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Prevalence of Rotator Cuff Tears in Operative Proximal Humerus Fractures Andrew Choo, MD; Garret Sobol, BA; Mitchell Maltenfort, PhD; Charles Getz, MD; Joseph Abboud, MD

abstract Proximal humerus fractures and rotator cuff tears have been shown to have increasing rates with advancing age, theoretically leading to significant overlap in the 2 pathologies. The goal of this study was to examine the prevalence, associated factors, and effect on treatment of rotator cuff tears in surgically treated proximal humerus fractures. A retrospective review was performed of all patients who had surgery for a proximal humerus fracture from January 2007 to June 2012 in the shoulder department of a large academic institution. Patient demographics, the presence and management of rotator cuff tears, and surgical factors were recorded. Regression analysis was performed to determine which factors were associated with rotator cuff tears. This study reviewed 349 fractures in 345 patients. Of these, 30 (8.6%) had concomitant rotator cuff tears. Those with a rotator cuff tear were older (average age, 68.7 vs 63.1 years), were more likely to have had a dislocation (40% vs 12.5%), and were more likely to have undergone subsequent arthroscopic repair or reverse total shoulder arthroplasty than those without a rotator cuff tear. Most (22 of 30) were treated with suture repair at the time of surgery, but 5 patients underwent reverse total shoulder arthroplasty based primarily on the intraoperative finding of a significant rotator cuff tear. A concomitant rotator cuff tear in association with a proximal humerus fracture is relatively common. Rotator cuff tears are associated with older patients and those with a fracture-dislocation. In rare cases, these cases may require the availability of a reverse shoulder prosthesis.

Figure: Preoperative anteroposterior radiograph of an 83-year-old woman with a 4-part right proximal humerus fracture.

The authors are from the Department of Orthopaedic Surgery (AC), University of Texas Health Science Center at Houston, Houston, Texas; and the Rothman Institute (MM) and the Department of Orthopaedics, Thomas Jefferson University (GS, CG, JA), Philadelphia, Pennsylvania. Dr Choo, Mr Sobol, and Dr Maltenfort have no relevant financial relationships to disclose. Dr Getz is a paid consultant for Zimmer and receives institutional support from Zimmer and Integra LifeSciences. Dr Abboud is a paid consultant for Arthrex; receives institutional support from OREF, Zimmer, DePuy, and Integra LifeSciences; is a paid speaker for and receives royalties from Integra LifeSciences; and owns stock or stock options in Mininvasive. Correspondence should be addressed to: Andrew Choo, MD, Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, 6400 Fannin St, Ste 1700, Houston, TX 77030 ([email protected]). Received: November 2, 2013; Accepted: March 4, 2014; Posted: November 6, 2014. doi: 10.3928/01477447-20141023-52

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P

roximal humerus fractures show a distinct age-related prevalence, with a sharp increase in numbers starting in the sixth and seventh decades of life because of the development of osteopenia and osteoporosis.1-3 With the relatively recent advent of locking plate technology and advances in surgical technique, a greater proportion of proximal humerus fractures are being treated operatively than in the past.4 In addition, multiple studies have shown an age-related increase in the prevalence of asymptomatic rotator cuff tears, with estimates of a full-thickness tear ranging from 6% to more than 50% in those in the seventh decade of life and older.5-10 Therefore, substantial overlap between the 2 patient populations would be expected. However, despite the amount of literature on the evaluation, management, and outcomes of proximal humerus fractures, surprisingly little has been written on the prevalence of rotator cuff tears in patients with proximal humerus fractures and how they might affect management. This is especially relevant in light of the recent introduction of the reverse shoulder prosthesis as a viable option in acute proximal humerus fractures for patients who are or are likely to be cuff-deficient.11-15 The goal of this study was to determine the prevalence and possible predisposing factors for full-thickness rotator cuff tears encountered during surgery for proximal humerus fractures. In addition, for patients with rotator cuff tears, the authors hoped to describe how this concomitant pathology affected treatment.

Materials and Methods A retrospective chart review was performed on all patients older than 18 years who underwent surgery with a diagnosis of proximal humerus fracture from January 2007 to June 2012 by a member of the shoulder and elbow service at the authors’ institution. The starting date was chosen to approximately correspond with the increased use of reverse shoulder arthroplasty for fracture. Eight shoulder surgeons oper-

NOVEMBER 2014 | Volume 37 • Number 11

Table 1

Data for Patients With and Without Rotator Cuff Tears Characteristic

Total

Rotator Cuff Tear

No Rotator Cuff Tear

P

Patients, No.

345

30

315

N/A

Fractures, No.

349

30 (8.6%)

319 (91.4%)

N/A

Mean age, y

63.6

68.7

63.1

.0337

112:233

7:23

105:210

.3116

Low energy

270 (77.4%)

25 (83.3%)

245 (76.8%)

High energy

59 (16.9%)

4 (13.3%)

55 (17.2%)

Unknown

20 (5.7%)

1 (3.3%)

19 (6.0%)

162/349 (46.4%)

15/30 (50.0%)

147/319 (46.1%)

Surgical neck

112

8

104

Greater tuberosity

42

7

35

Sex, M:F Mechanism

.7995

Classification 2-part

Other

8

0

8

98/349 (28.1%)

9/30 (30.0%)

89/319 (27.9%)

Surgical neck and greater tuberosity

85

8

77

Other

13

1

12

89/349 (25.5%)

6/30 (20.0%)

83/319 (26.0%)

52/349 (14.9%)

12/30 (40%)

40/319 (12.5%)

Open reduction and internal fixation

250/349 (71.6%)

18/30 (60.0%)

232/319 (72.7%)

N/Aa

Arthroscopic fixation

7/349 (2.0%)

3/30 (10.0%)

4/319 (1.3%)

.0047

Hemiarthroplasty

66/349 (18.9%)

2/30 (6.7%)

64/319 (20.1%)

.2306

Reverse total shoulder arthroplasty

26/349 (7.4%)

7/30 (23.3%)

19/319 (6.0%)

.002

Complications

58/349 (16.6%)

5/30 (16.7%)

53/319 (16.6%)

1

Reoperations

25/349 (7.2%)

3/30 (10.0%)

22/319 (6.9%)

.4431

3-part

4-part Dislocation Procedure

.8048

.0004 .0002

Abbreviations: F, female; M, male; N/A, not applicable. a Open reduction and internal fixation was used as reference for the logistic regression model.

ated on 387 fractures in 383 patients during that period. The indications and the type of surgery were at the discretion of the treating surgeon. Only surgical procedures that allowed direct visualization of the rotator cuff were included in the study, eliminating 7 patients who underwent closed reduction and percutaneous pinning and 1 patient who underwent intramedullary nailing. This left

all patients who were treated with open reduction and internal fixation (ORIF), hemiarthroplasty, and reverse shoulder arthroplasty and included those whose fractures had been treated primarily arthroscopically. Thirty patients had incomplete records, leaving a total of 349 fractures in 345 patients for review. Follow-up averaged 7.6 months (range, 0-53 months).

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Figure 1: Percentage of rotator cuff tears vs age.

Table 2

Percentage of Rotator Cuff Tears vs Age Age, y

No Tear

Tear

Tear

SE

≤30

6

0

0.00%

0.00%

31-40

17

1

5.56%

5.40%

41-50

31

1

3.13%

3.08%

51-60

60

7

10.45%

3.74%

61-70

115

7

5.74%

2.11%

71-80

51

7

12.07%

4.28%

≥81

39

7

15.22%

5.30%

Abbreviation: SE, standard error. P=.0337.

Narrative operative reports were then reviewed and correlated with preoperative and postoperative notes. Information obtained for each patient included age at the time of surgery, sex, mechanism of injury, Neer classification, presence or absence of dislocation at the time of injury, procedure performed, complications, and reoperations. Mechanism of injury was divided into low-energy vs high-energy injuries. Low-energy injuries included simple falls from standing. High-energy injuries included falls from height, motor vehicle collisions, and seizures. For fractures with concomitant rotator cuff tears, the tear pattern, preoperative knowledge of rotator cuff status, management of the tear, and change in surgical plan were also documented.

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Logistic regression analysis was used to create a model of the probability of rotator cuff tear vs the patient, fracture, and operative factors noted earlier. The model was optimized according to Akaike’s information criterion. Statistical significance was set at P

Prevalence of rotator cuff tears in operative proximal humerus fractures.

Proximal humerus fractures and rotator cuff tears have been shown to have increasing rates with advancing age, theoretically leading to significant ov...
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