Hinge plate technique for osteosynthesis of comminuted proximal humeral fractures

The methodology and interpretation of radiographic measures for malunion in proximal humerus fractures: a systematic review

BACKGROUND

Radiographic imaging is an essential tool for surgeons in classifying injury, guiding treatment decision-making, and assessing for adequate intraoperative reduction. However, the heterogeneity in radiographic outcome measures utilized in clinical studies evaluating proximal humerus fracture treatment has made it difficult for surgeons to interpret and analyze the available evidence, leading to continued controversy in the optimal management of these injuries. The aims of this systematic review are to 1) examine the literature to describe the methods for measuring and interpreting radiographic outcomes for malunion and 2) identify studies that have correlated functional outcome measures and radiographic outcome measures.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, a systematic review of the literature was performed using EMBASE, MEDLINE, and the Cochrane Database of Systematic Reviews from inception to January 30, 2024. Outcomes of interest included radiographic outcome measures and functional outcome measures including pain assessment and range of motion measurements.

RESULTS

A total of 36 studies that used radiographic measures of alignment following treatment and union of proximal humerus fractures were identified. The most common measure was the head-shaft angle, utilized in 33 studies (92%). Tuberosity position was reported in 22 studies (61%). Only 21 studies (58%) provided a clear and reproducible technique for obtaining radiographic measures. The interpretation for radiographic malunion varied between studies. Varus malunion, using head-shaft angle measures, was defined as under 105° to under 130° in different studies. Although there is known variation between patients, only 3 studies utilized the imaging from the contralateral shoulder to define patient specific measures for malunion. Twenty-two studies assessed for an association between head-shaft angle malunion and patient functional outcome measures.

DISCUSSION AND CONCLUSION

Given the broad and inconsistent definition of malunion used between the included studies, there remains a lack of clear threshold for radiographic measures of alignment that surgeons can use in their clinical decision-making for proximal humerus fractures. Based on the evidence available, we propose a consistent definition of head-shaft angle measurement drawn from specified radiographic views, with varus malunion defined as <125° and valgus malunion >140°. To optimize the management and outcome of these fractures, radiographic outcomes must be standardized and correlated with function.

The relationship between humeral head angulation and bone void within the humeral head in proximal humerus fractures

Background

The variability of humeral head angulation in proximal humerus fractures (PHFs) is a noteworthy observation. The purpose of this study was to investigate the potential association between humeral head angulation and bone void within the humeral head in PHFs.

Methods

We used the reconstruction function in Mimics software to generate three-dimensional models of fractures. Bony landmarks were employed to accurately define the calcar and humeral head zone. Boolean subtraction was performed to calculate the volume of head bone void.

Results

The cohort consisted of 60 (74.1 %) varus, 21 (25.9 %) valgus, and 23 (22.1 %) neutral angulated PHFs. The mean percentage of humeral head bone void was 38.5 ± 17.8 in varus, 36.3 ± 15.7 in valgus, and 30.1 ± 10.6 in neutral angulated PHFs. A significant difference was observed between the varus and neutral groups (P = 0.035). In addition, an analysis of humeral head bone void was conducted among patients aged over 65 years old, revealing a mean percentage of 42.7 ± 16.4 in varus (27 cases), 34.8 ± 14.5 in valgus (13 cases), and 28.1 ± 11.8 in neutral (8 cases) angulated PHFs. The difference between the varus and neutral groups was also significant (P = 0.023).

Conclusion

All types of angulation patterns exhibited humeral head bone void to some extent, with the varus-displaced PHFs demonstrating more obvious defects in comparison to the neutral angulated type.

Straight intramedullary MultiLoc nails for displaced proximal humeral fractures: health status, radiographic results, clinical outcome, and complications

BACKGROUND

The treatment of the displaced proximal humerus fractures (PHF) still facing a lot of unsolved problems. The aim of this study was to evaluate the clinical effect of MultiLoc nails for the treatment of PHF and present outcomes of patients with different Neer's classification and reduction quality.

METHODS

Adult patients with PHFs were recruited and treated with MultiLoc nail. Intraoperative data, radiographic and functional outcomes, as well as occurrence of postoperative complications were assessed.

RESULTS

48 patients met inclusion and exclusion criteria and were included in this study. The DASH Score were 32.2 ± 3.1 points at 12 months, and 37.3 ± 2.5 points at the final follow-up. The mean ASES score at 12 months and final follow-up were 74.4 ± 6.2 and 78.8 ± 5.1, respectively. The mean CM Score in all 48 patients reached 68 ± 6.4 points at the final follow-up, relative side related CM Score 75.2 ± 7.7% of contralateral extremity. The incidence rate of complications was 20.8%. Patients with fracture mal-union, adhesive capsulitis were observed but no secondary surgeries were performed. There was no significantly difference of DASH Score 12 months after surgery and at the last follow-up among patients with different Neer's classification or reduction quality. However, functional outcomes such as ASES score and CM score were significantly influenced by severity of fracture and the quality of fracture reduction.

CONCLUSIONS

Our study demonstrated that MultiLoc nails is well suited for proximal humeral fractures, with satisfactory health status recovery, good radiographic results, positive clinical outcomes and low rates of complications. The treatment for four part PHF still faces great challenges. Accurate fracture reduction was an important factor for good functional result.

Augmented versus non-augmented locking-plate fixation in proximal humeral fractures

Aims

Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures.

Methods

The search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Articles involving patients with complex proximal humeral fractures treated using open reduction with locking-plate fixation, with or without augmentation, were considered. A meta-analysis of comparative studies comparing locking-plate fixation with cement augmentation or with bone-graft augmentation versus locking-plate fixation without augmentation was performed.

Results

A total of 19 studies were included in the qualitative synthesis, and six comparative studies were included in the meta-analysis. Overall, 120 patients received locking-plate fixation with bone-graft augmentation, 179 patients received locking-plate fixation with cement augmentation, and 336 patients received locking-plate fixation without augmentation. No statistically relevant differences between the augmented and non-augmented cohorts were found in terms of the Disabilities of the Arm, Shoulder and Hand questionnaire score and Constant-Murley Score. The cement-augmented group had a significantly lower rate of complications compared to the non-augmented group.

Conclusion

While locking-plate fixation with cement augmentation appears to produce a lower complication rate compared to locking-plate fixation alone, functional outcomes seem comparable between augmented and non-augmented techniques.

Long-stemmed Hemiarthroplasty with Cerclage Wiring for the Treatment of Split-Head Fractures of the Proximal Humerus with Metaphyseal Extension: A Report of 2 Cases

Introduction

Complex fractures of the proximal humerus with splitting-head component and metaphyseal propagation are very rare injuries that are difficult to treat. Preservation of the humeral head is always considered except in cases with severe comminution and compromised vascularity where shoulder hemiarthroplasty is an alternative option.

Case Report

We present two male patients, 57- and 62-years-old who sustained such a complex proximal humeral fracture after a high-energy injury. They both managed with long-stemmed shoulder hemiarthroplasty and cerclage wiring of the metaphyseal area. They both demonstrated good clinical and radiological outcome at 32- and 24-months postoperatively.

Conclusion

We report the functional and radiological outcomes of two cases of a rare proximal humeral fracture's pattern - combination of splitting-head and metaphyseal comminution – that were managed with long-stemmed hemiarthroplasty and cerclage wire and demonstrated good midterm clinical outcome.