Percutaneous minimal osteosynthesis of fractures of the proximal humerus in elderly patients

The effect of different pin configurations on cyclic stability in pediatric proximal humerus fracture fixation: A Sawbones model study

BACKGROUND

In sawbones with proximal humerus fracture model, three different fixation configurations, Parallel-Straight K-wires, Cross-Straight K-wires and Palm-Tree Method, were biomechanically compared.

METHODS

A total of 36 anatomical pediatric humerus sawbones models were used. They were divided into three equal groups; parallel fixation with straight K-wires (Group PS), cross fixation with straight K-wires (Group CS), and Palm-Tree Method (Group PT). Models were tested in abduction and torsional at a speed of 0.5 mm/s and a 0-5 mm displacement range. Loading (N) and Stiffness (N/mm) data were calculated and compared statistically.

RESULTS

Group PS was significantly higher than the other two groups in abduction bending cyclic load values (P<0.001). It was also significantly higher in Group CS than in Group PT (P < 0.001). No significant differences were detected between the three different fixation groups' cyclic torsional load values (p < 0.05).

CONCLUSION

The parallel configuration with straight K-wires will provide a more stable fixation than the cross configuration with straight or Palm-Tree Method in pediatric proximal humeral sawbones fracture modeling.

Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures

BACKGROUND

Complex acute proximal humeral fractures may require prosthetic replacement of the proximal humerus. Reverse shoulder arthroplasty (RSA) has been suggested as an alternative to hemiarthroplasty in the management of such fractures. This study compared the functional outcomes of RSA with hemiarthroplasty in patients with acute proximal humeral fractures.

MATERIALS AND METHODS

All patients who underwent RSA or shoulder hemiarthroplasty for acute proximal humeral fractures between January 1, 1999, and December 31, 2010 were identified from The New Zealand Joint Registry. Baseline information, operative characteristics, and postoperative outcomes (Oxford Shoulder Score [OSS] at 6 months and 5 years, revision rate, and mortality rate) were examined and compared between the study groups.

RESULTS

During the study period, 55 patients underwent RSA and 313 underwent shoulder hemiarthroplasty for acute proximal humeral fractures. Compared with hemiarthroplasty patients, RSA patients were significantly older (mean age, 79.6 vs 71.9 years; P < .001) and more often women (93% vs 78%, P = .013). The 6-month OSS was 28.1 for RSA and 27.9 for hemiarthroplasty, which was not significantly different (P = .923); however, the RSA group had a significantly better 5-year OSS than the hemiarthroplasty group (41.5 vs 32.3; P = .022). There was no significant difference between the RSA and hemiarthroplasty groups in revision rate per 100 component-years (1.7 vs 1.1; P = .747) or in 1-year mortality (3.5% vs 3.6%; P > .99).

CONCLUSIONS

Patients with acute proximal humeral fractures who undergo RSA appear to achieve superior 5-year functional outcomes compared with patients who undergo hemiarthroplasty.

Intermediate outcomes following percutaneous fixation of proximal humeral fractures

BACKGROUND

Mini-open reduction and percutaneous fixation of proximal humeral fractures historically results in good outcomes and a low prevalence of osteonecrosis reported with short-term follow-up. The purpose of this study was to determine the midterm results of our multicenter case series of proximal humeral fractures treated with percutaneous fixation.

METHODS

Between 1999 and 2006, thirty-nine patients were treated with percutaneous reduction and fixation for proximal humeral fractures at three tertiary shoulder referral centers. Twenty-seven of these patients were available for intermediate follow-up at a minimum of three years (mean, eighty-four months; range, thirty-seven to 128 months) after surgery; the follow-up examination included use of subjective outcome measures and radiographic analysis to identify osteonecrosis and posttraumatic osteoarthritis on radiographs.

RESULTS

Osteonecrosis was detected in seven (26%) of the total group of twenty-seven patients at a mean of fifty months (range, eleven to 101 months) after the date of percutaneous fixation. Osteonecrosis was observed in five (50%) of the ten patients who had four-part fractures, two (17%) of the twelve patients who had three-part fractures, and none (0%) of the five patients who had two-part fractures. Posttraumatic osteoarthritis, including osteonecrosis, was present on radiographs in ten (37%) of the total group of twenty-seven patients. Posttraumatic osteoarthritis was observed in six (60%) of the ten patients who had four-part fractures, four (33%) of the twelve patients who had three-part fractures, and none (0%) of the five patients who had two-part fractures.

CONCLUSIONS

Intermediate follow-up of patients with percutaneously treated proximal humeral fractures demonstrates an increased prevalence of osteonecrosis and posttraumatic osteoarthritis over time, with some patients with these complications presenting as late as eight years postoperatively. Development of osteonecrosis did not have a universally negative impact on subjective outcome scores.

Proximal humeral fractures: a systematic review of treatment modalities

A systematic review was conducted of primary intervention of proximal humeral fracture, which is a common injury with significant morbidity. Keywords of proximal humeral fracture were entered into PubMed and Embase databases. Two evaluators reviewed abstracts from 1985 to 2004 for inclusion and exclusion criteria yielding 66 articles. These articles were evaluated independently for outcomes and quality of evidence using the Structured Effectiveness Quality Evaluation Scale and Sackett's Levels of Evidence. Patient characteristics and outcomes were recorded. The 66 studies included 2155 patients grouped by fracture types according to the Neer classification system. Studies differed by intervention, methods, outcome measures and results. Quality scores averaged 15/48; only 2 articles included randomized groups. Current studies typically lack randomization, comparators, and independent evaluation, with a resultant inability to produce clinical conclusions. Further research comparing primary treatment methods in a properly designed and controlled fashion is required, ideally using randomized controlled trials.

Outcomes after percutaneous reduction and fixation of proximal humeral fractures

The purpose of this study is to report the outcomes after closed or percutaneous reduction with percutaneous fixation of displaced proximal humeral fractures. This study included 35 patients from 3 institutions. Of these, 27 were followed up for a minimum of 1 year after surgery. The mean age at injury was 61 years. There were seven 2-part, eight 3-part, and twelve valgus-impacted 4-part proximal humeral fractures. All fractures were reduced and stabilized with percutaneous techniques only. The mean duration of follow-up was 35 months. All fractures healed after the index procedure. The mean pain score on a visual analog scale was 1.4. The mean American Shoulder and Elbow Surgeons and Constant scores were 83.4 and 73.9, respectively. Four patients healed with malunion, and in four, glenohumeral joint osteoarthritis developed. Fracture type, age, malunion, or osteoarthritis had no significance influence on measured outcomes. Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications.

Biomechanical comparison of different pin configurations during percutaneous pinning for the treatment of proximal humeral fractures

We investigate the influence on fracture stability of different pin configurations during percutaneous pinning for the treatment of proximal humeral fractures. We performed a matched-paired study of 18 pairs of adult fresh-frozen humeri (36 humeri), which were divided into 4 groups. A 2-part surgical neck fracture model was used in all humeri, and 4 terminal threaded pins (2.5 mm in diameter) were used for fixation. Parallel-type pinning (box type) was carried out in 2 groups, and convergent-type pinning (fan-shaped type) was used in the other 2 groups. For each specimen, both anti-shear ultimate load and anti-torsion ultimate load were measured. There was no statistical difference between the parallel pin construct and convergent construct with regard to anti-shear resistance (P = .73). However, the parallel pin construct had a significant advantage over the convergent construct regarding anti-torsion resistance. The parallel pin construct has better torsional stability when 1 cm is used for the pin-to-pin distance. We suggest that parallel pin fixation should be applied whenever possible.

[Operative treatment of proximal humeral fractures with helix wire]

BACKGROUND

Between 1 January 2000 and 31 December 2002, a total of 50 patients with a dislocated or unstable fracture of the proximal humerus were treated surgically with a titanium helix wire introduced retrogradely into the medullary cavity.

MATERIAL AND METHODS

Fracture classification showed 8 cases of a two-fragment fracture, 32 cases of a three-fragment fracture, and 10 cases of a so-called four-fragment fracture. A retrospective radiographic and medical review of all 50 patients showed postoperative complications in 24% of the cases; in 8 cases (16%) secondary loss of retention occurred with consecutive projection of the helix wires into the subacromial joint space. There were two cases each (4%) of perforation of the helix wire into the joint space without loss of retention and fracture dehiscence because of a blocking mechanism by the helix wire in the subcapital fracture gap. The postoperative revision rate was 18% (9/50) as a result. Of 50 patients with a titanium helix wire, 38 (76%) were reviewed after an average of 23 months (12-31). Radiologically partial necrosis of the head of the humerus was seen in two patients and there was necrosis of the head of the humerus with pseudarthrosis in one patient, which had a negative effect on the Constant score.

RESULTS

Because of a change of procedure (n=5) and intercurrent deaths (n=5) only 2 of 12 patients, in whom complications had occurred postoperatively, could be followed up clinically; the results of the follow-up are sure to be distorted by this selection effect. Of 38 patients, 32 (84%) showed very good to good results functionally; the average Constant score was 74 points and the average age- and sex-specific corrected score was 92%.

DISCUSSION

Thus, the procedure does not achieve better functional results compared to other rigid and semirigid internal fixation methods while it has a high complication and revision rate compared to other rigid and semirigid internal fixation methods. Moreover, early functional treatment is not possible so that the titanium helix wire represents a retention aid rather than stable internal fixation. Overall we cannot recommend the procedure for the operative management of proximal humerus fractures further and have abandoned it ourselves.

Mid term results of PlantTan plate in the treatment of proximal humerus fractures

This prospective study evaluates the clinical efficacy of a special implant, PlantTan plate used for fixation of displaced proximal humerus fractures. The PlantTan plate was used for internal fixation of closed displaced proximal humeral fractures in 68 patients from September 1999 to June 2002, in a University Hospital. One of the surgeries was for a non-union, and five patients were lost to follow-up. The patients' ages ranged from 19 to 76 years (mean 61 years and median 66 years). Of the remaining 62 patients, 42 were female and 20 were male. As defined using the Neer classification 19 patients had two part, 37 three part and 6 had four part fractures. Median follow-up was 19 months (11-38). The outcome was assessed using radiographs, American Shoulder and Elbow Surgeons (ASES) score and Hospital for Special Surgery (HSS) scoring system. Fifty-two patients achieved union in a median of 8 weeks. The median cumulative score of activities of daily living of ASES was 20.4/30 (13-27). According to HSS, 11 scored excellent, 26 good, 14 fair and 11 scored poor. Eight patients had fixation failure and two developed avascular necrosis. Eleven patients developed an infection. Six patients developed an infection resulting in implant removal. One had a transient and one permanent axillary nerve palsy. Since the PlantTan plate provides stability, early active rehabilitation can be instituted. The implant is distally placed reducing impingement symptoms. However, the implant requires wide surgical exposure, is bulky and has an unacceptable infection rate. The fixation failure is high in patients with osteoporosis. In view of the above encountered problems, the implant has been discontinued in our hospital.