Reverse shoulder arthroplasty for proximal humerus fractures

A reverse shoulder arthroplasty is a consideration for the treatment of comminuted four-part proximal humerus fractures in elderly patients. While a reverse TSA should not replace other treatment modalities, it is indicated in elderly patients with fractures that are not amenable to fixation. Immediate stability and relative independence from tuberosity healing are clear advantages, but the complication rate is substantially higher. Larger studies are necessary to clarify appropriate indications.     

Outcomes for reverse total shoulder arthroplasty after failed open reduction internal fixation versus primary reverse total shoulder arthroplasty for proximal humerus fractures

BackgroundThe purpose of this study is to determine the clinical and radiographic outcomes of reverse total shoulder arthroplasty (RTSA) after failed open reduction internal fixation (ORIF) for proximal humerus fracture (PHF) and compare them to outcomes of primary RTSA for PHF.MethodsWe performed a retrospective comparative study of patients who underwent RTSA between 2008 and 2015 at our institution by one of two fellowship-trained shoulder and elbow surgeons for an acute PHF or for continued pain or functional limitations following ORIF of a PHF. We compared the American Shoulder and Elbow Surgeons (ASES) scores, Simple Shoulder Test (SST) scores, range-of-motion, and radiographic measurements between cohorts.ResultsIn total, there were 20 patients treated with RTSA after failed ORIF and 30 patients treated acutely with RTSA for PHF. The average ASES score was significantly greater for primary RTSA (82.0 ± 13.5) than for delayed RTSA (64.0 ± 27.2, P = 0.016). The average SST score for primary RTSA (69.4%±19.1%) was significantly higher than the average for delayed RTSA (49.1%±8.9%, P = 0.020). Forward elevation achieved postoperatively was significantly greater for patients treated with primary RTSA versus those with delayed RTSA (130±31° vs 107±31°, P = 0.035). No difference was detected between groups in postoperative external rotation (P = 0.152) or internal rotation (P = 0.872). Radiographically, the tuberosities healed in an anatomic position in 70% of the primary cases versus the prior ORIF group in which the tuberosities were in an anatomic position in all cases (P = 0.007).ConclusionsIn an elderly population, primary RTSA for PHF resulted in better clinical outcomes compared to RTSA following failed ORIF in this retrospective cohort study.Level of EvidenceLevel III; Retrospective Comparative Study     

Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients

Proximal humerus fractures are the third most common fracture in elderly patients. Hemiarthroplasty has been the treatment of choice in patients with bone quality and fracture patterns not amenable to open reduction and internal fixation. Reverse total shoulder arthroplasty is a newer option that appears to be less dependent on tuberosity healing than hemiarthroplasty. The authors hypothesized that reverse total shoulder arthroplasty provides improved functional outcomes compared with hemiarthroplasty for fractures in elderly patients.A retrospective review was performed of all patients treated with arthroplasty for acute proximal humerus fractures in an orthopedic practice using a Current Procedural Terminology code search, patient charts, and radiographs. Validated outcome scores were used to assess satisfaction, function, and general well-being. Twenty-three patients were treated for acute proximal humerus fractures (11 reverse total shoulder arthroplasties and 12 hemiarthroplasties). Three patients were lost to follow-up, and 6 patients were deceased. Mean follow-up was 3.6 years (range, 1.3-8 years). Reverse total shoulder arthroplasty outperformed hemiarthroplasty with regard to forward flexion, American Shoulder and Elbow Society score, University of Pennsylvania shoulder score, and Single Assessment Numerical Evaluation score.Reverse total shoulder arthroplasty is a reliable option for acute, proximal humerus fractures that are not amenable to closed treatment or reconstruction in elderly patients. Improved functional outcomes when compared with hemiarthroplasty must be balanced against the increased cost and limited life expectancy of patients with this injury.     

Anatomic versus reverse shoulder arthroplasty for post-traumatic sequelae of operatively and nonoperatively treated proximal humerus fractures

BackgroundThis study aimed to determine whether there is a long-term difference in outcomes between anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (rTSA) performed for proximal humerus fracture (PHF) sequelae. Hypotheses were as follows: (1) patients undergoing aTSA would have improved functional outcomes but a greater incidence of adverse events (AEs) and reoperation than those undergoing rTSA and (2) patients undergoing shoulder arthroplasty after open reduction internal fixation (ORIF) would have worse outcomes with more AEs and reoperations than those undergoing shoulder arthroplasty for sequelae of nonoperatively managed PHF.MethodsA prospectively collected database was queried for patients with PHF sequelae undergoing aTSA or rTSA between 2007 and 2020 with minimum 2-year follow-up. Baseline demographics, perioperative data, postoperative AEs, functional outcomes, and range of motion (ROM) were compared between aTSA and rTSA groups. A secondary analysis was performed to compare patients treated with prior PHF ORIF vs. those treated nonoperatively.ResultsThere were 17 patients in the aTSA group and 83 patients in the rTSA group. Type I PHF sequelae predominated among patients who underwent aTSA (71% vs. 40%, P = .026). Incidence of total postoperative AEs was greater after aTSA than that after rTSA (12% vs. 5%, P = .277), with a significantly higher rate of glenoid aseptic loosening after aTSA (6% vs. 0%, P = .026). All AEs required reoperation except one in the rTSA group. The mean follow-up was 66 months for aTSA compared with 45 months for rTSA (P = .002). No differences in functional outcomes or ROM between aTSA and rTSA persisted beyond 3 months or at the final follow-up except external rotation, which favored aTSA for 3 years postoperatively. In the secondary analysis, there were 33 patients in the ORIF group and 67 in the non-ORIF group. One (3%) postoperative AE occurred in the ORIF group vs. five (7%) in the non-ORIF group (P = .385). At a mean follow-up of 4 years, there were no differences in functional outcome scores or ROM between ORIF and non-ORIF groups, except for patient-reported shoulder function (6.3 vs. 7.4, respectively, P = .037).ConclusionFor treatment of PHF sequelae, aTSA may result in a higher incidence of postoperative AEs and reoperation than rTSA, particularly due to glenoid aseptic loosening. No difference in functional outcome scores between aTSA and rTSA persists beyond 3 months or at the final follow-up. Although active external rotation is significantly improved after aTSA for the first 3 years postoperatively, no differences in ROM exist beyond 4 years at the final follow-up. Patients undergoing shoulder arthroplasty for PHF sequelae have comparable outcomes regardless of prior ORIF or nonoperative management.Level of evidenceLevel III; Retrospective Cohort Design; Treatment Study     

Acute versus delayed reverse total shoulder arthroplasty for proximal humerus fractures in the elderly: Mid-term outcomes

BackgroundTreatment of proximal humerus fractures (PHFs) via reverse total shoulder arthroplasty (RTSA) has shown early promise when compared to historical treatment modalities. Ideal surgical timing remains unclear. The purpose of this study was to compare the outcomes of early versus delayed RTSA for PHF. We hypothesized that acute RTSA would display superior outcomes compared to those receiving delayed surgical intervention.MethodsThis multicenter study retrospectively analyzed 142 patients who underwent RTSA for fracture. Patients treated within 4 weeks of injury were placed in the acute group (n = 102), and patients treated longer than 4 weeks after injury were placed in the chronic group (n = 38). A comprehensive panel of patient reported outcome measures, VAS pain scores, range of motion, and patient satisfaction were evaluated.ResultsThe acute group had significantly better final follow-up SPADI scores (20.8 ± 23.9 vs. 30.7 ± 31.7) (p<0.05). No further differences were detected in other postoperative range of motion measurements, subjective outcomes, or VAS scores.ConclusionsOur results suggest that patients treated acutely display similar mid-term outcomes to those who receive delayed treatment. With this in mind, surgeons may first give consideration to a period of nonoperative treatment.Level of evidenceLevel II.     

Reverse shoulder arthroplasty for proximal humeral fractures: better clinical midterm outcome after primary reverse arthroplasty versus secondary reverse arthroplasty after failed ORIF in the elderly

BackgroundJoint replacement surgery as a treatment for complex proximal humeral fractures is an established option, especially in the elderly. In light of the increased attention to reverse total shoulder arthroplasty (rTSA), this study has analyzed the outcomes of patients with primary reverse arthroplasty and after secondary reverse arthroplasty for failed osteosynthesis.MethodsWe retrospectively reviewed 57 patients with an average age of 76 years (min. 55; max. 94; SD 7) from 2010 and 2015 who underwent primary rTSA (30) and secondary rTSA after the failure of plate osteosynthesis (27) after proximal humeral fractures. The functional outcome of the operated shoulder was evaluated by clinical scores (Constant-Score, ASES, DASH and Oxford), range of motion (RoM), pain and activity level.ResultsPrimary rTSA had a significantly better functional outcome, mean-follow-up 37.3 months, measured by Constant-Score (57.13 vs 45.78 points; p= .015) compared to secondary RTSA, mean follow-up 42.1 months. A significantly better active abduction (P= .002), forward flexion (P = .003) and internal rotation (P = .037) was observed in the primary rTSA group, especially in the follow-up > 35 months.ConclusionReverse shoulder arthroplasty is an effective treatment for proximal humeral fractures as primary or revision surgery. The reliable clinical outcome especially in the follow-up to 40 months after primary reverse arthroplasty may suggest to prefer rTSA for complex humeral fractures in the elderly.Level of evidenceLevel III; Retrospective comparative study     

Laparoscopic converted to open colectomy: predictors and outcomes from the Nationwide Inpatient Sample

Background

Early in their learning curve, surgeons need to appropriately select patients to avoid conversion from laparoscopic to an open colectomy.

Methods

Using the Nationwide Inpatient Sample, laparoscopic and laparoscopic converted to open colectomies performed between 2002 and 2007 were compared. We evaluated patient and institutional characteristics to find significant predictors and outcomes of conversion.

Results

Between 2002 and 2007, the rate of conversion was high, ranging from 35.7% to 38.0%. Multivariate predictors of conversion included obesity, diverticulitis, inflammatory bowel disease, constipation, metastatic disease, nonelective admission, left or transverse colectomy, intraoperative complication, lower socioeconomic status, uninsured status, and rural hospital location. A colectomy for benign colon polyps was less likely to be converted. Conversion to an open colectomy did not increase inpatient mortality.

Conclusions

Predictors of conversion from open to laparoscopic colectomy were found from a national database reflecting all US laparoscopic colectomies. Conversion did not increase inpatient mortality.     

The relationship between age and short-term complications following reverse total shoulder arthroplasty for proximal humerus fractures

BackgroundProximal humerus fractures (PHFx) are common orthopedic injuries among the elderly. Although nonoperative management remains the primary treatment modality, more than one-third of PHFx are now treated surgically. Over the past decade, reverse total shoulder arthroplasty (RTSA) has gained popularity as a treatment option for PHFx, both in elderly patients with complex fractures and patients younger than 65 years. While the age range of patients undergoing RTSA for PHFx has expanded, little is known about the impact of age on postoperative complications. The purpose of this study was to examine the relationship between age and 30-day complication rates following RTSA for PHFx.MethodsThe National Surgical Quality Improvement Program database was queried for patients who underwent RTSA for PHFx between 2006 and 2018. Patient demographic data, surgical characteristics, and adverse outcomes were extracted. Patients were divided into four cohorts by age (<65, 65-75, 76-85, >85 years), and univariate as well as multivariate analyses were performed.ResultsA total of 1099 patients were identified with a mean age of 72.7 years. Overall, 6.73% of patients experienced one or more complications. Mean operative duration decreased with age (135 minutes in the <65 years old cohort vs. 119 minutes in the >85 years old cohort, P < .001), while average hospital stay increased with age (2.8 days in the <65 years old cohort vs. 4.2 days in the >85 years old cohort, P < .001). Neither the overall complication rate nor the mortality rate was significantly different between cohorts. Relative to the <65 years old cohort, perioperative blood transfusion and non-home discharge were significantly more common in the 76-85 years old and >85 years old cohorts. Age >75 years, preoperative dependent functional status, and ASA class 3 or 4 were found to be independent risk factors for perioperative blood transfusion. Age ≥65 years, female gender, congestive heart failure, preoperative dependent functional status, and ASA class 3 or 4 were found to be independent risk factors for non-home discharge. The rate of unplanned hospital readmission was highest in the >85 years old cohort (17.65%), though this difference did not reach statistical significance.ConclusionsWhile RTSA appears to be a safe treatment option for PHFx in appropriately selected elderly patients, a longer hospitalization and more frequent non-home discharge should be anticipated. Additionally, elderly patients should be closely monitored for postoperative anemia.Level of evidenceLevel III; Retrospective Cohort Study     

Comparison of complication rates in reverse total shoulder arthroplasty performed for degenerative conditions versus proximal humerus fractures

BackgroundIndications for reverse total shoulder arthroplasty (RTSA) have been expanding. In addition to degenerative joint disease (DJD), RTSA is now being used to treat proximal humerus fractures (PHF). The purpose of this study was to compare postoperative complications in RTSA performed for DJD versus PHF.MethodsA retrospective analysis of the PearlDiver National Database was performed. International Classification of Diseases 10 codes were used to identify RTSA patients from 2015-2018 and separate them into DJD and PHF cohorts. Demographics, comorbidities, and hospital data were identified and compared using a two-sample t-test and chi-squared test. Systemic complications at 90 days and surgical complications at 90 days, 1 year, and 2 years were compared using multivariable logistic regression.ResultsFifteen thousand six hundred seventy eight patients (92.6% DJD, 7.4% PHF) were identified. PHF patients were more likely to be older (70.3 vs. 69.7 years, P = .026), female (83.5% vs. 62.2%, P < .001), and have more medical comorbidities (Charlson Comorbidity Index 3.42 vs. 3.17, P = .006) than DJD patients. After controlling for patient factors, PHF patients were more likely than DJD patients to develop urinary tract infection (odds ratio [OR] 1.65, P < .001), deep vein thrombosis (OR 1.76, P = .024), and hematoma (OR 3.83, P < .001) within 90 days of RTSA. At 90 days, 1 year, and 2 years postoperatively, RTSA for PHF patients were also more likely than RTSA for DJD patients to sustain a periprosthetic fracture (OR 2.57, P < .001) and instability (OR 2.02, P < .001).ConclusionsPatients with DJD and PHF undergoing RTSA represent different patient populations with distinct postoperative clinical outcomes. RTSA for PHF has inferior outcomes, which is significant in an era of bundled payments.     

Position of shoulder arthroplasty and clinical outcome in proximal humerus fractures

Four-part proximal humeral fractures are frequently treated with shoulder replacement. Outcome of this procedure has not been standardized, and there are controversy data on range of motion (ROM) and active function of the shoulder. The aim of this study is to compare shoulder prosthesis position (SPP) in terms of version of humeral head and height of stem with clinical subjective and objective outcome. Fifty patients were treated with shoulder hemiarthroplasty for four-part proximal humeral fracture or fracture-dislocation of the humeral head. Radiological examination and CT-scan were performed preoperatively and at follow-up. Clinical outcome evaluation included active and passive ROM, and subjective perspective collected through SF-36, OSQ, ASES, and DASH. No significant correlation between stem height and clinical outcome were found. The prosthesis version correlates with all subjective questionnaires. The ROM was not correlated with stem height and prosthesis version. SPP involves clinical outcome, with great relevance of implant version.     

Position of shoulder arthroplasty and clinical outcome in proximal humerus fractures

Four-part proximal humeral fractures are frequently treated with shoulder replacement. Outcome of this procedure has not been standardized, and there are controversy data on range of motion (ROM) and active function of the shoulder. The aim of this study is to compare shoulder prosthesis position (SPP) in terms of version of humeral head and height of stem with clinical subjective and objective outcome. Fifty patients were treated with shoulder hemiarthroplasty for four-part proximal humeral fracture or fracture-dislocation of the humeral head. Radiological examination and CT-scan were performed preoperatively and at follow-up. Clinical outcome evaluation included active and passive ROM, and subjective perspective collected through SF-36, OSQ, ASES, and DASH. No significant correlation between stem height and clinical outcome were found. The prosthesis version correlates with all subjective questionnaires. The ROM was not correlated with stem height and prosthesis version. SPP involves clinical outcome, with great relevance of implant version.     

The Nationwide Inpatient Sample may contain inaccurate data for carotid endarterectomy and carotid stenting

The Nationwide Inpatient Sample (NIS) contains information from discharge abstracts submitted by hundreds of community hospitals across the United States, and it frequently has been used as a resource for population-based research comparing the safety of carotid artery stenting (CAS) to that of carotid endarterectomy (CEA). However, at least two findings from the NIS dataset seem open to question. First, several NIS studies have indicated that more than 90% of CEAs and CAS procedures now are being done in asymptomatic patients, a figure that substantially exceeds the prevalence of asymptomatic patients that has been reported elsewhere. Second, these studies also have suggested that the periprocedural stroke rate for CEA and CAS is lower at community hospitals contributing to the NIS than it was in the Carotid Revascularization Endarterectomy vs Stenting Trial (CREST), even though the surgeons and interventionalists participating in CREST were stringently selected according to their previous experience and results. Neither of these two findings seems to pass the test of face validity. Furthermore, some unexpectedly low stroke-to-death (STD) ratios are present in the NIS data, especially for CAS. These issues may be related to poor documentation of preprocedural symptoms and periprocedural strokes in the medical records and to subsequent coding errors in the hospital discharge abstracts on which the NIS is based.     

Triceps-sparing versus olecranon osteotomy for ORIF: analysis of 67 cases of intercondylar fractures of the distal humerus

The purpose of this study was to compare the triceps-sparing approach with olecranon osteotomy regarding their effects on the functional outcomes of intercondylar fractures of the distal humerus managed with open reduction and internal fixation (ORIF), by reviewing 67 cases of intercondylar distal humerus fractures surgically managed with either of the approaches during 2001-2009. The medical records and radiographs of 30 male and 37 female patients, with a mean age of 44.5 years (range, 16-77) and a mean follow-up time of 34.3 months (range, 6-89), were retrospectively reviewed. Flexion, extension, arc of flexion/extension, pronation, supination, arc of pronation/supination and the Mayo Elbow Performance Score (MEPS) were used to assess the functional outcomes of intercondylar distal humerus fractures treated with ORIF through the triceps-sparing approach or olecranon osteotomy. According to the AO Foundation (AO) classification, there were 10 cases of C1, 28 cases of C2 and 29 cases of C3 fractures. At the time of review, all fractures had united. Although there was no overall statistically significant difference in the average flexion, extension, arc of flexion/extension, pronation, supination and arc of pronation/supination between the triceps-sparing group (n = 34) and the olecranon osteotomy group (n = 33), patients above 60 years of age tended to have more extension loss (mean 22.9°, range 0-55°) after ORIF via the triceps-sparing approach, compared with any other surgical approach/age combination group. In the triceps-sparing group, although only 37.5% of patients over the age of 60 years obtained excellent/good MEPS, the rate increased to 100% in patients aged less than 40 years of age (P < 0.05). By contrast, the rate of excellent/good MEPS remained above 80% in all age groups of patients treated with ORIF via olecranon osteotomy. In conclusion, ORIF via the triceps-sparing approach confers inferior functional outcomes for intercondylar distal humerus fractures in patients over the age of 60 years, for whom the olecranon osteotomy approach may be a better choice. However, for patients less than 60 years of age, especially those less than 40 years of age, either approach confers satisfactory outcomes.     

人工半肩关节置换治疗肱骨近端粉碎骨折的疗效及影响因素分析

目的 探讨人工半肩关节置换治疗肱骨近端粉碎骨折的疗效及影响因素.方法 对2000年6月至2006年12月采用半肩关节置换治疗的34例肱骨近端粉碎骨折的患者资料进行回顾性研究.除1例为陈旧性骨折外,其余33例均为新鲜骨折.骨折根据Neer分型:三部分骨折6例,三部分骨折伴肩关节脱位4例,四部分骨折18例,四部分骨折伴肩关节脱位3例,肱骨头劈裂性骨折3例.随访采用Neer评分和视觉模拟(VAS)评分,分析年龄、大小结节重建方法、骨折类型、大小结节愈合质量对肩关节主动上举、主动外旋、Neer评分、VAS评分的影响.结果 所有患者获3～5年(平均3.6年)随访,28例无肩痛,5例偶有轻微肩痛,1例有中度肩痛.Neer评分:优14例,良12例,可7例,差1例,优良率为76.5%;肩关节活动范围平均为:上举100°,外旋30°,内旋L5水平;VAS评分平均3.1分.70岁以下年龄组和70岁以上年龄组在肩关节主动上举活动范围平均值和Neer评分平均值比较差异均有统计学意义(P＜0.05),解剖重建和重叠重建大小结节两组患者的各项指标比较差异均无统计学意义(P＞0.05),不同骨折类型组患者的各项指标比较差异均无统计学意义(P＞0.05),大小结节完全愈合组和大小结节愈合不良或吸收组的肩关节主动上举活动范围平均值比较差异有统计学意义(P=0.003).结论 人工半肩关节置换术治疗肱骨近端严重粉碎性骨折,疗效满意,但应严格掌握适应证.大小结节重建的质量、患者年龄、手术技巧等可以影响疗效.     

Three- and four-part proximal humerus fractures in the elderly: Eminence versus evidence

The majority of proximal humerus fractures are minimally displaced and good outcomes can be achieved with nonoperative treatment strategies. However, controversy exists regarding the best management of highly comminuted and displaced proximal humerus fractures that occur in elderly patients with poor bone quality. Although surgical options including open reduction and internal fixation or hemiarthroplasty can restore excellent function, the rate of catastrophic failure remains high measuring between 20% and 40%. Reverse total shoulder arthroplasty has recently been introduced as a means for treatment of these fractures with intermediate results demonstrating improved range of motion, functional outcomes, and lower rates of revision.