The results of ORIF of displaced unstable proximal humeral fractures using a locking plate

Intramedullary versus locking plate fixation for proximal humerus fractures: indications and technical considerations

Background

The incidence of proximal humerus fractures (PHFs) continues to increase with an aging population, and intramedullary nailing (IMN) and locking plate fixation are two commonly employed techniques for the surgical management of PHF. However, the optimal fixation method can be a source of ongoing controversy. Some influencing factors include the extent of humeral head involvement, fracture complexity, patient age, and surgeon preference. There are many studies that provide a mix of data either when comparing the two techniques or analyzing them in isolation. The aim of this review is to further elucidate the indications and technical considerations involved specifically in IMN vs. locking plate fixation for PHF to further aid orthopedic surgeons when choosing surgical management.

Methods

A narrative approach was chosen for this review allowing for a comprehensive review of literature, including recent findings pertaining to the comparison of management options for PHF. A comprehensive literature search was conducted using the PubMed, Embase, and Cochrane Library databases. The inclusion criteria involved studies that discussed "proximal humerus fracture" and either "intramedullary nail" or "locking plate fixation."

Results

Complications such as avascular necrosis, hardware failure, additional surgical interventions, infection, fracture redisplacement, rotator cuff rupture, and nonunion did not show significant differences between the two groups. Newer generation humeral nails have minimized early complications. As both techniques undergo further refinement and utilization when specifically indicated, functional outcomes, potential complications, and postoperative pain continue to be improved.

Conclusion

The available evidence suggests that both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method. The choice of technique should be tailored to patient factors such as fracture type, age, bone quality, and functional expectations. Surgeon experience also plays a role. While certain presentations may exhibit trends that favor one fixation, no specific technique can be universally recommended. Both IMN and LP have shown comparable and satisfactory outcomes, and the final fixation method chosen should take into account the unique characteristics of each patient.

Rehabilitation protocols in proximal humerus fracture management: A systematic review

Background

Proximal humerus fractures (PHFs) are relatively common, although optimal rehabilitation is unknown. This review aims to characterize the published rehabilitation regimens utilized for PHFs.

Methods

A systematic review was performed per PRISMA guidelines, utilizing PubMed/MEDLINE, Embase, and Cochrane. All studies reporting PHF rehabilitation protocols after nonoperative management, open reduction internal fixation with a plate, or intramedullary nailing were included.

Results

Forty articles comprising 3507 patients (66% female, weighted mean age 63.5 years) were included. Substantial variability was present regardless of management. Rehabilitation modalities reported were: sling use in 34 cohorts, most commonly for three weeks; pendulum exercises in 21 cohorts, most commonly starting at post-intervention day 1; post-intervention passive range of motion (ROM) for 30 cohorts, most commonly starting at two days; active-ROM in eight cohorts, most commonly starting at three weeks; active-assisted ROM for 21 cohorts, most commonly starting at three weeks; unlimited ROM for 20 cohorts, most commonly at 4 or 6 weeks; non-weight-bearing for six cohorts, most commonly for six weeks; strengthening for 16 cohorts, most commonly at six weeks; removal of all restrictions for nine cohorts, most commonly starting at six weeks.

Conclusions

Published rehabilitation protocols for PHFs vary considerably regardless of management. Future studies comparing methods of management need to consider the influence of postoperative rehabilitation protocol heterogeneity when aggregating data from multiple sites.

Level of Evidence

IV.

Management of Posttraumatic Avascular Necrosis of the Proximal Humerus

The etiology of avascular necrosis (AVN) of the proximal humerus can be classified as idiopathic or posttraumatic, the latter being mainly due to proximal humerus fractures. Evidence suggests that posttraumatic AVN may require surgical intervention more often than idiopathic AVN of the proximal humerus. This article provides a comprehensive review of the management of posttraumatic AVN of the proximal humerus. Early stage AVN (stages 1 to 3) is commonly treated with nonoperative intervention or core decompression of the humeral head, whereas later stage disease (stages 4 and 5) may require hemiarthroplasty or total shoulder arthroplasty to restore function. [Orthopedics. 2021;44(6):367-375.].

Comparison between minimally invasive deltoid-split and extended deltoid-split approach for proximal humeral fractures: a case-control study

BACKGROUND

With the rapid aging of the population, the incidence of proximal humeral fracture (PHF) has increased. However, the optimal method for open reduction and internal fixation (ORIF) remains controversial.

METHODS

We performed a retrospective analysis of patients with PHF who underwent locking plate internal fixation at our institution from January 2016 to December 2018. Patients were divided into two groups based on the surgical approach used: an expanded deltoid-split approach group (ORIF group) and minimally invasive deltoid-split approach group (minimally invasive percutaneous plate osteosynthesis, [MIPPO] group). The groups were compared in terms of demographic and perioperative characteristics, and clinical outcomes.

RESULTS

A total of 115 cases of PHF were included in our study, of which 64 cases were treated using the minimally invasive deltoid-split approach and 51 using the extended deltoid-split approach. Fluoroscopy was performed significantly less frequently in the ORIF group and the surgical duration was shorter. However, the postoperative visual analogue scale (VAS) pain score and duration of postoperative hospital stay were significantly higher compared to the MIPPO group. Moreover, secondary loss was significantly less extensive in the ORIF group compared to the MIPPO group, while there was no significant group difference in fracture healing time, Constant shoulder score, or complications at the last follow-up visit.

CONCLUSIONS

The clinical outcomes associated with both the minimally invasive and extended deltoid-split approaches were satisfactory. The data presented here suggest that the extended deltoid-split approach was superior to the minimally invasive deltoid-split approach in terms of operational time, fluoroscopy, and secondary loss of reduction, while the minimally invasive approach was superior in terms of postoperative pain and hospital stay. Accordingly, neither procedure can be considered definitively superior; the optimal surgical procedure for PHF can only be determined after full consideration of the situation and requirements of the individual patient.

Outcomes of 188 Proximal Humeral Fractures Treated with a Dedicated External Fixator with Follow-up Ranging from 2 to 12 Years

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.

Effect of screw thread length on stiffness of proximal humerus locking plate constructs: A finite element study

Plate-based treatment of proximal humerus fractures is associated with a high risk of complications such as screw perforation into glenohumeral joint. Smooth and threaded pegs were developed with the hope of minimising these risks. No consensus exists onto which threading profile achieves stiffest bone-plate construct. This study investigated the biomechanical effect of five percentages of threading on individual humeral head screws on a bone-plate construct. A finite element model simulating a two-part proximal humerus fracture treated with a Spatial Subchondral Support plate was developed and validated against in vitro biomechanical tests. The proportion of the humeral head screw length that was threaded was varied between 0%-100% in 25% increments. A 5-mm cantilever varus displacement was applied and the required load (F₅) was calculated. Full (100%) threading achieved the stiffest construct for all six screws. Fully threading all smooth pegs at once increased F₅ by 18%. Threading did not increase F₅ equally in all screws. Inferior three plate screws exhibited a larger increase in stiffness than superior three. Most of the mechanical benefits of threading in inferior three screws can be achieved by using threaded pegs (50% threading) while the superior three screws need to be fully threaded. In practice, the smooth surface profile may also offer additional mechanical benefits if implanted with longer lengths and larger diameters. Threading is an effective way of increasing the varus bending stiffness of proximal humerus plates constructs.

Complications Associated with Locking Plate of Proximal Humerus Fractures

Proximal humerus fractures constitute a significant percentage of fragility fractures. The growing use of locking plate has helped treat this problem, but at the same time has brought about complications. Past systematic reviews have documented these complications, however a large number of recent studies have been published since, reporting their own complication rates with different techniques. This study reviews the current complications associated with locking plate of proximal humerus fractures as well as methods to reduce them. A systematic review, following the PRISMA guidelines, was conducted in November 2013 and repeated in March 2015, using PubMed, Scopus, and Cochrane databases, to evaluate locking plate fixation (and complications) of traumatic proximal humerus fractures. Inclusion criteria included adults (>18 years), minimum of 12-month postoperative followup, articles within the last 5 years, and studies with >10 participants. Exclusion criteria included pathologic fractures, cadaveric studies, and nonhuman subjects. Eligible studies were graded using a quality scoring system. Articles with a minimum of 7/10 score were included and assessed regarding their level of evidence per the Journal of Bone and Joint Surgery and Centre for Evidence-Based Medicine guidelines. The initial query identified 51,206 articles from multiple databases. These records were thoroughly screened and resulted in 57 articles, consisting of seven Level 1, three Level 2, 10 Level 3, and 37 Level 4 studies, totaling 3422 proximal humerus fractures treated with locking plates. Intraarticular screw penetration was the most reported complication (9.5%), followed by varus collapse (6.8%), subacromial impingement (5.0%), avascular necrosis (4.6%), adhesive capsulitis (4.0%), nonunion (1.5%), and deep infection (1.4%). Reoperation occurred at a rate of 13.8%. Collapse at the fracture site contributed to a majority of the implant-related complications, which in turn were the main reasons for reoperation. The authors of these studies discussed different techniques that could be used to address these issues. Expanding use of locking plate in the proximal humerus fractures leads to improvements and advancements in surgical technique. Further research is necessary to outline indications to decrease complications, further.

Plate fixation of the proximal humerus: an international multicentre comparative study of postoperative complications

OBJECTIVE

The primary aim was to evaluate the number of complications following locking plate fixation of proximal humeral fractures in country X and in country Y. The secondary aim was to identify risk factors for complications.

METHODS

Multicentre retrospective case series of 282 consecutive patients with proximal humeral fractures, treated with a locking plate between 2010 and 2014.

SETTING

two level 1 trauma centres in country X and one in country Y. Data pertaining to demographics, postoperative complications and re-operations were collected. Fractures were classified according to the AO and Hertel classifications and experienced surgeons assessed the quality of reduction and plate fixation on the postoperative X-rays. Outcomes of the two different countries were compared and logistic regression analysis was performed to analyse the relationship between risk factors and complications.

RESULTS

During a median follow-up of 370 days, 196 complications were encountered in 127 patients (45%). The most frequent complications were: screw perforation in the glenohumeral joint (23%), persistent shoulder complaints (16%), avascular necrosis of the humeral head (10%) and secondary fracture displacement (5%). In 80 patients (28%), 132 re-operations were performed. The patients operated in country X had significantly more complications compared with the patients operated in country Y. For implant-related complications, advanced age, non-anatomic reduction of the greater tuberosity, and country of operation were risk factors.

CONCLUSION

The use of locking plates for proximal humeral fractures was associated with a high number of complications in both countries; the patients operated in country Y, however, had better results compared with the patients operated in country X.

LEVEL OF EVIDENCE

IV.

Locking plates versus intramedullary nails in the management of displaced proximal humeral fractures: a systematic review and meta-analysis

PURPOSE

To compare the clinical outcome and complications of locking plates versus intramedullary nails in patients with displaced proximal humeral fractures. Our hypothesis was that there would be no difference between these two implants with regard to clinical outcome and complications.

METHODS

We performed a systemic review of PubMed, EMBASE, Clinical Trials Registry, Cochrane Central Register of Controlled Trials and Google Scholar to identify all relevant randomized controlled trials, prospective and retrospective comparative studies on April 26, 2017. The studies of locking plates compared to intramedullary nails in patients with displaced proximal humeral fractures were included. We conducted a meta-analysis of shoulder functional scores, range of motion, pain scores, and complications.

RESULTS

This meta-analysis included 13 comparative studies with 958 patients (529 in the locking plate group and 429 in the intramedullary nail group). A significantly greater external rotation (MD = 9.67; 95% CI, 4.22-15.12; P = 0.0005) and a significantly higher penetration rate (RR = 1.75; 95% CI, 1.11-2.77; P = 0.02) were observed in the locking plate group compared with the intramedullary nail group. Constant-Murley scores, DASH scores and total complication rate were comparable between the two groups. Moreover, there were no significant differences in forward elevation, VAS scores, and other complications.

CONCLUSIONS

Current evidence indicates that locking plates and intramedullary nails have similar performance in terms of the functional scores and total complication rate. No superior treatment was suggested between locking plates and intramedullary nails for displaced proximal humeral fractures.

Hertel 7 fracture of the humeral head. Can two different fixation systems (Diphos/PHP) lead to different outcomes? A retrospective study

OBJECTIVE

To compare clinical outcomes and complication rates in the medium-to-long-term follow-up of Hertel 7 humeral head fractures treated with two different locking plates.

MATERIALS AND METHODS

A total of 52 patients with type 7 humeral head fracture (in accordance with Hertel classification) were enrolled retrospectively: 24 patients [4 male, 20 female; mean age (standard deviation [SD]): 68.9 (5.8) years] were treated with Diphos H plate (Group A) and 28 patients [6 male, 22 female; mean age (SD): 61.0 (7.5) years] with Proximal Humeral Plate (PHP; Group B). The mean follow-up periods were 25.6 and 18.9 months, respectively. Functional outcomes were assessed using the Constant score and Disabilities of the Arm, Shoulder and Hand (DASH) score; X-ray evaluation was also performed and complications were recorded.

RESULTS

The mean Constant score in the Diphos and PHP groups at follow-up were 75.6 (SD 13.4) and 78.9 (SD 12.8), respectively (p>0.05). The DASH score was similar in both groups (Diphos: 18.6, range 0-51.5; PHP: 16.8, range 0-47.8) (p>0.05). In our series, 9.6% of patients had complications; these included a case of aseptic non-union and a case of avascular necrosis of the humeral head in each group, and a secondary screw perforation in a patient treated with Diphos.

CONCLUSIONS

In patients with Hertel 7 proximal humeral fractures, Diphos and PHP lead to similar satisfactory functional outcomes and are associated with low complication rates; this confirms that both are useful implants for the treatment of this pattern of fracture.

Arthrofibrosis After Periarticular Fracture Fixation

Arthrofibrosis after periarticular fractures can create clinically significant impairments in both the upper and lower extremities. The shoulder, elbow, and knee are particularly susceptible to the condition. Many risk factors for the development of arthrofibrosis cannot be controlled by the patient or surgeon. Early postoperative motion should be promoted whenever possible. Manipulations under anesthesia are effective for a period of time in certain fracture patterns, and open or arthroscopic surgical debridements should be reserved for the patient for whom nonoperative modalities fail and who has a clinically significant deficit.

Radiographic morphometry and densitometry predict strength of cadaveric proximal humeri more reliably than age and DXA scan density

Methods are needed for identifying poorer quality cadaver proximal humeri to ensure that they are not disproportionately segregated into experimental groups for fracture studies. We hypothesized that measurements made from radiographs of cadaveric proximal humeri are stronger predictors of fracture strength than chronological age or bone density values derived from dual-energy x-ray absorptiometry (DXA) scans. Thirty-three proximal humeri (range: 39-78 years) were analyzed for: (1) bone mineral density (BMD, g/cm(2)) using DXA, (2) bulk density (g/cm(3)) using DXA and volume displacement, (3) regional bone density in millimeters of aluminum (mmAl) using radiographs, and (4) regional mean (medial+lateral) cortical thickness and cortical index (CI) using radiographs. The bones were then fractured simulating a fall. Strongest correlations with ultimate fracture load (UFL) were: mean cortical thickness at two diaphyseal locations (r = 0.71; p < 0.001), and mean mmAl in the humeral head (r = 0.70; p < 0.001). Weaker correlations were found between UFL and DXA-BMD (r = 0.60), bulk density (r = 0.43), CI (r = 0.61), and age (r = -0.65) (p values <0.01). Analyses between UFL and the product of any two characteristics showed six combinations with r-values >0.80, but none included DXA-derived density, CI, or age. Radiographic morphometric and densitometric measurements from radiographs are therefore stronger predictors of UFL than age, CI, or DXA-derived density measurements.

Displaced proximal humeral fractures: when is surgery necessary?

BACKGROUND

Several therapeutic methods have been traditionally used in the treatment of displaced proximal humeral fractures; however, the indication of these treatments is still controversial. The purpose of this study was to compare the medium-term functional results of four methods commonly used in the treatment of proximal humeral fractures [conservative treatment, proximal humeral nails (PHN), percutaneous K-wiring (PKW), and locking-plates (LP)] taking into consideration the type of fracture and the age of the patients.

METHODS

We conducted a retrospective cohort study on patients with proximal humeral fractures treated with one of the following methods: conservative treatment, PHN, PKW, or LP. Functional results were assessed using the absolute Constant score and the disabilities of the arm shoulder and hand score (DASH). The functional outcome was analysed according to age (≥65 years and <65 years) and fracture type (displaced 2-fragment and 3-4-fragment fractures).

RESULTS

A total of 113 patients were included in the study, with a mean age of 65.3 SD 15.2 years and average follow-up time of 26.2 SD 12.6 months. Patients under 65 years had higher Constant scores when treated with PHN and PKW than those treated conservatively (77.2 vs. 54.7, p=0.01 and 74.0 vs. 54.7, p=0.03, respectively). Patients above 65 years had higher Constant scores when treated with PKW compared to PHN and conservative treatment (68.7 vs. 51.9, p=0.02 and 68.7 vs. 55.9, p=0.029, respectively). In 2-fragment fractures, PKW resulted in higher Constant scores than conservative treatment (70.4 vs. 53.9, p=0.048). No differences were found in the final outcome between patients treated with LP and those treated conservatively regardless of age, and fracture type. There were also no differences between any of the evaluated methods in the treatment of 3-4-fragment fractures.

CONCLUSION

The use of PKW was associated with better functional results than conservative treatment in individuals of all ages, especially in patients with 2-fragment fractures; PKW also achieved better functional results than PHN in elderly patients. PHN was superior to conservative treatment in young individuals. No significant differences were found between LP and conservative treatment in any of the analysed categories.

Proximal humeral fracture fixation: multicenter study with carbon fiber peek plate

BACKGROUND

Locking plate fixation is a reliable treatment for many displaced proximal humeral fractures. Carbon fiber-reinforced-poly-ether-ether-ketone (CFR-PEEK) plates have recently been introduced as an alternative to traditional metallic plates.

METHODS

In a multicenter study involving the Orthopedic Services of 6 Italian hospitals, 182 patients with a proximal humeral fracture were treated with a Diphos H (Lima Corporate, San Daniele del Friuli, Italy) CFR-PEEK plate, 160 of whom were followed clinically and radiographically for 2 years or more. Fractures were classified by Neer's system. The functional results were assessed by Constant and DASH scores.

RESULTS

The average time to radiographic healing was 5.6 months in 158 of 160 cases. Mean Constant score was 76, and mean DASH score was 28 at 2 years. There were two nonunions (one septic and one aseptic) and 13 cases of partial (9) or massive (4) humeral head necrosis. In three of the 78 patients treated with the first-generation plates, hardware breakage happened during the operation and the plate was replaced. There was no failure among the cases treated with the thicker second-generation plate. In eight cases, there was a perforation of the humeral head by the cephalic screws.

CONCLUSIONS

CFR-PEEK plates proved as reliable as metallic plates in the treatment of proximal humeral fractures. The advantages of these new devices include a better visualization of fracture reduction during intraoperative fluoroscopic assessment and easy hardware removal due to the absence of screw-plate cold fusion.

Comparison between the spatial subchondral support plate and the proximal humeral locking plate in the treatment of unstable proximal humeral fractures

PURPOSE

The aim of our study was to evaluate the effect of the S3 (spatial subchondral support) humeral plate and to compare the clinical outcomes and complications after ORIF (open reduction and internal fixation) of proximal humeral fractures using either a S3 plate or a PHLP (proximal humeral locking plate).

METHODS

A total of 144 patients with displaced unstable proximal humeral fractures were treated with either a S3 plate or a PHLP. Each patient had a follow-up at least for one year. We retrospectively collected the data and compared the shoulder functional outcome as well as complications of these two methods.

RESULTS

During the one-year follow-up, the average Constant scores gradually improved for both groups. Patients treated with use of an S3 plate had better functional results at three and six months (P < 0.05). The one-year Constant score for all fracture types (Neer classified) were not significantly different between the S3 and PHLP group (P > 0.05). The complication rate was comparable between the two groups (P > 0.05).

CONCLUSIONS

The treatment using an S3 plate for displaced unstable proximal humeral fractures resulted in a good union rate and functional outcome, which is comparable to the PHLP treatment. The S3 humerus plate can be considered as an effective implant for ORIF of displaced unstable proximal humeral fractures.

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.

Factors predicting complication and reoperation rates following surgical fixation of proximal humeral fractures

BACKGROUND

The purpose of this study was to report complication and reoperation rates following non-arthroplasty fixation of shoulder fractures determined on the basis of observational, population-based data from all inpatient admissions in California over an eleven-year period.

METHODS

Records from all inpatient hospital discharges and subsequent readmissions related to operative non-arthroplasty treatment of proximal humeral fractures were obtained for patients in California from December 1994 through December 2005. These admissions were evaluated to identify patient and hospital characteristics associated with short and intermediate-term complications (within and after ninety days, respectively) as well as reoperation rates. Procedures performed included open reduction and internal fixation in 9254 patients, closed reduction and internal fixation in 1903 patients, and internal fixation without reduction in 302 patients.

RESULTS

The short-term complications included mortality in 401 patients (3.5%), which was associated with a higher Charlson comorbidity index (odds ratio [OR] = 1.5, p < 0.001) and male sex (OR = 1.7, p < 0.001); and pulmonary embolism in sixty patients (0.5%), which was associated with male sex (OR = 2.2, p = 0.007) and patient age of seventy-five years or older (OR = 3.6, p = 0.001). Intermediate-term reoperations included conversion to hemiarthroplasty in 174 patients (1.5%); and conversion to total shoulder arthroplasty in eight patients (0.07%), which was associated with an age of fifty to sixty-four years (hazard ratio = 2.8, p = 0.007). Overall, an age of sixty-five years or older, male sex, residence in an area with an income in the lowest two quintiles, and the presence of preexisting comorbidities were associated with elevated risks of short-term complications but not of intermediate-term conversion to arthroplasty. The ninety-day revision rate was 5.3%.

CONCLUSIONS

Surgical fixation of proximal humeral fractures has a low complication and mortality profile. The data provided in this study can serve in counseling patients about risks associated with operative fixation of displaced proximal humeral fractures.

The impact of preoperative coronal plane deformity on proximal humerus fixation with endosteal augmentation

OBJECTIVES

To examine the impact of preoperative coronal plane deformity on functional and radiographic outcomes on endosteal strut augmentation of proximal humerus fracture fixation.

DESIGN

Single surgeon, retrospective analysis of a prospective database. Case series.

SETTING

Academic level 1 trauma center.

PATIENTS/PARTICIPANTS

Seventy-two patients with isolated proximal humerus fractures fulfilled all inclusion/exclusion criteria with a minimum follow-up of 12 months.

INTERVENTION

Proximal humerus open reduction internal fixation with a laterally placed proximal humeral locking plate and endosteal placement of an allograft fibula treated through the anterolateral approach.

MAIN OUTCOME MEASUREMENTS

Global functional outcome as determined by the Disabilities of the Arm, Shoulder and Hand (DASH) score and Short Form 36 physical function. Shoulder-specific functional outcome as determined by the Constant-Murley and the University of California Los Angeles shoulder scores.

RESULTS

The mean age was 62 years old (range, 26-90 years). There were 32 varus fractures (neck-shaft angle, 110.8 degrees) and 40 valgus fractures (neck-shaft angle, 168.9 degrees). There was no significant difference in the initial postoperative (varus: 132.5 degrees, valgus: 135.5 degrees) and final (varus: 129.9 degrees, valgus: 132.2 degrees) neck-shaft angles or change in humeral height (varus: 0.94 mm, valgus: 1.48 mm). There were no significant differences in functional outcomes [Constant (varus: 85.2, valgus: 88.7) DASH (varus: 21.4, valgus: 13.9), University of California Los Angeles (28.6, varus 30.4), and Short Form 36 (varus: 66.8, valgus: 59.1)]. There were 2 patients in the valgus group and 3 patients in the varus group with an asymptomatic humeral head screw penetration (mean Constant 84.5, DASH 9.5). There was 1 deep infection in the varus group and 2 in the valgus group necessitating implant removal after fracture union. There was 1 case of avascular necrosis in the valgus group (DASH 19.4, Constant 73).

CONCLUSIONS

There were no significant differences in complication rates, radiographic, or clinical outcomes between fractures presenting with preoperative varus coronal displacement compared with those presenting with valgus coronal displacement. The equivalent outcomes may be attributed to the uniform operative technique and fibular strut augmentation used by the primary surgeon.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures?

BACKGROUND

Proximal humeral fractures are mainly associated with osteoporosis and are becoming more common with the aging of our society. The best surgical approach for internal fixation of displaced proximal humeral fractures is still being debated.

QUESTIONS/PURPOSES

In this prospective randomized study, we aimed to investigate whether the deltoid-split approach is superior to the deltopectoral approach with regard to (1) complication rate; (2) shoulder function (Constant score); and (3) pain (visual analog scale [VAS]) for internal fixation of displaced humeral fractures with a polyaxial locking plate.

METHODS

We randomized 120 patients with proximal humeral fractures to receive one of these two approaches (60 patients for each approach). We prospectively documented demographic and perioperative data (sex, age, fracture type, hospital stay, operation time, and fluoroscopy time) as well as complications. Followup examinations were conducted at 6 weeks, 6 months, and 12 months postoperatively, including radiological and clinical evaluations (Constant score, activities of daily living, and pain [VAS]). Baseline and perioperative data were comparable for both approaches. The sample size was chosen to provide 80% power, but it reached only 68% as a result of the loss of followups to detect a 10-point difference on the Constant score, which we considered the minimum clinically important difference.

RESULTS

Complications or reoperations between the approaches were not different. Eight patients in the deltoid-split group (14%) needed surgical revisions compared with seven patients in the deltopectoral group (13%; p = 1.00). Deltoid-split and deltopectoral approaches showed similar Constant scores 12 months postoperatively (Deltoid-split 81; 95% confidence interval [CI], 74-87 versus deltopectoral 73; 95% CI, 64-81; p = 0.13), and there were no differences between the groups in terms of pain at 1 year (deltoid-split 1.8; 95% CI, 1.2-1.4 versus deltopectoral 2.5; 95% CI, 1.7-3.2; p = 0.14). No learning-curve effects were noted; fluoroscopy use during surgery and function and pain scores during followups were similar among the first 30 patients and the next 30 patients treated in each group.

CONCLUSIONS

The treatment of proximal humeral fractures with a polyaxial locking plate is reliable using both approaches. For a definitive recommendation for one of these approaches, further studies with appropriate sample size are necessary.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Mechanisms of failure of locked-plate fixation of the proximal humerus: acoustic emissions as a novel assessment modality

OBJECTIVES

Locking plates are the predominant implants used for proximal humerus fractures. Despite a preponderance of good clinical outcomes, failures continue to occur. The purpose of this study was to investigate the failure mechanism of locked proximal humeral plate fixation and its relationship with bone density and screw length.

METHODS

Human cadaveric humeri were subjected to cyclic bending loads after an unstable 2-part fracture (Orthopedic Trauma Association classification 11 A-3) was created and stabilized with a locking proximal humeral plate. Acoustic emission (AE) sensors were mounted on the specimens to detect fracture displacement and generation of microcracks. The data were analyzed to evaluate construct failure.

RESULTS

Eight of 10 locking plate constructs in cadaver specimens failed in varus collapse. The primary influences on failure were cancellous bone density and cancellous bone screw length. AE monitoring demonstrated patterns of microcrack progression, predominantly along the inferior screws. The progression trends according to AE were similar to their respective actuator displacement versus time curves.

CONCLUSIONS

Cancellous bone density and total cancellous screw depth penetration seem to be critical variables. Although the patients' bone density cannot be controlled, surgeons may decrease the risk of failure by maximizing the length of the screws within the cancellous bone. Analysis of microcrack formation revealed that failures begin at the midportion and tips of the inferior screws and at the bone-plate interface of the inferior screws.

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.

Biomechanical analysis of a novel locking plate with smooth pegs versus a conventional locking plate with threaded screws for proximal humerus fractures

BACKGROUND

Repair of proximal humeral fractures with locking plates has greatly improved outcomes. However, an alarming rate of complications including screw cutout and impingement under the acromion has recently been reported. A novel locking plate with smooth pegs was developed to reduce these risks. The purpose of this study was to compare these 2 fixation methods with a cadaveric biomechanical study.

MATERIALS AND METHODS

Fourteen pairs of cadaveric proximal humeri (mean age, 77 years) were harvested, and bone density was measured. Osteosynthesis was performed on each pair using either a locking plate with threaded screws (TS group) or smooth pegs (SP group) on the contralateral side. Seven pairs of humeri were tested for cyclic bending, and 7 pairs for cyclic torsional evaluation: TS bending, SP bending, TS torsion, and SP torsion. The bending protocol consisted of cyclically loading to a maximum of 7.5 Nm bending moment for 10,000 cycles. The torsion protocol consisted of ±2 Nm of axial torque for 10,000 cycles. Surgical neck fractures were simulated by excising a 10-mm wedge of bone.

RESULTS

No implant failure or screw cutout was observed in any of the groups tested. Under bending loads, mean displacement of the distal fragment was significantly less for the SP group than that for the TS group over 5,000 cycles. In torsion tests, no significant differences were observed between the 2 fixation methods.

DISCUSSION

The SP group demonstrated superior biomechanical characteristics to the TS group in regards to cyclic bending.

Open reduction internal fixation of proximal humerus fractures

The treatment of proximal humerus fractures continues to evolve. While the many of these injuries can be managed nonoperatively, a certain percentage require operative treatment. Open reduction internal fixation can offer excellent outcomes when performed in the appropriate patient and utilizing proper techniques. This article reviews the most up-to-date literature regarding all phases of proximal humerus fracture osteosynthesis, including diagnosis, imaging, anatomic considerations, surgical indications, fixation, and surgical outcomes.

Surgeon volume is associated with cost and variation in surgical treatment of proximal humeral fractures

BACKGROUND

The issue of rising costs will likely dominate the healthcare debate in the forthcoming years.

QUESTIONS/PURPOSES

We assessed factors including surgeon volume that were associated with lower hospital costs and variations in surgical treatment for proximal humeral fractures.

METHODS

We used national databases for 2001 to 2008 to extract information on 25,731 patients undergoing surgery for proximal humeral fractures. We calculated hospital cost by converting hospital charges based on the hospital accounting reports collected by the Centers for Medicare & Medicaid Services.

RESULTS

In a multivariate linear regression analysis, higher surgeon volume, open reduction and internal fixation (versus hemiarthroplasty), and lower burden of comorbidities were associated with lower hospital cost. Higher surgeon volume was linearly associated with lower hospital costs such that, on average, adjusting for all other factors, a surgeon performing 20 shoulder arthroplasties per year saves a hospital approximately US $1800 per surgery. Factors associated with higher utilization of hemiarthroplasty included high surgeon volume (odds ratio [OR] = 1.46; 95% CI = 1.43, 1.97; as compared with low surgeon volume) and earlier years of our study period (OR = 0.61; 95% CI = 0.56, 0.66; for hemiarthroplasty in 2007-2008 versus 2001-2002).

CONCLUSIONS

Higher surgeon volume was associated with lower hospital costs for proximal humeral fractures. Therefore, policies on minimum volume requirements by hospitals may result in substantial cost savings. There is provider-based practice variation in the surgical treatment of proximal humeral fractures and evidence-based guidelines in this area are needed.

LEVEL OF EVIDENCE

Level III, economic analysis. See Instructions for Authors for a complete description of levels of evidence.

Outcomes for four-part proximal humerus fractures treated with a locking compression plate and an autologous iliac bone impaction graft

OBJECTIVES

The study aims to evaluate outcomes of autologous iliac bone impaction grafts (AIBIGs) with locking-compression plates (LCPs) in four-part proximal humeral fracture.

METHODS

Between October 2004 and October 2008, 21 AIBIG with LCP osteosyntheses were done for four-part proximal humeral fractures. Patients included seven males and 14 females. Their mean age at the time of the operation was 66.3±16.9 years (range: 24-87 years). Five patients had high-energy fractures other than fall from standing height. There were two fracture-dislocation cases, and three valgus-impacted fractures. The length of the calcar segment attached to the articular segment was 7.04±6.10mm; 13 of the 21 cases had lengths less than 8mm. Medial-hinge displacement was 16.77±15.84mm; 19 of the 21 cases had displacements more than 2mm.

RESULTS

There was no avascular necrosis of the humeral head and union was achieved in all cases. Varus collapse and hardware-related complications were not observed. Postoperative neck-shaft angles were found to be 129±9° (range: 109-146°). Neer scores were 92.0±6.3 (range: 81-100).

CONCLUSION

The results of using AIBIG with LCP for four-part proximal humeral fractures are excellent. There are significant bone defects in osteoporotic or comminuted fractures and LCP alone does not always provide reliable fixation. Therefore, meticulous technique and use of AIBIG in this complicated type of fracture can ensure a favourable outcome.

EVALUATION OF THE COMPLICATIONS OF SURGICAL TREATMENT OF FRACTURES OF THE PROXIMAL EXTREMITY OF THE HUMERUS USING A LOCKING PLATE

Objective: To evaluate the complications from surgical treatment using a locking plate among patients with fractures of the proximal extremity of the humerus. Methods: Between July 2004 and December 2009, 56 patients with fractures of the proximal extremity of the humerus were treated using the PHILOS^® plate. There were 19 male patients and 37 female patients, with a mean age of 62 years (range: 30 to 92 years). All the cases had a mean postoperative followup period of 12 months. Thirteen fractures were classified as presenting in two parts, 28 as three, eight as four and seven as epiphyseal fractures. Results: Among the patients operated, 26 were considered to have achieved excellent results, twelve good, ten fair and eight poor, according to the UCLA score. Thirty complications occurred in 20 patients (35.7%), among which the most frequent complication was inadequate reduction of the fracture, which occurred in eight cases. Subacromial impact, caused by the plate, occurred in seven cases, while inadequate fixation occurred in six cases. Other complications such as pseudarthrosis, adhesive capsulitis, avascular necrosis, loss of varus reduction and infection were also seen. Conclusion: The functional results from treating fractures of the proximal extremity of the humerus using a locking plate depended on correct anatomical reduction of the fracture and stable fixation of the implant. Complications still occur frequently, particularly because of intraoperative technical difficulty, fracture severity and possible inexperience of the surgeon.

Treatment of three- and four-part proximal humeral fractures with locking proximal humerus plate

OBJECTIVE

The purpose of this study was to evaluate the effectiveness and complications of the locking proximal humerus plate to treat proximal humerus fractures.

DESIGN

A retrospective clinical trial.

SETTING

Department of Orthopaedics, Tianjin Medical University General Hospital.

PATIENTS

Sixty-eight consecutive patients with three- or four-part fractures of the proximal humerus were treated with locking proximal humerus plates.

INTERVENTION

The deltopectoral anterolateral acromial approach was used to the proximal humerus; open reduction and locking proximal humerus plate were applied.

MAIN OUTCOME MEASUREMENTS

Constant Score was used to measure the shoulder functional recovery, and Visual Analog Scale (VAS) was used to measure subjective evaluation of pain. The radiology was observed.

RESULTS

After average 26.7 months, the average Constant Score was 72.6 ± 13.2 points and the average VAS was 1.2 ± 0.8 points. All the complications such as screw perforation into the glenohumeral joint, screws loosening, soft tissue infections, avascular necrosis and delayed union occurred in eight cases (11.8 %).

CONCLUSIONS

The effectiveness of the locking proximal humerus plate was similar to other published literatures on treating fractures of the proximal humerus; however, a lower complications rate in short follow-up time was observed in this study. It may potentially provide a favorable option for treating three- or four-part fractures of the proximal humerus. Dealing with each particular fracture pattern, surgeons should have a decision of appropriate way to internal fixation.

Retrograde nailing versus locking plate osteosynthesis of proximal humeral fractures: a biomechanical study

BACKGROUND

In locking plate osteosynthesis of proximal humeral fractures, secondary varus malalignment is a specific complication. Retron nails (Tantum AG, Neumunster, Germany), among others, have been designed to improve medial support of the calcar humeri. The aim of our biomechanical study was to examine whether Retron nails provide increased stiffness for axial loads and adequate stiffness for torsional loads when compared with Philos plates (Synthes AG, Umkirch, Germany).

MATERIALS AND METHODS

Twenty-two fresh-frozen paired humeri were collected. After potting the specimens, intact bones were exposed to sinusoidal axial (10-120 N) and torsional (±2.5 Nm) loading for 8 cycles to calculate the initial stiffness and exclude pairs with differences. Afterward, an unstable proximal humeral fracture (AO 11-A3) was created by means of an oscillating saw, and the respective osteosynthesis devices were implanted. After another 4 cycles, initial changes in stiffness were measured. Subsequently, all specimens were tested for 1,000 cycles of loading before final stiffness was assessed.

RESULTS

We found no statistically significant differences between Retron and Philos specimens after 4 or 1,000 cycles of loading.

CONCLUSION

Our study suggests that retrograde nailing provides sufficient stability for axial and torsional loading in 2-part fractures of proximal humeri.

Proximal periarticular locking plates in proximal humeral fractures: functional outcomes

BACKGROUND

Some recent studies have asserted that locking plates do not provide adequate fixation of proximal humeral fractures. The purpose of this study is to review our experience with proximal humeral locking plates, including complications, functional outcomes, and predictors of successful treatment.

MATERIALS AND METHODS

At our institution, 45 patients (46 shoulders) with displaced proximal humeral fractures were treated with a proximal humeral locking plate over a 6-year period. Patients underwent standard surgical and rehabilitation protocols and were evaluated clinically with Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons standardized outcome measurements and range of motion at last follow-up. Radiographs obtained preoperatively, immediately postoperatively, and at final follow-up were evaluated for fracture type, union, and change in alignment.

RESULTS

There were 43 patients (44 shoulders) available for range-of-motion and functional outcome measures with an average follow-up of 34 months. Fracture types included 19 two-part, 21 three-part, 3 four-part, and 1 head-splitting fracture. The mean Disabilities of the Arm, Shoulder and Hand score was 11. The average American Shoulder and Elbow Surgeons score was 85. The average visual analog pain score was 0.8. The average range of motion was as follows: elevation, 140°; external rotation at side, 49°; external rotation in abduction, 77°; and internal rotation, T11. No patient had evidence of screw cutout, varus collapse, or avascular necrosis. One patient required hardware removal.

CONCLUSIONS

Displaced proximal humeral fractures can be successfully fixed with locking plates when attention is paid to anatomic reduction, proper plate placement below to the greater tuberosity to allow abduction, screws in the head with subchondral bone purchase, calcar screws from inferior-lateral to superior-medial and delaying shoulder motion until at least 2 weeks.

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.

Functional outcomes for surgically treated 3- and 4-part proximal humerus fractures

Surgical treatment of 3- and 4-part proximal humeral fractures remains challenging. This study retrospectively evaluated functional outcomes of locked plate fixation vs hemi-arthroplasty in 57 patients with 3- and 4-part proximal humerus fractures from 2003 to 2005 with a mean follow-up time of 35 months (range, 15.7-52.7 months). Mean patient age was 56.9 years (range, 29-81.7 years) for the open reduction and internal fixation group (n=42) and 66.4 years (range, 38.1-90 years) for hemiarthroplasty group (n=15). All 57 patients completed the American Shoulder and Elbow Surgeons score, the Simple Shoulder Test, the Euroqol EQ-5D, [corrected] and the visual analog pain scale. Range of motion, the Constant Score, and the UCLA Shoulder score were used to evaluate a subset of 33 patients. Forty-one patients in the open reduction and internal fixation group achieved union, and 1 had symptomatic avascular necrosis requiring subsequent hemiarthroplasty. Two patients had implant removal for impingement symptoms. In the hemiarthroplasty group, there was 1 revision for a loose prosthesis. The American Shoulder and Elbow Surgeons score (P=.023), Simple Shoulder Test (P=.012), patient satisfaction (P=.034), Constant Score (P=.008), Kelsh Adjusted Constant Score (P=.015), UCLA Shoulder score (P=.01), and range of motion (forward flexion, P=.002; abduction, P=.001) were significantly better in the open reduction and internal fixation group than the hemiarthroplasty group. No significant differences between the groups existed in terms of SF-12 (physical, P=.118; mental, P=.134), Euroqol EQ-5D [corrected] (P=.169), or visual analog pain scale scores (P=.135), but all trended toward better with open reduction and internal fixation.

Locking plate versus nonsurgical treatment for proximal humeral fractures: better midterm outcome with nonsurgical treatment

BACKGROUND

Since its introduction, there has been controversy about the use of locking plates in the treatment of proximal humeral fractures. Have they really improved the functional outcome after a proximal humeral fracture or should nonsurgical treatment have a more prominent role? In order to evaluate our hypothesis that nonsurgical treatment for proximal humerus fractures should be the first choice of treatment, a matched controlled cohort study was conducted to compare the midterm (>1 year) functional and radiologic outcome of a group of patients treated with a locking plate and a matched group of patients treated nonsurgically. Complications in each group of patients were evaluated.

MATERIALS AND METHODS

Through direct matching, 17 patients (1 bilateral fracture) treated with a locking plate were matched to 18 patients treated nonsurgically. Medical records and radiographs were reviewed retrospectively to obtain relevant patient related data and fracture type according to Neer classification (i.e. 2-, 3- and 4-part fractures). At the time of clinical follow-up, EQ-5D, American Shoulder and Elbow Surgeons (ASES) score, visual analog pain (VAS) pain and VAS satisfaction scores were completed. Active range of motion was tested. New radiographs were made to evaluate fracture healing, complications and, in the locking plate group, the position of the plate and screws.

RESULTS

No significant differences were found in the characteristics of the patient groups. A significant difference in range of motion was found in favor of the nonsurgically treated patients. Results of ASES and patient satisfaction scores were also tending toward nonsurgical treatment. Furthermore, the complication rate was higher with locking plate treatment. Patients treated with a locking plate needed significantly more additional treatment on their injured shoulder (P = 0.005).

DISCUSSION

This study's main limitation was the fact that the choice of initial fracture management was based on clinical judgement, as well as patient's fitness for surgery and therefore not randomized. By matching for fracture type this bias was largely overcome. Surgical treatment had a higher complication rate, requiring more additional treatment, which was often related to the initial surgery. Improving surgical technique could possibly lead to better outcomes for the surgically treated patients. In addition to the more favorable outcomes, nonsurgical treatment is also a more cost effective treatment.

CONCLUSION

Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures.

Evidence for success with locking plates for fragility fractures

Fixation of fragility fractures with plates and screws often results in loss of fixation and need for revision surgery. Locking plates and screw were introduced to improve fixation of fragility fractures and have been in use for a decade. This review was conducted to compile evidence that locking plates and screws improve fixation of fragility fractures. A search of PubMed was performed to identify biomechanical studies as well as clinical series of fragility fractures treated with locking plates. Biomechanics papers had to use models of osteoporotic bone and had to directly compare locking plates with traditional plates. Clinical studies included case series in which locking plates were applied to elderly patients with fractures of the proximal humerus and periprosthetic distal femur fractures. Most studies are retrospective case series. Locking plates lead to greater stability and higher loads to failure than traditional plates. When applied to proximal humerus fractures, uncomplicated healing occurs in 85% of patients. Constant and Dash scores approach normal values. For distal femoral periprosthetic fractures, union rates of 75% are reported with a malunion rate of 10%. Early evidence suggests that locking plates improve results of treatment of proximal humerus fractures and distal femoral periprosthetic fractures in the elderly. Loss of fixation is associated with failure to achieve stability at the fracture site. Principles of fracture fixation in osteoporotic bone defined prior to the introduction of locking plates should still be applied.

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.

Evaluation and management of proximal humerus fractures

Fractures of the proximal humerus occur frequently, and are primarily insufficiency fractures that occur in the elderly. Thorough clinical evaluation is essential in identifying associated neurovascular injury, which warrants emergent surgical referral. Good quality radiographs remain a necessary diagnostic tool in the evaluation of proximal humerus injuries. An appreciation of the relevant anatomy and predictable patterns of deformation aid in understanding the basic classification of proximal humerus fractures. Most of these fractures are minimally displaced and can be treated nonoperatively with acceptable clinical outcomes. Familiarity with the basic surgical treatment modalities is helpful to physicians involved in the pre- and postoperative management. Significantly displaced proximal humerus fractures are typically treated with surgical reduction and internal fixation. Complex fractures in the elderly and fracture dislocations are indications for humeral head prosthetic replacement. Proximal humerus fractures are strongly associated with decreased bone mineral density and future fracture risk, and should prompt a referral for medical management of osteoporosis.