Outcomes of plate osteosynthesis for displaced 3-part and 4-part proximal humerus fractures with deltopectoral vs. deltoid split approach

Open reduction and internal fixation versus minimally invasive plate osteosynthesis of unstable proximal humerus fractures treated with locking plate and intramedullary allograft: A retrospective study

Background

This retrospective clinical study aims to compare the functional and radiological outcomes after open reduction and internal fixation versus minimally invasive plate osteosynthesis of unstable proximal humerus fractures treated with both locking plate and intramedullary graft.

Methods

Forty-seven patients with proximal humerus fractures were treated with either open reduction and internal fixation (25 cases) or minimally invasive plate osteosynthesis (22 cases) and evaluated retrospectively with a minimum follow-up of 12 months. Thirty-one fresh-frozen fibulae and 16 lyophilized tibia allografts were used for augmentation. Change of both neck-shaft angle and humeral head height were evaluated radiologically. Functional outcomes were assessed using Disabilities of the Arm, Shoulder and Hand Score (DASH), Absolute Constant-Murley Score (CSabs), Relative Constant-Murley Score (CSrel), and Individual Relative Constant-Murley Score (CSindiv).

Results

Follow-up period and age for open reduction and internal fixation/minimally invasive plate osteosynthesis were 27.4 ± 16.2/29.6 ± 17.6 months and 60.5 ± 13.7/66.3 ± 11.7 years. CSabs, CSrel, and CSindiv were 57.3 ± 21.2/52.4 ± 18.9, 73 ± 24.1/73.9 ± 23.4, and 69.6 ± 24.8/64 ± 25.5 for open reduction and internal fixation/minimally invasive plate osteosynthesis, p ≥ 0.409. DASH was 14.8 ± 12.5/18.7 ± 14.5 for open reduction and internal fixation/minimally invasive plate osteosynthesis, p = 0.324. Decrease of neck-shaft angle and humeral head height was 7.8 ± 9.4/8.2 ± 15.6° and 0.6 ± 5.5/1.4 ± 2.6 mm for open reduction and internal fixation/minimally invasive plate osteosynthesis, p ≥ 0.380. Surgical time was 165.8 ± 77.6/84.7 ± 38.1 min for open reduction and internal fixation/minimally invasive plate osteosynthesis, p < 0.001.

Conclusions

Locked plating with intramedullary graft augmentation of unstable proximal humerus fractures demonstrates similar functional and radiological outcomes when comparing open reduction and internal fixation with minimally invasive plate osteosynthesis. However, minimally invasive plate osteosynthesis is related to significantly shorter surgical time versus open reduction and internal fixation.

Patient satisfaction after removal of locking plates in proximal humeral fractures - worth the surgery under functional and cosmetic aspects?

Background

Locking plates are one of the most frequently used implants in surgical treatment of displaced proximal humeral fractures. In spite of this established implant and a standardized approach, reduced shoulder function might remain a mid-to long-term issue, furthermore scars may influence patient satisfaction as a cosmetic issue. Indications for a second surgery to remove implant and/or scar revision are common questions in this context.The aim of the present study was to assess the benefit of a second surgery, including implant removal and scar revision surgery, on patients' satisfaction under functional and cosmetic aspects.

Methods

Patients following displaced proximal humeral fractures treated by open reduction and internal fixation with a locking plate osteosynthesis via a delto-pectoral approach following implant removal were included retrospectively. A follow-up took place anamnestically before the incident or the primary surgery [A], before second surgery [B], and after second surgery (scar revision/implant removal) [C]. Functional outcome (Constant Score (CS)) of both shoulders was obtained using a patient-reported outcome measure to evaluate the contralateral side as well as percentage CS (%CS). Furthermore, the cosmetic outcome was evaluated for color, contour, and size.

Results

The clinical data of n = 81 patients with displaced proximal humeral fractures and the consecutive open reduction and internal fixation with a locking plate (51 women = 63.0% and 30 men = 37.0%; mean age: 53.7 ± 16.6 years) via a standardized deltopectoral approach could be included. The mean CS) before sustaining the humeral fracture or primary surgery [A] was anamnestically 85.8 ± 8.5 points and %CS 99.4 ± 8.4%. After open reduction and internal with a locking plate osteosynthesis [B], the mean CS was 72.2 ± 9.1 points and %CS 84.5 ± 8.7%. Following the scheduled implant removal and scar revision [C], the CS was 80 ± 13.1 points and %CS 92.3 ± 14.1%. After primary surgery, 26 patients (32.1%) complained about the scar because of color, contour, or size before the second surgery, and 23 patients (28.4%) afterwards.

Conclusion

Implant removal after locking plate osteosynthesis in proximal humeral fractures via a delto-pectoral approach leads to an improved outcome both functionally and cosmetically. CS as well as scar situation and patients' overall satisfaction could be improved with a second surgery. Nevertheless, the need for a second surgery depends on the patients' functional and cosmetic demands.

An updated systematic review and meta‑analysis comparing deltoid‑split approach with deltopectoral approach for proximal humerus fractures

The present review and meta-analysis aimed to summarize the currently available data and to compare the important clinical and functional outcomes in patients with proximal humerus fractures who were treated using deltoid split (DS) or deltopectoral (DP) surgical approaches. The PubMed, EMBASE, Scopus and Cochrane Central Register of Controlled Trials databases were systematically searched for randomized controlled trials or observational studies that reported functional outcome data of patients with fracture of proximal humerus who were surgically treated using DS and DP approaches. A total of 14 studies were included in the present meta-analysis. The duration of surgery [min; weighted mean difference (WMD), -16.44; 95% CI, -(25.25-7.63)], amount of blood loss [ml; WMD, -57.99; 95% CI, -(102.74-13.23)] and time to bone union [weeks WMD, -1.66; 95% CI, -(2.30-1.02)] was comparatively lower in patients that underwent DS. There were no statistically significant differences in the pain and quality of life scores, range of movement and risk of complications between the DS and the DP groups. Patients in the DS group had improved shoulder function and constant shoulder score (CSS) at 3 months post-surgery (WMD, 6.36; 95% CI, 1.06-11.65). No differences were observed between the two groups in terms of CSS and disabilities of the arm, shoulder and hand scores at 12 and 24 months post-operatively. The activity of daily living (ADL) score was significantly improved in the DS group at 3 (WMD, 1.23; 95% CI, 0.40-2.06), 6 (WMD, 0.99; 95% CI, 0.72-1.25) and 12 months (WMD, 0.83; 95% CI, 0.18-1.47) after the surgery. The present results suggested that DS and DP surgical approaches were associated with similar clinical outcomes. The DS approach was associated with certain perioperative benefits, as well as reduced time to bone union, improved shoulder function in the early postoperative period and improved ADL scores. These benefits may be considered while choosing between these two surgical approaches.

A Standardized Operative Protocol for Fixation of Proximal Humeral Fractures Using a Locking Plate to Minimize Surgery-Related Complications

The current literature suggests that up to 55% of complications after plate osteosynthesis treatment for patients with proximal humerus fractures are attributed to the surgical procedure. The hypothesis of this study was that a standardized surgical protocol would minimize surgery-related adverse events. This prospective cohort study included 50 patients with a mean age of 63.2 (range 28-92) years treated by one single surgeon using a previously published standardized surgical protocol. Clinical and radiological follow-up examinations were conducted for up to 24 months using Constant-Murley Score (CS), Subjective Shoulder Value (SSV) and radiographs in true anteroposterior, axial and y-view. Finally, CS was 73.9 (standard deviation [SD]: 14.0) points (89% compared to the uninjured shoulder), and SSV was 83.3% (SD: 16.7) at two years of follow-up. Postoperative radiologic evaluation revealed no primary surgical-related or soft-tissue-related complications (0%). The main complications were secondary, biological complications (20%), largely represented by avascular necrosis (8%). Eight patients underwent revision surgery, mainly for implant removal. In addition, a total of four patients were revised using a hemiarthroplasty (n = 2), reverse shoulder arthroplasty (n = 1) or re-osteosynthesis. The use of our standardized surgical technique on proximal humerus fractures improves fixation with regard to primary stability and prevents primary, surgical-technique-related complications. The subjective grading of a high level of difficulty surgery was associated with more complications.

Reverse shoulder arthroplasty for proximal humerus fractures: a comparison of the deltoid split and deltopectoral approaches

INTRODUCTION

Reverse shoulder arthroplasty (RSA) is a common treatment for three- and four-part proximal humerus fractures. RSA is commonly performed through a deltopectoral (DP) surgical approach; however, a deltoid split (DS) approach has been described. The purpose of this study was to compare the intraoperative and postoperative outcomes of patients undergoing RSA for proximal humerus fractures through a DP and DS approach.

MATERIALS AND METHODS

A retrospective study of patients who underwent RSA for proximal humerus fractures at our level 1 trauma center was performed. Patients were evaluated at a minimum 1-year follow-up. Intraoperative outcomes as well as patient-reported outcome measures (PROMs) were analyzed. Postoperative complications, reoperation rates, and radiographic outcomes were evaluated.

RESULTS

Sixteen patients were included in the DP group and 13 patients in the DS group. The average follow-up was 28.6 months in the DP group and 21.1 months in the DS group. There were no significant differences in patient demographics or injury characteristics. Operative time was significantly shorter in the DS group (103 min) compared to the DP group (123 min). Tuberosity repair was performed in 81.3% of patients in the DP group and 92.3% of patients in the DS group. No significant differences were found in PROMs at final follow-up. There were no significant differences in postoperative complications. Three patients in the DP group and one patient in the DS group required reoperation. Lastly, 81.8% of patients achieved tuberosity union in the DS group and 66.7% in the DP group; however, this did not reach statistical significance.

CONCLUSION

This study demonstrates that RSA for proximal humerus fractures performed through a DS or DP approach may result in similar intraoperative and postoperative outcomes, with no difference in reoperation or complication rates.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely, including in the use of surgery. This is an update of a Cochrane Review first published in 2001 and last updated in 2015.

OBJECTIVES

To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registries, and bibliographies of trial reports and systematic reviews to September 2020. We updated this search in November 2021, but have not yet incorporated these results.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults.  DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. We prepared a brief economic commentary for one comparison.

MAIN RESULTS

We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. Six comparisons were tested by 2 to 10 trials, the others by small single-centre trials only. Twelve studies evaluated non-surgical treatments, 10 compared surgical with non-surgical treatments, 23 compared two methods of surgery, and two tested timing of mobilisation after surgery. Most trials were at high risk of bias, due mainly to lack of blinding. We summarise the findings for four key comparisons below. Early (usually one week post injury) versus delayed (after three or more weeks) mobilisation for non-surgically-treated fractures Five trials (350 participants) made this comparison; however, the available data are very limited. Due to very low-certainty evidence from single trials, we are uncertain of the findings of better shoulder function at one year in the early mobilisation group, or the findings of little or no between-group difference in function at 3 or 24 months. Likewise, there is very low-certainty evidence of no important between-group difference in quality of life at one year. There was one reported death and five serious shoulder complications (1.9% of 259 participants), spread between the two groups, that would have required substantive treatment. Surgical versus non-surgical treatment Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures). There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants). There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year (EQ-5D (0: dead to 1: best quality): mean difference (MD) 0.01, 95% CI -0.02 to 0.04; 6 studies, 502 participants). There is low-certainty evidence of little between-group difference in mortality: one of the 31 deaths was explicitly linked with surgery (risk ratio (RR) 1.35, 95% CI 0.70 to 2.62; 8 studies, 646 participants). There is low-certainty evidence of a higher risk of additional surgery in the surgery group (RR 2.06, 95% CI 1.21 to 3.51; 9 studies, 667 participants). Based on an illustrative risk of 35 subsequent operations per 1000 non-surgically-treated patients, this indicates an extra 38 subsequent operations per 1000 surgically-treated patients (95% CI 8 to 94 more). Although there was low-certainty evidence of a higher overall risk of adverse events after surgery, the 95% CI also includes a slightly increased risk of adverse events after non-surgical treatment (RR 1.46, 95% CI 0.92 to 2.31; 3 studies, 391 participants). Open reduction and internal fixation with a locking plate versus a locking intramedullary nail Four trials (270 participants) evaluated surgical intervention for displaced fractures (63% were two-part fractures). There is low-certainty evidence of no clinically important between-group difference in shoulder function at one year (SMD 0.15, 95% CI -0.12 to 0.41; 4 studies, 227 participants), six months (Disability of the Arm, Shoulder, and Hand questionnaire (0 to 100: worst disability): MD -0.39, 95% CI -4.14 to 3.36; 3 studies, 174 participants), or two years (American Shoulder and Elbow Surgeons score (ASES) (0 to 100: best outcome): MD 3.06, 95% CI -0.05 to 6.17; 2 studies, 101 participants). There is very low-certainty evidence of no between-group difference in quality of life (1 study), and of little difference in adverse events (4 studies, 250 participants) and additional surgery (3 studies, 193 participants). Reverse total shoulder arthroplasty (RTSA) versus hemiarthroplasty There is very low-certainty evidence from two trials (161 participants with either three- or four-part fractures) of no or minimal between-group differences in self-reported shoulder function at one year (1 study) or at two to three years' follow-up (2 studies); or in quality of life at one year or at two or more years' follow-up (1 study). Function at six months was not reported. Of 10 deaths reported by one trial (99 participants), one appeared to be surgery-related. There is very low-certainty evidence of a lower risk of complications after RTSA (2 studies). Ten people (6.2% of 161 participants) had a reoperation; all eight cases in the hemiarthroplasty group received a RTSA (very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery. The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures. There is insufficient evidence from randomised trials to inform the choices between different non-surgical, surgical or rehabilitation interventions for these fractures.