The amount of impaction and loss of reduction in osteoporotic proximal humeral fractures after surgical fixation

Factors influencing choice of treatment for proximal humeral fractures elaborated in a Delphi consensus process

INTRODUCTION

Hitherto, the decision-making process for treatment of proximal humerus fractures (PHF) remains controversial, with no established or commonly used treatment regimens. Identifying fracture- and patient-related factors that influence treatment decisions is crucial for the development of such treatment algorithms. The objective of this study was to define a Delphi consensus of clinically relevant fracture- and patient-related factors of PHF for clinical application and scientific research.

METHODS

An online survey was conducted among an international panel of preselected experienced shoulder surgeons. An evidence-based list of fracture-related and patient-related factors affecting treatment outcome after PHF was generated and reviewed by the members of the committee through online surveys. The proposed factors were revised for definitions, and suggestions from the first round mentioned in the free text were included as possible factors in the second round of surveys. Consensus was defined as having at least a two-thirds majority agreement.

RESULTS

The Delphi consensus panel consisted of 18 shoulder surgeons who completed 2 rounds of online surveys. There was an agreement of more than two-thirds of the panel for three fracture-related factors affecting treatment decision in the case of PHF: head-split fracture, dislocated tuberosities, and fracture dislocation. Of all patient-related factors, a two-thirds consensus was reached for two factors: age and rotator cuff tear arthropathy.

CONCLUSION

This study successfully conducted a Delphi consensus on factors influencing decision-making in the treatment of proximal humeral fractures. The documented factors will be useful for clinical evaluation and scientific validation in future studies.

Predicting the deltoid tuberosity index in proximal humerus fractures using fracture characteristics and patient age: development of the LBQ-PHF score

BACKGROUND

The aim of this study was to investigate (1) whether fracture pattern and age are associated with local bone quality (LBQ), and (2) whether a scoring system based on these variables is able to predict LBQ in proximal humerus fractures (PHF).

MATERIALS AND METHODS

A retrospective study was performed of all acute PHF at a Level 2 trauma center with plain radiographs and CT between June 2009 and March 2022. Local bone quality was measured by using the deltoid tuberosity index (DTI). In addition to age and gender, fracture morphology was categorized using the following classification systems: Neer, Resch, AO Foundation/Orthopaedic Trauma Association (AO/OTA), and Hertel/LEGO. Additionally, coronal head alignment was calculated by measuring the head-shaft angle.

RESULTS

Only the Resch classification system revealed a significant relationship between fracture type and bone quality, as there was a significant association between coronal head alignment and DTI (p = 0.001). Valgus head alignment was observed significantly more frequent in patients with low bone quality (p = 0.002). Multinomial logistic regression analysis revealed a significant relative risk ratio for age (RRR = 0.97, [95% CI, 0.94-1], p = 0.039) and a non-significant trend for DTI (RRR = 1.26, [95% CI, 0.96-1.64], p = 0.092) for occurrence of anatomic relative to valgus head alignment. Using a DTI cut-off value of 1.3 instead of 1.4, age and also varus head alignment were identified as significant predictors of LBQ (OR = 1.12, [95% CI, 1.1-1.15], p < 0.001; OR = 0.54, [95% CI, 0.3-0.96], p = 0.037). A scoring system called the LBQ-PHF score (local bone quality in proximal humerus fractures), developed based on these two variables was able to predict LBQ with a sensitivity of 79.2% and a specificity of 86.7%.

CONCLUSION

Age and coronal humeral head alignment are independent predictors of LBQ in PHF. A simple scoring system developed based on these variables is able to assess BQ with solid predictive characteristics.

Allografts are not necessary for displaced proximal humeral fractures in patients less than 65 years old, a retrospective cohort study

INTRODUCTION

Displaced proximal humeral fractures (PHF) are frequently treated with locking plates to achieve osteosynthesis. Bone grafts are used as augmentation techniques to improve stability in osteoporotic patients. However, there has been little research into whether bone grafts are necessary for patients younger than 65 years old. This study compared radiographic and clinical outcomes between PHFs augmented with bone grafts or not in a younger population.

METHODS

Between January 2016 and June 2020, 91 patients treated with a locking plate alone (LP), and 101 patients treated with locking plates augmented with bone grafts (BG) were analyzed. Potential confounding factors for outcomes were adjusted by propensity score-matching analyses. For the retrospective cohort study, 62 patients from each group were evaluated for radiographic outcomes and clinical outcomes and compared.

RESULTS

Sixth-two patients in each group, both with a mean age of 52 years old, were with a mean follow-up time of 25 months in the LP group and 26 months in the BG group. There was no difference in demographic or surgical characteristics between the two groups after propensity score-matching. With regard to radiographic outcomes, the changes in neck-shaft angle (-5.1 ± 4.9 vs. -3.1 ± 5.3, p = 0.015) and humeral head height (-1.5 ± 2.5 vs. -0.4 ± 2.7, p = 0.002) were more obvious in the BG group. However, regarding functional outcomes, there were no significant differences between the two groups in DASH score, Constant-Murley score, or VAS score. Moreover, the complication rate was not significantly different between two groups.

DISCUSSION

Allografts only provide minor improvements of stability in radiography for patients less than 65 years old after locking plate fixation of PHFs, but don't improve shoulder function, relieve pain or reduce complications. We concluded that allografts are unnecessary for younger patients with displaced PHFs.

Hemiarthroplasty for proximal humerus fractures and for fracture sequelae: did not differ in their outcomes

Background

The role of hemiarthroplasty (HA) in the management of proximal humerus fractures (PHFs) and their sequalae has evolved with the development of contemporary internal fixation techniques and the widespread use of the reverse total shoulder arthroplasty. However, HA may still have a role in certain acute PHFs as well as select fracture sequalae. The aim of this investigation was to evaluate the outcomes of HA when used in acute fractures and fracture sequelae.

Methods

Over a 16-year period (2000 - 2016), 122 primary HA performed for either acute PHFs or fracture sequelae were identified. Of these, 70 (57.4%) HA were performed within 4 weeks of the injury, whereas 52 (42.6%) underwent HA for fracture nonunion, malunion, or avascular necrosis. The minimum follow-up period was 2 years. Outcomes included the visual analog scale for pain, range of motion, American Shoulder and Elbow Surgeons (ASES) score, complications, and reoperations inclusive of revision surgery. Cumulative incidence analysis was used to report implant survivorship with death as a competing risk.

Results

The mean follow-up time after HA was 4.8 years (range, 2-15 years) with no differences between groups (P = .102). Cohort comparisons demonstrated an older age (67.8 vs. 60.1; P = .004), lower rate of previous procedure (4.3% vs. 51.9%; P < .001), lower bone graft use (28.6% vs. 59.6%; P < .001), and a longer length of stay (5.9 vs. 3.0 days; P < .001) in the acute HA group. Additionally, no differences were observed between the acute and sequalae cohort in pain (2.0 vs. 2.5; P = .523), forward elevation (98° vs. 93°; P = .627), external rotation (30° vs. 23°; P = .215), internal rotation score (4.0 vs. 4.5; P = .589), satisfaction (P = .592), ASES scores (64.4 vs. 57.1; P = .168), complications (27.1% vs. 28.8%; P = .836), or reoperations (11.4% vs. 19.2%; P = .229). When comparing acute fractures and sequalae, the 15-year complication rates were 32.4% and 43.3%, respectively (P = .172), with 15-year reoperation rates of 13.7% and 24%, respectively (P = .098).

Conclusions

HA, whether performed acutely for a PHF or in a delayed fashion for fracture sequalae, demonstrated no statistically significant differences in outcomes for all examined parameters. HA in this setting may provide reasonable pain relief. However, limited motion, marginal ASES scores, and elevated rates of complications and reoperations can be expected up to 15 years postoperatively.

[Fracture analysis, indication for endoprosthesis and implant selection in proximal humeral fractures]

Proximal humeral fractures (PHF) are the third most common fracture in humans and the incidence is increasing. There are basically three treatment strategies: conservative, joint-preserving reconstructive or joint-replacing procedures. In addition to fracture morphology, patient-specific and surgeon-specific factors are particularly important when deciding on treatment. The experience and training of the surgeon also play a decisive role. In the case of joint-preserving treatment, the risk of osteosynthesis failure and of sequelae of the fracture must always be assessed. If conservative or reconstructive treatment methods are not promising, the joint-replacing procedure is the treatment of choice. The anatomical fracture prosthesis is only indicated, if at all, for young patients with a destroyed humeral head with a preserved rotator cuff and large fragments of the tuberosities. In advanced age, the implantation of a reverse endoprosthesis is increasingly used for dislocated, multifragmentary PHF. In both procedures, the anatomical healing of the tuberosities has a significant impact on the functional outcome.

[Augmentation in the treatment of proximal humeral and femoral fractures]

BACKGROUND

Proximal humeral and trochanteric femoral fractures in older patients are typically caused by low-energy trauma and are therefore often associated with osteoporosis. The treatment of such fragility fractures can be difficult as implant purchase is reduced in osteoporotic bone. By augmenting the fixation with cement the contact surface between implant and bone can be increased, which improves the stability of the osteosynthesis.

OBJECTIVE

This article describes the operative technique for the augmentation of trochanteric femoral fractures treated with the Trochanteric Fixation Nail-Advanced (TFNA, DePuy Synthes, Oberdorf BL, Switzerland) and proximal humeral fractures stabilized with a PHILOS plate (DePuy Synthes). Furthermore, the evidence for the augmentation of these two fracture types is elucidated.

RESULTS

Biomechanical studies could show an improved stability of the osteosynthesis after successful augmentation for both fracture types. The current evidence also indicates a clinical reduction of fixation failure. Whether the augmentation has an influence on the functional result could so far not yet clearly be proven.

CONCLUSION

Augmentation seems to be a safe and valuable addition to available treatment options especially for patients with fragility fractures.

Cortical bone thickness of the distal radius predicts the local bone mineral density

AIMS

The distal radius is a major site of osteoporotic bone loss resulting in a high risk of fragility fracture. This study evaluated the capability of a cortical index (CI) at the distal radius to predict the local bone mineral density (BMD).

METHODS

A total of 54 human cadaver forearms (ten singles, 22 pairs) (19 to 90 years) were systematically assessed by clinical radiograph (XR), dual-energy X-ray absorptiometry (DXA), CT, as well as high-resolution peripheral quantitative CT (HR-pQCT). Cortical bone thickness (CBT) of the distal radius was measured on XR and CT scans, and two cortical indices mean average (CBTavg) and gauge (CBTg) were determined. These cortical indices were compared to the BMD of the distal radius determined by DXA (areal BMD (aBMD)) and HR-pQCT (volumetric BMD (vBMD)). Pearson correlation coefficient (r) and intraclass correlation coefficient (ICC) were used to compare the results and degree of reliability.

RESULTS

The CBT could accurately be determined on XRs and highly correlated to those determined on CT scans (r = 0.87 to 0.93). The CBTavg index of the XRs significantly correlated with the BMD measured by DXA (r = 0.78) and HR-pQCT (r = 0.63), as did the CBTg index with the DXA (r = 0.55) and HR-pQCT (r = 0.64) (all p < 0.001). A high correlation of the BMD and CBT was observed between paired specimens (r = 0.79 to 0.96). The intra- and inter-rater reliability was excellent (ICC 0.79 to 0.92).

CONCLUSION

The cortical index (CBTavg) at the distal radius shows a close correlation to the local BMD. It thus can serve as an initial screening tool to estimate the local bone quality if quantitative BMD measurements are unavailable, and enhance decision-making in acute settings on fracture management or further osteoporosis screening. Cite this article: Bone Joint Res 2021;10(12):820-829.

Outcomes of Management of Proximal Humeral Fractures with Patient-Specific, Evidence-Based Treatment Algorithms

BACKGROUND

Previous studies have identified risk factors for different types of treatment of proximal humeral fracture (PHF) and allowed the development of a patient-specific, evidence-based treatment algorithm with the potential of improving overall outcomes and reducing complications. The purpose of this study was to evaluate the results and complications of treating PHF using this algorithmic approach.

METHODS

All patients with isolated PHF between 2014 and 2017 were included and prospectively followed. The initial treatment algorithm (Version 1 [V1]) based on patients' functional needs, bone quality, and type of fracture was refined after 2 years (Version 2 [V2]). Adherence to protocol, clinical outcomes, and complications were analyzed at a 1-year follow-up.

RESULTS

The study included 334 patients (mean age, 66 years; 68% female): 226 were treated nonoperatively; 65, with open reduction and internal fixation (ORIF); 39, with reverse total shoulder arthroplasty (RTSA); and 4, with hemiarthroplasty. At 1 year, the preinjury EuroQol 5-Dimension (EQ-5D) values were regained (0.88 and 0.89, respectively) and the mean relative Constant Score (CS) and Subjective Shoulder Value (SSV) (and standard deviation [SD]) were 96% ± 21% and 85% ± 16%. Overall complications and revision rates were 19% and 13%. Treatment conforming to the algorithm outperformed non-conforming treatment with respect to relative CS (97% versus 88%, p = 0.016), complication rates (16.3% versus 30.8%, p = 0.014), and revision rates (10.6% versus 26.9%, p < 0.001).

CONCLUSIONS

Treating PHF using a patient-specific, evidence-based algorithm restored preinjury quality of life as measured with the EQ-5D and approximately 90% normal shoulders as measured with the relative CS and the SSV. Adherence to the treatment algorithm was associated with significantly better clinical outcomes and substantially reduced complication and revision rates.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cancellous bone allograft is comparable to fibular strut allograft for augmentation in three- or four-part proximal humeral fractures

BACKGROUND

Bone grafts have been used for augmentation and improving stability of reduced fractures in proximal humeral fractures. The aim of this study was to analyze the clinical and radiological outcomes after the use of cancellous bone allografts (CAs) for augmentation in 3- or 4-part proximal humeral fractures, and compare with fibular strut allografts (FAs).

METHODS

Between November 2016 and February 2018, 55 patients, followed for at least 1 year, with 3- or 4-part proximal humeral fractures fixed with locking plates were included and grouped according to the type of allograft bone used for augmentation. In this retrospective analysis, we assessed and compared the clinical and radiological outcomes of the 2 groups, using the visual analog scale score, the Constant-Murley score (CMS), the disability of the arm, shoulder, and hand (DASH) score, the range of movement, neck-shaft angle (NSA), humeral head height (HHH), and the changes of NSA and HHH, as well as recording any complications. The repeatedly measured clinical and radiological outcomes were analyzed by linear mixed models. The differences in outcomes between groups at the final follow-up were compared using Student's t test.

RESULTS

There were 28 patients in the CA group and 27 patients in the FA group with an average follow-up of 14.5 months. The mean age of all patients was 64 (36-86). Nonsignificant group effects were observed on CMS (β = -8.792, P = .216), DASH (β = 1.329, P = .094), NSA (β = 1.432, P = .752), and HHH (β = 1.660, P = .628). At the final follow-up, the patients in the CA group showed no significant differences in visual analog scale (1.8 vs. 2.2, P = .276), CMS (81.5 vs. 75.4, P = .072), and DASH (11.0 vs. 13.5, P = .235) scores compared with the FA group. There were no significant differences in the change of NSA (6 vs. 4, P = .387) or HHH (1 vs. 2, P = .261).

CONCLUSIONS

Patients with 3- or 4-part proximal humeral fractures treated with locking plates combined with CAs have good clinical and radiographic outcomes, similar to those treated with FAs.

Treatment of Distal Metaphyseal Tibial Fractures with Anterolateral Plates or with Anterolateral-Medial Plates: A Retrospective Series

Distal metaphyseal tibial fractures (3-5 cm from the joint with zones of comminution or <3 cm from the joint) are challenging to fix and are associated with many complications. The study objective was to evaluate the functional outcomes and complications after treating distal metaphyseal tibial fractures using anatomical anterolateral tibia locking plates or anterolateral-medial plates. This retrospective study included 57 patients with distal metaphyseal tibial fractures. Thirty patients were treated by open reduction internal fixation with anterolateral plates; 27 patients were treated with anterolateral-medial plates. Patients were followed at regular intervals. The time to fracture union and complications were recorded. We evaluated the stage of fracture healing using the Radiographic Union Score for Tibial fractures. The patients treated with anterolateral plates had significantly higher rates of loss of reduction and malunion than those treated with anterolateral-medial plates (p = .02 and p = .002, respectively). There were no significant differences in the radiographic union scores (p = .22), non-union (p = .17), incision necrosis (p = .91), or infection (p = .94) between the 2 groups. The functional outcomes were assessed using the American Orthopedic Foot and Ankle Society hindfoot-ankle score at the 12-month follow-up. The mean hindfoot-ankle scores were 90.9 ± 5.0 (range 79 to 100, median 90) and 92.3 ± 5.1 (range 82 to 100, median 92) for the anterolateral plates and anterolateral-medial plates, respectively (p = .29). For distal metaphyseal tibial fractures, anterolateral-medial plates may be worthwhile for reducing loss of reduction and malunion.

Medial cortical positive support: A key factor for the postoperative stability of proximal humerus fractures

Treatments for proximal humerus fractures (PHFs) often fail to achieve anatomical reduction. The purpose of this study was to evaluate the role of positive medial cortical support (PMCS) in the nonanatomical reduction of PHFs.A retrospective analysis was performed of 78 patients with PHFs who underwent surgery from August 2014 to September 2017 and whose treatments did not achieve anatomical reduction. Based on the results of standard AP radiographs of the shoulders 3, 6, and 12 months after surgery, the patients were divided into PMCS or negative medial cortical support (NMCS) groups. The postsurgical change in head-shaft angle (HSA) between the 2 groups was compared. Shoulder joint function and visual analog scale (VAS) scores of the 2 groups were also compared at the same time.Of the 78 patients analyzed, 37 were in the PMCS group and, 41 in the NMCS group. There was no statistically significant difference in any of the characteristics of the 2 groups (P > .05), or in postsurgical HSA. However, the HSA of the 2 groups had become significantly different (P < .05) 3, 6, and 12 months following surgery. The changes in HSA of the 2 groups were different at various time points (P < .05). One year after surgery, the shoulder function score of the PMCS group was significantly better than that of the NMCS group, as was the VAS score (both P < .05).Patients whose surgery for PHF does not achieve anatomical reduction during surgery can undergo PMCS to achieve improved results, postoperatively. NMCS should be avoided as far as possible.

Current Controversies in the Treatment of Geriatric Proximal Humeral Fractures

➤

Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes. Factors such as surgeon experience as well as the quality and maintenance of the reduction may influence operative outcomes, and their impact on these findings merits further investigation.

➤

In the treatment of 2 and 3-part fractures involving the surgical neck, intramedullary nailing has demonstrated functional outcomes that are comparable with those of open reduction and internal fixation (ORIF).

➤

In the geriatric population, reverse total shoulder arthroplasty has demonstrated improved functional outcomes, with a decreased rate of reoperation, compared with hemiarthroplasty. Tuberosity repair has been shown to improve functional outcomes and range of motion after both procedures and should be performed at the time of arthroplasty.

➤

Several authors have demonstrated the negative effect of osteopenia on outcomes after ORIF of proximal humeral fractures. Augmentative procedures, including cortical strut augmentation, are being investigated to address this issue; their role in the treatment of these fractures is unclear at this time.

Factors associated with maintaining reduction following locking plate fixation of proximal humerus fractures: a population-based retrospective cohort study

Background

Loss of reduction (LoR) can occur after locking plate fixation of proximal humerus fractures (PHFs). This study determined biomechanical features of fracture fixation associated with preventing LoR postoperatively. One-year reoperation rates were also compared between those with/without LoR.

Methods

Population-based administrative data for 359 adults treated using a locking plate for PHF between 2010 and 2016 were examined. Two trained assessors reviewed standardized shoulder radiographs. LoR (Yes/No) was defined as any fracture displacement >0.5 cm, and/or >10° change in neck-shaft angle (NSA) alignment relative to intraoperative imaging. Multiple logistic regression assessed how the following affected maintaining reduction: (1) sex, (2) age, (3) Neer classification, (4) shaft impaction (SI), (5) shaft medialization (SM), (6) calcar reduction (CR), (7) NSA alignment, and (8) screw use.

Results

LoR was seen in 79 (22%) patients. LoR was significantly associated with increasing age (odds ratio [OR] = 1.06/yr, P < .001), fracture severity (4-part vs. 2-part fracture; OR = 4.63, P = .001), and varus NSA alignment (<125° vs. ≥145°: OR = 5.6, P = .02; <125° vs. 125-145°, OR = 2.2, P = .02]). Patients achieving simultaneous SI, SM, and CR were significantly less likely (OR = 0.009, P < .001) to lose reduction, after controlling for age, fracture severity, and NSA alignment. If only SI was achieved, patients were still significantly less likely to lose reduction relative to achieving none of these mechanical features (OR = 0.17, P = .006). Reoperations were higher when LoR occurred (n = 26/77 [33.4%]) compared with no LoR (n = 20/276 [7.2%]) (P < .001).

Conclusions

SI was strongly associated with preventing LoR in patients treated using a locking plate for PHF. SI with concurrent SM, CR, and a neutral or valgus NSA had the lowest rates of LoR. LoR was associated with higher rates of reoperation.

All-Suture Anchor Settling After Arthroscopic Repair of Small and Medium Rotator Cuff Tears

BACKGROUND

All-suture anchors are increasingly being used in rotator cuff repair. However, there are debates on the micromotion of all-suture anchors.

PURPOSE

To perform rotator cuff repair on patients with rotator cuff tears and different shoulder bone mineral densities (BMDs) and investigate (1) where the anchor is located under the cortex, (2) if there is any anchor migration settling during follow-up, and (3) if structural outcome differs according to shoulder BMD.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We retrospectively investigated 88 patients who underwent arthroscopic single-row repair for small- to medium-sized rotator cuff tears (age [mean ± SD], 58.8 ± 7.1 years) from 712 cases of rotator cuff tendon repair between November 2015 and February 2018. Inclusion criteria were as follows: use of an all-suture anchor; preoperative shoulder BMD; and magnetic resonance imaging (MRI) conducted preoperatively, 2 days after surgery, and 10 months after surgery. Patients were excluded from the study if they underwent open rotator cuff repair (n = 118), got surgery with a double-row technique (n = 178), underwent surgery with anchors other than the all-suture type (n = 273), received anchor insertion in sites other than the greater tuberosity owing to concomitant procedures such as biceps tenodesis and subscapularis repair (n = 29), did not take preoperative shoulder BMD (n = 15), had more than a large-size tear (n = 6), and were lost to follow-up (n = 5). After compression of the all-suture anchor during surgery, the strands were pulled multiple times to ensure that the anchor was fixed onto the bone with appropriate tension. BMD was measured before surgery. Depth to anchor (DA), anchor settling, and repaired rotator cuff integrity were measured with MRI. Patients were categorized into 3 groups: group A (BMD, <0.4 g/cm²; n = 31), group B (BMD, 0.4-0.6 g/cm²; n = 32), and group C (BMD, >0.6 g/cm²; n = 25). A total of 65 patients had follow-up MRI. On the basis of rotator cuff tendon integrity, patients were categorized into either a sufficient thickness group (group S, Sugaya classification grade II or lower; n = 44) or an insufficient thickness group (group I, Sugaya classification grade III or higher; n = 21).

RESULTS

On time-zero MRI, the DA differed significantly among groups (group A, 3.62 ± 2.02 mm; group B, 5.18 ± 2.13 mm; group C, 6.30 ± 3.34 mm) (P = .001). The DA was deeper in patients with a higher BMD at time zero (r = 0.374; P = .001), but the DA did not differ at follow-up MRI (mean, 10.3 months after surgery). On follow-up MRI, anchor settling tended to increase with deeper time-zero DA (r = 0.769; P < .001). Anchor settling was significantly different among groups (group A, 1.33 ± 1.08 mm; group B, 2.78 ± 1.99 mm; group C, 3.81 ± 2.19 mm) (P = .001). The proportion of patients with sufficient thickness in each group did not show a statistical difference (group A, 70.8%; group B, 72.7%; group C, 57.9%) (P = .550).

CONCLUSION

In conclusion, this study confirmed that the postoperative site of anchor insertion in arthroscopic single-row rotator cuff repair with all-suture anchors was located farther from the cortex in patients with higher shoulder BMD and closer to the subcortical bone in patients with lower BMD. On follow-up MRI, no further settling occurred past a certain distance from the cortex, and there was no significant difference in anchor depth or integrity of the rotator cuff tendon based on shoulder BMD. Therefore, minimal settling in the all-suture anchor did not show clinical significance.

Late screw-related complications in locking plating of proximal humerus fractures: A systematic review

Locking plating is a common surgical treatment of proximal humeral fractures with satisfactory clinical results. Implant-related complications, especially screw-related, have been reported, however, the lack of information regarding their onset, used surgical technique, complexity of the fracture, bone quality etc., prevents from understanding the causes for them. The aim of this systematic review is to identify the potential risk factors for late screw complications by gathering information about the patient characteristics, comorbidities, fracture types, surgical approaches and implant types. A PubMed search was performed using humerus, fractures, bone and locking as keywords in clinical papers written in English. All abstracts and manuscripts on distal or humerus shaft fractures, and those on proximal humerus fractures without any or with only iatrogenic complications were excluded. One hundred studies met the inclusion criteria, resulting in 33% of the reported cases having at least one complication, with 11% of all complications being screw-related. Most of the latter were secondary screw perforations and screw cut-outs, being predominantly linked to poor bone quality, while screw loosening and retraction were found less frequently as a result of locking mechanism failure. Overall, the amount of information for complications was limited and screw perforation was the most frequent screw-related complication, mostly reported in female patients older than 50 years, following four-part or AO/OTA type C fractures and detected four weeks postoperatively. The sparse information in the literature could be an indicator that the late screw complications might have been under-reported and under-described, making the understanding of the screw-related complications even more challenging.

Screw configuration in proximal humerus plating has a significant impact on fixation failure risk predicted by finite element models

BACKGROUND

Proximal humeral fractures occur frequently, with fixed angle locking plates often being used for their treatment. No current quantitative evidence for the effect of different screw configurations exists, and the large number of variations makes biomechanical testing prohibitive. Therefore, we used an established and validated finite element osteosynthesis test kit to quantify the effect of variations in screw configuration on predicted failure risk of PHILOS plate fixation for unstable proximal humerus fractures.

METHODS

Twenty-six low-density humerus models were osteotomized to create malreduced unstable 3-part fractures that were virtually fixed with PHILOS plates. Twelve screw configurations were simulated: 6 using 2 screw rows, 4 using 3 rows, and 1 with either 8 or 9 screws. Three physiological loading cases were modeled and an established finite element analysis methodology was used. The average peri-screw bone strain, previously demonstrated to predict fatigue cutout failure, was used to compare the different configurations.

RESULTS

Significant differences in peri-screw strains, and thus predicted failure risk, were seen with different combinations. The 9-screw configuration demonstrated the lowest peri-screw strains. Fewer screw constructs showed lower strains when placed further apart. The calcar screws (row E) significantly (P < .001) reduced fixation failure risk.

CONCLUSION

Screw configurations significantly impact predicted cutout failure risk for locking plate fixations of unstable proximal humerus fractures in low-density bone. Although requiring clinical corroboration, the result of this study suggests that additional screws reduce peri-screw strains, the distance between them should be maximized whenever possible and the calcar screws should be used.

Low complication rates in Minimally Invasive Plate Osteosynthesis (MIPO) for proximal humeral fractures at 5 years of follow-up

INTRODUCTION

Purpose of this study was to analyse the medium term follow-up of minimally invasive plate osteosynthesis (MIPO) for proximal humeral fractures in terms of postoperative shoulder function, radiological outcome and complications.

METHODS

76 consecutive patients with unstable proximal humeral fractures were treated using locking plate with a minimally invasive antero-lateral approach in two surgical centers. Constant score and radiographic evaluation of 74 patients were available at mean follow up of 5 years (minimum 4 years).

RESULTS

Mean Constant score was 74 (range to 28-100). Results were comparable in the two centers. Younger patients registered significantly higher scores (p < 0.05). 20 patients (27%) developed complications. Subacromial impingement occurred in 16,2% of cases for varus malreduction (6,7%) and for too proximal plate positioning (9,5%). Primary screws perforation (2,7%), secondary perforation due to cut-out (1,4%), avascular necrosis (AVN) of humeral head (1,4%), partial resorption of greater tuberosity (2,7%), secondary displacement of the greater tuberosity (2,7%) and stiffness (2,7%) were observed.

DISCUSSION AND CONCLUSIONS

Even at a medium term follow-up, MIPO for proximal humeral fractures ensured good and reproducible results for most common pattern of fractures. Major complications were lower respect to open procedures, because of soft tissue, deltoid muscle and circumflex vessels sparing.

Evidence-based algorithm to treat patients with proximal humerus fractures-a prospective study with early clinical and overall performance results

BACKGROUND

On the basis of patients' demands, bone quality, and fracture type, we developed an evidence-based treatment algorithm for proximal humerus fractures (PHF) that includes all treatment modalities from open reduction and internal fixation, hemiprosthesis, to reverse total shoulder arthroplasty. This study was done to assess its feasibility and early clinical outcome.

MATERIALS AND METHODS

Patients with isolated PHF in 2014 and 2015 were included in this prospective study. The quality of life (EQ-5D) and the level of autonomy before injury were recorded. The fractures were classified and local bone quality was measured. When possible, patients were treated according to the algorithm. Radiographic and clinical follow-up-Constant score, subjective shoulder value, and EQ-5D-took place after 3 months and 1 year. The rate of unplanned surgery was analyzed.

RESULTS

A total of 192 patients (mean age 66 years; 58 male, 134 female) were included. Of these, 160 (83%) were treated according to the algorithm. In total, 132 patients were treated conservatively, 36 with open reduction and internal fixation and 24 with reverse total shoulder arthroplasty or hemiarthroplasty. Generally, the mean EQ-5D before trauma and 1 year after treatment was equal to 0.88 to 0.9 points. After 1 year, the overall mean relative Constant score was 95% and mean subjective shoulder value 84%. Unplanned surgery was necessary in 21 patients.

CONCLUSION

This comprehensive algorithm is designed as a noncompulsory treatment guideline for PHF, which prioritize the patient's demands and biology. The high adherence proves that it is a helpful tool for decision making. Furthermore, this algorithm leads to very satisfying overall results with low complication and revision rates.

The outcome of surgical management of proximal humeral fractures using locking plates: comparison between locking plates with different geometry

BACKGROUND

Locking plate fixation appears to be a standard treatment for proximal humeral fracture. Different locking plate designs might result in different radiographic and functional outcomes. The original version of the Proximal Humeral Internal Locking System (PHILOS; DePuy Synthes, Warsaw, IN, USA) occupied the largest volume of the humeral head by screw distribution, whereas the Zimmer Periarticular Locking Plate (ZPLP) system (Zimmer Biomet, Warsaw, IN, USA) occupied the smallest.

METHODS

We enrolled 50 patients undergoing ZPLP treatment and 50 undergoing PHILOS treatment.

RESULTS

The postoperative amount of impaction was significantly higher using the ZPLP System than using the PHILOS. Subgroup analysis showed that medial calcar support was another critical factor that affected surgical outcomes, especially when using the ZPLP System.

CONCLUSION

The amount of postoperative impaction was significantly higher when the ZPLP was used compared with the PHILOS locking plate. Medial calcar support is another critical factor that affects surgical outcomes. However, no significant differences in functional outcomes (Constant-Murley score) between the ZPLP System and the PHILOS were noted at the 12-month follow-up.

Influence of Medial Support Screws on the Maintenance of Fracture Reduction after Locked Plating of Proximal Humerus Fractures

Background

Technical aspects of the correct placement of medial support locking screws in the locking plate for proximal humerus fractures remain incompletely understood. This study was to evaluate the clinical relationship between the number of medial support screws and the maintenance of fracture reduction after locked plating of proximal humerus fractures.

Methods

We retrospectively evaluated 181 patients who had been surgically treated for proximal humeral fractures (PHFs) with a locking plate between September 2007 and June 2013. All cases were then subdivided into one of four groups as follows: 75 patients in the medial cortical support (MCS) group, 26 patients in the medial multiscrew support (MMSS) group, 29 patients in the medial single screw support (MSSS) group, and 51 patients in the no medial support (NMS) group. Clinical and radiographic evaluations included the Constant-Murley score (CM), visual analogue scale (VAS), complications, and revision surgeries. The neck-shaft angle (NSA) was measured in a true anteroposterior radiograph immediately postoperation and at final follow-up. One-way analysis of variance or Kruskal-Wallis test was used for statistical analysis of measurement data, and Chi-square test or Fisher's exact test was used for categorical data.

Results

The mean postoperative NSAs were 133.46° ± 6.01°, 132.39° ± 7.77°, 135.17° ± 10.15°, and 132.41° ± 7.16° in the MCS, MMSS, MSSS, and NMS groups, respectively, and no significant differences were found (F = 1.02, P = 0.387). In the final follow-up, the NSAs were 132.79° ± 6.02°, 130.19° ± 9.25°, 131.28° ± 12.85°, and 127.35° ± 8.50° in the MCS, MMSS, MSSS, and NMS groups, respectively (F = 4.40, P = 0.008). There were marked differences in the NSA at the final follow-up between the MCS and NMS groups (P = 0.004). The median (interquartile range [IQR]) NSA losses were 0.0° (0.0-1.0)°, 1.3° (0.0-3.1)°, 1.5° (1.0-5.2)°, and 4.0° (1.2-7.1)° in the MCS, MMSS, MSSS, and NMS groups, respectively (H = 60.66, P < 0.001). There were marked differences in NSA loss between the MCS and the other three groups (MCS vs. MMSS, Z = 3.16, P = 0.002; MCS vs. MSSS, Z = 4.78, P < 0.001; and MCS vs. NMS, Z = 7.34, P < 0.001). There was also significantly less NSA loss observed in the MMSS group compared to the NMS group (Z = -3.16, P = 0.002). However, there were no significant differences between the MMSS and MSSS groups (Z = -1.65, P = 0.225) or the MSSS and NMS groups (Z = -1.21, P = 0.099). The average CM scores were 81.35 ± 9.79, 78.04 ± 8.97, 72.76 ± 10.98, and 67.33 ± 12.31 points in the MCS, MMSS, MSSS, and NMS groups, respectively (F = 18.68, P < 0.001). The rates of excellent and good CM scores were 86.67%, 80.77%, 65.52%, and 43.14% in the MCS, MMSS, MSSS, and NMS groups, respectively (χ² = 29.25, P < 0.001). The median (IQR) VAS scores were 1 (0-2), 1 (0-2), 2 (1-3), and 3 (1-5) points in the MCS, MMSS, MSSS, and NMS groups, respectively (H = 27.80, P < 0.001). Functional recovery was markedly better and VAS values were lower in the MCS and MMSS groups (for CM scores: MCS vs. MSSS, P < 0.001; MCS vs. NMS, P < 0.001; MMSS vs. MSSS, P = 0.031; and MMSS vs. NMS, P < 0.001 and for VAS values: MCS vs. MSSS, Z = 3.31, P = 0.001; MCS vs. NMS, Z = 4.64, P < 0.001; MMSS vs. MSSS, Z = -2.09, P = 0.037; and MMSS vs. NMS, Z = -3.16, P = 0.003).

Conclusions

Medial support screws might help enhance mechanical stability and maintain fracture reduction when used to treat PHFs with medial metaphyseal comminution or malreduction.

The influence of local bone quality on fracture pattern in proximal humerus fractures

INTRODUCTION

Bone mineral density and fracture morphology are widely discussed and relevant factors when considering the different treatment options for proximal humerus fractures. It was the aim of this study to investigate the influence of local bone quality on fracture patterns of the Neer classification as well as on fracture impaction angle in these injuries.

MATERIALS AND METHODS

All acute, isolated and non-pathological proximal humerus fractures admitted to our emergency department were included. The fractures were classified according to Neer and the humeral head impaction angle was measured. Local bone quality was assessed using the Deltoid Tuberosity Index (DTI). The distribution between DTI and fracture pattern was analysed.

RESULTS

191 proximal humerus fractures were included (61 men, mean age 59 years; 130 women, mean age 69.5). 77 fractures (40%) were classified as one-part, 72 (38%) were two-part, 24 (13%) were three- and four-part and 18 (9%) were fracture dislocations. 30 fractures (16%) were varus impacted, whereas 45 fractures (24%) were classified as valgus impacted. The mean DTI was 1.48. Valgus impaction significantly correlated with good bone quality (DTI ≥ 1.4; p = 0.047) whereas no such statistical significance was found for the Neer fracture types.

DISCUSSION

We found that valgus impaction significantly depended on good bone quality. However, neither varus impaction nor any of the Neer fracture types correlated with bone quality. We conclude that the better bone quality of valgus impacted fractures may be a reason for their historically benign amenability to ORIF. On the other hand, good local bone quality does not prevent fracture comminution.

Humeral head inferior subluxation in proximal humerus fractures

PURPOSE

The objectives of this study are to propose a reliable radiologic method for detecting static inferior subluxation of humeral head, to calculate the relative intra- and inter-observer reliability, and to evaluate its presence pre- and post-surgery.

METHODS

This is a retrospective observational study of patients surgically treated for a fracture of the proximal humerus. Fractures were classified using Codman-Lego criteria (radiographic, CT images), osteoporosis was assessed. To identify inferior subluxation, an original method is proposed. This measurement was done pre-operatively, at three and 12 month post-operatively. Clinical evaluation was recorded at final follow-up using Constant Score.

RESULTS

One hundred fifty fractures surgically treated were studied. Intra- and inter-observer reliabilities were excellent and high, respectively. In pre-operative x-rays, a significant inferior subluxation was noted in 17/150 cases (11.3%), with significant correlation with fracture pattern (p=0.045), female sex (p=0.038), age older than 70 (p=0.003), obesity (BMI>30, p=0.03), and local osteoporosis (p=0.002). At three month of follow-up, 22 cases (14.6%) had inferior subluxation, with significant correlation with female sex (p=0.04), age older than 70 (p=0.002), obesity (p=0.02), pin or screw articular surface perforation (p<0.001). At 12 month of follow-up, seven cases showed persistent inferior subluxation, with significant correlation with age older than 70 (p=0.032), obesity (p=0.041), screw joint perforation and lower Constant Score (p<0.001).

DISCUSSION

Inferior subluxation was mostly found in osteoporotic fractures of the elderly, obese, and of female sex both pre- and post-operatively. The intra- and inter-observer reliabilities of proposed radiographic measurement were high and excellent, respectively.

CONCLUSIONS

In the early postoperative months, we found a high correlation between inferior subluxation and articular surface perforation; when persisting at later follow-ups, we might speculate that it could represent an early phase of avascular necrosis of the humeral head.

LEVEL OF EVIDENCE

Level III, observational study.

How bone quality may influence intraoperative and early postoperative problems after angular stable open reduction-internal fixation of proximal humeral fractures

BACKGROUND

With the introduction of the deltoid tuberosity index (DTI), a simple radiographic tool has become available to measure bone mineral density of the proximal humerus. The aim of this study was to assess the influence of local bone mineral density on the early failure rate after angular stable open reduction-internal fixation of proximal humeral fractures (PHFs).

METHODS

We retrospectively followed up all patients treated with angular stable implants for PHFs from 2007 to 2014. The fractures were classified according to Neer, and the DTI, metaphyseal head extension (MHE), medial hinge displacement, and quality of reduction were assessed. Failures were defined as head screw cutouts.

RESULTS

The study included 146 patients (mean age, 66 years; range, 20-94 years). The mean follow-up period was 11 months (range, 3-94 months). Of the fractures, 91% were classified as 2- or 3-part fractures and 9% as 4-part fractures. The mean DTI was 1.44 (range, 1.19-2.11), and the mean MHE was 12 mm (range, 0-48 mm). The reduction result was at least acceptable in 80% of fractures. Screw cutouts were found in 23%. The DTI and MHE were the most significant preoperative predictors for the reduction result. The DTI (P = .036) and age (P = .02) were independent preoperative factors, and a good reduction (P = .001) was the only intraoperative factor influencing cutout.

DISCUSSION

This study proves that good bone quality and a long MHE are helpful for the reduction. Furthermore, good bone quality, a younger age, and a good reduction prevent later cutout. We conclude that local bone quality is a relevant factor in the treatment plan for PHFs.

Immediate intensive mobilization compared with immediate conventional mobilization for the impacted osteoporotic conservatively treated proximal humeral fracture: a randomized controlled trial

PURPOSE

To select in a 2-year survey of proximal humerus fractures accessing the emergency department, a population of osteoporotic stable impacted fractures and to randomize them into two groups, one with an immediate intensive mobilization program and the other with an immediate conventional mobilization program.

METHODS

In emergency department, patients with clinical signs of shoulder girdle fracture were submitted to standard X-ray examination and CT scan. Patients with stable (absence of metaphyseal comminution or fifth fragment) osteoporotic (cortical bone thickness lower than 6 mm) impacted (Is any part of metaphysis or head impacted into the shaft? YES/NO) proximal humerus fractures were selected for randomization in one of the two groups. Group 1: early intensive mobilization; Group 2: early conventional mobilization. Functional and radiographic assessment was recorded at 3, 6 and 12 months of follow-up.

RESULTS

In the considered period, 120 patients were affected by a stable impacted osteoporotic proximal humerus fracture. At the final follow-up, 36 patients in group 1 and 39 patients in group 2 were available for statistical analysis. Functional and radiographic scores were comparable, with a trend of significance in favor of group 2. No fracture in any of the group showed significant loss of reduction respect to 6 months of follow-up. 4 (10%) and 1 (2.5%) patients in groups 1 and 2 were not compliant with the rehabilitation program (p = 0.037).

CONCLUSIONS

This randomized controlled trial showed that impacted osteoporotic proximal humerus fractures can be managed non-operatively with an early conventional rehabilitation program composed by 10 sessions of passive motion twice a week, followed by recovery of active range of motion for further 10 sessions thrice a week, while no advantage is given by a more aggressive rehabilitation regimen. Self-assisted exercises should be explained to patients to maximize the effects of the assisted program.

LEVEL OF EVIDENCE

Level 1, randomized controlled double-blinded trial.

The Adequacy of Diagnosis and Treatment for Osteoporosis in Patients with Proximal Humeral Fractures

Background

The purpose of this study was to evaluate whether physicians' practice was adequate for the diagnosis and treatment of osteoporosis in patients with proximal humeral fracture over the age of 50 years, which is one of major osteoporotic fractures.

Methods

A retrospective nation-wide cohort study was performed using data collected in 2010 by the Korean Health Insurance Review Agency. The incidences of fractures around the hip, spine, and proximal humerus in patients more than 50 years of age, the frequencies of diagnostic bone density scan for osteoporosis, and the prescription for the osteoporosis medication were analyzed and compared.

Results

A search of database identified 48,351 hip fractures, 141,208 spine fractures, and 11,609 proximal humeral fractures in patients more than 50 years of age in 2010. Among these patients, 12,097 (25.0%) of hip fractures, 41,962 (29.7%) of spine fractures, and 1,458 (12.6%) of proximal humeral fractures underwent diagnostic bone density scan (p < 0.001); 4,773 (9.9%) of hip fractures, 27,261 (19.3%) of spine fractures, and 639 (5.5%) of proximal humeral fractures were managed with at least one medication approved for the treatment of osteoporosis (p < 0.001). Furthermore, 1,217 (2.5%) of hip fractures, 7,271 (5.2%) of spine fractures, and 188 (1.6%) of proximal humeral fractures received diagnostic bone density scans as well as osteoporosis medications (p < 0.001). Younger patients (50–69 years of age) were less likely to be evaluated and managed for osteoporosis relative to older patients (≥ 70 years of age) (p < 0.001); and men were less likely to be evaluated and managed for osteoporosis relative to women (p < 0.001).

Conclusions

Current physicians' practice pattern may be inadequate for the diagnosis and treatment of osteoporosis in patients of proximal humeral fractures over the age of 50 years. Additional study and educational programs are necessary to improve this care gap, beginning with physicians who are responsible for the fracture treatment and shoulder diseases.

Failure of fracture fixation in osteoporotic bone

This manuscript will provide an overview of how the age and osteoporosis related changes in mechanical properties of bone affect the stability of osteosynthesis constructs, both from a mechanical as well as from a clinical perspective. The manuscript will also address some of the principles of fracture fixation for osteoporotic fractures and discuss applications of osteoporotic fracture fixation at sites typically affected by fragility fractures, namely the distal radius, the proximal humerus, the femur and the spine. The primary aim of operative treatment in elderly individuals is the avoidance of immobilization of the patient. In selected cases conservative treatment might be required. Generally, choice of treatment should be individualized and based on the evaluation of patient-specific, fracture-specific and surgeon-specific aspects. The orthopaedic surgeon plays an essential role in enabling functional recovery by providing good surgery but a multidisciplinary approach is essential in order to support the patient to regain his/her quality of life after fragility fracture. Overall, the therapy of fractures in osteoporotic bone in the elderly requires a multidisciplinary therapeutic acute care concept including treatment of co-morbidities and correct choice of timing, and technique of the operative intervention.