Trends in surgical management of proximal humeral fractures in adults: a nationwide study of records in Germany from 2007 to 2016.
INTRODUCTION
Proximal humeral fractures (PHF) are among the most common adult fractures. However, valid epidemiologic population-based data, including differentiation of treatment modalities, are lacking.


MATERIALS AND METHODS
Using the ICD codes and associated OPS codes for PHF, a retrospective analysis of 2007-2016 Federal Statistical Office of Germany data was performed. Data were evaluated for total incidence of PHF as well as total use, annual utilization rates, age, and sex distributions of all associated surgical procedures. Simple linear regressions were performed to evaluate trends in treatment modalities.


RESULTS
There were 642,556 cases of PHF. During the study period, incidence changed substantially from 65.2 to 74.2 per 100,000 inhabitants with a significant rise in elderly (> 70 years) patients (P < 0.001). The number of surgical procedures increased by 39%, with locking plate fixation being the most common procedure (48.3%), followed by intramedullary nailing (IMN) (20.0%), hemiarthroplasty (HA) (7.5%), K-wire fixation (6.4%), and reverse shoulder arthroplasty (RSA) (5.6%). The utilization rate increased for locking plates, K-wires, and RSA and decreased for HA and IMN. Particularly, the utilization of RSA exhibited a  > eightfold increase. Significant linear correlation of procedure and time were found for all surgical treatments.


CONCLUSIONS
During this period, the number of inpatient PHFs, especially in the elderly, increased. Although locking plate fixation remained the most common treatment method, RSA had the greatest proportional increase over time, supporting its growing popularity in the light of the current scientific evidence. This incline was offset by a corresponding decrease in HA and IMN, which may be related to a growing knowledge of their application limitations.


LEVEL OF EVIDENCE
Descriptive epidemiology study, large database analysis.
['Klug|Alexander|A|http://orcid.org/0000-0002-2085-1545', 'Gramlich|Yves|Y|', 'Wincheringer|Dennis|D|', 'Schmidt-Horlohé|Kay|K|', 'Hoffmann|Reinhard|R|']
D000328:Adult D000368:Aged D019643:Arthroplasty, Replacement D001860:Bone Plates D001864:Bone Wires D005260:Female D005593:Fracture Fixation, Internal D005594:Fracture Fixation, Intramedullary D005858:Germany D062785:Hemiarthroplasty D006801:Humans D015994:Incidence D008297:Male D008875:Middle Aged D012044:Regression Analysis D012189:Retrospective Studies D017678:Sex Distribution D012784:Shoulder Fractures
Proximal humeral fractures Epidemiology Locking plate Hemiarthroplasty Reverse shoulder arthroplasty Treatment patterns