Complication rates and outcomes stratified by treatment modalities in proximal humeral fractures: a systematic literature review from 1970–2009

Patient Safety in Surgery

Christian Bahrs³  Klaus Dietz¹  Sonja D Bahrs²  Kuno Weise³  Bernd Rolauffs³  Alexander Tepass³ 

[1] Department of Medical Biometry, Eberhard-Karls University, Tübingen, Germany;Department of Radiology, Eberhard-Karls University, Tübingen, Germany;Department of Trauma and Reconstructive Surgery, Eberhard-Karls University, Tübingen, Germany

关键词: Shoulder fractures;    Complication;    Treatment;    Proximal humeral fracture;    Systematic review;   

Others  :  790285
DOI  :  10.1186/1754-9493-7-34

 received in 2013-09-11, accepted in 2013-11-05,  发布年份 2013

【 摘 要 】

Background

The optimal treatment of complex, displaced proximal humeral fractures is controversial. A systematic literature review of the time period from 1970 to 2009 was conducted. The purpose was to evaluate the clinical success and complications of the available treatment modalities to determine specific treatment recommendations for the different fracture patterns.

Methods

The databases (PubMed/EMBASE) were searched for the time period (01/1970–09/2009). Study quality, treatment modalities, classification, outcome scores and complications of 200 publications including 9377 patients were analyzed. Interventions were compared by analysis of variance with subsequent Tukey’s-test. Complication rates among methods were compared by using Pearson’s-chi-square-test and pairwise comparisons using Fisher’s-two-tailed-exact-test.

Results

Hemiarthroplasty, angle-stable plate and non-operative treatment were used for 63% of the follow-up-patients. For 3- and 4-part fractures, patients with hemiarthroplasty [3-Part: 56.4 (lower/upper 95% confidence interval (CI): 43.3-68.7); 4-Part: 49.4 (CI: 42.2-56.7)] received a lower score than different surgical head-preserving methods such as ORIF [3-Part: 82.4 (CI: 76.6-86.9); 4-Part: 83.0 (CI:78.7-86.6)], intramedullary nailing [3-Part: 79.1 (CI:74.0-83.4)] or angle-stable plates [4-Part: 66.4 (CI: 59.7-72.4)].

The overall complication rate was 56%. The most common complications were fracture-displacement, malunion, humeral head necrosis and malreduction. The highest complication rates were documented for conventional plate and hemiarthroplasty and for AO-C, AO-A, for 3- and 4-part fractures. Only 25% of the data were reported with detailed classification results and the corresponding outcome scores.

Discussion

Despite the large amount of patients included, it is difficult to determine adequate recommendations for the treatment of proximal humeral fractures because a relevant lack of follow-up data impaired subsequent analysis. For displaced 3- and 4-part fractures head-preserving therapy received better outcome scores than hemiarthroplasty. However, a higher number of complications occurred in more complex fractures and when hemiarthroplasty or conventional plate osteosynthesis was performed. Thus, when informing the patient for consent, both the clinical results and the possibly expected complications with a chosen treatment modality should be addressed.

【 授权许可】

   
2013 Tepass et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Lind T, Kroner K, Jensen J: The epidemiology of fractures of the proximal humerus. Arch Orthop Trauma Surg 1989, 108:285-287.
• [2]Rose SH, Melton LJ 3rd, Morrey BF, Ilstrup DM, Riggs BL: Epidemiologic features of humeral fractures. Clin Orthop Relat Res 1982, 168:24-30.
• [3]Court-Brown CM, Caesar B: Epidemiology of adult fractures: a review. Injury 2006, 37:691-697.
• [4]Palvanen M, Kannus P, Niemi S, Parkkari J: Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 2006, 442:87-92.
• [5]Sakuma M, Endo N, Oinuma T, Endo E, Yazawa T, Watanabe K, Watanabe S: Incidence and outcome of osteoporotic fractures in 2004 in Sado City, Niigata Prefecture, Japan. J Bone Miner Metab 2008, 26:373-378.
• [6]Court-Brown CM, Garg A, McQueen MM: The epidemiology of proximal humeral fractures. Acta Orthop Scand 2001, 72:365-371.
• [7]Tepass A, Blumenstock G, Weise K, Rolauffs B, Bahrs C: Current strategies for the treatment of proximal humeral fractures: an analysis of a survey carried out at 348 hospitals in Germany, Austria, and Switzerland. J Shoulder Elbow Surg 2013, 22:e8-e14.
• [8]Neer CS 2nd: Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970, 52:1077-1089.
• [9]Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audige L: Fracture and dislocation classification compendium - 2007: orthopaedic trauma association classification, database and outcomes committee. J Orthop Trauma 2007, 21:S1-S133.
• [10]Neer CS 2nd: Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970, 52:1090-1103.
• [11]Vallier HA: Treatment of proximal humerus fractures. J Orthop Trauma 2007, 21:469-476.
• [12]Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD: Innovations in the management of displaced proximal humerus fractures. J Am Acad Orthop Surg 2007, 15:12-26.
• [13]Handoll HH, Gibson JN, Madhok R: Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2003, CD000434.
• [14]Bell JE, Leung BC, Spratt KF, Koval KJ, Weinstein JD, Goodman DC, Tosteson AN: Trends and variation in incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly. J Bone Joint Surg Am 2011, 93:121-131.
• [15]Roux A, Decroocq L, El Batti S, Bonnevialle N, Moineau G, Trojani C, Boileau P, de Peretti F: Epidemiology of proximal humerus fractures managed in a trauma center. Orthop Traumatol Surg Res 2012, 98:715-719.
• [16]Drosdowech DS, Faber KJ, Athwal GS: Open reduction and internal fixation of proximal humerus fractures. Orthop Clin North Am 2008, 39:429-439. vi
• [17]Kontakis G, Tosounidis T, Galanakis I, Megas P: Prosthetic replacement for proximal humeral fractures. Injury 2008, 39:1345-1358.
• [18]Ruchholtz S, Nast-Kolb D: Humeral head fractures. Unfallchirurg 2003, 106:498-512. quiz 512–493
• [19]Resch H: Fractures of the humeral head. Unfallchirurg 2003, 106:602-617.
• [20]Voigt C, Lill H: Primary hemiarthroplasty in proximal humerus fractures. Orthopade 2007, 36:1002-1012.
• [21]Magovern B, Ramsey ML: Percutaneous fixation of proximal humerus fractures. Orthop Clin North Am 2008, 39:405-416. v
• [22]Young AA, Hughes JS: Locked intramedullary nailing for treatment of displaced proximal humerus fractures. Orthop Clin North Am 2008, 39:417-428. v-vi
• [23]Martin TG, Iannotti JP: Reverse total shoulder arthroplasty for acute fractures and failed management after proximal humeral fractures. Orthop Clin North Am 2008, 39:451-457. vi
• [24]Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D: The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 2009, 62:e1-e34.
• [25]Thanasas C, Kontakis G, Angoules A, Limb D, Giannoudis P: Treatment of proximal humerus fractures with locking plates: a systematic review. J Shoulder Elbow Surg 2009, 18:837-844.
• [26]Misra A, Kapur R, Maffulli N: Complex proximal humeral fractures in adults–a systematic review of management. Injury 2001, 32:363-372.
• [27]Lanting B, MacDermid J, Drosdowech D, Faber KJ: Proximal humeral fractures: a systematic review of treatment modalities. J Shoulder Elbow Surg 2008, 17:42-54.
• [28]Kontakis G, Koutras C, Tosounidis T, Giannoudis P: Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br 2008, 90:1407-1413.
• [29]Nijs S, Broos P: Outcome of shoulder hemiarthroplasty in acute proximal humeral fractures: a frustrating meta-analysis experience. Acta Orthop Belg 2009, 75:445-451.
• [30]MacDermid JC: An introduction to evidence-based practice for hand therapists. J Hand Ther 2004, 17:105-117.
• [31]Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J: Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 2003, 73:712-716.
• [32]Downs SH, Black N: The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998, 52:377-384.
• [33]Boutron I, Moher D, Altman DG, Schulz KF, Ravaud P: Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Annals of internal medicine 2008, 148:295-309.
• [34]Altman DG, Schulz KF, Moher D, Egger M, Davidoff F, Elbourne D, Gotzsche PC, Lang T: The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Annals of internal medicine 2001, 134:663-694.
• [35]Moher D, Schulz KF, Altman D: The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. Jama 2001, 285:1987-1991.
• [36]Bahrs C, Badke A, Rolauffs B, Weise K, Zipplies S, Dietz K, Eingartner C: Long-term results after non-plate head-preserving fixation of proximal humeral fractures. Int Orthop 2010, 34(6):883-889.
• [37]Bahrs C, Lingenfelter E, Fischer F, Walters EM, Schnabel M: Mechanism of injury and morphology of the greater tuberosity fracture. J Shoulder Elbow Surg 2006, 15:140-147.
• [38]Bahrs C, Oehm J, Rolauffs B, Eingartner C, Weise K, Dietz K, Helwig P: T-plate osteosynthesis–an obsolete osteosynthesis procedure for proximal humeral fractures? Middle-term clinical and radiological results. Z Orthop Unfall 2007, 145:186-194.
• [39]Bahrs C, Rolauffs B, Dietz K, Eingartner C, Weise K: Clinical and radiological evaluation of minimally displaced proximal humeral fractures. Arch Orthop Trauma Surg 2009, 130:673-679.
• [40]Bahrs C, Rolauffs B, Sudkamp NP, Schmal H, Eingartner C, Dietz K, Pereira PL, Weise K, Lingenfelter E, Helwig P: Indications for computed tomography (CT-) diagnostics in proximal humeral fractures: a comparative study of plain radiography and computed tomography. BMC Musculoskelet Disord 2009, 10:33. BioMed Central Full Text
• [41]Bahrs C, Schmal H, Lingenfelter E, Rolauffs B, Weise K, Dietz K, Helwig P: Inter- and intraobserver reliability of the MTM-classification for proximal humeral fractures: a prospective study. BMC Musculoskelet Disord 2008, 9:21. BioMed Central Full Text
• [42]Bahrs C, Zipplies S, Ochs BG, Rether J, Oehm J, Eingartner C, Rolauffs B, Weise K: Proximal humeral fractures in children and adolescents. J Pediatr Orthop 2009, 29:238-242.
• [43]Tingart M, Bathis H, Lefering R, Bouillon B, Tiling T: Constant score and neer score. A comparison of score results and subjective patient satisfaction. Unfallchirurg 2001, 104:1048-1054.
• [44]Gilbart MK, Gerber C: Comparison of the subjective shoulder value and the constant score. J Shoulder Elbow Surg 2007, 16:717-721.
• [45]Abdi H: Bonferroni and Sidak corrections for multiple comparisons. In Encyclopedia of Measurement and Statistics. 2007 edition. Edited by Salkind N. Thousand Oaks (CA); 2007.
• [46]Kraulis J, Hunter G: The results of prosthetic replacement in fracture-dislocations of the upper end of the humerus. Injury 1976, 8:129-131.
• [47]Padua R, Bondi R, Ceccarelli E, Campi A, Padua L: Health-related quality of life and subjective outcome after shoulder replacement for proximal humeral fractures. J Shoulder Elbow Surg 2008, 17:261-264.
• [48]Urgelli S, Crainz E, Maniscalco P: Conservative treatment vs prosthetic replacement surgery to treat 3- and 4-fragment fractures of the proximal epiphysis of humerus in the elderly patient. Chir Organi Mov 2005, 90:345-351.
• [49]Court-Brown CM, McQueen MM: The impacted varus (A2.2) proximal humeral fracture: prediction of outcome and results of nonoperative treatment in 99 patients. Acta Orthop Scand 2004, 75:736-740.
• [50]Nanda R, Goodchild L, Gamble A, Campbell RS, Rangan A: Does the presence of a full-thickness rotator cuff tear influence outcome after proximal humeral fractures? J Trauma 2007, 62:1436-1439.
• [51]Lill H, Bewer A, Korner J, Verheyden P, Hepp P, Krautheim I, Josten C: Conservative treatment of dislocated proximal humeral fractures. Zentralbl Chir 2001, 126:205-210.
• [52]Schai P, Imhoff A, Preiss S: Comminuted humeral head fractures: a multicenter analysis. J Shoulder Elbow Surg 1995, 4:319-330.
• [53]Rasmussen S, Hvass I, Dalsgaard J, Christensen BS, Holstad E: Displaced proximal humeral fractures: results of conservative treatment. Injury 1992, 23:41-43.
• [54]Serin E, Karatosun V, Balci C, Koseoglu HC, Ersoy HH: Two-prong splint in the treatment of proximal humeral fracture. Arch Orthop Trauma Surg 1999, 119:368-370.
• [55]Russo R, Visconti V, Lombardi LV, Ciccarelli M, Giudice G: The block-bridge system: a new concept and surgical technique to reconstruct articular surfaces and tuberosities in complex proximal humeral fractures. J Shoulder Elbow Surg 2008, 17:29-36.
• [56]Siebler G, Walz H, Kuner EH: Minimal osteosynthesis of fractures of the head of the humerus. Indications, technic, results. Unfallchirurg 1989, 92:169-174.
• [57]Speck M, Regazzoni P: 4-fragment fractures of the proximal humerus. Alternative strategies for surgical treatment. Unfallchirurg 1997, 100:349-353.
• [58]Robinson CM, Christie J: The two-part proximal humeral fracture: a review of operative treatment using two techniques. Injury 1993, 24:123-125.
• [59]Bastian JD, Hertel R: Initial post-fracture humeral head ischemia does not predict development of necrosis. J Shoulder Elbow Surg 2008, 17:2-8.
• [60]Lill H, Korner J, Glasmacher S, Hepp P, Just A, Verheyden P, Josten C: Crossed screw osteosynthesis of proximal humerus fractures. Unfallchirurg 2001, 104:852-859.
• [61]Wachtl SW, Marti CB, Hoogewoud HM, Jakob RP, Gautier E: Treatment of proximal humerus fracture using multiple intramedullary flexible nails. Arch Orthop Trauma Surg 2000, 120:171-175.
• [62]Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R: A new locking plate for unstable fractures of the proximal humerus. Clin Orthop Relat Res 2005, 430:176-181.
• [63]Bathis H, Tingart M, Bouillon B, Tiling T: Surgical treatment of proximal humeral fractures. Is the T-plate still adequate osteosynthesis procedure? Zentralbl Chir 2001, 126:211-216.
• [64]Kuchle R, Hofmann A, Hessmann M, Rommens PM: The cloverleaf plate for osteosythesis of humeral head fractures. Definition of the current position. Unfallchirurg 2006, 109:1017-1024.
• [65]Kocialkowski A, Wallace WA: Closed percutaneous K-wire stabilization for displaced fractures of the surgical neck of the humerus. Injury 1990, 21:209-212.
• [66]Lill H, Hepp P, Rose T, Konig K, Josten C: The angle stable locking-proximal-humerus-plate (LPHP) for proximal humeral fractures using a small anterior-lateral-deltoid-splitting-approach - technique and first results. Zentralbl Chir 2004, 129:43-48.
• [67]Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, Kohut G, Ekelund A, Muller M, Audige L, Babst R: Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma 2009, 23:163-172.
• [68]Gallinet D, Clappaz P, Garbuio P, Tropet Y, Obert L: Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: a comparative study of 40 cases. Rev Chir Orthop Traumatol 2009, 95:48-55.
• [69]Schmal H, Klemt C, Sudkamp NP: Evaluation of shoulder arthroplasty in treatment of four-fragment fractures of the proximal humerus. Unfallchirurg 2004, 107:575-582.
• [70]Kollig E, Kutscha-Lissberg F, Roetman B, Mielke E, Muhr G, Hahn MP: Primary hemiarthroplasty after complex fracture of the humeral head–functional late results. Zentralbl Chir 2003, 128:125-130.
• [71]Reuther F, Muller S, Wahl D: Management of humeral head fractures with a trauma shoulder prosthesis: correlation between joint function and healing of the tuberosities. Acta Orthop Belg 2007, 73:179-187.
• [72]Fallatah S, Dervin GF, Brunet JA, Conway AF, Hrushowy H: Functional outcome after proximal humeral fractures treated with hemiarthroplasty. Can J Surg 2008, 51:361-365.
• [73]Gronhagen CM, Abbaszadegan H, Revay SA, Adolphson PY: Medium-term results after primary hemiarthroplasty for comminute proximal humerus fractures: a study of 46 patients followed up for an average of 4.4 years. J Shoulder Elbow Surg 2007, 16:766-773.
• [74]Schai P, von Flue M, Staubli AE, Vogt B: Functional results of Neer II type hemi-arthroplasty joint replacement of multi-fragment humerus head fractures. Helv Chir Acta 1991, 57:799-804.
• [75]Dietrich M, Meier C, Lattmann T, Zingg U, Gruninger P, Platz A: Complex fracture of the proximal humerus in the elderly. Locking plate osteosynthesis vs hemiarthroplasty. Chirurg 2008, 79:231-240.
• [76]Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, Mole D: Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg 2002, 11:401-412.
• [77]Bastian JD, Hertel R: Osteosynthesis and hemiarthroplasty of fractures of the proximal humerus: outcomes in a consecutive case series. J Shoulder Elbow Surg 2009, 18:216-219.
• [78]Gierer P, Simon C, Gradl G, Ewert A, Vasarhelyi A, Beck M, Mittlmeier T: Complex proximal humerus fractures–management with a humeral head prosthesis? Clinical and radiological results of a prospective study. Orthopade 2006, 35:834-840.
• [79]Solberg BD, Moon CN, Franco DP, Paiement GD: Surgical treatment of three and four-part proximal humeral fractures. J Bone Joint Surg Am 2009, 91:1689-1697.
• [80]Grassi FA, Tajana MS: Partial prosthetic replacement of the shoulder in fractures and fracture-dislocations of the proximal humerus. Chir Organi Mov 2005, 90:179-190.
• [81]Kabir K, Burger C, Fischer P, Weber O, Florczyk A, Goost H, Rangger C: Health status as an important outcome factor after hemiarthroplasty. J Shoulder Elbow Surg 2009, 18:75-82.
• [82]Movin T, Sjoden GO, Ahrengart L: Poor function after shoulder replacement in fracture patients. A retrospective evaluation of 29 patients followed for 2–12 years. Acta Orthop Scand 1998, 69:392-396.
• [83]Gerber C, Werner CM, Vienne P: Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg Br 2004, 86:848-855.
• [84]Robinson CM, Teoh KH, Baker A, Bell L: Fractures of the lesser tuberosity of the humerus. J Bone Joint Surg Am 2009, 91:512-520.
• [85]Kralinger F, Schwaiger R, Wambacher M, Farrell E, Menth-Chiari W, Lajtai G, Hubner C, Resch H: Outcome after primary hemiarthroplasty for fracture of the head of the humerus. A retrospective multicentre study of 167 patients. J Bone Joint Surg Br 2004, 86:217-219.
• [86]Moeckel BH, Dines DM, Warren RF, Altchek DW: Modular hemiarthroplasty for fractures of the proximal part of the humerus. J Bone Joint Surg Am 1992, 74:884-889.
• [87]Robinson CM, Page RS, Hill RM, Sanders DL, Court-Brown CM, Wakefield AE: Primary hemiarthroplasty for treatment of proximal humeral fractures. J Bone Joint Surg Am 2003, 85-A:1215-1223.
• [88]Guy P, Slobogean GP, McCormack RG: Treatment preferences for displaced three- and four-part proximal humerus fractures. J Orthop Trauma 2010, 24:250-254.
• [89]Soucacos PN, Johnson EO, Babis G: Randomised controlled trials in orthopaedic surgery and traumatology: overview of parameters and pitfalls. Injury 2008, 39:636-642.
• [90]Chan S, Bhandari M: The quality of reporting of orthopaedic randomized trials with use of a checklist for nonpharmacological therapies. J Bone Joint Surg Am 2007, 89:1970-1978.
• [91]Poolman RW, Struijs PA, Krips R, Sierevelt IN, Lutz KH, Bhandari M: Does a "Level I Evidence" rating imply high quality of reporting in orthopaedic randomised controlled trials? BMC medical research methodology 2006, 6:44. BioMed Central Full Text
• [92]Simunovic N, Devereaux PJ, Bhandari M: Design considerations for randomised trials in orthopaedic fracture surgery. Injury 2008, 39:696-704.
• [93]Gurusamy KS, Gluud C, Nikolova D, Davidson BR: Assessment of risk of bias in randomized clinical trials in surgery. Br J Surg 2009, 96:342-349.
• [94]Cook JA: The challenges faced in the design, conduct and analysis of surgical randomised controlled trials. Trials 2009, 10:9. BioMed Central Full Text
• [95]Hoppe DJ, Schemitsch EH, Morshed S, Tornetta P 3rd, Bhandari M: Hierarchy of evidence: where observational studies fit in and why we need them. J Bone Joint Surg Am 2009, 91(Suppl 3):2-9.
• [96]Campbell AJ, Bagley A, Van Heest A, James MA: Challenges of randomized controlled surgical trials. Orthop Clin North Am 2010, 41:145-155.
• [97]Harvie P, Pollard TC, Chennagiri RJ, Carr AJ: The use of outcome scores in surgery of the shoulder. J Bone Joint Surg Br 2005, 87:151-154.
• [98]Goldhahn S, Sawaguchi T, Audige L, Mundi R, Hanson B, Bhandari M, Goldhahn J: Complication reporting in orthopaedic trials. A systematic review of randomized controlled trials. J Bone Joint Surg Am 2009, 91:1847-1853.
• [99]Agudelo J, Schurmann M, Stahel P, Helwig P, Morgan SJ, Zechel W, Bahrs C, Parekh A, Ziran B, Williams A, Smith W: Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma 2007, 21:676-681.
• [100]Plecko M, Kraus A: Internal fixation of proximal humerus fractures using the locking proximal humerus plate. Oper Orthop Traumatol 2005, 17:25-50.
• [101]Solberg BD, Moon CN, Franco DP, Paiement GD: Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma 2009, 23:113-119.