Mid-term functional outcome (minimum 24 months, mean 4 years) after locking plate osteosynthesis for displaced fractures of the proximal humerus in 557 cases.

BACKGROUND: The best surgical management of displaced proximal humeral fractures remains a matter of considerable debate. This study presents mid-term functional outcome (median 4 years) after locking plate osteosynthesis for displaced proximal humeral fractures. METHODS: Between February 2002 and December 2014 1031 patients with 1047 displaced proximal humeral fractures were treated by open reduction and locking plate fixation with the same implant and received consecutive prospective follow up at least 24 months after surgical treatment. Clinical follow-up consisted of Constant Murley score (CS), Disabilities of the Arm, Shoulder and Hand score (DASH), and Short Form 36 questionnaire (SF-36). Complete follow-up could be performed in 557 (53.2%) cases, with a mean follow-up of 4.0 ± 2.7 years. RESULTS: Of 557 patients (67% women; mean age at time of osteosynthesis: 68.3 ± 15.5 years) absolute CS of all patients 4 ± 2.7 years after surgery was 68.4 ± 20.3 points. Normalized CS according to Katolik was 80.4 ± 23.8 points, and CS in percentage to the contralateral side (%CS) was 87.2 ± 27.9%. DASH score was at 23.8 ± 20.8 points. Osteosynthesis related complications (secondary displacement, screw cutout, avascular necrosis (n = 117 patients) were associated with lower functional scores (mean CS was 54.5 ± 19.0 p.; nCS 64.5 ± 22.9 p.;%CS 71.2 ± 25.0%; DASH score 31.9 ± 22.4 p.). The SF 36 was 66.5 points in the case cohort and a vitality mean of 69.4 points. Patients with a complication showed lower results (SF 36 56.7; vitality mean 64.9 points). CONCLUSIONS: Overall, patients following locking plate osteosynthesis of displaced proximal humeral fractures showed good to moderate outcomes four years after surgery. Mid-term functional outcomes correlate significantly with those at 1 year postoperatively. Furthermore, there is a significant negative correlation of midterm functional outcome with the occurrence of complications. LEVEL OF EVIDENCE: Level III, prospective nonconsecutive patients.

Time to surgery after proximal femur fracture in geriatric patients depends on hospital size and provided level of care: analysis of the Registry for Geriatric Trauma (ATR-DGU).

PURPOSE: Proximal femur fractures predominantly affect older patients and can mark a drastic turning point in their lives. To avoid complications and reduce mortality, expert associations recommend surgical treatment within 24-48 h after admission. Due to the high incidence, treatment is provided at a wide range of hospitals with different size and level of care, which may affect time to surgery. METHODS: Data from 19,712 patients included from 2016 to 2019 in the Registry for Geriatric Trauma (ATR-DGU) were analyzed in terms of time to surgery, in-house mortality, mobilization on the first postoperative day, ambulation status on the 7th day after surgery, and initiation of osteoporosis therapy. Participating hospitals were grouped according to their classification as level I, II or III trauma centers. Also presence of additional injuries, intake and type of anticoagulants were considered. Linear and logistic regression analysis was performed to evaluate the influence of hospitals level of care on each item. RESULTS: 28.6% of patients were treated in level I, 37.7% in level II, and 33.7% in level III trauma centers. There was no significant difference in age, sex and ASA-score. Mean time to surgery was 19.2 h (IQR 9.0-29.8) in level I trauma centers and 16.8 h (IQR 6.5-24) in level II/III trauma centers (p < 0.001). Surgery in the first 24 h after admission was provided for 64.7% of level I and 75.0% of level II/III patients (p < 0.001). Treatment in hospitals with higher level of care and subsequent increased time to surgery showed no significant influence on in-house mortality (OR 0.90, 95%-CI 0.78-1.04), but negative effects on walking ability 7 days after surgery could be observed (OR 1.28, 95%-CI 1.18-1.38). CONCLUSION: In hospitals of larger size and higher level of care the time to surgery for patients with a proximal femur fracture was significantly higher than in smaller hospitals. No negative effects regarding in-house mortality, but for ambulation status during in-hospital stay could be observed. As the number of these patients will constantly increase, specific treatment capacities should be established regardless of the hospitals size.

Increased Geriatric Treatment Frequency Improves Mobility and Secondary Fracture Prevention in Older Adult Hip Fracture Patients-An Observational Cohort Study of 23,828 Patients from the Registry for Geriatric Trauma (ATR-DGU).

Interdisciplinary orthogeriatric care of older adult hip fracture patients is of growing importance due to an ageing population, yet there is ongoing disagreement about the most effective model of care. This study aimed to compare different forms of orthogeriatric treatment, with focus on their impact on postoperative mobilization, mobility and secondary fracture prevention. In this observational cohort study, patients aged 70 years and older with a proximal femur fracture requiring surgery, were included from 1 January 2016 to 31 December 2019. Data were recorded from hospital stay to 120-day follow-up in the Registry for Geriatric Trauma (ATR-DGU), a specific designed registry for older adult hip fracture patients. Of 23,828 included patients from 95 different hospitals, 72% were female, median age was 85 (IQR 80-89) years. Increased involvement of geriatricians had a significant impact on mobilization on the first day (OR 1.1, CI 1.1-1.2) and mobility seven days after surgery (OR 1.1, CI 1.1-1.2), initiation of an osteoporosis treatment during in-hospital stay (OR 2.5, CI 2.4-2.7) and of an early complex geriatric rehabilitation treatment (OR 1.3, CI 1.2-1.4). These findings were persistent after 120 days of follow-up. Interdisciplinary treatment of orthogeriatric patients is beneficial and especially during in-patient stay increased involvement of geriatricians is decisive for early mobilization, mobility and initiation of osteoporosis treatment. Standardized treatment pathways in certified geriatric trauma departments with structured data collection in specific registries improve outcome monitoring and interpretation.

Supraspinatus Tenotomy in Reverse Shoulder Arthroplasty for Fractures: A Comparative Cohort Study.

BACKGROUND: The aim of this study was to evaluate the functional and radiographic outcome in patients with reverse total shoulder arthroplasty (RSA) for displaced proximal humeral fractures (PHF) with or without tenotomy of the supraspinatus tendon. METHODS: Between June 2011 and June 2018, 159 patients (age >65 years) with a displaced proximal humeral fracture underwent reverse total shoulder arthroplasty (Grammont design) in a single-center study and were longitudinally followed up. In all cases, the tuberosities were attached to the prosthesis in a standardized procedure. Functional outcome, range of motion as well as tuberosity integration, resorption and displacement were assessed at final follow-up. Outcomes were compared between patients that underwent RSA in combination with tenotomy of the supraspinatus (ST) and patients that underwent RSA without supraspinatus tenotomy (NT). RESULTS: At a mean follow up of 22.2 ± 16.4 months 76 patients (mean age 77.1 ± 7.2 years, 83% women) could be evaluated (follow-up rate 47.8%). There were no statistically significant differences between the ST (n = 29) and NT groups (n = 47) in tuberosity integration, resorption 20°: 65.5% vs. 14.9%, p < 0.05) and active abduction (>120°: 89.7% vs. 21.3%, p < 0.05). Tuberosity integration (ST and NT together: n = 34) showed better functional results than resorption or displacement (p < 0.05). CONCLUSIONS: Tenotomy of the supraspinatus tendon in RSA for displaced PHF leads to similar radiographic results regarding tuberosity integration, resorption and displacement but better functional outcome with regard to range of motion. LEVEL OF EVIDENCE: III.

Injuries of the sternoclavicular region indicate concomitant lesions and need distinguished imaging.

PURPOSE: To evaluate injuries of the sternoclavicular region as indicator injury for relevant concomitant injuries and to evaluate the modalities of initial imaging. We hypothesised a high incidence of concomitant injuries as well as a deficiency of X-ray as the initial gold standard. METHODS: We retrospectively analysed patients suffering from injuries of the sternoclavicular region between 2002 and 2017. We analysed amongst injury type and severity, initial imaging (X-ray vs. CT scan of the sternoclavicular region vs. whole-body scan), and complement of imaging with regard to defined concomitant injury localisations and the resulting necessity and urgency of surgery. RESULTS: We included n = 61 patients. The mean ISS was 13.5 ± 17, n = 13 (21.3%) cases were classified as "severely injured" (ISS ≥ 16). N = 29 (47.5%) achieved an initial X-ray, n = 10 (16.4%) an initial CT scan of the sternoclavicular region, and n = 22 (36%) an initial whole-body CT scan. Initial imaging correlated significantly with ISS. In n = 21 (72.4%) cases of the X-ray group a significant complement from X-ray to CT scan of the sternoclavicular region was indicated (p ≤ 0.001). N = 31 (50.8%) patients suffered from concomitant injuries. N = 39 (63.9%) of all patients underwent any kind of surgery, thereof n = 23 (37.7%) related to their sternoclavicular injuries. CONCLUSION: Injuries of the sternoclavicular complex are indicators for the presence of multiple injuries. A CT scan of the sternoclavicular region including ipsilateral apex of the lung and upper rib cage comprised a large proportion of concomitant injuries. Mapping those injuries during initial imaging improves treatment process, avoids underdiagnostic, and decreases uncertainties.

Screw-Tip Augmented Locked Plating Versus Primary Reverse Total Shoulder Arthroplasty in Displaced Proximal Humeral Fractures: A Retrospective Comparative Cohort Study With a Mean Follow-Up of 39 Months.

INTRODUCTION: This study compared the clinical and radiologic outcomes of screw-tip augmented locking plate osteosynthesis (STA) vs primary reverse total shoulder arthroplasty (RSA) in elderly patients with displaced proximal humeral fractures. METHODS: 60 patients (age >65 years) with a displaced proximal humeral fracture underwent open reduction and internal fixation with locking plate and fluoroscopy controlled screw-tip augmentation. Sixty matched individuals (age, gender, fracture pattern, and mean follow-up) treated by RSA for fractures were identified from the institutional database and outcomes as well as occurring complications and need for revision surgery were compared. RESULTS: At 39 months' follow-up, 25 patients in the STA group (mean age 74.5 ± 12 years, 76.7% woman) showed a mean Constant Score (CS) of 68 ± 18.8 points. Mean %CS compared to the contralateral side was 81.6 ± 19.8%. Of 60 matched individuals in the RSA group, 22 patients (mean age 78.9 ± 8.2 years, 76.7% woman) showed a mean CS of 60.6 ± 21.2 points (P = .33), and the mean %CS compared to the contralateral side was 81.6 (74.7 ± 18.6)% (P = .14). The overall complication rate in STA group was 32% (secondary varus or valgus displacement >10°, n = 4, avascular necrosis, n = 4). In RSA group, the overall complication rate was 4.5% (P = <.05). We observed one early onset infection. Revision surgery with removal of the prosthesis and PMMA spacer implantation for two-stage revision was necessary. The follow-up rate was 41.7 vs 36.7%. CONCLUSIONS: Screw-tip augmented locked plating and reverse total shoulder arthroplasty result in comparable satisfying functional outcome 3 years following a displaced proximal humeral fracture in elderly patients. However, we noted a higher complication and revision rate in the STA group. In contrast, primary reversed shoulder arthroplasty resulted in a lower rate of complications and revisions, which may be beneficial in elderly patients.

Glenohumeral joint lavage does not affect clinical outcomes in open reduction and internal fixation of displaced intracapsular proximal humeral fractures: a prospective, randomized, double-blinded trial.

BACKGROUND: This prospective, randomized, and double-blinded trial evaluates the effect of intraoperative glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures. METHODS: Between January 2016 and April 2018, 86 patients (mean age: 65.2 ± 16.3 years) with a displaced intracapsular proximal humeral fracture were treated by open reduction and internal fixation using locking plates. Patients were randomized to either locked plating followed by intraoperatively performed glenohumeral joint lavage (group L, n = 36) or locked plating without the lavage (group NL, n = 36). Functional outcome assessment included range of shoulder motion, strength, and the Constant score, obtained 6 weeks, 3 months, 6 months, and 12 months postoperatively. A total of 62 shoulders could be reviewed for final investigation (86% follow-up). RESULTS: One year after open reduction and internal fixation, the mean Constant score was 70 ± 14 (group L, n = 31) compared with 73 ± 14 (group NL, n = 31, P = .272). The mean forward flexion and abduction in group L was 134 ± 33 and 128 ± 33 as compared with 139 ± 32 and 135 ± 32 in group NL, respectively (P = .538, P = .427). The mean external rotation was 40 ± 16 (group L) compared with 44 ± 16 (group NL) (P = .210). The overall complication rate was 9.6% and did not differ significantly between the groups (P = .321). In group L, there were 2 cases of avascular necrosis (6.5%) and 1 case of secondary displacement (3.2%). In group NL, 1 case of avascular necrosis (3.2%) and 1 case of secondary displacement were noted (3.2%, P = .742). CONCLUSION: The results of this study do not demonstrate a need for glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures with regard to shoulder function at 1-year follow-up.

Operative treatment of 2-part surgical neck type fractures of the proximal humerus in the elderly: Cement augmented locking plate PHILOS™ vs. proximal humerus nail multiloc®.

INTRODUCTION: The purpose of this prospective randomized controlled clinical trial was to compare locked plating with intramedullary nailing in the treatment of displaced 2-part surgical neck type proximal humeral fractures in elderly patients. PATIENTS AND METHODS: Patients ≥60 years of age with a displaced 2-part surgical neck type fracture of the proximal humerus were surgically treated and randomized for either augmented locking plate fixation Group LP or multiplanar intramedullary nailing Group IN. The primary outcome parameter was the Disabilities of the Shoulder, Arm and Hand (DASH) Score after 24 months. Secondary outcome parameters were the age- and gender adjusted Constant Murley Score (CS), the American Shoulder and Elbow Score (ASES), the Oxford Shoulder Score (OSS) and the Short Form 36 (SF-36) after 6 weeks, 3 months, 6 months, 12 and 24 months. Further parameters included the quality of fracture reduction as well as complications and revision surgeries. 60 patients with a mean age of 75±9.8 were included and longitudinally followed over 24 months (follow-up rate: 83.3%). RESULTS: The mean DASH-Scores at 24 months was 32.6 ± 9.7 points in Group LP versus 37.8 ± 8.3 points in Group IN (p = 0.04). The mean Constant Murley Score at 24 months follow-up was 76.2 ± 7.7 points in Group LP compared to 72 ± 9.1 points in Group IN (p = 0.08). The ASES at 24 months follow-up was 75.1 ± 9 points in Group LP versus to 73.5 ± 8.9 in Group IN (p = 0.51). The OSS at 24 months was 43.7 ± 8.1 in Group LP compared to 38.2 ± 10 in Group IN (p = 0.03). The SF-36 at 24 months was 74.7 ± 12.5 in Group LP versus to 70.9 ± 12.8 in Group IN (p = 0.29). Screw cutting out was observed in n = 2 (6,7%) cases of Group LP, and in none of Group IN (p = 0.49). Revision surgery was necessary in n = 2 (6.7%) cases of Group LP and in two cases of Group IN (6.7%, p = 1). CONCLUSION: Functional outcomes are similar at 2-years follow-up in locked plating with screw tip augmentation compared to intramedullary nailing. Both implants reached low complication- and revision rates for two-part surgical neck types fractures of the proximal humerus in patients ≥60 years, if anatomic fracture reduction and accurate implant position was obtained.

Open reduction and internal fixation of displaced proximal humeral fractures. Does the surgeon's experience have an impact on outcomes?

INTRODUCTION: To evaluate outcomes following open reduction and internal fixation of displaced proximal humeral fractures with regards to the surgeon's experience. MATERIAL AND METHODS: Patients were included undergoing ORIF by use of locking plates for displaced two-part surgical neck type proximal humeral fractures. Reduction and functional outcomes were compared between procedures that were conducted by trauma surgeons [TS], senior (>2 years after board certified) trauma surgeons [STS] and trauma surgeons performing ≥50 shoulder surgeries per year [SS]. Quality of reduction was measured on postoperative x-rays. Functional outcomes were assessed by gender- and age-related Constant Score (nCS). Secondary outcome measures were complication and revision rates. RESULTS: Between 2002-2014 (12.5 years) n = 278 two-part surgical neck type humeral fractures (AO 11-A2, 11-A3) were included. Open reduction and internal fixation was performed with the following educational levels: [TS](n = 68, 25.7%), [STS](n = 110, 41.5%) and [SS](n = 77, 29.1%). Functional outcome (nCS) increased with each higher level of experience and was significantly superior in [SS] (93.3) vs. [TS] (79.6; p = 0.01) vs. [STS] (83.0; p = 0.05). [SS] (7.8%) had significantly less complications compared with [TS] (11.3%; p = 0.003) and [STS](11.7%; p = 0.01) moreover significantly less revision rates (3.9%) vs. [TS](8.2%) and [STS](7.4%) (p<0.001). Primary revision was necessary in 13 cases (4.7%) due to malreduction of the fracture. CONCLUSION: Quality of reduction and functional outcomes following open reduction and internal fixation of displaced two-part surgical neck fractures are related to the surgeon's experience. In addition, complications and revision rates are less frequent if surgery is conducted by a trauma surgeon performing ≥50 shoulder surgeries per year.