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BACKGROUND:Proximal humeral fracture in older adults is one of the three major osteoporotic fractures.Anatomic locking plate fixation is the first choice for most scholars to treat difficult-to-reduce and complex fracture types.However,the probability of reduction failure after the operation is high,which seriously affects patients'quality of life. OBJECTIVE:To investigate the correlation between deltoid tuberosity index and postoperative reduction failure of proximal humeral fractures in the elderly,analyze and filter preoperative independent risk factors for reduction failure of proximal humeral fractures in the elderly,and construct and verify the effectiveness of a clinical prediction model. METHODS:The clinical data of 153 elderly patients with proximal humeral fractures who met the diagnosis and inclusion criteria and received open reduction and locking plate surgery in Foshan Hospital of TCM from June 2012 to June 2021 were collected.The patients were divided into the reduction failure subgroup and the reduction maintenance subgroup.The independent risk factors were selected by multivariate Logistic regression analysis,and the nomogram was constructed by R language.After 1000 times of resampling by Bootstrap method,the Hosmer-Lemeshow goodness of fit correlation test,receiver operating characteristic curve,calibration curve,clinical decision,and influence curve were plotted to evaluate its goodness of fit,discrimination,calibration ability,and clinical application value.Fifty-five elderly patients with proximal humeral fractures from June 2013 to August 2021 were selected as the model's external validation group to evaluate the prediction model's stability and accuracy. RESULTS AND CONCLUSION:(1)Of the 153 patients in the training group,44 patients met reduction failure after internal plate fixation.The prevalence of postoperative reduction failure was 28.8%.Multivariate Logistic regression analysis identified that deltoid tuberosity index[OR=9.782,95%CI(3.798,25.194)],varus displacement[OR=4.209,95%CI(1.472,12.031)],and medial metaphyseal comminution[OR=4.278,95%CI(1.670,10.959)]were independent risk factors for postoperative reduction failure of proximal humeral fractures in older adults(P<0.05).(2)A nomogram based on independent risk factors was then constructed.The Hosmer-Lemeshow test results for the model of the training group showed that χ2=0.812(P=0.976)and area under curve=0.830[95%CI(0.762,0.898)].The calibration plot results showed that the model's predicted risk was in good agreement with the actual risk.The decision and clinical influence curves showed good clinical applicability.(3)In the validation group,the accuracy rate in practical applications was 86%,area under curve=0.902[95%CI(0.819,0.985)].(4)It is concluded that deltoid tuberosity index<1.44,medial metaphyseal comminution,and varus displacement were independent risk factors for reduction failure.(5)The internal and external validation of the risk prediction model demonstrated high discrimination,accuracy,and clinical applicability could be used to individually predict and screen the high-risk population of postoperative reduction failure of proximal humeral fractures in the elderly.The predicted number of patients at high risk is highly matched to the actual number of patients who occur when the model's threshold risk probability is above 65%,and clinicians should use targeted treatment.
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BACKGROUND:Internal fixation and open reduction with locking plate is the main treatment for proximal humeral fractures with medial column instability.However,reduction failure is one of the main postoperative complications,and accurate risk factor assessment is beneficial for screening high-risk patients and clinical decision selection. OBJECTIVE:To construct four types of prediction models by different machine learning algorithms,compare the optimal model to analyze and sort the risk variables according to their weight scores on the impact of outcome,and explore their significance in guiding clinical diagnosis and treatment. METHODS:262 patients with proximal humeral fractures with medial column instability,aged(60.6±10.2)years,admitted to Foshan Hospital of Traditional Chinese Medicine between June 2012 and June 2022 were included.All patients underwent open reduction with locking plate surgery.According to the occurrence of reduction failure at 5-month follow-up,the patients were divided into a reduction failure group(n=64)and a reduction maintenance group(n=198).Clinical data of patients were collected,and model variables and their classification were determined.The data set was randomly divided into a training set and a test set according to a 7:3 ratio,and the optimal hyperparameters were obtained in the training set according to a 5-fold cross-over test.Four machine learning prediction models of logistic regression,random forest,support vector machine,and XGBoost were constructed,and the performance of different algorithms was observed in the test set using AUC,correctness,sensitivity,specificity,and F1 scores,so as to comprehensively evaluate the prediction performance of the models.The best-performing model was evaluated using SHAP to assess important risk variables and to evaluate its clinical guidance implications. RESULTS AND CONCLUSION:(1)There were significant differences between the two groups in deltoid tuberosity index,fracture type,fracture end with varus deformity before operation,fragment length of inferior metaphyseal of humerus,postoperative reduction,cortical support of medial column of proximal humerus,and insertion of calcar screw(P<0.05).(2)The best-combined performance of the four machine models was XGBoost.The AUC,accuracy,and F1 scores were 0.885,0.885,and 0.743,respectively;followed by random forest and support vector machine,with both models performing at approximately equal levels.Logistic regression had the worst combined performance.The SHAP interpretation tool was used in the optimal model and results showed that deltoid tuberosity index,medial humeral column cortical support,fracture type,fracture reduction quality,and the status of the calcar screw were important influencing fators for postoperative fracture reduction failure.(3)The accuracy of using machine learning to analyze clinical problems is superior to that of traditional logistic regression analysis methods.When dealing with high-dimensional data,the machine learning approach can solve multivariate interaction and covariance problems well.The SHAP interpretation tool can not only clarify the importance of individual variables but also obtain detailed information on the impact of dummy variables in each variable on the outcome.
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Objective:To compare proximal humerus internal locking system (PHILOS) and Multiloc intramedullary nail in the treatment of proximal humerus fracture-anterior dislocation.Methods:A retrospective study was performed to analyze the data of 33 patients with proximal humerus fracture-anterior dislocation who had been treated by open reduction and internal fixation from June 2015 to April 2021 at Department of Upper Limbs, Zhengzhou Orthopaedic Hospital. According to methods of internal fixation, the patients were divided into an extramedullary group and an intramedullary group. In the extramedullary group of 18 cases subjected to internal fixation with PHILOS, there were 8 males and 10 females with an age of (53.3 ± 10.6) years, and 1 2-part fracture, 15 3-part fractures and 2 4-part fractures by the Neer classification. In the intramedullary group of 15 cases subjected to internal fixation with Multiloc intramedullary nail, there were 8 males and 7 females with an age of (51.5 ± 11.2) years, and 14 3-part fractures and 1 4-part fracture by the Neer classification. The 2 groups were compared in terms of incision length, operation time, intraoperative blood loss, postoperative complications, and visual analog scale (VAS), range of shoulder motion, and Constant-Murley score at postoperative 12 months.Results:The 2 groups were comparable due to insignificant differences in their preoperative general data ( P>0.05). All patients were followed up for (20.8 ± 4.7) months. The incision length in the intramedullary group [(11.6 ± 1.7) cm] was significantly shorter than that in the extramedullary group [(17.6 ± 2.0) cm], and the intraoperative blood loss in the former [(106.7 ± 34.4) mL] was significantly lower than that in the latter [(151.7 ± 45.7) mL] ( P<0.05). The VAS scores at 1 week and 1 month after surgery [2.0 (2.0, 3.0) and 0.0 (0.0, 1.0) respectively] in the intramedullary group were significantly lower than those in the extramedullary group [3.0 (3.0, 3.3) and 1.0 (0.0, 1.3) respectively] ( P<0.05). The external rotation of the shoulder at the last follow-up in the intramedullary group (65.3° ± 15.5°) was significantly larger than that in the extramedullary group (50.6° ± 13.9°) ( P<0.05). There were no significant differences in operation time, incidence of postoperative complications, VAS score at 12 months after operation, Constant-Murley score or range of shoulder motion at the last follow-up between the 2 groups ( P>0.05). Conclusions:In the treatment of proximal humerus fracture-anterior dislocation, open reduction and internal fixation with both PHILOS and Multiloc intramedullary nail can result in a favorable prognosis when the fracture-dislocation is well reduced and fixated. However, the Multiloc intramedullary nail may lead to better early pain relief, less surgical invasion, and better functional recovery of the external rotation of the shoulder.
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Objective:To evaluate the clinical efficacy of the axillary approach in the treatment of scapular glenoid fracture.Methods:A retrospective analysis was performed of the 12 patients who had been treated for scapular glenoid fracture from November 2019 to April 2021 at Department of Upper Limb Orthopaedics, Zhengzhou Orthopaedic Hospital. They were 4 males and 8 females, aged from 30 to 75 years (mean, 53.5 years). According to the Ideberg classification, there were 2 cases of type Ⅰa, 9 cases of type Ⅱ and one case of type Ⅴa. All cases were treated through the axillary approach. Two patients complicated with anterior shoulder dislocation were treated with manual reduction under anesthesia before operation and the other 10 cases with special plate fixation through the axillary approach. The 3 patients complicated with fracture of greater tuberosity were fixated with a special plate through the lateral shoulder split deltoid approach. Constant-Murley score, visual analogue scale (VAS) and Hawkins grading were used at the last follow-up to evaluate shoulder function, pain and stability after operation.Results:All patients were followed up for 9 to 20 months (mean, 14.4 months). The operation time ranged from 55 to 110 min (mean, 76.3 min), intraoperative bleeding from 60 to 160 mL (mean, 103.8 mL), and hospital stay from 8 to 14 d (mean, 11.1 d). All incisions healed primarily and all scapular glenoid fractures got united 6 months after operation. The last follow-up showed no shoulder instability, neurovascular injury or internal fixation failure. At the last follow-up, the range of motion of the shoulder was 159.2°±26.1° in forward bending, 156.7°±29.6° in abduction, 48.3°± 15.3° in external rotation (neutral position), and 73.3°±12.3° in internal rotation (neutral position), and the Constant-Murley score was (94.0±5.3) points. The range of motion of the shoulder and Constant-Murley score were significantly improved compared with those before operation (10.8°±11.6°, 7.5°±11.4°, 5.8°±10.0°, 42.5°±16.0° and 4.9±4.0, respectively) (all P<0.05). The VAS score was 0 in 11 patients and 2 in one patient at the last follow-up. Conclusion:The axillary approach is feasible for the treatment of scapular glenoid fracture, because it is hidden and less invasive, leading to good clinical outcomes.
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Objective To investigate the clinical effects of headless double-threaded compression screws plus microplate for treatment of capitellar fracture of Ring type Ⅱ.Methods In the period from March 2015 to February 2018,12 capitellar fractures of Ring type Ⅱ were treated at Department of Upper limb Orthopedics,Zhengzhou Orthopaedics Hospital.There were 8 men and 4 women,aged from 25 to 57 years (average,35.4 years).There were 5 left and 7 right fractures.The fractures were exposed and reduced through the posterolateral elbow approach in 6 patients and through the lateral elbow approach in the other 6 ones.Fixation of all the fractures was conducted with headless double-threaded compression screws plus microplate.At the final follow-up,the elbow function was evaluated by the Mayo elbow performance score and the severity of traumatic arthritis by the Broberg & Morrey imaging criteria.Results All the patients were followed up for 9 to 36 months (average,23 months).The fracture healing time ranged from 9 to 12 weeks (average,10.6weeks).The final follow-ups revealed fine stability of the affected elbow joint in all the patients,and no loss of reduction,loosening or breakage of internal fixators or ischemic necrosis in any case.At the final follow-ups,the elbow inflection angles ranged from 90° to 130° (average,114.3°),the elbow extension angles from 0° to 20°(average,12.4°),the forearm pronation angles from 50° to 85° (average,70.5°) and the forearm supination angles from 45° to 80° (average,64.3°).The Mayo elbow performance scores at the final follow-up averaged 93.2points (from 85 to 100 points),yielding 8 excellent and 4 good cases.According to the Broberg & Morrey imaging criteria,10 patients showed no regressive change and 2 patients change by one grade.Conclusions A proper surgical approach should be chosen according to the preoperative imaging findings.The fracture of articular surface can be firmly fixated by head-less double-threaded compression screws and the integrity of the distal lateral column of the humerus can be restored with a microplate to achieve a strong biomechanical fixation.Fine clinical outcomes can be obtained by early functional exercise.