Surgical treatment of displaced proximal humerus fractures is associated with decreased 1-year mortality in patients aged 65 years and older: a retrospective study of Medicare patients.

BACKGROUND: Proximal humerus fracture (PHF) is a risk factor for 1-year mortality. This study aimed to determine if surgery is associated with lower mortality compared to nonoperative treatment following PHF in older patients. METHODS: This retrospective cohort study used the Medicare Limited Data set. Patients aged 65 years and older with a PHF diagnosis in 2017-2020 were included. Treatment was classified as nonoperative, open reduction internal fixation (ORIF), total shoulder arthroplasty (TSA), or hemiarthroplasty. Multivariable logistic regression models examined (a) predictors of treatment type and (b) the association of treatment type with 1-year mortality, adjusting for patient demographics, comorbidities, frailty, and fracture severity among other variables. A subgroup analysis examined how the relationship between treatment type and 1-year mortality varied based on fracture severity. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) are reported. RESULTS: In total, 49,072 patients were included (mean age = 76.6 years, 82.3% female). Most were treated nonoperatively (77.5%), 10.9% underwent ORIF, 10.6% underwent TSA, and 1.0% underwent hemiarthroplasty. Examples of factors associated with receipt of operative (versus nonoperative treatment) included worse fracture severity and lower frailty. The 1-year mortality rate after the initial PHF diagnosis was 11.0% for the nonoperative group, 4.0% for ORIF, 5.2% for TSA, and 6.0% for hemiarthroplasty. Compared to nonoperative treatment, ORIF (aOR 0.55; 95% CI [0.47, 0.64]; P < .001) and TSA (aOR 0.59; 95% CI [0.50, 0.68]; P < .001) were associated with decreased odds of 1-year mortality. In the subgroup analysis, ORIF and TSA were associated with a lower 1-year mortality risk for 2-part and 3-/4-part fractures. CONCLUSIONS: Compared to nonoperative treatment, surgery (particularly TSA and ORIF) was associated with a decreased odds of 1-year mortality. This relationship remained significant for 2-part and 3-/4-part fractures after stratifying by fracture severity.

What Are the Functional Outcomes and Pain Scores after Medial Clavicle Fracture Treatment?

BACKGROUND: Medial clavicle fractures are uncommon, occurring in older and multiply injured patients. The management of these fractures and the factors that predispose toward poor outcomes are controversial. Furthermore, the functional outcomes of treatment are not well characterized or correlated with fracture patterns. QUESTIONS/PURPOSES: (1) To determine minimum 1-year functional outcomes using QuickDASH scores and pain scores after medial clavicle fractures and (2) to identify factors associated with these outcome variables. METHODS: In an institutional review board-approved, retrospective study, we identified adult patients with medial clavicle fractures at two tertiary care referral centers in a single metropolitan area in the United States from January 2010 to March 2019. Our initial query identified 1950 patients with clavicle fractures, from which 74 adult patients with medial clavicle fractures and at least 1 year of follow-up were identified. We attempted to contact these eligible patients by telephone for functional outcomes and pain scores. Twenty-six patients were deceased according to the most recent Social Security Death Index data and public obituaries, three declined participation, and 14 could not be reached, leaving 42% of the total (31 of 74) and 65% (31 of 48) of living patients included in the analysis. Demographic characteristics, fracture characteristics, and clinical and radiographic union as assessed by plain radiography and CT were collected through record review. Twenty-nine patients were treated nonoperatively and two patients underwent open reduction internal fixation. Sixty-eight percent (21 of 31) of the included patients also had radiographic follow-up at least 6 weeks postoperatively; two patients had persistent nonunion at a mean of 5 ± 3 years after injury. Our primary response variable was the QuickDASH score at a minimum of 1 year (median [range] 5 years [2 to 10]). Our secondary response variable was the pain score on a 10-point Likert scale. A bivariate analysis was performed to identify factors associated with these response variables. The following explanatory variables were studied: age, gender, race, dominant hand injury, employment status, manual labor occupation, primary health insurance, social deprivation, BMI, diabetes mellitus, smoking status, American Society of Anesthesiologists physical status classification, Charlson Comorbidity Index, nonisolated injury, high-energy mechanism of injury, nondisplaced fracture, fracture comminution, superior-inferior fracture displacement, medial-lateral fracture shortening, and surgical treatment of the medial clavicle fracture. RESULTS: The mean QuickDASH score was 12 ± 15, and the mean pain score was 1 ± 1 at a mean of 5 ± 3 years after injury. The mortality rate of the cohort was 15% (11 of 74) at 1 year, 22% (16 of 74) at 3 years, and 34% (25 of 74) at 5 years after injury. With the numbers available, no factors were associated with the QuickDASH score or pain score, but it is likely we were underpowered to detect potentially important differences. CONCLUSION: Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury. This likely reflects both the frailty of a predominantly older patient population and the fact that these often are high-energy injuries. The outcome measures in our cohort were not associated with fracture displacement, shortening, or comminution; however, our sample size was underpowered on these points, and so these findings should be considered preliminary. Further studies are needed to determine the subset of patients with this injury who would benefit from surgical intervention. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Mortality after a proximal humeral fracture.

AIMS: The aims of this study were to investigate the mortality following a proximal humeral fracture. Data from a large population-based fracture register were used to quantify 30-day, 90-day, and one-year mortality rates after a proximal humeral fracture. Associations between the risk of mortality and the type of fracture and its treatment were assessed, and mortality rates were compared between patients who sustained a fracture and the general population. METHODS: All patients with a proximal humeral fracture recorded in the Swedish Fracture Register between 2011 and 2017 were included in the study. Those who died during follow-up were identified via linkage with the Swedish Tax Agency population register. Age- and sex-adjusted controls were retrieved from Statistics Sweden and standardized mortality ratios (SMRs) were calculated. RESULTS: A total of 18,452 patients who sustained a proximal humeral fracture were included. Their mean age was 68.8 years (16 to 107) and the majority (13,729; 74.4%) were women. A total of 310 (1.68%) died within 30 days, 615 (3.33%) within 90 days, and 1,445 (7.83%) within one year after the injury. The mortality in patients sustaining a fracture and the general population was 1,680/100,000 and 326/100,000 at 30 days, 3,333/100,000 and 979/100,000 at 90 days, and 7,831/100,000 and 3,970/100,000 at one year, respectively. Increasing age, male sex, low-energy trauma, type A fracture, concomitant fractures, and non-surgical treatment were all independent factors associated with an increased risk of mortality. CONCLUSION: Compared with the general population, patients sustaining a proximal humeral fracture have a significantly higher risk of mortality up to one year after the injury. The risk of mortality is five times higher during the first 30 days, diminishing to two times higher at one year, suggesting that these patients constitute a strikingly frail group, in whom appropriate immediate management and medical optimization are required. Cite this article: Bone Joint J 2020;102-B(11):1484-1490.

Mortality after inpatient stay for proximal humeral fractures.

BACKGROUND: A proximal humeral fracture is well established as a fracture of fragility in elderly patients. However, this injury does not receive the same emphasis on post-injury management as a femoral neck fracture. The objectives of this study were to establish the influence of sustaining a proximal humeral fracture on mortality and to identify the variables predictive of 5-year mortality. METHODS: Between January 2007 and January 2011, 288 consecutive patients who were admitted after sustaining a proximal humeral fracture were identified from the clinical coding department. Data were retrospectively collected and included patient demographic characteristics, comorbidities, anemia, physical and social independence, length of inpatient stay, management, and mortality. RESULTS: Of the patients, 13 (4.5%) had died at 1 month; 28 (9.7%), at 3 months; 46 (16.0%), at 1 year; and 117 (40.6%), at 5 years. A Cox proportional hazards regression identified male sex, comorbidities, unemployment or retirement, and nonoperative management as independent predictors of 5-year mortality. CONCLUSIONS: Elderly patients who require admission after sustaining a proximal humeral fracture are frail and subject to a greater-than-average risk of mortality for their age. The risk of mortality is greater for those of male sex who have comorbidities and a loss of physical and social independence.

Epidemiology and mortality in older patients treated by reverse shoulder arthroplasty for displaced proximal humerus fractures.

INTRODUCTION: Reverse shoulder arthroplasty (RSA) is rapidly becoming the preferred treatment for displaced proximal humerus fractures in older patients. However, few studies have analyzed the target population and the effect of RSA on survival, although the socioeconomic impact of this type of surgery is considerable. PATIENTS AND METHODS: This was a retrospective epidemiological study of all patients with a displaced proximal humeral fracture treated by RSA in 14 public and private hospitals throughout France between 1995 and 2016. The French hospital discharge database (PMSI) was analyzed to isolate an 898-patient cohort who underwent RSA within 6 weeks of the fracture event. In 87% of cases, this was a 3- or 4-fragment fracture. We analyzed the epidemiological characteristics of the patients at the time of fracture, their survival (Kaplan-Meier estimate) and factors that may impact survival. RESULTS: The mean age at the time of fracture and surgery was 79 years (46-98 years). Eighty percent of the cohort was female (sex ratio: 0.18 [p=0.0042], with 21% obesity rate [BMI>30]) and 60% of patients were ASA 1-2. The most common comorbidities were cardiovascular and neurological. The survival rate after RSA was 94% at 1 year and 73% at 5years. At the latest follow-up of 19 years, 42% of patients were still alive. In 18% of cases, the patient died within the first 15 days. The presence of comorbidities (ASA score>3-4) (p<0.004) and/or cognitive disorders (p<0.0001) were risk factors for early mortality. The time to surgery, type of fracture, associated fractures and discharge destination (return home, transfer to nursing home) had no effect on postoperative mortality in our cohort. CONCLUSION: Despite being older (79 years) at the time of proximal humerus fracture, patients who underwent RSA treatment had a high survival rate (94% at 1 year, 73% at 5years), which is better than the survivorship reported after surgical treatment of femoral neck fractures (81-87% at 1 year, 38% at 5years). The presence of comorbidities (ASA>3-4) and/or cognitive disorders are risk factors for early mortality and should be taken into account to prevent early death. LEVEL OF EVIDENCE: IV, Retrospective study.

Readmissions, revisions, and mortality after treatment for proximal humeral fractures in three large states.

BACKGROUND: Proximal humeral fractures can be treated non-operatively or operatively with open reduction and internal fixation (ORIF) and arthroplasty. Our objective was to assess practice patterns for operative and non-operative treatment of proximal humeral fractures. We also report on complications, readmissions, in-hospital mortality, and need for surgery after initial treatment of proximal humeral fractures in California, Florida, and New York. METHODS: The State Inpatient Databases and State Emergency Department Databases from the Healthcare Cost and Utilization Project, sponsored by the Agency for Healthcare Research and Quality, were used for the states of California (2005-2011), Florida (2005-2014), and New York (2008-2014). Data on patients with proximal humeral fractures was extracted. Patients underwent non-operative or operative (ORIF or arthroplasty) treatment at baseline and were followed for at least 4 years from the index presentation. If the patient needed subsequent surgery, time to event was calculated in days, and Kaplan-Meier survival curves were plotted. RESULTS: At the index visit, 90.3% of patients with proximal humeral fractures had non-operative treatment, 6.7% had ORIF, and 3.0% had arthroplasty. 7.6% of patients initially treated non-operatively, 6.6% initially treated with ORIF, and 7.2% initially treated with arthroplasty needed surgery during follow-up. Device complications were the primary reason for readmission in 5.3% of ORIF patients and 6.7% of arthroplasty patients (p < 0.0001). All-cause in-hospital mortality was 9.8% for patients managed non-operatively, 8.8% for ORIF, and 10.0% for arthroplasty (p = 0.003). CONCLUSIONS: A majority of patients with proximal humeral fractures underwent non-operative treatment. There was a relatively high all-cause in-hospital mortality irrespective of treatment. Given the recent debate on operative versus non-operative treatment for proximal humeral fractures, our study provides valuable information on the need for revision surgery after initial treatment. The differences in rates of revision surgery between patients treated non-operatively, with ORIF, and with arthroplasty were small in magnitude. At nine years of follow-up, ORIF had the lowest probability of needing follow-up surgery, and arthroplasty had the highest.

[Traumatology in the elderly : Multimodal prevention of delirium and use of augmentation techniques]. / Alterstraumatologie : Multimodale Delirprävention und Verwendung von Augmentationstechniken.

Recent data show that 20-80% of surgery patients are affected by delirium during inpatient clinical treatment. The medical consequences are often dramatic and include a 20 times higher mortality and treatment expenses of the medical unit increase considerably. At the University Hospital of Münster a multimodal and interdisciplinary concept for prevention and management of delirium was developed: all patients older than 65 years admitted for surgery are screened by a specialized team for the risk of developing delirium and treated by members of the team if there is a risk of delirium. Studies proved that by this multimodal approach the incidence of delirium was lowered and therefore the quality of medical care improved.When surgical treatment of fractures in the elderly is required, limited bone quality as well as pre-existing implants can complicate the procedure. Secondary loss of reduction after osteosynthesis and avulsion of the implant in particular must be prevented. Augmentation of the osteosynthetic implant with bone cement can increase the bone-implant interface and therefore stability can be improved. Additional intraoperative 3D imaging can be necessary depending on the localization of the fracture. In biomechanical studies we could prove greater stability in the osteosynthesis of osteoporotic fractures of the distal femur when using additional bone cement; therefore, the use of bone cement is an important tool, which helps to prevent complications in the surgical treatment of fractures in the elderly. Nevertheless, special implants and technical skills are required and some safety aspects should be considered.

Evidencia orientada al paciente: tratamiento de fracturas desplazadas de húmero proximal en adultos / Treatment of displaced fractures of the proximal humerus in adults

El tratamiento de fracturas desplazadas de húmero proximal puede realizarse de manera conservadora o quirúrgica. A partir de una viñeta clínica en la cual una señora adulta mayor tiene una fractura de húmero proximal por una caída de su propia altura se realizó una búsqueda bibliográfica que identificó una revisión sistemática Cochrane que compara ambas alternativas de tratamiento. Los resultados clínicos que resume esta revisión indican que el tratamiento quirúrgico no sería superior al tratamiento conservador y se asociaría a un número mayor de procedimientos quirúrgicos adicionales. (AU)

The treatment of displaced fracture of the proximal humerus can be managed surgically or conservatively. From a clinical vi-gnette in which an elderly woman suffers a proximal fracture of the humerus due to a fall from her own height, a bibliographic search was run and identified a Cochrane systematic review which compared both treatment options. The clinical results sum-marized in this review indicated that surgical treatment would not be superior to conservative management. Furthermore, surgi-cal treatment would be associated with a greater number of additional surgical procedures. (AU)

Outcome after operative treatment of proximal humeral fractures in elderly patients.

BACKGROUND: The proximal humeral fracture (PHF) (5 %) of the elderly is the third most common fracture after proximal femoral and distal radius fractures. Proximal femoral fractures often lead to a loss of autonomy. OBJECTIVES: The aim of this study is to show how PHF changes the patient's autonomy and the coping with everyday life as well as which factors influence the outcome 1 year (y) after surgery. MATERIALS AND METHODS: Data of 62 patients with surgical treatment of a PHF ≥ 60 y was prospectively collected. With a telephone interview Short Form (SF) 12 (physical and mental health; PH, MH), Barthel Index (BI), range of motion, pain, and satisfaction was observed after 3 and 12 months. The dependence of outcome on different factors was investigated. RESULTS: The mean age was 73.3 y (median 73, 60-94). Mortality after 3 months was 3 % and after 1 y 11 %. The PH before the injury (47.9) was significantly better than after 3 months (37.1) and after 1 y (42.6). The MH showed no difference. The BI before the injury (92) was significantly better than after 3 months (86), but the same after 1 y (91). After 1 y > 50 % were able to abduct and flex the arm > 90°. More than two-thirds were able to perform everyday life activities for body care and nutrition after 1 y. Approximately, 73 % of the patients had little or no pain, and 84 % were satisfied with the result after 1 y. Good score values before the fracture resulted in better outcome. Higher severity in fracture led to a higher level of pain. DISCUSSION: A surgically treated PHF in the elderly does not lead to a relevant impairment in quality of life. Despite the lack of complete retrieval of range of motion patients achieve a good to very good result in coping with everyday life.

Mortality after shoulder arthroplasty: 30-day, 90-day, and 1-year mortality after shoulder replacement--5853 primary operations reported to the Danish Shoulder Arthroplasty Registry.

BACKGROUND: The primary aim was to quantify the 30-day, 90-day, and 1-year mortality rates after primary shoulder replacement. The secondary aims were to assess the association between mortality and diagnoses and to compare the mortality rate with that of the general population. METHODS: The study included 5853 primary operations reported to the Danish Shoulder Arthroplasty Registry between 2006 and 2012. Information about deaths was obtained from the Danish Cause of Death Register and the Danish Civil Registration System. Age- and sex-adjusted control groups were retrieved from Statistics Denmark. RESULTS: The mean age was 69.3 ± 11.6 years, and 69.2% of patients were women. Of the patients, 39 (0.7%) died within 30 days, 88 (1.5%) within 90 days, and 222 (3.8%) within 1 year. Fracture patients had an incidence rate of 1256 per 100,000 within 30 days, which was significantly higher than the incidence rate of 182 per 100,000 in the general population (P < .001), whereas osteoarthritis patients had an incidence of 111 per 100,000, which was significantly lower than the incidence rate of 125 per 100,000 in the general population. CONCLUSIONS: Fracture patients had a 6 times higher incidence of death within 30 days than the general population. However, the difference was equalized during the first year. This finding indicates that the injury and arthroplasty procedure are associated with an increased risk of death for these patients. Pulmonary, cardiac, and abdominal causes of death were common, and for fracture patients in particular, close postoperative monitoring of pulmonary, cardiac, and abdominal conditions seems important.

A Comparison of the Charlson and Elixhauser Comorbidity Measures to Predict Inpatient Mortality After Proximal Humerus Fracture.

OBJECTIVES: Proximal humerus fractures are very common in infirm elderly patients and are associated with appreciable inpatient mortality. We sought to compare the discriminative ability of the Charlson and Elixhauser comorbidity measures for predicting inpatient mortality after proximal humerus fractures. METHODS: Data from the Nationwide Inpatient Sample (2002-2011) were obtained. We constructed 2 main multivariable logistic regression models, with inpatient mortality as the dependent variable and 1 of the 2 comorbidity scores, as well as age and sex, as independent variables. A base model that contained only age and sex was also evaluated. The predictive performance of the Charlson and Elixhauser comorbidity measures was assessed and compared using the area under the receiver operating characteristic curve (AUC) derived from these regression models. RESULTS: Elixhauser comorbidity adjustment provided better discrimination of inpatient mortality [AUC = 0.840, 95% confidence interval (CI), 0.828-0.853] than the Charlson model (AUC = 0.786, 95% CI, 0.771-0.801) and the base model without comorbidity adjustment (AUC = 0.722, 95% CI, 0.705-0.740). In terms of relative improvement in predictive ability, the Elixhauser score performed 46% better than the Charlson score. CONCLUSIONS: Given that inadequate comorbidity risk adjustment can unfairly penalize hospitals and surgeons that care for a disproportionate share of infirm and sick patients, wider adoption of the Elixhauser measure for mortality prediction after proximal humerus fracture-and perhaps other musculoskeletal injuries-merits to be considered.

Increased mortality after upper extremity fracture requiring inpatient care.

BACKGROUND AND PURPOSE: Increased mortality after hip fracture is well documented. The mortality after hospitalization for upper extremity fracture is unknown, even though these are common injuries. Here we determined mortality after hospitalization for upper extremity fracture in patients aged ≥16 years. PATIENTS AND METHODS: We collected data about the diagnosis code (ICD10), procedure code (NOMESCO), and 7 additional characteristics of 5,985 patients admitted to the trauma ward of Central Finland Hospital between 2002 and 2008. During the study, 929 women and 753 men sustained an upper extremity fracture. The patients were followed up until the end of 2012. Mortality rates were calculated using data on the population at risk. RESULTS: By the end of follow-up (mean duration 6 years), 179 women (19%) and 105 men (14%) had died. The standardized mortality ratio (SMR) for all patients was 1.5 (95% CI: 1.4-1.7). The SMR was higher for men (2.1, CI: 1.7-2.5) than for women (1.3, CI: 1.1-1.5) (p < 0.001). The SMR decreased with advancing age, and the mortality rate was highest for men with humerus fractures. INTERPRETATION: In men, the risk of death related to proximal humerus fracture was even higher than that reported previously for hip fracture. Compared to the general population, the SMR was double for humerus fracture patients, whereas wrist fracture had no effect on mortality.

Association of perioperative blood transfusion and adverse events after operative treatment of proximal humerus fractures.

BACKGROUND: The purpose of this study was to assess the relationship between perioperative blood transfusion for proximal humerus fracture and inpatient mortality, adverse events, prolonged hospital stay, and nonroutine disposition. METHODS: Among the >55,000 patients with an operatively treated proximal humerus fracture identified in the Nationwide Inpatient Sample between 2008 and 2011, 17% received a perioperative blood transfusion. Multivariable logistic regression analyses addressed the association of blood transfusion with inpatient mortality, adverse events, hospital stay, and nonroutine discharge, accounting for comorbidities and other known confounders. RESULTS: Perioperative blood transfusion for fracture of the proximal humerus was not associated with inhospital death, but it was independently associated with inpatient adverse events (odds ratio (OR) 4.4, 95% confidence interval (CI) 4.2-4.6), prolonged hospital stay (OR 2.8, 95% CI 2.7-2.9), and increased nonroutine discharge (OR 1.8, 95% CI 1.7-1.9). CONCLUSIONS: Inpatients with fracture of the proximal humerus who receive transfusion are not more likely to die in hospital, but they do stay longer, experience more adverse events, and are less likely to be discharged home. Additional study is merited to determine if the judicious use of blood transfusion in the perioperative period can decrease inpatient morbidity and health-care resource utilisation. LEVEL OF EVIDENCE: Level II, Retrospective Design, Prognosis Study.

The outcome of proximal humeral fractures in the elderly: predictors of mortality and function.

This study describes the epidemiology and outcome of 637 proximal humeral fractures in 629 elderly (≥ 65 years old) patients. Most were either minimally displaced (n = 278, 44%) or two-part fractures (n = 250, 39%) that predominantly occurred in women (n = 525, 82%) after a simple fall (n = 604, 95%), who lived independently in their own home (n = 560, 88%), and one in ten sustained a concomitant fracture (n = 76, 11.9%). The rate of mortality at one year was 10%, with the only independent predictor of survival being whether the patient lived in their own home (p = 0.025). Many factors associated with the patient's social independence significantly influenced the age and gender adjusted Constant score one year after the fracture. More than a quarter of the patients had a poor functional outcome, with those patients not living in their own home (p = 0.04), participating in recreational activities (p = 0.01), able to perform their own shopping (p < 0.001), or able to dress themselves (p = 0.02) being at a significantly increased risk of a poor outcome, which was independent of the severity of the fracture (p = 0.001). A poor functional outcome after a proximal humeral fracture is not independently influenced by age in the elderly, and factors associated with social independence are more predictive of outcome.

[Morbidity and mortality of surgically treated proximal humerus fractures]. / Morbimortalidad en fracturas de húmero proximal tratadas quirúrgicamente.

BACKGROUND: The aim of the present study is to analyse the factors associated with mortality and the capacity to perform daily life activities (DLA) in patients with surgically treated proximal humeral fractures. METHODS: A retrospective study was conducted on 94 patients with a surgically treated proximal humeral fracture, with a mean follow-up of 8 years (2 - 12 years). A correlation analysis was performed to determine the relationship between the type of fracture, surgical technique, comorbidities and mortality and DLA. The Student t test was used for statistical analysis. RESULTS: A total of 72 patients were identified, 18.6% of them died during follow-up, all diagnosed with some comorbidity. There was no correlation between mortality, type of fracture or the technique used. Most of the patients (85.4%) had comorbidities, and 79.5% were completely independent for DLA. Although there was no relationship with the type of fracture, there was a significant reduction in the performing of DLA in patients treated with hemiarthroplasty, and in patients with neurological disorders. CONCLUSIONS: There was a mortality of 18.6% among patients with surgically treated proximal humerus fractures. The majority of surgically treated patients were fully independent for DLA at long-term follow-up.

External validity of a population-based study on osteoporosis and fracture.

BACKGROUND AND PURPOSE: Little is known about the characteristics of non-participants in epidemiological studies. We evaluated external validity by comparing fracture and mortality rate in participants and non-participants in a longitudinal study on risk factors for fracture. METHODS: 1,604 randomly selected women, 75 years of age, were invited to attend a study on osteoporosis and fracture. 1,044 women attended the study (participants) and 560 women did not participate (non-participants). Fracture data for all were obtained prospectively from radiographic records. Mortality data were obtained through the population register. Mean follow-up was 13 (11-15) years. Cumulative survival was compared with the log-rank test. Fracture incidence rates per 1,000 person-years were compared with Mann-Whitney U-tests. In addition, fracture comparisons were made with the cumulative incidence function and Gray's test. RESULTS: 454 participants (44%) died during the follow-up, as compared to 372 of the non-participants (66%) (p < 0.001). The fracture incidence rate for any type of fracture was 43 for participants and 47 for non-participants (p = 1.0). The fracture incidence rate for typical osteoporotic fracture was 36 for participants and 39 for non-participants (p = 0.6). The corresponding values for distal forearm fracture were 11 and 7 (p = 0.002), they were 8 and 9 for proximal humerus fracture (p = 0.9), 13 and 10 for vertebral fracture (p = 0.007), 15 and 18 for hip fracture (p = 0.8), and they were 6 and 5 for pelvic fracture (p = 0.3). The cumulative incidence function confirmed the results. INTERPRETATION: Our findings suggest that participants had a lower mortality rate than non-participants. Distal forearm and vertebral fractures were more frequent in participants. However, the external validity for fractures in general appeared to be satisfactory.

Shoulder hemiarthroplasty for complex humeral fractures: a 5 to 10-year follow-up retrospective study.

BACKGROUND: Shoulder hemiarthroplasty is considered a standard treatment in case of complex proximal humeral fractures. However, great variability affects the clinical outcomes. In this work, we examined the clinical and radiographic outcomes in a series of patients treated with hemiarthroplasty for 3- and 4-part humeral fractures and focused on factors affecting the final result. MATERIALS AND METHODS: In this study, we included 27 patients who had received a shoulder hemiarthroplasty between 2001 and 2005 at our institution. These patients were evaluated at an average of 7.2 years after surgery. All patients were managed within 10 days from trauma by the same surgeon and underwent the same time-scheduled rehabilitation program. Average age at surgery was 71.9 years. RESULTS: Implant survival was 88.9 %. At the latest follow-up, mean DASH and SST-12 scores were 26.8 and 6.5, respectively. Mean Constant-Murley score was 52.4. Tuberosities complications and reduction in the acromion-humeral distance were negatively related to clinical outcome. Age at surgery displayed a negative correlation with clinical outcome, despite not reaching the statistical significance. This is mainly due to great variability in the elder group of patients. CONCLUSIONS: Shoulder hemiarthroplasty is a useful and effective solution for complex humeral fractures, with good results in the majority of patients. However, outcomes display a great variability in relation to X-ray alterations and age at surgery. A careful attention in patient selection is needed in order to standardize the clinical results associated with this kind of prosthetic implant.

Falls and comorbidity: the pathway to fractures.

AIMS: To compare nationwide time trends and mortality in hip and proximal humeral fractures; to explore associations between incidences of falls risk related comorbidities (FRICs) and incidence of fractures. METHODS: The study is a retrospective cohort study using nationwide Danish administrative registries from 2000 through 2009. Individuals aged 65 years or older who experienced a hip or a proximal humeral fracture were included. Incidence of hip and of proximal humeral fractures, incidence of FRICs (ischemic heart disease, COPD, dementia, depression, diabetes, heart failure, osteoporosis, Parkinson's disease and stroke) and incidence rate ratios (IRR) for fractures in patients with FRICs, and all-cause mortality up to 10 years after a hip or a proximal humeral fracture were analysed. RESULTS: A total of 89,150 patients experienced hip fractures and 48,581 proximal humeral fractures. From 2000 through 2009, the incidence of hip fractures per 100,000 individuals declined by 198 (787 to 589, OR = 0.75, CI: 0.72-0.80) among males and by 483 (1758 to 1275, OR = 0.74, CI: 0.72-0.77) among females. Incidences of FRICs decreased. The absolute reduction in fractures was most pronounced for the age group above 75 years (2393 to 1884, OR = 0.81, CI: 0.78-0.83), but the relative reduction was more pronounced in the age group of 65-75 years old (496 to 342, OR = 0.70, CI: 0.66-0.74). IRRs for hip fractures and for proximal humeral fractures were significantly elevated in patients with FRICs. CONCLUSIONS: The results suggest that the overall reduction in fractures can be explained by reduction in falls related comorbidity.

Treatment choice affects inpatient adverse events and mortality in older aged inpatients with an isolated fracture of the proximal humerus.

BACKGROUND: This study tests the null hypothesis that, among patients aged 65 and older admitted to a United States hospital with an isolated fracture of the proximal humerus (no other injuries or fractures), there are no differences between operative (fixation or arthroplasty) and nonoperative treatments with respect to inpatient adverse events, inpatient mortality, and discharge to a long-term care facility rates accounting for comorbidities. METHODS: Using a large national database representing an estimated 132,005 patients aged 65 and older admitted to a US hospital with an isolated proximal humerus fracture between 2003 and 2007. Sixty-one percent did not have surgery, 22% were treated with open reduction and internal fixation (ORIF), and 17% were treated with arthroplasty. RESULTS: The risk of an in hospital adverse event was 21% overall and was 4.4 times greater with arthroplasty and 2.7 times greater with ORIF compared to nonoperative treatment. The risk of in hospital death was 1.8% overall and was 2.8 times greater with ORIF compared to nonoperative treatment. Patients treated operatively were less likely to be discharged to a long-term facility compared to patients treated nonoperatively. CONCLUSION: In spite of a tendency to treat the most infirm patients (those that are not discharged to home) nonoperatively, operative treatment (open reduction and internal fixation in particular) is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted to the hospital with an isolated fracture of the proximal humerus and should perhaps be offered more judiciously. LEVEL OF EVIDENCE: Level III, retrospective cohort study, treatment study.

What are the factors influencing outcome among patients admitted to a hospital with a proximal humeral fracture?

BACKGROUND: Fracture of the proximal humerus is common in older patients during the decline of their physical health. QUESTIONS/PURPOSES: Our purpose was to evaluate the association between specific risk factors in patients with fractures of the proximal humerus and any inpatient adverse events, mortality, and discharge to a short-term or long-term care facility. METHODS: The National Hospital Discharge Survey (NHDS) provided estimates of all adult patients who were admitted to hospitals after fractures of the proximal humerus in the United States between 1990 and 2007. The influences of sex, age, days of care, diagnosis and procedures (based on ICD-9 codes) on inpatient adverse events and death, and discharge to a short-term or long-term care facility, were studied in bivariate and multivariable analyses. RESULTS: Among an estimated 867,282 patients admitted for proximal humerus fractures, 20% experienced adverse events, and 2.3% died in the hospital. Older age, concomitant femur and femoral neck fractures or head trauma, operative fracture care, congestive heart failure, and chronic alcoholism were associated with inpatient adverse events. Intubation, acute myocardial infarctions, malignancies, and skull fractures were associated with inpatient deaths. Older age, lower limb fractures, specific comorbidities (obesity, congestive heart failure, dementia), and inpatient adverse events (pneumonia, anemia treated with transfusion) were associated with discharges to short-term or long-term care facilities. CONCLUSIONS: Knowledge of risk factors for inpatient adverse events, mortality, and discharge to facilities can help make treatment decisions, improve overall care, discharge planning, and resource utilization for patients with proximal humeral fractures.