Locked Stem Reverse Total Shoulder Arthroplasty for Complex Proximal Humerus Fracture in the Elderly: Clinical and Radiological Short-Term Results.

Purpose: To evaluate both the short-term clinical and radiological results of reverse shoulder arthroplasty (RSA) with uncemented locked stem in the management of a proximal humerus fracture (PHFs) in the elderly. Methods: Retrospective study including 40 consecutive 3-4 part proximal humerus fractures treated with reverse shoulder arthroplasty with a minimum of 24 months follow-up. In all the cases, the greater tuberosity (GT) was reattached with a standardized suture technique and a local horseshoe bone graft. All the patients were assessed at the 24-month follow-up with Constant-Murley Score (CMS) and Visual Analog Score (VAS). Radiographic healing of the greater tuberosity was noted in addition to stem locking screws radiographic changes. Complications and revision rates were reported. Results: Mean final CMS for this cohort was 80 points. The greater tuberosity healed in the anatomic position in 90% of the cases (N = 36), obtaining an average CMS of 80 in these patients. Healing of the greater tuberosity did not occur in 10% of the cases (N = 4), obtaining an average CMS of 60. All patients scored above 100° in forward elevation with a mean of 140°. Mean active external rotation was 30°. Low-grade scapular notching was reported in <1% of the cases. Major complications were reported in one patient with an acromial fracture. No complications or loosening of stem locking screws were noted. There were no reoperations. Conclusion: In the elderly population, reverse shoulder arthroplasty utilizing a fracture-specific locking stem, low-profile metaphysis, suture-friendly groove, meticulous suture technique, and local bone grafting allows adequate fixation, variable prosthesis height adjustment, and enhances greater tuberosity healing. This approach yields positive short-term clinical outcomes without complications related to the stem's locking screws. Level of Evidence: Level IV Retrospective Case Series.

Straight antegrade humeral nailing and risk of iatrogenic injury of supraspinatus tendon footprint: An MRI study.

Background: Straight antegrade humeral nailing (SAHN) is associated with excellent clinical results in proximal humerus fractures. The optimal entry point is the top of the humeral head. However, the anatomy is variable, and the entry point can affect supraspinatus tendon footprint (SSP-F) or fracture reduction. The aim of this study was to analyze the relationship between the SSP-F and SAHN entry point by analyzing magnetic resonance imaging (MRI) studies of the humerus. Methods: In total 58 MRI studies of entire humerus were reviewed. The mean age was 51.6 ± 12.4 years, with 40 female patients. The distance between the SSP-F and the SAHN insertion point (critical distance: CD), the width of the footprint, and the neck-shaft angle (NSA) were measured. Univariate and multivariate analysis were performed. Results: The mean CD was 7.51 mm ± 2.81 (0-12.9 mm) with 51.7% of proximal humerus "critical type" (CD <8 mm). The CD was found to be lower in females, with no difference found with varying age (62.5% "critical type"). CD correlated with NSA (linear regression). "Critical type" correlated with female gender and NSA (logistic regression). Discussion: More than half of the humerus are "critical types" as to SAHN and may, therefore, be at risk for procedure-related complications.

Fractura desplazada de húmero proximal

Introducción: Las fracturas de húmero proximal representan entre un 4-6 % de todas las fracturas y en algunos grupos poblacionales inciden en un 10 %. El manejo quirúrgico permite la cicatrización anatómica de los huesos y tejidos blandos; favorece la función de la extremidad y minimiza el riesgo. Objetivo: Evaluar los diferentes tipos de tratamiento para las fracturas de húmero proximal a partir de la presentación de cuatro casos. Presentación de casos: Los cuatros pacientes se evaluaron por la escala de Constant, independientemente de los procederse quirúrgicos. Tres de ellos tuvieron un seguimiento mínimo de seis meses y sobrepasaron los 80 puntos. El otro paciente se mantuvo en consulta durante tres meses y logró una puntuación por encima de 50. Conclusiones: El método quirúrgico debe permitir una fijación estable para la movilización temprana de la articulación. Al elegirlo debe tenerse en cuenta la edad, la geometría de la fractura, la calidad ósea y los criterios de Hertel.

Introduction: Fractures of the proximal humerus represent 4 to 6% of all fractures and 10% in some population groups. Surgical management allows anatomical healing of bones and soft tissues; promotes limb function and minimizes risk. Objective: To evaluate the different types of treatment for proximal humerus fractures from the presentation of four cases. Case report: Four patients were evaluated by the Constant scale, regardless of the surgical procedure. Three of them had a minimum follow-up of six months and exceeded 80 points. The other patient was kept in consultation for three months and achieved a score above 50. Conclusions: The surgical method should allow stable fixation for early joint mobilization. When choosing it, age, fracture geometry, bone quality and Hertel criteria must be taken into account.

Computed Tomography Does Not Improve Intra- and Interobserver Agreement of Hertel Radiographic Prognostic Criteria.

Background and Objectives: Proximal humerus fractures are the second most frequent site of avascular necrosis (AVN), occurring in up to 16% of cases. The Hertel criteria have been used as a reference for the prediction of humerus head ischemia. However, these are based solely on the use of radiographs, which can make interpretation extremely difficult due to several reasons, such as the overlapping fragments, severity of the injury, and noncompliant acute pain patients. The objectives of the study were to evaluate the role of computed tomography (CT) in the interpretation of the Hertel criteria and to evaluate the intra- and interobserver agreement of orthopedic surgeons, comparing their area of expertise. Materials and Methods: The radiographs and CT scans of 20 skeletally mature patients who had fractures of the proximal humerus were converted to jpeg and mov, respectively. All images were evaluated by eight orthopedic surgeons (four trauma surgeons and four shoulder surgeons) in two different occasions. The intra- and interobserver agreement was assessed by using the Kappa coefficient. The level of significance was 5%. Results: There was a weak-to-moderate intraobserver agreement (κ < 0.59) for all examiners. Only the medial metaphyseal hinge greater than 2 mm was identified by 87.5% of evaluators both in the radiographic and CT examinations in the two rounds of the study (p < 0.05). There was no significant interobserver agreement (κ < 0.19), as it occurred only in some moments of the second round of evaluation. Conclusions: The prognostic criteria for humeral head ischemia evaluated in this study showed weak intra- and interobserver agreement in both the radiographic and tomographic evaluation. CT did not help surgeons in the primary interpretation of Hertel prognostic criteria used in this study when compared to the radiographic examination.

Intraobserver and interobserver agreement in the classification and treatment of proximal humeral fractures.

BACKGROUND: There is controversy surrounding the reliability of radiographic measurements and existing classifications for proximal humeral fractures. METHODS: Ten orthopedists, divided into 2 groups by length of experience, evaluated radiographs in 3 views from 40 proximal humeral fractures. We evaluated 11 radiographic criteria (including the Neer and pathomorphologic classifications, head-shaft angle, displacement of the humeral shaft, and lesser and greater tuberosities) and treatment indication. We also analyzed the criteria that most influenced the choice of treatment. RESULTS: Interobserver reliability was substantial for the presence of fracture of the greater tuberosity (κ = 0.749) and medial metaphyseal comminution (κ = 0.627) and moderate for the pathomorphologic classification (κ = 0.504), displacement of the greater tuberosity (κ = 0.422), and treatment decision (κ = 0.565). Intraobserver reliability was substantial for treatment indication (κ = 0.620) and presence of displacement of the fracture of the greater tuberosity (κ = 0.627 and 0.611) and moderate for the Neer (κ = 0.490) and pathomorphologic (κ = 0.607) classifications. The results were influenced by the observer's experience. The surgical indication was influenced by the pathomorphologic classification in 50% of the evaluators (odds ratio, 4.85; range, 3.30-8.65). CONCLUSION: The pathomorphologic classification has higher reliability than the Neer classification and was the factor that most influenced the surgical decision. The determination of the presence of fracture and displacement of the greater tuberosity and medial metaphyseal comminution is reliable with the use of simple radiographs, and the results were influenced by the observer's experience.

Zona de seguridad para tornillo de bloqueo cefálico posterior-anterior durante enclavijado endomedular retrógrado del húmero: estudio ex vivo en muestras óseas / Safe zone for anterior-posterior cranial blocking screw during retrograde intramedullary nailing of the humerus: ex-vivo study in bone specimens

OBJETIVO: Definir una zona segura, usando como referencia la línea intercondílea anterior (LCA) del codo para realizar los bloqueos anteroposteriores durante el enclavijado endomedular retrógrado humeral (CEMR). MÉTODOS: Estudio experimental ex-vivo. Trece húmeros humanos fueron analizados. Se tomaron fotografías registrando la porción distal de los húmeros paralelos a la LCA, elevando el húmero distal 10cm. Tres evaluadores independientes realizaron las siguientes mediciones: ángulo del surco bicipital (SB) a la altura del cuello quirúrgico humeral (S, formado por las paredes medial y lateral del SB; zona de peligro) y el ángulo complementario lateral (formado por el límite lateral de la tróclea y la pared lateral del SB a la altura del cuello quirúrgico humeral; zona segura). RESULTADOS: Valor promedio de S: 3,1±0,5° (3,3-4), coeficiente de correlación intraclase: 0,057 (p=0,057). Valor promedio del ángulo complementario lateral: 87,5±3,3° (81,3-92,5), coeficiente de correlación intraclase: 0,304 (p=0,217). Considerando 3 desviaciones estándar del promedio de los ángulos medidos (para aumentar los parámetros de seguridad) la zona segura se enmarcó entre los 0° y los 80° con relación a la LCA. CONCLUSIÓN: En este estudio la zona de seguridad del bloqueo cefálico anteroposterior para evitar el daño del tendón bicipital durante el enclavijado endomedular retrógrado humeral se localizó entre los 0° y 80° con relación a la LCA.

OBJECTIVE: To define a safe zone, using the anterior intercondylar line (AIL) of the elbow as a reference to perform anterior-posterior (AP) cranial blocks during retrograde intramedullary humeral nailing (RIHN). METHODS: An ex-vivo experimental study was performed by analysing 13 human humeri. Photographs were taken, recording the distal portion of the humeri parallel to the AIL, elevating the distal humerus 10cm. Three independent evaluators made the following measurements: Bicipital groove (BG) angle at the level of the surgical neck of the humerus (S, formed by the medial and lateral walls of the BG; danger zone) and the Lateral Complementary Angle (LCA, formed by t5he lateral trochlear limit and the lateral wall of the BG at the level of the surgical neck of the humerus; safe zone). RESULTS: The mean value of S: 3.1±0.5° (3.3-4), intraclass correlation coefficient (ICC): 0.057 (P=.057). The mean value of the AIL: 87.5±3.3° (81.3-92.5), ICC: 0.304 (P=.217). Using 3 standard deviations from the mean of the angles measured (in order to increase the safety parameters), the safety zone is located between 0° and 80° in relation to the AIL. CONCLUSION: In this study, the safety zone of the AP cranial block, in order to avoid damage to bicipital tendon during RIHN, is situated between 0° and 80° in relation to the AIL.

The rotation of the humeral head does not alter radiographic evaluation of the head-shaft angle.

BACKGROUND: The head-shaft angle is used to plan osteotomies and arthroplasties and to assess the radiographic outcomes of surgical treatment for proximal humerus fractures. There are no published data showing whether different degrees of arm rotation interfere with the evaluation of this angle. METHODS: Eighteen humeri from adult cadavers were used. Radiographs were taken with the specimens initially placed in a true anteroposterior position and then subsequently positioned with internal and external rotations of 10°, 20°, and 30°. All radiographs were evaluated by 3 shoulder and elbow surgeons at 2 different times 3 months apart. The head-shaft angle was measured using a picture archiving and communication system. RESULTS: For the humerus in the neutral position, the head-shaft angle was 137° ± 4°. With the anatomic specimen positioned with increasing external and internal rotations, there was a maximum difference of 2° compared with the value observed in the neutral position, which was not a significant difference (P = .911). Measurements of the head-shaft angle showed a good interobserver correlation coefficient, with a value of 0.788 (0.728-0.839) for all measurements. The intraobserver correlation coefficient ranged from moderate to excellent (0.536-0.938). CONCLUSION: The head-shaft angle did not change significantly with varying degrees of humeral rotation. The interobserver correlation coefficient showed good reliability, and the intraobserver correlation was moderate to excellent.