Centenarians with proximal humeral fracture

The COVID-19 pandemic had a severe influence on the entire health sector. Until today, the effect of a SARS-CoV-2 infection on older patients with a proximal humeral fracture (PHF) is unknown. This study examined the following questions: Did the incidence of PHF of older people in Germany vary during the pandemic? Did the treatment change between the lockdown and non-lockdown periods? Was a SARS-CoV-2 infection associated with a worse outcome? Retrospective claims data of the BARMER health insurance were analysed. All in- and outpatient cases of insurance holders ≥65 years from 01/2010 to 09/2022, with coded diagnosis of PHF were analysed. Primary endpoints were the 1-month incidence of PHF per 100,000 insurance holders, number of operative therapies, in-hospital death and in-hospital major adverse events (MAEs). 174,898 inpatient PHF cases were included. During the lockdown periods, the total incidence fell, while the outpatient incidence partially increased during the pandemic-period. Regarding the therapy allocation, there were no relevant persisting changes. In a detailed analysis of 23,979 PHF cases from 01/2020 to 09/2022, 4.1% patients suffered from a SARS-CoV-2 infection and showed a notably higher in-hospital mortality (8.1% vs 2.5%; risk adjusted OR 2.79, 95% CI 2.11-3.70, p < 0.001) and more MAEs (17.0% vs 7.8%; risk adjusted OR 1.43, 95% CI 1.15-1.77, p < 0.001). During the COVID-19 pandemic, the overall incidence of PHF in older patients was reduced. The treatment allocation did not change between the pre- and intra-pandemic period. An infection with SARS-CoV-2 was associated with higher mortality and more MAEs.

Complications Following Intramedullary Nailing of Proximal Humerus and Humeral Shaft Fractures – A Systematic Review

Optimal treatment of 3- and 4-part proximal humerus fractures (PHFs) remains controversial. Although commonly recommended for less comminuted PHFs, the outcomes of treatment with proximal humerus nailing (PHN) are more equivocal. The purpose of this study was to report on radiographic and clinical outcomes of patients undergoing PHN fixation of 3- and 4-part PHFs at minimum one-year follow-up. Our hypothesis was that the findings would demonstrate satisfactory radiographic and clinical outcomes, with low rates of complications and revision surgeries. Between 2008 and 2016, 121 patients with comminuted, low-energy, osteoporotic, PHFs underwent fixation via Targon PHN (Aesculap, Tuttlingen, Germany). Of these, 60 patients met inclusion and exclusion criteria and were included in this analysis (mean age 72; range 65-85). All completed a minimum 1-year follow-up (range 12.5-82months). Patients with 3-part PHFs were compared to patients with 4-part PHFs. Clinical, radiographic, and functional outcomes were assessed at postoperative visits. Patient reported outcomes included pain, the American Shoulder and Elbow Surgeons (ASES) score and the Simple Shoulder Test (SST). Radiographic union and revision and complication rates were assessed. Overall, 37 (62%) fractures were classified as Neer 3 and 23 (38%) were classified as Neer 4. Both groups achieved similar postoperative range of motion. Patients with 3-part fractures reported significantly lower postoperative pain (0.76 ± 1.8 vs. 1.65 ± 2.2, p = 0.0047). Patients with 3-part fractures reported significantly better ASES scores (82.4 ± 19.2 vs. 70.8 ± 21.9, p = 0.02) and non-statistically significant higher SST scores (8.4 ± 3.2 vs. 7.43 ± 3.8, p = 0.14). Adequate fracture union was achieved in 53 fractures (88.3%). Three patients (5%) had varus malunion or greater tuberosity displacement, one (1.7%) had mechanical failure, and three (5%) had radiographic evidence of avascular necrosis. Between groups, there was no difference in failure rates. Proximal humeral nails can successfully be used by experienced surgeons in fixation of comminuted and displaced proximal humeral fractures in selected patients with osteoporosis. While patients with both 3- and 4-part fractures demonstrate fracture union with satisfactory outcomes, patients with 3-part fractures demonstrate significantly higher postoperative functional scores.

Increasing Rate of Shoulder Arthroplasty for Geriatric Proximal Humerus Fractures in the United States, 2010–2019

Introduction: Medial column instability has been identified as a key factor contributing to the increased failure rates observed after locking plate (LP) fixation for unstable proximal humerus fractures (PHFs). Recent studies have reported promising biomechanical and clinical outcomes with the use of LP fixation augmented by an additional plate for medial column stabilization. The current article provides an overview of the available clinical literature for dual plate fixation of unstable PHFs with medial column instability. Materials and methods: For the arrangement of this narrative, non-systematic review, an exploratory search in the MEDLINE (via PubMed) database using the keywords combinations: “proximal humerus fracture” and “dual plate”; “proximal humerus fracture” and “double plate”; “proximal humerus fracture” and “additional plate” was conducted. Results: The initial search in Pubmed yielded 24 studies, but only 9 studies satisfied the inclusion criteria and were subject to further analysis. There were 165 patients with PHFs in the nine included studies. The average age was 57 years (range 18–84 years). The average follow-up was 21.8 months (range 12–52 months). The average Constant-Murley Score at the final follow-up was 79.9 (71.5–90.4). There were a total of 12 (7.3%) reported clinically relevant complications and 15 (9.1%) re-interventions. Various plates were used as additional fixation to the PHLP: 1/3 tubular plate; a Variable Angle Locking Compression Plate (Distal Radius System); non-locking 3-hole T-plate; 2.7-mm T-shaped locking plate; anatomical medial locking plate; 2.7-mm micro-locking plate; Conclusion: Adding a second plate to PHLP fixation for unstable PHFs with medial column insufficiency has shown promising clinical outcomes with a relatively low complication rate, despite the additional soft tissue dissection required. The anterior placement of the secondary plate is less technically demanding and can serve as a temporary reposition tool. However, anterior plating has been associated with a higher risk of avascular necrosis compared to medial plating. The variability in techniques and implants used for dual plating complicates drawing definitive conclusions. Moreover, the current evidence is limited, and additional studies with a higher level of evidence are needed to support the efficacy and routine application of the dual plating technique for unstable PHFs.

Reverse shoulder arthroplasty (RSA) is a promising option for proximal humerus fractures (PHFs) and also used as a salvage procedure for failed treatment. Whether the timing of RSA would influence the clinical outcomes is controversial. This meta-analysis compared outcomes between immediate RSA (iRSA) and salvage RSA (sRSA) in geriatric patients with PHFs. PubMed, Embase, Web of Science and Cochrane Library databases were searched up to 1st April 2024. Comparative studies reporting outcomes of iRSA and sRSA in geriatric patients with PHFs were included. A random-effects model was used for meta-analysis. The primary outcome was the revision rate. Secondary outcomes included shoulder function and complications. Risk ratios (RR) were calculated for dichotomous outcomes, and weighted mean differences (WMDs) were used for continuous variables. Meta-regression model and subgroup analysis were used to explore sources of potential heterogeneity for the primary outcome. Seventeen studies with 27,756 cases (24442 receiving iRSA and 3314 receiving sRSA) were included. Compared with sRSA, iRSA was associated with a lower risk of revision (RR = 0.41, P < 0.001), greater range of motion (ROM) (abduction: WMD = 11.32°, P < 0.001; forward flexion: WMD = 11.51°, P < 0.001; external rotation: WMD = 3.77°, P = 0.048) and statistically superior shoulder functional scores (Constant-Murley score: WMD = 5.57, P < 0.001; American Shoulder and Elbow Surgeons score: WMD = 10.38, P < 0.001; Simple Shoulder Test score: WMD = 0.91, P = 0.001; Shoulder Pain and Disability Index: WMD = - 14.50, P < 0.001), and lower risk of complications (infection: RR = 0.42, P = 0.019; dislocation: RR = 0.34, P = 0.007; nerve palsy: RR = 0.49, P = 0.026). The meta-regression model and subgroup analysis showed that sRSA after failed prior surgery had the highest revision rate (9.4%) as compared with iRSA (3.7%). In elderly patients with PHFs, iRSA is associated with lower revision and complication rates, as well as statistically superior shoulder function and ROM, compared with sRSA. However, the clinical significance of some functional differences remains uncertain. CRD42024534751.

Proximal humeral fractures (PHF) are the third most common fracture in geriatric traumatology. No standard evidence-based treatment has been established so far. The epidemiology and economic burden highlight the importance of atargeted treatment strategy. Epidemiology of PHF and analysis of the influence of preoperative length of stay, comorbidities and quality of patient life. Additionally, a comparison to the more frequently studied proximal femoral fractures. Aroutine data analysis of 17,322cases admitted for inpatient treatment with an observational period of 1 year was performed following an established model. Descriptive statistics included comorbidities, treatment procedures and mortality. Analytical statistics using logistic regression with the primary endpoints of early revision, mortality and decubitus within 1 year. In the investigated PHFs there was a mortality of 13% within 1 year, which is increased three-fold in patients with comorbidities such as cancer. There was an increase of 57% in patients who first received a care level following PHF. A preoperative care level in general significantly decreased survival. The most frequently used surgical procedure was fixation via stable-angle plate (used in 43%). The preoperative length of stay did not impact survival. Intrinsic factors such as preoperative comorbidities are crucial for the mortality after PHF. The PHF affects patients' lives less than proximal femoral fractures. With comparable comorbidity profiles, possible reasons are the lower levels of immobilization and less dependency on care before the fracture in comparison to proximal femoral fractures.

Objective:Probe into the impact of comprehensive nursingintervention on clinical efficacy of 45 cases of patients withproximal humeral fracture treated with locking plate throughsubacromial small incision. Method: equally divide 90 cases ofpatients with proximal humeral fracture into an observation groupand a control group in a random manner. Both of the two groupswere treated with locking plate through subacromial small incision.Give routine orthopedic nursing to the control group, whileimplementing comprehensive nursing intervention on the basis ofroutine orthopedic nursing to observation group, including mentalintervention, comfortable nursing, recovery nursing, etc. Comparethe nursing efficacy of the two groups. Result: operations werecompleted in small incision to cases of both groups. By adoptingConstant scoring method and ASES and through statisticaltreatment, the differences in blood loss, operation time andduration of postoperative pain of patients with those applyingtraditional internal plate fixation, replacement of the humeral headand treatment with locking plate through deltoid &amp; pectoralismajor have statistical significance (P ＜ 0.05). The duration ofpostoperative pain of patients is shortened and the blood loss isless. Conclusion: implementing the comprehensive nursingintervention to patients with proximal humeral fracture treatedwith locking plate through subacromial small incision can improvethe treatment effect, alleviate the postoperative pain, lower theoccurrence rate of complications, and improve prognosis as well aslife quality. The clinical effect is satisfying.

Proximal humeral fractures (PHF) are among the most common adult fractures. However, valid epidemiologic population-based data, including differentiation of treatment modalities, are lacking. Using the ICD codes and associated OPS codes for PHF, a retrospective analysis of 2007-2016 Federal Statistical Office of Germany data was performed. Data were evaluated for total incidence of PHF as well as total use, annual utilization rates, age, and sex distributions of all associated surgical procedures. Simple linear regressions were performed to evaluate trends in treatment modalities. There were 642,556 cases of PHF. During the study period, incidence changed substantially from 65.2 to 74.2 per 100,000 inhabitants with a significant rise in elderly (> 70years) patients (P < 0.001). The number of surgical procedures increased by 39%, with locking plate fixation being the most common procedure (48.3%), followed by intramedullary nailing (IMN) (20.0%), hemiarthroplasty (HA) (7.5%), K-wire fixation (6.4%), and reverse shoulder arthroplasty (RSA) (5.6%). The utilization rate increased for locking plates, K-wires, and RSA and decreased for HA and IMN. Particularly, the utilization of RSA exhibited a > eightfold increase. Significant linear correlation of procedure and time were found for all surgical treatments. During this period, the number of inpatient PHFs, especially in the elderly, increased. Although locking plate fixation remained the most common treatment method, RSA had the greatest proportional increase over time, supporting its growing popularity in the light of the current scientific evidence. This incline was offset by a corresponding decrease in HA and IMN, which may be related to a growing knowledge of their application limitations. Descriptive epidemiology study, large database analysis.

Treatment of humeral head fractures in the elderly remains a challenge. Within the framework of demographic change the incidence as well as the direct and indirect consequences of injuries will rise. The analysis of an optimal treatment should include functional parameters as well as global health parameters, e.g. quality of life. The aim of this study was the evaluation of functional outcome, institutionalization (necessity of placement in a residential care home for the elderly, even if temporary), the influence of cognitive deficits, quality of life and the pattern of complications after primary reverse shoulder arthroplasty. The study included a total of 34 patients (mean age 79.8 ± 6.7 years, 29 female) after implantation of a reversed modular fracture arthroplasty. The mean follow-up was 23 ± 10.6 months). The functional Constant-Murley score (CS), radiology results as well as the extent of institutionalization and quality of life as measured by the EQ-5D questionnaire were collated. The clinical examination showed good results in the CS (54 points, SD ± 9). In comparison to the age and gender-related CS according to Gerber the patient scores amounted to 78.9 %. The comparison of patients with and without cognitive deficits did not show any differences (53 vs. 54 points, p = 0.6525). The rate of institutionalization after treatment of humeral head fractures by reversed fracture arthroplasty was 2.94 %. The quality of life measured with EQ-5D showed a health-related quality of life (HRQoL) of 0.801. The rate of complications was 2.94 % involving an incomplete lesion of the radial nerve which was in regression. The results of this study showed good to moderate functional results, very low rates of complications and institutionalization and very good results according to the HRQoL. In comparison to conservative treatment or plate osteosynthesis, better results were achieved in this study with respect to HRQoL.

To determine whether uncemented implants would provide similar outcomes while avoiding the complications associated with cement in the treatment of elderly patients with proximal humerus fractures (PHFs) with primary reverse total shoulder arthroplasty (RTSA). Case series. A single Level I trauma center. A prospectively obtained cohort of 30 patients who underwent uncemented RTSA as initial treatment for a comminuted PHF: 4 male, 26 female; average age 71 ± 11 years. Uncemented RTSA. (1) Radiographic analysis, (2) postoperative clinical range of motion, and (3) functional outcome scores: the American Shoulder and Elbow Surgeons Shoulder score and the Simple Shoulder Test score. Radiographic analysis showed 97% achieved stable humeral stem fixation and 70% had healing of the tuberosities in anatomical position. Average range of motion was 130 ± 31 degrees of forward flexion, 32 ± 18 degrees of external rotation, and internal rotation to the midlumbar spine. Average American Shoulder and Elbow Surgeons Shoulder score was 82.0 ± 13.5 (with an average pain rating of 0.8 ± 1.3), and average Simple Shoulder Test score was 69.4% ± 19.1%. Our data show that treatment of comminuted PHFs in elderly patients with uncemented RTSA can consistently produce good clinical outcomes with a low rate of complications and suggest that cement may not be necessary for RTSA in the trauma setting. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

High rate of maintaining self-dependence and low complication rate with a new treatment algorithm for proximal humeral fractures in the elderly population

Low complication rates in Minimally Invasive Plate Osteosynthesis (MIPO) for proximal humeral fractures at 5 years of follow-up

Introduction:Proximal humerus fractures are the seventh most frequent fracture in adults, and the third in patients over 65 years old, 5.7% of whole diagnosed fractures. Most of these fractures can be treated conservatively and achieve good results. However, more and more frequently we are confronted with dislocated and multifragmentary fractures, and with elderly and high functional demanding patients. In patients with osteoporosis and poor general conditions external fixation can be performed as rapid and mininvasive procedure with good outcome and low complication rates. The authors investigated the use of external fixation in the treatment of proximal humerus fractures. The objective is to demonstrate the effectiveness of this method as a valid alternative to other surgical techniques.Materials and Methods:A multicentre study was conducted at 7 hospitals in Italy from 2014 through 2018. We recruited all proximal humeral fractures (as classified with the Neer system) that are surgically treated with the same external fixator DOS, for a total of 110 patients, evaluated later with Oxford Shoulder Scale (OSS) and disability of the arm, shoulder and hand score (DASH) at 1, 2 and 6 months.Results:The patients have passed from a score of 75,37 in the first month to a score of 29,47in the sixth month at the DASH and from 47,02 to 27,71 at the OSS. The data further confirm the increased incidence of these fractures in women and in a mean age of about 65.Conclusions:Although it does not represent the golden standard in the treatment of fractures of the proximal humerus, in our experience the minimal osteosynthesis with external fixator turned out to be a very valid help especially for the simplicity and speed of the method, as well as for the exciting functional results. sometimes superior to other methods. The preliminary results from the different centers have confirmed this hypothesis. We hope this will be a good starting point for further in-depth studies. (www.actabiomedica.it)

Aim: to analyze the current evidence on the surgical treatment of proximal humeral fractures, comparing the functional results and associated complications of plate osteosynthesis and nail osteosynthesis. The initial hypothesis was that osteosynthesis with intramedullary nail presents results as satisfactory as fixation with plate but with a lower complication rate. Methods: a systematic review of the literature was carried out following the PRISMA guidelines, using the PubMed and Cochrane Central databases. The search was performed on February 26, 2024, with the following terms: (Proximal humeral fracture) AND (nail) AND (plate) NOT (shaft). The Joanna Briggs Institute's quality assessment tool was used to evaluate the selected trials. Results: five clinical trials (level of evidence I) comparing plate osteosynthesis and intramedullary nail in the treatment of proximal humeral fractures were included. All trials conclude that both fixations had similar functional results, and 4 of the 5 trials found a higher number of complications in the group treated with looking plates. Conclusions: Osteosynthesis with plates and osteosynthesis with nails are valid surgical options for the treatment of proximal humeral fractures. Postoperative functional results are similar in both groups, but fewer complications associated with treatment with intramedullary nails have been described, confirming the initial hypothesis of this work.