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March 31, 2021  

Proximal Humeral Fractures: More Data on Nonunion Risk

Proximal humeral fractures tend to occur in a bimodal distribution, namely, in younger, primarily male patients and in older (>65 years of age), primarily female patients. In the latter population, such fractures are often related to low bone density, and we in the orthopaedic community now recognize the imperative to evaluate at-risk individuals through measures such as DXA scanning and laboratory assessments of bone health in order to institute appropriate monitoring and pharmacotherapy.

Regarding the treatment of these fractures, several large trials have demonstrated that, for select fracture patterns, nonsurgical care results in clinical and functional outcomes that are equal to or better than surgical care with open reduction and internal fixation or arthroplasty. The question for treating clinicians is: are there proximal humeral fracture patterns that have higher rates of complications (chiefly nonunion) following nonsurgical care?

In a retrospective study reported in JBJS, Goudie and Robinson evaluated the rate of nonunion among patients who were treated nonoperatively for a proximal humeral fracture at their regional trauma center in the UK. They also sought to develop and validate a prediction model to assess nonunion risk, measuring the effect of 19 patient demographic and radiographic variables on healing.

Overall, 231 (10.4%) of the 2,230 included patients experienced nonunion. Among those with valgus angulation of the humeral head (395 patients), the nonunion prevalence was <1%, and none of the other variables evaluated were associated with increased risk of nonunion in a multivariable analysis. However, among the 1,835 patients with neutral or varus angulation of the head, the prevalence of nonunion was 12.4%, and decreasing head-shaft angle, increasing head-shaft translation, and smoking were independently predictive of nonunion.

Important to note is the residual pain and diminished function that often accompanies nonunion. Still, the authors rightly point out that “surgery aimed solely at preventing nonunion exposes patients to the risk of other complications that are not encountered with nonoperative treatment.” But, based on these findings about fracture morphology, they conclude that “medically fit patients with translated and/or angulated fractures should be counseled about smoking cessation and considered for surgery to avoid the debilitating effects of subsequent nonunion.” Patients with these fracture characteristics deserve closer scrutiny in our efforts to provide the best treatment for proximal humeral fractures.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Click here for a JBJS Clinical Summary on proximal humeral fractures.

December 22, 2020  

Patient Misperception of Musculoskeletal Disease Onset

Often when I ask patients about the reason for their visit, I inquire about specific events. For example, “What were you doing when you hurt your knee?” For acute injuries, they can usually describe the exact moment they tore their ACL or dislocated their shoulder. In an adolescent sports clinic, where I spend much of my time, this acute scenario is the norm, but what about patient conversations regarding gradual-onset disease processes such as carpal tunnel syndrome (CTS) or osteoarthritis? These pathologies develop over many years, but patients with such conditions may fixate on when their disease became symptomatic–and may therefore mistakenly attribute a chronic condition to an acute injury.

Lemmers et al. investigate this complex body-mind concept in the December 16, 2020 issue of The Journal. The authors sought to analyze factors associated with the misperception of disease onset due to the recent experience of symptoms in 121 adult patients with CTS, cubital tunnel syndrome, upper-extremity osteoarthritis, or rotator cuff tendinosis. The patients filled out questionnaires for depression, anxiety, pain catastrophizing, self-efficacy, and upper-extremity physical function, in addition to supplying basic demographic information.

Based on the responses, most patients understood that their problem was not new but was instead “age-appropriate.” However, 18% of patients perceived the sudden onset of symptoms as a “new” disease, and 24% felt the problem was related to at least 1 injury or event. After multivariable analysis, Lemmers et al. found that Hispanic ethnicity and publicly funded or no insurance were independently associated with the perception that an event/injury caused the problem. The authors candidly admit that this area needs much more research, but they surmise that this latter finding could be related to lower health literacy.

This work highlights that we need to make sure our patients understand exactly what is happening with their musculoskeletal system. Because misperception of a disease’s cause and onset could affect patient decision-making, it is incumbent upon us as surgeons to be vigilant for possible misconceptions during our shared decision-making discussions with patients. As Lemmers et al. conclude, “Patients who do not understand what is happening to their body might choose different health strategies than they would if their understanding were accurate.”

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

October 28, 2020  

What’s New in Shoulder and Elbow Surgery 2020

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all such OrthoBuzz specialty-update summaries.

This month, Matthew R. Schmitz, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from the >40 studies summarized in the October 21, 2020 “What’s New in Shoulder and Elbow Surgery.

Rotator Cuff Repair
–A prospective randomized study compared operative and nonoperative treatment of small and medium-sized chronic full-thickness rotator cuff tears. At 10 years, the outcomes of primary repair were superior to those of nonoperative treatment, but both groups improved significantly over time.

Anterior Shoulder Instability
–A randomized trial compared arthroscopic Bankart repair to arthroscopic washout in the treatment of a first-time anterior dislocation. Bankart repair was associated with lower recurrence rates, fewer revisions, and better maintenance of functional outcomes.

–A prospective study evaluated the amount of glenoid bone loss associated with a single instability event in young athletes (average age of 20 years).1 A first-time dislocation was associated with a 6.8% bone loss. In the setting of recurrent instability, total bone loss averaged 10.2% at the time of enrollment and 22.8% after a subsequent instability event.

Proximal Humeral Fractures in the Elderly
–A randomized controlled trial compared locking-plate fixation with reverse total shoulder arthroplasty in treating intra-articular displaced proximal humeral fractures in patients 65 to 85 years of age. At 2 years, Constant-Murley scores were significantly better in the reverse total shoulder arthroplasty group.

“Little League” Elbow
–A prospective MRI-based study of Little League baseball players aged 12 to 15 years2 found that 58% of the players had abnormal upper-extremity MRI findings, and that in 80% of those players, the MRI findings worsened with continued baseball play. The authors suggest that surgeons discourage year-round play in young baseball players.

References

  1. Dickens JF, Slaven SE, Cameron KL, Pickett AM, Posner M, Campbell SE, Owens BD. Prospective evaluation of glenoid bone loss after first-time and recurrent anterior glenohumeral instability events. Am J Sports Med.2019 Apr;47(5):1082-9.
  2. Holt JB, Pedowitz JM, Stearns PH, Bastrom TP, Dennis MM, Dwek JR, Pennock AT. Progressive elbow magnetic resonance imaging abnormalities in Little League baseball players are common: a 3-year longitudinal evaluation. Am J Sports Med.2020 Feb;48(2):466-72. Epub 2019 Dec 4.
October 27, 2020  

A Genetic Basis for Adhesive Capsulitis?

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.

Adhesive capsulitis (AC), colloquially known as frozen shoulder, is associated with conditions such as diabetes, cardiopulmonary disorders, stroke, Parkinsonism, and injury. However, many cases are idiopathic. Given the inflammatory nature of the condition, clinicians often administer intra-articular steroid injections in recalcitrant cases where physical therapy alone is too painful or nonproductive. Some cases, particularly in patients with diabetes, may require manipulation, brisement, or arthroscopic release.

To better understand the genetic basis of AC, investigators obtained punch tissue samples from the middle glenohumeral ligament and rotator cuff interval from AC patients undergoing arthroscopic release surgery (mean age of 53 years) and from a comparative group of patients undergoing arthroscopic surgery for shoulder instability (mean age of 24 years).1 The researchers performed RNA sequencing-based transcriptomics on the samples and, after identifying differentially expressed genes, they applied real-time reverse transcription polymerase chain reaction (RT-PCR) to obtain more detailed genetic data.

A total of 545 genes were differentially expressed. The top 50 were associated with extracellular matrix remodeling. Patient age and sex did not have a major influence on gene expression. The genes marked by overexpression (not necessarily protein expression) were genes for matrix metallopeptidase 13 and platelet-derived growth factor subunit B. Other suspects included the gene for metalloprotease 9 and COL18A1.

In the discussion, the authors comment on the association between AC and protein tyrosine kinase 2 (PTK2), also known as focal adhesion kinase (FAK). FAK activation is particularly sensitive to fibronectin and other integrins. Activated FAK also controls cell migration and focal adhesion assembly. These interesting associations may also shine light onto the etiology of other musculoskeletal diseases.

Reference

  1. Kamal N, McGee SL, Eng K, Brown G, Beattie S, Collier F, Gill S, Page RS.
    Transcriptomic analysis of adhesive capsulitis of the shoulder.     J Orthop Res. 2020 Oct;38(10):2280-2289. doi: 10.1002/jor.24686. Epub 2020 Apr 17. PMID: 32270543
July 7, 2020  

Rethinking How We Spend Healthcare Dollars During—and After—the Pandemic

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Frederick A. Matsen, MD and Jeremy S. Somerson, MD.

The coronavirus pandemic is having a profound effect on healthcare economics. A recent article in Health Affairs1 estimates that the median direct medical cost of a single symptomatic COVID-19 case can exceed $3,000 during the course of the infection alone. As of this writing, there have been almost 2.5 million confirmed cases in the US,2 with the number of known cases doubling every 2 months.3 These numbers suggest that the direct medical costs of the pandemic could easily exceed $8 billion. In addition, federal legislation enacted to help mitigate the effects of the pandemic is estimated to cost more than $480 billion over the next 10 years.4

Independently, the application of new technologies has also been pushing healthcare costs upward for decades. Long before the pandemic, a 2008 report from the  Congressional Budget Office concluded that “the bottom line from all these analyses is that the single most important factor driving the long-term increase in health care costs involves medical technology” and that “technological advances on average have brought major health improvements, but they often then get applied in settings where their benefits seem much less obvious.”5

In orthopaedics, we are strongly attracted to technology. In some cases – such as arthroscopy – technological advances enable less invasive, more effective, and safer treatments. In other cases, the patient benefits “seem much less obvious.” A recent review article makes the following observations about technology use in arthroplasty:

  • Computer-assisted technologies that are used in arthroplasty include navigation, image-derived instrumentation, and robotics.
  • Computer-assisted navigation improves accuracy and allows for real-time assessment of component positioning and soft-tissue tension.
  • It is not clear whether the implementation of these technologies improves the clinical outcome of surgery.
  • High cost and time demands have prevented the global implementation of computer-assisted technologies.

If we take shoulder arthroplasty as a general example, we see that prior to the introduction of routine preoperative CT scans, 3D planning, patient-specific instrumentation, metal-backed and augmented glenoid components, and short-stemmed and stemless humeral components, the results of anatomic total shoulder replacement for osteoarthritis were excellent, with 10-year revision rates under 5%.6,7 Such outcomes do not leave much room for improvement from newer technologies, each of which carries incremental costs of research, development, clearance by the FDA, marketing, learning curves, and potential product recalls and unanticipated long-term adverse effects.8 As Rosenthal et al. recently pointed out, “Since 3D planning and intraoperative navigation is more costly than 2D planning, and augmented glenoid components are more costly than standard glenoid components, the cost-benefit of these changes with respect to mid-term and long-term clinical outcomes and implant survival has not been ascertained.”9

Robust clinical data are needed to establish the incremental benefit to patients of each new technology in order to justify its associated incremental costs in comparison to legacy approaches that have been in place for years.

As a more specific example, the average cost of a preoperative shoulder CT scan ranges from $625 to $8,400,10 yet it remains to be demonstrated whether application of this technology leads to better shoulder arthroplasty outcomes in comparison to results obtained with conventional preoperative radiographic imaging.11 Agyeman et al. recently concluded that  “although CT scans are associated with greater financial cost and exposure to radiation than radiographs, the literature has yet to describe the additional clinical value and/or potential cost-value benefit as a result of improved outcomes provided by the use of CT scans in patients undergoing total shoulder arthroplasty, even when integrated with virtual planning software and generation of patient specific instrumentation.” If a preoperative shoulder CT scan costs $1,000, the very low end of the aforementioned range, avoiding routine preoperative CTs in 3 shoulder-arthroplasty patients would save an amount of money equal to the average direct medical cost of a patient with COVID-19—$3,000.

We conclude that this is a good time to seriously reconsider how we apply new technologies in orthopaedics by asking a simple question: Are we spending our more-precious-than-ever healthcare dollars in ways that best serve the population as a whole?

Frederick A. Matsen III, MD is a professor in the Department of Orthopaedics and Sports Medicine at the University of Washington Medical Center in Seattle. Jeremy S. Somerson, MD is a fellowship-trained shoulder and elbow surgeon at the University of Texas Medical Branch in Galveston.

References

  1. Bartsch SM, Ferguson MC, McKinnell JA, O’Shea KJ, Wedlock PT, Siegmund SS, et al. The potential health care costs and resource use associated with COVID-19 in the United States. Health Aff (Millwood). 2020;39(6):927-35.
  2. John Hopkins University CSSE. COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at John Hopkins University (JHU). 2020 Accessed June 28, 2020. Available from: https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6.
  3. Hernandez S, O’Key S, Watts A, Manley B, Pettersson H, CNN. Tracking Covid-19 cases in the US. CNN, 2020 Accessed June 28, 2020. Available from: https://www.cnn.com/interactive/2020/health/coronavirus-us-maps-and-cases/.
  4. Congressional Budget Office. The budgetary effects of laws enacted in response to the 2020 Coronavirus pandemic, March and April 2020. 2020 Accessed June 28, 2020. Available from: https://www.cbo.gov/system/files/2020-06/56403-CBO-covid-legislation.pdf.
  5. Congressional Budget Office. Technological change and the growth of health care spending. 2008 Accessed June 28, 2020. Available from: https://www.cbo.gov/publication/24748.
  6. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Annual report 2019: Hip, Knee & Shoulder Arthroplasty. Total Shoulder outcomes over two decades. Figure ST22, Page 16. 2019 Accessed June 28, 2020. Available from: https://aoanjrr.sahmri.com/documents/10180/668596/Hip%2C+Knee+%26+Shoulder+Arthroplasty/c287d2a3-22df-a3bb-37a2-91e6c00bfcf0.
  7. Neer CS, 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am. 1982;64(3):319-37.
  8. Somerson JS, Neradilek MB, Hsu JE, Service BC, Gee AO, Matsen FA, 3rd. Is there evidence that the outcomes of primary anatomic and reverse shoulder arthroplasty are getting better? Int Orthop. 2017;41(6):1235-44.
  9. Rosenthal Y, Rettig SA, Virk M, Zuckerman JD. The impact of preoperative three-dimensional planning and intraoperative navigation of shoulder arthroplasty on implant selection and operative time: a single surgeon’s experience. J Shoulder Elbow Surg. 2020;Epub ahead of print.
  10. Poslusny C. How much does a CT scan cost? New Choice Health, Inc., Pensacola, FL, Accessed June 28, 2020. Available from: https://www.newchoicehealth.com/ct-scan/cost.
  11. Matsen FA, 3rd, Whitson A, Hsu JE, Stankovic NK, Neradilek MB, Somerson JS. Prearthroplasty glenohumeral pathoanatomy and its relationship to patient’s sex, age, diagnosis, and self-assessed shoulder comfort and function. J Shoulder Elbow Surg. 2019;28(12):2290-300.
June 9, 2020  

Revision Shoulder Arthroplasty: IV or Oral Antibiotics?

Surgeons performing revision shoulder arthroplasty typically order postoperative antibiotics to be administered while they wait for results from intraoperative cultures. Based on their index of suspicion from preoperative exams and intraoperative observations, they order either intravenous (high suspicion of infection) or oral (low suspicion) antibiotics during the waiting period. In the June 3, 2020 issue of JBJS, Yao et al. report on a retrospective review of 175 patients who underwent revision shoulder arthroplasty, finding that surgeons’ presumptive choice of antibiotic type matched the culture results in 75% of the cases.

Among the 175 patients in the study, IV antibiotics were initiated in 62, while 113 patients received oral antibiotics. Cultures from 49 of the 62 patients started on IV antibiotics came back positive, and cultures from 83 of the 113 patients started on oral antibiotics came back negative. Treatment of patients whose initial antibiotic regimen did not match culture results was modified accordingly.

After multivariate analysis Yao et al. found that male sex, prior ipsilateral infection, and intraoperative presence of a humeral membrane were 3 independent predictors of surgeons initiating IV antibiotics. Antibiotic-related adverse events (including GI, dermatologic, and allergic reactions) occurred in 19% of the patients. Not surprisingly, the rate of these complications was highest among those receiving IV antibiotics.

Although the surgeons’ empirical initiation of antibiotic administration route was “correct” 75% of the time, that still left 25% of the patients needing modification of therapy based on culture results. While the authors observe that their study was  not designed “to report the relative effectiveness of the 2 antibiotic protocols in minimizing the risk of recurrent infection,” their findings confirm that preoperative and intraoperative observations can help surgeons select the “right” type of antibiotic without culture results—and that is heartening.

May 12, 2020  

Insights into Frozen Shoulder Inflammation

You don’t need a PhD in molecular pathophysiology to appreciate the fact that inflammation is a complex biological process. And you don’t need to be a shoulder subspecialist in orthopaedics to realize that symptoms of frozen shoulder (aka idiopathic adhesive capsulitis, or IAC) are common presenting complaints among middle-aged patients, especially women. In the May 6, 2020 issue of The Journal of Bone& Joint Surgery, a retrospective case-control study by Park et al. reveals some new insights about the association between adhesive capsulitis and inflammation, with a specific focus on the inflammatory marker high-sensitivity C-reactive protein (hsCRP).

The authors analyzed blood-sample results from 202 patients diagnosed with IAC and 606 age- and sex-matched controls. In addition to hsCRP, Park et al. investigated HbA1c, cholesterol, triglycerides, inflammatory lipoproteins, thyroid-stimulating hormone, the ratio of triglycerides to HDL (TG/HDL), BMI, and diabetes.

Park et al. determine that a blood level of hsCRP  >1.0 mg/L is an independent marker for IAC. They also conclude that the relationship between hsCRP and other findings in this study confirms the associations between IAC and previously cited risk factors of diabetes and dyslipidemia. Based on the fasting-glucose and HbA1c findings in this study, the authors additionally conclude that hyperglycemia and insulin resistance—frequent precursors to type-2 diabetes—are also strong risk factors for IAC.

Taken together, the results suggest the presence of an additive inflammatory effect among medical comorbidities in patients with IAC. But in his Commentary on this study, Michael Khazzam, MD says that these results alone cannot be used in clinical practice to counsel patients being treated for IAC. Ideally, he says, these findings could help inform future work that might provide a reliable method to predict, early in the disease process, the severity of IAC and the expected timetable for complete resolution of symptoms.

April 21, 2020  

How to Conduct a Virtual Orthopaedic Examination

For obvious reasons, the use of telemedicine has surged during the COVID-19 pandemic. If you are wondering what a “virtual” orthopaedic physical exam looks like, Tanaka et al. explain the process in words and images in a recent fast-tracked JBJS article.

At the time they schedule their virtual visit, patients are asked to confirm their audiovisual capabilities, and they receive specific instructions about camera positioning, body positioning, setting, and attire to improve the efficiency of the visit.

Tanaka et al. give step-by-step instructions for virtually evaluating the knee, hip, shoulder, and elbow. They describe how they measure range of motion using a web-based goniometer (see Figure), and they explain how to conduct virtual strength tests for each joint. To enable post-exam follow-up discussions with patients, the authors recommend using “the screen-sharing function that is presumably available on all interactive telehealth platforms.”

The authors acknowledge the limitations inherent in a virtual orthopaedic exam, such as the inability to directly palpate the joint or perform provocative tests. They also admit that the patient population that would potentially benefit the most from televisits—older patients with limited mobility and who are at higher risk for infection during the pandemic—are also those who may have the most difficulty implementing the technology.

The rapid rise of telemedicine in orthopaedics has occurred due to unexpected necessity, but many expect that its widespread use will continue post-pandemic. Tanaka et al. cite future directions for the technology, including the development of validated, modified examination techniques and advancements that will improve interactivity during the physical examination. For now, though, these experience-based guidelines should help orthopaedists optimize the quality and efficiency of their upcoming virtual visits for common musculoskeletal conditions.

April 21, 2020  

What’s New in Sports Medicine 2020

Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of OrthoBuzz summaries of these “What’s New” articles. This month, co-author Christopher Y. Kweon, MD selected the 5 most clinically compelling findings from the 40 studies summarized in the April 15, 2020 “What’s New in Sports Medicine.”

ACL Graft Choice
—A randomized controlled trial (RCT) comparing bone-tendon-bone autograft, quadrupled hamstring tendon autograft, and double-bundle hamstring autograft for ACL reconstruction in young adults found the following:

  • No between-group differences in patient-reported quality-of-life scores at 5 years
  • Significantly higher rates of traumatic graft reinjuries in the hamstring-tendon and double-bundle groups
  • Relatively low (37%) return to preinjury level of activity for the entire population, with no significant between-group differences

Meniscal Repairs with Bone Marrow Venting
—A double-blinded RCT1 of patients with complete, unstable, vertical meniscal tears compared isolated meniscal repair to meniscal repair with a bone marrow venting procedure (BMVP). Meniscal healing, as assessed with second-look arthroscopy at a mean of 35 weeks, was 100% in the BMVP group and 76% in the control group (p = 0.0035). Secondary pain and function measures at 32 to 51 months were also better in the BMVP group.

Rotator Cuff Repair Rehab
—A multisite RCT2 among >200 patients who received arthroscopic repair of a full-thickness rotator cuff tear compared standard rehabilitation (patients wore a sling at all times except when performing prescribed exercises) and early mobilization (patients wore a sling only when needed for comfort). Early mobilizers showed significantly better forward flexion and abduction at 6 weeks, but no subjective or objective differences (including retear rate) were found at any other time points.

Remplissage for Anterior Shoulder Instability
—A systematic review3 of studies investigating arthroscopic Bankart repair with and without remplissage found significantly higher instability-recurrence rates with isolated Bankart repair. Overall, the addition of remplissage appears to yield better patient-reported function scores compared with isolated Bankart repair alone.

Syndesmotic Ankle Injuries
—A meta-analysis of 7 RCTs (335 patients)4 comparing dynamic versus static fixation for syndesmotic injuries of the ankle found that the overall risk of complications was significantly lower in the dynamic fixation group. Reoperation rates were similar in the two groups, but implant breakage or loosening was reduced with dynamic fixation devices. Compared with static fixation, the dynamic fixation group also had higher AOFAS scores and lower VAS scores at various time points.

References

  1. Kaminski R, Kulinski K, Kozar-Kaminska K, Wasko MK, Langner M, Pomianowski S. Repair augmentation of unstable, complete vertical meniscal tears with bone marrow venting procedure: a prospective, randomized, double-blind, parallel-group, placebo-controlled study. Arthroscopy.2019 May;35(5):1500-1508.e1. Epub 2019 Mar 20.
  2. Sheps DM, Silveira A, Beaupre L, Styles-Tripp F, Balyk R, Lalani A, Glasgow R, Bergman J, Bouliane M; Shoulder and Upper Extremity Research Group of Edmonton (SURGE). Early active motion versus sling immobilization after arthroscopic rotator cuff repair: a randomized controlled trial. Arthroscopy.2019 Mar;35(3):749-760.e2.
  3. Lazarides AL, Duchman KR, Ledbetter L, Riboh JC, Garrigues GE. Arthroscopic remplissage for anterior shoulder instability: a systematic review of clinical and biomechanical studies. Arthroscopy.2019 Feb;35(2):617-28. Epub 2019 Jan 3.
  4. Grassi A, Samuelsson K, D’Hooghe P, Romagnoli M, Mosca M, Zaffagnini S, Amendola A. Dynamic stabilization of syndesmosis injuries reduces complications and reoperations as compared with screw fixation: a meta-analysis of randomized controlled trials. Am J Sports Med.2019 Jun 12. [Epub ahead of print].
March 20, 2020  

Displaced Proximal Humeral Fractures: Fix or Replace?

Nonoperative management of proximal humerus fractures in the elderly used to be fairly common, but multiple studies have shown poor outcomes. Open reduction and internal fixation (ORIF) with locked-plate constructs has shown some promise, but it has been fraught with complications. Most recently, reverse total shoulder arthroplasty (rTSA) has emerged as a possible surgical solution, but this is a complicated procedure, and questions have arisen about long-term outcomes.  Compounding this conundrum are the varying degrees of severity of proximal humeral fractures.

In the March 18, 2020 issue of The Journal, Fraser et al. share 2-year results from a multicenter, single-blinded randomized trial that compared rTSA to ORIF for severely displaced proximal humeral fractures in patients 65 to 85 years of age. Included patients (n=124) had OTA/AO 11-B2 or 11-C2 fractures with >45° valgus or >30° varus in the anteroposterior view, or >50% displacement of the humeral head. Using the Constant shoulder score as the primary outcome measure, the authors demonstrated both a statistically significant and clinically meaningful difference favoring rTSA in this cohort.

The mean Constant score was 68.0 points for the rTSA group compared to 54.6 points for the ORIF group. The mean between-group difference, 13.4 points, was significant (p<0.001) and exceeded the minimal clinically important difference of 10 points.  The Constant-score difference between ORIF and rTSA was most pronounced (18.7 points) in patients with C2 fractures, but there was no significant score difference in those with B2 fractures. Secondary outcomes (Oxford Shoulder Scores) showed a consistent trend of the rTSA group scoring higher than the ORIF group at 2 years.

Although this study indicates an advantage for rTSA, one must consider that only severely displaced fractures were investigated and that 2-year follow-up for joint arthroplasty is considered short term. In a Commentary about this article, Peter A. Cole, MD points out that “if there was a 25% revision rate for reverse TSA at 5 to 10 years, then the superior results would be reversed, and we would be reinventing another wheel in orthopaedics.”

Clearly, longer-term studies in this population are a necessity, and Fraser et al. say they plan to follow these patients in 5-year intervals.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media

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