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Displaced proximal humeral fractures: When is surgery necessary? Iskandar Tamimi a,*, Guillermo Montesa b, Francisco Collado b, David Gonza´lez b, Pablo Carnero b, Facundo Rojas b, Mohamed Nagib b, Vero´nica Pe´rez b, Miguel A´lvarez b, Faleh Tamimi a a b
Faculty of Dentistry, McGill University, Montreal, Canada Traumatology and Orthopedic Surgery Department HRU Carlos Haya, Malaga, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 February 2015 Received in revised form 12 May 2015 Accepted 31 May 2015
Background: Several therapeutic methods have been traditionally used in the treatment of displaced proximal humeral fractures; however, the indication of these treatments is still controversial. The purpose of this study was to compare the medium-term functional results of four methods commonly used in the treatment of proximal humeral fractures [conservative treatment, proximal humeral nails (PHN), percutaneous K-wiring (PKW), and locking-plates (LP)] taking into consideration the type of fracture and the age of the patients. Methods: We conducted a retrospective cohort study on patients with proximal humeral fractures treated with one of the following methods: conservative treatment, PHN, PKW, or LP. Functional results were assessed using the absolute Constant score and the disabilities of the arm shoulder and hand score (DASH). The functional outcome was analysed according to age (65 years and <65 years) and fracture type (displaced 2-fragment and 3–4-fragment fractures). Results: A total of 113 patients were included in the study, with a mean age of 65.3 SD 15.2 years and average follow-up time of 26.2 SD 12.6 months. Patients under 65 years had higher Constant scores when treated with PHN and PKW than those treated conservatively (77.2 vs. 54.7, p = 0.01 and 74.0 vs. 54.7, p = 0.03, respectively). Patients above 65 years had higher Constant scores when treated with PKW compared to PHN and conservative treatment (68.7 vs. 51.9, p = 0.02 and 68.7 vs. 55.9, p = 0.029, respectively). In 2-fragment fractures, PKW resulted in higher Constant scores than conservative treatment (70.4 vs. 53.9, p = 0.048). No differences were found in the final outcome between patients treated with LP and those treated conservatively regardless of age, and fracture type. There were also no differences between any of the evaluated methods in the treatment of 3–4-fragment fractures. Conclusion: The use of PKW was associated with better functional results than conservative treatment in individuals of all ages, especially in patients with 2-fragment fractures; PKW also achieved better functional results than PHN in elderly patients. PHN was superior to conservative treatment in young individuals. No significant differences were found between LP and conservative treatment in any of the analysed categories. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Proximal humerus fracture Locking plate Proximal humeral nail Kirschner wires Conservative treatment Functional outcome Age Fracture type
Introduction Displaced proximal humeral fractures are relatively common in elderly and osteoporotic patients and can lead to significant functional incapacity [1]. Multiple treatment methods have been used in the management of these fractures including conservative
* Corresponding author at: McGill University, 2001 McGill College Avenue, Suite 500, Montreal, Quebec, H3A 1G1 Canada. Tel.: +1 514 398 7203. E-mail addresses:
[email protected],
[email protected] (I. Tamimi).
treatment, direct suturing of the fracture fragments, proximal humeral nails (PHN), percutaneous K-wiring (PKW), percutaneous fixed angle locking plates (LP), open reduction and internal fixation with LP, and partial or total shoulder arthroplasty [2]. However, the management of these fractures is controversial and surgeons base their indications subjectively on a series of factors such as degree of displacement, number of fragments, surgical experience, baseline functional status of the patient, hand dominance, and age. The literature comparing these therapeutic options is limited, and to our knowledge there are no published cohort studies that compare four of the main treatment modalities (PHN, conservative
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treatment, LP and PKW) [3,4]. On the other hand, the success rates of the different treatment options used in the management of displaced proximal humeral fractures may also vary according to patient’s age and fracture type; as the bone quality and general health status changes with age [5]. Accordingly, the purpose of this study was to compare the medium-term functional results of four methods commonly used in the treatment of proximal humeral fractures [conservative treatment, PHN, PKW, and LP] taking into consideration the type of fracture and the age of the patients. Materials and methods
Clinical features The following parameters were retrieved from patients’ files and computerised records: age, gender, fracture side, pre-surgical comorbidities (e.g., liver disease, ischemic heart disease, chronic renal failure) type of fracture according to Neer’s classification (2, 3 or 4-displaced fragments), type of treatment [conservative treatment, PHN (Expert, Synthes, Stratec Medical Ltd, Oberdorf, Switzerland), LP (PHILOS, Synthes, Stratec Medical Ltd, Oberdorf, Switzerland), and PKW], date of surgery, postoperative complications (i.e., hardware migration, malunion, avascular necrosis, pseudarthrosis, infections, and screw protrusion), and follow-up period.
Patient selection Treatment options We conducted a retrospective cohort study on four treatment methods for proximal humeral fractures [conservative treatment, PHN, PKW, and LP]. All patients with the diagnosis of displaced proximal humeral fracture treated in our center, between January 1st, 2008 and December 31st, 2013 were reviewed. Patients’ records were withdrawn from the computerised database of the Orthopedic Surgery Department without any exposure information. All displaced proximal humeral fractures that occurred within the study period were reviewed. Patients with pathological fractures (i.e., secondary to osteomalacia, Paget’s disease, primary bone tumors or bone metastasis), treated with shoulder hemiarthroplasty, with a follow-up of less than 8 months, and those who were lost or died during follow-up were excluded from the analysis.
The selection of the treatment method depended mainly on the surgeon’s experience and did not follow a strict intradepartmental protocol due to the lack of solid guidelines. When conservative treatment was applied, patients were immobilised in a sling bandage stabilising the arm against the chest for 2 weeks. A closed reduction was performed if the displacement between the head and the distal fragment was above 50% of the diaphyseal diameter; in these cases, a control X-ray was performed after the reduction. Follow-up X-rays were performed at 2, 4 and 6 weeks; pendular exercises were started after 2 weeks if there was no apparent crepitation at the fracture site (Fig. 1) [2]. PKW was performed following closed reduction under imageintensifier. Reduction was achieved by gentle arm manipulation
Fig. 1. (A) AP X-ray of the shoulder showing a displaced 3-fragment proximal humerus fracture in valgus position. (B) Transthoracic X-ray of the shoulder showing posterior angulation (>458) of the fracture and displacement of the greater tuberosity. (C and D) AP and transthoracic X-rays showing evidence of consolidation after 5 weeks of conservative treatment.
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and manual traction. Two to four 2.5 mm K-wires were inserted through the lateral and or medial epicondyles, depending on the type of fracture [6]. K-wires were bent distally to control migration and situated in the subchondral bone, approximately 5–8 mm from the articular surface. Finally, the K-wires were left under the skin to avoid infections and the arm was then immobilised in a sling as previously described (Fig. 2) [2]. Metal removal was performed once fracture consolidation was confirmed, approximately 4 months after surgery. Patients treated with LPs underwent a deltopectoral approach; fracture reduction was performed by a careful manipulation of the fragments in order to avoid excessive periosteal damage. Fragments were reduced into position by direct methods or with a K-wire used as a ‘‘joystick’’; reduction was confirmed by image-intensifier. After reduction and provisional stabilisation using threaded K-wires, stable fixation was performed with a LP and a minimum of 6 proximal and 3 distal screws. The arm was then immobilised in a sling and pendular exercises were initiated (Fig. 3) [7]. Individuals that were treated with PHN fixation underwent a closed fracture reduction under image-intensifier control. Then a small deltoid-splitting and rotator cuff incision was made. The medullary canal was opened with an awl and a guide wire was introduced in the humeral canal. The nail connected to the aiming arm was then inserted into the medullary canal; proximal locking was performed using a spiral blade or a locking screw depending on the bone quality. Finally, the rotator cuff incision was carefully sutured and mobilisation was initiated on the second postoperative day [8,9] (Fig. 4). In order to confirm the
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correct reduction of the fracture a post-operative control X-ray was performed in all cases regardless of the surgical treatment applied. Clinical evaluation The functional assessment was performed at least 8 months after the fracture diagnosis using the absolute Constant score, and the disabilities of the arm shoulder and hand score (DASH) [10,11]. The absolute Constant score has a maximum punctuation of 100 points; higher scores represent a better functional outcome. The DASH ranges from 0 to 100 points; higher scores represent a worse functional outcome. The morbidity of the patients was evaluated using the Charlson Comorbidity Index (CCI) [12]. Individuals were divided into 2 different subgroups according to their preoperative general status (CCI <3.5 and 3.5). Functional results were analysed according to the treatment option applied (conservative treatment, PHN, LP and PKW), age (65 years and <65 years) and fracture type (displaced 2-fragment and 3–4-fragment fractures). Data management and statistical analysis Data were analysed with SPSS 17.0 software (SPSS Inc, Chicago, IL, USA), Origin Pro 8.0 (OriginLab Corporation, Northampton, USA), and G*power 3.0.10 (Universita¨t Kiel, Germany). Mean values were expressed with their corresponding standard deviation (SD). Normal distribution was confirmed in each group using
Fig. 2. (A) AP X-ray of the shoulder showing a displaced surgical neck fracture of the proximal humerus, with no apparent contact between the two fragments. (B) Transthoracic X-ray of the shoulder showing a good lateral alignment of the fracture. (C) Post-surgical X-ray confirming an adequate reduction and stabilisation of the fracture with percutaneous Kirschner wires. (D) AP X-ray performed 3 months after the initial surgery, showing some evidence of consolidation and penetration of the articular surface by both Kirschner wires; the patient was booked for prompt hardware removal.
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Fig. 3. (A) AP X-ray of the shoulder showing a displaced 3-fragment fracture of the proximal humerus in valgus position. (B) Transthoracic X-ray of the shoulder showing a good lateral alignment of the fracture. (C) Post-surgical X-ray confirming an adequate reduction and fixation of the fracture with a locking plate (PHILOS). (D) AP X-ray of the shoulder showing some evidence of consolidation 3 months after surgery.
the Shapiro–Wilk test. Odd ratios were presented with 95% coefficient intervals. Differences between continuous variables were analysed using the one-way ANOVA and LSD test, whereas differences between binary variables were analysed using the Chi square test. Correlation between continuous variables was measured using the Pearson correlation coefficient. Results were considered significant when two-tailed P values were < 0.05. Power analysis were performed using two-tailed post-hoc t-test for two independent means with an a-error probability of 0.05.
There were no significant differences between the different therapeutic options with regards to age, gender or injured side. In patients above 65 years with 3–4-fragment fractures, PKW and IMN were less frequently used than LP and conservative treatment (Table 1). Regarding the preoperative general status of the patients, individuals who underwent osteosynthesis with LP and PHN had a better basal condition according to the CCI when compared with patients that were treated conservatively or with PKW (Table 1). Post-surgical results
Results Patient demographics and clinical features The total number of patients with displaced proximal humeral fractures who were treated in our center during the study period was 182, among whom 113 individuals [76 (67.4%) females and 37 (32.6%) males)] were included and 69 patients were excluded [3 pathological fractures, 5 hemiarthroplasties, 16 deaths, 45 lost to follow-up]. We registered 45 (39.2%) 2-fragment fractures and 68 (60.2%) 3–4-fragment fractures. Conservative treatment was applied in 25 (22.1%) cases, whereas surgery was considered in 88 (77.9%) patients [PHN fixation in 19 (16.8%), LP 44 (38.9%), and PKW 25 (22.2%)]. The mean age was of 65.3 SD 15.2 years and the mean follow-up time at functional assessment was of 26.2 SD 12.6 months (ranging from 8 to 55 months). Fractures were more common on the right side 67 (59.3%) than on the left 46 (40.7%).
The mean follow-up time from the date of the fracture was of 28.0 SD 8.5 months for conservative treatment, 25.9 SD 15.0 for LP, 27.6 SD 14.0 for PKW, and 22.5 SD 9.0 for PHN. No significant differences were found between the different groups in terms of follow-up time (Table 2). The total number of registered complications was 22 (19.5%) (7 cases of hardware migration, 6 vicious consolidation, 3 avascular necrosis, 3 pseudarthrosis, 1 superficial infection, 1 postoperative bleeding, and 1 screw protrusion). A total of 8 (18.2%) complications were registered in patients treated with LP, 6 (24.0%) in those treated with PKW, 7 (36.8%) in patients treated with PHN, and 1 (5%) in patients treated conservatively. There were no significant statistical differences in the complication rates between the different surgical treatments. The overall functional outcome according to the Constant score was more favourable in patients that underwent PKW than in those treated conservatively [70.0 vs. 57.2, p = 0.012 (power 87%)]. There were no overall significant
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Fig. 4. (A) AP X-ray of the shoulder showing a displaced 3-fragment fracture of the proximal humerus extending to the proximal diaphysis. (B) Post-surgical X-ray confirming an adequate reduction and fixation of the fracture with a proximal humeral nail (Expert). (C and D) AP X-rays of the shoulder performed 1 months and 5 months after the initial surgery, respectively, showing a progressive consolidation of the fracture.
differences between LP and conservative treatment [Constant score: p = 0.086, (power 45%), DASH: p = 0.47 (power 12%)], nor between the other treatment methods (Table 2). Functional results according to age In patients under 65 years of age, the use of PHN or PKW lead to higher Constant scores than those achieved with conservative treatment [77.2 vs. 54.7, p = 0.01 (power 96%) and 74.0 vs. 54.7, p = 0.031 (power 87%), respectively)] (Table 3). No significant differences were found in the Constant and DASH scores between patients under 65 years of age who were treated conservatively and those treated with LP (p = 0.09, and p = 0.47, respectively). In patients over 65 years of age, the use of PKW had better Constant scores than PHN and conservative treatment [68.7 vs. 51.9, p = 0.02 (power 70%) and 68.7 vs. 55.3, p = 0.029 (power 74%), respectively] (Table 3). No significant differences in the Constant and DASH functional scores were found between patients treated conservatively and those treated with LP in this group (p = 0.39, and p = 0.80, respectively) (Table 3). The results of PHNs were age dependent, the mean Constant score in patients under 65 years was 77.2 vs. 51.9 in patients above 65 years [p = 0.01 (power 84%)] (Table 3) (Fig. 5). Moreover, there were no significant differences in the fracture type (i.e., 2-fragment and 3–4 fragment fractures) distribution according to age in patients treated with PHN OR 0.31 (CI 95% 0.04–2.6) (Table 1). Functional results according to fracture type In 2-fragment fractures the use of PKW achieved Constant scores that were significantly higher than conservative treatment [70.4 vs. 53.9, p = 0.048 (power 77%)]. We did not find significant differences in the Constant and DASH functional scores between
patients with 2-fragment fractures that were treated conservatively and those treated with LP (p = 0.33 and 0.45, respectively). In 3–4-fragment fractures, no statistical significant results were found between any of the different treatment modalities (Table 3). Discussion The objectives of this study were to compare four therapeutic methods commonly used to treat patients with displaced proximal humeral fractures [conservative treatment, PHN, PKW, and LP], and to analyse the effect of age and fracture type on the functional outcome of these patients. Accordingly, we observed that PKW was better than conservative treatment in individuals of all ages, especially in patients with 2-fragemt fractures. PHN was superior to conservative treatment in young individuals, and the use of PKW achieved better functional results than PHN in elderly patients. No significant differences were found between LP and conservative treatment in any of the analysed categories. PKW vs. conservative treatment In young patients, PKW had superior functional results compared with conservative treatment, even though there were no differences in the fracture type distribution between these treatment categories (Tables 1 and 3). The use of PKW in proximal humerus fractures has multiple advantages such as minimal blood loss, shorter surgical time, less soft tissues stripping, and less cost [13,14]. Nevertheless, PKW techniques are also associated with complications like pintract infection, poor reduction, malunion, and pin migration [14]. The insertion of metalwork in the humeral epicondylar area can also injure neurovascular structures such as
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6 Table 1 Patient demographics and clinical features. Parameter Patients age, y Age <65 N (%) Age 65 N (%) OR (95% CI) OR (95% CI) OR (95% CI) Fracture type, age <65 y N (%) 2-Fragments N (%) 3–4 Fragments N (%) OR (95% CI) OR (95% CI) OR (95% CI) Fracture type, age 65 y N (%) 2-Fragments N (%) 3–4 Fragments N (%) OR (95% CI) OR (95% CI) OR (95% CI) Gender Female N (%) Male N (%) OR (95% CI) OR (95% CI) OR (95% CI) Injured arm Right N (%) Left N (%) OR (95% CI) OR (95% CI) OR (95% CI) CCI CCI <3.5 CCI 3.5 OR (95% CI) OR (95% CI) OR (95% CI)
Conservative (n = 25)
Locking plate (n = 44)
Kirschner wires (n = 25)
Proximal humeral nail (n = 19)
7 (28) 18 (72) 1
22 (50) 22 (50) 2.6 (CI 0.90–7.4) 1
8 (32) 17 (68) 1.2 (CI 0.4–4.1) 0.47 (CI 0.17–1.3) 1
9 (47.4) 10 (52.6) 2.3 (CI 0.66–8.1) 0.9 (CI 0.31–2.6) 1.9 (CI 0.56–6.6)
2 (10.5) 5 (18.5) 1
6 (31.6) 16 (59.3) 1.1 (CI 0.16–7.06) 1
6 (31.6) 2 (7.4) 0.13 (CI 0.013–1.31) 0.12 (CI 0.02–0.8)* 1
5 (26.3) 4 (14.8) 0.32 (CI 0.04–2.61) 0.3 (CI 0.06–1.5) 2.4 (CI 0.3–19.0)
5 (19.2 13 (31.7) 1
2 (7.7) 20 (48.8) 3.8 (CI 0.64–22.9) 1
11 (42.3) 6 (14.6) 0.2 (CI 0.05–0.87)* 0.05 (CI 0.01–0.29)* 1
19 (76) 6 (30) 1
29 (65.9) 15 (34.1) 0.61 (CI 0.2–1.9) 1
18 (72) 7 (28.0) 0. 8 (CI 0.23–2.9) 1.3 (CI 0.45–3.9) 1
10 (52.6) 9 (47.4) 0.35 (CI 0.1–1.3) 0.57 (CI 0.19–1.7) 0.43 (CI 0.12–1.5)
15 (60) 10 (40) 1
28 (63.6) 16 (36.4) 1.2 (CI 0.42–3.2) 1
14 (44) 11 (56) 0.85 (CI 0.28–2.6) 0.73 (CI 0.27–1.98) 1
11 (57.9) 8 (42.1) 0.92 (CI 0.27–3.1) 0.79 (CI 0.26–2.4) 1.1 (CI 0.32–3.6)
8 (32) 17 (68) 1
27 (61) 17 (38) 3.4 (CI 1.2–9.5)* 1
8 (32) 17 (68) 1.0 (CI 0.31–3.28) 0.3 (CI 0.1–0.84)* 1
12 (63) 7 (36.8) 3.6 (CI 1.04–12.8)* 1.1 (CI 0.36–3.3) 3.6 (CI 1.04–12.8)*
8 (30.8) 2 (4.9) 0.1 (CI 0.01–0.61)* 0.02 (CI 0.003–0.2)* 0.46 (CI 0.07–2.89)
Abbreviations: CI, confidence interval; y, years; OR, odds ratio; CCI, Charlson Comorbidity Index; N (%), values are expressed as percentages. *Significant p-values (<0.05) for OR.
the ulnar nerve [15]. Fortunately, most of these complications are relatively minor and PKW can still be considered a relatively safe technique that can be particularly useful in patients with compromised health status and in situations were open surgery is contraindicated [16]. In elderly individuals, PKW was also more beneficial than conservative treatment. These findings should be interpreted with caution as these two groups had different fracture type distributions, and the use of PKW in osteoporotic bone is known to cause poorer fracture reductions, and higher pin migration rates [14,16]. Nevertheless, our observations are in agreement with a previous retrospective study performed on 51 elderly
patients who were treated either with PKW or conservatively [16]. In 2-fragment fractures, PKW achieved better functional results than conservative treatment in patients of similar age (Tables 1 and 3). These results are also consistent with previous studies that reported satisfactory functional results associated to the use of PKW in the treatment of 2-fragment fractures [14,17]. PHN vs. Conservative treatment The functional outcome of PHN in individuals with similar fracture types appeared to be age dependent. In young patients,
Table 2 Post-surgical results. Group characteristics
Conservative (n = 25)
Locking plate (n = 44)
Kirschner wires (n = 25)
Proximal humeral nail (n = 19)
Follow-up, months (SD) <25 N (%) 25 N (%) OR (95% CI) OR (95% CI) OR (95% CI)
28.0 (SD 8.5) 9 (36) 16 (64) 1
25.9 (SD 15) 23 (52.3) 21 (45.5) 1.9 (CI 0.7–5.3) 1
27.6 (SD 14) 10 (40) 15 (60) 1.19 (CI 0.45–5.4) 0.61 (CI 0.2–1.6) 1
22.5 (SD 9.0) 10 (52.6) 9 (47.4) 2.0 (CI 0.59–6.7) 1.0 (CI 0.34– 3.0) 1.7 (CI 0.5–5.6)
Complications N (%) DASH N (SD) CS N (SD)
1 (4) 38.4 (19.2) 57.2 (12.7)a
8 (18.2) 34.5 (20.3) 62.9 (16.8)
6 (24.0) 28.9 (20.9) 70.0 (18.8)
7 (36.8) 34.9 (26.5) 63.9 (23.6)
a
Abbreviations: CI, confidence interval; OR, odds ratio; CS, absolute Constant-Murley score; DASH, the disabilities of the arm shoulder and hand score; N (%), values are expressed as percentages. a Indicates significant differences between two values with the same letter, p = 0.012 (power 87%). The rest of p values are not significant.
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Table 3 Functional results according to age and fracture type. Clinical feature
Conservative (n = 25)
Locking plate (n = 44)
Kirschner wires (n = 25)
Proximal humeral nail (n = 19)
DASH
CS
DASH
CS
DASH
CS
DASH
CS
Fracture type 2-Fragments 3–4 Fragments
41.7 (SD 30.6) 37.1 (SD 13.5)
53.9 (SD 12.6)a 55.7 (SD 14.3)
32.1 (SD 15.1) 35.0 (SD 21.6)
63.0 (SD 4) 62.9 (SD 18.4)
27.2 (SD 20.3) 32.4 (SD 23)
70.4 (SD 17.4)a 70.5 (SD 23.0)
36.0 (SD 29.4) 32.4 (SD 20.9)
63.3 (SD 24.9) 65.2 (SD 22.6)
Age group Patients <65 Patients 65
41.7 (SD 22.0) 37.1 (SD 18.5)
54.7 (SD 4.6)c,b 55.3 (SD 15.9)f
33.6 (SD 22) 35.4 (SD 19.2)
65.6 (SD 15.6) 60.2 (SD 17.7)
23.9 (SD 20.7) 31.2 (SD 21.1)
74.0 (SD 20.8)c 68.7 (SD 18.3)d,
22.9 (SD 20.6) 45.7 (SD 27.4)
77.2 (SD 20.6)b, 51.9 (SD 19.9)d,
f
e e
Abbreviations: CS, absolute Constant-Murley score; DASH, the disabilities of the arm shoulder and hand score. a–f Indicate significant differences between two values with the same letter. ap = 0.048 (power 77%), bp = 0.01 (power 96%), cp = 0.031 (power 87%), dp = 0.020 (power 70%), e p = 0.014 (power 84%), fp = 0.029 (power 74%). The rest of p values are not significant.
PHN was associated with better results than conservative treatment, yet the outcome gradually deteriorated with age (Fig. 5) (Tables 1 and 3). A previous study on a series of 40 patients, reported that conservative treatment had better functional results than PHN; however, it did not analyse the effect age may have on the functional outcome considering that the age of the studied individuals varied significantly (i.e., 27–87 years) [18]. The use of PHN has the advantage of causing less soft tissue damage and fewer infections at the fracture site than other surgical procedures [19]. However, the conventional antegrade approach used in PHN can damage the subacromial space and rotator cuff tendons, and cause postoperative shoulder pain [20]. The prevalence of partial or complete tears of the rotator cuff tendons in patients over the age of 60 years is approximately of 54% [21]. Elderly patients with debilitated rotator cuff tendons could be less tolerant to the iatrogenic injuries caused by the anterograde surgical approach used in PHN. In addition, poor bone quality in elderly individuals could also condition the mechanical stability of proximal humeral fractures leading to deficient primary fixations and implant failure [22,23]. These factors could explain why PHN seems to achieve better results in younger individuals. PKW vs. PHN The use of PKW in the elderly achieved better functional results than PHN in patients with a comparable fracture distribution (Tables 1 and 3). As mentioned above, these results could be explained by the additional damage to rotator cuff tendons caused by the insertion of PHN in older individuals [22,23]. Accordingly, the use of PKW could be a better option than PHN in older patients.
LP vs. Conservative The use of LP did not prove to be more beneficial than conservative treatment in neither young nor elderly individuals (Table 3) (Fig. 5). These results are consistent with a previous work that reported no differences in the functional outcome between conservative and LP in a randomised controlled trial conducted on patients above 60 years of age with displaced 3 and 4-fragment [24]. Some studies have also warned of potential complications associated with the use of LP such as humeral head necrosis, plate impingement and screw cut out [25,26]. These complications can be related to the surgical technique, the position of the implant and locking screws, and the characteristics and severity of the fracture [25,26]. LP is currently used in the treatment of displaced 2, 3 and 4-fragment fractures, proximal humerus pseudarthrosis, and when the bone quality is poor [2,27,28]. However, these indications may change as new evidence does not find significant advantages of LP over conservative treatment [22,29,30]. On the other hand, conservative treatment is a safe therapeutic option for the management of proximal humeral fractures of different complexity, with reasonable functional results, and few complications [5]. Conservative treatment is currently indicated in non-displaced fractures and fractures of the greater tuberosity displaced less than 5 mm superiorly or 10 mm posteriorly [2]. However, this concept may change in the near future as authors continue to report evidence supporting the use of this therapeutic option in displaced 3–4-fragment fractures [24,31–33]. Furthermore, studies conducted on elderly patients treated either conservatively or with hemiarthroplasty have not found differences in the final functional outcome between these two treatment options [32,33]. Strengths and weaknesses
Fig. 5. The functional outcome (Constant-Murley score) of patients treated with proximal humeral nails vs. age (R Square = 0.41, p = 0.003).
This study points out how age may influence the outcome of methods used in the treatment of patients with proximal humerus fractures. Moreover, this is the first cohort study that compares four techniques commonly used in the treatment of proximal humerus fractures, and provides novel findings that challenge some of the current thoughts on aggressive surgical management of these fractures. Another strength of this study is the homogeneity of the study groups regarding the age and gender of the patients, which increases the reliability of our results. In addition, despite the small cohort size we managed to detect significant differences between different treatment options with a statistical power that ranged between 70 and 96% and an a-error of 0.05. On the other hand, there are a series of possible limitations associated with this work. Firstly, the small sample size in each study group limited the statistical power to detect b errors (e.g., stating that there were no significant differences between LP vs. conservative treatment). We must also add that there could be a
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selection bias, as surgeons at this institution selected the treatment method based on their own experience and clinical expertise. Therefore, treatment allocation in this study was not randomised and the indication for treatment could be related to uncontrolled risk factors such as demographic differences between groups (e.g., differences in the fracture distribution between the different groups). In addition, we decided to include displaced 3 and 4fragment fractures in the same category to gain additional statistical power; consequently, we could not identify differences between these two fracture types. Another limitation was the fact that we did not include other relevant surgical methods that are routinely used in many centers such as hemiarthroplasty and percutaneous fixed angle LP. This was due to the limited number of cases that were registered in our center. Finally, the mean follow-up period was of 26.2 SD 12.6 months, which can be considered medium-term. Therefore, the analysis of long term complications such or avascular necrosis post-traumatic arthritis was relatively limited. Future research This study is not a definitive opinion since it lacks the rigor of prospective randomised trials but it indicates that further work needs to be done in the field. Accordingly, future clinical trials should be performed in order to confirm our findings and reduce the limitations that we confronted in this work. Moreover, future studies could be designed to compare the use of PKW, percutaneous fixed angle LP and hemiarthroplasy vs. conservative treatment taking into consideration the fracture type and age of the patients. Clinical message In this study PKW was superior to conservative treatment in individuals of all ages, especially in patients with 2-fragment fractures. PKW was also a better option than PHN in the elderly. PKW is a non-invasive technique, relatively safe, and cost effective, and therefore should be considered as an appropriate option in the previously mentioned situations. We believe that PHN could be of particular use in young patients, but should be avoided in patients above the age of 65 years who frequently have a poor bone quality and deteriorated rotator cuffs. Finally, no differences were observed between LP and conservative treatment in any of the analysed categories. Therefore, we cannot encourage the use of LP in the treatment of proximal humerus fractures.
Conclusions In our hands, patients under the age of 65 years with displaced 2-fragment fractures had better functional results when treated with PKW or PHN. The use of PKW in the treatment of patients above the age of 65 years with displaced 2-fragment fractures was associated with superior functional results than conservative treatment. The use of PHN in elderly patients was associated with poor functional results. Finally, there were no differences in the functional outcome between conservative treatment and surgery in the treatment of patients with displaced 3–4-fragment fractures.
Conflict of interest There are neither financial nor non-financial competing interests.
Acknowledgements XiXi Wu DDSa.
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