A prospective study of a new locking plate for proximal humeral fracture

Outcomes of Locking Plates in Proximal Humeral Fractures: A Systematic Review

A systematic review of the clinical and radiological outcomes of locking plates in proximal humeral fractures in the current English literature was performed using Medline, CINAHL, AMED and EMBASE electronic databases to July 2009 via Ovid. There were 1266 proximal humeral fractures included in the review. The mean age of the patients was 61.7 years and there were 70.3% women. Based on the Neer classification, the review included 27% two-part, 39.5% three-part and 23.6% four-part fractures. At final follow-up, the Constant score was in the range 59 to 80, and the Disabilities of the Arm, Shoulder and Hand scores were in the range 15.2 to 51.8. The most frequent postoperative complication described was intra-articular screw perforation in 8.5% of fractures. Other complications included avascular necrosis (5.1%), subacromial impingement (3.1%), loss of reduction (3.7%) and implant failure (3.15%). Unplanned secondary surgical procedures were undertaken in 14.2% of cases. This systematic review has demonstrated that locking plate systems are suitable for stabilizing proximal humeral fractures. The current evidence base presents a number of methodological weaknesses and randomized controlled trials at independent centres reporting long-term results are required to compare locking plate systems with alternative fixation techniques used in the treatment of proximal humeral fractures.

The results of tension band rotator cuff suture fixation of locked plating of displaced proximal humerus fractures

INTRODUCTION

The purpose of this study was to assess 1-year outcomes of patients with displaced proximal humerus fractures who underwent treatment with locked plate fixation with rotator cuff suture augmentation.

METHODS

A total of 86 patients who had sustained 2, 3 and 4-part displaced proximal humerus fractures underwent locked plate fixation with multiple sutures placed in the cuff tendons. Clinical outcome variables included active forward elevation (AFE), active external rotation (AER), and Constant and American Shoulder and Elbow Surgeons (ASES) scores. Post-operative variables included the following complications: varus re-collapse, loss of fixation, osteonecrosis of the humeral head (AVN), screw cut out, hardware failure and infection.

RESULTS

Forty-one patients were available with minimum of 1-year follow-up. Mean AFE was 142±17.0° and AER was 41±13.0°. The overall complication rate was 14.6%, with osteonecrosis being the most common (12.2%). Of the 21 patients (51.2%) that initially had varus displacement, all but one maintained anatomic reduction and fixation. Mean ASES score was 78.2±20.0 and average Constant score was 72.7±17.6. Bivariate analyses demonstrated that pre-operative medial comminution (p=0.297) or varus collapse (p=0.95) were not associated with an increased likelihood of sustaining a complication.

CONCLUSIONS

Follow-up of patients in this series demonstrated a low overall complication rate and excellent functional outcomes. We believe suture augmentation of the rotator cuff can counteract varus forces on proximal humerus fractures fixed with locked plates, and should be performed routinely in displaced 2, 3 and 4 part fractures.

Geometry of Proximal Humerus Locking Plates

OBJECTIVES

Proximal humerus fractures are commonly treated with open reduction and internal fixation with periarticular locking plates. This study compared the geometry of proximal humerus locking plate's screw distribution, amount of bone-screw interface, and the volume the screws occupy within the humeral head, as well as how leaving the screws short of the articular surface affects these measures.

METHODS

Locking plates from 7 manufacturers were applied to foam humerus models. The entry and exit hole of each screw trajectory was digitized using a 3-dimensional motion tracking system. A trajectory for each screw was modeled, as well as the volume enclosed by the screw trajectories. The following outcome metrics were calculated: the bone-screw interface, the volume enclosed by the screws, and the effect of leaving the screws short of the articular surface.

RESULTS

Biomet had the most bone-screw interface (7259 mm), whereas Zimmer had the least (3982 mm). The original Synthes plate had the largest screw volume, occupying 31.5% of the humeral head, whereas Smith & Nephew and Zimmer had the lowest volumes, occupying 21.2% and 12.6%, respectively. Leaving the screws 15 mm short of the articular surface resulted in the most reduction in volume for the Depuy plate (50%) and the least reduction for the new version of the Synthes plate (29%).

CONCLUSIONS

Many different manufactured periarticular locking plates exist to stabilize a proximal humeral fracture. Clinicians need to be familiar with the different plate configurations, screw lengths, and trajectories, which affect potential biomechanical performance and can optimize fracture site maintenance.

Fractures and fracture-dislocations of the proximal humerus: A retrospective analysis of 82 cases treated with the Philos(®) locking plate

OBJECTIVE

To present the experience in a single institution of the management of 82 consecutive fractures and fracture-dislocations of the proximal humerus treated with the Proximal Humeral Internal Locking System (Philos(®)) plate.

MATERIALS AND METHODS

A total of 81 patients with 82 proximal humerus fractures (one patient had bilateral fracture) were treated at our institution with open reduction and internal fixation with Philos(®) plate from January 2008 to December 2012 and the clinico-radiological outcome was analysed. Twelve of these patients also had a dislocation of the proximal humerus. According to the Neer classification, there were seven two-part fractures, 40 three-part fractures and 35 four-part fractures. All patients received a similar physical therapy programme following internal fixation. Mean final follow-up was 32 months. Functional outcome was evaluated for each patient using the Constant-Murley score; radiographic evaluation was also conducted and complications were recorded.

RESULTS

At the end of the follow-up period, the mean Constant-Murley score for the injured side was 75 points (range 42-92); results were graded as excellent for eight patients, good for 52, moderate for 17 and poor for five. Twenty-three patients (28%) had complications during the follow-up period. Reoperation was required in 12 patients. Complications included avascular necrosis of the humeral head in 10 patients (12%), varus positioning of the head in four patients (4.8%), impingement syndrome in three patients (3.6%), secondary screw perforation in three patients (3.6%), non-union of the fracture in two patients (2.4%) and infection in one patient (1.2%).

CONCLUSIONS

Open reduction and internal fixation of proximal humeral fractures with the Philos(®) plate was associated with good clinical outcomes provided the correct surgical technique was used. To better evaluate the real incidence of complications, it is important to follow patients for more than one year after surgery as some complications may arise after this time.

Proximal humeral fractures: a review of current concepts

The majority of proximal humerus fractures are sustained via low energy falls in the elderly population. These patients can attain an acceptable level of function via non-operative treatment. There is yet to be a clear consensus on treatment options suitable for those that fall outside of this majority group. Open reduction internal fixation, intra medullary nailing and arthroplasty surgery have all been used to varying effects. Good results are achievable if complications such as mal-union, non-union and avascular necrosis can be avoided. This review aims to clarify the options available to the current day trauma surgeon.

Functional outcomes following locking plate fixation of complex proximal humeral fractures

The purpose of this study was to evaluate the functional outcome of patients with complex proximal humeral fractures fixated by locking plate technology. Eighty-nine patients (27 men, 62 women) older than 50 years with 3- and 4-part proximal humeral fractures were treated using locking plate fixation and followed up for more than 1 year. Functional outcomes were assessed by using the Disabilities of the Arm, Shoulder, and Hand (DASH) and Constant scores, and the complications were evaluated through physical and radiographic examinations. Mean DASH and Constant scores for all 89 patients were 19.6 and 66.6 points, respectively. No significant differences existed in the 2 scores between patients with 3- and 4-part fractures. Of the 71 patients without complications, 68 had an excellent functional outcome according to the DASH score, whereas 2 patients had an excellent outcome on the Constant score. For the 18 patients with complications, the functional outcomes were significantly poorer compared with patients without complications. According to the Constant score, all patients with complications were classified into a moderate or poor functional outcome, but the rate was 12% with the DASH score. In patients with 3- and 4-part proximal humeral fractures fixed with locking plate fixation, complications were the major cause of compromised functional outcomes. Based on these results, different conclusions would be reached when the functional outcome was assessed by using the DASH and Constant scores separately. Because the clinician-based Constant score may bias the results, patient-based assessments, such as the DASH score, are required for the evaluation of functional outcome after shoulder surgery.

Factors associated with the decision for operative versus non-operative treatment of displaced proximal humerus fractures in the elderly

BACKGROUND

In the management of displaced proximal humerus fractures in the elderly, wide variation has been documented. However, no prior study has investigated the factors that currently lead surgeons to treat patients with surgical fixation, arthroplasty or non-operative management. The purpose of this study was to identify the factors associated with treatment selection in the management of displaced proximal humerus fractures in individuals over the age of 60 years. To this end, we conducted a retrospective review of all such injuries that presented to our two level-I trauma centres between 2006 and 2009.

PATIENTS AND METHODS

From our prospectively collected trauma database, we identified 229 displaced proximal humerus fractures that met all inclusion and exclusion criteria. Data were collected on patient-, fracture- and surgeon-related characteristics that were plausibly related to the decision for treatment. The choice of management was recorded, and logistic regression was used to identify factors associated with the decision for treatment.

RESULTS

In the multivariate analysis, the predictors of operative intervention as opposed to non-operative treatment were younger patient age (p = 0.038), associated orthopaedic injuries requiring surgery (p = 0.012), higher Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification (p = 0.012), translation-type displacement (p = 0.0012) and associated glenohumeral dislocation (p = 0.0006). In addition, shoulder and upper extremity specialists were found to choose operative intervention significantly more frequently than orthopaedic trauma specialists (49.1% vs. 26.1%, adjusted relative risk (RR) 1.96, p = 0.012). Factors associated with the decision for arthroplasty as opposed to fixation were higher Charlson score (p = 0.045), higher Neer classification (p = 0.012), and higher AO classification (p = 0.0097).

CONCLUSIONS

In this study of displaced proximal humerus fractures in the elderly, the decision for surgery was influenced by the patient's age, the presence of associated orthopaedic injuries, the severity of the fracture and the presence of an associated glenohumeral dislocation. In addition, treatment by a shoulder or upper extremity specialist (as opposed to an orthopaedic trauma specialist) was associated with a higher likelihood of operative intervention. Further investigation into the resultant clinical outcomes is required to determine whether the use of these characteristics to select operative candidates is appropriate and beneficial for patients.

Is it worth fixing proximal humeral fractures at increased vascular risk?

OBJECTIVE

To evaluate fixation of proximal humeral fractures by anterograde nailing, in terms of fracture reduction, bone healing; osteonecrosis; functional consequences of osteonecrosis and malunion.

DESIGN

Prospective, consecutive, multicenter based.

SETTING

Academic Trauma Centers; approval was received from the ethics committee of the institutions involved in the study.

METHODS

Fifty-one patients were enrolled prospectively, with 31 3-part and 20 4-part displaced fractures (head displacement greater than 45°, tuberosity-head gap greater than 10mm, diaphyseal gap greater than 10mm). A Telegraph™ nail (FH Orthopedics, Heimsbrunn, France) was the fixation device used, introduced through a superolateral transdeltoid approach under fluoroscopic guidance. The assessment included Simple Shoulder Test, absolute Constant score, X-rays every 3 months and CT-scan at final evaluation. Twelve patients died and one was lost to follow-up. Immediate complications included secondary displacement in four patients.

RESULTS

There were no infections, no deltoid muscle or axillary nerve damage, and all the fractures united. After a mean follow-up of 24.1 months, malunion was observed in 29% of the remaining 38 patients and osteonecrosis in 32%. Both complications were more frequent and extensive in patients with 4-part fractures. The osteonecrosis area influenced the Constant score, which was 55.8 points when the area was less than 30%, 50.6 points between 30 and 50%, and 38 points when larger than 50%. Head malunion affected the Simple Shoulder Test and the Constant score.

CONCLUSION

Nailing may thus be recommended for 3-part fractures, because osteonecrosis is less frequent, more focused, and better tolerated in this sub-group. In contrast, antegrade nailing was not more beneficial than other internal fixation techniques for preventing osteonecrosis or head malunion in patients with 4-part fractures.

LEVEL OF EVIDENCE

Level IV: prospective study.

Proximal humeral fractures

Proximal humeral fractures may present with many different configurations in patients with varying co-morbities and expectations. As a result, the treating physician must understand the fracture pattern, the quality of the bone, other patient-related factors, and the expanding range of reconstructive options to achieve the best functional outcome and to minimize complications. Current treatment options range from non-operative treatment with physical therapy to fracture fixation using percutaneous or open techniques to arthroplasty reconstructions. This article reviews the current literature on the classification and treatment options for proximal humeral fractures, while seeking to help the reader to define the most appropriate treatment plan for each individual patient with this type of fracture.

Modern perspectives of open reduction and plate fixation of proximal humerus fractures

Recent innovations have greatly increased the range of proximal humeral fractures that are amenable to open reduction and plate fixation.The optimum technique for some of the more complex fracture patterns is not yet fully refined.This article aims to describe the recent advances in the treatment of complex proximal humeral fractures by open reduction and locking plate fixation, focusing particularly on the indications for surgery, the operative techniques, and the expected outcomes after treatment.

Results of proximal humeral locked plating with supplemental suture fixation of rotator cuff

HYPOTHESIS

This study retrospectively reports the results of 81 patients with proximal humeral fractures that were treated operatively. We hypothesized that treatment of these injuries through a standardized technique of precountored locked plating and supplemental tension band suture fixation would result in improved clinical outcomes.

MATERIALS AND METHODS

All patients were evaluated with a minimum follow-up of 1 year. Clinical assessment was performed postoperatively with American Shoulder and Elbow Surgeons (ASES) scores and active range of motion measurements. Radiographic parameters assessed included Neer fracture pattern, fracture union, hardware failure, the presence of avascular necrosis, and medial calcar length and stability. Fractures were classified as 4-part in 14 (17%), 3-part in 41 (51%), and 2-part in 26 (32%).

RESULTS

The average ASES score was 80 (range, 27-100). The final range of motion averaged 131° of anterior elevation and 41° of external rotation. Fracture union was achieved in all patients, and there were no tuberosity failures. Complications included intraarticular screw penetration in 3 (3.7%) and avascular necrosis in 5 (6.2%).

DISCUSSION

Locked plating and supplemental tension band fixation can lead to fracture union and favorable outcomes. Restoration of the medial calcar and supplemental suture fixation may decrease the incidence of hardware-related complications.

New trends in fixation of proximal humeral fractures: a review

Surgical treatment of proximal humeral fractures continues to be a challenge especially in osteoporotic patients. Locking plates and intramedullary nails have been used with satisfactory results but the previous reported complications have not been substantially reduced. Most of the existing studies involve a small number of patients followed up for a rather short period of time. Since proximal humeral fractures constitute a heterogenous group of complex fractures in an even more heterogenous population, no single fixation method is a panacea. Choice of implant and method of fixation should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. Based on the findings of the existing clinical studies the authors propose a treatment algorithm.

Proximal humeral fractures: current concepts in classification, treatment and outcomes

Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery. This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.

Displaced proximal humeral fractures: an Indian experience with locking plates

Background

The treatment of displaced proximal humerus fractures, especially in elderly, remains controversial. The objective of this study was to evaluate functional outcome of locking plate used for fixation of these fractures after open reduction. We also attempted to evaluate the complications and predictors of loss of fixation for such an implant.

Methods

Over two and a half years, 56 patients with an acute proximal humerus fracture were managed with locking plate osteosynthesis. 47 of these patients who completed a minimum follow up of 1 year were evaluated using Constant score calculation. Statistical analysis was done using SPSS 16 and a p value of less than 0.05 was taken as statistically significant.

Results

The average follow up period was around 21.5 months. Outcomes were excellent in 17%, good in 38.5%, moderate in 34% while poor in 10.5%. The Constant score was poorer for AO-OTA type 3 fractures as compared to other types. The scores were also inferior for older patients (> 65 years old). Complications included screw perforation of head, AVN, subacromial impingement, loss of fixation, axillary nerve palsy and infection. A varus malalignment was found to be a strong predictor of loss of fixation.

Conclusion

Locking plate osteosynthesis leads to satisfactory functional outcomes in all the patients. Results are better than non locking plates in osteoporotic fractures of the elderly. However the surgery has steep learning curve and various complications could be associated with its use. Nevertheless we believe that a strict adherence to the principles of locking plate use can ensure good result in such challenging fractures.