Early locking plate removal following open reduction and internal fixation of proximal humeral fractures could prevent secondary implant-related complications

The acromion plate angle: a simple measurement to predict clinical outcomes after plate removal in proximal humerus fractures

BACKGROUND

One-third of patients who undergo open reduction and internal fixation of proximal humerus fractures require subsequent plate removal (PR). It is currently unclear which patients will benefit most from this procedure. Therefore, to support preoperative decision-making we sought to identify predictive factors of the clinical benefits of PR.

MATERIALS AND METHODS

All patients with open reduction and internal fixation for proximal humerus fractures from 2014 to 2020 were recorded prospectively in an institutional register. All those with a 1-year follow-up were included in the study. The clinical and radiographic follow-ups after 12 months, and before and after PR were evaluated. The radiographic analysis included measuring known parameters (acromion tuberosity index, lateral acromion angle, critical shoulder angle) and a new measurement: the acromion plate angle (APA).

RESULTS

We included 91 patients of whom 31 had undergone later PR. A significant difference between the group without and with PR was only seen in the age (P ≤ .001). Significant improvement in the absolute Constant score (CS) (+12.6), relative CS (+16.6), elevation (+29.5°), abduction (+32.6°), and external rotation (+18.1°) (P values <.001) was observed following PR. The regression analysis revealed that older age and low APA were significant predictors of clinically relevant improvement of the absolute CS. Optimal cut-off values for age (>55 years) and APA (<36°), corresponding to a minimal increase of 10 points in the absolute CS, were also identified.

CONCLUSION

Significant improvements in absolute CS and range of motion were achieved in all patients after PR. Even though it was performed more frequently in younger patients, patients >55 years profited the most. An APA of <36° was found to be a positive predictor for significant and relevant functional improvement after PR. Its easy use on ap radiographs allows uncomplicated integration into the clinical decision-making process and helps inform the patients in terms of what to expect after the intervention.

Risk factors for osteonecrosis of the humeral head after internal fixation of proximal humeral fractures: a systematic review and meta-analysis

BACKGROUND

Osteonecrosis of the humeral head (ONHH) is a severe complication after the internal fixation of proximal humeral fractures (IFPHF). The risk factors remain controversial though many studies have reported. In this research, meta-analysis was used to evaluate which surgeon-level factors can be modified to lower the risk and we hope to provide evidence-based support for preventing ONHH.

METHODS

Literature was retrieved from PubMed, Cochrane Library, Embase, Web of Science, and Scopus for eligible studies published up to January 2023. The pooled odds ratios (ORs) were calculated with their corresponding 95% confidence intervals (CIs) to evaluate. STATA 15.1 software was applied for data synthesis, sensitivity synthesis, and publication bias.

RESULTS

45 articles were published between 2000 and 2022, and 2482 patients were finally included. All articles were observational research, with 7 case-control studies and 38 cohort studies, and the Newcastle Ottawa Scale (NOS) score ranged from 7 to 9. The pooled results suggested that age (OR 0.32, 95% CI 0.14-0.74, P = 0.01), reduction quality (OR 0.08, 95% CI 0.01-0.44, P = 0.00), fracture type (OR 0.44, 95% CI 0.25-0.78, P = 0.01), surgical approach (OR: 4.06, 95% CI 1.21-13.61, P = 0.02) and fixation implant (OR = 0.68, 95% CI = 0.34-1.33, P = 0.02) were risk factors for ONHH after IFPHF. According to sensitivity analysis, Begg (P = 0.42) and Egger (P = 0.68) tests, the results were stable and exhibited no publication bias.

CONCLUSIONS

The study showed that age, reduction quality, fracture type, surgical approach and fixation implant were risk factors for ONHH after IFPHF, while gender, varus or valgus, timely operation, injured side, and the existence of medial support have little influence on ONHH, as they could not be considered risk factors and still need further investigations.

Proximal humeral fracture-dislocation: Outcome analysis in osteosynthesis and arthroplasties

PURPOSE

Proximal humeral fracture-dislocations (PHFD) are challenging to treat. In older patients, usually arthroplasty is performed. In younger patients, osteosynthesis is chosen. This study presents functional outcomes of these different treatment modalities.

METHODS

All patients operated for PHFD from 2010 until 2017 were included. Osteosynthesis was performed in younger patients and if reconstruction was possible. Either an open deltopectoral approach or a minimal invasive plate osteosynthesis (MIPO) was performed. Hemiarthroplasty (HA) was done if reconstruction of the tubercles was possible, age was below 63 years and no signs of osteoarthritis were present. In all other cases, a reverse total shoulder arthroplasty (rTSA) was done. The primary endpoint was functional outcome assessed with the QuickDASH Score (QDS). Secondary outcomes were subjective shoulder value (SSV), complications, revisions, and conversion into arthroplasty.

RESULTS

The mean follow-up of 40 patients was 56 ± 24 months. The mean QDS was 4.5 (0.6-9.1) and the mean SSV was 90 (80-98.6). Of these, 33 patients (mean age: 50) had an osteosynthesis, 25 were treated with MIPO. Only 18% were converted into an arthroplasty after a mean of 22 months. Among them, 7 patients received a primary arthroplasty (mean age: 68), no revisions were recorded. Subgroup analysis showed functional outcome deficits in avascular necrosis (AVN) compared to no AVN (p = 0.021), revision surgery compared to no revision (p = 0.040) and in HA compared to rTSA (p = 0.007).

CONCLUSION

Both osteosynthesis and primary arthroplasty after PHFD can lead to good or even excellent functional outcome. Revision rates in osteosynthesis are high. Revision procedures or secondary conversion into arthroplasty after failed osteosynthesis decrease outcome scores significantly.

Is Device Removal Necessary after Fixed-Angle Locking Plate Osteosynthesis of Proximal Humerus Fractures?

Background and Objectives: The aim of this study was to evaluate whether device removal in symptomatic patients following locking plate osteosynthesis of a proximal humerus fracture improves the clinical outcomes. Materials and Methods: Seventy-one patients who underwent fixed-angle locking plate osteosynthesis of a proximal humerus fracture were included. Thirty-three patients underwent device removal at a mean time of 10.4 months after index surgery (removal group). Thirty-eight patients who retained the device after index surgery (retention group) were included in the control group. Visual analog scale (VAS) pain score, University of California at Los Angeles (UCLA) score, American Shoulder and Elbow Surgeons (ASES) score, and range of motion (ROM) were evaluated pre- and postoperatively. Results: At the final follow-up, mean UCLA score, ASES score, and all ROMs were significantly higher in the removal group compared to the retention group (p < 0.001). However, no significant difference in mean VAS pain score was observed between the two groups. Comparison of the clinical outcomes before and after device removal surgery showed significant improvement in all clinical scores and ROMs after device removal (p < 0.001). Conclusions: Device removal surgery in symptomatic patients following locking plate osteosynthesis of a proximal humerus fracture can result in significant improvement in functional outcomes.

Functional outcomes before and after implant removal in patients with posttraumatic shoulder stiffness and healed proximal humerus fractures: does implant material (PEEK vs. titanium) have an impact? - a pilot study

Background

Posttraumatic shoulder stiffness remains a problem after proximal humerus fracture (PHF) despite good healing rates. The aim of this pilot study was to determine whether the implant material and overlying soft tissue have an effect on shoulder range of motion (ROM) before and after implant removal (IR).

Methods

16 patients (mean age 55.2 ± 15.3 (SD) years; 62.5% female) were included who underwent operative treatment with locking plates of either carbon fiber reinforced Polyetheretherketone (PEEK) (PEEKPower® humeral fracture plate, Arthrex, Naples, Florida, USA, n = 8) or titanium alloy (Ti) (Philos®, DePuy Synthes, Johnson & Johnson Medical, Raynham, Massachusetts, USA, n = 8) for PHF. All patients presented with a limited ROM and persistent pain in everyday life after the fracture had healed, whereupon IR was indicated. ROM before and after IR were compared as well as the Constant Score (CS) and the CS compared to the contralateral shoulder (%CS) 1 year after IR.

Results

In group PEEK, elevation was 116.3° ± 19.2° pre- and 129.4° ± 23.7° post-IR (p = 0.027). External rotation was 35.0° ± 7.6° pre- and 50.6° ± 21.8° post-IR (p = 0.041). External rotation with the humerus abducted 90° was 38.8° ± 18.1° pre- and 52.5° ± 25.5° post-IR (p = 0.024). In group Ti, elevation was 110.0° ± 34.6° pre- and 133.8° ± 31.1° post-IR (p = 0.011). External rotation with the humerus at rest was 33.8° ± 23.1° pre- and 48.8° ± 18.7° post-IR (p = 0.048). External rotation with the humerus abducted 90° was 40.0° ± 31.6° pre- and 52.5° ± 22.5° post-IR (p = 0.011). Comparison of the two implant materials showed no significant difference. The overall CS was 90.3 ± 8.8, the %CS was 91.8% ± 14.7%.

Conclusion

There was no significant difference in ROM, CS and %CS with respect to plate materials, although lower cell adhesion is reported for the hydrophobic PEEK. However, all patients showed improved functional outcomes after IR in this pilot study. In patients with shoulder stiffness following locked plating for PHF, implants should be removed and open arthrolysis should be performed, independently from the hardware material.

Level of evidence

II

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05061-x.

Surgical treatment of proximal humeral fractures with the transosseous suture fixation

BACKGROUND

The surgical treatment of displaced proximal humeral fractures is commonly affected by implant-related complications. We evaluated the functional and radiographic results of transosseous suture fixation in a series of displaced proximal humeral fractures (PHF).

METHODS

Sixty-four patients were retrospectively classified by age, sex, and the Neer fracture classification. Two-part greater tuberosity (2pGT) displaced fractures and 3-part (varus and valgus) and 4-part valgus impacted fractures were managed with fragment reduction and transosseous suture fixation. Patients with minimum follow-up of 24 months and assessed with the Constant-Murley score (CMS) were included. Radiological and medical complications, as well as reinterventions were also recorded.

RESULTS

Forty-six patients with a mean follow-up of 58 (24-132) and a mean age of 58 years old were analyzed. Patients with 2pGT (n = 10) fractures had a CMS of 76 points (59-89); patients with 3-part fractures (n = 22) had a score of 67 points (13-91); and those with 4-part fractures (n = 14) had a score of 64 (24-76) points. The overall complication rate was 6 out of 46, and 4 patients required reintervention for different reasons. Patients presenting with 3-part varus fractures had significantly lower functional outcomes scores (p = 0.007). Humeral head osteonecrosis was present in 9 patients and significantly affected the functional outcomes (p < 0.05). However, only three out of nine patients with osteonecrosis required subsequent surgery at the indicated follow-up.

CONCLUSIONS

The fracture reduction and transosseous fixation technique represents a safe technique with low complication and reintervention rates. The presence of humeral head necrosis did not lead to subsequent surgical intervention because no hardware had protruded.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Elective removal vs. retaining of hardware after osteosynthesis in asymptomatic patients-a scoping review

BACKGROUND

Osteosynthesis is the internal fixation of fractures or osteotomy by mechanical devices (also called hardware). After bone healing, there are two options: one is to remove the hardware, the other is to leave it in place. The removal of the hardware in patients without medical indication (elective) is controversially discussed. We performed a scoping review to identify evidence on the elective removal of hardware in asymptomatic patients compared to retaining of the hardware to check feasibility of performing a health technology assessment. In addition, we wanted to find out which type of evidence is available.

METHODS

A systematic literature search was performed in PubMed, Embase, EconLit, and CINAHL (November 2019). We included studies comparing asymptomatic patients with an internal fixation in the lower or upper extremities whose internal fixation was electively (without medical indication) removed or retained. We did not restrict inclusion to any effectiveness/safety outcome and considered any comparative study design as eligible. Study selection and data extraction was performed by two reviewers.

RESULTS

We identified 13476 titles/abstracts. Of these, we obtained 115 full-text publications which were assessed in detail against the inclusion criteria. We included 13 studies (1 RCT, 4 cohort studies, 8 before-after studies) and identified two ongoing RCTs. Nine assessed the removal of the internal fixation in the lower extremities (six of these syndesmotic screws in ankle fractures only) and two in the upper extremities. One study analysed the effectiveness of hardware removal in children in all types of extremity fractures. Outcomes reported included various scales measuring functionality, pain and clinical assessments (e.g. range of motion) and health-related quality of life.

CONCLUSIONS

We identified 13 studies that evaluated the effectiveness/safety of hardware removal in the extremities. The follow up times were short, the patient groups small and the ways of measurement differed. In general, clinical heterogeneity was high. Evidence on selected topics, e.g. syndesmotic screw removal is available nevertheless not sufficient to allow a meaningful assessment of effectiveness.