Comparison between the spatial subchondral support plate and the proximal humeral locking plate in the treatment of unstable proximal humeral fractures

Dual Locking Plate Osteosynthesis for 3- or 4-Part Proximal Humeral Fractures Combined with Multiple Fractures of the Greater Tuberosity

BACKGROUND

This retrospective study was conducted to evaluate the efficacy of dual locking plate osteosynthesis for treating 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity.

METHODS

From January 2012 to December 2018, 19 skeletally mature patients, who suffered 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity, were treated with open reduction and internal fixation using a dual locking plate technique through a delto-pectoral approach. Indexes for evaluation included fracture healing, quality of reduction, and incidence of complications (infections, screw perforation into the glenohumeral joint, subacromial impingement, hardware failure, avascular necrosis, and loss of reduction). Shoulder function was evaluated using Constant-Murley scoring.

RESULTS

The patients were assessed at a mean time of 25.3 months after surgery. Union of fractures was radiographically confirmed for all 19 patients. The mean Constant-Murley patient score was 85.2 points, and complications were identified in two patients during follow-up evaluations.

CONCLUSIONS

The method of using dual locking plate osteosynthesis through a delto-pectoral approach resulted in a satisfactory union rate, excellent fracture reduction, low complication rate and good shoulder function for patients with complex proximal humeral fractures. The method is effective for treating 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity.

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.

Evaluation of open reduction and internal fixation of proximal humerus fractures using a locking plate with smooth pegs - A retrospective study

BACKGROUND

Optimal treatment of displaced proximal humeral fractures is controversial. This retrospective study aims to identify complications and clinical outcomes using a locking plate with smooth pegs instead of screws (S3 plate).

METHOD

Eighty-two patients with displaced proximal humeral fracture classified with 2-4 fragments (Neer's classification) treated with open reduction and internal fixation (ORIF) with S3 plate were studied retrospectively. Clinical outcome according to constant score; Single Shoulder Value; Disabilities of Arm, Shoulder and Hand; and European Quality of life-5 dimensions and complication rate defined radiologically including peg penetration, avascular necrosis, and loss of reduction was assessed minimum 2.5 years after surgery.

RESULTS

A total of 11 peg penetrations were identified (13.6%). Avascular necrosis was seen in 8.5% (n = 7). Mean constant score at follow-up was 64.4 with a relative constant score of 87% (standard deviation 18%) compared to the contralateral uninjured side. The mean Disabilities of Arm, Shoulder and Hand score was 12.7 and mean European Quality of life-5 dimensions score 0.83. The mean Single Shoulder Value was 78.3. No cases of deep infection were seen.

CONCLUSIONS

Fixation with S3 plate shows a proper osteosynthesis and the functional outcome is good. Symptomatic peg penetrations are rare and the incidence is lower compared to what has been reported with locked screws.

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.

History of internal fixation with plates (part 2): new developments after World War II; compressing plates and locked plates

The first techniques of operative fracture with plates were developed in the 19th century. In fact, at the beginning these methods consisted of an open reduction of the fracture usually followed by a very unstable fixation. As a consequence, the fracture had to be opened with a real risk of (sometimes lethal) infection, and due to unstable fixation, protection with a cast was often necessary. During the period between World Wars I and II, plates for fracture fixation developed with great variety. It became increasingly recognised that, because a fracture of a long bone normally heals with minimal resorption at the bone ends, this may result in slight shortening and collapse, so a very rigid plate might prevent such collapse. However, as a consequence, delayed healing was observed unless the patient was lucky enough to have the plate break. One way of dealing with this was to use a slotted plate in which the screws could move axially, but the really important advance was recognition of the role of compression. After the first description of compression by Danis with a "coapteur", Bagby and Müller with the AO improved the technique of compression. The classic dynamic compression plates from the 1970s were the key to a very rigid fixation, leading to primary bone healing. Nevertheless, the use of strong plates resulted in delayed union and the osteoporosis, cancellous bone, comminution, and/or pathological bone resulted in some failures due to insufficient stability. Finally, new devices represented by locking plates increased the stability, contributing to the principles of a more biological osteosynthesis while giving enough stability to allow immediate full weight bearing in some patients.

Clinical and radiological outcomes of unstable proximal humeral fractures treated with a locking plate and fibular strut allograft

PURPOSE

To evaluate the clinical and radiological outcomes of unstable proximal humeral fractures (PHFs) treated with a locking plate and fibular strut allograft.

METHODS

This study included 36 patients [7 men, 29 women; mean age, 68 years (range, 22-94 years)] with unstable PHFs with medial column disruption. All patients were treated with open reduction and internal fixation using a locking plate and fibular strut allograft. Post-operative assessment included clinical outcomes, shoulder range of motion, radiographic examination, and any complications. Post-operative radiological assessment including the humerus neck-shaft angle (NSA) and the humeral head height was performed.

RESULTS

At the mean two year follow-up visit, the mean American Shoulder and Elbow Society (ASES) and University of California, Los Angeles (UCLA) scores were 77 and 28, respectively. According to the UCLA rating scale, the result was excellent in six, good in 20, fair in six, and poor in four cases. According to the Paavolainen method, 31 patients had good results with an NSA of 130 ± 10°; three patients showed fair results with an NSA of 100-120°, and two patients experienced a poor result with an NSA of <100°. When calculating the humeral head height, the mean loss of reduction was measured as 1.6 mm (from 10.8 or 9.2 mm). Varus collapse and avascular necrosis of the humeral head was noted in two patients for each condition.

CONCLUSIONS

For unstable proximal humerus fractures, particularly in elderly patients with severe osteoporosis or in younger patients with a four-part fracture, locking plate fixation with a fibular strut allograft provided rigid medial support and showed satisfactory clinical and radiological outcomes.