Proximal and distal humeral fractures. Outcome of primary arthroplasty

Abstract

This thesis deals with both proximal humeral fractures and elbow injuries, especially distal humeral fractures. The main focus is difficult fractures in the elderly. Few randomized controlled trials (RCTs) are available. If the joint surface is considerably affected (e.g. comminution and displacement), arthroplasty is a treatment option. Comparing more recently introduced types of arthroplasty with established types lies at the center of this thesis. In Study I, reverse total shoulder arthroplasty (rTSA) was compared with hemiarthroplasty (HA), the established type of arthroplasty for proximal humeral fractures for many years. The understanding that tuberosity healing has a positive effect on the outcome of HA following the treatment of proximal humeral fractures is widespread. The available evidence has not, however, been summarized in a meta-analysis, which was done in Study II. In Study III, elbow hemiarthroplasty (EHA) was compared with total elbow arthroplasty (TEA), an established treatment for distal humeral fractures. Patient-reported outcome measures (PROMs), such as the Oxford Elbow Score (OES), are used increasingly. A short recall period may have advantages for PROMs. The effect of shortening the recall period for the OES was explored in Study IV. Study I: In an RCT, of patients with 3- or 4-part proximal humeral fractures (≥ 70 years of age), the mean Constant score was higher for rTSA (n = 41) than for HA (n = 43, 58.7 vs. 47.7, 95% CI: 3.0–18.9) as was mean flexion (125° vs. 90°, 95% CI: 20–49°) and abduction (112° vs. 83°, 95% CI: 15–43°). Study II: In a systematic review and meta-analysis, tuberosity healing (n = 317) was found to provide better function than failed tuberosity healing (n = 217) for patients treated with HA for proximal humeral fractures with better Constant scores (mean difference (MD) = 10.8 points, 55.4 vs. 44.6, 95% CI: 3.8–17.9) and flexion (MD = 34°, 107° vs. 73°, 95% CI: 23– 46°). Study III: In an RCT, patients (≥ 60 years of age) with unreconstructable distal humeral fractures had similar function following treatment with EHA (n = 18) and TEA (n = 17) in terms of mean Disabilities of the arm, shoulder and hand (DASH) scores (21.6 vs. 27.2, 95% CI: −7.5–18.6) and Mayo elbow performance scores (MEPS, 85.0 vs. 88.2, 95% CI: −8.9–15.4). Study IV: When used with a 7-day recall period, the OES (75 patients) demonstrated good measurement properties (construct validity, responsiveness and reliability). In conclusion, rTSA provides better shoulder function than HA for elderly patients with displaced 3- and 4-part proximal humeral fractures, at least in most elderly women. Moreover, tuberosity healing provides better shoulder function than failed tuberosity healing after treatment with HA for a proximal humeral fracture. For unreconstructable distal humeral fractures, EHA and TEA provide similar function, at least in elderly women. Other factors, such as activity level, should be considered when choosing between these treatments. The results of Study IV further establish the OES as a well-validated, elbow-specific PROM and support the use of a 7-day recall period.