Eythór Jónsson - Proximal and distal humeral fractures – outcome of primary arthroplasty

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Link directly to the doctoral thesis

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 to guide treatment choices. If the joint surface is considerably affected (for example by 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), which was 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, previously been summarized in a meta-analysis, which was done in Study II.

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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 to assess outcome. A short recall period may have advantages for PROMs. The effect of shortening the recall period for the Oxford Elbow Score 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 patients treated with rTSA (n = 41) than for patients treated with 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).

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Study IV: When used with a 7-day recall period, the OES demonstrated good measurement properties based on an analysis of 75 patients, in terms of 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 and is preferable to HA, 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 treatment options. The results of Study IV further establish the Oxford Elbow Score as a well-validated, elbow-specific PROM and support the use of a 7-day recall period.

MORE INFORMATION - Illustration at the top
Illustration 27, from page 71 in the thesis:
Management of epicondyles and columns in hemiarthroplasty for distal humeral fracture, view from anterior. A) A distal humeral fracture with very thin distal fragments. Both the lateral and medial column are fractured. The collateral ligaments are intact. The lateral ulnar collateral ligament lies behind the radial head, extending to its insertion on the ulna. B) The thin articular fragments are removed. The prosthesis is inserted and the joint reduced. C) The epicondyle/column fragments are reduced. A number of methods have been described for fixation, including plate fixation (medial side) and cerclage with wire or sutures (lateral side).
Illustration av Pontus Andersson/ Pontus Art Production