Management of Three- and Four-Part Proximal Humerus Fractures.

The management of three- and four-part proximal humerus fractures remains controversial because the literature has supported all forms of management, including nonsurgical management, open reduction and internal fixation (ORIF), and shoulder arthroplasty. Specific patient factors ultimately influence the decision of which treatment best fits the patient and the fracture. Surgeons should understand the rationale for nonsurgical and surgical management of these fractures, including ORIF and reverse shoulder arthroplasty.

Difficulty in decision making in the treatment of displaced proximal humerus fractures: the effect of uncertainty on surgical outcomes.

BACKGROUND: Decision making in the management of proximal humerus fractures can be difficult in situations in which the surgeon is uncertain of the ideal treatment. METHODS: Two shoulder surgeons operatively treated 476 proximal humerus fractures from 1998-2014 with open reduction-internal fixation (ORIF), hemiarthroplasty, or reverse shoulder arthroplasty. Operative treatment was stratified by year to determine the evolution of technological influences on treatment over time. To evaluate the effect of uncertainty, 274 clinical vignettes were created for all patients with 1 year of follow-up or more and reviewed by 3 fellowship-trained shoulder surgeons to determine the type of treatment for each case. To evaluate the effect of certainty, range of motion for each patient with unanimous agreement on treatment was analyzed. RESULTS: ORIF treatment increased from 40% to 62% after release of the proximal humerus locking plate. Introduction of the fracture stem in 2011 increased reverse shoulder arthroplasty for fractures from 8.8% to 44.3%. Unanimous agreement on either operative or nonoperative treatment occurred 70.5% of the time. Only 63.5% of patients received the actual treatment selected (P = .001). Patients for whom unanimous agreement matched actual treatment in the ORIF treatment group showed improvement of forward elevation (144° vs 123°, P = .005) and abduction (129° vs 103°, P = .002). CONCLUSION: Successful management of displaced proximal humerus fractures requires both technical and decision-making abilities. The difficulty in making these decisions is reflected by the agreement of experienced shoulder surgeons only 63.5% of the time regarding the treatment performed. When uncertainty occurs, patients may have reduced outcomes as seen in the ORIF treatment group.

Massive Rotator Cuff Tears in Patients Older Than Sixty-five: Indications for Cuff Repair versus Reverse Total Shoulder Arthroplasty.

The decision to perform rotator cuff repair (RCR) versus reverse total shoulder arthroplasty (rTSA) for massive rotator cuff tear (MCT) without arthritis can be difficult. Our aim was to identify preoperative variables that are influential in a surgeon's decision to choose one of the two procedures and evaluate outcomes. We retrospectively reviewed 181 patients older than 65 who underwent RCR or rTSA for MCT without arthritis. Clinical and radiographic data were collected and used to evaluate the preoperative variables in each of these two patient populations and assess outcomes. Ninety-five shoulders underwent RCR and 92 underwent rTSA with an average followup of 44 and 47 months, respectively. Patients selected for RCR had greater preoperative flexion (113 vs 57), abduction (97 vs 53), and external rotation (42 vs 32), higher SST (3.1 vs 1.9) and ASES scores (43.8 vs 38.6), and were less likely to have had previous cuff surgery (6.3% vs 35.9%). Patients selected for rTSA had a smaller acromiohumeral interval (4.8 vs 8.7) and more superior subluxation (50.6% vs 14.1%). Similar preoperative characteristics included pain, comorbidities, and BMI. Patients were satisfied in both groups and had significant improvement in motion and function postoperatively. Both RCR and rTSA can result in significant functional improvement and patient satisfaction in the setting of MCT without arthritis in patients older than 65. At our institution, patients who underwent rTSA had less pre-operative motion, lower function, more evidence of superior migration, and were more likely to have had previous rotator cuff surgery.

The influence of patient- and surgeon-specific factors on operative duration and early postoperative outcomes in shoulder arthroplasty.

BACKGROUND: Increased operative duration has been shown to have demonstrable effects on the outcomes and complications in multiple areas of orthopedic surgery. We sought to determine if patient- and surgeon-specific factors correlated to operative duration in shoulder arthroplasty. Our hypothesis was that increased surgeon and trainee volume would decrease operative times and that more complex pathology would increase operative duration. METHODS: A retrospective review of primary and revision total and reverse shoulder arthroplasties performed at a single institution from 2012 through 2015 was performed evaluating the correlation between specific patient and surgeon factors and operative duration. The influence of operative duration on postoperative length of stay and risk of readmission within 30 days was also analyzed. RESULTS: For surgeon-specific factors, high surgeon volume (>30 shoulder arthroplasties/year) was associated with shorter operative duration (105.9 vs. 128.3 minutes; P < .001). Progression through the fellowship academic year was found to be associated with decreased surgical times (100.7 vs. 116.5 minutes; P < .0001). Certain complex pathologic processes (reverse shoulder arthroplasty for sequelae of prior fracture, total shoulder arthroplasty for dysplastic glenoid morphology, revision surgery) showed increased operative times. Patients with postoperative readmission had a longer mean operative time (163 vs. 107.1 minutes). CONCLUSIONS: Increased surgeon and trainee volumes were associated with decreased operative duration in shoulder arthroplasty. Patients with more complex pathology were more likely to have increased surgical times. Postoperative readmission within 30 days was associated with increased operative duration. Consideration of patient selection by surgeons to minimize operative times may reduce readmissions.