Background 

Multiple surgical treatments exist for proximal humerus fractures (PHFs), but current practice patterns and short-term complication profiles remain poorly understood. This is in part due to changes in treatment paradigms over the past decade. A more thorough understanding of the evolution in management over this time as well as an appreciation of the preoperative factors associated with both the chosen surgical modality and short-term complications will help inform future surgical considerations.

Questions/purposes 

In this study, we sought to: (1) characterize trends in the surgical management of PHFs over time, including usage rates of various surgical modalities and changes in complication rates; (2) identify preoperative variables associated with the selection of surgical modality; and (3) assess the independent covariates of acute 30-day complications, including demographic variables, injury characteristics, and treatment type.

Methods 

The National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology and ICD-9 and ICD-10 codes to identify individuals with PHF undergoing open reduction and internal fixation (ORIF), hemiarthroplasty (HA), or reverse total shoulder arthroplasty (RTSA) from 2007 to 2018. The NSQIP database was utilized because of its collection of detailed preoperative demographic information and large repository of clinically derived data, which is felt to be more accurate than claims or administrative data. In total, 5889 patients with PHFs met the inclusion criteria. Patients 17 years or older were included. Patients with isolated greater tuberosity, humeral shaft, and distal humerus fractures; nonunions; malunions; and those undergoing revision procedures were excluded. A Cochran-Armitage test was used to evaluate surgical trends over time. Multivariable logistic regression models were created to identify covariates associated with surgical modality and complications. Although complications were either classified as major or minor, specific complications were also individually analyzed to avoid potentially misleading conclusions associated with pooling.

Results 

The proportion of patients with PHFs undergoing RTSA (4% in 2007 and 34% in 2018; p < 0.001) and ORIF (46% in 2007 and 57% in 2018; p < 0.001) increased over time, and the proportion of those undergoing HA (50% in 2007 and 9% in 2018; p < 0.001) decreased. Across each surgical modality, minor complication rates decreased over time (RTSA: 10% in 2018; p < 0.001; ORIF: 5% in 2018; p = 0.01; and HA: 6% in 2018; p = 0.01). After controlling for confounding variables like diabetes, chronic obstructive pulmonary disease, congestive heart failure, dialysis, and preoperative blood transfusion, the following factors were independently associated with an increased odds of a patient undergoing RTSA rather than HA: older age, higher BMI, independent functional status, and smoking. The following factors were independently associated with a decreased odds of a patient undergoing ORIF rather than RTSA and HA: older age, higher BMI, higher American Society of Anesthesiologists (ASA) classification, smoking, steroid/immunosuppressant use, as well as three- and four-part fractures. After controlling for age, ASA classification, functional status, and preoperative blood transfusion, we also found that in the latter part of the study period, arthroplasty (RTSA and HA) was no longer independently associated with 30-day major or minor complications compared with ORIF.

Conclusion 

The increasing utilization of RTSA and decreasing short-term complication rates for fixation and arthroplasty alike represent a substantial change compared even with recent historic norms in the management of proximal humerus fractures. Quantifying demographics, injury characteristics, and comorbidities associated with both the choice of surgical modality and complications serves as the groundwork for decision support tools, which can inform patients and surgeons of the probability of a particular surgical modality being chosen and the risk of complications, based on national benchmarks. Future studies should investigate longer term complication rates, as many differences between the approaches being compared might occur beyond the perioperative period and our study had no means to address questions about complications beyond that period, but obviously those must be considered when choosing a treatment for patients with these injuries. Future work might also investigate the mechanisms behind the decreasing rates of short-term complications.

Level of Evidence 

Level III, therapeutic study.

中文翻译：

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肱骨近端骨折手术短期并发症有所减少：国家手术质量改进计划数据库分析

背景 

肱骨近端骨折（PHF）有多种手术治疗方法，但目前的治疗模式和短期并发症情况仍知之甚少。这部分是由于过去十年治疗范式的变化。更全面地了解这段时间管理的演变以及对与所选手术方式和短期并发症相关的术前因素的了解将有助于为未来的手术考虑提供信息。

问题/目的 

在本研究中，我们试图：（1）描述 PHF 手术治疗随时间变化的趋势，包括各种手术方式的使用率和并发症发生率的变化；(2) 确定与手术方式选择相关的术前变量；(3) 评估急性 30 天并发症的独立协变量，包括人口统计学变量、损伤特征和治疗类型。

方法 

使用现行程序术语和 ICD-9 和 ICD-10 代码查询国家外科质量改进计划 (NSQIP) 数据库，以识别接受切开复位内固定 (ORIF)、半关节置换术 (HA) 或反向全肩关节置换术的 PHF 患者(RTSA)，从 2007 年到 2018 年。使用 NSQIP 数据库是因为它收集了详细的术前人口统计信息和大量临床衍生数据，人们认为这些数据比索赔或管理数据更准确。总共有 5889 名 PHF 患者符合纳入标准。17 岁或以上的患者也被纳入其中。孤立性大结节、肱骨干、肱骨远端骨折患者；不工会；畸形愈合；那些正在进行修订程序的人被排除在外。使用 Cochran-Armitage 检验来评估随时间推移的手术趋势。创建多变量逻辑回归模型来识别与手术方式和并发症相关的协变量。尽管并发症分为严重或轻微，但也对具体并发症进行了单独分析，以避免与合并相关的潜在误导性结论。

结果 

接受 RTSA（2007 年为 4%，2018 年为 34%；p < 0.001）和 ORIF（2007 年为 46%，2018 年为 57%；p < 0.001）的 PHF 患者比例随着时间的推移而增加，并且接受 RTSA 的患者比例不断增加HA（2007 年为 50%，2018 年为 9%；p < 0.001）下降。在每种手术方式中，轻微并发症发生率随着时间的推移而下降（RTSA：2018 年为 10%；p < 0.001；ORIF：2018 年为 5%；p = 0.01；HA：2018 年为 6%；p = 0.01）。在控制了糖尿病、慢性阻塞性肺病、充血性心力衰竭、透析和术前输血等混杂变量后，以下因素与患者接受 RTSA 而不是 HA 的几率增加独立相关：年龄较大、BMI 较高、独立功能状态和吸烟。以下因素与患者接受 ORIF 而不是 RTSA 和 HA 的几率降低独立相关：年龄较大、BMI 较高、美国麻醉医师协会 (ASA) 分级较高、吸烟、类固醇/免疫抑制剂的使用以及三、四类药物的使用四部分骨折。在控制年龄、ASA分级、功能状态和术前输血后，我们还发现，在研究后期，与相比，关节置换术（RTSA和HA）不再与30天主要或次要并发症独立相关。或者如果。

结论 

即使与最近肱骨近端骨折治疗的历史标准相比，RTSA 的使用不断增加，固定和关节成形术的短期并发症发生率降低，也代表着巨大的变化。量化人口统计学、损伤特征以及与手术方式和并发症的选择相关的合并症是决策支持工具的基础，它可以告知患者和外科医生选择特定手术方式的可能性以及并发症的风险。在国家基准上。未来的研究应该调查长期并发症发生率，因为所比较的方法之间的许多差异可能会在围手术期之后发生，而我们的研究无法解决该时期之后的并发症问题，但显然在为患者选择治疗方法时必须考虑这些问题带着这些伤害。未来的工作还可能调查短期并发症发生率降低背后的机制。

证据水平 

III级，治疗研究。