Shoulder-specific Outcome after Proximal Humerus Fracture Influences Medium-term Overall Quality of Life

Abstract

Background Surgical treatment of proximal humerus fracture is an established procedure. Postoperative complications have been shown to have a significant impact on shoulder-specific outcome. Little is known to date about an influence on injury-independent quality of life.

Aim of the Work The aim of this retrospective study is to analyse whether patients with a poor functional outcome after surgically treated proximal humerus fracture also show a reduced general quality of life in the medium term. Emphasis is placed on the analysis of patients with poor functional outcome due to postsurgical complications.

Material and Methods Evaluation of all patients operated at one level 1 trauma centre with a proximal humerus fracture in the period 01.01.2005 to 31.12.2015 and follow-up using validated scores (Constant-Murley Score [CMS], EQ-5D). Two groups, group A with good outcome (∆CMS ≤ 15P.) and group B with poor outcome (∆CMS ≥ 16P.), were defined. Furthermore, descriptive variables including definition of a complication were defined in advance. Results: 138 patients were included in the study (group A: 91, group B: 47). The mean follow-up was 93.86 months ± 37.33 (36–167). Group B had significantly more complications. Furthermore, patients with poor outcome regarding the shoulder (group B) were also found to have significantly lower EQ-VAS (78.9 ± 19.2 [20.0–100] vs. 70.4 ± 19.5 [15.0–98.0]; p = 0.008) and EQ index (0.91 ± 0.14 [0.19–1.00] vs. 0.82 ± 0.17 [0.18–1.00]; p < 0.001).

Discussion In conclusion, in the present study, the patients with poor outcome of shoulder function in CMS have significantly lower overall quality of life after a mean of more than 6 years of follow-up. The poor outcome was due to a significantly higher postoperative complication rate. This was independent of the fracture morphology present and the surgical procedure used.

Keywords

shoulder fractures - humerus - fracture fixation internal - Constant Score - EQ-5D

Publication History

Received: 28 March 2021

Accepted after revision: 06 October 2021

Article published online:
01 February 2022

• Literatur

• 1 Karl JW, Olson PR, Rosenwasser MP. The Epidemiology of Upper Extremity Fractures in the United States, 2009. J Orthop Trauma 2015; 29: e242-e244 DOI: 10.1097/BOT.0000000000000312. (PMID: 25714441)
• 2 Kannus P, Niemi S, Sievänen H. et al. Stabilized Incidence in Proximal Humeral Fractures of Elderly Women: Nationwide Statistics From Finland in 1970–2015. J Gerontol A Biol Sci Med Sci 2017; 72: 1390-1393 DOI: 10.1093/gerona/glx073. (PMID: 28475669)
• 3 Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand 2001; 72: 365-371 DOI: 10.1080/000164701753542023. (PMID: 11580125)
• 4 Fraser AN, Bjørdal J, Wagle TM. et al. Reverse Shoulder Arthroplasty Is Superior to Plate Fixation at 2 Years for Displaced Proximal Humeral Fractures in the Elderly: A Multicenter Randomized Controlled Trial. J Bone Joint Surg Am 2020; 102: 477-485 DOI: 10.2106/JBJS.19.01071. (PMID: 31977825)
• 5 Mellstrand Navarro C, Brolund A, Ekholm C. et al. Treatment of humerus fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and evolution of practice. PLoS One 2018; 13: e0207815 DOI: 10.1371/journal.pone.0207815. (PMID: 30543644)
• 6 Rangan A, Handoll H, Brealey S. et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA 2015; 313: 1037-1047 DOI: 10.1001/jama.2015.1629. (PMID: 25756440)
• 7 Handoll HHG, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2015; (11) CD000434 DOI: 10.1002/14651858.CD000434.pub4.
• 8 Frank FA, Niehaus R, Borbas P. et al. Risk factors for secondary displacement in conservatively treated proximal humeral fractures. Bone Joint J 2020; 102-B: 881-889 DOI: 10.1302/0301-620X.102B7.BJJ-2020-0045.R1. (PMID: 32600138)
• 9 Zirngibl B, Biber R, Bail HJ. Humeral head necrosis after proximal humeral nailing: what are the reasons for bad outcomes?. Injury 2016; 47 (Suppl. 07) S10-S13 DOI: 10.1016/S0020-1383(16)30847-6. (PMID: 28040070)
• 10 Borer J, Schwarz J, Potthast S. et al. Mid-term results of minimally invasive deltoid-split versus standard open deltopectoral approach for PHILOS™ (proximal humeral internal locking system) osteosynthesis in proximal humeral fractures. Eur J Trauma Emerg Surg 2020; 46: 825-834 DOI: 10.1007/s00068-019-01076-7. (PMID: 30643920)
• 11 Richard GJ, Denard PJ, Kaar SG. et al. Outcome measures reported for the management of proximal humeral fractures: a systematic review. J Shoulder Elbow Surg 2020; 29: 2175-2184 DOI: 10.1016/j.jse.2020.04.006. (PMID: 32951643)
• 12 Olerud P, Tidermark J, Ponzer S. et al. Responsiveness of the EQ-5D in patients with proximal humeral fractures. J Shoulder Elbow Surg 2011; 20: 1200-1206 DOI: 10.1016/j.jse.2011.06.010. (PMID: 22014617)
• 13 Grobet C, Marks M, Tecklenburg L. et al. Application and measurement properties of EQ-5D to measure quality of life in patients with upper extremity orthopaedic disorders: a systematic literature review. Arch Orthop Trauma Surg 2018; 138: 953-961 DOI: 10.1007/s00402-018-2933-x. (PMID: 29654354)
• 14 Neer 2nd CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970; 52: 1077-1089 (PMID: 5455339)
• 15 Herdman M, Gudex C, Lloyd A. et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res 2011; 20: 1727-1736 DOI: 10.1007/s11136-011-9903-x. (PMID: 21479777)
• 16 Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987; (214) 160-164 (PMID: 3791738)
• 17 Constant CR, Gerber C, Emery RJH. et al. A review of the Constant score: modifications and guidelines for its use. J Shoulder Elbow Surg 2008; 17: 355-361 DOI: 10.1016/j.jse.2007.06.022. (PMID: 18218327)
• 18 Devlin NJ, Brooks R. EQ-5D and the EuroQol Group: Past, Present and Future. Appl Health Econ Health Policy 2017; 15: 127-137 DOI: 10.1007/s40258-017-0310-5. (PMID: 28194657)
• 19 Holmgren T, Oberg B, Adolfsson L. et al. Minimal important changes in the Constant-Murley score in patients with subacromial pain. J Shoulder Elbow Surg 2014; 23: 1083-1090 DOI: 10.1016/j.jse.2014.01.014.
• 20 Kukkonen J, Kauko T, Vahlberg T. et al. Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery. J Shoulder Elbow Surg 2013; 22: 1650-1655 DOI: 10.1016/j.jse.2013.05.002. (PMID: 23850308)
• 21 Torrens C, Guirro P, Santana F. The minimal clinically important difference for function and strength in patients undergoing reverse shoulder arthroplasty. J Shoulder Elbow Surg 2016; 25: 262-268 DOI: 10.1016/j.jse.2015.07.020. (PMID: 26422525)
• 22 Dabija DI, Jain NB. Minimal Clinically Important Difference of Shoulder Outcome Measures and Diagnoses: A Systematic Review. Am J Phys Med Rehabil 2019; 98: 671-676 DOI: 10.1097/PHM.0000000000001169. (PMID: 31318747)
• 23 Launonen AP, Sumrein BO, Reito A. et al. Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial. PLoS Med 2019; 16: e1002855 DOI: 10.1371/journal.pmed.1002855. (PMID: 31318863)
• 24 Olerud P, Ahrengart L, Ponzer S. et al. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg 2011; 20: 747-755 DOI: 10.1016/j.jse.2010.12.018. (PMID: 21435907)
• 25 Fjalestad T, Strømsøe K, Blücher J. et al. Fractures in the proximal humerus: Functional outcome and evaluation of 70 patients treated in hospital. Arch Orthop Trauma Surg 2005; 125: 310-316 DOI: 10.1007/s00402-005-0803-9. (PMID: 15843948)
• 26 Li F, Liu X, Wang F. et al. Comparison between minimally invasive plate osteosynthesis and open reduction-internal fixation for proximal humeral fractures: a meta-analysis based on 1050 individuals. BMC Musculoskelet Disord 2019; 20: 550 DOI: 10.1186/s12891-019-2936-y. (PMID: 31627717)
• 27 Xie L, Zhang Y, Chen C. et al. Deltoid-split approach versus deltopectoral approach for proximal humerus fractures: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2019; 105: 307-316 DOI: 10.1016/j.otsr.2018.12.004. (PMID: 30878231)
• 28 Fialka C, Oberleitner G, Stampfl P. et al. Modification of the Constant-Murley shoulder score-introduction of the individual relative Constant score Individual shoulder assessment. Injury 2005; 36: 1159-1165 DOI: 10.1016/j.injury.2004.12.023. (PMID: 16214462)
• 29 Spross C, Meester J, Mazzucchelli RA. et al. Evidence-based algorithm to treat patients with proximal humerus fractures-a prospective study with early clinical and overall performance results. J Shoulder Elbow Surg 2019; 28: 1022-1032 DOI: 10.1016/j.jse.2019.02.015. (PMID: 31003888)
• 30 Brouwer ME, Reininga IHF, El Moumni M. et al. Outcomes of operative and nonoperative treatment of 3- and 4-part proximal humeral fractures in elderly: a 10-year retrospective cohort study. Eur J Trauma Emerg Surg 2019; 45: 131-138 DOI: 10.1007/s00068-017-0890-7. (PMID: 29285612)
• 31 Lopiz Y, Garríguez-Pérez D, Martínez-Illán M. et al. Third-generation intramedullary nailing for displaced proximal humeral fractures in the elderly: quality of life, clinical results, and complications. Arch Orthop Trauma Surg 2020; DOI: 10.1007/s00402-020-03678-y. (PMID: 33175196)
• 32 Schumaier A, Grawe B. Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient. Geriatr Orthop Surg Rehabil 2018; 9: 2151458517750516 DOI: 10.1177/2151458517750516. (PMID: 29399372)
• 33 Südkamp N, Bayer J, Hepp P. et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am 2009; 91: 1320-1328 DOI: 10.2106/JBJS.H.00006. (PMID: 19487508)
• 34 Robinson CM, Stirling PHC, Goudie EB. et al. Complications and Long-Term Outcomes of Open Reduction and Plate Fixation of Proximal Humeral Fractures. J Bone Joint Surg Am 2019; 101: 2129-2139 DOI: 10.2106/JBJS.19.00595. (PMID: 31800426)
• 35 Maugendre E, Gadisseux B, Chantelot C. et al. Epidemiology and mortality in older patients treated by reverse shoulder arthroplasty for displaced proximal humerus fractures. Orthop Traumatol Surg Res 2019; 105: 1509-1513 DOI: 10.1016/j.otsr.2019.07.026. (PMID: 31732395)
• 36 Werner BC, Rawles RB, Jobe JT. et al. Obesity is associated with increased postoperative complications after operative management of distal humerus fractures. J Shoulder Elbow Surg 2015; 24: 1602-1606 DOI: 10.1016/j.jse.2015.04.019. (PMID: 26163280)
• 37 Bockmann B, Buecking B, Franz D. et al. Mid-term results of a less-invasive locking plate fixation method for proximal humeral fractures: a prospective observational study. BMC Musculoskelet Disord 2015; 16: 160 DOI: 10.1186/s12891-015-0618-y. (PMID: 26141352)
• 38 Bestehorn K. Prospektive und retrospektive Studien – ein Überblick. In: Lenk C, Duttge G, Fangerau H. Handbuch Ethik und Recht der Forschung am Menschen. Berlin, Heidelberg: Springer; 2014: 83-85 DOI: 10.1007/978-3-642-35099-3_13
• 39 Boehm D, Wollmerstedt N, Doesch M. et al. Entwicklung eines Fragebogens basierend auf dem Constant-Murely-Score zur Selbstevaluation der Schulterfunktion durch den Patienten. Unfallchirurg 2004; 107: 397-402 DOI: 10.1007/s00113-004-0757-3. (PMID: 15060778)
• 40 Henkelmann R, Theopold J, Kitsche J. et al. Comorbidities, substance abuse, weight and age are independent risk factors for postoperative complications following operation for proximal humerus fractures: a retrospective analysis of 1109 patients. Arch Orthop Trauma Surg 2021; DOI: 10.1007/s00402-021-04022-8. (PMID: 34258658)