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Background This study compares open reduction and internal fixation (ORIF) versus hemiarthroplasty (HA) in the management of proximal humerus fracture-dislocations and complex articular humeral head fractures. Methods The records of consecutive patients with Neer 3- and 4-part fracture-dislocations, surgical neck fracture-dislocations with severe a...
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Introduction:
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Background:
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Citations
... Other identified risk factors that may increase the risk of non-union include age, female sex, smoking, and osteoporosis. [20] Hemiarthroplasty Hemiarthroplasty (HA) has largely fallen out of favor in the treatment of proximal humerus fractures given the advances in reverse shoulder arthroplasty (RSA) techniques and comparatively improved outcomes seen in patients treated with either ORIF or RSA [29,30]. While this technique is being utilized less frequently for proximal humerus fractures, it remains a useful procedure for certain indications, specifically in younger patients (40 to 65 years old) with complex, non-reconstructible articular injuries with or without associated glenohumeral dislocation [4]. ...
Purpose of Review
Proximal humerus fracture dislocations typically result from high-energy mechanisms and carry specific risks, technical challenges, and management considerations. It is vital for treating surgeons to understand the various indications, procedures, and complications involved with their treatment.
Recent Findings
While these injuries are relatively rare in comparison with other categories of proximal humerus fractures, fracture dislocations of the proximal humerus require treating surgeons to consider patient age, activity level, injury pattern, and occasionally intra-operative findings to select the ideal treatment strategy for each injury.
Summary
Proximal humerus fracture dislocations are complex injuries that require special considerations. This review summarizes recent literature regarding the evaluation and management of these injuries as well as the indications and surgical techniques for each treatment strategy. Thorough pre-operative patient evaluation and shared decision-making should be employed in all cases. While nonoperative management is uncommonly considered, open reduction and internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder replacement are at the surgeon’s disposal, each with their own indications and complication profile.
... The main reason for this assessment was based on bias in the selection of participants for all 16 studies. Seven studies [23,24,28,[36][37][38]41] overall risk of bias was serious. The main reason for this assessment was based on bias due to confounding for all seven. ...
... All level II evidence studies were assessed as having fair quality, with a mean score of 65 (range 59-67). Five of the twenty-six LOE III studies [19,24,34,41,43] were assessed as having fair quality, and the other twentyone studies had poor quality. The MINORS score (Table 8) for non-randomized studies assessed one study [41] as having good quality, twenty studies [16, 17, 19, 22-24, 26-28, 30-32, 34, 36, 38, 40, 43, 44, 47, 48, 50] as having fair quality, and five studies [20,35,37,45,46] as low quality. ...
IntroductionThe purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing surgical interventions for proximal humerus fractures.Methods
Systematic review of Medline, Embase, Scopus, and Google Scholar, including all level 1–3 studies from 2000 to 2022 comparing surgical treatment with ORIF, IM nailing, hemiarthroplasty, total and reverse shoulder arthroplasty (RTS) was conducted. Clinical outcome scores, range of motion (ROM), and complications were included. Risk of bias was assessed using the Cochrane Collaboration’s ROB2 tool and ROBINs-I tool. The GRADE system was used to assess the overall quality of the body of evidence. Heterogeneity was assessed using χ2 and I2 statistics.ResultsThirty-five studies were included in the analysis. Twenty-five studies had a high risk of bias and were of low and very low quality. Comparisons between ORIF and hemiarthroplasty favored ORIF for clinical outcomes (p = 0.0001), abduction (p = 0.002), flexion (p = 0.001), and external rotation (p = 0.007). Comparisons between ORIF and IM nailing were not significant for clinical outcomes (p = 0.0001) or ROM. Comparisons between ORIF and RTS were not significant for clinical outcomes (p = 0.0001) but favored RTS for flexion (p = 0.02) and external rotation (p = 0.02). Comparisons between hemiarthroplasty and RTS favored RTS for clinical outcomes (p = 0.0001), abduction (p = 0.0001), and flexion (p = 0.0001). Complication rates between groups were not significant for all comparisons.
Conclusions
This meta-analysis for surgical treatment of proximal humerus fractures demonstrated that ORIF is superior to hemiarthroplasty, ORIF is comparable to IM nailing, reverse shoulder arthroplasty is superior to hemiarthroplasty but comparable to ORIF with similar clinical outcomes, ROM, and complication rates. However, the study validity is compromised by high risk of bias and low level of certainty. The results should therefore be interpreted with caution. Ultimately, shared decision making should reflect the fracture characteristics, bone quality, individual surgeon’s experience, the patient’s functional demands, and patient expectations.Level of evidence: Level III; systematic review and meta-analysis.
... Although there are few studies comparing ORIF with HA for treating PHFs in young patients, many surgeons believe that young patients should be treated with ORIF to preserve bone stock, improve tuberosity healing, and prevent glenoid erosion that can follow HA. 44 In our study, trauma surgeons preferred ORIF for treating PHFs in young patients, whereas shoulder surgeons were split between ORIF and HA for young patients with a head-split fracture or limited humeral head subchondral bone (Fig. 1). These results likely reflect trauma surgeons' greater experiences with fracture fixation. ...
Background
Proximal humerus fractures (PHFs) are managed with open reduction and internal fixation (ORIF), hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), or nonoperatively. Given the mixed results in the literature, the optimal treatment is unclear to surgeons. The purpose of this study was to survey orthopedic shoulder and trauma surgeons to identify the patient- and fracture-related characteristics that influence surgical decision-making.
Methods
We distributed a 23-question closed-response email survey to members of the American Shoulder and Elbow Surgeons (ASES) and Orthopaedic Trauma Association (OTA). Questions posed to respondents included demographics, surgical planning, indications for ORIF and arthroplasty, and the use of surgical augmentation with ORIF. Numerical and multiple-choice responses were compared between shoulder and trauma surgeons using unpaired t-tests and chi-square tests, respectively.
Results
Respondents included 172 shoulder and 78 trauma surgeons. When surgery is indicated, most shoulder and trauma surgeons treat two-part (69%) and three-part (53%) PHFs with ORIF. Indications for managing PHFs with arthroplasty instead of ORIF include an intra-articular fracture (82%), bone quality (76%), age (72%), and previous rotator cuff dysfunction (70%). In patients older than 50 years old, 90% of respondents cited a head-split fracture as an indication for arthroplasty. Both shoulder and trauma surgeons preferred RSA for treating PHFs presenting with a head-split fracture in an elderly patient (94%), pre-existing rotator cuff tear (84%), and pre-existing glenohumeral arthritis with an intact cuff (75%). Similarly, both groups preferred ORIF for PHFs in young patients with a fracture dislocation (94%). In contrast, while most trauma surgeons preferred to manage PHFs in low functioning patients with a significantly displaced fracture or non-reconstructable injury nonoperatively (84% and 86%, respectively), shoulder surgeons preferred either RSA (44% and 46%, respectively) or nonoperatively (54% and 49%, respectively) (P < .001). Similarly, while trauma surgeons preferred to manage PHFs in young patient with a head-split fracture or limited humeral head subchondral bone with ORIF (98% and 87%, respectively), shoulder surgeons preferred either ORIF (54% and 62%, respectively) or HA (43% and 34%, respectively) (P < .001).
Conclusions
ORIF and HA are preferred for treating simple PHFs in young patients with good bone quality or fracture dislocations, whereas RSA and nonoperative management are preferred for complex fractures in elderly patients with poor bone quality, rotator cuff dysfunction, or osteoarthritis. The preferred management differed between shoulder and trauma surgeons for half of the common PHF presentations, highlighting the need for future research.
Level of Evidence
Survey Study; Experts
... O ptimal surgical management for proximal humerus fracture dislocations continues to be a topic of debate among orthopaedic surgeons. Owing to the prevalence of complications after ORIF, including loss of fixation, screw cut out, and AVN of the humeral head, hemiarthroplasty or reverse arthroplasty is preferred by some authors, particularly in the elderly population [11][12][13] . A heightened concern for ischemia of the humeral head is cited by some authors as a relative indication for hemiarthroplasty over ORIF 1,5,6 . ...
Case:
We present the case of a 36-year-old patient with a 4-part proximal humerus fracture with subcoracoid dislocation and devascularization of the humeral head after a fall onto his right shoulder.
Conclusion:
The patient was successfully treated with open reduction and locking plate fixation to demonstrate that a successful postoperative functional outcome with humeral head survival can be achieved in these complex situations.
... Effectiveness was defined using quality-adjusted life years (QALY) based on a single institutional study evaluating clinical outcomes of ORIF versus HA in the management of complex articular fracture and fracture-dislocations of the proximal humerus. 33 SF-36 survey scores obtained from each cohort were converted to utility weights considered over a 1-year time horizon. Each branch of the decision tree was assigned a utility score, a value ranging from 0 to 1 measured in QALYs. ...
... The true rate of AVN and hardware complications following ORIF of complex proximal humerus fractures is unknown, but this study used a conservative estimate of 30% based on literature review, which was similar to the rate observed in our cohort of 26.7%. 33 Rates of tuberosity complications in the literature are variable, but again a conservative estimate of 34% was utilized, which was smaller than that observed in our cohort at 53%. 33 Given the paucity of health-related quality of life scores in the literature regarding surgical management of proximal humerus fractures, SF-36 scores were obtained from a small cohort of 30 patients from our institution who were evaluated with a mean 5-year follow-up. Utility scores obtained from these SF-36 scores must be interpreted with caution, as there was a significant difference in age between the patients who underwent ORIF and HA. ...
... The true rate of AVN and hardware complications following ORIF of complex proximal humerus fractures is unknown, but this study used a conservative estimate of 30% based on literature review, which was similar to the rate observed in our cohort of 26.7%. 33 Rates of tuberosity complications in the literature are variable, but again a conservative estimate of 34% was utilized, which was smaller than that observed in our cohort at 53%. 33 Given the paucity of health-related quality of life scores in the literature regarding surgical management of proximal humerus fractures, SF-36 scores were obtained from a small cohort of 30 patients from our institution who were evaluated with a mean 5-year follow-up. Utility scores obtained from these SF-36 scores must be interpreted with caution, as there was a significant difference in age between the patients who underwent ORIF and HA. ...
Objectives
To determine if open reduction and internal fixation (ORIF) is more cost-effective than hemiarthroplasty (HA) in the management of proximal humerus fracture.
Design
Retrospective cohort study with cost-effectiveness analysis.
Setting
Tertiary referral center in Rochester, NY.
Patients/participants
The records of 459 consecutive patients in whom a proximal humerus fracture was treated surgically at our institution between the years 2002 and 2012 were studied retrospectively. We identified 30 consecutive patients with a mean follow-up of 60.3 months (13.6–134.5 months) of which 15 patients underwent primary ORIF and another 15 underwent primary HA for the management of head-splitting fracture or fracture-dislocation of the proximal humerus.
Intervention
HA or ORIF for the management of proximal humerus fracture.
Main outcome measurements
SF-36 scores were converted to utility weights, and a cost-effectiveness model was designed to evaluated ORIF and HA.
Results
Given the baseline assumptions, ORIF was slightly more costly but also more effective (0.75 quality-adjusted life years [QALY] vs 0.67 QALY) than HA. The incremental cost-effectiveness ratio (ICER) was $5319/QALY for ORIF compared to HA, which is less than the cost-effectiveness standard utilized based on a willingness to pay of $50,000/QALY.
Conclusions
Compared to HA, ORIF is the more cost-effective approach for the surgical management of complex proximal humerus fractures. These data are limited by patient selection which would impact the relative utility scores. These results suggest that ORIF should be considered the preferable surgical approach given payer and patient perspectives. Level of Evidence: This is a Level III retrospective, cohort therapeutic study.
Background
Proximal humerus fractures are common injuries. Although certain fracture types may benefit from surgery including open reduction internal fixation (ORIF), the optimal method for fixation is unclear. Newer implant designs that improve healing by minimizing hardware failure and recurrent fracture displacement may optimize clinical outcomes.
Methods
Over a 27 month period, 37 consecutive patients with proximal humerus fractures were treated by a single surgeon with a lateral humeral plate though which an intramedullary nitinol cage was inserted. Additional screws were placed through the tuberosities and cage as required. Fractures were classified by both the Neer classification and angulation or displacement in the coronal plane. At most recent follow-up, radiographic results, patient reported outcome measurements, range of motion, complications and re-operations were recorded.
Results
Thirty-one patients had a minimum of 1 year of clinical and radiographic follow-up. Average follow-up was 91 weeks. Using the Neer classification, there were 4 two part, 21 three part, and 6 four-part fractures. Twenty-one fractures were displaced in valgus and 10 in varus. Outcome measurements at most recent follow-up demonstrated an average ASES (68), Single Assessment Numeric Evaluation (70), quick DASH (27), Veterans Rand-12 (PCS 37 and MCS 51), Constant score (55), PROMIS (29), Oxford Shoulder Score (23). Average active range of motion was 134o for forward elevation, 91o for abduction, 30o (-10o to 60o) of external rotation with the arm at the side and to L1 (T6-S4) for internal rotation with the arm at the side.
There were 11 complications (35%), including two axillary nerve neuropraxias that resolved and four cases of AVN (13%). Six patients had unplanned re-operations (19%). One revision was for loose hardware removal, one for revision ORIF after a fall, and four for component removal and revision to shoulder arthroplasty. There was no screw cutout or varus head collapse.
Conclusion
The management of proximal humerus fractures remains challenging. Our results demonstrate similar fracture healing, clinical improvement and complication rates compared to conventional ORIF with screws and a side plate. At one year follow-up, there are low rates of recurrent fracture displacement and screw cutout. There were higher than expected rates of AVN as compared to other studies using a similar fixation construct. Larger studies and longer follow-up may demonstrate decreased rates of revision surgery and superior outcomes. Additional studies may determine whether this fixation method is superior to others for proximal humerus fractures.
Background
Management of displaced four-part fractures of proximal humerus is a challenge, as it is difficult to produce consistently good result with the current methods of fixation. Varus collapse of the head and eventual failure of plate fixation in up to 45% has been reported. We present an innovative method of intramedullary fixation for displaced four-part fractures of proximal humerus. The aim of this study is to present the results of an intramedullary fixation device used for displaced four-part fractures of proximal humerus in patients under 70 years of age.
Patients & Methods
Thirty patients with an average age of 56 years, with displaced four-part fracture of proximal humerus, underwent fixation using an intramedullary device. The device consists of a circular staple which is impacted in the head and engages into the neck of an intramedullary uncemented stem. The stem has a sleeve which provides the ability to adjust the height and there by facilitates accurate reduction of the tuberosity with ease. Fracture union was assessed with plain radiograph and clinical outcomes were assessed using the ASES and Constant scores.
Results
Union was achieved in 93.33% of the patients with mean ASES and Constant scores of 75.2 and 73.97 respectively, at average follow-up of 25.83 months. None of the patients had tuberosity avulsion, tuberosity non-union or resorption. Two patients had humeral head non-union and 2 had AVN. Two patients underwent revision surgery (6.67%), one for AVN (avascular necrosis) and one for non-union.
Conclusion
In patients under the age of 70 years with displaced four-part fractures of proximal humerus, this intramedullary device provides a simple and reproducible method of internal fixation with predictable union of tuberosity and shoulder function.
Level of evidence
Level IV; Case Series; Treatment Study
