OBJECTIVE: This systematic review and meta-analysis compared clinical outcome measures in patients undergoing reverse shoulder arthroplasty (RSA) for proximal humerus fracture (PHF) with healed versus non-healed greater tuberosity (GT).
METHODS: We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines querying PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane for studies that stratified results by the GT healing status. Studies that did not attempt to repair the GT were excluded. We extracted and compared clinical outcomes including postoperative forward flexion (FF), external rotation (ER), internal rotation (IR), Constant score, and complications and revision rates.
RESULTS: Of the included patients, 295 (78.5%) demonstrated GT healing while 81 did not (21.5%). The healed GT cohort exhibited increased postoperative FF (P < .001), ER (P < .001), IR (P = .006), and Constant score (P = .006) compared to the non-healed GT cohort. The overall dislocation rate was 0.8% with no study differentiating GT status of dislocation cases.
CONCLUSIONS: Healing of the GT after RSA for PHF yields improved postoperative range of motion and strength, whereas patient-reported pain and function were largely not affected by GT healing indicating merit to RSA for PHF regardless of the likelihood of the GT healing.

Comminuted proximal humerus fractures are often repaired by metal plates, but potentially still experience bone refracture, bone \"stress shielding,\" screw perforation, delayed healing, and so forth. This \"proof of principle\" investigation is the initial step towards the design of a new plate using alternative materials to address some of these problems. Finite element modeling was used to create design graphs for bone stress, plate stress, screw stress, and interfragmentary motion via three different fixations (no, 1, or 2 \"kickstand\" [KS] screws across the fracture) using a wide range of plate elastic moduli (EP = 5-200 GPa). Well-known design optimization criteria were used that could minimize bone, plate, and screw failure (i.e., peak stress < ultimate tensile strength), reduce bone \"stress shielding\" (i.e., bone stress under the new plate ≥ bone stress for an intact humerus, titanium plate, and/or steel plate \"control\"), and encourage callus growth leading to early healing (i.e., 0.2 mm ≤ axial interfragmentary motion ≤ 1 mm; shear/axial interfragmentary motion ratio <1.6). The findings suggest that a potentially optimal configuration involves the new plate being manufactured from a material with an EP of 5-41.5 GPa with 1 KS screw; but, using no KS screws would cause immediate bone fracture and 2 KS screws would almost certainly lead to delayed healing. A prototype plate might be fabricated using alternative materials suggested for orthopedics and other industries, like fiber-metal laminates, fiber-reinforced polymers, metal foams, pure polymers, shape memory alloys, or 3D-printed porous metals.

UNASSIGNED: Treating complex three- and four-part proximal humerus fractures, especially in the elderly, remains contentious, with internal fixation using locking plates and shoulder arthroplasty being primary options. Although proximal humerus locking plates are more commonly used than shoulder replacements, they have a high complication rate. Factors like low bone density, advanced age, multiple fragment fractures, and medial cortical support loss negatively impact treatment outcomes. This study evaluates the functional and radiographic outcomes of using locking plates for treating these fractures in patients aged 50 and older, and the factors influencing outcomes and complication rates at the Ho Chi Minh City Hospital for Trauma and Orthopedics.
UNASSIGNED: A descriptive case series study was conducted on 58 patients aged 50 and older (15 males, 43 females) with three- and four-part proximal humerus fractures. These patients underwent open reduction and internal fixation with Locking - compression plate (LCP) periarticular proximal humerus plates at the Ho Chi Minh City Hospital for Traumatology and Orthopedics (HTO) from April 2020 to April 2022. The minimum postoperative follow-up period was 12 months.
UNASSIGNED: The average age of the patients was 62.78 ​± ​7.73 years, with a mean follow-up of 26.24 ​± ​5.93 months. Among them, 41 had three-part fractures (70.68 ​%) and 17 had four-part fractures (29.32 ​%). At the final follow-up (≥12 months), the mean Constant-Murley score was 70.81 ​± ​9.15, and the mean QDASH score was 8.33 ​± ​2.77. Complications occurred in 6 cases (10.34 ​%). Complex fractures, such as four-part fractures with displacement greater than 2 ​mm, had lower Constant-Murley scores and higher QDASH scores (p ​< ​0.05). Age, gender, bone density by deltoid tuberosity index (DTI), bone grafting, and rotator cuff sutures showed similar trends, but the differences were not statistically significant.
UNASSIGNED: Open reduction and internal fixation (ORIF) provides good bone healing and functional outcomes for three- and four-part proximal humerus fractures. Factors such as age, gender, bone density, bone grafting, and rotator cuff sutures do not significantly affect outcomes. Therefore, osteoporosis should not be a contraindication for ORIF with locking plates in these cases. Complex fractures, however, often lead to poorer outcomes and higher complication rates post-surgery.

OBJECTIVE: This study aims to evaluate the clinical application efficacy of the ultrasound-guided Joystick technique for percutaneous leverage reduction in conjunction with Kirschner wires and external fixator in the treatment of difficult-to-reduce pediatric Salter-Harris II type proximal humerus fractures.
METHODS: A retrospective analysis was conducted on children with Salter-Harris II type proximal humerus fractures, who failed manual closed reduction from January 2018 to March 2022. The group consisted of 7 males and 2 females, aged between 10 and 14 years. The surgical method involved percutaneous leverage reduction using the ultrasound-guided Joystick technique, combined with Kirschner wires and external fixation. Throughout the procedure, ultrasound is used for monitoring, with the fracture condition being determined before surgery. An external support screw is inserted into the distal end of the humerus as an operating lever, along with 3.5 mm Kirschner wire for ultrasound-guided reduction and maintenance of position during the operation. Following fixation with Kirschner wire, a combination external fixator is applied. After fixation is completed, ultrasound is used once more to assess the quality of fracture reduction, followed by verification of the reduction status using a C-arm X-ray machine.
RESULTS: All surgeries were successfully completed with a 100 % success rate in resetting. Notably, there were no postoperative complications like nerve or vascular injury, malunion, nonunion, or bone bridge formation in the proximal humeral physis. Three cases experienced minor complications (redness and swelling at the screw sites), which improved with conservative management. The follow-up period ranged from 6 to 18 months, averaging 10.6 months, with fracture clinical healing occurring within 6 to 8 weeks (average 6.3 weeks). The final follow-up revealed excellent functional outcomes, with Neer scores ranging from 90 to 100 (average 96.3 points).
CONCLUSIONS: The ultrasound-guided Joystick technique for percutaneous leverage reduction in conjunction with Kirschner wires and external fixator can effectively treat difficult-to-reduce Salter-Harris II proximal humeral fractures in children, avoiding open reduction and minimizing intraoperative radiation exposure. This approach offers good stability and facilitates early rehabilitation, aligning with the ERAS (Enhanced Recovery After Surgery) concept in fracture management, thus warranting clinical promotion.

BACKGROUND: If reduction images of fractures can be provided in advance with artificial-intelligence (AI)-based technology, it can assist with preoperative surgical planning. Recently, we developed the AI-based preoperative virtual reduction model for orthopedic trauma, which can provide an automatic segmentation and reduction of fractured fragments. The purpose of this study was to validate a quality of reduction model of Neer 3- or 4-part proximal humerus fractures established by AI-based technology.
METHODS: To develop the AI-based preoperative virtual reduction model, deep learning performed the segmentation of fracture fragments, and a Monte Carlo simulation completed the virtual reduction to determine the best model. A total of 20 pre/postoperative three-dimensional computed tomography (CT) scans of proximal humerus fracture were prepared. The preoperative CT scans were employed as the input of AI-based automated reduction (AI-R) to deduce the reduction models of fracture fragments, meanwhile, the manual reduction (MR) was conducted using the same CT images. Dice similarity coefficient (DSC) and intersection over union (IoU) between the reduction model from the AI-R/MR and postoperative CT scans were evaluated. Working times were compared between the two groups. Clinical validity agreement (CVA) and reduction quality score (RQS) were investigated for clinical validation outcomes by 20 orthopedic surgeons.
RESULTS: The mean DSC and IoU were better when using AI-R that when using MR (0.78 ± 0.13 vs. 0.69 ± 0.16, p < 0.001 and 0.65 ± 0.16 vs. 0.55 ± 0.18, p < 0.001, respectively). The working time of AI-R was, on average, 1.41% of that of MR. The mean CVA of all cases was 81%±14.7% (AI-R, 82.25%±14.27%; MR, 76.75%±14.17%, p = 0.06). The mean RQS was significantly higher when AI-R compared with MR was used (91.47 ± 1.12 vs. 89.30 ± 1.62, p = 0.045).
CONCLUSIONS: The AI-based preoperative virtual reduction model showed good performance in the reduction model in proximal humerus fractures with faster working times. Beyond diagnosis, classification, and outcome prediction, the AI-based technology can change the paradigm of preoperative surgical planning in orthopedic surgery.
METHODS: Level IV.

BACKGROUND: Approximately 70 % of proximal humerus fractures (PHF) occur after the age of 60. High complication rates have been described in correlation with the treatment of PHF. Major risk factors for the outcome might be frailty, mobility and comorbidities of patients at the time of hospital admission. The aim of this study was to create risk adjusted quality indicators for surgical treatment of proximal humerus fractures based on German claims data and to evaluate the impact of the Hospital Frailty Risk Score (HFRS) on risk adjustment.
METHODS: Retrospective claims data (2015-2021) were used to create risk adjusted quality indicators for eight outcomes by clustered multivariable logistic regression. The comparison of different risk adjustment model performances was done by ROC-AUC and Standardized Mortality/Morbidity Ratios.
RESULTS: In total, N = 34,912 patients (median age 75 years, 80.3 % female) were included. The most common surgical procedure was open reduction and internal fixation with plate osteosynthesis with 39.7 %, followed by reverse shoulder arthroplasty with 25.3 %. The most influential risk factor for all outcomes was a high HFRS with an Odds Ratio of 2.0 (95 %-Confidence Interval 1.8-2.3) for any secondary surgery (365 days) up to an Odds Ratio of 17.6 (95 %-Confidence Interval 14.9-20.8) for general complications during the index stay.
CONCLUSIONS: Comparative quality reporting for the surgical treatment of PHF appears feasible with the developed models for risk adjustment using claims data. Preoperative evaluation of HFRS in PHF can contribute to risk assessment, and individual patient management. It therefore enables personalized treatment decisions.

UNASSIGNED: Patients with fractures of the proximal humerus often local complications and failures attributed to osteoporosis. Currently, there is a lack of straight forward screening methods for assessing the extent of local osteoporosis in the proximal humerus. This study utilizes machine learning techniques to establish a diagnostic approach for evaluating local osteoporosis by analyzing the patient\'s demographic data, bone density, and X-ray ratio of the proximal humerus.
UNASSIGNED: A cohort comprising a total of 102 hospitalized patients admitted during the period spanning from 2021 to 2023 underwent random selection procedures. Resulting in exclusion of 5 patients while enrolling 97 patients for analysis encompassing patient demographics, shoulder joint anteroposterior radiographs, and bone density information. Using the modified Tingart index methodology involving multiple measurements denoted as M1 through M4 obtained from humeral shafts. Within this cohort comprised 76 females (78.4 %) and 21 males (21.6 %), with an average age of 73.0 years (range: 43-98 years). There were 25 cases with normal bone density, 35 with osteopenia, and 37 with osteoporosis. Machine learning techniques were used to randomly divide the 97 cases into training (n = 59) and validation (n = 38) sets with a ratio of 6:4 using stratified random sampling. A decision tree model was built in the training set, and significant diagnostic indicators were selected, with the performance of the decision tree evaluated using the validation set. Multinomial logistic regression methods were used to verify the strength of the relationship between the selected indicators and osteoporosis.
UNASSIGNED: The decision tree identified significant diagnostic indicators as the humeral shaft medullary cavity ratio M2/M4, age, and gender. M2/M4 ≥ 1.13 can be used as an important screening criterion; M2/M4 < 1.13 was predicted as local osteoporosis; M2/M4 ≥ 1.13 and age ≥83 years were also predicted as osteoporosis. M2/M4 ≥ 1.13 and age <64 years or males aged between 64 and 83 years were predicted as the normal population; M2/M4 ≥ 1.13 and females aged between 64 and 83 years were predicted as having osteopenia. The decision tree\'s accuracy in the training set was 0.7627 (95 % CI (0.6341, 0.8638)), and its accuracy in the test set was 0.7895 (95 % CI (0.6268, 0.9045)). Multinomial logistic regression results showed that humeral shaft medullary cavity ratios M2/M4, age, and gender in X-ray images were significantly associated with the occurrence of osteoporosis.
UNASSIGNED: Utilizing X-ray data of the proximal humerus in conjunction with demographic information such as gender and age enable the prediction of localized osteoporosis, facilitating physicians\' rapid comprehension of osteoporosis in patients and optimization of clinical treatment plans.
UNASSIGNED: Level IV retrospective case study.

UNASSIGNED: Despite extensive literature dedicated to determining the optimal treatment of isolated greater tuberosity (GT) fractures, there have been few studies to guide the management of GT fracture dislocations. The purpose of this review was to highlight the relevant literature pertaining to all aspects of GT fracture dislocation evaluation and treatment.
UNASSIGNED: A narrative review of the literature was performed.
UNASSIGNED: During glenohumeral reduction, an iatrogenic humeral neck fracture may occur due to the presence of an occult neck fracture or forceful reduction attempts with inadequate muscle relaxation. Minimally displaced GT fragments after shoulder reduction can be successfully treated nonoperatively, but close follow-up is needed to monitor for secondary displacement of the fracture. Surgery is indicated for fractures with >5 mm displacement to minimize the risk of subacromial impingement and altered rotator cuff biomechanics. Multiple surgical techniques have been described and include both open and arthroscopic approaches. Strategies for repair include the use of transosseous sutures, suture anchors, tension bands, screws, and plates. Good-to-excellent radiographic and clinical outcomes can be achieved with appropriate treatment.
UNASSIGNED: GT fracture dislocations of the proximal humerus represent a separate entity from their isolated fracture counterparts in their evaluation and treatment. The decision to employ a certain strategy should depend on fracture morphology and comminution, bone quality, and displacement.

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