Two-part fractures and fracture dislocations

Patient-reported outcome was close to the Danish background population 6 months after non-surgical treatment of Neer 2-part surgical neck fractures: a prospective cohort study in patients aged 60 or above

BACKGROUND AND PURPOSE

 Neer 2-part surgical neck fractures are the most common displaced proximal humerus fractures. We aimed to evaluate patient-reported outcome in a consecutive series of older people receiving nonoperative treatment.

METHODS

 This is a single-center prospective cohort study. We included patients aged 60 or above referred to a Danish university hospital. The preregistered protocol followed the recommendations from randomized trials. Patients were followed at the outpatient clinic at 2, 6, and 24 weeks. After 24 weeks, they were evaluated with Oxford Shoulder Score (OSS, 0-48, 48 best) and EuroQoL 5 dimensions, 3 levels (EQ-5D-3L, -0.624 to 1, 1 best). Clinical failure was defined as conversion to surgery or OSS ≤ 24. Population norms were reported to interpret the cohort data, but no formal statistical comparisons between historical cohorts were planned. We used descriptive statistics to report rates and proportions.

RESULTS

 For 36 months, 268 patients (mean age 76, 79% female) with Neer 2-part surgical neck fractures received non-surgical treatment. After excluding patients with concomitant fractures, dementia, or death, complete follow-up was available for 167 patients. 8 patients (3.0%) had surgery. The mean OSS was 37.2 (SD 8.1), which equals 78% of maximum shoulder function. The norm for the population of the same age and gender was 82%. The mean EQ-5D-3L score was 0.79 (SD 0.16), while the norm for the same-age population was 0.82. 16 (10%) had an OSS score of 24 or below.

CONCLUSION

 Non-surgical treatment in older people with Neer 2-part surgical neck fractures resulted after 6 months in patient-reported shoulder function and quality of life close to that of the Danish background population.

Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial

BACKGROUND

Although increasingly used, the benefit of surgical treatment of displaced 2-part proximal humerus fractures has not been proven. This trial evaluates the clinical effectiveness of surgery with locking plate compared with non-operative treatment for these fractures.

METHODS AND FINDINGS

The NITEP group conducted a superiority, assessor-blinded, multicenter randomized trial in 6 hospitals in Finland, Estonia, Sweden, and Denmark. Eighty-eight patients aged 60 years or older with displaced (more than 1 cm or 45 degrees) 2-part surgical or anatomical neck proximal humerus fracture were randomly assigned in a 1:1 ratio to undergo either operative treatment with a locking plate or non-operative treatment. The mean age of patients was 72 years in the non-operative group and 73 years in the operative group, with a female sex distribution of 95% and 87%, respectively. Patients were recruited between February 2011 and April 2016. The primary outcome measure was Disabilities of Arm, Shoulder, and Hand (DASH) score at 2-year follow-up. Secondary outcomes included Constant-Murley score, the visual analogue scale for pain, the quality of life questionnaire 15D, EuroQol Group's 5-dimension self-reported questionnaire EQ-5D, the Oxford Shoulder Score, and complications. The mean DASH score (0 best, 100 worst) at 2 years was 18.5 points for the operative treatment group and 17.4 points for the non-operative group (mean difference 1.1 [95% CI -7.8 to 9.4], p = 0.81). At 2 years, there were no statistically or clinically significant between-group differences in any of the outcome measures. All 3 complications resulting in secondary surgery occurred in the operative group. The lack of blinding in patient-reported outcome assessment is a limitation of the study. Our assessor physiotherapists were, however, blinded.

CONCLUSIONS

This trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus. These results suggest that the current practice of performing surgery on the majority of displaced proximal 2-part fractures of the humerus in older adults may not be beneficial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01246167.

Treatment of the surgical neck fracture of the humerus with a novel external fixator in the elderly with osteoporosis: biomechanical analysis

Background

No consensus exists on the treatment of proximal humerus fractures, especially in the elderly patients with osteoporosis. This study was aimed to evaluate the biomechanical characteristics of a novel external fixator in treating two-part surgical neck fracture of the proximal humerus in the elderly patients with osteoporosis.

Methods

Sixteen female elderly humeral shaft specimens with osteoporosis were randomized into 2 groups. Models with the surgical neck two-part fracture of the proximal humerus were built, in which a novel external fixator (test group) and a clover plate (control group) were applied separately. In the test group, the fracture was firstly fixed with intersection pinning using 3 Schanz pins (3.5 mm), followed by the novel external fixation frame. In the control group, a clover plate and 6 cortical bone screws were applied. Biomechanical testing of the specimens was performed to assess the resistance to load bearing and torsional stress. The parameters of the two groups were compared using independent t-test.

Results

Ultimate bearing capacity and load bearing at different parts with the humerus rotation were higher (P < 0.05) in the external fixator group (145.16 ± 17.42 N and 140 N respectively) than those in the plate group (120.21 ± 13.15 N and 69.63 ± 25.16–90.78 ± 17.18 N respectively). As for resistance to torsional stress, plate’s torque fluctuated between 1 Nm and 5 Nm, while the external fixator’s torque values were more evenly (P < 0.01) distributed with the fluctuation within 1 Nm.

Conclusions

In the fixation of two-part humeral fracture in elderly patients with osteoporosis, the new external fixator seemed to be superior to plate fixation in load bearing and resistance to torsional stress.

Management of Acute Proximal Humeral Fractures

Proximal humeral fractures, which typically occur in elderly persons, are among the most common fractures. A myriad of nonsurgical and surgical treatment options exist for these injuries, including short-term immobilization and early physical therapy, percutaneous fixation, plate osteosynthesis, intramedullary nailing, hemiarthroplasty, and reverse shoulder arthroplasty. The choice of treatment depends on the fracture type and severity, surgeon expertise, patient age, and patient health status.

Clinical Effects of the Probing Method with Depth Gauge for Determining the Screw Depth of Locking Proximal Humeral Plate

Background. The use of locking plates has gained popularity to treat proximal humeral fractures. However, the complication rates remain high. Biomechanical study suggested that subchondral screw-tip abutment significantly increased the stability of plant. We present a simple method to obtain the proper screw length through the depth gauge in elderly patients and compared the clinical effects with traditional measuring method. Methods. 40 patients were separated into two groups according to the two surgical methods: the probing method with depth gauge and the traditional measuring method. The intraoperative indexes and postoperative complications were recorded. The Constant and Murley score was used for the functional assessment in the 12th month. Results. Operative time and intraoperative blood loss indicated no statistical differences. X-ray exposure time and the patients with screw path penetrating the articular cartilage significantly differed. Postoperative complications and Constant and Murley score showed no statistical differences. Conclusions. Probing method with depth gauge is an appropriate alternative to determine the screw length, which can make the screw-tip adjoin the subchondral bone and keep the articular surface of humeral head intact and at the same time effectively avoid frequent X-ray fluoroscopy and adjusting the screws.

[The role of short Telegraph nail in the treatment of fractures of the upper end of the humerus: about 19 cases]

La fracture de l'extrémité supérieure de l'humérus est la troisième fracture en fréquence chez les sujets âgés et leur répartition est bimodale touchant préférentiellement le sujet âgé ostéoporotique après un traumatisme à faible énergie ou plus rarement le sujet jeune par mécanisme à forte cinétique. Le traitement des fractures complexes de l'humérus proximal est le sujet de nombreuses controverses Le clou Telegraph constitue une approche thérapeutique très efficace pour les fractures déplacées de l'extrémité supérieure de l'humérus, de technique chirurgicale facile mais avec une courbe d'apprentissage et permettant un protocole de rééducation dans l'immédiat de l'intervention. C'est un matériel d'enclouage antérograde de 15 cm de long, plein verrouillé en proximal et en distal, le verrouillage proximal est assuré par 4 vis spongieuses, de filetage long, stables dans le clou et cela confère une solidité tout-à-fait remarquable à ce montage alors que le verrouillage distal est assuré au niveau du V deltoïdien en zone avasculaire et là où il n'y a pas de passage nerveux. L’étude présentée concerne 19 patients traités par un clou Telegraph court dans le traitement des fractures de l'extrémité supérieure de l'humérus entre 2013 et 2015 et elle a pour but d'analyser les résultats radio-cliniques et d’évaluer la répercussion de cette technique sur la fonction de l’épaule. Le clou Telegraph proposé depuis plus de 12 ans à peu près, a rencontré et continue de rencontrer un réel succès. Il permet de traiter très efficacement les fractures simples type 2 et 3, mais aussi les fractures impactées en valgus à 4 fragments. L'ostéosynthèse par clou Telegraph est une solution efficace, rapide et reproductible dans le traitement chirurgical des fractures de l'extrémité supérieur de l'humérus même en cas des fractures complexes et permet une reprise rapide de la mobilité de l’épaule.

Management of displaced surgical neck fractures of the humerus: health related quality of life, functional and radiographic results

INTRODUCTION

There is no controversy about the need for surgical treatment of the displaced surgical neck fractures of the humerus, but there are few studies comparing the results of the three preferred types of surgical treatment. To expand the knowledge needed in decision making, a patient series is reviewed using health related quality of life (HRQoL), functional and radiographic data from patients treated with percutaneous pinning, locking plates or intramedullary nails.

MATERIALS AND METHODS

Retrospective observational cohort study of patients who underwent internal fixation of fractures of the surgical neck of the humerus between 2004 and 2009 (mean follow-up 40.67 ± 17.93 months). Fifty patients fulfilled the inclusion criteria (mean age 70.04 ± 13.15 years). Nine had been treated by percutaneous pinning, fifteen with locking plates and twenty-six with intramedullary nails. We compared the results between the three groups of the HRQoL with the EuroQol5D questionnaire; the functional capacity of the operated and non-operated shoulder with the Constant score; and the radiographic result with plain X-rays.

RESULTS

Forty-eight patients had achieved fracture healing. The plating and nailing groups had a better fracture reduction compared with the pinning group (p <0.05). The EuroQol-5D did not discriminate between groups (mean 0.65 ± 0.26; p >0.05). The mean Constant score of the K-wire group (47.67 ± 22.42) was lower than those of the plating (82.45 ± 17.69) and nailing groups (72.72 ± 15.96) (p = 0.001), with no differences between plates and nails. There was positive correlation between the EuroQol-5D result and the Constant score (r = 0.490; p <0.005). The fractured shoulder was worse in each item of the Constant score than the non-operated one in patients treated with pins and nails. Patients treated with plates achieved similar results between operated and non-operated shoulder in three items: arm positioning, internal and external rotation. Seventeen patients (six re-operated) had some kind of complication during follow-up.

CONCLUSION

Patients treated with pinning achieved a worse radiographic and Constant score than patients treated with plates or nails. Although we did not find differences between the plating and nailing groups, patients treated with plates got a Constant score more similar to the non-operated shoulder.

Conservative treatment, plate fixation, or prosthesis for proximal humeral fracture. A prospective randomized study

Background

Proximal humerus fracture is the third most common fracture type after hip and distal radius fracture in elderly patients. A comprehensive study by Palvanen et al. demonstrated an increase in the annual fracture rate of 13.7% per year over the past 33 years. Should this trend continue, the fracture rate would triple over the next three decades. The increasing incidence of low-energy fractures raises questions about the optimal treatment in terms of functional outcome, pain, and rehabilitation time, as well as the economical impact. Despite the high incidence and costs of proximal humerus fractures, there is currently no valid scientific evidence for the best treatment method. Several publications, including a Cochrane review outline the need for high-quality, well-designed randomized controlled trials.

Methods/Design

The study is a prospective, randomized, national multi-center trial. The hypothesis of the trial is that surgical treatment of displaced proximal humerus fractures achieves better functional outcome, pain relief, and patient satisfaction compared to conservative treatment. The trial is designed to compare conservative and surgical treatment of proximal humerus fractures in patients 60 years and older. The trial includes two strata. Stratum I compares surgical treatment with locking plates to conservative treatment for two-part fractures. Stratum II compares multi-fragmented fractures, including three- and four-part fractures. The aim of Stratum II is to compare conservative treatment, surgical treatment with the Philos locking plate, and hemiarthroplasty with an Epoca prosthesis. The primary outcome measure will be the Disabilities of the Arm, Shoulder and Hand (DASH) score and the secondary outcome measures will be the EuroQol-5D (EQ-5D) value, OSS, Constant-Murley Score, VAS, and 15D.

Recruiting time will be 3 years. The results will be analyzed after the 2-year follow-up period.

Discussion

This publication presents a prospective, randomized, national multi-center trial. It gives details of patient flow, randomization, aftercare and also ways of analysis of the material and ways to present and publish the results.

Trial registration

ClinicalTrials.gov identifier: NCT01246167

Hemiarthroplasty versus angle-stable locking compression plate osteosynthesis in the treatment of three- and four-part fractures of the proximal humerus in the elderly: design of a randomized controlled trial

BACKGROUND

The optimal surgical management of dislocated three- and four-part fractures of the proximal humerus in elderly patients remains unclear. Most used techniques are hemiarthroplasty and angle-stable locking compression plate osteosynthesis. In the current literature there is no evidence available presenting superior results between hemiarthroplasty and angle-stable locking compression plate osteosynthesis in terms of speed of recovery, pain, patient satisfaction, functional outcome, quality of life or complications.

METHODS/DESIGN

A randomized controlled multicenter trial will be conducted. Patients older than 60 years of age with a dislocated three- or four-part fracture of the proximal humerus as diagnosed by X-rays and CT-scans will be included. Exclusion criteria are a fracture older than 14 days, multiple comorbidity, multitrauma, a pathological fracture, previous surgery on the injured shoulder, severely deranged function caused by a previous disease, "head-split" proximal humerus fracture and unwillingness or inability to follow instructions. Participants will be randomized between surgical treatment with hemiarthroplasty and angle-stable locking compression plate osteosynthesis. Measurements will take place preoperatively and 3 months, 6 months, 9 months, 12 months and 24 months postoperatively. Primary outcome measure is speed of recovery of functional capacity of the affected upper limb using the Disabilities of Arm, Shoulder and Hand score (DASH). Secondary outcome measures are pain, patient satisfaction, shoulder function, quality of life, radiological evaluation and complications. Data will be analyzed on an intention-to-treat basis, using univariate and multivariate analyses.

DISCUSSION

Both hemiarthroplasty and angle-stable locking compression plate osteosynthesis are used in the current treatment of dislocated three-and four-part fractures of the proximal humerus. There is a lack of level-1 studies comparing these two most-used surgical treatment options. This randomized controlled multicenter trial has been designed to determine which surgical treatment option provides the fastest recovery of functional capacity of the affected upper limb, and will provide better outcomes in pain, satisfaction, shoulder function, quality of life, radiological evaluation and complications.

TRIAL REGISTRATION NUMBER

The trial is registered in the Netherlands Trial Registry (NTR2461).

Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus

INTRODUCTION

Angular stable osteosynthesis has become the gold standard in the operative treatment of proximal humeral fractures. The aim of this article is to determine the indications for osteosynthesis versus primary arthroplasty based on clinical and radiological parameters.

METHODS

A total of 368 surgically treated proximal humeral fractures were reviewed. Preoperative X-rays were used to evaluate the displacement and vascularity of the humeral head (according to the Hertel criteria) and the AO (Arbeitsgemeinschaft für Osteosynthesefragen) fracture type. Postoperative X-rays were analysed to assess the quality of the reduction, the reconstruction of the medial hinge and the displacement of the tuberosities. Follow-up X-rays were used to evaluate healing progress, the occurrence of avascular necrosis, loss of reduction and implant related failures. The American Shoulder and Elbow Surgeons score (ASES score) was used to evaluate the functional outcome. Correlations between a set of variables, type of treatment and eventual outcome were verified in both univariate and multivariate settings, with the significance rate set at p<0.05.

RESULTS

In total, 307 shoulders were evaluated. Mean follow-up was 4.3 years and showed a 15.3% failure rate, a 23.8% re-operation rate and a mean ASES score of 75.3. Better results were noted in patients who were younger at the time of surgery. More displaced fractures, AO type C fractures, varus fracture configuration and reduced head vascularity all led to a worse outcome. Anatomical reduction correlated with better results. Articular fractures had better results when treated with a plate.

CONCLUSION

Surgical treatment of proximal humeral fractures remains difficult, with a failure rate of 15.3% and a re-operation rate of 23.8% at 4.3 years. A significantly displaced varus articular fracture in the older patient results in the worst outcome.

Biomechanical evaluation of two-part surgical neck fractures of the humerus fixed by an angular stable locked intramedullary nail

OBJECTIVE

The aim of the current study was to see how different interlocking mechanisms would affect construct stability and overall failure in the treatment of two-part surgical neck fractures in the proximal humerus in vitro.

METHODS

Left and right bones of eight pairs of fresh-frozen human cadaveric humeri were assigned to either a group with conventional or a group with angular stable distal interlocking. The different experimental interlocking mechanisms were used in a surgical neck fracture model of the humerus (Orthopaedic Trauma Association 11- A3) stabilized by a proximal humeral nail. The following variables were evaluated by biomechanical tests: hysteresis width in bending and torsion, stiffness, and fracture gap movement during cyclic axial loading until failure and the overall failure mechanism of the construct.

RESULTS

The angular stable group showed significantly less motion in initial bending and torsion and higher bending stiffness throughout the complete deformation cycle compared with the conventional interlocked group. Fracture gap movement was significantly less in the angular stable group. Higher stability was mainly observed in the early phase of the applied loading pattern; however, ultimate failure was not related to distal interlocking but occurred in the proximal fragment in both groups.

CONCLUSIONS

An experimental angular stable distal interlocking system of proximal humeral nails shows higher construct stability in the early phase of fracture fixation in vitro. In terms of overall failure, loss of fixation in the proximal fragment was crucial and not different between groups.

Biomechanical comparison of a proximal humeral locking plate using two methods of head fixation

HYPOTHESIS

Locking plates have emerged as the implant of choice for stabilization of proximal humeral fractures. The biomechanical properties of a locked plating system using smooth pegs vs threaded screws for fixation of the humeral head were compared to test the hypothesis that there would be no biomechanical difference between pegs and threaded screws.

MATERIALS AND METHODS

Sixteen pairs of fresh frozen cadaveric humeri were randomized to have a surgical neck gap osteotomy stabilized with a locked plate using threaded screws (n=8) or smooth pegs (n=8). The intact contralateral humerus served as a control. Each specimen was tested with simultaneous cyclic axial compression (40 Nm) and torsion (both +/-2 Nm and +/-5 Nm) for 6000 cycles. All specimens were loaded to failure. Interfragmentary motion and load-displacement curves were analyzed to identify differences between the groups. Our data were then compared to previously published forces across the glenohumeral joint to provide evidence based recommendations for postoperative use of the shoulder.

RESULTS

There was a statistically significant difference between test specimens and their paired control (P < .001) in cyclic testing and load to failure. Differences between the smooth pegs and threaded screws were not statistically significant.

DISCUSSION

There is no biomechanical difference between locked smooth pegs and locked threaded screws for proximal fragment fixation in an unstable 2-part proximal humeral fracture model.

CONCLUSION

Our study contributes to the published evidence evaluating forces across the glenohumeral joint and suggests that early use of the affected extremity for simple activities of daily living may be safe. Use of the arm for assisted ambulation requiring a crutch, cane, walker, or wheelchair should be determined on a case-by-case basis.