[4-fragment fractures of the proximal humerus. Alternative strategies for surgical treatment]

Clinical investigation for displaced proximal humeral fractures in the elderly: a randomized study of two surgical treatments: reverse total prosthetic replacement versus angular stable plate Philos (The DELPHI-trial)

BACKGROUND

Treatment for displaced proximal humeral fractures is still under debate. Few studies exist at the highest level of evidence. Although reversed total shoulder prosthesis has gained popularity and showed promising results in the treatment for proximal humeral fractures in the elderly patients, no randomized controlled trials exist to the authors' knowledge.

METHODS/DESIGN

This study is a randomized semi-blinded controlled multicenter trial designed according to the Consort statement and the recommendations given by the Cochrane reviewers for proximal humeral fractures. The study will investigate whether a reversed total shoulder prosthetic replacement gain better functional outcome compared to open reduction and internal fixation using an angular stable plate in displaced three- and four parts proximal humeral fractures after two and five years follow-up.Participants are aged 65-85 admitted in seven different hospitals with a displaced proximal humeral fracture according to AO-OTA type 11-B2 or 11-C2. The intervention group is surgical treatment using a reversed total shoulder prosthesis (Delta X-tend) compared to open reduction and internal fixation with an angular stable plate (Philos) and thread cerclage in the control group. 60 patients will be randomized to each group.The primary outcome is shoulder function (Constant score). Secondary outcomes will be patient self-assessment form (Oxford shoulder score), a quality of life questionnaire (15D score) and resource implications (cost-effectiveness). Follow-ups take place at 3, 6, 12 and 24 months, and five years. The trial design is semi-blinded with blinded physiotherapists performing the functional testing of patients at all follow-ups.Randomization to treatment groups is electronic online, by independent supervisor (web-CRF). The recruitment of patients started at January 1.st 2013. Inclusion of 120 patients during three years is expected.

DISCUSSION

This semiblinded trial include a high number of patients compared to existing randomized trials in this field. To our knowledge and according to ClinicalTrials.gov, this is the first study that compare these two treatments for a displaced proximal humeral fracture in elderly patients. This may provide important information to help the surgeon to decide the best treatment in the future.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01737060.

Complication rates and outcomes stratified by treatment modalities in proximal humeral fractures: a systematic literature review from 1970-2009

Background

The optimal treatment of complex, displaced proximal humeral fractures is controversial. A systematic literature review of the time period from 1970 to 2009 was conducted. The purpose was to evaluate the clinical success and complications of the available treatment modalities to determine specific treatment recommendations for the different fracture patterns.

Methods

The databases (PubMed/EMBASE) were searched for the time period (01/1970–09/2009). Study quality, treatment modalities, classification, outcome scores and complications of 200 publications including 9377 patients were analyzed. Interventions were compared by analysis of variance with subsequent Tukey’s-test. Complication rates among methods were compared by using Pearson’s-chi-square-test and pairwise comparisons using Fisher’s-two-tailed-exact-test.

Results

Hemiarthroplasty, angle-stable plate and non-operative treatment were used for 63% of the follow-up-patients. For 3- and 4-part fractures, patients with hemiarthroplasty [3-Part: 56.4 (lower/upper 95% confidence interval (CI): 43.3-68.7); 4-Part: 49.4 (CI: 42.2-56.7)] received a lower score than different surgical head-preserving methods such as ORIF [3-Part: 82.4 (CI: 76.6-86.9); 4-Part: 83.0 (CI:78.7-86.6)], intramedullary nailing [3-Part: 79.1 (CI:74.0-83.4)] or angle-stable plates [4-Part: 66.4 (CI: 59.7-72.4)].

The overall complication rate was 56%. The most common complications were fracture-displacement, malunion, humeral head necrosis and malreduction. The highest complication rates were documented for conventional plate and hemiarthroplasty and for AO-C, AO-A, for 3- and 4-part fractures. Only 25% of the data were reported with detailed classification results and the corresponding outcome scores.

Discussion

Despite the large amount of patients included, it is difficult to determine adequate recommendations for the treatment of proximal humeral fractures because a relevant lack of follow-up data impaired subsequent analysis. For displaced 3- and 4-part fractures head-preserving therapy received better outcome scores than hemiarthroplasty. However, a higher number of complications occurred in more complex fractures and when hemiarthroplasty or conventional plate osteosynthesis was performed. Thus, when informing the patient for consent, both the clinical results and the possibly expected complications with a chosen treatment modality should be addressed.

Evolution of treatment of of the proximal humerus fractures (review)

The article in generalized form acquaints with the publications devoted to the bases of proximal humeral fractures treatment. A brief digression on anatomy and biomechanics of the humeral joint allows to consider the main morphological features of it. The most commonly used classification of proximal humeral fractures concisely classify many types of damage. According to the clinical and anatomical characteristics of fractures tracked the historical aspect, the development and the current state of the most common methods of treatment. In his review collected works authors share their experience in the application of methods. It allows to further the perspective directions.

Fraturas da extremidade proximal do úmero: estudo comparativo entre dois métodos de fixação

OBJETIVO: Comparar o resultado do tratamento das fraturas da extremidade proximal do úmero. osteossíntese com a placa em t de pequenos fragmentos (grupo a), promovendo uma estabilização relativa, em contraposição à placa com parafusos bloqueados (grupo b). MÉTODOS: São alocados de forma aleatória 18 pacientes e avaliados prospectivamente, segundo critérios clínicos, escala funcional e parâmetros radiográficos da redução obtida. RESULTADOS: Pela escala analógica de dor a média aos seis meses de evolução foi 2,1 para o grupo a e 2,2 para o grupo b, a amplitude de elevação no grupo a foi de 140ºe de 143ºno grupo b e a pontuação na escala funcional da ucla foi respectivamente 30 e 31. Nas radiografias avaliadas; no grupo a, três pacientes obtiveram ângulos medidos após a estabilização entre 0º e 10º de desvio em relação à anatomia normal e seis entre 11º e 40º, no grupo b sete pacientes com ângulos entre 0º e 10º e dois entre 11º e 20º. CONCLUSÕES: Nos resultados precoces e tardios não ocorreram diferenças clínicas e funcionais nos dois grupos, prevalecendo uma alta incidência de bons resultados. as medidas radiográficas das reduções obtidas ficaram mais próximas do anatômico no grupo tratado com placas bloqueadas.

Proximal humeral fractures and intramedullary nailing: Experience with a new nail system

OBJECTIVES

The goal of this study was to evaluate fracture healing and alignment as well as functional outcome and complication risks after internal fixation with the intramedullary proximal humeral nail (PHN). This device shows promise for applications involving the reconstruction of the humeral shaft and head with minimal soft tissue stripping and for providing a locked, fixed-angle construct for secure fixation to permit controlled, early, and active rehabilitation.

DESIGN

Prospective case-series.

SETTING

Multicenter study in 11 trauma units.

PATIENTS

One-hundred and fifty-one patients were treated for the same number of proximal humerus fractures.

INTERVENTION

Open reduction and internal fixation with the intramedullary PHN.

MAIN OUTCOME MEASUREMENTS

Occurrence of postoperative complications during and up to 1 year of follow-up. The patients were actively followed up for 1 year with radiological assessment to observe fracture healing, alignment, reduction, and necrosis and by functional outcome measurements, including Constant, Disabilities of the Arm, Shoulder and Hand (DASH), and Neer scores.

RESULTS

A total of 113 patients (77% of 147 surviving patients) were available for the 1-year follow-up assessment, among whom 99% of all examined fractures had healed at this last time point. The range of motion (ROM) of the injured shoulder satisfactorily improved between all of the follow-up periods and by 1 year, 84-92% (ratio of injured to healthy contralateral shoulder) capacity had been achieved for all movements. The Constant score had significantly increased at the 3- and 6-month follow-ups, and by the final 1-year examination, this score attained up to 89% of the contralateral side. The mean baseline DASH was 5.9, with 62% of the total patient population having a zero DASH score. DASH scores higher than the preinjury scores were only observed in patients > 90 years of age, with this score significantly increasing with a mean difference of five points at the 1-year follow-up. At this last examination time point, patients had also reached a "satisfactory" mean Neer score of 85. Intraoperative complications were few (i.e., only four cases were documented) and solely related to the surgical technique; these problems included perforation of the articular surface by the oblique bolt or incorrect positioning of an additional screw. Humeral head necrosis was not common, with only four cases observed. Implant/surgery complications occurred in 63% (30/48) of the patients and included 13 cases of "cut through" (secondary impaction of the humeral head), nine cases of perforation of the articular surface, and four cases of implant loosening. Only four deaths were reported, and all were considered to be purely related to the patient and not to their participation in this study.

CONCLUSION

Nailing of proximal humeral fractures with the PHN is possible, but indication is limited to mainly A- and B-type fractures. The results of this multicenter study with many participating surgeons show that the operative technique is demanding and that the majority of documented complications are related to a violation of published basic technical steps during the operative procedure.

Tetracycline labeling as a measure of humeral head viability after 3- or 4-part proximal humerus fracture

HYPOTHESIS

Specifically located humeral head biopsies from three-part proximal humerus fractures taken at the time of hemiarthroplasty will show greater tetracycline labeling under fluorescent microscopy than those biopsies taken from four-part fractures. Additionally, biopsies from younger patients would show greater fluorescence than older patients.

MATERIAL AND METHODS

Nineteen consecutive adult patients (range 43-83 years) underwent hemiarthroplasty as definitive treatment for 20 displaced three- and four-part proximal humerus fractures after having received 500 mg of tetracycline hydrochloride orally every six hours for the immediate five preoperative days. Humeral head biopsies were taken from four pre-determined locations intraoperatively. The biopsies were prepared and analyzed with fluorescent microscopy.

RESULTS

All specimens in each biopsy location demonstrated fluorescence. There was no difference between the mean rank gray values for the four biopsy locations (p = 0.78 with the Friedman test). There was no difference between the mean rank gray values for the four biopsy locations when analyzed according to three-part vs four-part fracture (p > 0.05 with the Mann-Whitney test). There was an inverse relationship between age and fluorescence for the anterosuperior biopsy location (p = 0.033 with Spearman correlation).

DISCUSSION

Vascular supply is preserved in displaced three- and four-part proximal humerus fractures. With intact vascularity to the humeral head, head-preserving techniques utilizing stable, site-specific fixation and minimal dissection should be considered in the treatment of displaced three- and four-part proximal humerus fractures.

CONCLUSION

Vascular supply is preserved in displaced three- and four-part proximal humerus fractures, especially in younger patients in the anterosuperior aspect of the humeral head.

LEVEL OF EVIDENCE

Basic Science Study.

A new osteosynthesis device for the treatment of proximal humerus fractures. Description of the technique and preliminary results

The treatment of third proximal humerus complex fractures represents a challenge and osteosynthesis techniques are still controversial. The Authors report a new device that has been planned and used to treat this type of fracture, suitable for both young and elderly patients. The device consists of a perforated prismatic-triangular titanium cage (PTTC), available in different sizes so that it can be inserted in the bone cavity as a bridge. Thus, it supports the cephalic cap and, resting on the metaepiphyseal walls, allows greater and lesser tuberosities to be restored using osteosutures or minimal osteosynthesis devices. Furthermore, bone chips or bone substitutes can be inserted as filling in the perforated parts. From June 2005 to February 2006 we used this osteosynthesis surgical technique to treat 10 patients, 4 females and 6 males, all affected by proximal humerus complex fractures. No specific complications during and after surgery were noticed. The reported results are still to be considered as preliminary, but they are very encouraging. In all the cases the effective internal stabilisation allowed anatomical reduction of fragments, their stable fixation, reconstruction close to standard anatomy and early rehabilitation.

The block-bridge system: a new concept and surgical technique to reconstruct articular surfaces and tuberosities in complex proximal humeral fractures

Surgical treatment of complex displaced fractures of proximal humerus has changed in the last few years. Osteosynthesis has a high rate of nonunion, malunion, and avascular necrosis, and the results of hemiarthroplasty are not always functionally satisfactory. We report the results of a new technique for the reconstruction of the proximal humerus around a triangular-shaped bone block positioned inside the head and the metaphysis. The fragments are stabilized with minimal osteosynthesis by Kirschner wires, screws, or sutures. From 2001 to 2005, we treated 33 patients (20 men, 13 women) aged 34 to 74 years. The functional results were evaluated by the Constant score, with a mean follow-up of 24 months (range,12-36 months) The mean Constant score was 68 (range, 47-90). The results were excellent or good in 23 patients. The mean active anterior elevation was 160 degrees , all were pain free, and they returned to their preoperative activities, including sports. One patient had a symptomatic avascular necrosis that was treated with a hemiarthroplasty. The results show that this new technique has good clinical results with a low percentage of complications.

Unexpected high complication rate following internal fixation of unstable proximal humerus fractures with an angled blade plate

OBJECTIVES

The increasing number of fractures of the proximal humerus, especially in the elderly, carries with it the unsolved problem of the optimal treatment for the displaced or unstable fractures. The authors' goal was to analyze whether fixation with a bent valgus angled blade plate could improve the outcomes reported in the literature to date.

DESIGN

Prospective clinical study.

SETTING

Urban level 1 university trauma center.

PATIENTS

Over a 27-month period, 42 consecutive patients were treated for an unstable or displaced proximal humerus fracture.

INTERVENTION

Open reduction and internal fixation with a 90-degree cannulated angled blade plate prebent to 110 degrees.

MAIN OUTCOME MEASUREMENTS

Active follow-up for 1 year with assessment of objective and subjective functional results (ie, motion; strength; Constant score; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and visual analog scale (VAS)) and radiographic assessment (reduction, alignment, necrosis, and nonunion).

RESULTS

Follow-up was completed for 86% of the patients, who achieved a mean Constant score of 66 points (82% of the contralateral side) with a mean forward flexion of 125 degrees and an average strength of 72% of the contralateral side. Low disability (mean DASH score 22) and pain values (mean VAS 2) were demonstrated after this type of stabilization. The overall complication rate was 33% (12/36), with protrusion of the blade into the glenohumeral articulation as the most frequent problem (8/36, 22%). The negative impact of an adverse event on subjective and objective outcomes was only significant for forward flexion (P = 0.02). Neither clinical outcome nor complication rate was different when compared to patients with regard to fracture type (3 versus 4 parts) or age (younger or older than 70 years).

CONCLUSIONS

Fixation of displaced proximal humeral fractures with an angled blade plate provided sufficient stability. Blade perforation into the humeral joint occurred in every fourth patient and was found to be the major reason for a high complication rate. In view of this major problem, the technique described here cannot be recommended, even though the absence of nonunions in our series seems to support the low invasiveness of this surgical approach.

New trends in the treatment of proximal humerus fractures

For complex proximal humeral fractures, most authors agree on the importance of anatomic reduction and stable fixation to allow early range of motion. Currently a variety of techniques are used such as K-wires, t-plates, and primary prosthesis among others. However, no current treatment guidelines have been established. Newer implants provide greater angular stability, better biomechanical properties, and enhanced anchorage in these complex injuries. These implants therefore have a potential for achieving better results in treating complex fractures. We discuss current treatment concepts and focus on biomechanics and early results of new implants designed to provide angular stability.

LEVEL OF EVIDENCE

Expert Opinion, Level V. See the Guidelines for Authors for a complete description of levels of evidence.

Fractures in the proximal humerus: functional outcome and evaluation of 70 patients treated in hospital

INTRODUCTION

Patients with proximal humeral fractures are mostly elderly. In addition to the proximal humeral fracture, they often have other injuries related to poor bone quality. The surgical treatment of proximal humeral fractures in elderly patients with comminuted fractures is associated with several problems and a high frequency of complications. The aims of this study were to evaluate patients with a proximal humeral fracture treated in a hospital, assess the outcome of the fracture treatment, and decide whether surgical treatment of displaced proximal humeral fractures is superior to conservative treatment or not.

MATERIALS AND METHODS

Patients with fractures of the proximal part of the humerus treated in our hospital were followed during two different periods (14 and 10 months). The study in the first time period was retrospective in design, while in the second period the patients were followed prospectively. Seventy patients, (71% women) with a mean age of 71 years, were included in the study. A functional test was performed within 12-14 months after the injury using a modified Rowe shoulder score. Surgical treatment was performed in 15 patients (21%). Neither the surgical approach nor the implants used for osteosynthesis were standardized. Fifty-five patients (79%) were treated conservatively with a modified Velpeau bandage or a sling.

RESULTS

The fractures were classified according to AO into type A (27%), type B (58%) and type C (14%). Osteoporotic risk factors were present in many of the patients, mainly characterized by other skeletal injuries than the proximal humeral fracture (43%). In the group of complex, displaced, non-impacted fractures B2, B3, C2, C3 included (20 fractures), the group treated conservatively had a mean Rowe score of 48/75 (64% of maximum score) and SD 16.8, while in the surgically treated group the mean score was 28/75 (38% of maximum score) and SD 8.1. The difference between the two treatments was significant, with a p-value of 0.01 in favour of the conservatively treated group.

CONCLUSION

The number of patients in each of the fracture groups was low, but surgery did not benefit the patients with complex, displaced fractures in this study.

Die Versorgung dislozierter 3- und 4-Fragmentfrakturen des proximalen Humerus mit einem winkelstabilen Plattenfixateur

In the presented prospective study 35 consecutive patients with displaced 3- and 4-part fractures of the proximal humerus, including fracture dislocations, were treated with a fixator plate comprising angular stability between May 2001 and December 2002. After 18.5 (8-29) months 31 (89%) fractures were available for follow-up. Good and very good results were obtained in 64%. A poor result was documented in 23%. 64% of the patients had no or mild pain, 71% were able to abduct the arm over 90 degrees . Fracture classification according to Neer and AO had no influence on the outcome, with a mean Constant Score of 76 points. Partial avascular necrosis (AVN) of the humeral head was seen in 16% of all cases representing 4% of the fractures without dislocation and 80% of the fracture dislocations. Fracture dislocation (p=0.02) and AVN (p=0.005) had a negative effect on the Constant Score, with AVN being a predictor for a high level of pain (p=0.04). Secondary dislocation of the greater tuberosity was seen in two patients, loosening of screws in one patient and a fracture below the plate in another one. Secondary dislocation or loss of reduction of the head was not recorded. Angle stable plate fixation with tension band wiring of the tuberosities is an effective and safe option to treat this difficult fractures, also in elderly patients with osteoporotic bone. Because 40% of the 4-part fractures with fracture dislocation yielded a satisfactory or better result, the plate fixator with angular stability may be an alternative to prosthetic replacement in selected cases.

Cadaveric-biomechanical evaluation of bone-implant construct of proximal humerus fractures (Neer type 3)

BACKGROUND

A biomechanical cadaver study was performed to test the stability and strength of screw osteosynthesis of surgical neck fractures of the humerus.

METHODS

After bone density measurement, 64 cadaver proximal humerus bones were bent to create a subcapital fracture. The fracture was then stabilized by means of screw osteosynthesis randomly assigned to subgroups of screw positioning, size of screw, and stress test (torsion/bending).

RESULTS

Two screws applied laterally and parallel were 34.2% more stable than the normal arrangement. Bone density had a dominant role with regard to maximal bending and torsion force, but no significance was found with respect to additional screws through the major tuberculum or diameter of screws.

CONCLUSION

Two of the smaller 4.5-mm cannulated screws should be applied parallel from the lateral direction. Only range-of-motion exercises that produce a bending stress should be considered early after surgery, avoiding axial stress.