Clinical outcomes of triceps reflecting anconeus pedicle and olecranon osteotomy approach for distal humerus intercondylar fractures.

BACKGROUND: The preferred treatment for distal humeral intercondylar fractures is open reduction and internal fixation. While there is consensus about the posterior approach, several posterior approaches have been developed. It is debatable as to which approach is best. AIM: To compare triceps reflecting anconeus pedicle (TRAP) and olecranon osteotomy approaches for internal fixation of distal humeral intercondylar fracture. METHODS: In total, 40 cases of Arbeitsgemeinschaft für Osteosynthesefragen/Association of the Study of Internal Fixation type C, closed, and Gustilo type I intercondylar humeral fractures were included. Patients ranged in age from 18 years to 70 years. The patients were randomized into two groups: TRAP group and olecranon osteotomy group, with 20 cases in each. All were followed up at 6 wk, 3 months, 6 months, and 12 months. Functional outcomes were measured in terms of flexion-extension arc, Disabilities of Arm, Shoulder and Hand score, and Mayo Elbow Performance Score. RESULTS: The mean age was 43.2 years in the TRAP group and 37.5 years in the olecranon osteotomy group. The mean operative time and mean duration of hospital stay in the TRAP group were significantly higher than in the olecranon osteotomy group (119.5 vs 111.5 min and 9.85 vs 5.45 d, respectively). The mean arc of flexion-extension, Disabilities of Arm, Shoulder and Hand score, and Mayo Elbow Performance Score were comparable without any significant difference in the groups at the 12-month follow-up (107.0 vs 106.2, 18.3 vs 15.7, and 84.2 vs 86.2, respectively). Ulnar paresthesia and superficial infections were comparable in both groups (2 cases vs 3 cases and 3 cases vs 2 cases, respectively). Hardware prominence was significantly higher in the olecranon osteotomy group, mostly due to tension band wiring. CONCLUSION: Both approaches were equivalent, but there is a need for further study including higher numbers of subjects and longer study duration to prove the benefits of one approach over the other.

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.

The effect of plate location on radial nerve palsy recovery time associated with humeral shaft fractures.

BACKGROUND: This study aims to investigate the influence of plate placement on nerve regeneration in humerus fractures accompanied by radial nerve injury. METHODS: A retrospective analysis was conducted on a cohort of 94 patients with humerus fractures and concomitant radial nerve injury treated between January 2018 and November 2022. After applying exclusion criteria, 31 patients were included in the study. Clinical outcomes were assessed by comparing demographic data, surgical duration, radial nerve recovery time, the Mayo Elbow Performance Score (MEPS), Disabilities of the Arm Shoulder and Hand (DASH), and the Medical Research Council (MRC) scale. RESULTS: Two distinct groups were established: lateral plating and anteromedial (AM) plating. These groups demonstrated comparability regarding age, gender, and body mass index (BMI). No statistically significant differences were observed between the groups concerning MEPS and MRC. The AM plating group notably exhibited shorter surgical durations, faster recovery times, and lower DASH scores. CONCLUSION: According to the findings of this investigation, in cases of humerus fractures accompanied by radial nerve injury, AM plating may be preferable over lateral plating due to its association with reduced surgical durations and expedited nerve recovery.

[Trauma-associated vascular injuries and the vascular surgical/interventional options for vascular reconstruction]. / Traumaassoziierte Gefäßverletzungen und deren gefäßchirurgische/interventionelle Rekonstruktionsmöglichkeiten.

AIM: The aim of this work is to illustrate the diversity of vascular injuries in terms of vascular segments or body regions, accident mechanisms and specific patient constellations. METHOD: A representative case collection was compiled based on current and relevant scientific references in PubMed, own clinical experiences, vascular surgical and novel image-guided interventional options. RESULTS: The diagnostics of vascular injuries in the context of trauma and fractures are based on a thorough physical examination. In addition, the hard and soft signs preferred by the Western Trauma Association should be included in the decision. Doppler ultrasonography examination is the safest and gentlest noninvasive examination procedure for a suspected vascular injury due to repeatable and comparative measurements. The stabilization of a fracture, ideally using an external fixator, should be performed before vascular reconstruction whenever possible, unless massive bleeding, hypovolemic shock or a rapidly spreading hematoma represent an immediate indication for surgery. In pediatric supracondylar fractures, avascular injury without relevant ischemia has frequently been described (pink pulseless hand). In this case, the fracture should first be reduced as the pulse often recovers. Due to the increasing availability, good technical handling and high technical success rate as well as the relatively limited interventional trauma, endovascular treatment of traumatic vascular injuries has become widely accepted. Traumatic aortic ruptures are associated with a high mortality even at the accident site. Rapid endovascular treatment using a stent prosthesis significantly increases the injured person's chances of survival. CONCLUSION: Vascular injuries in connection with fractures or multiple injuries require interdisciplinary cooperation between the specialties involved.

[Elbow hemiarthroplasty for coronal shear fractures of the distal humerus]. / Ellenbogenhemiprothese bei koronaren Abscherfrakturen des distalen Humerus.

OBJECTIVE: The aim of the operation is to replace the articular surface of the distal humerus in cases of nonreconstructible fractures of the distal humerus. INDICATIONS: Active patients with high functional requirements, in whom weight limitation of total elbow arthroplasty should be avoided. CONTRAINDICATIONS: Contraindications include fractures with irreconstructible epicondyles and/or irreconstructible collateral ligaments, as well as ulnohumeral, or radiohumeral osteoarthritis. SURGICAL TECHNIQUE: Following subcutaneous anterior transposition of the ulnar nerve, surgical dislocation of the elbow joint is achieved through a paratricipital approach with release of the soft tissue structures from the humerus. After resection of the trochlea, the intramedullary canal of the humerus is prepared using rasps in order to implant the hemiprosthesis with retrograde cementing. Finally, the medial and lateral collateral ligaments as well as the flexors and extensors are repaired. POSTOPERATIVE MANAGEMENT: Early functional rehabilitation in a hinged elbow orthosis while avoiding varus/valgus stress after wound healing is completed. RESULTS: Between 2018 and 2022, 18 patients with coronal shear fractures were treated with elbow hemiarthroplasty. The mean Mayo Elbow Performance Score (MEPS) was 79 (70-95) after a mean follow-up of 12 months. The mean range of motion was 99° (70-130°) in extension-flexion and 162° (90-180°) in pronation-supination.

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.

Optimal Screw Orientation for Fixation of Coronal Shear Fractures: A Biomechanical Comparison.

OBJECTIVE: Coronal shear fractures of the capitellum are rare injuries which can be challenging to treat. The aim of this study was to compare the biomechanical properties of different internal screw fixation techniques for Dubberley type IA fractures of the capitellum. METHODS: In this biomechanical study, Dubberley type IA fractures of the capitellum were created in 30 human fresh-frozen humeri. The specimens were then divided into three groups: fixation was either performed with 3 x 3.0 mm headless cannulated compression screws (HCCSs) in anteroposterior (AP) orientation (AP group), 3 x 3.0 mm HCCSs in posteroanterior (PA) orientation (PA group) or with 2 x 3.0 mm HCCSs in PA orientation and 1 x 3.0 mm HCCS in lateral orientation (LAT group). Displacement under cyclic loading and ultimate load-to-failure were evaluated in all specimens. RESULTS: There was no significant difference in fragment displacement after 2000 cycles between AP and PA groups (0.8 ± 0.5 mm vs. 0.8 ± 0.6 mm; p = 0.987) or PA and LAT groups (0.8 ± 0.6 mm vs. 0.8 ± 0.3 mm; p = 0.966). LAT group showed the highest load-to-failure (548 ± 250 N) without reaching statistically significant difference to AP group (388 ± 173 N; p = 0.101). There was also no significant difference between AP and PA groups (388 ± 173 N vs. 422 ± 114 N; p = 0.649). CONCLUSIONS: Variations in screw placement had no statistically significant influence on cyclic displacement or load-to-failure in Dubberley Type IA fractures. However, fracture fixation in two planes - both the coronal and the sagittal plane - by adding a screw in a lateral to medial direction may be beneficial to increase primary stability.

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.

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.

Biomechanical analysis of push-pull principle versus traditional approach in locking plates for proximal humeral fracture treatment.

INTRODUCTION: Proximal humerus fractures are usually treated with locking plates, which could present recurrence, screw penetration, joint varization. The push-pull principle was introduced to prevent these risks and showed promising results; a dedicated design was then developed and this feasibility study aims to compare the biomechanical performances of such dedicated push-pull plate with the traditional locking plate using finite elements. MATERIALS AND METHODS: The humerus geometry was obtained from Sawbone CT-scans; the geometries of a traditional locking plate and of the dedicated push-pull one were used. A fracture was added below the humeral head and the plates were virtually implanted. The wire pulling mechanism was simulated connecting the plate to the humeral head apex, considering two levels of tension. Three testing set-ups (axial, torsion and compression bending) were simulated. Stress distributions on bone, plate and screws were measured. RESULTS: Stress distribution on the distal humerus was similar for both plates. Stress distribution on the proximal humerus was more homogeneous for the push-pull model, showing less unloaded sections (up to 78%). The different levels of tension applied to the wire returned slight differences in terms of stress values, but the comparison with the traditional approach gave similar outcomes. CONCLUSIONS: More homogeneous stress distribution is found with the push-pull plate in all three testing set-ups, showing lower unloaded areas (and thus lower stress-shielding) compared to the traditional plate; the screws implemented returned to be all loaded in at least one of the set-ups, thus showing that they all contribute to plate stability.

Low and high body mass index and lower numbers of screws in the articular segment are risk factors for non-union of distal humeral fractures in the elderly: A multi-center retrospective study (TRON study).

Background: Distal humerus fracture in the elderly is a challenging fracture for orthopedic surgeons. Non-union is one of the serious complications of distal humerus fracture after surgery. This retrospective multicenter study aimed to estimate the incidence of distal humeral non-union after open reduction and internal fixation, determine factors related to non-union, and compare the postoperative results of cases with non-union to cases with the union. Methods: Among 423 patients diagnosed with distal humeral fracture and who were treated by surgical therapy in 2010-2020 from our database called TRON. Only 190 subjects met the inclusion criteria. We performed a logistic regression analysis with the presence of non-union as the response variable to examine risk factors. We compare the Mayo Elbow Performance Scores of cases with non-union to cases with the union. Results: Non-union occurred after surgery in 15 patients (7.9%). The logistic regression analysis showed that body mass index<20 kg/m2 and ≥25 kg/m2, and ≤3 screws in the articular segment were significant explanatory factors for non-union (odds ratio 10.4 and 47.8, respectively). The Mayo Elbow Performance Scores were significantly worse in patients with non-union. Discussion: Low and high body mass index and three or fewer screws in the articular segment might be risk factors for non-union of distal humerus fracture in the elderly. Non-union is associated with poor clinical outcomes.

A Systemic Review of Adolescent Supracondylar Fractures: What Is the Surgical Treatment, Open Reduction With Internal Fixation (ORIF) or Closed Reduction With Percutaneous Pinning (CRPP)?

Supracondylar humerus (SCH) fractures represent the most frequent elbow injury in young children. These fractures can be treated through either closed reduction with percutaneous pinning (CRPP) or open reduction with internal fixation (ORIF). Yet, the optimal treatment option for adolescents remains unclear. This research contrasts the results of CRPP and ORIF treatments for distal humerus fractures in adolescents. In June 2023, we conducted a comprehensive search of PUBMED, OVID MEDLINE, Web of Science, Cochrane Central Register of Controlled Trials, and various trial registries without any time restrictions. We evaluated the quality of qualifying studies using the Methodological Index for Non-randomized Studies (MINORS) and Cochrane risk measures for bias. We extracted data particularly related to patient demographics, fracture details, medical procedures followed, complications encountered, and the resulting outcomes. Out of the 488 studies identified, only four satisfied the inclusion criteria. Both methods illustrated comparable outcomes in terms of range of motion, averaging approximately 118 degrees in the ORIF group versus a span of 114 to 128 degrees in the CRPP group. The immobilization period varied, spanning 10 to 13 days for ORIF versus 24 to 29 days for CRPP. Despite this, CRPP displayed a decreased necessity for additional surgery. Notably, one study indicated a higher frequency of heterotopic ossification within the ORIF group. This review indicates that both CRPP and ORIF are effective for treating supracondylar fractures in adolescents, yielding similar results. However, CRPP has a lower need for follow-up surgery. Future studies with larger sample sizes are needed to solidify these findings, providing stronger guidance for treatment.

Biomechanical Comparisons of All-Suture Suspensory Button versus Interference Screw for Inlay Subpectoral Bicep tenodesis.

BACKGROUND: All-suture buttons (ASB) and interference screw (IS) are commonly utilized in the inlay subpectoral biceps tendon tenodesis. However, the biomechanical characteristics of these two methods have not been compared directly. The aim of present study was to compare the biomechanical properties of ASB versus IS for inlay subpectoral biceps tendon tenodesis in a human cadaveric model. METHODS: Sixteen fresh-frozen human cadaveric shoulders were randomly divided into two experimental inlay biceps tenodesis groups: ASB or IS. After tenodesis, every specimen was preloaded at 5 N for 2 minutes, followed with a cyclic loading test from 5 to 70 N for 500 load cycles. Then the load-to-failure test was performed. Afterwards, the humerus was placed in a cylinder tube and secured with anchoring cement. Lastly, a two-point bending test was performed to determine the strength of the humerus. Destructive axial force was applied, and the failure strength and displacement were recorded. RESULTS: No difference in stiffness was observed between the two groups (ASB=27.4 ± 3.5 N/mm vs IS= 29.7 ± 3.0 N/mm; P=.270). Cyclic displacement was significantly greater in the ASB group (6.8 ± 2.6 mm) than the IS group (3.8 ± 1.1 mm; P=.021). In terms of failure load, there were no statistical differences among the two groups (P=.234). The ASB group was able to withstand significantly greater displacement (11.9 ± 1.6 mm) before failure than the IS group (7.8 ± 1.5mm; P=.001). During the humeral bending test, the ASB group exhibited significantly greater maximal load (2354.8 ± 285.1 N vs 2086.4 ± 296.1 N; P=.046) and larger displacement (17.8 ± 2.8mm vs 14.1± 2.8 mm; P=.027) before fracture. CONCLUSIONS: In inlay subpectoral bicep tenodesis, ASB fixation appears to offer comparable stiffness and failure load to that of IS fixation. Additionally, the ASB group exhibited greater resistance to load and displacement before humeral fracture. However, the ASB group did demonstrate increased cyclic displacement compared to IS group.

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 (PHFs). 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 2 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 < .001). Moreover, the 7-52-week cohort had significantly higher odds of revision indicated for dislocation (OR 2.24, P < .001), mechanical loosening (OR 1.71, P < .001), PJI (OR 1.74, P < .001), and PPF (OR 1.96, P < .001). CONCLUSIONS: Using SSLR, we were successful in identifying 2 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 4-6 weeks of nonoperative management may be appropriate without altering the risks associated with RTSA.

A Partial Frontal Fracture of the Humeral Trochlea: A Case Report.

Fractures of the lower end of the humerus are uncommon but serious, potentially compromising elbow function. This article reports the case of a young patient with a fracture of the inner cheek of the humeral trochlea, resulting from a public road accident. The diagnosis was established by radiography and CT scan, confirming a displaced fracture associated with an avulsion fracture of the coronoid process. Surgical treatment was carried out with fixation of the osteochondral fragment and evacuation of the intra-articular fragments. Two months after the operation, the patient regained good joint function with a resumption of professional activity.

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.

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.

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.