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Treatment of proximal humerus fractures in geriatric patients - Can pathological DEXA results help to guide the indication for allograft augmentation?

ABSTRACT: INTRODUCTION:Reconstruction of proximal humerus fracture continues to represent a challenge, especially in severe osteopenia. However, there still is a lack of consensus and clear indication on use of allograft augmentation. Therefore, this study aims to investigate outcome after osteosynthesis with and without allograft augmentation. It focuses on bone density results obtained by DEXA as potential examination that might help decision-making. METHODS:This study included patients aged 65 years and older that were treated at one Level 1 trauma center between 2007 and 2018. Inclusion criteria: Proximal humerus fracture treated with or without allograft, conclusive data-sets. Exclusion criteria: prior surgical treatment of the proximal humerus, open fracture with bone loss, neurological damage. Patients were stratified according to the use of allograft augmentation in two groups: Group NA (no allograft augmented PHILOS) and Group A (PHILOS with allograft augmentation). Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Fractures were graded according to the classification by Neer. Radiographic union was analyzed at 6 weeks, 12 weeks, and at year follow up. Complications include surgical site infection, implant failure, humeral head necrosis, or delayed union. Allograft was used in cases of 1inch/3cm3 bone-loss or an egg-shell situation, where the patient refused arthroplasty. RESULTS:This study included 167 patients, with 143 (85%) in the Group NA, and 24 (15%) in the Group A. There were no significant differences in age, gender, injury distribution, and distribution of Neer classification or CCI. Patients in Group A had significantly lower T-scores preoperatively (-2.87 ± 1.08 versus -0.9 ± 2.12, p = 0.003). No difference occurred in any of the complications. At one-year follow-up, the range of motion was comparable in both groups. CONCLUSION:In patients with allograft augmentation and severe osteopenia, similar clinical and radiological results were obtained when compared with patients with better preoperative bone density scores (T-scores, DEXA). In view of a lack of guidelines indicating the indication for the use of allograft, this difference may be worth further study.

SUBMITTER: Halvachizadeh S

PROVIDER: S-EPMC7145012 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Treatment of proximal humerus fractures in geriatric patients - Can pathological DEXA results help to guide the indication for allograft augmentation?

Halvachizadeh Sascha S Berk Till T Rauer Thomas T Hierholzer Christian C Pfeifer Roman R Pape Hans-Christoph HC Allemann Florin F

PloS one 20200409 4

<h4>Introduction</h4>Reconstruction of proximal humerus fracture continues to represent a challenge, especially in severe osteopenia. However, there still is a lack of consensus and clear indication on use of allograft augmentation. Therefore, this study aims to investigate outcome after osteosynthesis with and without allograft augmentation. It focuses on bone density results obtained by DEXA as potential examination that might help decision-making.<h4>Methods</h4>This study included patients a ...[more]

PMID: 32271792

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Project description:Background Proximal humerus fractures (PHFs) are generally surgically treated with open reduction internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA). Diverse fracture patterns and a high prevalence in the elderly population make it difficult to establish objective guidelines for the decision to undergo surgical treatment. The purpose of this study was to investigate risk factors associated with readmission, reoperation, and nonhome discharge following ORIF, HA, and TSA for PHFs. Methods Data on all patients who underwent ORIF, TSA, or HA for treatment of closed PHF between 2015 and 2017 were obtained by querying the American College of Surgeons National Surgical Quality Improvement database. Rates of postoperative readmission, nonhome discharge, and reoperation within 30 days were collected. Multivariate logistic regression was employed to identify predictors of readmission, nonhome discharge, and reoperation. Results A total of 2825 patients were included in this study: 1829 underwent ORIF, 707 underwent TSA, and 289 underwent HA. The significant predictors for readmission were having an American Society of Anesthesiologists class ≥ 3 (odds ratio [OR] 1.95, P = .003) and being of dependent functional status (OR 3.15, P < .001). The significant predictors for reoperation were male sex (OR 2.41, P < .001) and dependent functional status (OR 2.92, P = .006). The significant predictors for nonhome discharge were age 66-80 years (OR 7.00, P < .001), age ≥ 81 years (OR 16.31, P < .001), American Society of Anesthesiologists ≥3 (OR 2.34, P < .001), dependent functional status (OR 2.48, P < .001), and inpatient status (OR 3.32, P < .001). TSA showed slightly higher rates of nonhome discharge than HA and ORIF. Conclusion Significant risk factors for readmission, reoperation, and nonhome discharge within 30 days following surgical treatment for PHF were identified. Additionally, TSA was significantly associated with nonhome discharge compared with HA and ORIF.

Project description:IntroductionCement augmentation of the proximal humerus internal locking system (PHILOS) screws might reduce complication rates in osteoporotic bones. This study compared the risk of mechanical failure during the first year after PHILOS™ treatment of proximal humerus fractures (PHF) without (control group) and with (augmented group) screw augmentation. Secondary objectives were to report shoulder functions, quality of life (QoL), adverse events (AEs), and reoperation rates.Materials and methodsThis multicenter randomized trial enrolled patients aged ≥ 65 years with displaced/unstable PHF from eight European centers. Randomization was performed during surgery through sealed opaque envelopes. Mechanical failures were assessed by two independent reviewers via radiographs, shoulder function by Quick DASH, SPADI, and Constant Murley scores, and QoL by EQ-5D. Follow-ups were planned at postoperative 6 weeks, 3, 6, and 12 months.ResultsThe preliminary analysis of 6-week radiographs of the first 59 enrolled patients suggested a mechanical failure rate lower than expected and the difference between groups was too small to be detected by the planned sample size of 144. The trial was prematurely terminated after 67 patients had been enrolled: 34 (27 eligible) in the control group and 33 (29 eligible) in the augmented group. Follow-ups were performed as planned. Nine patients had mechanical failures and the failure rates (95% CI) were: augmented group, 16.1% (5.5; 33.7); control group, 14.8% (4.2; 33.7); the relative risk (95% CI) for the augmented group was 1.09 (0.32; 3.65) compared to the control group (p = 1.000). No statistically significant differences in shoulder function, QoL, and AEs were observed between study groups at 1 year. Nine patients (15.8%) underwent a revision.ConclusionsDue to premature termination, the study was underpowered. A larger study will be necessary to determine if cement augmentation lowers the risk of mechanical failure rate.

Project description:Joint-preserving surgical treatment of complex unstable proximal humerus fractures remains challenging, with high failure rates even following state-of-the-art locked plating. Enhancement of implants could help improve outcomes. By overcoming limitations of conventional biomechanical testing, finite element (FE) analysis enables design optimization but requires stringent validation. This study aimed to computationally enhance the design of an existing locking plate to provide superior fixation stability and evaluate the benefit experimentally in a matched-pair fashion. Further aims were the evaluation of instrumentation accuracy and its potential influence on the specimen-specific predictive ability of FE. Screw trajectories of an existing commercial plate were adjusted to reduce the predicted cyclic cut-out failure risk and define the enhanced (EH) implant design based on results of a previous parametric FE study using 19 left proximal humerus models (Set A). Superiority of EH versus the original (OG) design was tested using nine pairs of human proximal humeri (N = 18, Set B). Specimen-specific CT-based virtual preoperative planning defined osteotomies replicating a complex 3-part fracture and fixation with a locking plate using six screws. Bone specimens were prepared, osteotomized and instrumented according to the preoperative plan via a standardized procedure utilizing 3D-printed guides. Cut-out failure of OG and EH implant designs was compared in paired groups with both FE analysis and cyclic biomechanical testing. The computationally enhanced implant configuration achieved significantly more cycles to cut-out failure compared to the standard OG design (p < 0.01), confirming the significantly lower peri-implant bone strain predicted by FE for the EH versus OG groups (p < 0.001). The magnitude of instrumentation inaccuracies was small but had a significant effect on the predicted failure risk (p < 0.01). The sample-specific FE predictions strongly correlated with the experimental results (R2 = 0.70) when incorporating instrumentation inaccuracies. These findings demonstrate the power and validity of FE simulations in improving implant designs towards superior fixation stability of proximal humerus fractures. Computational optimization could be performed involving further implant features and help decrease failure rates. The results underline the importance of accurate surgical execution of implant fixations and the need for high consistency in validation studies.

Dataset Information

Treatment of proximal humerus fractures in geriatric patients - Can pathological DEXA results help to guide the indication for allograft augmentation?

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Treatment of proximal humerus fractures in geriatric patients - Can pathological DEXA results help to guide the indication for allograft augmentation?

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