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Patient, fracture characteristics may affect treatment of proximal humerus fractures
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NEW YORK — A retrospective review presented at the American Shoulder and Elbow Surgeons Annual Meeting showed younger patients with less complex proximal humerus fractures were more commonly treated with open reduction and internal fixation, while older patients with more complex fractures were more commonly treated with reverse shoulder arthroplasty.
B. Israel Yahuaca, MD, and colleagues analyzed patient and fracture characteristics, postoperative falls, reoperation and range of motion for 425 patients with proximal humerus fractures treated with open reduction and internal fixation (ORIF), hemiarthroplasty or reverse shoulder arthroplasty.
Yahuaca said in his presentation here, “Our questions were: What factors influence the choice of device? Does that treatment affect the range of motion? Do the healing and reoperation rates vary by treatment type and do the patient characteristics influence any risk of recurrent fall or injury?”
Yahuaca noted patients who were older and had a higher American Society of Anesthesiologists (ASA) grade and fracture class were more likely to be treated with arthroplasty compared with younger patients with a lower ASA grade and fracture class who were more likely to be treated with ORIF.
“We can see the average age for reverse was higher and this was significant, as well as the majority of two-part [fractures] were treated with operative fixation, while a higher percentage of more complex [fractures] were treated with reverse [shoulder arthroplasty],” Yahuaca said.
significant differences were only found between ORIF and hemiarthroplasty, according to Yahuaca. He added younger patients and ORIF showed higher fracture union rates, while ORIF and hemiarthroplasty had significantly higher reoperation rates vs. reverse shoulder arthroplasty.
“We had almost a quarter of our patients, 97 of the 425, who had a recurrent fall and 73% of those had at least one more fracture,” Yahuaca said. – by Casey Tingle
Reference:
Yahuaca BI, et al. Paper 32. Presented at: American Shoulder and Elbow Surgeons Annual Meeting; Oct. 17-19, 2019; New York.
Disclosure: Yahuaca reports no relevant financial disclosures.
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Michael McKee, MD, FRCSC
This large retrospective study examines the outcome of 425 proximal humeral fractures treated surgically with either open reduction [and] internal fixation (ORIF; n=211), hemiarthroplasty (n=108) or reverse shoulder arthroplasty (n=106). The median age of the patients was 65 years, and 75% were women, with a preponderance of complex injuries (89% were three- or four-part fractures).
Despite the fact that the patients receiving reverse shoulder arthroplasty were older (mean age 73.0 years vs. 64.7 years in the hemiarthroplasty group) the reverse shoulder arthroplasty group had significantly better motion, and a lower reoperation rate (6.6% vs. 15.7%) compared to the hemiarthroplasty group. The ORIF group was significantly younger (61.6 years) than the arthroplasty groups and overall had better motion, but there was a 17% reoperation rate in the ORIF group.
Interestingly, postoperatively 23% of patients had at least one fall that resulted in a further 80 fractures that included distal radius, proximal humerus and hip fractures.
While there is a significant selection bias (age, American Society of Anesthesiologist grade, fracture type) and lack of a control (nonoperative) group in this retrospective study, the data would support the recent trend toward reverse shoulder arthroplasty over hemiarthroplasty for displaced proximal humeral fractures in older patients. While the ORIF group had superior range of motion, the reoperation rate of 17% in expert hands is alarming and clearly there is room for improvement in this area. Lastly, there was a significant subsequent fracture rate in this group of individuals that represents an opportunity for intervention.
University of Arizona College of Medicine - Phoenix
Phoenix
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