The treatment of complex proximal humeral fractures: analysis of the results of 55 cases treated with PHILOS plate

Proximal humeral fractures treated with a low-profile plate with enhanced fixation properties

BACKGROUND

Our purpose was to evaluate the clinical and radiographic outcomes of proximal humeral fractures treated with a new generation plating system and compare results with a meta-analysis of recent literature.

METHODS

Between 2014 and 2017, 93 patients (18 males, 75 females) with proximal humerus fractures were treated with open reduction and internal fixation (ORIF) using a Pantera® Plate. These low-profile plates are anatomically shaped and include "cross-elements" that form a three-dimensional scaffold in bone to enhance fixation stability. According to Neer classification, there were 24 two-part fractures, 49 three-part fractures and 20 four-part fractures (4 with dislocated heads). X-rays and Constant Shoulder Scores (CSS) were used to evaluate healing, complications, and clinical outcomes. Results were compared with a meta-analysis of similar studies reported in literature over the last 10 years.

RESULTS

Eighty-three patients with a minimum follow-up of 2 years had a mean CSS of 72 (53-90) graded as excellent for 23 patients (28%), good for 35 (42%), fair for 14 (17%), and poor for 11 (13%). Fractures healed without complication in 75 (91%) patients. Eight (9%) complications were observed, i.e., three avascular necrosis of the humeral head, one case of implant loosening, two cases of subacromial impingement and two superficial infections. There was no significant correlation between Neer fracture stage and patient outcome (p = 0.257). Compared to the literature, this method had a lower complication grade (p = 0.03), though it did not significantly differ in its clinical outcomes (p = 0.08).

CONCLUSIONS

The investigated plating system includes design features that can potentially increase utility for ORIF of proximal humeral fractures. While the complication profile was signficantly less than reported in the literature for standard proximal humerus plates, clinical outcomes were similar. Further studies will be required to better understand the role of plate design on treatment of these challenging fractures.

LEVEL OF EVIDENCE

IV, therapeutic study.

Angular stable plate versus reverse shoulder arthroplasty for proximal humeral fractures in elderly patient

BACKGROUND

Treatment of complex proximal humeral fractures in the elderly is a challenge and reverse shoulder arthroplasty (RTSA) is now an important alternative to open reduction internal fixation (ORIF) with angular stable plate. The purpose of this study is to compare clinical and radiological outcomes of RTSA and ORIF in the elderly.

METHODS

We retrospectively analyzed patients treated for three- or four-part displaced fractures of the proximal humerus. Range of motion, disabilities of the arm, shoulder and hand (DASH) and Constant scores were recorded. X-ray exam in three projections completed the clinical observation at follow-up.

RESULTS

Forty-eight patients were enrolled after a mean follow-up of 37 months: 22 RTSA and 26 ORIF. Mean age at trauma was 74 years. Compared with RTSA patients, ORIF patients had significantly higher mean external rotation (28° vs. 14°) and better results in modal internal rotation (hand at D7 vs. hand at L5-S1). No significant differences were seen in DASH and Constant scores. Avascular necrosis and loss of reduction with varus dislocation of the humeral head were the most frequent causes of revision surgery in ORIF (34.6%) while the revision rate of the RTSA was 9.1%.

CONCLUSION

In this study, both treatments showed good clinical outcomes, but RTSA resulted in lower revision rate than ORIF. Even if external and internal rotation in RTSA patients were worse than ORIF, they did not affect the patient's quality of life. So, the reverse arthroplasty seems to be a more reliable treatment.

External fixation can be an option for proximal humerus fractures Neer 3-4

Background:

Proximal humeral fractures (PHF) account for 4-6% of all fractures and 25% of humeral fractures. While conservative treatment is the gold standard for simple fractures, there is no consensus about the best treatment choice for complex PHF in the elderly. Recently a new external fixator was introduced in clinical practice for treatment of complex PHF. Aim of the study was to evaluate the functional results of this therapeutic approach.

Methods:

Data were retrospectively analyzed. Inclusion criteria were: three- and four-part PHF according to Neer, treatment with closed reduction and external fixation, normal Abbreviated Mini Mental Test score, independence in the daily living, non-pathological fracture, glenohumeral joint with moderate osteoarthritic changes and availability of clinical and radiological follow-up. For each patient demographic data, comorbidities, surgery time and estimated blood loss were recorded. Clinical and radiological evaluation were performed at 1, 2, 6, 12 months.

Results:

17 patients were enrolled. Mean age was 69.7 years. Fractures were classified according to Neer as type III in 10 cases and type IV in 7 cases. The mean operating time was 22 minutes. Mean Constant score value at follow up was 74 ± 11,52 at 2 months, 82 ± 11,16 at 6 months and 85 ± 9,86 at 12 months.

Conclusion:

These preliminary results show that the studied system is easy to use, minimally invasive, effective in reducing surgical and hospitalization time. The results in terms of functional recovery are encouraging, showing a reduced number of complications. (www.actabiomedica.it)

Cadaveric Analysis of Proximal Humerus Locking Plate Fit: Contour Mismatch May Lead to Malreduction

OBJECTIVES

To investigate proximal humerus locking plate fit in a large sample of human proximal humeri.

METHODS

A total of 97 cadaveric human humeri were selected. Humerus length, head diameter, and neck-shaft angle were measured. Three-hole and 5-hole 3.5-mm proximal humerus locking compression plates were affixed. A digital caliper was used to measure the maximum gap distance from the plate to the bone. Analysis of variance and student's t tests were conducted to evaluate differences in plate-bone distance between the 2 plate lengths, gender, race, age, and laterality. Correlation between plate-bone distance and humerus length, head diameter, and neck-shaft angle were determined.

RESULTS

Mean plate-bone distance for the 3-hole plate was 1.5 ± 0.6 mm (range 0.3-2.9 mm), and for the 5-hole plate was 2.5 ± 0.9 mm (range 0.7-5.0 mm) (P = 0.01). Female and right-sided humeri were shown to have significantly larger plate-bone gap distance when compared with counterparts (P = 0.01). No correlation was found between plate-bone gap distance and humeral length (R = 0.03), head diameter (R = 0.05), or neck-shaft angle (R = 0.08).

CONCLUSION

The proximal humerus locking plate was under-contoured and spanned all 97 specimens. Greater plate-bone distance was observed with the 5-hole plate versus the 3-hole plate. Applying the plate flush to bone may lead to medial displacement of the humeral head at the calcar increasing risk of loss of fracture fixation. In fractures with any metaphyseal comminution, malreduction will be more pronounced. Caution should be exercised when using the proximal humerus locking plate as a reduction aide.

Detection of primary screw perforation in locking plate osteosynthesis of proximal humerus fracture by intra-operative 3D fluoroscopy

PURPOSE

The purpose of this study was to identify the rate of primary screw perforations after osteosynthesis of proximal humerus fractures with intra-operative 3D fluoroscopy and to analyse the rate of secondary screw perforations as well as complications, outcome, and revision surgeries after a minimum of 12 months.

MATERIALS AND METHODS

Thirty-three patients (20 female, 13 male, median age 67 years, range 35-85 years) with displaced proximal humerus fractures were included. After reduction and fixation, an intra-operative 3D fluoroscopy was performed to evaluate primary screw perforations (PS) and screws with "near perforation" (nPS). These screws were changed intra-operatively. Patients were followed-up for a minimum of 12 months. Clinical and radiological parameters, such as secondary screw perforation, secondary loss of reduction, or functional outcome, were investigated.

RESULTS

In six patients (18.2%), humeral head screws were changed due to primary PS (n = 2) or nPS (n = 4) after the intra-operative 3D fluoroscopy. Follow-up revealed an adapted constant score (%CMS) of 76.2% after a mean follow-up of 17.7 months. Two secondary screw perforations were observed (6%). Loss of reduction was observed in eight patients (24.2%).

CONCLUSION

The intra-operative 3D reveals a high rate of primary screw perforations or near perforations. Immediate change of these screws may lead to a lower rate of secondary screw perforations and, therefore, reduce post-operative complications.

Surgical management of complex proximal humeral fractures: pinning, locked plate and arthroplasty : Clinical results and functional outcome on retrospective series of patients

PURPOSE

The aim of the study was to compare the clinical results and related complications of four different surgical treatments of complex proximal humeral fractures according to their classification and features of patients.

METHODS

Between 2007 and 2011, 92 consecutive patients with diagnosis of three-four-part displaced fractures, fractures with head dislocation and head-splitting fractures were evaluated postoperatively with Constant-Murley score, disability of arm, shoulder and hand score and simple shoulder test.

RESULTS

All the treatment modalities showed from optimal to good mean functional results. The statistical analysis comparing each treatment group showed better outcomes scores (p < 0.05) for: locked plating versus HA, locked plating versus RSA and RSA versus HA. No differences between postoperative range of motion, complication rate and overall revision rate of the treatment groups were found at the end of follow-up (p > 0.05). Overall complication rate of surgical treatment of complex PHF was 31.5% (29 patients) with overall revision rate of 14.1%. Among patients with complications 77.8% of HA (7 of 9) required revision surgery (p < 0.05).

CONCLUSIONS

The treatment of complex PHF is nowadays a challenge even for skilled shoulder surgeons. The several viable operative options give good results whenever used for the correct indication. The range of reported complications from 18.2 to 37.5% remains concerning, but most of them did not affect clinical outcome in this series. Accurate preoperative characterization of the fracture pattern is necessary, and high surgical skills of the different operative techniques, including arthroplasty, are recommended to meet the increased functional expectations of patients.

LEVEL OF EVIDENCE

Therapeutic series, Level IV.