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Clinical outcomes of locking plate fixation for proximal humerus fractures in patients aged 60 and older: A retrospective cohort study in Vietnam
⁎Corresponding author: Anh Hoang Dang. danghoanganh.hvqy@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Proximal humerus fractures (PHF) are increasingly common among elderly patients and present significant treatment challenges, particularly in low-resource settings. While locking plate fixation is widely used and achieves reliable bone union, data on functional outcomes and real-world complications in Vietnamese populations remain limited. This study aims to evaluate the clinical outcomes of locking plate fixation in older patients and compare them to younger adults.
We conducted a retrospective cross-sectional study involving 42 patients with closed PHF treated with locking plate fixation at Military Hospital 175 from January 2022 to December 2023. Data were collected during the 6-month postoperative follow-up. Variables included Constant-Murley scores, radiographic union status, complications, and scar evaluation. Patients were categorized into two groups: those under 60 and those 60 or older.
All patients achieved radiographic union by 6 months. The ≥60 groups exhibited a lower Constant score (60.58 ± 6.86) compared to the <60 groups (68.93 ± 8.82), and this difference was statistically significant (p < 0.01). Shoulder stiffness and scar stretching were more frequent in the elderly. No implant failures, deep infections, or reoperations were observed. Barriers to structured rehabilitation and limited access to physiotherapy were common among older adults.
Locking plate fixation in elderly Vietnamese patients with PHF achieves high rates of bone union but only modest functional recovery. The limited improvement in shoulder function is likely related to age-associated factors and significant challenges in postoperative rehabilitation. These findings underscore the need for improved access to physiotherapy and comprehensive postoperative care in Vietnam. Larger, prospective studies using patient-reported outcome measures and longer follow-up are needed to guide future treatment strategies.
Keywords
Elderly
Shoulder function
Proximal humerus fracture
Locking plate fixation
1 Introduction
Proximal humerus fractures (PHF) are among the most common injuries in older adults, ranking third after hip and distal radius fractures, and accounting for approximately 5 % of all adult fractures worldwide1,2. The global incidence of PHF continues to rise in parallel with increasing life expectancy and a growing elderly population. In Vietnam, similar to many other developing countries, improved access to healthcare and an aging demographic have resulted in a greater clinical burden of these injuries.
Treatment of PHF in older adults is challenging due to poor bone quality, increased fracture comminution, higher risk of complications, and delayed functional recovery. While non-operative management is suitable for minimally displaced fractures, surgical intervention is often indicated in displaced or unstable patterns to restore anatomy and enable early mobilization. Locking plate fixation has emerged as the standard of care for displaced PHF, particularly in osteoporotic bone, due to its biomechanical stability and ability to maintain reduction.3 Some studies have reported satisfactory rates of bone union with locking plates; however, functional outcomes in the elderly remain highly variable, with many patients experiencing shoulder stiffness, reduced range of motion, or soft tissue complications4,5.
Despite the increasing adoption of locking plate fixation for PHF in Vietnam and other developing countries, there remains a significant lack of real-world clinical data specific to our local context. Most published studies originate from high-resource healthcare settings, where access to structured rehabilitation, physiotherapy, and long-term follow-up is routine. By contrast, in Vietnam, postoperative care is often limited by socioeconomic factors, patient education, and uneven availability of rehabilitation services. Moreover, the majority of elderly patients reside in rural or suburban areas, facing barriers in transport, continuity of care, and adherence to prescribed physiotherapy regimens. These local challenges can critically impact recovery and may lead to functional outcomes that differ from those reported in the international literature.
To address this gap, the present study aims to evaluate the clinical outcomes of locking plate fixation for proximal humerus fractures in Vietnamese patients aged 60 and older, as compared to a younger cohort, at a major trauma center. We focus not only on bone union but also on functional results and early complications, under real-world conditions with typical limitations of our healthcare environment. Our primary goal is not to claim novelty in surgical technique, but to provide practical, region-specific data that may guide local clinical practice and future health policy, as well as to highlight the challenges facing elderly patients in accessing optimal postoperative rehabilitation.
2 Methods
2.1 Study design and population
This was a retrospective cross-sectional study conducted at Military Hospital 175, Ho Chi Minh City, Vietnam. The study period was from January 2022 to December 2023.
2.2 Patient selection
We reviewed the medical records of all adult patients (≥18 years) diagnosed with closed proximal humerus fractures (PHF) who underwent open reduction and internal fixation (ORIF) using locking plate systems during the study period.
2.3 Inclusion criteria
Age 18 years or older.
Closed, non-pathological proximal humerus fracture.
Treated surgically with locking plate fixation at our center.
Available for at least 6 months of postoperative follow-up.
2.4 Exclusion criteria
Pathological fractures (e.g., metastatic, primary bone tumor)
Pre-existing brachial plexus injuries precluding reliable functional assessment.
Multiple trauma affecting the ipsilateral limb.
Severe cognitive impairment or medical contraindication to surgery.
Patients declining participation or lost to follow-up before 6 months.
Eligible patients were identified from the hospital database and contacted via telephone and mail. Those consenting to participate underwent clinical reassessment and radiographic evaluation at the 6-month follow-up visit. The response rate and number of patients lost to follow-up were recorded and reported in the Results.
2.5 Surgical technique
All procedures were performed using a standardized deltopectoral approach under general anesthesia by experienced trauma surgeons. Locking plate fixation was conducted following AO principles. Postoperative radiographs were obtained to verify fracture reduction and implant position.
2.6 Rehabilitation protocol
A structured postoperative rehabilitation program was prescribed for all patients, beginning with passive range-of-motion exercises from the first week, progressing to active-assisted and active movements as tolerated. Physiotherapy sessions were provided at our hospital during hospitalization, and patients were instructed to continue exercises at home after discharge. However, adherence to the recommended protocol and availability of supervised rehabilitation varied due to patient socioeconomic status, travel distance, and resource limitations. These challenges were documented during follow-up interviews and are discussed in the Limitations.
2.7 Data collection
Clinical and demographic data were extracted from medical records and operative notes, including age, sex, injury mechanism, fracture type (Neer classification), surgical details, and comorbidities. At the 6-month follow-up, patients were evaluated for:
Shoulder function: Using the Constant-Murley Score (CMS), assessed by two independent orthopedic surgeons. The CMS is a widely used tool for comprehensively assessing shoulder function, initially developed by Constant and Murley in the early 1980s and officially published in 1987.3 It has since become the gold standard for determining both healthy shoulders and those receiving treatment for trauma or degeneration conditions. The total score ranges from 0 to 100 points, with 35 points assigned to subjective parameters, specifically pain intensity and the ability to perform daily activities. The remaining 65 points are distributed among objective assessments, with 40 points allocated for active range of motion and 25 for isometric muscle strength (1 point per pound, equal to 0.45).3
Radiographic union: Evaluated on standard anteroposterior and lateral radiographs by two orthopedics doctors. Bone union was assessed both clinically and through radiographic evaluation during follow-up. The healing status was classified as a union, delayed union, or nonunion based on the following criteria:
Union: Clinical signs include the absence of fracture-related pain, a lack of tenderness at the fracture site, and a palpable callus mass. Radiographic signs indicate bridging callus formation across the fracture line, obliteration of the fracture gap, restoration of the intramedullary canal, and reconstitution of normal bone contour.
Delayed union: Clinical signs include persistent pain or tenderness at the fracture site during movement or palpation, and potential indicators of instability, such as screw loosening or implant-related issues, and motion. Radiographic signs include a poorly defined fracture line, absence of bridging callus, and a lack of progressive radiographic findings of healing.
Nonunion: Clinical signs include persistent or worsening pain at the fracture site during weight-bearing or palpation, absence of palpable callus, and limited mechanical stability (even when fixation is still present). Radiographic signs include a visible fracture line, sclerosis or atrophy at the fracture ends, and no signs of callus formation gap.
Complications: including implant failure, infection, nonunion, shoulder stiffness, and abnormal scarring (classified as pliable, hypertrophic, stretched, or inflamed).
Pliable scar: soft, flat, and asymptomatic.
Hypertrophic scar: thickened, raised scar within wound margins.
Scar stretching: widened but flat scar with normal pigmentation.
Inflamed or draining scar: signs of erythema, serous or purulent discharge, or chronic sinus formation.
Adherence to rehabilitation: based on patient self-report and available physiotherapy records.
Patient-reported outcome measures (PROMs), such as DASH or EQ-5D, were not systematically collected due to the retrospective design and incomplete data in routine practice. This limitation is acknowledged in the Discussion.
2.8 Statistical analysis
Statistical analysis was performed using Stata version 14.0. Continuous variables are presented as means and standard deviations, and categorical variables as frequencies and percentages. Comparisons between the ≥60 years and <60 years groups were made using Student's t-test for continuous variables and chi-square test for categorical variables. A p-value <0.05 was considered statistically significant. Given the small sample size, no multivariate analysis was performed. No pre-study sample size calculation was conducted, as this study represents a consecutive series of eligible patients over the defined period.
3 Results
Table 1 summarizes the demographic characteristics and injury patterns of the study population. The mean age of all patients was 51.38 ± 14.63 years, with the younger group (under 60 years) averaging 44.03 ± 10.7 and the older group (60 years and above) averaging 67.77 ± 6.51. Gender distribution was relatively balanced in both groups, with males comprising 47.62 % and females 52.38 % of the total sample. Road traffic accidents were the most common mechanism of injury overall (73.81 %), but low-energy falls accounted for a significantly higher proportion in the ≥60 years group (38.46 %) compared to the <60 years group (13.79 %). The majority of fractures in older adults were classified as 3-part fractures (69.23 %), while younger patients had a higher proportion of 2-part fractures.
| Variable | <60 years (n = 29) | ≥60 years (n = 13) | Total (n = 42) |
| Mean age (years) | 44.03 ± 10.7 | 67.77 ± 6.51 | 51.38 ± 14.63 |
| Gender | |||
| Male | 14 (48.28 %) | 6 (46.15 %) | 20 (47.62 %) |
| Female | 15 (51.72 %) | 7 (53.85 %) | 22 (52.38 %) |
| Mechanism of injury | |||
| Traffic accidents | 23 (79.31 %) | 8 (61.54 %) | 31 (73.81 %) |
| Low-energy fall | 4 (13.79 %) | 5 (38.46 %) | 9 (21.43 %) |
| Work-related injury | 2 (6.9 %) | 0 | 2 (4.76 %) |
| Sports accidents | 0 | 0 | 0 |
| Number of broken parts | |||
| 1 part | 0 | 0 | 0 |
| 2 parts | 12 (41.38 %) | 4 (30.77 %) | 16 (38.1 %) |
| 3 parts | 14 (48.28 %) | 9 (69.23 %) | 23 (54.76 %) |
| 4 parts | 3 (10.34) | 0 | 3 (7.14 %) |
Table 2 shows the radiographic bone union outcomes at 6 months after surgery. Radiographic bone union was achieved in all evaluated patients (100 %). There were no cases of nonunion or implant failure identified in either age group. Two orthopedic surgeons independently reviewed all radiographs to minimize assessment bias.
| Age Group | Number of Healed Cases | Number of Nonunion Cases | Bone Union Rate (%) |
| <60 years (n = 29) | 29 | 0 | 100 % |
| ≥60 years (n = 13) | 13 | 0 | 100 % |
Table 3 compares the functional outcomes between the two age groups using the CMS system. The mean score in the <60-year group was 68.93 ± 8.82, with a 95 % confidence interval (CI) ranging from 65.58 to 72.29. In contrast, the ≥60-year group had a lower mean score of 60.58 ± 6.86 (95 % CI: 56.43 to 64.72). The difference was statistically significant (p = 0.004). This finding suggests reduced postoperative functional recovery in older adults, despite similar rates of bone healing.
| Age Group | Mean Score | Standard Deviation | 95 % Confidence Interval | p-value |
| <60 years (n = 29) | 68.93 | 8.82 | 65.58–72.29 | p = 0.004 |
| ≥60 years (n = 13) | 60.58 | 6.86 | 56.43–64.72 |
Table 4 presents the distribution of postoperative complications by age group. The mean score for shoulder stiffness was slightly lower in the ≥60-year group (24.61 ± 2.75) compared to the <60-year group (27.17 ± 4.12), with a combined average of 26.38 ± 3.91 across the entire sample. Scar stretching occurred in 12 patients (28.57 %), with a significantly higher incidence in the elderly group (46.15 %) compared to the younger group (20.69 %). Notably, there were no reported implant failures or osteomyelitis cases in either age group. These findings indicate that while serious complications are uncommon, functional limitations and soft tissue sequelae, especially scar-related issues, are more common in older individual patients.
| Complication | <60 years (n = 29) | ≥60 years (n = 13) | Total (n = 42) |
| Shoulder stiffness | 27.17 ± 4.12 | 24.61 ± 2.75 | 26.38 ± 3.91 |
| Scar stretching | 6 (20.69 %) | 6 (46.15 %) | 12 (28.57 %) |
| Implant failure | 0 | 0 | 0 |
| Osteomyelitis | 0 | 0 | 0 |
4 Discussion
This study evaluated the clinical outcomes of locking plate fixation for proximal humerus fractures in Vietnamese patients aged 60 and older, compared to a younger cohort, in a real-world setting at a major trauma center. Our results demonstrated a 100 % radiographic bone union rate in both age groups, which is consistent with previous literature supporting the mechanical stability of locking plate fixation, even in osteoporotic bone6,7. However, functional recovery, as measured by the Constant-Murley Score, was significantly lower in elderly patients, despite similar rates of bone healing. These findings are in line with international studies reporting that advanced age is a major determinant of poorer functional outcomes after surgical fixation of proximal humerus fractures8,9.
Our study adds to the limited local data from Vietnam, where unique challenges such as resource constraints, limited access to physiotherapy, and socioeconomic barriers may further hinder recovery in older people. In our cohort, low-energy falls were a more common injury mechanism among older adults, and the majority of elderly patients had more complex, three-part fractures, both factors associated with worse prognoses.
Although our radiographic union rate was high, the modest functional improvement observed in elderly patients likely reflects the interplay of multiple local factors. In Vietnam, structured rehabilitation services are not universally available, especially for patients living in rural areas. Many elderly patients face financial and logistical obstacles that limit their participation in outpatient physiotherapy or supervised exercise programs. This lack of structured rehabilitation, compounded by lower baseline activity levels, probably contributes to the persistent deficits in shoulder function after surgery. We were unable to collect systematic data on adherence to rehabilitation, which remains a key limitation, but informal interviews and clinical experience support this interpretation.
Unlike some Western studies, our study did not include PROMs such as the DASH or EQ-5D scores. This limitation, due to the retrospective nature of our data and lack of routine collection in clinical practice, restricts our ability to fully assess the impact of surgery on quality of life and patient satisfaction. We acknowledge that future research in Vietnam should incorporate PROMs and longer follow-up to capture late complications (e.g., avascular necrosis, late stiffness) and to provide a more holistic evaluation of outcomes.
The role of alternative surgical options, such as reverse shoulder arthroplasty or nonoperative management, remains underexplored in Vietnam. While several recent international trials suggest that reverse shoulder arthroplasty may provide superior function in selected elderly patients, the high cost and technical demands currently limit its widespread adoption in developing countries, including ours. Comparative studies between locking plate fixation and these alternatives in our local context would be valuable and are warranted for future research.
This study has several limitations. First, the sample size was small, particularly in the elderly subgroup, and our findings should be interpreted as preliminary and hypothesis-generating. Second, the retrospective single-center design may introduce selection bias and limit generalizability. Third, we did not perform a priori sample size calculation, and no multivariate analysis was feasible due to the limited number of cases. Fourth, our follow-up period was only 6 months, which is insufficient to capture all relevant complications and long-term functional outcomes. Finally, as noted above, we were unable to systematically assess rehabilitation adherence and did not collect patient-reported outcome measures.
Despite these limitations, this study provides valuable real-world data on the outcomes of locking plate fixation in elderly Vietnamese patients, a population for which published evidence remains scarce. Our results highlight the importance of addressing barriers to postoperative rehabilitation and developing targeted strategies to optimize functional recovery in older people. We strongly recommend that future studies in Vietnam and similar settings be prospective in design, include larger, multi-center cohorts, incorporate PROMs, and directly compare different treatment modalities with a focus on access to and quality of rehabilitation services.
5 Conclusion
Locking plate fixation for proximal humerus fractures in Vietnamese patients aged 60 and older achieved high rates of bone union but only modest functional recovery. The limited improvement in shoulder function likely reflects both age-related factors and significant barriers to structured rehabilitation in our local context. Our findings highlight the need for comprehensive postoperative care and improved access to physiotherapy to optimize outcomes in older people. Further prospective, multi-center studies using patient-reported outcome measures are needed to guide treatment strategies for this population.
CRediT authorship contribution statement
Doanh Quoc Tran: Conceptualization, Investigation, Data curation, Methodology, Writing – original draft. Sang Anh Nguyen: Formal analysis, Validation, Visualization, Writing – review & editing. Anh Hoang Dang: Supervision, Project administration, Resources, Funding acquisition, Writing – review & editing.
Ethics
The study was authorized by the Scientific Council of Military Hospital 175 under Decision No. 5339/QD-BV, dated December 31, 2023.
Data statement
All data generated or analyzed during this study are included in the published article.
Patients consent
Patients and their families consent to participate in the study.
Funding
No external funding was received for this study.
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