Association between Deltoid Muscle Density and Proximal Humeral Fracture in Elderly Patients.

Background: The potential role of deltoid muscle density in the occurrence of proximal humeral fractures remains uncertain. Therefore, the primary objective of this study was to examine the correlation between deltoid muscle density, as measured by CT attenuation value in Hounsfield units (HU), and the incidence of proximal humeral fractures in elderly patients. By investigating this association, we aim to shed light on the possible influence of deltoid muscle density on fracture risk in this specific population. Methods: A total of 68 patients with computed tomography (CT) images were retrospectively reviewed. Among them, 34 patients presented with fractures following low-energy injuries, while the remaining 34 patients served as controls and underwent CT scans after low-energy injuries without any fractures. The muscle density of the deltoid muscles was assessed at the approximate tubercle of humerus. We compared these parameters between the two groups and conducted analyses considering factors such as age, sex, laterality, and deltoid muscle density of the shoulders. Results: The demographic factors related to the shoulder did not exhibit any significant association with proximal humeral fracture. However, we observed a noteworthy difference in deltoid muscle density between patients with fractures (40.85 ± 1.35) and the control group (47.08 ± 1.61) (p = 0.0042), indicating a lower muscle density in the fracture group. Conclusion: Based on the findings of this study, we can conclude that there exists a negative correlation between deltoid muscle density and the incidence of proximal humeral fractures. These results suggest that lower deltoid muscle density may be associated with an increased risk of proximal humeral fractures in the elderly population under investigation.

Postoperative outcomes of third-generation shoulder hemiarthroplasties for three-and four-part proximal humeral fractures: A systematic review of published studies from 2012 to 2022.

Background: The aim of this study was to provide up-to-date evidence on the outcomes for hemiarthroplasties (HAs) that were performed using modern third-generation prostheses (post-2004) for isolated (excluding head-splits and fracture-dislocations) three-and four-part proximal humerus fractures (PHFs). Methods: PubMed, Medline, Embase and the Cochrane register were searched from January 1, 2012, to November 15, 2022, conforming to the PRISMA guidelines. The outcome measures were the complication rates, revision rates, surgery-related postoperative mortality, post-operative clinical outcome scores and radiological outcomes. Results: 432 hemiarthroplasties in 432 patients were performed across the 11 eligible studies (two prospective and 9 retrospective). Three studies compared HA versus reverse shoulder replacement (RSR); one study compared HA with locking plate fixation (LPF) and RSR; one study compared HA with LPF. 61.1 % and 19.4 % of hemiarthroplasties were performed using cemented and uncemented techniques respectively, while cementing data was ill-defined in 19.4 % of shoulders. The results for the outcome measures have been derived directly from the included studies and no statistical pooling was performed, due to heterogeneity in the different study designs and outcomes. Descriptive data synthesis from the included studies showed that third generation HAs have higher overall postoperative complication rates, with similar revision and mortality rates when compared to RSR and LPF for three-and four-part PHFs. RSR and LPF showed better statistically significant improvements than HA for the Constant-Murley score, Quick DASH, forward flexion and abduction. Mixed results were observed for the DASH score, ASES score and internal rotation ROM between RSR/LPF versus HA. Conclusion: Low to moderate quality evidence from this review showed that even third-generation HA prostheses provided worse overall outcomes than RSR and LPF for three-and four-part PHFs.

Time trends in proximal humeral fractures from 1944 to 2020 - A cohort study in Malmö, Sweden.

BACKGROUND: Most studies infer increasing incidence of proximal humeral fractures (PHF) from the 1950´s until the 1990´s. Recent time trends are less clear. OBJECTIVES: Our primary objective was to identify time trends in the age- and sex-adjusted adult incidence of PHF in Malmö, Sweden, from year 1944 until 2020. Our secondary objectives were to describe the variation in incidence according to age, the monthly distribution, and to compare data from the two most recent decades with earlier. STUDY DESIGN AND METHODS: Malmö has one emergency hospital where acute fractures are treated. We identified PHF in adult patients (≥ 18 years) by reviewing relevant radiology examinations during 17 sample years from year 1944 to 2020. We used jointpoint analyses to estimate time trends. RESULTS: We identified 3 031 PHF during the study period (3 231 161 person years), 73% were sustained by women with mean age of 69 years (mean age in men 59). Joinpoint analyses indicated an increase in the age- and sex-adjusted incidence of PHF from year 1944 (52 per 100 000 person years) until 1977 (120 per 100 000) and thereafter a decrease until 2020 (85 per 100 000). A seasonal variation with more fractures during winter months, was apparent in earlier but not recent decades. CONCLUSIONS: The age- and sex-adjusted incidence of PHF increased in Malmö, Sweden, from the 1940´s until year 1977 and thereafter decreased until 2020. More fractures were seen during winter months in earlier but not recent decades.

Intramedullary Plating of Complex Proximal Humerus Fractures: A Case Series.

Objectives: To assess fracture union rates using novel intramedullary plate technique. Post-operative humeral neck-shaft angles, patient range of motion and complication profile were secondary outcomes of interest. Methods: Single surgeon, retrospective case series of surgical technique at major trauma centre in Scotland. A 2.0mm mini-fragment plate was secured to the humeral head to act as an intramedullary strut during fixation in complex proximal humerus fractures. Fracture union and neck-shaft angle were assessed radiologically, whilst range of motion and complication profiles were assessed clinically. Results: Twelve patients were followed up for an average of 10 months post-operatively. All achieved bony union with a mean neck-shaft angle of 128°. Mean range of motion values were 100° forward elevation, 83° abduction, 60° internal rotation and 37° external rotation. Four patients required further surgical intervention- two for hardware prominence, one for adhesive capsulitis and one for subsequent rotator cuff failure. There were no cases of avascular necrosis or infection. Conclusion: This novel technique addresses the established biomechanical propensity of proximal humerus fractures to fail in varus collapse and screw cut-out. This method provides an alternative to arthroplasty in the most severe proximal humerus fractures and is readily adopted via standard orthopaedic kit.

Factors affecting hospital admission, hospital length of stay and new discharge destination post proximal humeral fracture: a retrospective audit.

BACKGROUND: Outcomes following proximal humeral fracture (PHF) may be impacted by a range of clinical, fracture and premorbid factors. The aim of this study was to examine factors impacting hospital admission; length of stay (LOS) and new discharge destination for patients presenting to hospital with PHF. METHODS: Retrospective audit conducted at a tertiary health service. Data was collected from adult patients presenting to hospital with a PHF over a 54-month period. Fractures that were pathological or sustained during admission were excluded. Univariable and multivariable logistic and negative binomial regression were used to explore factors associated with hospital admission, LOS and new discharge destination. RESULTS: Data were analyzed from 701 participants (age 70 years (IQR 60, 81); 72.8% female); 276 (39.4%) participants required a hospital admission. New discharge destination was required for 109 (15.5%) participants, of whom 49 (45%) changed from home alone to home with family/friend(s). Greater comorbidities, as indicated by the Charlson Comorbidity Index score, were associated with hospital admission, longer LOS and new discharge destination. Premorbid living situations of home with family/friend(s) or from an external care facility were associated with a decreased likelihood of hospital admission, shorter LOS and reduced risk of a new discharge destination. Surgical treatment was associated with shorter LOS. Older age and dementia diagnosis were associated with a new discharge destination. CONCLUSIONS: Many factors potentially impact on the likelihood or risk of hospitalization, LOS and new discharge destination post PHF. Patients with greater comorbidities are more likely to have negative outcomes, while patients who had premorbid living situations of home with family/friend(s) or from an external care facility are more likely to have positive outcomes. Early identification of factors that may impact patient outcomes may assist timely decision making in hospital settings. Further research should focus on developing tools to predict hospital outcomes in the PHF population.

OUTCOME OF SHOULDER HEMIARTHROPLASTY FOR COMPLEX PROXIMAL HUMERAL FRACTURE IN VIETDUC UNIVERSITY HOSPITAL.

ABSTRACTS: Translational Study Introduction: The proximal humeral fracture accounts for 4-5% of all fractures1 and traffic accidents are often the main cause of this injury in Vietnam. Shoulder hemiarthroplasty is a suitable option in treating a complex proximal humeral fracture, especially in the elderly, and improves quality of life. This study describes clinical and radiographic characteristics of complex proximal humerus fractures and evaluates the results of shoulder hemiarthroplasty for this type of fracture at Viet Duc University Hospital Materials and methods: A retrospective study of 78 cases with complex proximal humeral fractures underwent shoulder hemiarthroplasty in Viet Duc University Hospital from January 2017 to December 2021. RESULTS: Traffic accidents (42 cases, 53.8%); daily-life accidents (34 cases, 43.6%), other causes were less common (2 cases, 2.6%). 74.4% of the patients had no pain, 17.4% mild pain, 7.7% moderate pain, and no patients suffered from severe pain that required regular narcotic analgesics. The mean postoperative Constant score was 67.45 ± 13.20. CONCLUSION: In Viet Nam, the most common cause of injury was a traffic accident, primarily occurring in young males with complex proximal humerus fractures, shoulder hemiarthroplasty for complex proximal humerus fractures improves postoperative pain and shoulder function.

Reverse Total Shoulder Arthroplasty Within 6 Weeks of Proximal Humerus Fracture is Associated with the Lowest Risk of Revision.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular treatment strategy in the management of complex proximal humeral fractures (PHF). However, no definitive consensus has been reached regarding the optimal surgical timing of RTSA following PHF, particularly considering nonoperative management is often a viable option. Therefore, the aim of this study was (1) to identify optimal timing intervals that maximize the likelihood of revision following RTSA and (2) to determine differences in revision etiologies using the identified timing intervals. METHODS: A retrospective cohort analysis of patients undergoing PHF-indicated RTSA from 2010 to 2021 was conducted using a national administrative claims database. Stratum specific likelihood ratio (SSLR) analysis was conducted to determine data-driven timing strata between PHF and RTSA that maximized the likelihood of revision surgery within 2-years of RTSA. To control for confounders, multivariable regression analysis was conducted to confirm the identified data-driven strata's association with 2-year revision rates as well as compare the likelihood of various indications for revision including mechanical loosening, dislocation, periprosthetic joint infection (PJI), and periprosthetic fracture (PPF). RESULTS: In total, 11,707 patients undergoing TSA following PHF were included in this study. SSLR analysis identified two timing categories: 0-6 weeks and 7-52 weeks from the time of PHF to TSA surgery. Relative to the 0-6 week cohort, the 7-52 week cohort was more likely to undergo revision surgery within 2-years (OR: 1.93, P < 0.001). Moreover, the 7-52 week cohort had significantly higher odds of revision indicated for dislocation (OR: 2.24, P < 0.001), mechanical loosening (OR: 1.71, P < 0.001), PJI (OR: 1.74, P < 0.001), and PPF (OR: 1.96, P < 0.001). CONCLUSIONS: Using SSLR, we were successful in identifying two data-driven timing strata between PHF and RTSA that maximized the likelihood of 2-year revision surgery. As it can be difficult to determine whether RTSA or nonoperative management is initially more appropriate, considering the results of this study, an early trial of 4 to 6 weeks of nonoperative management may be appropriate without altering the risks associated with RTSA.

Comparing Intramedullary Nails and Locking Plates in Displaced Proximal Humerus Fracture Management: A Systematic Review and Meta-Analysis.

This study aims to provide an updated review comparing the complication rates and clinical outcomes of intramedullary nails and locking plates (LPs) in displaced proximal humerus fracture (PHF) management. We performed a systematic review of the Cochrane Central Register of Controlled Trials, Clinical Trials Registry, EMBASE, and PubMed. Studies with level III evidence or higher comparing intramedullary nails and LPs used for internal fixation of displaced PHFs were included. The Methodological Index for Nonrandomized Studies (MINORS) criteria and Cochrane Handbook for Systematic Reviews of Interventions 5.2.0 were used to assess the risk of bias. Our meta-analysis included a comparison of method-related complications, pain scores, range of motion (ROM), and functional scores. A total of 13 comparative studies were included: five randomized controlled trials, three prospective cohort studies, and five retrospective cohort studies. The total number of patients included was 1,253 (677 in the LP group and 576 in the intramedullary nail group). Superior Constant-Murley scores and external rotation ROM were found in the LP group during the early postoperative period. However, long-term functional scores and complication rates were comparable between the two groups. We conclude that intramedullary nailing and LP fixation are both equally effective for the treatment of displaced PHFs. Neither treatment appears superior at this time, and more large-scale randomized controlled trials should be conducted to further evaluate the potential benefit of LPs in the early postoperative period.

Reverse shoulder arthroplasty or nothing for patients with displaced proximal humeral fractures: a randomized controlled trial.

BACKGROUND: The benefits of reverse shoulder arthroplasty compared to nonoperative treatment for patients presenting with complex proximal fractures have been rarely explored. The aim of this prospective study was to compare the functional results of reverse shoulder arthroplasty with those of nonsurgical treatment in patients with displaced proximal humeral fractures. METHODS: A multicentric prospective randomized control trial of patients older than 70 years who sustained an acute proximal humeral fracture (3 or 4 parts), with less than 3 weeks of evolution, and had no previous condition or surgery on the affected shoulder was conducted. Patients were randomly assigned to the intervention group (implantation of a reverse shoulder arthroplasty and tuberosities reattachment) or the control group (nonoperative treatment). Functional outcome was assessed using the Constant-Murley score (CMS) at the 1-year follow-up. Complications and reinterventions were considered secondary outcomes. The power of the study relied on the inclusion of 81 patients to recognize a statistically significant difference of 10 points between CMS scores in the groups. Analysis was performed based on the intention to treat principle. RESULTS: Eighty-one patients were randomized to surgical treatment or nonoperative treatment, while 66 patients completed the 1-year follow-up evaluation. There was no significant difference between the groups in terms of age (76.1 yo vs. 77.43 yo, P = .43), sex (81.08% women in the surgical group vs. 84.09% in the nonoperative group, P = .72), or type of fracture according to Neer's classification system (P = .06). At the 1-year follow-up, the group assigned to undergo the intervention had better functional outcomes than the nonoperative treatment group (mean CMS; 61.24, SD: 13.33 vs. mean CMS: 52.44, SD: 16.22, P: .02), with a mean difference of 8.84 points, 95% CI (1.57, 16.11). Two patients in the intervention group (6.5%) suffered major complications (periprosthetic joint infection and axillary nerve palsy). No major complications were observed in the nonoperative group. One patient in the intervention group underwent secondary surgery for a periprosthetic joint infection. CONCLUSIONS: Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture. The difference in CMS is close to the clinically significant thresholds, and some harms are associated with the operative treatment.

Fibula allograft in complex three-part and four-part proximal humeral fractures in active patients, a matched case-control study.

Background: About 20% of proximal humerus fractures (PHFs) are unstable and/or markedly displaced and therefore require surgery. Locking plate fixation after anatomical reduction has become the current treatment of choice for these fractures in the active population. However, studies have shown complication rates up to 36%, such as loss of reduction and avascular necrosis. To date, data from literature are inconclusive on outcomes following the use of an intramedullary fibula allograft in PHFs, possibly due to the case mix. It is hypothesized that the use of a fibula allograft is beneficial to prevent secondary displacement of the fracture in cases where the medial hinge is markedly displaced and unstable, resulting in better clinical and patient reported outcomes. Methods: In this multicenter matched cohort study, patients with an unstable, displaced PHF, including anatomic neck fractures and significantly displaced surgical neck fractures, were included. Patients that were treated with a locking plate augmented with a fibula allograft were matched to patients who had undergone locking plate reconstruction without the allograft. The matches were made based on fracture characteristics, age, and performance status. Functional outcomes, Patient Reported Outcome Measures, complications, and radiographic results were compared. Results: Twelve patients with fibula allograft augmented osteosyntheses were included and matched to 12 control patients. The mean age was 58 years in the fibula allograft group compared to 62 years in the control group. Minimum follow-up was 12 months. Disability of the Arm Shoulder and Hand score, Constant Shoulder score, abduction, and external rotation were significantly better in the fibula allograft group (17.4 ± 8.6 vs. 26.1 ± 19.2, P = .048; 16.5 ± 11.5 vs. 19.8 ± 16.5 P = .040; mean 127° ± 38° vs. mean 92° ± 49° P = -.045; 50° ± 21° vs. mean 26° ± 23°, P = .004). There was no statistically significant difference in the Oxford Shoulder score between groups (P = .105). The Visual Analog Scale was not significantly different between groups (3.1 ± 1.8 vs. 1.6 ± 1.9, P = .439). Radiographic union was reached in 11 patients of the fibula allograft group compared to 8 in the control group (P = .317). The complication rate was twice as high in the control group (3 vs. 7). Conclusion: Additional support of the medial hinge in unstable PHFs with a locking plate in combination with a fibula allograft appears to create a more stable construct without compromising the viability of the articular surface of the head. The use of a fibula allograft in selected complex cases could therefore result in better clinical outcomes with lower complication rates.

Valgising angular stable plate fixation in the treatment of multifragmentary proximal humeral fractures in elderly patients.

INTRODUCTION: The frequency of proximal humeral fractures shows an increasing tendency, especially in the elderly, who are frequently affected by osteoporosis. The adequate treatment of complex, displaced fractures poses a serious challenge. Among surgical treatment options, osteosynthesis with an angular stable plate is preferred, however, the implant-related complication rate may be exceptionally high. In our present study, we report the short-term outcomes of our new method of valgising angular stable plate fixation which we use for multifragmentary, displaced proximal humeral fractures in elderly patients. MATERIALS AND METHODS: We retrospectively evaluated the clinical and radiological outcomes of 52 patients (46 female and 6 male, age: 71.9 ± 9.6) who suffered dislocated three- or four-part fractures and underwent valgising angular stable plate fixation. RESULTS: Mean follow-up time was 17.3 months, while the functional outcomes were as following: excellent in 26, good in 18, moderate in 5 and poor in 3 patients. The mean Constant-Murley Score was 82.5 ± 11.2. Functional outcomes only showed significant correlation (p = 0.031) with age and were proven unrelated to fracture type, BMI and known primary diseases. The cumulative complication rate was 9.6% and revision rate was 5.8%. Neurological deficit, pseudoarthrosis or avascular humeral head necrosis did not occur during the follow-up period. CONCLUSIONS: Valgising angular stable plate fixation that we apply for proximal humeral fractures provided favourable functional outcomes and a low postoperative complication rate due to the optimal head and plate placement. The method is especially effective for the treatment of displaced three- and four-part fractures with weakened, osteoporotic bone structure.

Tuberosity refixation improves functional outcome following primary reverse shoulder arthroplasty in proximal humeral fracture.

INTRODUCTION: The purpose of this prospective study was to examine clinical results of tuberosity refixation in RSA for the treatment of displaced PHF in elderly patients. We hypothesized that tuberosity refixation would increase clinical outcome. METHODS: In this prospective study, 50 patients were included after receive a primary RSA for complex proximal humeral fracture between March 2013 and December 2015 for follow-up after three, 12 and 24 months. A functional and radiological assessment was performed on the patients. RESULTS: At final follow-up after a mean period of 25.1 months, data were available for 30 women and 6 men (74% of the included overall study collective) with a mean age of 77 years (range 55-93 years) at time of surgery. The tuberosities were refixated in 74% (n = 37) and in 26% (n = 13) resected. RSA with tuberosity refixation resulted in better clinical shoulder function compared to RSA with non-refixated tuberosities. The data show an external rotation with a significant difference (24.9° vs. 14°, p < 0.05) in favor of participants with refixation. The raw CMS was statistically significant (71.3 vs. 56.3, p < 0.05) after refixation, and SSV was significant improved (82.7% vs. 68%, p < 0.05) in the same group. Among 3 of 50 patients a total of 3 complications occurred with a total of 6% surgical revision. CONCLUSIONS: In this prospective study, tuberosity refixation as part of fracture treatment using RSA results in better external rotation, subjective assessment of shoulder recovery (measured by SSV and by raw CMS) in elderly patients, compared with tuberosity excision. LEVEL OF EVIDENCE: II, Prospective comparative study.

The long-term results of shoulder hemiarthroplasty in irreducible four-part fracture-dislocation of the proximal humerus without rotator cuff tear arthropathy.

PURPOSE: Although there are concerns about nonunion of the greater tuberosity or shoulder weakness, hemishoulder arthroplasty (HSA) is a viable treatment option for irreducible four-part proximal humerus fractures-dislocation without rotator cuff tear arthropathy. This study aims to analyze the long-term radiological and functional outcomes of HSA. METHODS: This study enrolled 36 patients who underwent HSA due to irreducible four-part proximal humerus fracture-dislocation without rotator cuff tear arthropathy between March 2005 and May 2020. The exclusion group included 10 reverse total shoulder arthroplasty patients. The mean age and mean follow-up period were 68.6 years old and 48.6 months, respectively. Radiological assessments, such as vertical and horizontal greater tuberosity position, greater tuberosity healing, and implant position, were evaluated. Clinically, American Shoulder and Elbow Surgeons Score (ASES), Constant-Murley Score (CMS), and range of motion were evaluated. RESULTS: The greater tuberosity union rate was 55.6% (n = 20), with 44.4% (n = 16) experiencing nonunion, malunion, and bone resorption. The mean vertical and horizontal greater tuberosity positions showed significant difference at last follow-up compared to immediate postoperation. The retroversion of the implant was 23.8 ± 4.61°, and the acromio-humeral interval was 7.6 ± 1.34 mm. The mean last follow-up ASES and CMS were 39.5 ± 4.03 and 55.4 ± 10.41, respectively. The mean active forward flexion, abduction, internal rotation, and external rotation were 100.9 ± 15.04°, 92.5 ± 14.47°, 44.2 ± 12.83°, and 42.5 ± 15.32°, respectively. CONCLUSION: In long-term follow-up, the greater tuberosity was superiorly migrated and externally rotated. Active forward flexion and abduction in the last follow-up were significantly limited. However, in terms of pain relief, a satisfactory result was seen.

Clinical and radiographic long-term outcomes of hemiarthroplasty for complex proximal humeral fractures.

BACKGROUND: Hemiarthroplasty (HA) is a treatment option for complex proximal humeral fractures not suitable for conservative treatment or open reduction-internal fixation. Long-term outcomes using a large-metaphyseal volume prosthesis in the management of proximal humeral fractures have not been reported thus far. METHODS: Between 2006 and 2010, 41 patients with proximal humeral fractures were treated with HA at our institution (average age, 62 years; age range, 38-85 years). Nine patients underwent revision surgery, 3 were lost to follow-up, and 7 died unrelated to the index surgical procedure. Twenty-two patients were reviewed clinically and radiographically after a mean period of 10.4 years (range, 9-13 years). RESULTS: Of the 9 HA failures, 7 occurred within the first 2 postoperative years: 2 patients had infections and 5 had greater tuberosity nonunions or malunions. The other 2 patients underwent revision for rotator cuff deficiency >5 years after initial surgery. Among the patients available for final follow-up, the implant survival rate was 71% (22 of 31 patients). At final follow-up, these patients showed a mean relative Constant score of 76% (range, 49%-96%), mean active elevation of 116° (range, 60°-170°), and mean external rotation of 28° (range, 0°-55°). The majority had good or excellent internal rotation, with internal rotation to the 12th thoracic vertebra in 13 patients (59%) and to the eighth thoracic vertebra in 7 (31%). The mean Subjective Shoulder Value was 76% (range, 40%-100%). Clinical outcomes did not significantly deteriorate over a period of 10 years, except for flexion (P < .001) and internal rotation (P = .002). On analysis of greater tuberosity healing, 1 patient had a nonunion and 10 patients (45%) had a malunion, whereas the greater tuberosity had healed in an anatomic position in 12 patients (55%). Patients with a displaced malunion of the greater tuberosity did not have inferior clinical results at last follow-up. Only 2 patients showed glenoid erosion, and in no patients could stem loosening be identified at final follow-up. CONCLUSION: The revision rate following large-metaphyseal volume HA to treat a proximal humeral fracture was 29% after 10 years postoperatively, with failure within 2 years largely related to greater tuberosity nonunion or malunion and failure later related to rotator cuff insufficiency. Patients with a retained implant showed good clinical and radiographic long-term results, without relevant deterioration over time even when the greater tuberosity healed in a nonanatomic position.

Cell-Based Therapy by Autologous Bone Marrow-Derived Mononuclear Cells for Bone Augmentation of Plate-Stabilized Proximal Humeral Fractures: A Multicentric, Randomized, Open Phase IIa study.

Proximal humerus fractures are common in an aging population. The standard operative treatment is open reduction internal fixation (ORIF) using an angular stable plate. However, this procedure has complications such as a relatively high rate of secondary dislocation, humeral head necrosis or nonunion caused by delayed bony consolidation. Autologous bone marrow mononuclear cells (BMC) combined with a ß-TCP scaffold could support bone healing and is considered clinically safe. This multicentric, randomized, open phase IIa clinical trial (Clinical Trials. Gov Identifier: NCT02803177, Eudra CT No: 2015-001820-51) evaluated whether autologous BMC with ß-TCP in addition to ORIF reduces the incidence of secondary dislocations in patients with proximal humerus fracture. Ninty-four patients equally divided between verum group (BMC+ß-TCP) and control group (ß-TCP only) were targeted and calculated. At the time of planned interim evaluation, ie, enrolment of 56 patients, no statistical difference in secondary dislocations or complications was demonstrated in either group after an observation period of 12 weeks. Radiographic bone healing and DASH score to determine shoulder function were comparable between both groups. Bone marrow harvest and BMC transplantation did not result in any severe adverse events. Therefore, the study was terminated after the interim analysis, as no other result could be expected. From the study results, it can be concluded that the application of autologous BMC is well tolerated, and bone healing can be achieved. Augmentation of bone defects with ß-TCP could be shown to be feasible and might be considered in other clinical situations.

Preventing secondary screw perforation following proximal humerus fracture after locking plate fixation: a new clinical prognostic risk stratification model.

INTRODUCTION: After locking plate (LP) fixation, secondary screw perforation (SSP) is the most common complication in proximal humerus fracture (PHF). SSP is the main cause of glenoid destruction and always leads to reoperation. This study aimed to identify independent risk parameters for SSP and establish an individualized risk prognostic model to facilitate its clinical management. METHODS: We retrospectively reviewed the medical information of patients with PHF who underwent open reduction and internal LP fixation at one medical center (n = 289) between June 2013 and June 2021. Uni- and multivariate regression analyses identified the independent risk factors. A novel nomogram was formulated based on the final independent risk factors for predicting the risk of SSP. We performed internal validation through concordance indices (C-index) and calibration curves. To implement the clinical use of the model, we performed decision curve analyses (DCA) and risk stratification according to the optimal cutoff value. RESULTS: A total of 232 patients who met the inclusion criteria were enrolled. The incidence of SSP was 21.98% at the last follow-up. We found that fracture type (odds ratio [OR], 3.111; 95% confidence interval [CI], 1.223-7.914; P = 0.017), postoperative neck-shaft angle (OR, 4.270; 95% CI 1.622-11.239; P = 0.003), the absence of calcar screws (OR, 3.962; 95% CI 1.753-8.955; P = 0.003), and non-medial metaphyseal support (OR,7.066; 95% CI 2.747-18.174; P = 0.000) were independent predictors of SSP. Based on these variables, we developed a nomogram that showed good discrimination (C-index = 0.815). The predicted values of the new model were in good agreement with the actual values demonstrated by the calibration curve. Furthermore, the model's DCA and risk stratification (cutoff = 140 points) showed significantly higher clinical benefits. CONCLUSIONS: We developed and validated a visual and personalized nomogram that could predict the individual risk of SSP and provide a decision basis for surgeons to create the most optional management plan. However, future prospective and externally validated design studies are warranted to verify our model's efficacy.

Stress shielding: short-term radiological results of the reverse shoulder arthroplasty with an anatomic proximal coated stem in proximal humeral fractures.

PURPOSE: This study aims to determine the stress shielding and other radiological outcomes of patients who underwent an uncemented reverse shoulder arthroplasty (RSA) with an anatomic proximal coated stem for complex proximal humeral fractures (PHF) with 3 or 4 parts at 2 years postoperatively. METHODS: 37 shoulders underwent an uncemented RSA for PHF from November 2015 to February 2019 and were followed up for 2 years. A radiographic assessment of stress shielding, filling ratio, stem stability (radiolucent lines/subsidence/alignment), tuberosity healing and notch was performed. RESULTS: The mean age at the time of surgery was 72 years (range, 61-85). Stress shielding was appreciated in 31 shoulders (83.8%). The most important characteristic of stress shielding is cortical resorption: Grade 3 resorption occurred in 3 shoulders (8.1%) and grade 4 in 23 (62.2%) as per the grading system defined by Inoue et al. (Inoue et al. in J Shoulder Elbow Surg 26:1984-1989, 2017). A high occurrence of bone resorption was observed in Gruen zones 2 (Lateral Stress shielding) and 7 (Medial Stress shielding). The mean distal filling ratio in patients without stress shielding was 78,48(SD 14,9), whereas in patients with stress shielding, it was slightly higher with a mean of 81,68% (SD 4,89). Tuberosity healing was found in 94.6% (35/37) of the shoulders. No patient had any radiolucent line. No notch was observed. CONCLUSION: At short-term follow-up, a high rate of tuberosity healing was achieved (94.6%) even though stress shielding was found in 83.8% (31/37) of the shoulders. Bone resorption was most frequently observed externally at zone 2 (Lateral stress shielding) and internally at zone 7 (Medial stress shielding). A higher filling ratio was associated with an increased occurrence of stress shielding. The uncemented anatomic humeral component did not result in early loosening. LEVEL OF EVIDENCE: IV; Case Series; Treatment study.

Does age affect patient outcomes after humeral head replacement in the treatment of acute proximal humeral fractures? A comparative cohort study with a minimum 10 years long-term follow-up.

BACKGROUND: Humeral head replacement (HHR) is now rarely recommended for complex proximal humeral fractures (PHFs) in older patients. However, in relatively young and active patients with unreconstructable complex PHFs, controversy still exists regarding the treatment options of reverse shoulder arthroplasty and HHR. The goal of this study was to compare the survival, functional, and radiographic outcomes of HHR in patients aged <70 years and those aged ≥70 years after a minimum 10 years follow-up. METHODS: Eighty-seven out of 135 patients undergoing primary HHR were enrolled and then divided into 2 groups based on age: <70 years and ≥70 years. Clinical and radiographic evaluations were performed with a minimum follow-up of 10 years. RESULTS: There were 64 patients (mean, 54.9 years) in the younger group and 23 patients (mean, 73.5 years) in the older group. The younger and older groups had comparable 10-year implant survivorship (98.4% vs. 91.3%). Patients aged ≥70 years had worse American Shoulder and Elbow Surgeons scores (74.2 vs. 81.0, P = .042) and lower satisfaction rates (12% vs. 64%, P < .001) than younger patients. At the final follow-up, older patients had worse forward flexion (117° vs. 129°, P = .047) and internal rotation (17 vs. 15, P = .036). More greater tuberosity complications (39% vs. 16%, P = .019), glenoid erosion (100% vs. 59%, P = .077), and humeral head superior migration (80% vs. 31%, P = .037) were also identified in patients aged ≥70 years. CONCLUSIONS: Unlike the increased risk for revision and functional deterioration over time after reverse shoulder arthroplasty for PHFs in younger patients, a high implant survival rate with lasting pain relief and stable functional outcomes could be observed in younger patients after HHR during long-term follow-up. Patients aged ≥70 years had worse clinical outcomes, lower patient satisfaction, more greater tuberosity complications, and more glenoid erosion and humeral head superior migration than those aged <70 years. HHR should not be recommended for the treatment of unreconstructable complex acute PHFs in older patient populations.

Kirschner wire versus external fixation in the treatment of proximal humeral fractures in older children and adolescents: a comparative study.

OBJECTIVE: The purpose of this study was to compare the therapeutic effects of Kirschner wire fixation and external fixation in the treatment of proximal humeral fractures in older children and adolescents. METHODS: A retrospective analysis was performed on the clinical data of older children and adolescents who underwent surgery at our institution for proximal humeral fractures between April 2014 and May 2022. One group (n = 28) underwent fracture reduction and Kirschner wire fixation, and the other group (n = 23) underwent external fixation. During the follow-up, the differences in shoulder joint function between the two groups were compared by analysing Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) and Constant-Murley scores. Postoperative complications were also recorded. RESULTS: The operation time of the Kirschner wire group was shorter than that of the external fixation group (69.07 ± 11.34 min vs. 77.39 ± 15.74 min, P = 0.33). The time to remove the fixator in the external fixation group was shorter than that in the Kirschner wire group (6.74 ± 1.57 vs. 7.61 ± 1.22, P = 0.032). The Quick DASH score and Constant-Murley score of the patients in the external fixation group were significantly better than those in the Kirschner wire group at 3 months after surgery (5.63 ± 4.33 vs. 8.93 ± 6.40, P = 0.040; 93.78 ± 2.43 vs. 91.75 ± 2.15, P = 0.003). There was no significant difference in the Quick DASH score or Constant-Murley score between the patients in the external fixator group and those in the Kirschner wire group at 9 months after the operation (2.77 ± 3.14 vs. 3.17 ± 3.68, P = 0.683; 97.39 ± 1.80 vs. 96.57 ± 2.15, P = 0.152). The most common complication of the two groups was pin tract infection. The incidence rate of infection was higher in the external fixation group than that in the Kirschner wire group (9 vs. 4, P = 0.043). CONCLUSION: Both Kirschner wire fixation and external fixation of N-H III and IV proximal humeral fractures in older children and adolescents produce good outcomes. External fixation is a preferred surgical treatment option for paediatric proximal humerus fractures because early mobilization of the affected limb can be realized.