared to 106° (P = .28). The corresponding values for the Constant score were 61 versus 58 (P = .64), for DASH 26 versus 35 (P = .19), and the mean EQ-5D _index score was 0.70 compared to 0.59 (P = .26). In spite of good primary reduction in 86% of the fractures in the locking plate group, 13% of the patients had a fracture complication requiring a major reoperation and 17% had a minor reoperation.

Conclusion

The results of our study indicate an advantage in functional outcome and HRQoL in favor of the locking plate compared to nonoperative treatment in elderly patients with a displaced 3-part fracture of the proximal humerus, but at the cost of additional surgery in 30% of the patients.

Section snippets

Patients

In an RCT with a 2-year follow-up, we included 60 patients with an acute displaced 3-part fracture of the surgical neck of the humerus, according to the classification of Neer,28, 29 allocated to treatment with open reduction and internal fixation with a locking plate or nonoperative treatment between April 2003 and March 2008. The fracture inclusion criteria, based on conventional radiographs and computer tomography, were a displacement of the shaft of more than 10 mm and/or >45° of angulation

Results

A flow chart for all patients included is shown in Figure 1. One patient in the nonoperative group opted to be excluded from the study after randomization and 1 patient in the locking plate group was treated with a primary hemiarthroplasty (HA). According to the radiological examinations, this patient had a 3-part fracture with a displaced greater tubercle and a minimally displaced lesser tubercle (2 mm), but at surgery a displacement of both tubercles exceeding 10 mm was diagnosed; ie, it was

Discussion

The results of the study indicate an advantage in functional outcome and quality of life in favor of the locking plate as compared to nonoperative treatment in elderly patients with a displaced 3-part fracture of the proximal humerus. However, despite a modern fixation technique and overall good primary reductions in the locking plate group, 13% of the patients had a severe complication requiring a major reoperation and 17% had a minor secondary surgical intervention. Regardless of the primary

Conclusion

In summary, the results of the study indicate an advantage in functional outcome and quality of life in favor of the locking plate, as compared to nonoperative treatment in elderly patients with a displaced 3-part fracture of the proximal humerus. The main advantage appeared to be an improved ROM. However, despite a modern fixation technique and overall good primary reductions in the locking plate group, 13% of the patients had a severe complication requiring a major reoperation and 17% had a

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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Humeral fractures (HF) are common orthopedic pathologies. Reviewing the content and quality of influential literature over time is important to advance scientific research regarding a specific topic. This study aims to explore and appraise the fifty most cited HF studies that had been published in orthopedic literature.
The Web of Science database was used to conduct a systematic search for articles pertaining to HF. Articles were sorted out in descending order of citations and were included based on their relevance to HF. Data and metrics of the included studies were recorded. The methodological quality of the studies was assessed using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies criteria. Statistical analysis was conducted to explore any significant relationships between the date of publication and other relevant variables.
Included articles (N = 50) were published between 1959 and 2015, with a total of 14,864 accumulated citations. Europe and North America contributed to all but one of the included studies. The Journal of Bone and Joint Surgery contributed to the highest number of included articles with 27 articles (54%). The proximal humerus was the most commonly explored HF location in our study (72%). The average MCMS and Methodological Index for Non-randomized Studies scores were reported to be 64.6 and 10.4, respectively, and the majority of articles (52%) were considered level four case series. Year of publication was found to have a positive correlation with increasing level of evidence(r = −0.301, P = .044), citation density (r = 0.734, P < .001), and MCMS score (r = 0.41, P = .01).
The level of evidence, MCMS scores, and citation density of influential HF literature has been increasing with time, reflecting the increasing effort and work being put in that field. While the findings seem encouraging, additional high-quality research is needed to help achieve better treatment strategies and outcomes.
Poor midterm clinical outcomes and a high percentage of unsatisfying results are reported after seizure-related shoulder injuries, especially after posterior proximal humerus fracture-dislocations
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Treating seizure-related shoulder injuries is challenging, and an evidence-based consensus to guide clinicians is lacking. The aim of this prospective single-center observational clinical trial was to evaluate the clinical results of a cohort of patients undergoing treatment of seizure-related shoulder injuries, to categorize them according to the lesion’s characteristics, with special focus on patients with proximal humerus fracture-dislocations (PHFDs), and to define groups at risk of obtaining unsatisfactory results. We hypothesized that patients with a PHFD, considered the worst-case scenario among these injuries, would report worse clinical results in terms of the quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) as compared to the other patients.
Patients referred to a tertiary epilepsy center who have seizure-related shoulder injuries and with a minimum follow-up of 1 year were included. A quality-of-life assessment instrument (EQ-5D-5L), a district-specific patient-reported outcome measure (qDASH), and a pain assessment tool (visual analog scale [VAS]) were used for the clinical outcome evaluation. Subjective satisfaction and fear of new shoulder injuries was also documented. Categorization and subgroup analysis according to the presence and features of selected specific lesions were performed.
A total of 111 patients were deemed eligible and 83 were available for follow-up (median age 38 years, 30% females), accounting for a total of 107 injured shoulders. After a median follow-up of 3.9 (1.6-8.2) years, overall moderate clinical results were reported. In addition, 34.1% of the patients reported a VAS score ≥35 mm, indicating moderate to severe pain, and 34.1% a qDASH score ≥40 points, indicating severe disability of an upper limb. These percentages rose to, respectively, 45.5% and 48.5% in the subgroup of patients with PHFDs and to 68.8% and 68.8% in patients experiencing posterior PHFD. Overall, 46.9% of the patients considered themselves unsatisfied with the treatment and 62.5% reported a persistent fear of a new shoulder injury.
Patients with seizure-related shoulder injuries reported only moderate clinical results at their midterm follow-up. Older age, male sex, and absence or discontinuation of antiepileptic drug (AED) treatment were identified as characterizing features of patients with posterior dislocation episodes. In patients with PHFD, a tendency to worse clinical results was observed, with posterior PHFD patients emerging as a definite subgroup at risk of reporting unsatisfying results after treatment.
A network meta-analysis of multiple modalities for the treatment of complex proximal humeral fractures in older adults
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The databases PUBMED, EM-BASE, the Cochrane Central Register of Controlled Trials, Web of Science, and CNKI were searched for randomised controlled trials on complex proximal humeral fractures in older people, ranging from inception of each database to May 2023.
This meta-analysis included 14 randomised controlled trials, containing 791 patients aged over 60 years who were treated for complex proximal humeral fractures. Reverse shoulder arthroplasty and hemiarthroplasty yielded the highest Constant shoulder scores, whilst conservative treatment performed poorly. Hemiarthroplasty and open reduction internal fixation yielded the best performances on the visual analogue pain scale, whilst conservative treatment performed poorly. Reverse shoulder arthroplasty and open reduction internal fixation allowed for maximum forward flexion and outreach of range of motion, whilst hemiarthroplasty allowed for the least. Open reduction internal fixation and reverse shoulder arthroplasty allowed for maximum internal rotation of the range of motion, whilst conservative treatment allowed for the least. Hemiarthroplasty and conservative treatment allowed for maximum external rotation of the range of motion, whilst open reduction internal fixation allowed for the least.
Compared with open reduction internal fixation, reverse shoulder arthroplasty yields better Constant shoulder scores and allows for greater forward flexion and outreach of range of motion of the shoulder joint in complex proximal humerus fractures in older patients. Meanwhile, hemiarthroplasty yields the best visual analogue scale scores and allows for maximum external rotation of the range of motion. However, open reduction with internal fixation remains the preferred clinical treatment for complex proximal humeral fractures in older patients.
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Most proximal humeral fractures can be treated nonoperatively, but there are specific indications to perform surgery for some of these fractures. Optimal treatment remains subject to debate, since no consensus has been reached for the best therapy for these fractures. This review provides an overview of randomized controlled trials (RCTs) comparing treatment for proximal humeral fractures. Fourteen RCTs comparing different operative and nonoperative types of treatment for PHF are included. Different RCTs comparing the same interventions for PHF have drawn different conclusions. It also highlights reasons why consensus has not been reached based on these data, and how this could be addressed in future research. Previous RCTs have included different patient groups and fracture patterns, may have been prone to selection bias, often were underpowered for subgroup analysis, and showed inconsistency in the outcome measures used. Based on this, and appreciating that treatment may be tailored to specific fracture types and patient characteristic like age, a better way to move forward could be to use a (international) multicenter prospective cohort study. Such a registry-type study should use accurate patient selection and enrollment, well-defined fracture patterns, standardized surgical techniques performed according to the preferences of the surgeon, and with a standardized follow-up.
Inferior surgical outcomes following reverse total shoulder arthroplasty for nonunion and malunion compared to acute arthroplasty: a nationwide matched cohort analysis
2023, Seminars in Arthroplasty JSES
Reverse total shoulder arthroplasty (rTSA) has become popularized in the management of acute proximal humerus fractures (PHFs). Limited evidence exists to compare the outcomes of acute rTSA to management following failed open reduction and internal fixation. We aimed to analyze the differences between acute rTSA for PHF compared to subsequent rTSA for nonunion/malunion.
Patients who underwent primary rTSA from 2016 to 2020 were identified in the Premier Healthcare Database. Nonunion, malunion, and hardware complication patients were identified using International Classification of Diseases Tenth Revision diagnosis codes and compared to acute PHF controls. Patients were matched in a 1:1 fashion to acute fracture based on age (±3 years), sex, race, and presence of pertinent comorbidities. Patient demographics, hospital factors, patient comorbidities, and 90-day complications were assessed and compared between the two cohorts. Descriptive statistics and regression analysis were employed with significance set at P < .05.
Prior to matching, 8561 nonunion/malunion cases and 11,134 acute rTSA controls were identified. Patients undergoing acute rTSA for PHF were older, had longer length of stay, and higher total costs (P < .0001). When compared to acute rTSA for fracture, nonunion/malunion patients were at increased risk of multiple surgical complications including periprosthetic joint infection (odds ratio [OR]: 4.56; 95% confidence interval [CI]: 2.95-7.04; P < .0001), periprosthetic fracture (OR: 2.86; 95% CI: 2.09-3.93), stiffness (OR: 2.01; 95% CI: 1.17-3.44; P = .01), and dislocation (OR: 2.37; 95% CI: 1.80-3.12; P < .0001). However, patients undergoing acute rTSA had higher rates of all medical complications investigated, including deep vein thrombosis, pulmonary embolism, pneumonia, myocardial infarction, acute kidney infection, and sepsis (P < .001).
rTSA after nonunion/malunion of PHFs is associated with increased risk of surgical complications compared to acute rTSA. Initial rTSA for PHFs may mitigate subsequent increased risk of surgical complication and should be considered as the initial treatment option in patients with PHFs. However, the increased risk of medical complications seen in acute PHF warrants attention and diligent medical optimization from providers.

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: The study was supported in part by grants from the Trygg-Hansa Insurance Company and the Stockholm County Council.

: The study was approved by the Local Ethics Committee in Huddinge, Stockholm, Sweden (number 342/02).

: The study was conducted according to the principles of the Helsinki Declaration. All patients gave their informed consent to participate in the study and the protocol was approved by the Local Ethics Committee in Huddinge, Stockholm, Sweden (number 342/02).

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ShoulderInternal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial

Background

Patients and methods

Results

Conclusion

Section snippets

Patients

Results

Discussion

Conclusion

Disclaimer

J Clin Epidemiol

Health Policy

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Injury

Injury

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Injury

Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis

J Orthop Trauma

Swedish population health-related quality of life results using the EQ-5D

Qual Life Res

Proximal humeral internal locking system (PHILOS) for the treatment of proximal humeral fractures

Arch Orthop Trauma Surg

Age related recovery of shoulder function after injury

A clinical method of functional assessment of the shoulder

Clin Orthop Relat Res

Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment

J Bone Joint Surg Br

The epidemiology of proximal humeral fractures

Acta Orthop Scand

The time trade-off method: results from a general population study

Health Econ

Shoulder
Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial