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Background: Although the Neer and AO/OTA classifications have been widely accepted, observer reliability studies of these two classifications have questioned their reliability and reproducibility to date. We developed an entirely new classification, the Mitsuzawa classification, for dislocated and displaced proximal humeral fractures and tested all three classifications for their intra- and interobserver reliability. Methods: Two experienced shoulder surgeons and two orthopedic residents independently evaluated the Xray (xR) values of 100 proximal humeral fractures (PHFs). The inclusion criteria for PHFs were (1) fracture-dislocation of the glenohumeral joint, (2) severely displaced fracture that required arthroplasty, such as hemi-arthroplasty or reverse shoulder arthroplasty, and (3) age > 18 years. Four reviewers classified all 100 fractures according to the Neer, AO/OTA, and Mitsuzawa classifications on two occasions. The intraobserver reliability was calculated using a Cohen κ statistic, while the interobserver reliability was calculated using a Fleiss κ statistic. Results: The average intraobserver agreements for the Neer, AO/OTA, and Mitsuzawa classifications were 0.57 (moderate), 0.67 (substantial), and 0.77 (substantial), respectively. The average interobserver agreements for the Neer, AO/OTA, and Mitsuzawa classifications were 0.49 (moderate), 0.56 (moderate), and 0.73 (substantial), respectively. The most common fracture type in each classification was an anterior dislocated fracture with a greater tuberosity fragment, which corresponded to A3a (57 cases) in the Mitsuzawa classification. Conclusions: The Mitsuzawa classification of PHF incorporates different perspectives regarding glenohumeral compatibility, assessment before and after shoulder dislocation reduction, and the degree of displacement of the proximal stump of the humeral shaft. Compared with the Neer and AO/OTA classifications, our new classification system adopted a user-friendly flowchart format and provided satisfactory intra- and interobserver reliability. Level of evidence: Level IV. [ABSTRACT FROM AUTHOR]

The last few years have been characterized by increasing numbers of reverse shoulder arthroplasties. In addition to the classic indication of cuff tear arthropathy, the use for complex proximal humeral fractures (PHFs) and rotator cuff tear (RCT) in very old patients have been established. The objective of this study is to clarify and substantiate the above statements specifically for Germany (based on official data from 2010 to 2022). Since substantial changes in the structure of the population are expected over time, all data must be adjusted for these changes. The hypotheses are (1) the German population is ageing with a shift to more elderly patients over time, and (2) the general use of shoulder arthroplasty (total anatomic - shoulder arthroplasty (aTSA) and reverse - rTSA) has increased during the time period, but the effect is beyond the shift of age stratification but attributable to a change of hospital admissions and surgical therapy for PHF and RCT. In this retrospective study, data were collected from the National Bureau of Statistics in Germany for the period of 2010 to 2022. Three different data sources were combined for the analysis: a database regarding the structure of the population in age groups for every year, a database reporting relevant operation codes, and the data on hospital admissions based on ICD-10 codes. The relevant data were extracted and combined using Excel spread sheets (Microsoft Corporation, version 2019). Absolute numbers are reported and adjusted for 100.000 inhabitants in each age group in order to calculate the incidence. Only slight change in absolute numbers of the population (n = 81751602 to 84358845, +3%) was observed, but a substantial shift toward the group of elderly people: the peak age group has shifted from 40-50 to 55-65. The number of TSA has significantly increased (n = 15000 to n = 28117, +187%; incidence 18.35 to 28.53, +155%). The number of rTSA has largely increased (n = 5326 to n = 24067, +452%; incidence 6.51 to 28.53, +438%), whereas the number of aTSA steadily decreased (n = 9674 to n = 4050, -42%; incidence 11.83 to 4.80, −41%). The number of revision arthroplasties has increased 1.8-fold (n = 2179 to n = 3893; incidence 1.7-fold). The peak revision rate shifted from the age group 70-75 toward 90- 95; 76% of all revision cases were performed in patients 65 years and older in 2010 increasing to 87% in 2022. Hospital admissions for PHF have increased 7.8-fold (n = 110091 to n = 810907). The peak in the age groups has shifted by a decade from 70-74 to 80-84. The absolute number of surgical therapy for PHF has decreased (n = 12816 to n = 9562, 75%; incidence 72%). The number of hospital admissions for RCT increased by 2.6-fold (n = 47004 to n = 124096; incidence + 255%). The number of surgical interventions for RCT increased by 3.7% (n = 51350 to n = 53294; incidence 62.8 to 63.2). Combined numbers for the operative therapy of PHF, RCT, and rTSA show an increase of +124% (n = 69491 to n = 86715) with a peak shift on one decade toward the age group 60-94 with 79% of the patients in 2022. The increased use of rTSA, as expressed by incidence, is strongly correlated with the increasing proportion of people aged 65 and over. The data show a substantial increase in the use of shoulder arthroplasty procedures in Germany in the observed time period, with the main driving factor being the increase of rTSA, whereas aTSA numbers decreased. The combined analysis of the hospital admissions and operative procedures performed to treat PHF and RCT indicated a shift of treatment numbers from open reduction and internal fixation and rotator cuff repair in the elderly toward the alternative use of rTSA in this age group. The observed shift of the stratification of age groups gives a further explanation for the increase in rTSA use: the number of patients in the age groups with the typical and alternative indications for rTSA substantially increased with a shift of the peak age group towards the elderly of one decade. Healthcare officials should be aware of these fundamental changes in the population, which create further demands on the health care system. The expected continuation of rising numbers of rTSA needs to be addressed by providing adequate resources such as reimbursement, surgical and rehabilitation facilities, and staff. [ABSTRACT FROM AUTHOR]

Background: Conventional techniques for the fixation of displaced proximal humeral fractures include the use of locking plates, intramedullary nailing, hemiarthroplasty and reverse shoulder replacement. Valgus-impacted fractures are a common subtype of proximal humeral fracture, but there are few publications concerning the outcomes of treatment. This study aims to review outcomes following an 'all-suture' technique for this fracture subtype without the use of transosseous sutures. Methods: All patients over the age of 18 who presented with 3- or 4-part valgus-impacted proximal humeral fractures and who underwent 'all-suture' repair at our centre were included. We reviewed their post-operative imaging and collected data on post-operative complications and patient-reported outcome measures. Results: We identified 15 patients who had undergone all-suture fixation. The cohort's mean age was 56. Eleven patients were female. Eight patients had 3-part fractures and seven patients had 4-part fractures. There were no major post-operative complications. All fractures united. The mean Oxford Shoulder Score was 43.7 and the mean Single Assessment Numerical Evaluation score was 85.9 at the final follow-up. Discussion: Our results suggest that all-suture fixation of proximal humeral fractures presents an attractive alternative to conventional techniques, whilst avoiding complications relating to metalwork implantation. [ABSTRACT FROM AUTHOR]

Objectives Proximal humeral fractures (PHFs) show a high incidence in aged patients. While nondisplaced fractures achieve good results by conservative treatment, surgical procedures are discussed controversially. Next to open reduction and internal fixation (ORIF), the primary use of reverse shoulder arthroplasty (RSA) has become increasingly important. The aim of this study was to investigate the clinical function, activities of daily living (ADL), as well as pain assessment in patients with PHFs, treated by ORIF or RSA. Methods A retrospective comparison study was assessed. From November 2011 to March 2016, 34 patients (17 matched pairs) that had undergone either ORIF or RSA of the proximal humerus, were included in this study. Pain was measured by numeric rating scale (NRS). ADL were obtained by Katz‐Index and SF‐12. Moreover, shoulder function was assessed using the Oxford Shoulder Score (OSS). The maximum range of motion (ROM) was also recorded. From November 2011 to March 2016, 34 patients (17 matched pairs) that had undergone either ORIF (Figure or RSA of the proximal humerus) were included in this study. For statistical analyses, Student's t‐test, Wilcoxon test, and Chi‐Quadrat test were used. Statistical significance was indicated with p

BACKGROUND: Secondary screw perforation of the articular surface is one of the major complications after locking plate internal fixation of proximal humerus fracture, and cut-out screws can damage shoulder function by abrading the glenoid and causing impingement of the acromion. Therefore, accurate risk prediction has positive clinical significance. OBJECTIVE: To screen risk factors for secondary screw perforation after proximal humerus fracture plating by machine learning methods, and to develop and validate a risk prediction model that facilitates clinicians to identify and intervene in high-risk patients at an early stage. METHODS: Clinical data of 214 patients with proximal humerus fractures who underwent locking plate internal fixation from June 2013 to June 2022 were collected as a training group to establish the model, and 61 similar patients from another hospital in the same period were included in the external validation group. The patients were divided into secondary screw perforation and screw maintenance groups according to whether they developed secondary screw perforation after surgery. The training group used three machine learning algorithms, namely, random forest, support vector machine, and logistic regression, to construct the prediction model. The recursive feature elimination method was used, and 10-fold cross-validation resampling was used as the screening method for the variables, and the intersection of the variables that were included when the accuracy of the three models was the highest was taken as the highly correlated with the secondary screw perforation reliable risk variables. The dynamic predictive model was constructed by R language software and presented as a web calculator, and the model was internally and externally validated. The internal test of the model was conducted by the Bootstrap method with 1 000 resamples, and the area under the receiver operating characteristic curve, the calibration curve, and the clinical decision curve were used to evaluate the differentiation, calibration ability, and clinical application value of the model. The Youden index was used to determine the optimal risk threshold of the prediction model, according to which the patients in the external validation group were divided into high- and low-risk groups, and the stability and extensibility of the model were evaluated according to the accuracy of its risk prediction ability. RESULTS AND CONCLUSION: (1) The machine learning algorithm identified four risk variables that were highly correlated with secondary screw perforation, namely cortical support of the proximal medial humeral column, deltoid tuberosity index, fracture type, and postoperative reduction. (2) The constructed risk prediction model showed good discrimination and accuracy [area under the curve=0.874, 95% confidence interval (0.827, 0.922)], and the calibration curve showed good agreement between the model predicted risk and the actual occurrence risk. (3) The clinical decision curve suggested that the model had good clinical applicability when the probability of the risk threshold was in the 0.1-0.75 range. (4) A risk probability of 26% was the optimal threshold for model risk stratification, and the external validation group used model risk stratification to predict secondary screw perforation with an overall accuracy rate of 84%. (5) The risk prediction model has good accuracy and extrapolation, and may provide a basis for guiding clinical treatment. [ABSTRACT FROM AUTHOR]

Abstract Introduction Proximal humerus fractures are usually treated with rigid angle-stable plates or nails. As an alternative, semi-rigid, minimally invasive systems have been developed for supportive fixation. A new system uses this principle with 2.5 mm partially threaded pins and external fixation. Aim This study aimed to compare the fracture stability of the fixator with an angular stable plate about whether the mechanical stability is sufficient for early postoperative mobilisation. Materials and methods Human proximal humeri (paired, female, age ≥ 60, n = 8) were cut to a 3-part fracture and treated with an external fixator (Galaxy Shoulder, Orthofix) or an angular stable plate (Philos, DePuy Synthes). A physiological load was simulated in vitro based on a 45° abduction motion. The load level was continuously increased from 10 to 320 N within 10,000 cycles simulating the loads during rehabilitation. This was followed by another 10,000 cycles at 320 N for fatigue testing. Fracture motion was recorded with a 3D camera. Fracture stability was evaluated at a partial load of 160 N and 240 N (simulating loads during early mobilisation). Results The fracture motion at the lateral aspect was significantly (p

BACKGROUND: Internal fixation and open reduction with locking plate is the main treatment for proximal humeral fractures with medial column instability. However, reduction failure is one of the main postoperative complications, and accurate risk factor assessment is beneficial for screening high-risk patients and clinical decision selection. OBJECTIVE: To construct four types of prediction models by different machine learning algorithms, compare the optimal model to analyze and sort the risk variables according to their weight scores on the impact of outcome, and explore their significance in guiding clinical diagnosis and treatment. METHODS: 262 patients with proximal humeral fractures with medial column instability, aged (60.6±10.2) years, admitted to Foshan Hospital of Traditional Chinese Medicine between June 2012 and June 2022 were included. All patients underwent open reduction with locking plate surgery. According to the occurrence of reduction failure at 5-month follow-up, the patients were divided into a reduction failure group (n=64) and a reduction maintenance group (n=198). Clinical data of patients were collected, and model variables and their classification were determined. The data set was randomly divided into a training set and a test set according to a 7:3 ratio, and the optimal hyperparameters were obtained in the training set according to a 5-fold cross-over test. Four machine learning prediction models of logistic regression, random forest, support vector machine, and XGBoost were constructed, and the performance of different algorithms was observed in the test set using AUC, correctness, sensitivity, specificity, and F1 scores, so as to comprehensively evaluate the prediction performance of the models. The best-performing model was evaluated using SHAP to assess important risk variables and to evaluate its clinical guidance implications. RESULTS AND CONCLUSION: (1) There were significant differences between the two groups in deltoid tuberosity index, fracture type, fracture end with varus deformity before operation, fragment length of inferior metaphyseal of humerus, postoperative reduction, cortical support of medial column of proximal humerus, and insertion of calcar screw (P < 0.05). (2) The best-combined performance of the four machine models was XGBoost. The AUC, accuracy, and F1 scores were 0.885, 0.885, and 0.743, respectively; followed by random forest and support vector machine, with both models performing at approximately equal levels. Logistic regression had the worst combined performance. The SHAP interpretation tool was used in the optimal model and results showed that deltoid tuberosity index, medial humeral column cortical support, fracture type, fracture reduction quality, and the status of the calcar screw were important influencing fators for postoperative fracture reduction failure. (3) The accuracy of using machine learning to analyze clinical problems is superior to that of traditional logistic regression analysis methods. When dealing with high-dimensional data, the machine learning approach can solve multivariate interaction and covariance problems well. The SHAP interpretation tool can not only clarify the importance of individual variables but also obtain detailed information on the impact of dummy variables in each variable on the outcome. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

Copyright of Acibadem Saglik Bilimleri Dergisi is the property of Acibadem University Medical School and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Despite total shoulder arthroplasty (TSA) and reverse TSA (rTSA) being fundamentally different procedures, and indicated in different pathologies (rTSA for rotator cuff deficiency [RCD] and proximal humeral fractures [PHFx] and anatomic TSA [aTSA] for glenohumeral osteoarthritis [GHOA]), they have the same Current Procedural Terminology (CPT) code (23472). This paper's aim is to investigate differences in operative time and work-related value units (wRVUs) per hour among these pathologies, and ultimately determine if there is a need to assign separate CPTs for aTSA and rTSA. A retrospective cohort of data from the American College of Surgeons–National Surgical Quality Improvement Program was collected, all patients who underwent aTSA or rTSA (CPT: 23472) between the years of 2006 and 2019 for diagnoses of GHOA, RCD, and PHFx were included. Data collected included patient age, body mass index, operative time, and wRVUs per hour. Compared to GHOA (reference group), the average operative time for the RCD cohort was 12.242 minutes shorter (P <.001), while the wRVUs were higher by 1.627 (P <.001). The average operative time for rTSAs in the PHFx cohort were 17.615 minutes longer (P <.001), while the wRVUs were lower by 2.205 (P <.001). The average operative time for rTSAs for both RCDs and PHFx were longer than that for aTSAs for GHOA. Additionally, wRVUs were lower for rTSAs for RCD and PHFx compared to aTSAs for GHOA. This elucidates inconsistency in reimbursement structure for the procedures, which should be revisited. [ABSTRACT FROM AUTHOR]

Reverse shoulder arthroplasty (RSA) has extended its indications in recent years to include complex proximal humerus fractures (PHFs) in elderly patients. The traditional approach in cases of PHF has been to cement the stem but, as in orthopedic surgery, the current trend in PHF is to avoid cementing the humeral stem as well. We evaluated 63 patients (representing 63 shoulders) who underwent RSA with uncemented stem after acute fracture of the proximal humerus. We analyzed the clinical and radiological outcomes, as well as medium-term complications, using two different prosthesis models. The mean postoperative follow-up period was 21-23 months, and the mean age of the patients was 74.5 years. The average Constant Score was 56.94 points; there were no statistical significant differences in Constant Score depending on the prosthesis model used. No cases of aseptic loosening were observed. However, there was evidence of stress-shielding in prostheses with diaphyseal fixation, although this phenomenon did not appear to have functional or clinical consequences for the patients. Intraoperative complications occurred in 6.35% of cases, and postoperative complications were noted in 4.92%. Based on the results of this study, we can affirm that the use of RSA with cementless stems in PHF can be a safe alternative, providing satisfactory clinical, functional, and radiographic results in the short term without the need to use cement in their fixation. The choice of prosthesis model may influence the occurrence of radiographic phenomena but does not seem to affect clinical outcome. [ABSTRACT FROM AUTHOR]

BACKGROUND: Proximal humeral fractures (PHFs) are common fractures in older adults and their prevalence is on the rise. Recovery following this fracture can be complex and disabling. Treatment varies from non-surgical management such as immobilisation to surgical procedures, with choice dependent on type and severity of fracture and patient health. OBJECTIVE: Several systematic reviews have considered the evidence for non-surgical versus surgical management of PHF in older adults. This commentary considers these findings for clinical practice and further research. METHODS: Three systematic reviews exploring non-surgical versus surgical management were selected based on the quality of their included evidence, and individually critically appraised. Findings from the reviews were reported for each outcome, and the implications considered for clinical practice and future research. RESULTS: Findings from the three reviews suggest that surgical management of PHF in older adults does not result in better functional outcomes or quality of life and non-surgical management should achieve acceptable upper limb function while decreasing the risks of surgery. More complex three-part fractures may also be managed non-surgically with fair to good functional results relative to fracture severity. CONCLUSION: The findings align with current guidance to offer non-surgical management to uncomplicated cases of PHF in adults and older adults. More complex three-part PHFs may also be managed well non-surgically. There is however a lack of evidence and guidance on the specifics of rehabilitation for this type of management and further research is needed to evaluate the factors that contribute to the effectiveness of non-surgical interventions. [ABSTRACT FROM AUTHOR]

Abstract 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.

Introduction: In the last few years, short metaphyseal-socket prosthetic humeral stems have been introduced for reverse shoulder arthroplasty (RSA). A short stem may have advantages in humeral force distribution, reducing shear stress and preserving bone stock, keeping in mind the need for possible future revision surgery. The main objective of our study was to validate the use of a short stem prosthesis in the surgical treatment of humeral fractures by comparing clinical and radiological outcomes of our studied implant with those obtained with the use of traditional long-stem implants. Methods: In this multicentric, controlled prospective study, 125 patients with proximal three- or four-fragment humerus fractures were selected and treated with RSA. A short stem was used in group A (n = 53, mean age: 75.6 ± 5.6 years old), and a long stem was used in group B (n = 72, mean age: 71.76 ± 3). Active range of motion (ROM), Constant score (CS), Quick DASH, American Shoulder and Elbow Surgeons Shoulder (ASES) score, and Visual Analog Scale (VAS) scores were collected and analyzed at 2 years mean follow-up, as well as humeral and glenoid bone resorption (sum Inoue scores and Sirveaux scores were used). Results: No statistically significant differences were observed between group A and B in ROM, Constant score (51.69 ± 15.8 vs. 53.46 ± 15.96, p > 0.05), Quick DASH (31.5 ± 21.81 vs. 28.79 ± 13.72, p = 0.85), ASES (82.53 ± 17.79 vs. 84.34 ± 15.24, p = 0.57), or the VAS (0.53 ± 1 vs. 0.56 ± 1.07, p = 0.14) at the final follow-up. No statistically significant differences were found in the radiographic parameters between the two groups. No statistically significant differences were found for the average degree of humeral and glenoid bone resorption either. Conclusions: The use of a short metaphyseal-socket stem can be considered a safe, effective, and feasible option in reverse shoulder arthroplasty for treating proximal humerus fractures. Our results are encouraging, with no statistically significant differences identified between the proposed treatment and traditional long stems. [ABSTRACT FROM AUTHOR]

BACKGROUND: Intramedullary nails and locking plates are widely used in the treatment of proximal humeral fractures, but there is no consensus on the choice of internal fixation. OBJECTIVE: To compare the biomechanical stability of intramedullary nails and locking plates in the treatment of two-part and three-part proximal humeral fractures by finite element analysis. METHODS: CT data of the humerus of a volunteer were collected and imported into Minics 21.0, Geomagic Wrap, Soildwork 2017, and Abaqus 2021 to establish finite element models of two-part and three-part fractures treated with two internal fixation methods, respectively. Group A: two-part fracture fixed with intramedullary nail model; group B: two-part fracture fixed with locking plate model; group C: three-part fracture fixed with intramedullary nail model; group D: three-part fracture fixed with locking plate model. The stress distribution, displacement degree, and maximum value of the humerus and internal fixation were compared and analyzed. RESULTS AND CONCLUSION: (1) The maximum stress and maximum displacement of the humerus were the smallest in the model of group A, and the maximum stress and maximum displacement of the humerus were the largest in the model of group D. The stress of the locking plate group was mainly concentrated in the medial inferior part of the humeral head and the screw hole area, while the stress of the intramedullary nail group was mainly concentrated around the fracture line and the lateral inferior part of the surgical neck of the humerus. There is no significant difference in displacement distribution between the two. It is mainly concentrated in the distal humerus. (2) The maximum stress value of the intramedullary nail was the lowest in the model of group A, and the maximum stress value of the locking plate was the highest in the model of group D. The maximum stress of the two internal fixations was mainly concentrated in the talar screw and the connection with the internal fixation. The stress cloud distribution of the locking steel plate was concentrated, while the stress cloud distribution of the intramedullary nail was more uniform. (3) The results showed that compared with the locking plate, the intramedullary nail had more biomechanical advantages, and this advantage was more obvious in three-part fractures. [ABSTRACT FROM AUTHOR]

BACKGROUND: Proximal humeral fracture in older adults is one of the three major osteoporotic fractures. Anatomic locking plate fixation is the first choice for most scholars to treat difficult-to-reduce and complex fracture types. However, the probability of reduction failure after the operation is high, which seriously affects patients’ quality of life. OBJECTIVE: To investigate the correlation between deltoid tuberosity index and postoperative reduction failure of proximal humeral fractures in the elderly, analyze and filter preoperative independent risk factors for reduction failure of proximal humeral fractures in the elderly, and construct and verify the effectiveness of a clinical prediction model. METHODS: The clinical data of 153 elderly patients with proximal humeral fractures who met the diagnosis and inclusion criteria and received open reduction and locking plate surgery in Foshan Hospital of TCM from June 2012 to June 2021 were collected. The patients were divided into the reduction failure subgroup and the reduction maintenance subgroup. The independent risk factors were selected by multivariate Logistic regression analysis, and the nomogram was constructed by R language. After 1000 times of resampling by Bootstrap method, the Hosmer-Lemeshow goodness of fit correlation test, receiver operating characteristic curve, calibration curve, clinical decision, and influence curve were plotted to evaluate its goodness of fit, discrimination, calibration ability, and clinical application value. Fifty-five elderly patients with proximal humeral fractures from June 2013 to August 2021 were selected as the model’s external validation group to evaluate the prediction model’s stability and accuracy. RESULTS AND CONCLUSION: (1) Of the 153 patients in the training group, 44 patients met reduction failure after internal plate fixation. The prevalence of postoperative reduction failure was 28.8%. Multivariate Logistic regression analysis identified that deltoid tuberosity index [OR=9.782, 95%CI (3.798, 25.194)], varus displacement [OR=4.209, 95%CI (1.472, 12.031)], and medial metaphyseal comminution [OR=4.278, 95%CI (1.670, 10.959)] were independent risk factors for postoperative reduction failure of proximal humeral fractures in older adults (P < 0.05). (2) A nomogram based on independent risk factors was then constructed. The Hosmer-Lemeshow test results for the model of the training group showed that χ² =0.812 (P=0.976) and area under curve=0.830[95%CI (0.762, 0.898)]. The calibration plot results showed that the model’s predicted risk was in good agreement with the actual risk. The decision and clinical influence curves showed good clinical applicability. (3) In the validation group, the accuracy rate in practical applications was 86%, area under curve=0.902[95%CI (0.819, 0.985)]. (4) It is concluded that deltoid tuberosity index < 1.44, medial metaphyseal comminution, and varus displacement were independent risk factors for reduction failure. (5) The internal and external validation of the risk prediction model demonstrated high discrimination, accuracy, and clinical applicability could be used to individually predict and screen the high-risk population of postoperative reduction failure of proximal humeral fractures in the elderly. The predicted number of patients at high risk is highly matched to the actual number of patients who occur when the model’s threshold risk probability is above 65%, and clinicians should use targeted treatment. [ABSTRACT FROM AUTHOR]

Case: (1) A 69-year-old man sustained a proximal humeral fracture-dislocation. During emergency surgery, copious bleeding occurred. A pseudoaneurysm was identified 30 days postoperatively. (2) A 69-year-old man sustained a proximal humeral fracture and axillary artery injury. Physical examination demonstrated a cold but pink hand. Hemiarthroplasty and bypass vein grafting were performed. (3) An 86-year-old woman sustained a proximal humeral fracture and axillary artery injury. Her hand had turned cold and pale. Reverse shoulder arthroplasty and bypass vein grafting were performed. Conclusion: In cases of proximal humeral fractures with significant displacement, concomitant axillary artery injury must be assessed and if there is a high index of suspicion, prompt advanced imaging is necessary. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Fractures of the proximal humerus (PHF) are commonly treated conservatively. Evidence suggests that a period of immobilization of one week or less may lead to some advantages compared to a traditional 3-4 weeks of immobilization. The purpose of this systematic review was to assess the clinical and radiological results in the case of early rehabilitation vs. delayed rehabilitation after PHF. MATERIALS AND METHODS: In July 2023, a literature search was carried out on the PubMed, MEDLINE, and Embase databases to identify all the randomized trials comparing early rehabilitation vs. delayed rehabilitation after PHF. The following data were extracted from each included study: patients’ demographics, study design and level of evidence, follow-up times, treatment groups, evaluation scores adopted, and overall clinical and radiological findings. The quality of the trials was assessed using the Cochrane Risk of Bias Assessment. RESULTS: A total of 5 studies, including 378 patients and dealing with early vs. delayed rehabilitation in case of conservative treatment of PHF, were included in this study. Early rehabilitation was started within 1 week and consisted mainly of pendulum exercise and progressive passive mobilization. Early rehabilitation was associated with better pain and functional scores within the first 3 months in 3 studies. No difference in pain or function was reported at 6 months or longer follow-up, and no differences in complications rate were observed between early vs. delayed rehabilitation groups. CONCLUSIONS: This systematic review suggests that early mobilization within one week in case of conservative treatment of PHF leads to improved function recovery and reduced pain, especially in the first months of rehabilitation, without differences at longer follow-up and without increasing complications rate. Reducing immobilization time could accelerate function recovery and regaining independence in daily life activities. [ABSTRACT FROM AUTHOR]

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BackgroundMuscular forces drive proximal humeral fracture deformity, yet it is unknown if arm position can help mitigate such forces. Our hypothesis was that glenohumeral abduction and humeral internal rotation decrease the pull of the supraspinatus and subscapularis muscles, minimizing varus fracture deformity.MethodsA medial wedge osteotomy was performed in eight cadaveric shoulders to simulate a two-part fracture. The specimens were tested on a custom shoulder testing system. Humeral head varus was measured following physiologic muscle loading at neutral and 20° humeral internal rotation at both 0° and 20° glenohumeral abduction.ResultsThere was a significant decrease in varus deformity caused by the subscapularis (p

Abstract 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.

Copyright of Hungarian Medical Journal / Orvosi Hetilap is the property of Akademiai Kiado and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. 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). 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. 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. [ABSTRACT FROM AUTHOR]

Background: The morphology of proximal humeral fractures (PHFs) is complex, and the fixation and selection of implants need to be guided by the fracture type and classification, which requires an accurate understanding of the fracture line. This study had three purposes. 1) Define and analyze the fracture lines and morphological features of all types PHFs by three-dimensional (3D) mapping technology. 2) Determine the osteotomy position of the biomechanical model of the PHFs according to the fracture heat map. 3) Based on the analysis of the pathological morphology and distribution of a large number of consecutive cases of PHFs, propose a novel classification of PHFs.Methods: We retrospectively collected 220 cases of PHFs and generated a 3D fracture map and heat map based on computed tomography (CT) imaging. Through analysis of the fracture morphology of the 220 PHFs, a novel classification was proposed. The primary criterion for staging was the continuity between the humeral head and the greater tuberosity and lesser tuberosity, and the secondary criterion was the relationship between the humeral head segment and the humeral shaft.Results: The fracture line was primarily found around the metaphyseal zone of region of the surgical neck, with the most extensive distribution being below the larger tuberosity and on the posterior medial side of the epiphysis. We suggest that the osteotomy gap should be immediately (approximately 5–10 mm) below the lower edge of the articular surface. The most common type of fracture was type I3 (33 cases, 15.0%), followed by type IV3 fracture (23 cases, 10.4%), and type III2 fracture (22 cases, 10.0%). Interobserver and intraobserver reliability analysis for the fracture classification revealed a k value (95% confidence interval) of 0.639 (0.57–0.71) and 0.841, P < 0.01, respectively.Conclusion: In this study, the fracture line and morphological characteristics of PHFs were clarified in detail by 3D mapping technique. In addition, a new classification method was proposed by analysis of the morphological characteristics of 220 PHFs, A two-part fracture model for PHFs is also proposed.

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.

Abstract Aims Frozen shoulder and proximal humeral fracture can cause pain, stiffness and loss of function. The impact of these symptoms on patients can be measured using the comprehensively validated, 12-item Oxford Shoulder Score (OSS). Evidence suggests that pain and function may have a differential impact on patients’ experience of shoulder conditions, and this may be important for clinical management. We therefore explored the factor structure of the OSS within the UK FROST and PROFHER trial populations. Methods We performed exploratory factor analysis (EFA), followed by confirmatory factor analysis (CFA), on baseline UK FROST data from 490 of the 503 trial participants. Data at 6 months post-randomisation were used for 228 of the 250 participants for the PROFHER trial. Results UK FROST factor extraction results, using Velicer's Minimum Average Partial and Horn's Parallel Analysis tests, suggested a unifactorial solution, but two factors were weakly indicated by the less reliable ‘Kaiser’s eigenvalue > 1’ and scree tests. We explored this further using EFA. Eight items (2 to 7, 9 and 10) loaded onto a ‘Function’ factor, three on a ‘Pain’ factor (1, 8 and 12) and item 11 cross-loaded. However, one- and two-factor models were rejected in CFA. Factor extraction of PROFHER data at 6 months demonstrated a single first-order factor solution, which was also subsequently rejected in CFA. Conclusion Insufficient evidence was found, within the constraints of the data available, to support the use of ‘Pain’ and ‘Function’ sub-scales of the OSS in either patient population.

Abstract 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.

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

Purpose: This study shows the effectiveness of locking compression plate for proximal humeral fractures in elderly patients over 80 years old without structural bone grafting compared age group of 65–79 (Group 1) with 80 and above (Group 2). Methods: This study included sixty-one patients who underwent using locking compression plate for proximal humeral fractures between April 2016 and November 2021. The patients were divided into two groups. The neck shaft angle (NSA) was checked at immediately after surgery, at 1 month and the final follow-up visit. The NSA changes in the two groups were compared using the independent t-test. In addition, multiple regression analysis was used to find out which factors affect NSA changes. Results: In group 1, the mean difference between NSA immediately after surgery and 1 month after surgery was 2.74°, and group 2 was 2.89°. In group 1, the mean difference in NSA for 1 month after surgery and at the last follow-up was 1.43°, and group 2 was 1.75°. No significant difference was observed in the NSA changes between two groups (p = 0.59, 0.173). Bone marrow density and four-part fracture type were significant difference in NSA changes (p = 0.003, 0.035). The disabilities of the arm, shoulder and hand scale (DASH scale), age, medical support, diabetes and three-part fracture type were no significant in NSA changes. Conclusions: Using locking compression plate without structural bone grafting is a good option in elderly patients over 80 years old and can help achieve radiological results similar to patients which age group of 67–79. [ABSTRACT FROM AUTHOR]

Proximal humerus fractures account for a large proportion of all fractures and increase steadily with age due to decreasing bone density. The choice of the best possible therapeutic procedure is often difficult and this topic has been controversially discussed in the literature published to date. In the case of non-displaced or only slightly displaced fractures, conservative therapy is a suitable procedure. From a certain degree of dislocation, surgical therapy becomes necessary. Joint-preserving surgery should generally be preferred in young patients. Primary inverse fracture arthroplasty for nonreconstructible fractures has become increasingly important in recent years because of its satisfactory postoperative results. Clear indications for endoprosthetic joint replacement include a narrow calvarial fragment, lack of medial support, a zone of comminution in the tuberosity, and patient-related factors such as preexisting omarthrosis, or rotator cuff insufficiency. The fundamental advantage of the inverse total endoprosthesis over the anatomic hemiprosthesis is its independence from rotator cuff function. Although the function of the inverse prosthesis is not dependent on the bony healing of the tuberosity, tuberosity re-fixation should be aimed for, as this achieves better functional results. The primary inverse fracture prosthesis shows good long-term functional results and is therefore the procedure of choice for proximal humerus fractures that can no longer be reconstructed. [ABSTRACT FROM AUTHOR]

Copyright of Chinese Journal of Tissue Engineering Research / Zhongguo Zuzhi Gongcheng Yanjiu is the property of Chinese Journal of Tissue Engineering Research and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

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Proximal humeral fractures (PHFs) are one of the most common types of fractures, accounting for up to 5% of all fractures, and they are the third most common fracture in the elderly population, increased by more than three times between 1970 and 2002 (1, 2, 3, 4). By 2030, the incidence of PHFs is expected to further grow, due to the ageing population and a more active lifestyle among the elderly (4). The treatment strategy of PHFs depends on different aspects: patient characteristics (age and co-morbidity), injury patterns (fracture type and displacement), and different available options about the surgical technique (5, 6, 7). The majority of PHFs are undisplaced or minimally displaced, thus treated conservatively, while displaced or unstable fractures require surgical treatment to achieve an optimal functional outcome (8, 9). Various surgical techniques, like open reduction and internal fixation (ORIF) with proximal humeral plate, intramedullary nailing, and arthroplasty, have been described in the literature (10, 11). In recent years, the locking plate has become increasingly used for the fixation of PHFs, especially for elderly patients (12, 13, 14).

Objective Greater tuberosity (GT) fragments were communicated, and additional techniques to increase the GT fragment stability after the locking plate fixation was necessary. This study aimed to analyze the reinforcement effects on the anterior‐avulsion GT fragment in Neer three‐part proximal humeral fractures (PHFs) using transosseous suture and suture anchor techniques. Methods Eighteen fresh‐frozen human cadaveric shoulder specimens were used in the study. Standardized fracture of the GT and surgical neck was created in 18 human cadaveric proximal humerus. The GT fragments were reinforced with transosseous suture (TS), suture anchor (SA), and suture in addition to the PHILOS plate fixation. The fixed humerus was tested by applying static loading to the supraspinatus tendon. Load forces and fragment displacement were evaluated by a biomechanical testing machine, and the load to 3‐ and 5‐mm displacements, load to failure, and mode of failure were recorded for all specimens. Nonparametric variables were examined by the Kruskal–Wallis test, and the Bonferroni post hoc test was used to analyze the mean loads to create 3‐ and 5‐mm displacements as well as the failure load. Results The age, female proportion, and bone mineral density showed no statistically significant differences between the three groups. The mean loading force to create 3‐mm and 5‐mm displacement in the TS group (254.9 ± 77.4, 309.6 ± 152.7) were significantly higher than those in the suture group (136.1 ± 16.7, 193.4 ± 14.5) (P = 0.024, P = 0.005). For the SA group, the force to create 3‐ and 5‐mm displacement (204.3 ± 60.9, 307.8 ± 73.5) were comparable to those in the TS group (P = 0.236, P = 0.983). Moreover, the loading force to failure in the TS group (508.6 ± 217.7) and SA group (406.6 ± 114.9) was significantly higher than that in the suture group (265.9 ± 52.1) (P = 0.021, P = 0.024). In the TS group, three failed due to tendon‐bone junction rupture; bone tunnel broken occurred in two specimens; suture rupture could also be seen in one specimen. All specimens in the suture group failed because of suture rupture. In the SA group, three specimens failed due to suture rupture; two failed secondary to tendon‐bone junction rupture; and one failed because of shaft fracture. Conclusions Transosseous suture is a new type of reinforcement for GT fragment in Neer‐three part PHFs. The transosseous suture was superior to the suture only in the reinforcement of the anterior‐avulsion GT fragment of Neer three‐part PHFs, and it had comparable biomechanical strength to the suture anchor.

Objective Restoration of the medial support is especially important for the treatment of proximal humeral fractures. The objective of this study was to investigate the radiographic and clinical outcomes of intramedullary nail fixation with a special focus on the presence of calcar comminution. Methods In this retrospective study of patients with displaced proximal humeral fractures that were treated by intramedullary nail between January 2018 and July 2021, fracture morphology and the calcar integrity were noted on preoperative radiographs. Patients were divided into two groups according to calcar integrity. During follow‐up, radiological assessment and functional outcome, including the deltoid tuberosity index (DTI), neck shaft angle (NSA), visual analog scale (VAS), the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST) score, active and passive range of motion, were performed. A Student t‐test and univariate logistic regression analysis was used. Results A total of 83 patients (54 female, 29 male) had complete follow‐up (average, 12.8 months; range, 10 to 33 months) and functional assessment in our study. The average age was 58.6 years (range, 20 to 89 years). The mean loss of NSA was 4° (range, 0°–12°) and no significant difference was found between two groups (p = 0.27). DTI had an average of 1.50 ± 0.19 (range 1.13–2.04). Patients with intact calcar achieved greater range of forward elevation (129.06 ± 11.91 vs. 121.05 ± 11.97, p = 0.01), and higher SST scores (8.61 ± 1.85 vs. 7.37 ± 2.22, p = 0.02). Two groups showed similar outcomes in VAS, ASES score, and range of abduction. One patient demonstrated a proximal interlocking screw cutting through and osteonecrosis of the humeral head, who underwent a second surgery for screw removal. There were no cases of infection, malunion, nonunion, nerve injury, subacromial impingement, or rotator cuff tear during the study period. Conclusion Intramedullary nail can favorably be used to manage proximal humeral fractures with good early radiographic and functional outcomes, even for those with comminuted calcar.

Objective Research on proximal fractures in the humeral bicipital groove (BG), a region in which bones are not commonly fractured, is considered sparse in the literature. The objective of this research was to present the definite characteristics and distribution of BG fractures. Methods This retrospective study included and enrolled 119 proximal humeral fractures in adult patients with complete radiography data to identify the fracture distribution in the BG from January 2021 to August 2021. The bicipital region was divided into three parts, i.e. the upper 1/3, middle 1/3, and lower 1/3 of the BG, and the distribution of fracture lines was transcribed on the male or female template, as appropriate. In addition, the normal contralateral humerus was used to calculate the cortical thickness of the supratubercular groove and different parts of the BG (upper, middle, and lower parts). The Mann–Whitney test or one‐way ANOVA along with LSD tests were used to determine differences in the fracture distribution and cortical thickness between men and women. Results Fractures of the BG in both men and women were mainly located in the upper 2/3 region of the BG, especially in the middle 1/3 of the BG. There were significant differences in the cortical thickness of the BG in men compared with that in women. The cortical thickness was highest in the supratubercular ridge but not the BG in men and women, respectively. Conclusion This research concluded that bony BG fractures were always observed in the middle part of the BG and were mainly found in patients with four fractures of the proximal humerus. As a unique fracture pattern, the existence of a bony BG fracture always means that a patient has been injured by a relatively severe mechanism, and more attention should be given to these proximal humeral fractures.

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. [ABSTRACT FROM AUTHOR]

Background: Proximal humerus fractures are seen frequently, particularly in older patients. The development of new osteosynthesis materials is being driven by the high complication rates following surgical treatment of proximal humerus fractures. Plate osteosyntheses made of steel, titanium and, for several years now, carbon fiber-reinforced polyetheretherketone (CFR-PEEK) are used most frequently. Methods: A prospective, randomized study was conducted in order to evaluate whether there are differences in the functional postoperative outcome when comparing CFR-PEEK and titanium implants for surgical treatment of proximal humerus fractures. The primary outcome of shoulder functionality 1 year after surgery was measured with the DASH score, the Oxford Shoulder Score, and the Simple Shoulder Test. Results: Bony consolidation of the respective fracture was confirmed in all the patients included in the study within the scope of postoperative follow-up care. No significant differences in the DASH score, Oxford Shoulder Score, or Simple Shoulder Test were observed 1 year post-operatively when comparing the implant materials CFR-PEEK and titanium. Conclusions: There are no differences in terms of the functional outcome between CFR-PEEK plates and titanium implants 1 year after surgery. Studies on the long-term outcomes using CFR-PEEK plates in osteoporotic bone should be the subject of further research. [ABSTRACT FROM AUTHOR]

Correct classification of fractures according to their patterns is critical for developing a treatment plan in orthopaedic surgery. Unfortunately, for proximal humeral fractures (PHF), methods for proper classification have remained a jigsaw puzzle that has not yet been fully solved despite numerous proposed classifications and diagnostic methods. Recently, many studies have suggested that three-dimensional printed models (3DPM) can improve the interobserver agreement on PHF classifications. Moreover, Virtual Reality (VR) has not been properly studied for classification of shoulder injuries. The current study investigates the PHF classification accuracy relative to an expert committee when using either 3DPM or equivalent models displayed in VR among 36 orthopaedic surgery residents from different hospitals. We designed a multicentric randomised controlled trial in which we created two groups: a group exposed to a total of 34 3DPM and another exposed to VR equivalents. Association between classification accuracy and group assignment (VR/3DPM) was assessed using mixed effects logistic regression models. The results showed VR can be considered a non-inferior technology for classifying PHF when compared to 3DPM. Moreover, VR may be preferable when considering possible time and resource savings along with potential uses of VR for presurgical planning in orthopaedics. [ABSTRACT FROM AUTHOR]