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A Biomechanical Study of Tuberosity-Based Locked Plate Fixation Compared with Standard Proximal Humeral Locking Plate Fixation for 3-Part Proximal Humeral Fractures. J Orthop Trauma 2020; 34:e233-e238. [PMID: 31977668 DOI: 10.1097/bot.0000000000001744] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND One of the main shortcomings of current proximal humeral plate designs is their inability to reliably secure the greater tuberosity (GT) or lesser tuberosity, leading to fixation failure, nonunion, and rotator cuff dysfunction. Traditional proximal humeral locking plates (PHLPs) rely on isolated screw fixation or suture repair to maintain reduction of the greater and/or lesser tuberosities. This study evaluates a tuberosity-based plate (TBP) specifically designed to improve tuberosity fixation, which may decrease tuberosity displacement and related clinical sequelae. METHODS Five cadaveric specimens (10 shoulders) were randomized to receive either standard PHLP or TBP fixation. The specimens were skeletonized except for the rotator cuff insertion on the GT. A reproducible 3-part osteotomy was performed for each cadaver, creating head, shaft, and GT segments. Anatomic reduction and plate fixation were performed according to the surgical technique guide for each plate system, with an equal number of screws placed in each plate both proximally and distally. GT fixation was enhanced with standardized suture augmentation through the rotator cuff in every specimen in both groups. In each trial, fracture displacement, load to failure, number of cycles endured, and mechanism of failure were noted. RESULTS The mean load to tuberosity fixation failure for the PHLP and TBP groups was 220 and 502 N (P = 0.005), respectively. CONCLUSIONS The TBP had a significantly higher load to failure and significantly lower mean fracture displacement compared with the PHLP.
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Theopold J, Weihs K, Feja C, Marquaß B, Josten C, Hepp P. Detection of articular perforations of the proximal humerus fracture using a mobile 3D image intensifier - a cadaver study. BMC Med Imaging 2017; 17:47. [PMID: 28764643 PMCID: PMC5540431 DOI: 10.1186/s12880-017-0201-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 04/12/2017] [Indexed: 11/10/2022] Open
Abstract
Background The purpose of this study was to investigate the accuracy of perforation detection with multiplanar reconstructions using a mobile 3D image intensifier. Methods In 12 paired human humeri, K-wires perforating the subchondral bone and placed just below the cartilage level were directed toward five specific regions in the humeral head. Image acquisition was initiated by a fluoroscopy scan. Within a range of 90°, 45° external rotation (ER) and 45° internal rotation (IR). The number and percentage of detected perforating screws were grouped and analyzed. Furthermore, the fluoroscopic images were converted into multiplanar CT-like reconstructions. Each K-wire perforation was characterized as “detected” or “not detected”. Results In the series of fluoroscopy images in the standard neutral position at 30° internal rotation, and 30° external rotation, the perforations of all K-wires (n = 56) were detected. Twenty-nine (51.8%) of them were detected in one AP view, 22 (39.3%) in two AP views, and five (8.9%) in three AP views. All K-wire perforations (100%, n = 56) were detected in multiplanar reconstructions. Conclusion In order to reveal all of the intraoperative and postoperative screw perforations in a “five screw configuration”, conventional AP images should be established in both the neutral positions (0°), at 30° internal rotation and 30° external rotation. Alternatively, the intraoperative 3D scan with multiplanar reconstructions enables a 100% rate of detection of the screw perforations.
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Affiliation(s)
- Jan Theopold
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Kevin Weihs
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Christine Feja
- Institute of Anatomy, University of Leipzig, Liebigstrasse 13, 04103, Leipzig, Germany
| | - Bastian Marquaß
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Pierre Hepp
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
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Abstract
BACKGROUND The rising incidence of osteoporotic fractures requires novel treatment strategies. OBJECTIVE Implant augmentation with bone cement is considered to be a promising approach but the benefits and risks need to be carefully evaluated. METHODS Experimental investigation of the biomechanical potential and the associated risks with special reference to the osteoporotic proximal femur and proximal humerus. RESULTS Even small amounts of bone cement (3 ml) applied to the proximal femur in combination with intramedullary nailing led to more than a 50% increase in the number of test cycles before failure. The heat and pressure generated in the bone did not exceed critical thresholds. Short to midterm effects of subchondral cement placement on the adjacent cartilage can be excluded. The risk for cement leakage needs to be considered. CONCLUSION Implant augmentation offers high biomechanical potential to prevent mechanical complications after fracture fixation in osteoporotic bone. Early and confident mobilization of elderly patients therefore appears to be possible. With appropriate handling, associated risks seem controllable; however, implant augmentation cannot be applied as a routine concept for osteoporotic fracture management. The application requires careful evaluation on a case by case basis under comprehensive consideration of mechanical and biological factors.
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Affiliation(s)
- M Windolf
- AO Forschungsinstitut Davos, Clavadelerstrasse 8, 7270, Davos, Schweiz,
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Significant Differences Between Local Reporting and Central Assessment of Radiographic Complications in a Prospective, Multicenter Study About Locking Plate Fixation of Proximal Humerus Fractures. J Orthop Trauma 2016; 30:e336-e339. [PMID: 27327963 DOI: 10.1097/bot.0000000000000641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare reporting outcomes of radiographic complications conducted by an independent review board and the responsible on-site study personnel in a multicenter study about locking plate fixation of proximal humeral fractures. DESIGN Prospective, multicenter study; setting: 9 level I trauma centers. PATIENTS One hundred fifty patients (age 50-90) with a radiographically confirmed displaced proximal humeral fracture fixed with a locking plate were included in the study. INTERVENTION All radiographic data were reevaluated by an independent review board according to predefined criteria. MAIN OUTCOME MEASUREMENTS Differences in outcomes between the review board and the on-site assessment were analyzed with a paired t test. Interrater agreements between the central review board and on-site assessments were estimated by means of kappa statistics. RESULTS The review board revealed significantly more radiographic complications than the on-site assessment (P = 0.006), except for the complication "head necrosis." The interrater agreement was slight to moderate in all calculated categories. CONCLUSIONS Implementation of a complication review board using predefined criteria is recommended for clinical studies to prevent underreporting of radiographic complications by on-site assessment.
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Sprecher CM, Schmidutz F, Helfen T, Richards RG, Blauth M, Milz S. Histomorphometric Assessment of Cancellous and Cortical Bone Material Distribution in the Proximal Humerus of Normal and Osteoporotic Individuals: Significantly Reduced Bone Stock in the Metaphyseal and Subcapital Regions of Osteoporotic Individuals. Medicine (Baltimore) 2015; 94:e2043. [PMID: 26705200 PMCID: PMC4697966 DOI: 10.1097/md.0000000000002043] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Osteoporosis is a systemic disorder predominantly affecting postmenopausal women but also men at an advanced age. Both genders may suffer from low-energy fractures of, for example, the proximal humerus when reduction of the bone stock or/and quality has occurred.The aim of the current study was to compare the amount of bone in typical fracture zones of the proximal humerus in osteoporotic and non-osteoporotic individuals.The amount of bone in the proximal humerus was determined histomorphometrically in frontal plane sections. The donor bones were allocated to normal and osteoporotic groups using the T-score from distal radius DXA measurements of the same extremities. The T-score evaluation was done according to WHO criteria. Regional thickness of the subchondral plate and the metaphyseal cortical bone were measured using interactive image analysis.At all measured locations the amount of cancellous bone was significantly lower in individuals from the osteoporotic group compared to the non-osteoporotic one. The osteoporotic group showed more significant differences between regions of the same bone than the non-osteoporotic group. In both groups the subchondral cancellous bone and the subchondral plate were least affected by bone loss. In contrast, the medial metaphyseal region in the osteoporotic group exhibited higher bone loss in comparison to the lateral side.This observation may explain prevailing fracture patterns, which frequently involve compression fractures and certainly has an influence on the stability of implants placed in this medial region. It should be considered when planning the anchoring of osteosynthesis materials in osteoporotic patients with fractures of the proximal humerus.
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Affiliation(s)
- Christoph M Sprecher
- From the AO Research Institute Davos, Davos, Switzerland (CMS, FS, TH, RGR, SM); Department of Anatomy (CMS, SM); Department of Orthopaedic Surgery, University of Munich (LMU) (FS); Department of General-, Trauma-, Hand and Plastic Surgery, University of Munich (LMU), Munich, Germany (TH); and Department of Trauma Surgery, Medical University of Innsbruck, Innsbruck, Austria (MB)
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The Deltoid Lift: A Cadaveric Analysis and the Literature Review of a Novel Surgical Approach to the Proximal Humerus. Tech Hand Up Extrem Surg 2015. [PMID: 26197155 DOI: 10.1097/bth.0000000000000091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Obtaining adequate exposure of the proximal humerus for anatomic reduction of complex intra-articular fractures or in the surgical treatment of tumor may be difficult. Here we describe a novel approach to the proximal humerus: the deltoid lift, and perform a cadaveric analysis objectively quantifying the exposure. The deltoid lift offers significantly greater exposure to the proximal humerus as compared with the deltopectoral approach.
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Bockmann B, Buecking B, Franz D, Zettl R, Ruchholtz S, Mohr J. Mid-term results of a less-invasive locking plate fixation method for proximal humeral fractures: a prospective observational study. BMC Musculoskelet Disord 2015; 16:160. [PMID: 26141352 PMCID: PMC4491200 DOI: 10.1186/s12891-015-0618-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 06/24/2015] [Indexed: 12/02/2022] Open
Abstract
Background The optimal treatment for proximal humeral fractures remains under debate. In this article, we report the mid-term results of patients who underwent the less-invasive implantation of a polyaxial locking plate for displaced proximal humeral fractures. Methods This study included patients who were treated with a polyaxial locking plate via an anterolateral deltoid split approach from May 2008 to December 2011. We evaluated outcome parameters after a minimum follow-up period of 2.5 years (median 4.5 years, follow-up rate 62 %) including the age- and gender-dependent Constant score, the activities of daily living score, and the visual analog scale for both pain and subjective shoulder function. Results Of the 140 patients who underwent surgery, 114 were included in the follow-up and 71 completed the questionnaire. Fifteen patients (21 %) exhibited 2-fragment fractures, and 56 patients (79 %) exhibited 3- and 4-part fractures. The Constant score improved significantly (4.5 years: 70 ± 21, p < 0.001) between the first two follow-ups (6 weeks: 35 ± 14, 6 months: 56 ± 18, p < 0.001), and also between 6 months and 4.5 years post-surgery. At the final follow-up, the activities of daily living score had not reached pre-fracture levels (before trauma: 27 ± 5, 4.5 years: 20 ± 8, p < 0.001). A multivariate analysis showed that age has a more significant influence on the final outcome than fracture morphology or gender. Conclusion Although the less-invasive surgical procedure is a feasible treatment option in proximal humeral fractures with acceptable complications and considerable improvement during the first six months, a lengthy recovery time is required. The majority of our patients did not become pain-free or reach pre-fracture activity levels.
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Affiliation(s)
- Benjamin Bockmann
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35043, Marburg, Germany.
| | - Benjamin Buecking
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35043, Marburg, Germany.
| | - Daniel Franz
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35043, Marburg, Germany.
| | - Ralph Zettl
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35043, Marburg, Germany.
| | - Steffen Ruchholtz
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35043, Marburg, Germany.
| | - Juliane Mohr
- Department of Trauma Surgery, Otto-von-Guericke University, Leipziger Strasse 44, 39120, Magdeburg, Germany.
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Abstract
OBJECTIVES This study was performed to identify the risk factors for reduction loss after locking plate fixation of proximal humerus fractures. DESIGN Retrospective study. SETTING University trauma center. PATIENTS AND INTERVENTION We retrospectively evaluated 252 patients who had been surgically treated for proximal humeral fractures with locking plates between January 2004 and December 2011. MAIN OUTCOME MEASUREMENTS Charts and standardized x-rays (true anteroposterior and axillary lateral views) were used to evaluate the Neer and AO OTA fracture types, initial neck-shaft angle (NSA, varus displacement), medial comminution, postoperative NSA (reduction adequacy), medial support restoration, healing progress, reduction loss, and implant-related problems immediately after surgery and at 2 weeks, 1 month, 3 months, 6 months, 9 months, and at least 1 year after surgery. Reduction loss was defined as (1) ≥10 of angulation in any direction, (2) ≥5 mm of height loss of the humeral head from the plate, and (3) fixation failure. RESULTS Reduction loss occurred in 6.7% (17 of 252) of cases; revision surgeries were performed in all cases. Univariable logistic regression analysis revealed that older age (P = 0.023), osteoporosis (P = 0.001), varus displacement (P = 0.001), medial comminution (P = 0.001), reduction adequacy (P = 0.036), and insufficient medial support (P = 0.001) had significant correlations with reduction loss. CONCLUSIONS Multivariable regression analysis revealed that osteoporosis (less than -2.5 bone mineral density, P = 0.015), displaced varus fracture (less than 110° of NSA, P = 0.025), medial comminution (more than 1 fragment, P = 0.018), and insufficient medial support (no cortical or screw support, P = 0.001) were independent risk factors for reduction loss in the proximal humerus fractures surgery. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Which parameters affect medium- to long-term results after angular stable plate fixation for proximal humeral fractures? J Shoulder Elbow Surg 2015; 24:727-32. [PMID: 25441560 DOI: 10.1016/j.jse.2014.08.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/28/2014] [Accepted: 08/13/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Very little information on medium- to long-term results is available for surgically treated proximal humeral fractures. The aim of this prospective treatment study was to present long-term results after angular stable plate fixation of displaced proximal humeral fractures and to detect which specific patient- and fracture-related parameters affect the clinical outcome. METHODS We performed a prospective clinical and radiologic evaluation of 77 patients with a displaced proximal humeral fracture (28 Neer 2-part, 38 3-part, and 11 4-part fractures; 28 AO A fractures, 30 AO B fractures, and 19 AO C fractures) treated with angular stable plate fixation after a mean follow-up period of 96 months (range, 74-133 months). We assessed outcomes with the Constant, University of California-Los Angeles (UCLA), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores and evaluated specific patient- and fracture-related parameters including complications. RESULTS The mean Constant, University of California-Los Angeles (UCLA), and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were 79, 31, and 12 points. Reasons for revisions were implant-related impingement (n = 13), screw perforation (n = 10), infection (n = 4), and secondary fracture displacement (n = 1). There was a significant association between worse score results and occurrence of secondary fracture displacement, screw perforation, residual bone deformities, and a rotator cuff defect at follow-up. CONCLUSIONS Good medium- to long-term results after angular stable plate fixation of displaced proximal humeral fracture can be expected. A reconstruction within a range of 15° in both anteroposterior and axillary views and <5-mm tuberosity displacement should be the aim of head-preserving surgery to prevent complications, such as secondary fracture displacement and screw perforation, and a less favorable long-term result.
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Hepp P, Theopold J, Jarvers JS, Marquaß B, von Dercks N, Josten C. [Multiplanar reconstruction with mobile 3D image intensifier. Surgical treatment of proximal humerus fractures]. Unfallchirurg 2015; 117:437-44. [PMID: 23703621 DOI: 10.1007/s00113-013-2367-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of this study was to analyze the applicability and advantages of the intraoperative use of a mobile 3D C-arm with multiplanar imaging for surgery of acute proximal humerus fractures. MATERIALS AND METHODS In this study 20 patients (11 female, 9 male, median age 70 years, range 35-91 years) with dislocated proximal humerus fractures (6 with 2 segments, 10 with 3 segments and 4 with 4 segments) were included. Preoperatively 3D scanning was performed and a reevaluation of the fracture in comparison to the plain radiographs was performed. After operative treatment another scan was performed to evaluate technical complications. RESULTS In comparison to the multiplanar reconstructions fracture morphology could not be correctly detected in 5 out of the 20 cases with plain radiographs. The preoperative image quality of the multiplanar reconstructions showed a significantly better assessment in comparison to the image quality with osteosynthesis (p < 0.05). The screws had to be replaced in 5 of the 20 patients. CONCLUSION Intraoperative 3D imaging with mobile image intensifier enables an accurate analysis of fracture morphology. Furthermore a quasi real time preoperative planning, evaluation of reduction and implant position with immediate operative relevance can be realized.
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Affiliation(s)
- P Hepp
- Klinik für Unfall- Wiederherstellungs- und Plastische Chirurgie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland,
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Burke NG, Kennedy J, Cousins G, Fitzpatrick D, Mullett H. Locking plate fixation with and without inferomedial screws for proximal humeral fractures: a biomechanical study. J Orthop Surg (Hong Kong) 2014; 22:190-4. [PMID: 25163953 DOI: 10.1177/230949901402200215] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE. To compare the efficacy of locking plate fixation with and without inferomedial screws in maintaining the reduction of a proximal humeral fracture. METHODS. 22 synthetic humerus models were used. A standardised 3-part proximal humeral fracture with a 4-mm wedge segment was created and fixed with a locking plate and screws with (n=11) and without (n=11) inferomedial screws. The intrafragmentary motion of the construct at 250, 500, 750, and 1000 cycles of 532 N loading, and the load to failure of the 2 groups were compared. RESULTS. Locking plate fixation with inferomedial screws reduced the mean intrafragmentary motion in all cycles (p<0.01) and increased the load to failure (1452 N vs. 1159 N, p<0.001), compared to fixation without inferomedial screws. CONCLUSION. Additional inferomedial screws provide medial column support for fracture healing. This may reduce intrafragmentary motion and thus implant complications resulting from varus malalignment such as screw perforation or loss of reduction.
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Affiliation(s)
- Neil G Burke
- Department of Orthopaedic Research, Royal College of Surgeons, Dublin, Ireland
| | - Jim Kennedy
- Department of Orthopaedic Research, Royal College of Surgeons, Dublin, Ireland
| | - Grainne Cousins
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland
| | - David Fitzpatrick
- School of Electrical and Mechanical Engineering, University College Dublin, Ireland
| | - Hannan Mullett
- Department of Orthopaedic Research, Royal College of Surgeons, Dublin, Ireland
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Maqdes A, Levy B, Klouche S, Hardy P. The feasibility and results of an arthroscopic removal of humeral locking plates and glenohumeral arthrolysis after proximal humeral fractures. Knee Surg Sports Traumatol Arthrosc 2014; 22:456-61. [PMID: 23397421 DOI: 10.1007/s00167-013-2437-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 01/29/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE This study describes the use of standard shoulder arthroscopy techniques to remove a proximal humerus locking plate following proximal humerus fracture. The goal of this study was to assess the feasibility and results of this technique. METHODS This was a retrospective non-comparative study. Inclusion criteria were fracture union when hardware was removed, significant residual glenohumeral stiffness after 6 months of physiotherapy, arthrogenic screw(s) and/or osteonecrosis (partial or complete) of the humeral head resulting in significant pain. RESULTS Eleven patients were included in this study. Surgery was successful in all cases, and surgery lasted a mean of 105 ± 10.5 min. Patients' mean age was 54.6 ± 10.6 years and the mean hospital stay 1.6 ± 0.8 days. No patient was lost to follow-up. At the mean last follow-up of 17.7 ± 23.4 months, pain and all functional parameters improved significantly: the Constant score (43.4 ± 8.8 vs 60.5 ± 0.3, p = 0.003), the visual analogue pain score (4.7 ± 1.5 vs 2.8 ± 2.3, p = 0.012), the shoulder abduction (77.7 ± 18.6 vs 104.5 ± 27.3, p = 0.004), the flexion (85.9 ± 30.7 vs 97.7 ± 27.7, p = 0.026) and the external rotation (15 ± 12 vs 31.8 ± 13.6, p = 0.004). Internal rotation improved from L3 to T12. All seven patients who practiced sports before the initial fracture had returned to sports approximately 6 months postoperatively. No infections or wound dehiscence occurred. CONCLUSION Shoulder arthroscopy was found to be feasible for removal of hardware following proximal humeral fracture and can be associated with diagnostic and therapeutic arthroscopy and glenohumeral arthrolysis if required.
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Affiliation(s)
- Ali Maqdes
- Hôpitaux Universitaires Paris Ile-de-France Ouest, AP-HP, 92100, Boulogne-Billancourt, France,
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Kirchhoff C, Biberthaler P. [Indication for primary fracture prosthesis of the shoulder]. Unfallchirurg 2013; 116:1015-29. [PMID: 24233085 DOI: 10.1007/s00113-013-2423-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Although fractures of the proximal humerus are one of the most common osteoporotic fracture types, no generally accepted treatment algorithm exists in the current literature. For young patients with high functional demands and good rehabilitation potential, we recommend humeral head salvage therapy. If symptomatic humeral head necrosis occurs, the implantation of an anatomic endoprothesis is possible on a secondary basis. For patients with a biological age > 70 years suffering from a persisting defect of the rotator cuff along with a humeral head fracture or from a multiple fragment fracture of the humeral head, we increasingly prefer implantation of a reverse shoulder prosthesis due to good clinical results. However, because of technical aspects and a high complication rate, treatment using the reverse fracture prosthesis should be reserved for surgeons with expertise in this particular field. After analyzing the fracture- and patient-specific risk factors and performance expectations, the trauma surgeon can select the best individual therapy with the patient.
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Affiliation(s)
- C Kirchhoff
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität München, Ismaningerstraße 22, 81675, München, Deutschland
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Pak P, Eng K, Page RS. Fixed-angle locking proximal humerus plate: an evaluation of functional results and implant-related outcomes. ANZ J Surg 2013; 83:878-82. [DOI: 10.1111/ans.12370] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Ponnaren Pak
- Barwon Orthopaedic Research Unit; The Geelong Hospital; Geelong Victoria Australia
| | - Kevin Eng
- Barwon Orthopaedic Research Unit; The Geelong Hospital; Geelong Victoria Australia
- School of Medicine; Deakin University; Geelong Victoria Australia
| | - Richard S. Page
- Barwon Orthopaedic Research Unit; The Geelong Hospital; Geelong Victoria Australia
- School of Medicine; Deakin University; Geelong Victoria Australia
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Ketterl R. Wird das Outcome durch den Einsatz einer minimalinvasiven Operationstechnik mit winkelstabiler Plattenosteosynthese bei proximalen Humerusfrakturen verbessert? ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s11678-013-0218-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Mechanisms of failure of locked-plate fixation of the proximal humerus: acoustic emissions as a novel assessment modality. J Orthop Trauma 2013. [PMID: 23187155 DOI: 10.1097/bot.0b013e31827934c1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Locking plates are the predominant implants used for proximal humerus fractures. Despite a preponderance of good clinical outcomes, failures continue to occur. The purpose of this study was to investigate the failure mechanism of locked proximal humeral plate fixation and its relationship with bone density and screw length. METHODS Human cadaveric humeri were subjected to cyclic bending loads after an unstable 2-part fracture (Orthopedic Trauma Association classification 11 A-3) was created and stabilized with a locking proximal humeral plate. Acoustic emission (AE) sensors were mounted on the specimens to detect fracture displacement and generation of microcracks. The data were analyzed to evaluate construct failure. RESULTS Eight of 10 locking plate constructs in cadaver specimens failed in varus collapse. The primary influences on failure were cancellous bone density and cancellous bone screw length. AE monitoring demonstrated patterns of microcrack progression, predominantly along the inferior screws. The progression trends according to AE were similar to their respective actuator displacement versus time curves. CONCLUSIONS Cancellous bone density and total cancellous screw depth penetration seem to be critical variables. Although the patients' bone density cannot be controlled, surgeons may decrease the risk of failure by maximizing the length of the screws within the cancellous bone. Analysis of microcrack formation revealed that failures begin at the midportion and tips of the inferior screws and at the bone-plate interface of the inferior screws.
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Biomechanical evaluation of locking plate fixation of proximal humeral fractures augmented with calcium phosphate cement. J Orthop Trauma 2013; 27:399-404. [PMID: 23114412 DOI: 10.1097/bot.0b013e318278c595] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the influence of calcium phosphate cement augmentation on failure of locking plate fixation of proximal humeral fracture fixation in a cadaveric fracture model. METHODS A 5-mm wedge osteotomy was created in each of 11 paired fresh-frozen human cadaveric humeri (age > 65 years). Specimens were randomly assigned to receive either locked plate fixation (group 1) or locked plate fixation with cement augmentation (group 2). Constructs were tested for axial stiffness, load to failure, and failure mode using a material testing machine. RESULTS Cement-augmented specimens resisted higher loads (1936 ± 609 N) in comparison to nonaugmented specimens (1373 ± 590 N) (P = 0.01). In group 1, varus displacement and glenohumeral screw perforation occurred in all cases. Varus displacement occurred in 2 cases in group 2, whereas glenohumeral screw perforation did not occur in any of the cases. Cement augmentation led to a significant increase in axial stiffness (P = 0.04). CONCLUSIONS Calcium phosphate cement-augmented locking plates enhanced fixation stability in proximal humeral fractures and reduced glenohumeral screw perforation in this 2-part cadaveric model. The ultimate advantage of this method remains to be determined in vivo.
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Tepass A, Blumenstock G, Weise K, Rolauffs B, Bahrs C. Current strategies for the treatment of proximal humeral fractures: an analysis of a survey carried out at 348 hospitals in Germany, Austria, and Switzerland. J Shoulder Elbow Surg 2013; 22:e8-14. [PMID: 22818893 DOI: 10.1016/j.jse.2012.04.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Revised: 03/25/2012] [Accepted: 04/01/2012] [Indexed: 02/01/2023]
Abstract
BACKGROUND The therapeutic spectrum for the treatment of displaced proximal humeral fractures ranges from conservative therapy to head-preserving surgical interventions and joint replacement. This study initiated a survey on the current treatment options with regard to diagnostics, choice of therapy, and complications that are encountered at trauma surgeries and orthopedic hospitals in Germany, Austria, and Switzerland. MATERIALS AND METHODS The survey included 743 hospitals. The questionnaire covered information on demographics, diagnostics, classification, therapy, and complications of proximal humeral fractures. RESULTS The questionnaire was completed by 348 hospitals. Five of 6 hospitals treat more than 40% of the fractures surgically. The percentage distribution of the available implants is at 63.4% for angular stable plates, 30.9% for intramedullary nails, and 10.1% for fracture prostheses. The 5 complications reported most frequently were nonanatomic reduction (83%), implant perforation (73%), secondary displacement of the fracture (71%), avascular necrosis (67%), and implant-related impingement (59%). CONCLUSIONS A preference for surgical treatment of proximal humeral fractures was found, with stabilization predominantly being attempted by the use of angle-stable implants. The 2 most common complications were "nonanatomic reduction of fractures" and the more specific problem of "implant perforation" when fixed-angle implants were used for treatment.
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Affiliation(s)
- Alexander Tepass
- Klinik für Unfall- und Wiederherstellungschirurgie, BG-Unfallklinik Tübingen, Eberhard-Karls-Universität Tübingen, Schnarrenbergstrasse 95,Tübingen, Germany
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Management of displaced surgical neck fractures of the humerus: health related quality of life, functional and radiographic results. Injury 2012; 43 Suppl 2:S12-9. [PMID: 23622986 DOI: 10.1016/s0020-1383(13)70174-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There is no controversy about the need for surgical treatment of the displaced surgical neck fractures of the humerus, but there are few studies comparing the results of the three preferred types of surgical treatment. To expand the knowledge needed in decision making, a patient series is reviewed using health related quality of life (HRQoL), functional and radiographic data from patients treated with percutaneous pinning, locking plates or intramedullary nails. MATERIALS AND METHODS Retrospective observational cohort study of patients who underwent internal fixation of fractures of the surgical neck of the humerus between 2004 and 2009 (mean follow-up 40.67 ± 17.93 months). Fifty patients fulfilled the inclusion criteria (mean age 70.04 ± 13.15 years). Nine had been treated by percutaneous pinning, fifteen with locking plates and twenty-six with intramedullary nails. We compared the results between the three groups of the HRQoL with the EuroQol5D questionnaire; the functional capacity of the operated and non-operated shoulder with the Constant score; and the radiographic result with plain X-rays. RESULTS Forty-eight patients had achieved fracture healing. The plating and nailing groups had a better fracture reduction compared with the pinning group (p <0.05). The EuroQol-5D did not discriminate between groups (mean 0.65 ± 0.26; p >0.05). The mean Constant score of the K-wire group (47.67 ± 22.42) was lower than those of the plating (82.45 ± 17.69) and nailing groups (72.72 ± 15.96) (p = 0.001), with no differences between plates and nails. There was positive correlation between the EuroQol-5D result and the Constant score (r = 0.490; p <0.005). The fractured shoulder was worse in each item of the Constant score than the non-operated one in patients treated with pins and nails. Patients treated with plates achieved similar results between operated and non-operated shoulder in three items: arm positioning, internal and external rotation. Seventeen patients (six re-operated) had some kind of complication during follow-up. CONCLUSION Patients treated with pinning achieved a worse radiographic and Constant score than patients treated with plates or nails. Although we did not find differences between the plating and nailing groups, patients treated with plates got a Constant score more similar to the non-operated shoulder.
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Gradl G, Stedtfeld HW, Morlock M, Sellenschloh K, Püschel K, Mittlmeier T, Gradl G. Locking plate fixation of humeral head fractures with a telescoping screw. A comparative biomechanical study versus a standard plate. Injury 2012; 43:734-8. [PMID: 21944432 DOI: 10.1016/j.injury.2011.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 07/20/2011] [Accepted: 08/10/2011] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Locking plate fixation of humeral head fractures bares the risk of glenohumeral screw penetration. In order to circumvent this problem it is recommended to insert shorter locking screws having at least a 6mm distance to the humeral head cortex. This in turn may reduce fixation stability and may lead to early varus displacement. One second frequent failure mechanism is cranial displacement of the greater tubercle. The study evaluates the biomechanical properties of a locking plate employing an additional telescoping screw that may enhance resistance to varus displacement. Screw in screw fixation of the greater tubercle may reduce the rate of cranial displacement. METHODS In four paired fresh-frozen human cadaver humeri (age>70 years) a Neer IV/3 fracture was created with a 5mm osteotomy gap simulating metaphyseal comminution. Limbs were randomly assigned to receive plate fixation with an additional telescoping screw (Humerus Tele Screw: HTS) and on the contralateral limb Philos plate fixation before biomechanical evaluation (MTS-Bionix 858.2). Standard locking screws were placed in both groups 6mm below the radiological head circumference; the telescoping screw was placed in the subchondral layer. The greater tubercle was fixed with an additional screw in both techniques, in the HTS group the screw was anchored in the sleeve of the telescrew (screw in screw fixation). FINDINGS Fixation stability with a mean stiffness of 300.9±28.8 N/mm in the HTS plate group proved to be significantly higher than in the Philos plate group (184.2±23.4 N/mm; p=0.006). The HTS plate also resisted higher loads in terms of fixation failure with loss of reduction at 290±58.6 N in comparison to 205±8.6 N for the Philos plate (p=0.2). Displacement of the greater tubercle occurred in no case of the HTS plate group and in two out of four cases in the Philos plate group. INTERPRETATION The HTS plate provides high fixation stability in an in vitro humeral head fracture model and securely prevents displacement of the greater tubercle.
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Affiliation(s)
- Gertraud Gradl
- Department for Trauma Surgery, University of Aachen, Germany.
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Lill H, Katthagen C, Hertel A, Gille J, Voigt C. All-arthroscopic intramedullary nailing of 2- and 3-part proximal humeral fractures: a new arthroscopic technique and preliminary results. Arch Orthop Trauma Surg 2012; 132:641-7. [PMID: 22101409 DOI: 10.1007/s00402-011-1430-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Indexed: 02/09/2023]
Abstract
PURPOSE The most criticism of antegrade humeral nailing is the potentially deleterious effect on the shoulder function, which is caused by the trauma to the M. supraspinatus (SSP) at the nail insertion site. We describe a new technique of all-arthroscopical intramedullary nailing, which preserves the rotator cuff, and compare it with the conventional open procedure. METHODS From 11/2009 to 12/2010 82 patients with unstable, displaced proximal humeral fractures were treated surgically. Twenty-one of these patients received an intramedullary nailing. Sixteen of 21 met the inclusion criteria. Based on the surgeon's arthroscopic experience, patients were assigned to the arthroscopic (group I, n = 8) or open group (group II, n = 8). Both groups were compared due to the replacement results, complications, time of surgery and fluoroscopy. Concomitant intraarticular pathologies were assessed (group I). First clinical results after a median follow-up of 13 months (group I) and 14 months (group II) were reported. RESULTS Between group I and II, no significant differences were seen in patients age [77 years (range 45-90 years) vs. 76 years (range 65-92 years)], gender (6 female/2 male vs. 5 female/3 male) and fracture pattern (six 2-/two 3-part fractures vs. five 2-/three 3-part fractures). The reduction was evaluated by the caput-diaphysis-angle, which was median 137° (range 120-147°) in group I and 132° (range 120-158°) in group II (p = 0.959). Postoperatively, group I showed one varus-, group II two varus- and valgus deformities. Median time of surgery was 75 min (range 45-182 min) versus 70 min (range 40-146 min) (p = 0.442), fluoroscopy time 1.5 min (range, 0.6-3.7 min) versus 1.2 min (range 0.3-2.2 min) in group I and II (p = 0.336). Concomitant pathologies like one traumatic bicipital tendon-lesion and three partial lesions of the SSP were observed and treated in group I. Constant Scores and Visual Analogue Scale did not differ significantly between both groups at the time of follow-up. CONCLUSIONS All-arthroscopical humeral nailing is possible, preserves the rotator cuff and provides equal replacement and functional results like the open technique. An arthroscopically visualized optimal nail insertion point provides less frequent head deformities. Level of evidence Level III.
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Affiliation(s)
- Helmut Lill
- Department of Trauma and Reconstructive Surgery, Friederikenstift Hospital Hannover, Humboldtstraße 5, 30169, Hannover, Germany,
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Minimally invasive polyaxial locking plate fixation of proximal humeral fractures: a prospective study. ACTA ACUST UNITED AC 2012; 71:1737-44. [PMID: 22182882 DOI: 10.1097/ta.0b013e31823f62e4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The surgical treatment for displaced humeral head fractures overlooks a broad variety of surgical techniques and implant systems. A standard operative procedure has not yet been established. In this article, we report our experience with a second-generation locking plate for the humeral head fracture that is applied in a standardized nine-step minimally invasive surgical technique (MIS). METHODS In a prospective study from May 2008 until November 2009, a cohort of 79 patients with 80 proximal humerus fractures were operated in a MIS procedure using a polyaxial locking plate. Follow-up examination at 6 weeks and 6 months postoperative included radiologic examinations and a clinical outcome analysis by the Constant Score, the Visual Analog Scale for pain, and the Daily Activity Score. RESULTS The mean patient age was 65.5 years ± 19 years. According to the Neer classification, there were 18 (22.5%) two-part (Neer III), 48 (60%) three-part (Neer IV), and 14 (17.5%) four-part fractures (Neer IV/V). The operation time averaged 65.6 minutes ± 27 minutes. In 13 patients (16.3%), revision was necessary because of procedure-related complications. After 6 months, the Visual Analog Scale for pain was 2.7 ± 1.6 and the Daily Activity Score showed 19.6 ± 6 points. The average age-related Constant Score after 6 months was 67.5 ± 24 points. CONCLUSIONS MIS surgery of displaced humeral head fractures can be performed in all types of humeral head fractures leading to low complication rates and good clinical outcome. A standardized stepwise procedure in fracture reduction and fixation is recommended to achieve reliable good results.
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Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches. ACTA ACUST UNITED AC 2011; 71:1364-70. [PMID: 21768907 DOI: 10.1097/ta.0b013e31820d165d] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Locking proximal humerus plate (LPHP) fixation has recently become available for the treatment of proximal humeral fractures. However, the preliminary results were contradictory. The technical requirements for success when using LPHP remain to be defined. Maybe the approach to the proximal humerus plays an important role, not the implants. We analyzed two surgical approaches to proximal humeral fractures. METHODS Between April 2004 and October 2007, 63 consecutive patients with displaced proximal humeral fractures who underwent LPHP osteosynthesis in our institute were classified to two treatment groups retrospectively: the deltopectoral incision and the deltoid-splitting incision according to surgeon's preference. The Constant and Disabilities of the Arm, Shoulder and Hand scores were recorded for clinical assessment. Quality of reduction, fracture union, and radiographic complications were recorded for radiographic assessment. Electrophysiological abnormalities were also assessed. RESULTS There were no significant differences between the groups with regard to demographic data, preoperative radiographic findings, and duration of follow-up. There were also no significant differences between the groups with regard to operative time (p = 0.918), blood loss (p = 0.407), hospital stay (p = 0.431), postoperative head-shaft angle (p = 0.769), union time (p = 0.246), final head-shaft angle (p = 0.533), Constant score (p = 0.677), Disabilities of the Arm, Shoulder and Hand score (p = 0.833), radiographic complications (p = 1.000), and presence of electrophysiological abnormalities (p = 0.296). Avascular necrosis of the humeral head was found in three patients, all of whom in the deltopectoral approach group. CONCLUSION We found no statistically significant difference in clinical, radiographic, and electrophysiological outcomes between the deltopectoral approach and deltoid-splitting approach while surgical treatment of proximal humeral fractures.
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Jones CB, Sietsema DL, Williams DK. Locked plating of proximal humeral fractures: is function affected by age, time, and fracture patterns? Clin Orthop Relat Res 2011; 469:3307-16. [PMID: 21691910 PMCID: PMC3210268 DOI: 10.1007/s11999-011-1935-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Locking plate fixation of proximal humeral fractures improves biomechanical stability. It has expanded the indications of traditional open reduction internal fixation and become increasingly common for treating unstable, displaced proximal humeral fractures. Despite improved stability it is unclear whether these improve function and if so for which patients. QUESTIONS/PURPOSES We therefore determined patient function after a locked plating technique for the treatment of unstable proximal humeral fractures based on age, time, fracture pattern, and associated injures. PATIENTS AND METHODS We retrospectively reviewed 66 patients with 69 proximal humeral fractures treated with a locked proximal humeral plating technique from 2002-2006 using prospectively gathered data. Function was measured using the Short Musculoskeletal Function Assessment (SMFA), Disability of the Arm, Shoulder, and Hand (DASH), and SF-36 at 6, 12, and 24 months. Fracture healing was determined radiographically and complication rates were determined from the medical records. RESULTS At 2 years, DASH scores were 26.5 and 37.4 for isolated and polytrauma patients, respectively. For age differences, DASH scores were 33.1 and 28.9 for ages younger than 60 and 60 years old or older, respectively. At 2 years, SMFA scores were higher (worse) in older compared with younger patients. Function, but not bother continues to improve in younger patients up to 2 years. More severe fracture patterns performed worse in all SMFA indices at 2 years. Polytrauma patients consistently experienced worse mobility than isolated injury patients at each time interval. CONCLUSIONS With locked plating of unstable proximal humeral fractures, older patients function as well as younger patients; improvement continues until 1 year postoperatively, the Neer fracture classification differentiates function, and polytrauma patients perform worse clinically. Long-term functional deficits persist. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Clifford B. Jones
- Orthopaedic Associates of Michigan, Michigan State University, 230 Michigan Street NE, Suite 300, Grand Rapids, MI 49503 USA
| | - Debra L. Sietsema
- Orthopaedic Associates of Michigan, Michigan State University, Grand Rapids, MI USA
| | - Daniel K. Williams
- Grand Rapids Orthopaedic Surgical Residency Program, Grand Rapids, MI USA
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Are polyaxially locked screws advantageous in the plate osteosynthesis of proximal humeral fractures in the elderly? A prospective randomized clinical observational study. J Orthop Trauma 2011; 25:596-602. [PMID: 21670709 DOI: 10.1097/bot.0b013e318206eb46] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the results of plate osteosynthesis using either polyaxial or nonpolyaxially locked screw-plate systems in proximal humeral fractures in the elderly. DESIGN Prospective, randomized. SETTING Level I trauma center. METHODS Fifty-six patients (older than 60 years) with isolated, displaced three- and four-part fractures were included. Twenty-five patients (median age, 75.5 years) were randomized to a polyaxial locking screw plate (Group 1), whereas 31 patients (median age, 72 years) were treated with a locking screw plate (Group 2). Follow-up evaluations were performed 3, 6, and 12 months postoperatively using the Simple Shoulder Test, Disabilities of the Arm, Shoulder and Hand score, and Constant score as well as radiographs. The results and the complications were compared between both groups. RESULTS Forty-eight patients were available for follow-up (Group 1, 20 of 25; Group 2, 28 of 31). The Simple Shoulder Test, Disabilities of the Arm, Shoulder and Hand, and Constant score improved significantly from 3 to 12 months and did not differ between groups. Twelve months after the index procedure, the Simple Shoulder Test score was 8.6 ± 3.2 points in Group 1 and 9.7 ± 1.8 points in Group 2. The Disabilities of the Arm, Shoulder and Hand score was 17.8 ± 16.2 in Group 1 and 15.7 ± 11.8 in Group 2. The mean Constant score amounted to 73% ± 17% in Group 1 and 81% ± 13% in Group 2. There were six complications in Group 1 and eight in Group 2. CONCLUSIONS Both the functional outcomes and the rate of complications after polyaxial locked plate osteosynthesis of proximal humeral fractures in elderly patients were comparable to those treated with nonpolyaxial implants. Despite the theoretical advantages of polyaxial locked plating in proximal humerus fractures, this study could not show a verifiable clinical advantage of these plates.
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Brorson S, Frich LH, Winther A, Hróbjartsson A. Locking plate osteosynthesis in displaced 4-part fractures of the proximal humerus. Acta Orthop 2011; 82:475-81. [PMID: 21657970 PMCID: PMC3237040 DOI: 10.3109/17453674.2011.588856] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 03/08/2011] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE There is considerable uncertainty about the optimal treatment of displaced 4-part fractures of the proximal humerus. Within the last decade, locking plate technology has been considered a breakthrough in the treatment of these complex injuries. METHODS We systematically identified and reviewed clinical studies on the benefits and harms after osteosynthesis with locking plates in displaced 4-part fractures. RESULTS We included 14 studies with 374 four-part fractures. There were 10 case series, 3 retrospective observational comparative studies, 1 prospective observational comparative study, and no randomized trials. Small studies with a high risk of bias precluded reliable estimates of functional outcome. High rates of complications (16-64%) and reoperations (11-27%) were reported. INTERPRETATION The empirical foundation for the value of locking plates in displaced 4-part fractures of the proximal humerus is weak. We emphasize the need for well-conducted randomized trials and observational studies.
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Affiliation(s)
- Stig Brorson
- Department of Orthopaedic Surgery, Herlev University Hospital, Herlev, Denmark.
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How does a varus deformity of the humeral head affect elevation forces and shoulder function? A biomechanical study with human shoulder specimens. J Orthop Trauma 2011; 25:399-405. [PMID: 21637119 DOI: 10.1097/bot.0b013e31820beb80] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES A biomechanical study was performed to test the hypothesis that a varus deformity of the humeral head decreases supraspinatus (SSP) efficiency and increases deltoid elevation forces in human specimens. METHODS Twenty-four fresh-frozen human shoulder specimens were prepared by preserving the rotator cuff and deltoid. A defined, medial closed-wedge osteotomy was performed and lateral locked plate applied to simulate a varus deformity of 45° in Group I (n = 8) and 20° in Group II (n = 8). The control group (n = 8) was not osteotomized. The effect of the deformities on arm elevation forces was measured in a robot-assisted shoulder simulator under a physiologically loaded rotator cuff during three elevation phases. Phase 1 encompassed 0° to 30°, Phase 2 was from 30° to 60°, and Phase 3 included 60° to 90° of shoulder elevation. RESULTS SSP efficiency, defined as the degree of elevation attained per unit muscle force, was significantly less in Group I compared with Group II (P = 0.036) and the control group (P = 0.039) (Group I = 0.12 ± 0.03°/N, Group II 0.18 ± 0.05°/N, and control group 0.24 ± 0.10°/N). Under physiological loading of the rotator cuff, the deltoid (DELT) elevation forces were significantly greater in Group I (Pphase 1 = 0.015, Pphase 3 = 0.001) and Group II (Pphase 1 = 0.015, Pphase 3 = 0.006) compared with the control group in elevation Phase 1 (Group I: 3.20 ± 1.04 N/°, Group II: 3.03 ± 0.96 N/°, control group: 2.01 ± 0.53 N/°) and Phase 3 (Group I: 2.50 ± 0.85 N/°, Group II: 1.55 ± 0.28 N/°, control group: 1.21 ± 0.18 N/°). When the SSP was unloaded, the DELT elevation forces were significantly greater in Group l than in Group II (P = 0.040) and the control group (P = 0.004) during elevation Phase 3 (Group I: 2.12 ± 0.60 N/°, Group II: 1.47 ± 0.34 N/°, control group: 1.24 ± 0.32 N/°). CONCLUSIONS A varus deformity of the humeral head changes the pretension of the rotator cuff and results in a significantly decreased SSP efficiency (45° varus) and significantly higher arm elevation forces (20° varus). Clinically, the study's findings are relevant because they indicate that varus deformities of more than 20° should not be accepted intraoperatively and might indicate the need for surgical correction in case of subsequent symptoms.
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Arthroskopische Materialentfernung nach winkelstabiler Plattenosteosynthese am proximalen Humerus. Unfallchirurg 2011; 115:47-54. [DOI: 10.1007/s00113-011-1953-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Zettl R, Müller T, Topp T, Lewan U, Krüger A, Kühne C, Ruchholtz S. Monoaxial versus polyaxial locking systems: a biomechanical analysis of different locking systems for the fixation of proximal humeral fractures. INTERNATIONAL ORTHOPAEDICS 2011; 35:1245-50. [PMID: 21301828 DOI: 10.1007/s00264-011-1220-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 01/18/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The development of locking plate systems has led to polyaxial screws and new plate designs. This study compares monoaxial head locking screws (PHILOS© by Synthes) and a new generation of polyaxial locking screws (NCB-LE© by Zimmer) with respect to biomechanical stability. METHODS On nine pairs of randomised formalin fixed humerus specimens, standardised osteotomies and osteosyntheses with nine monoaxial (group A) und nine polyaxial (group B) plate/screw systems were performed. A material testing machine by Instron (M-10 14961-DE) was used for cyclic stress tests and crash tests until defined breakup criteria as endpoints were reached. RESULTS After axial cyclic stress 200 times at 90 N, plastic deformation was 1.02 mm in group A and 1.25 mm in group B. After the next cycle using 180 N the additional deformation averaged 0.23 mm in group A and 0.39 mm in group B. The deformation using 450 N was 0.72 mm in group A compared to 0.92 mm in group B. The final full power test resulted in a deformation average of 0.49 mm in group A and 0.63 mm in group B after 2,000 cycles using 450 N. When reaching the breakup criteria the plastic deformation of the NCB plate was 9.04 mm on average. The PHILOS plate was similarly deformed by 9.00 mm. As a result of the crash test, in group A the screws pulled out of the humeral head four times whereas the shaft broke one time and another time the implant was ripped out. The gap was closed four times. In group B, there were three cases of screw cut-through, four shaft fractures/screw avulsions from the shaft and two cases of gap closure. CONCLUSION The two systems resist the cyclic duration tests and the increasing force tests in a similar manner. The considerable clinical benefits of the polyaxial system are enhanced by equal biomechanical performance.
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Affiliation(s)
- Ralph Zettl
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Giessen and Marburg GmbH, Baldingerstraße, 35041 Marburg, Germany.
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Abstract
Arthroscopic implant removal involves innovative minimally invasive surgical techniques which offer the advantages of minimally invasive surgery in addition to the possibility of glenohumeral inspection, arthrolysis and treatment of concomitant intraarticular pathologies compared to open surgical procedures. In the following article the surgical techniques and significance of arthroscopic implant removal from the shoulder joint will be described. The first results of a complete arthroscopic plate removal from the humeral head will be described. Compared to the open technique, greater satisfaction of the patients, more rapid pain relief and improvement of the shoulder function in the early postoperative time could be observed. During the follow-up interval the results of the two techniques converge.
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Faraj D, Kooistra BW, Vd Stappen WAH, Werre AJ. Results of 131 consecutive operated patients with a displaced proximal humerus fracture: an analysis with more than two years follow-up. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2010; 21:7-12. [PMID: 21837232 PMCID: PMC3150824 DOI: 10.1007/s00590-010-0655-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Accepted: 05/13/2010] [Indexed: 01/05/2023]
Abstract
Objective The purpose of this study is to determine the efficacy of the open reduction and fixation of a dislocated proximal humerus fracture with a locking plate, also evaluating the incidence of complications and functional recovery of the shoulder. A retrospective study focusing on patients who had suffered a fracture of the proximal humerus and were treated by means of an open reduction and internal fixation with a locking plate, using either the Philos or the LPHP plate. We have also included a comparison of these two plates. Method Ninety-two patients were found to be eligible and were included in our study. These patients had all been treated for a proximal humerus fracture between 2002 and 2008. We included those patients who could be classified as a class 2, 3, or 4 according to the Neer classification. Demographic data, surgical technique, and peri/post-operative complications were collected from medical records. Patients were followed-up and the Oxford Shoulder Score (OSS) was filled in by phone. The mean age of our patient population was 66.2 (15–97), with a male: female ratio of 1:5 (15:77). (The median follow-up was 2.4 years (0.2–5.8). Fourteen of our patients died during follow-up, while 25 patients were otherwise lost to follow-up. For this study, out of the original 131 patients, this finally resulted in 92 patients whom we followed-up post-operatively. Results Ninety-two patients (70%, 92/131) were interviewed. The mean Oxford Shoulder Score (OSS) was 19.76 (11–54). The overall complication rate was 39.1% (36/92). The most frequently occurring complications in our patient population were hemorrhage 3.3%; dislocation of the caput humeri and/or tuberculum majus 2.2%; persistent pain 3.3%; Avascular necrosis (AVN) of the humeral head 0%; Loss of reduction and screw cutout 6.5%; Plate breakout 6.5%; Subacromial Impingement 11.9%; Frozen shoulder 3.3%; rotator cuff rupture 1.1%, and infection 1.1%. Of the entire group of patients originally included in this study, 29% was re-operated due to one of the above-mentioned complications. Conclusion In conclusion, the locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures. The incidence of complications and subsequent re-operation is relatively high, however, comparable to or slightly better when compared to data found in literature. Subacromial Impingement seems to occur more frequently when a Philos plate is implemented. We therefore suggest that randomized clinical trials determining the possible superiority of one specific type of plate in patients with a displaced proximal humerus fracture are to be performed in future.
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Affiliation(s)
- D Faraj
- Department of Surgery, Canisius Wilhelmina Hospital, P.O. Box 9015, 6500 GS Nijmegen, The Netherlands
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Voigt C, Geisler A, Lill H. Arthroscopic locking plate removal after proximal humeral fractures. Arch Orthop Trauma Surg 2010; 130:391-5. [PMID: 19387668 DOI: 10.1007/s00402-009-0882-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Indexed: 11/27/2022]
Abstract
The incidence of proximal humeral fractures increases. The locking plate osteosynthesis is a standard procedure to treat displaced proximal humeral fractures. In the mostly affected elderly patients with an osteoporotic bone structure, complication rate is still high. An implant removal is commonly required. But also younger patients often request for hardware removal. The open implant removal with a subacromial and subdeltoideal arthrolysis is an extensive secondary surgery for the patients. We present a new technique to remove a locking plate from the proximal humerus arthroscopically with all advantages of the minimally invasive surgery, and the possibility to treat concomitant intraarticular pathologies parallelly.
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Affiliation(s)
- Christine Voigt
- Department of Trauma and Reconstructive Surgery, Diakoniekrankenhaus Friederikenstift gGmbH, Humboldtstrasse 5, Hannover, Germany.
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Papadopoulos P, Karataglis D, Stavridis SI, Petsatodis G, Christodoulou A. Mid-term results of internal fixation of proximal humeral fractures with the Philos plate. Injury 2009; 40:1292-6. [PMID: 19539283 DOI: 10.1016/j.injury.2009.03.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2008] [Revised: 02/21/2009] [Accepted: 03/05/2009] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To report our experience from the use of the Philos plate for the treatment of three- and four-part proximal humeral fractures and to investigate factors influencing the final outcome. MATERIALS AND METHODS Between April 2005 and September 2007, 29 Philos plates were implanted in 17 women and 12 men, with a mean age of 62.3 years (range: 28-80 years). Positioning of the plate was performed under fluoroscopic control, through a deltopectoral approach and with the patient in the beach chair position. 27 patients were available for follow-up (mean: 17.9 months; range: 12-39). Follow-up included plain shoulder radiographs and functional assessment with Constant-Murley score. RESULTS Healing of the fracture occurred uneventfully within 6 months. In three patients, humeral head collapsed due to aseptic necrosis after fracture healing and the plate had to be removed in two cases. In one patient, fracture healing occurred in >10 degrees varus displacement. The clinical result according to the Constant-Murley score was 86 points (range: 58-112). CONCLUSIONS Internal fixation with the Philos plate seems to be a reliable option in the operative treatment of upper end humeral fractures, especially in osteoporotic bone. It allows secure fracture fixation and quick shoulder mobilisation, while quick and uneventful fracture healing and very satisfactory clinical results are achieved.
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Affiliation(s)
- Periklis Papadopoulos
- 1st Orthopaedic Department of Aristotle University of Thessaloniki, G. Papanikolaou General Hospital, 57010 Exohi, Thessaloniki, Greece
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Thanasas C, Kontakis G, Angoules A, Limb D, Giannoudis P. Treatment of proximal humerus fractures with locking plates: a systematic review. J Shoulder Elbow Surg 2009; 18:837-44. [PMID: 19748802 DOI: 10.1016/j.jse.2009.06.004] [Citation(s) in RCA: 243] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Revised: 05/11/2009] [Accepted: 06/11/2009] [Indexed: 02/07/2023]
Abstract
HYPOTHESIS Locking plates with special configuration for the anatomic region of the proximal humerus have been introduced recently to address the difficulties of stabilizing proximal humeral fractures. The purpose of this study was to carry out a systematic review of the literature on the efficacy and early to medium term functional results of locking plates for stabilization of proximal humeral fractures. METHODS Using the PubMed database, a systematic review of the English and German literature was carried out in order to assess the efficacy and complications related to the use of these plates and the patients' functional outcome, using the key words "locking plates proximal humeral fractures," "angular stability plates proximal humeral fractures," "PHILOS plate," and "LPHP plate." Our criteria for eligibility were clinical studies with more than ten cases followed-up, adult patients, and adequate data provided at least in terms of implant related complications. Articles written in English and German language were included. Exclusion criteria were: studies dealing exclusively with 2-part fractures (since this category has a more favorable outcome); experimental studies; case reports; and, literature other than English or German. Each one of the articles was evaluated for quality of the study using the Structured Effectiveness Quality Evaluation Scale (SEQES). RESULTS Twelve studies including 791 patients met the inclusion criteria. Patients in these studies continued to improve up to one year, achieving a mean Constant score of 74.3. The incidence of the reported complications was: avascular necrosis 7.9%, screw cut-out 11.6% and re-operation rate 13.7%. DISCUSSION The high incidence of cut-out may be secondary to the rigidity of the implant in combination with medial inadequate support, in cases compromised by severe underlying osteoporotic bone. Definition of indications for the use of locking plates and attention on technical aspects of applying them would help optimization of the results. LEVEL OF EVIDENCE Systematic Review.
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Affiliation(s)
- Christos Thanasas
- Clinical Trauma Fellow, Academic Department of Trauma & Orthopaedic Surgery, School of Medicine, University of Leeds, UK
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Bone quality measured by the radiogrammetric parameter "cortical index" and reoperations after locking plate osteosynthesis in patients sustaining proximal humerus fractures. Arch Orthop Trauma Surg 2009; 129:1251-9. [PMID: 19440726 DOI: 10.1007/s00402-009-0889-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Indexed: 10/20/2022]
Abstract
AIM To analyse the radiogrammetric parameter "cortical index" (CI) and its predictive value for proximal humerus fractures. Furthermore, to investigate the reoperations and the cause of reoperations after locking plate osteosynthesis of displaced proximal humerus fractures. PATIENTS AND METHODS 113 consecutive patients (73 women and 40 men) with a median age of 66 years (range 18-100 years) were included in this study. The median follow-up time in our database was 4.7 years (range 45-72 months). For a comparative matched-group analysis of the CI, patients with a fall on the shoulder without fracture were selected. Demographic data and all reoperations were recorded after median 58 months postoperatively. The CI was measured at the proximal humeral diaphysis. RESULTS The CI showed to be significant lower in the fracture group (mean 0.28) when compared to the matched group (mean 0.47, p < 0.01). 39% patients underwent a reoperation within 40 months postoperatively. 24% were reoperated within the first 12 months postoperatively, and 15% were reoperated after 12 months or later. The reoperation was independent of bone quality (p = 0.85). CONCLUSIONS The risk for reoperation is independent of the CI even though the CI may be a predictor for proximal humerus fracture. Younger patients should be aware that surgical treatment of proximal humerus fractures might be a two-stage surgery. Regular follow-up visits for older patients during the first postoperative year must be assured.
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Voigt C, Hurschler C, Rech L, Vosshenrich R, Lill H. Additive fiber-cerclages in proximal humeral fractures stabilized by locking plates: no effect on fracture stabilization and rotator cuff function in human shoulder specimens. Acta Orthop 2009; 80:465-71. [PMID: 19562564 PMCID: PMC2823188 DOI: 10.3109/17453670903110659] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE The effect of additive fiber-cerclages in proximal humeral fractures stabilized by locking plates on fracture stabilization and rotator cuff function is unclear. Here it was assessed in a human cadaver study. METHODS 24 paired human shoulder specimens were harvested from median 77-year-old (range 66-85) female donors. An unstable 3-part fracture model with an intact rotator cuff was developed. 1 specimen of each pair received an additive fiber-cerclage of the rotator cuff after plate fixation, and the other one received a plate fixation without an additive fiber-cerclage. Force-controlled hydraulic cylinders were used to simulate physiological rotator cuff tension, while a robot-assisted shoulder simulator performed 4 relevant cases of load: (1) axial loading at 0 degrees, (2) glenohumeral abduction at 60 degrees, (3) internal rotation at 0 degrees abduction, and (4) external rotation at 0 degrees abduction, and imitated hanging arm weight during loading without affecting joint kinematics. A 3-dimensional real-time interfragmentary motion analysis was done in fracture gaps between the greater tuberosity and the head, as well as subcapital. The capacity of the rotator cuff to strain was analyzed with an optical system. RESULTS Interfragmentary motion was similar between the groups with and without fiber-cerclages, in both fracture gaps and in any of the cases of load. Cerclages did not impair the capacity of the rotator cuff to strain. INTERPRETATION; Provided that unstable 3-part fractures are reduced and stabilized anatomically by a locking plate, additive fiber-cerclages do not reduce interfragmentary motion. Additive fiber-cerclages may be necessary in locking plate osteosyntheses of multiple-fractured greater tuberosities or lesser tuberosity fractures that cannot be fixed sufficiently by the plate.
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Affiliation(s)
| | - Christof Hurschler
- Laboratory of Biomechanics and Biomaterials, Department of Orthopedic Surgery, Hannover Medical SchoolHannoverGermany
| | - Louise Rech
- Department of Trauma and Reconstructive Surgery, Germany
| | - Rolf Vosshenrich
- Institute of MRI Diagnostics, Diakoniekrankenhaus Friederikenstift gGmbHGermany
| | - Helmut Lill
- Department of Trauma and Reconstructive Surgery, Germany
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Voigt C, Ewig M, Vosshenrich R, Lill H. Wertigkeit der MRT in der präoperativen Diagnostik proximaler Humerusfrakturen vs. CT und konventionelles Röntgen. Unfallchirurg 2009; 113:378-85. [DOI: 10.1007/s00113-009-1662-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Functional outcomes after nonoperative management of fractures of the proximal humerus. J Shoulder Elbow Surg 2009; 18:612-21. [PMID: 19559373 DOI: 10.1016/j.jse.2009.03.024] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Revised: 01/16/2009] [Accepted: 03/31/2009] [Indexed: 02/01/2023]
Abstract
BACKGROUND Prospective follow-up data after nonoperative treatment for fractures of the proximal humerus are scarce. We studied functional outcomes and rates of complication and failure after conservative management of these common injuries. MATERIALS AND METHODS Consecutive patients aged older than 18 years presenting to the emergency department of a large district hospital with an isolated, closed proximal humeral fracture considered suitable for functional treatment by the surgeon on charge were enrolled in a prospective, externally monitored observational study. Surgeons were free to reduce the fracture and to prescribe any type of sling or brace. Active follow-up after 12 weeks, 6, and 12 months included plain radiographs, Constant score, and Disabilities of Arm, Shoulder and Hand (DASH) score. RESULTS We enrolled 160 patients (118 women; mean age, 63.3 +/- 14.8 years), and 124 completed 1-year follow-up. There were 85, 71, and 4 AO 11 A, B, and C fractures, and 75 one-part, 60 two-part, 23 three-part, and 2 four-part and head-splitting fractures. After 1 year, the mean difference in Constant scores between the injured and contralateral shoulder was 8.2 (95% confidence interval [CI], 6.0-10.4). The mean difference in 1-year DASH scores to baseline assessment was 10.2 points (95% CI 7.3-13.1 points). The risk of delayed and nonunion was 7.0% (95% CI, 3.6%-12.3%). Four patients subsequently underwent surgical fixation, and 5 had arthroscopic subacromial decompression. CONCLUSION This study may provide reference values for future investigations and stresses ceiling effects that will make it difficult to demonstrate a significant advantage of surgical over nonoperative treatment in patients with proximal humeral fractures. LEVEL OF EVIDENCE Level 4; Prospective case series without a control group.
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Abstract
PURPOSE To evaluate the treatment outcome of Philos plate fixation for displaced proximal humeral fractures in 27 consecutive patients. METHODS 6 men and 21 women aged 22 to 85 (mean, 56) years underwent Philos plate fixation for displaced proximal humeral fractures. 11 patients were aged 60 years or younger and 16 older than 60 years. All fractures were closed with no associated injuries and classified as 2-part (n=13), 3-part (n=12), and 4-part (n=2), according to the Neer classification. Patients were assessed radiologically and functionally using the Constant shoulder score. RESULTS Patients were followed up for 6 to 24 (mean, 13) months. All the fractures united except in a 76- year-old woman with a 3-part fracture in whom there was fracture collapse and screw penetration of the humeral head at 6 weeks. She subsequently developed non-union and avascular necrosis. The mean Constant shoulder score was 70 (range, 28-88). 11 patients had a score exceeding 75, 13 were scored between 50 and 75, and 3 were below 50. CONCLUSION Philos plate fixation provided stable fixation, minimal metal work problems and enabled early range-of-motion exercises to achieve acceptable functional results.
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Affiliation(s)
- M A Fazal
- Department of Orthopaedics, Chase Farm Hospital, London, United Kingdom.
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Helwig P, Bahrs C, Epple B, Oehm J, Eingartner C, Weise K. Does fixed-angle plate osteosynthesis solve the problems of a fractured proximal humerus? A prospective series of 87 patients. Acta Orthop 2009; 80:92-6. [PMID: 19297792 PMCID: PMC2823244 DOI: 10.1080/17453670902807417] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND PURPOSE There is considerable controversy about the treatment of complex, displaced proximal humeral fractures. Various types of head-preserving osteosynthesis have been suggested. This prospective case series was designed to evaluate the perioperative and early postoperative complications associated with fixed-angle implants and to record outcome after bone healing. PATIENTS AND METHODS Fractures of the proximal humerus were stabilized surgically in 87 patients (mean age 64 (16-93) years) by application of a fixed-angle plate (65 PHILOS, 22 T-LCP). There were 34 2-segment fractures, 42 3-segment fractures, and 11 4-segment fractures, including 7 dislocation fractures. Follow-up assessment after a minimum of 12 months was based on the Constant, UCLA, and DASH scores and on radiographs. RESULTS Postoperative complications included soft tissue problems (n = 9), humeral head necrosis (n = 9), screw perforation (n = 11), secondary displacements (n = 14), and delayed fracture healing (n = 4). Treatment outcomes recorded on the various scores were very good in 60-82% of the cases. INTERPRETATION Screw perforation of fixed-angle implants has replaced the complications of secondary displacement and implant loosening after using conventional plates. Even with the use of fixed-angle implants, fractures of the proximal humerus are associated with a high complication rate and sometimes poor outcome.
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Affiliation(s)
- Peter Helwig
- 1Department of Orthopaedics and Traumatology, Albert Ludwigs UniversityFreiburgGermany
| | - Christian Bahrs
- 2Department of Trauma and Reconstructive Surgery, BG Trauma CenterTübingenGermany
| | - Björn Epple
- 2Department of Trauma and Reconstructive Surgery, BG Trauma CenterTübingenGermany
| | - Justus Oehm
- 2Department of Trauma and Reconstructive Surgery, BG Trauma CenterTübingenGermany
| | - Christoph Eingartner
- 3Department of Trauma and Reconstructive Surgery Unit, Caritas Hospital, Bad MergentheimGermany
| | - Kuno Weise
- 2Department of Trauma and Reconstructive Surgery, BG Trauma CenterTübingenGermany
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Allende C, Allende BT. The use of a new locking 90 degree blade plate in the treatment of atrophic proximal humerus nonunions. INTERNATIONAL ORTHOPAEDICS 2008; 33:1649-54. [PMID: 18974986 DOI: 10.1007/s00264-008-0686-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Revised: 10/02/2008] [Accepted: 10/02/2008] [Indexed: 10/21/2022]
Abstract
This level IV case series study prospectively evaluated patients with atrophic proximal humerus nonunions stabilised with a locking 90 degree blade plate. All patients were women with an average age of 69 years (range 56-78). Time from trauma to nonunion treatment averaged 23 months. Five patients had had previous surgical treatments. Two patients had a history of infection and one patient with active infection was reconstructed in two stages. Follow-up averaged 22 months (range 18-36); union was achieved in all seven cases after an average of 5.85 months. The DASH score at the last follow-up averaged 25 points and Constant score averaged 72.7 points. No patient required additional procedures. At the last follow-up all patients were free of infection, and there were no cases of avascular necrosis. The results with locked 90 degree blade plates in atrophic nonunions of the proximal humerus in adults were favourable in this series.
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Affiliation(s)
- Christian Allende
- Department of Upper Extremity and Reconstructive Surgery, Sanatorio Allende, Hospital Nacional de Clínicas, Universidad Nacional de Córdoba, Hipolito Yrigoyen 384, Cordoba, 5000, Argentina.
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Kirchhoff C, Braunstein V, Kirchhoff S, Sprecher CM, Ockert B, Fischer F, Leidel BA, Biberthaler P. Outcome analysis following removal of locking plate fixation of the proximal humerus. BMC Musculoskelet Disord 2008; 9:138. [PMID: 18847508 PMCID: PMC2569939 DOI: 10.1186/1471-2474-9-138] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Accepted: 10/12/2008] [Indexed: 11/21/2022] Open
Abstract
Background Concerning surgical management experience with locking plates for proximal humeral fractures has been described with promising results. Though, distinct hardware related complaints after fracture union are reported. Information concerning the outcome after removal of hardware from the proximal humerus is lacking and most studies on hardware removal are focused on the lower extremity. Therefore the aim of this study was to analyze the functional short-term outcome following removal of locking plate fixation of the proximal humerus. Methods Patients undergoing removal of a locking plate of the proximal humerus were prospectively followed. Patients were subdivided into the following groups: Group HI: symptoms of hardware related subacromial impingement, Group RD: persisting rotation deficit, Group RQ: patients with request for a hardware removal. The clinical (Constant-Murley score) and radiologic (AP and axial view) follow-up took place three and six months after the operation. To evaluate subjective results, the Medical Outcomes Study Short Form-36 (SF-36), was completed. Results 59 patients were included. The mean length of time with the hardware in place was 15.2 ± 3.81 months. The mean of the adjusted overall Constant score before hardware removal was 66.2 ± 25.2% and increased significantly to 73.1 ± 22.5% after 3 months; and to 84.3 ± 20.6% after 6 months (p < 0.001). The mean of preoperative pain on the VAS-scale before hardware removal was 5.2 ± 2.9, after 6 months pain in all groups decreased significantly (p < 0.001). The SF-36 physical component score revealed a significant overall improvement in both genders (p < 0.001) at six months. Conclusion A significant improvement of clinical outcome following removal was found. However, a general recommendation for hardware removal is not justified, as the risk of an anew surgical and anesthetic procedure with all possible complications has to be carefully taken into account. However, for patients with distinct symptoms it might be justified.
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Affiliation(s)
- Chlodwig Kirchhoff
- Department of Orthopedic Sports Surgery, Technische Universitaet Muenchen, Connollystrasse 32, D-80809 Munich, Germany.
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Young AA, Hughes JS. Locked intramedullary nailing for treatment of displaced proximal humerus fractures. Orthop Clin North Am 2008; 39:417-28, v-vi. [PMID: 18803972 DOI: 10.1016/j.ocl.2008.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Controversy surrounds the optimal technique for fixation of displaced fractures, although locked intramedullary nailing is emerging as a preferred technique in managing displaced proximal humerus fractures in appropriately selected patients. This technique provides stable fracture fixation allowing early postoperative mobilization critical in ensuring a pain-free shoulder with a functional range of motion. Additional advantages include the ability to insert by way of a minimally invasive approach with limited soft tissue dissection, achieve accurate anatomic reduction, provide a secure construct even in the situation of osteopenic bone or comminution, and manage fractures of the proximal humerus extending into the shaft.
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Affiliation(s)
- Allan A Young
- Department of Orthopaedic and Traumatic Surgery, Royal North Shore Hospital, Pacific Highway, St. Leonards, Sydney, NSW 2065, Australia
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Voigt C, Hurschler C, Althainz J, Vosshenrich R, Lill H. Die additive Zuggurtung der Rotatorenmanschette bei der winkelstabilen Plattenosteosynthese am proximalen Humerus. Unfallchirurg 2008; 111:514-22. [DOI: 10.1007/s00113-008-1439-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Percutaneous humeral plating of fractures of the proximal humerus: results of a prospective multicenter clinical trial. J Orthop Trauma 2008; 22:153-8. [PMID: 18317047 DOI: 10.1097/bot.0b013e3181694f7d] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the safety and functional outcome of a recently described surgical technique of percutaneous plating for proximal humerus fractures. DESIGN Prospective clinical trial. SETTING : Two urban Level 1 university trauma centers. PATIENTS From February 2002 to December 2003, 34 consecutive patients underwent surgery by 5 trauma surgeons from 2 teaching hospitals. Twenty-seven patients had 1-year follow-up. INTERVENTION The technique involved 2 minimal incisions with a lateral deltoid split and a more distal shaft incision. A proximal humerus-specific locking plate was implemented. MAIN OUTCOME MEASUREMENTS DASH (disabilities of the arm, shoulder, and hand) and Constant-Murley evaluation scores were used for functional evaluation. The presence of complications was noted. RESULTS Specifically, there were no axillary nerve injury injuries and no loss of reduction. The average Constant score at 1 year was 82 and the DASH score was 26. CONCLUSION This study demonstrated that the functional outcome results correspond to a normal age-adjusted score signifying an acceptable result.
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Schoepp C, Oswald D, Schofer M, Kortmann HR. Standardverfahren zur Behandlung proximaler Humerusfrakturen. ACTA ACUST UNITED AC 2008. [DOI: 10.1007/s10039-008-1369-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
OBJECTIVE The purpose of this study was to determine the efficacy of proximal humerus locking plates (PHLP) and to clarify predictors of loss of fixation. DESIGN Retrospective review of patients with proximal humerus fractures fixed with a PHLP. SETTING Five Level 1 trauma centers. PATIENTS One hundred fifty-three patients (111 female, 42 male) 18 years or older with a displaced fracture or fracture-dislocation of the proximal humerus treated with a PHLP between January 1, 2001 and July 31, 2005. INTERVENTION Demographic data, trauma mechanism, surgical approach, and perioperative complications were collected from the medical records. Fracture classification according to the AO/OTA, radiographic head-shaft angle, and screw tip-articular surface distance in true anteroposterior (AP) and axillary lateral radiographs of the shoulder were measured postoperatively. Varus malreduction was defined as a head-shaft angle of <120 degrees. MAIN OUTCOME MEASUREMENTS Statistical analysis was done to establish correlations between loss of fixation and postoperative head-shaft angle in the true AP radiograph, patient age, fracture type, trauma mechanism, number of locking head screws, and type of plate. RESULTS The mean age was 62.3 +/- 15.4 years (22-92) and the mean injury severity score (ISS) was 9.5 +/- 10.16 (4-57; n = 73). The surgical approach was deltopectoral (90.2%) or transdeltoid (9.8%). No intraoperative complications were reported. The mean postoperative head-shaft angle was 130 degrees (95 degrees to 160 degrees; SD = 13). The overall incidence of loss of fixation was 13.7%. There was a statistically significant association between varus reduction (<120 degrees) and loss of fixation (30.4% when the head-shaft angle was <120 degrees versus 11% when the head-shaft angle was > or =120 degrees; P = 0.02). CONCLUSION This series presents the experience using PHLP in 5 Level 1 trauma centers. There were no intraoperative complications related to the locking plate systems. Despite the use of fixed-angle devices, loss of fixation occurred, primarily in the presence of varus malreduction. Our findings suggest that avoiding varus should substantially decrease the risk of postoperative failures.
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Brunner U, Köhler S. Schulterendoprothetik bei posttraumatischen Deformitäten durch Frakturfolgen. DER ORTHOPADE 2007; 36:1037-49. [PMID: 17960361 DOI: 10.1007/s00132-007-1157-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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