Comparison Of Different Surgical Methods For The Treatment Of Complex Proximal Humeral Fractures Inelderly Patients

OBJECTIVE: Compare the differences between three surgical methods for the treatment of complex proximal humeral fractures in elderly patients.Comprehensive analysis of surgical efficacy.Explore risk factors for poor prognosis.To provide a basis for the selection of surgical methods and promote the improvement of surgical efficacy.METHODS: All patients aged over 65 and admitted to the 1st ward of Orthopaedic Trauma in Shanghai Sixth People's hospital from January 2016 to December 2017 and received surgical treatment for Neer three-or fourpart proximal humeral fractures were analyzed.According to the surgical methods,the patients were divided into three groups: open reduction and internal fixation,hemiarthroplasty and reverse total shoulder arthroplasty.Perioperative data were collected.Regular follow-up was conducted after surgery.The active range of motions were recorded and functional scores were performed.Complications were recorded.The differences between the three surgical methods were compared comprehensively.RESULTS: A total of 48 patients met the inclusion criteria,including 30 patients with open reduction and internal fixation,13 patients with hemiarthroplasty,and 5 patients with reverse total shoulder arthroplasty.Female patients accounted for 71%(34/48)of all patients,with an average age of 75 years.Overall functional outcome was satisfied.Active flexion,abduction range of motion,on average,reached 115°,96°.The average scores of Neer,OSS,CS,UCLA and DASH were 74,23,60,28 and 27 points,respectively.Between the three surgical methods,reverse total shoulder arthroplasty had the best functional outcome.The abduction range of motion was significantly(P=0.018)higher than the other two surgical methods with best functional scores,but the external rotation was worse.It also had the highest cost,longest length of stay,longest operation time and most intraoperative bleeding.44%(7/13)of patients in hemiarthroplasty group had a special type of fracture,including glenohumeral joint dislocation,humeral head splitting or impression.This was significantly higher than the 3%(1/30)of open reduction and internal fixation group,but similar functional outcomes were achieved.Neer classification had no significant influence on the choice of surgical method(P=0.092).However,there was a significant strong correlation(P=0.002,|Phi|=0.510)between the existence of special types and the selection of shoulder arthroplasty.The radiographic findings in complications of patients with open reduction and internal fixation and hemiarthroplasty that may have a great influence on the function were similar(41%,9/22;44%,4/9).Poor tuberosity healing significantly affected functional outcome.However,only 2 patients in the open reduction and internal fixation group had humeral head avascular necrosis,requiring revision surgery.In reverse total shoulder arthroplasty group,only 1 patient had scapular notching.Of all the patients,1 had deep infection,2 had pneumonia,and 1 died during follow-up.No intraoperative fracture,intraoperative nerve injury,periprosthetic fracture,prosthesis loosening,dislocation of glenohumeral joint was occurred.CONCLUSIONS: Shoulder arthroplasty could reduce the revision rate and achieve a better functional outcome in the elderly with complex proximal humeral fractures,especially in patients combined with glenohumeral joint dislocation,humeral head splitting or impression.If combined with comminuted tuberosities or insufficient rotator cuff at the same time,primary reverse total shoulder arthroplasty could achieve stable and better functional outcome,but its absolute contraindication should be noted.The improvement of preoperative examination,rational selection of surgical methods,proficiency in surgical operation,learning of new techniques,introduction of new materials and postoperative rehabilitation guidance will improve postoperative outcomes.