Proximal humeral fractures : outcome of treatment with shoulder arthroplasty

Introduction:

Proximal humerus fractures are a common injury, particularly in the elderly and especially in women. The preferred treatment approach is usually nonsurgical, with surgery reserved for cases that meet specific fracture patterns and patient-specific criteria.

The aim of this thesis was to study the use of arthroplasty as a treatment option for proximal humeral fractures.

Study I: Revision after shoulder replacement for acute fracture of the proximal humerus. A Nordic registry-based study of 6,756 cases:

The aim was to investigate revision rates and reasons for revision after shoulder arthroplasty for acute fractures of the proximal humerus.

Common data sets were collected from the Danish, Norwegian, and Swedish registries which conducted shoulder arthroplasty after acute fractures.

The number and proportion of reverse total shoulder arthroplasties (rTSA) performed during the study period increased steadily. Of the 222 arthroplasties revised between 2004 and 2013, infection was the most common reason. The relative risk of revision due to infection was higher for rTSA than for shoulder hemiarthroplasties (SHA). In addition, patients younger than 75 years had a higher relative risk of revision, and survival with SHA was worse in younger patients than in older patients.

Conclusion: Both SHA and rTSA have similar survival rates. However, the factors leading to a revision decision are not fully known, and reported survival rates may not reflect patients' functional outcomes. Patients with acute fractures often have comorbidities and are less amenable to revision surgery. Inclusion of patient reports in the data set would provide important information. The risk of infection was higher after rTSA than after SHA, and differences in revision rates between systematic reviews and national registries may be due to inclusion criteria. Comparisons between SHA and rTSA should be made with caution.

Study II: Western Ontario Osteoarthritis of the Shoulder Index (WOOS) - a validation for use in proximal humerus fractures treated with arthroplasty:

The objective was to validate the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) as a patient-reported outcome measures (PROM) for use in proximal humeral fractures treated with arthroplasty.

Patients from Swedish Shoulder Arthroplasty registry (SSAR) who underwent surgery after PHF with SHA and had surgery Karolinska hospital and Danderyd hospital were selected. Those who accepted performed shoulder-specific PROM and WOOS retest, and the necessary clinical examinations, Constant score (CS) and American shoulder and elbow Society (ASES), were performed at Danderyd Hospital.

The validity of the WOOS has excellent correlation with all shoulder-specific scores and good correlation with EQ -5D. Test-retest reliability of WOOS overall and in subgroups also shows excellent correlation. Cronbach's alpha supports the construct of WOOS, and no floor or ceiling effects were observed.

Conclusion: WOOS is a reliable tool for assessing patients with SHA after PHF. Our study supports the continued use of WOOS in SSAR and further studies with WOOS and arthroplasty after proximal humerus fractures.

Study III: Reverse total shoulder arthroplasty provides better shoulder function than hemiarthroplasty for displaced 3- and 4-part proximal humeral fractures in patients aged 70 years or older: a multicenter randomized controlled trial:

The aim was to compare the outcomes of 3–4-part fractures of the proximal humerus treated with reverse total shoulder arthroplasty (rTSA) and hemiarthroplasty (SHA) in patients aged ≥70 years in a multicenter randomized controlled trial.

An RCT multicenter study was conducted, and eight hospitals recruited patients for the study.

The rTSA group had a higher mean Constant score (58.7) compared with SHA (47.7), with a mean difference of 11.1 points (95% CI, 3.0–18.9). Patients who underwent rTSA reported greater satisfaction with their shoulders on average and had better range of motion. However, no differences were noted in WOOS, EQ -5D or pain at VAS. We noted three adverse events in the rTSA group and four in the SHA group.

Conclusion: Our study showed that the rTSA group had better shoulder function as measured by the Constant score compared with SHA. This could explain why rTSA patients were more satisfied with their shoulder function. The main difference could be explained by a better range of motion in the rTSA group.

Study IV: Timing of surgery for proximal humeral fracture treated with shoulder hemiarthroplasty, best results with surgery within 2 weeks:

The aim was to evaluate the validity of the national recommendation "surgery with arthroplasty within 2 weeks" by investigating the timing to surgery in patients operated on with shoulder arthroplasty after proximal humerus fractures.

Data was collected from SSAR. In addition, the date of fracture was collected from the hospitals that could provide that information.

Preoperative delay had a negative impact on WOOS, EQ -5D, and patient satisfaction scores. The best outcomes, as measured by the WOOS score at a follow-up of at least 1 year, were observed when surgery was performed within 6-10 days of the reported fracture date. A delay of more than 10 days was associated with a worse outcome.

Conclusion: The current recommendation in Sweden to perform shoulder hemiarthroplasty within two weeks after proximal humerus fracture is considered valid.

List of scientific papers

I. Revision after shoulder replacement for acute fracture of the proximal humerus. A Nordic registry-based study of 6,756 cases. Stig Brorson, Björn Salomonsson, Steen L Jensen, Anne Marie Fenstad, Yilmaz Demir, and Jeppe V Rasmussen. Acta Orthopaedica. 2017; 88 (4): 446–450,
https://doi.org/10.1080/17453674.2017.1307032

II. Western Ontario Osteoarthritis of the Shoulder Index (WOOS) - a validation for use in proximal humerus fractures treated with arthroplasty. Yilmaz Demir, Hanna Sjöberg, Andre Stark and Björn Salomonsson. BMC Musculoskelet Disord. 2023 Jun 2;24(1):450.
https://doi.org/10.1186/s12891-023-06578-5

III. Reverse total shoulder arthroplasty provides better shoulder function than hemiarthroplasty for displaced 3- and 4-part proximal humeral fractures in patients aged 70 years or older: a multicenter randomized controlled trial. Eythor O. Jonsson, Carl Ekholm, Björn Salomonsson, Yilmaz Demir, Per Olerud, and Collaborators in the SAPF Study Group. Journal of Shoulder and Elbow Surgery. Volume 30, Issue 5, May 2021, Pages 994-1006.
https://doi.org/10.1016/j.jse.2020.10.037

IV. Timing of surgery for proximal humeral fracture treated with shoulder hemiarthroplasty, best results with surgery within 2 weeks. Yilmaz Demir, Alma Vuorinen, Max Gordon, Anders Nordqvist, Björn Salomonsson. [Manuscript]
https://doi.org/10.21203/rs.3.rs-2185864/v1