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Harbrecht A, Hackl M, Leschinger T, Müller LP, Wegmann K. Focus on stability: biomechanical evaluation of external fixation technique versus locking plate osteosynthesis in 3-part proximal humeral fractures. J Shoulder Elbow Surg 2022; 31:1666-1673. [PMID: 35247574 DOI: 10.1016/j.jse.2022.01.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/21/2022] [Accepted: 01/23/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the primary stability and displacement tendencies of an external fixation system in 2 different configurations in comparison to locking plate fixation in a 3-part proximal humeral fracture model. METHODS Twenty-one fresh-frozen human cadaveric proximal humeral specimens were divided into 3 groups of 7 stripped specimens. An unstable 3-part fracture of the proximal humerus was set. Construct A consisted of the Galaxy Fixation Shoulder System, with fixation in accordance with the manufacturer's recommended technique (3 pairs of threaded wires). Construct B was fixed with an additional pair of threaded wires according to the recommendations of Gumina et al (4 pairs of threaded wires). The remaining 7 specimens were fixed with a locking plate. By use of an optical motion capture system, relative motion at the fracture site and failure load were evaluated during a cyclic loading protocol. RESULTS Plate osteosynthesis showed the highest cyclic load to failure (895 ± 239 N; range, 597-1135 N), followed by construct B (692 ± 121 N; range, 432-788 N) and construct A (350 ± 190 N; range, 139-615 N). Statistically significant differences were found between plating and construct A (P < .001), between plating and construct B (P = .031), and between construct B and construct A (P = .013). Relative motion at the fracture site, in terms of change in distance during cyclic loading, was lowest with construct B measured at the peak load of 395 N after 11 steps (1.73 ± 1.98 mm; range, 0.53-5.96 mm) and highest with construct A (8.46 ± 10.67 mm; range, 2.26-20.79 mm). Angular change measured at the peak load after 11 steps was lowest with construct B (1.19° ± 0.36°; range, 0.59°-1.7°) and highest with construct A (2.44° ± 1.63°; range, 0.77°-4.04°). Statistically significant differences were found between construct A and construct B and between construct A and plating at various steps of cyclic loading. CONCLUSION In this biomechanical study of unstable 3-part proximal humeral fractures, locking plate osteosynthesis demonstrated the highest possible load application. External fixator application with 8 threaded wires (construct B) revealed the least relative motion at the fracture site, without a statistically significant difference compared with locking plates. It therefore represents another valid technique for treatment regarding primary stability. The use of external fixator application with 6 threaded wires (construct A) resulted in the lowest stability and the highest rates of displacement.
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Affiliation(s)
- Andreas Harbrecht
- Center for Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany; Department of Anatomy I, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany.
| | - Michael Hackl
- Center for Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Tim Leschinger
- Center for Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Lars P Müller
- Center for Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Kilian Wegmann
- Center for Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
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Adeyemo A, Bertha N, Perry KJ, Updegrove G. Implant Selection for Proximal Humerus Fractures. Orthop Clin North Am 2021; 52:167-175. [PMID: 33752838 DOI: 10.1016/j.ocl.2020.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Proximal humerus fractures (PHF) are a common orthopedic injury; however, their treatment remains largely controversial with evidence supporting a wide array of treatments. Although many injuries can be treated nonoperatively, there has been much debate about surgical management of PHF. A detailed review of the literature was performed relative to operative management options specifically related to implant choices. Although no definitive answers are available regarding best practice, there is literature to guide operative decision-making and implant selection based on both patient- and surgeon-specific factors.
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Affiliation(s)
- Adeshina Adeyemo
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA
| | - Nicholas Bertha
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA
| | - Kevin J Perry
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA
| | - Gary Updegrove
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA.
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Cecere AB, Toro G, De Cicco A, Braile A, Paoletta M, Iolascon G, Schiavone Panni A. How to improve the outcomes of surgically treated proximal humeral osteoporotic fractures? A narrative review. Orthop Rev (Pavia) 2020; 12:8529. [PMID: 32922699 PMCID: PMC7461645 DOI: 10.4081/or.2020.8529] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 04/17/2020] [Indexed: 02/08/2023] Open
Abstract
Proximal humeral fractures (PHF) are the third most common non-vertebral fragility fractures after hip and distal radius. It still controversial which treatment might be more appropriate, and surgically treated outcomes depends also on an appropriate technique. In order to clarify surgical indications, tips and pitfall a narrative review was conducted. Pinning, external fixation, plating and internal fixators has each one its advantages and disadvantages. During the procedure an appropriate use of the fixation device and handling of the soft tissue might be associated with better outcomes. Calcar comminution, varus angulation, medial dislocation of the shaft, fracture-dislocation are factors that could lead to choose a replacement. Hemiarthroplasty and reverse total shoulder arthroplasty are the most common prosthesis used in PHF. The restoration of humeral length and tuberosities might lead to an improvement in clinical outcomes and prosthesis survivorship.
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Affiliation(s)
- Antonio Benedetto Cecere
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples.,Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Annalisa De Cicco
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples
| | - Adriano Braile
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples
| | - Alfredo Schiavone Panni
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples
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The Current State of the Problem of Treatment of Patients with Proximal Humeral Fractures against the Background of Osteoporosis. JOURNAL OF BIOMIMETICS BIOMATERIALS AND BIOMEDICAL ENGINEERING 2020. [DOI: 10.4028/www.scientific.net/jbbbe.46.35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This study focuses on problems of treatment of proximal humeral fractures occurring against the background of osteoporosis. It presents statistics on osteoporosis and lower energy trauma among patients in the Russian Federation and abroad. The high susceptibility to osteoporotic changes in the bone structure of the male population of Russia compared to the global statistics of osteoporosis among men was emphasized. The main classifications used in the clinical practice of orthopedists and traumatologists allow to identify the type of fracture by clinical and anatomical basis and to structure the existing patient management tactics to achieve the most optimal result of treatment and restoration of limb function. There is an analysis of publications representing various methods of fracture treatment, which helps to use the most optimal methods of relevant fractures treatment.
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Blonna D, Assom M, Bellato E, Pisanu G, Greco V, Marmotti A, Rossi R. Outcomes of 188 Proximal Humeral Fractures Treated with a Dedicated External Fixator with Follow-up Ranging from 2 to 12 Years. J Bone Joint Surg Am 2020; 101:1654-1661. [PMID: 31567802 DOI: 10.2106/jbjs.18.00734] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The treatment of a displaced proximal humeral fracture is still a matter of controversy. Minimally invasive techniques are considered promising options. The purpose of this study was to report outcomes at medium to long-term follow-up after surgical treatment with pins stabilized with an external fixator. METHODS A total of 235 patients (average age, 64 years [95% confidence interval (CI), 62 to 65 years]) were treated with closed or open reduction and fixation with pins stabilized by an external fixator specifically designed for proximal humeral fractures. The pins were inserted using a "pins-crossing-fracture" or a "pins-bridging-fracture" technique. One hundred and eighty-eight patients had a minimum radiographic and clinical follow-up of 2 years. Outcomes were assessed using the Oxford Shoulder Score (OSS), the subjective shoulder value (SSV), a visual analog scale (VAS) for pain, and, for 155 patients, the Constant score. RESULTS Eighty-one (43%) of the 188 patients had a 2-part fracture, 60 (32%) had a 3-part fracture, and 47 (25%) had a 4-part fracture. The reduction was performed with percutaneous maneuvers in 120 shoulders or a deltopectoral approach, in 68. The external fixator was applied using a "pins-crossing-fracture" technique in 133 shoulders and using a "pins-bridging-fracture" technique in 55. At last follow-up, mean clinical scores were as follows: OSS, 42.6 (95% CI, 42 to 44); SSV, 85.5 (95% CI, 83 to 88); and VAS for pain, 1 (95% CI, 0.7 to 1.2). The complication rate at 3 months was 16% (37 of 235). The most frequent complication was pin-track infection (19 of 235, 8%). A total of 50 patients had ≥1 complication (50 of 188, 27%) and 6 (3%) underwent revision surgery. More complications were observed with the "pins-crossing-fracture" technique. CONCLUSIONS In our experience, the use of the external fixator has been a valuable option in the treatment of proximal humeral fractures. The complication and revision rates were acceptable. Most of the complications encountered were manageable without revision surgery. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Davide Blonna
- Orthopedics and Traumatology Department, Mauriziano-Umberto I Hospital, Turin, Italy
| | - Marco Assom
- Orthopedics and Traumatology Department, ASL To4 Ciriè Hospital, Turin, Italy
| | - Enrico Bellato
- Orthopedics and Traumatology Department, San Luigi Gonzaga Hospital, Turin, Italy.,University of Turin Medical School, Turin, Italy
| | | | | | - Antonio Marmotti
- Orthopedics and Traumatology Department, San Luigi Gonzaga Hospital, Turin, Italy
| | - Roberto Rossi
- Orthopedics and Traumatology Department, Mauriziano-Umberto I Hospital, Turin, Italy.,University of Turin Medical School, Turin, Italy
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Huang H. Treatment of the surgical neck fracture of the humerus with a novel external fixator in the elderly with osteoporosis: biomechanical analysis. BMC Musculoskelet Disord 2019; 20:218. [PMID: 31092231 PMCID: PMC6521449 DOI: 10.1186/s12891-019-2599-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 04/30/2019] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Haijing Huang
- Department of trauma Orthopedic, Tianjin Hospital, No. 406, Jiefang south Road, Hexi District, Tianjin, 300021, China.
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Aguado HJ, Ariño B, Moreno-Mateo F, Bustinza EY, Simón-Pérez C, Martínez-Zarzuela M, García-Virto V, Ventura PS, Martín-Ferrero MÁ. Does an early mobilization and immediate home-based self-therapy exercise program displace proximal humeral fractures in conservative treatment? Observational study. J Shoulder Elbow Surg 2018; 27:2021-2029. [PMID: 29803503 DOI: 10.1016/j.jse.2018.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/26/2018] [Accepted: 04/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Nonoperative management of proximal humeral fractures (PHFs) is the most common treatment, but its functional outcome may improve with early mobilization. In frail osteoporotic patients, quick recovery of prefracture independency is mandatory. This study assessed fracture displacement in PHFs managed with conservative treatment after early mobilization and a home-based self-exercise program. METHODS We retrospectively analyzed the radiologic displacement of fracture fragments of PHFs treated conservatively with early mobilization and a home-based self-exercise program. RESULTS Included were 99 patients with 26 one-part, 32 two-part, 32 three-part, and 9 four-part PHFs managed conservatively, followed by early mobilization and a home-based self-exercise program. In the x-ray examinations, the head displaced from varus into valgus 55° ± 23° to 42° ± 22°, in the normal range of anatomic values. The medial hinge displaced from medial to the diaphysis (+1 ± 6 mm) to lateral to the head (-0.6 ± 6 mm). The greater tuberosity displaced cranially from -1 ± 7 mm to 2 ± 5 mm. The Constant score at the 1-year follow-up was 79.69 ± 16.3. DISCUSSION AND CONCLUSIONS The home-based self-exercise program for conservative treatment of PHFs displaces the head-diaphysis angle and the medial hinge toward anatomic reduction, but there is a risk of greater tuberosity cranial displacement. Functional results are fairly good, allowing frail patients to keep on with their independency and life style. Because a large number of patients might need further physiotherapy, the quality of the home-based self-exercises should be supervised.
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Affiliation(s)
- Héctor J Aguado
- Orthopedic and Trauma Surgery (Trauma Unit), Hospital Clínico Universitario, Valladolid, Spain; Medical School, University of Valladolid, Valladolid, Spain.
| | - Blanca Ariño
- Orthopedic and Trauma Surgery, Hospital Clínico Universitario, Valladolid, Spain
| | | | - Elías Y Bustinza
- Orthopedic and Trauma Surgery, Hospital Clínico Universitario, Valladolid, Spain
| | - Clarisa Simón-Pérez
- Medical School, University of Valladolid, Valladolid, Spain; Orthopedic and Trauma Surgery (Upper Limb Unit), Hospital Clínico Universitario, Valladolid, Spain
| | | | - Virginia García-Virto
- Orthopedic and Trauma Surgery (Trauma Unit), Hospital Clínico Universitario, Valladolid, Spain
| | | | - Miguel Ángel Martín-Ferrero
- Medical School, University of Valladolid, Valladolid, Spain; Orthopedic and Trauma Surgery, Hospital Clínico Universitario, Valladolid, Spain
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Zirngibl B, Biber R, Bail HJ. Humeral head necrosis after proximal humeral nailing: what are the reasons for bad outcomes? Injury 2016; 47 Suppl 7:S10-S13. [PMID: 28040070 DOI: 10.1016/s0020-1383(16)30847-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Humeral head necrosis (HHN) remains a major problem in fracture care. Neither its occurrence, its extend, nor its impact on clinical outcomes is predictable on the long term. This study was designed to evaluate clinical and radiological outcomes in patients depending on the influence of HHN. PATIENTS AND METHODS 32 patients with a 3-6 year follow up participated in this study. Their humeral fractures had been stabilized with a standard Targon PH nail (Aesculap, Tuttlingen, Germany) for an acute humeral head fracture. Constant score (CS), DASH score, UCLA shoulder rating scale, and Neer score were assessed. Range of motion (ROM) as well as pain during exercise was documented (VAS). HHN was detected radiologically and graded in stages 0-5. RESULTS All fractures had healed. HHN was found in 10 cases (31.3%). 4 patients (12.5%) showed interlocking screw perforation as part of the head collapse caused by HHN. Median CS was 73 (range: 24-85). There was no association detectable between number of fracture fragments and CS (p ≥ 0.631). The median DASH score was 16.4 (range: 0-74.1), UCLA score 30 (range: 9-35), Neer score 80 (range: 29-100). Three (37.5%) of the patients with a stage IV or V osteonecrosis reported about pain (twice VAS grade 4, once VAS grade 5). All patients suffering from pain were affected by high grade HHN and screw perforation. CS was nonsignificantly affected by HHN (75.5 vs. 63.5; p = 0.12), however massively diminished if additional implant protrusion was present (63.5 vs. 25; p = 0.02). Findings for normalised CS, relative CS, DASH score, UCLA shoulder rating scale, Neer score, and ROM were analogous. DISCUSSION Whereas HHN itself seems to contribute only mildly to functional outcome, we identified screw protrusion as major predictor for bad clinical results. The high rate of HHN found in our study (31.3%) may be attributed to the inclusion of mild HHN and our long follow-up period, as it is known that late-onset HHN may occur more than 3 years after trauma. CONCLUSIONS HHN may lead to screw perforation, resulting in poorest outcomes. We recommend regular clinical and radiographic follow-up for at least five years in order to detect impending screw perforation and plan screw removal in time.
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Affiliation(s)
- Birgit Zirngibl
- Department of Trauma and Orthopaedic Surgery, Paracelsus Medical University, Nuernberg General Hospital, Breslauer Str. 201, 90471 Nuernberg, Germany.
| | - Roland Biber
- Department of Trauma and Orthopaedic Surgery, Paracelsus Medical University, Nuernberg General Hospital, Breslauer Str. 201, 90471 Nuernberg, Germany
| | - Hermann Josef Bail
- Department of Trauma and Orthopaedic Surgery, Paracelsus Medical University, Nuernberg General Hospital, Breslauer Str. 201, 90471 Nuernberg, Germany
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Abstract
INTRODUCTION Proximal humeral fractures with a spiral line of fracture extending from the humeral head to the diaphyseal region are increasing. Treatment for these fractures is comparable to that for shaft fractures. The purpose of this study was to evaluate the use of a new "Long" humeral nail for this type of lesion and identify the best distal locking. MATERIALS AND METHODS Forty-three patients treated with a Long Diphos Nail® were selected for this study: main exclusion criteria were poor cognitive and responsive ability to physical therapy, four-part fracture requiring humeral head replacement, an isolated greater or lesser tubercle fracture and a head-splitting fracture. All patients were divided into two groups according to the distal locking (single or double) and clinically evaluated at 1, 3, 6 and 12 months after surgery. The following parameters were evaluated: fracture healing on radiographic images every month; level of pain with Visual Analogue Scale (VAS); recovery of shoulder function or ability to resume normal daily activities according to the Constant Scoring System (CSS); patient satisfaction; and complications, like fracture consolidation defect or delay. A statistical analysis was performed. RESULTS Improvements in pain, satisfaction and shoulder functional recovery were recorded. Patients reached fracture healing in two to six months. The mean healing time was better for double distal locking (p=0.04).There was a clinically greater difference (p=0.006) between the groups for the mean Constant score at 3 months follow-up, with better results for the double distal locking group. Complications were: one patient with a consolidation delay with a single distal locking screw breakage; it was necessary to remove the nail and perform a second treatment. CONCLUSIONS The results of the study indicate the efficacy of Long Diphos Nail® in the treatment of fractures with a line of fracture extending to the proximal diaphyseal region. The features of a multiplane stabilisation above the fracture and a distal double locking may represent the key for a good fixation for 11-A2, A3 or B2 fractures with a long spiral line. A double distal locking reduces fracture micro-instability and so patients recover function and strength quicker because of less pain at the fracture site. STUDY DESIGN retrospective, cohort of cases. LEVEL OF EVIDENCE IV.
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Abstract
Necrosis of the humeral head, infections and non-unions are among the most dangerous and difficult-to-treat complications of proximal humeral fractures. The aim of this work was to analyse in detail non-unions and post-traumatic bone defects and to suggest an algorithm of care. Treatment options are based not only on the radiological frame, but also according to a detailed analysis of the patient, who is classified using a risk factor analysis. This method enables the surgeon to choose the most suitable treatment for the patient, thereby facilitating return of function in the shortest possible time. The treatment of such serious complications requires the surgeon to be knowledgeable about the following possible solutions: increased mechanical stability; biological stimulation; and reconstructive techniques in two steps, with application of biotechnologies and prosthetic substitution.
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Aguado HJ, Mingo J, Torres M, Alvarez-Ramos A, Martín-Ferrero MA. Minimally invasive polyaxial locking plate osteosynthesis for 3-4 part proximal humeral fractures: our institutional experience. Injury 2016; 47 Suppl 3:S22-S28. [PMID: 27692102 DOI: 10.1016/s0020-1383(16)30602-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The objectives of this study were to describe the surgical technique of fixation of 3-4 part proximal humeral fractures with polyaxial locking plates utilising a minimally invasive approach and to evaluate the accuracy of reduction and stability of fixation. PATIENTS AND METHODS We retrospectively reviewed 90 patients. Fractures were classified according to the Neer classification system. Different radiological parameters were measured to assess the quality of reduction and the stability of fixation. Complications and clinical outcomes were evaluated after one year of minimum follow up. RESULTS There were 76 women and 14 men, with a mean age of 67.4years ±13 (range, 29-85). There were 60 3-part and 30 4-part fractures. Frozen cancellous allograft was used in 30 cases (33.3%). All fractures progressed to union and at one year follow up, the mean Constant score was 79.6±12(range, 62-100). Mean forward flexion, abduction, external rotation and internal rotation were 155°, 148°, 39° and vertebra Dorsal 8, respectively. Complications were noted in seven patients while the postoperative "head-diaphysis angle", "greater tuberosity height" and "medial metaphysis reconstruction" were close to the anatomical parameters; no significant differences were noted at one year radiological follow up. CONCLUSION Reliable and stable fixation can be expected with the use of polyaxial locking plate through a minimally invasive approach for the treatment of 3-4 part proximal humeral fractures. Satisfactory functional results for this procedure can be obtained.
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Affiliation(s)
- Héctor J Aguado
- Trauma Unit, Orthopaedic and Traumatology Department, Hospital Clínico Universitario, Valladolid, Spain.
| | - Juan Mingo
- Trauma Unit, Orthopaedics and Traumatology Department, Complejo Asistencial Universitario, Palencia, Spain
| | - Miguel Torres
- Trauma Unit, Orthopaedics and Traumatology Department, Complejo Asistencial Universitario, Palencia, Spain
| | - Aranzazú Alvarez-Ramos
- Orthopaedics and Traumatology Department, Hospital Universitario "Río Hortega", Valladolid, Spain
| | - Miguel A Martín-Ferrero
- Trauma Unit, Orthopaedic and Traumatology Department, Hospital Clínico Universitario, Valladolid, Spain
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Patel S, Colaco HB, Elvey ME, Lee MH. Post-traumatic osteonecrosis of the proximal humerus. Injury 2015; 46:1878-84. [PMID: 26113032 DOI: 10.1016/j.injury.2015.06.026] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 06/08/2015] [Indexed: 02/02/2023]
Abstract
Post-traumatic osteonecrosis of the proximal humerus represents a challenging problem to the surgeon. It is commonly seen following multi-fragmentary fractures of the proximal humerus which may affect the long-term functional recovery after such injuries. This review summarises the current evidence on risk factors, reasons why estimating its epidemiology is difficult, the vascular supply of the humeral head, classification, and management options.
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Affiliation(s)
- Shelain Patel
- Dept of Orthopaedics, University College London Hospital, 235 Euston Road, London NW1 2BU, United Kingdom.
| | - Henry B Colaco
- Shoulder Unit, St. George's Hospital, Blackshaw Road, London SW17 0QT, United Kingdom
| | - Michael E Elvey
- Dept of Orthopaedics, University College London Hospital, 235 Euston Road, London NW1 2BU, United Kingdom
| | - Marcus H Lee
- Dept of Orthopaedics, University College London Hospital, 235 Euston Road, London NW1 2BU, United Kingdom
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13
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Siebenbürger G, Van Delden D, Helfen T, Haasters F, Böcker W, Ockert B. Timing of surgery for open reduction and internal fixation of displaced proximal humeral fractures. Injury 2015; 46 Suppl 4:S58-62. [PMID: 26542867 DOI: 10.1016/s0020-1383(15)30019-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Open reduction and internal fixation is one established method for treatment of displaced fractures of the proximal humerus. However, the timing of surgery and its effect on complications have not yet been investigated in the literature. Hence, aim of this study was to analyze the occurrence of complication following locked plating of proximal humeral fractures when surgery was delayed in comparison to early intervention. METHODS Between February 2002 and November 2010, 497 patients with displaced proximal humeral fractures were treated by open reduction and locked plating. 329 patients were available for follow-up with a minimum of 12 months after surgery. Outcome analysis included radiographic evidence of loss of fixation (> 10° of secondary displacement), screw-cutout and avascular head necrosis. Outcomes were analyzed with regards to age, gender and fracture pattern and were compared between time intervals in which the primary surgery had been conducted; early intervention (< 48 h), timely scheduled for surgery (3-5 days) and delayed intervention (>5 days). RESULTS Of 329 patients (68.4% women; median age at time of surgery: 69.9 years, 95% Confidence Interval (CI) 68.2, 71.2) the median time between fracture incident and surgical intervention was 3.2 days (95%CI: 3.1, 3.3). Surgery was performed in a 2-part fracture at a median of 3.3 days (95%CI: 3.2, 3.4) after trauma, in a 3-part fracture after 3.3 days (95%CI: 3.1, 3.4), in a 4-part fracture 2.9 days (95%CI: 2.8, 3.0), in head split type fracture 2.2 days (95%CI: 2.0, 2.4) and in dislocation type fracture 0.8 days after trauma (95%CI: 0.7, 0.9, p = 0.40). Loss of fixation was observed in 12.8% (n = 42 patients), of which in 4.9% (n = 16) screw cutout was evident and in 6.8% of cases (n = 20) avascular head necrosis was diagnosed. Patients in which complication was observed were treated at median 2.5 days after trauma (95% CI, 1.8, 3.2), in comparison, patients without evidence of complications were treated at a median of 3.2 days (95% CI, 2.8-3.8, p = 0.35). The odds ratio regarding occurrence of complications for patients treated <48 hours was 0,924, for patients in which surgery was performed 3-5 days after the incident the odds ratio was 0,836 and in patients treated > 5 days the odds ratio was 1,637. CONCLUSIONS Loss of fixation following open reduction and internal fixation of proximal humeral fractures was not more frequently observed when surgery was performed 3-5 days after the incident in comparison to early intervention (< 48 h). However, a delay of intervention > 5 days is related to significant increase of complications. Thus, if open reduction and internal fixation is indicated, reconstruction of the proximal humerus should be performed within 5 days of the fracture event. In head split and dislocated fracture types anatomic reconstruction completed within 48 h from the incident may be beneficial with regards to risk of avascular necrosis.
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Affiliation(s)
- Georg Siebenbürger
- Department of Trauma and Orthopedic Surgery, Munich University Hospital (LMU), Munich, Germany
| | - Dustin Van Delden
- Department of Trauma and Orthopedic Surgery, Munich University Hospital (LMU), Munich, Germany
| | - Tobias Helfen
- Department of Trauma and Orthopedic Surgery, Munich University Hospital (LMU), Munich, Germany
| | - Florian Haasters
- Department of Trauma and Orthopedic Surgery, Munich University Hospital (LMU), Munich, Germany
| | - Wolfgang Böcker
- Department of Trauma and Orthopedic Surgery, Munich University Hospital (LMU), Munich, Germany
| | - Ben Ockert
- Department of Trauma and Orthopedic Surgery, Munich University Hospital (LMU), Munich, Germany.
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