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Czarnecki P, Falis M, Bonczar M, Ostrowski P, Wcisłek J, Romanowski L. Assessing complications and functional outcomes in proximal humerus fracture management: a retrospective comparison between conservative and intramedullary nailing treatments. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1427-1433. [PMID: 38233566 DOI: 10.1007/s00590-023-03822-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/21/2023] [Indexed: 01/19/2024]
Abstract
INTRODUCTION Fractures of the proximal end of the humerus (FPH) are the second most common fractures in the upper limb after fractures of the distal radius and are two to three times as common in women than in men. Therefore, the main objective of the present study was to compare and analyze the complications and the functional outcomes in patients with displaced FPH receiving conservative and surgical treatments with intramedullary nailing. METHODS A retrospective cross-sectional study was conducted to establish the differences in complications risks between surgical and non-surgical treatment of the FPH. For this purpose, the clinical and radiological results of 67 consecutive patients were analyzed. RESULTS A total of 25 patients were included in the non-surgically treated group. A total of 42 patients were included in the surgically treated group. Complications occurred in a total of 4 (16.0%) patients after the non-surgical treatment. Those included frozen shoulder (n = 2), nonunion (n = 1), and avascular necrosis of the humeral head (n = 1). Complications occurred in a total of 18 (42.6%) patients after the surgical treatment. Non-surgically treated patients had statistically significantly (p < 0.05) lower scores in the Constant-Murley scale in all of the categories. CONCLUSION The present study demonstrates an overall prevalence of complications to be 16% in patients treated conservatively and 42.6% in patients treated surgically. In the non-surgical cohort, the frozen shoulder was the most frequently observed complication (8%). Interestingly, non-anatomical repositioning was the most prevalent complication in surgically treated patients. Due to the complexity of the FPH, we believe that the surgeon needs to have comprehensive knowledge regarding the characteristics of this fracture, the available treatment options, and the possible complications that may occur. This can enhance patient safety and provide satisfactory clinical outcomes.
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Affiliation(s)
- Piotr Czarnecki
- Department of Traumatology, Orthopaedics and Hand Surgery, Poznań University of Medical Sciences, 61-545, Poznań, Poland.
| | | | - Michał Bonczar
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
| | - Patryk Ostrowski
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
- Youthoria, Youth Research Organization, Kraków, Poland
| | - Józef Wcisłek
- Department of Traumatology, Orthopaedics and Hand Surgery, Poznań University of Medical Sciences, 61-545, Poznań, Poland
| | - Leszek Romanowski
- Department of Traumatology, Orthopaedics and Hand Surgery, Poznań University of Medical Sciences, 61-545, Poznań, Poland
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Matsumura N, Furuhata R, Nakamura T, Kimura H, Suzuki T, Iwamoto T. Blocking screw augmentation in intramedullary nailing for displaced surgical neck fractures of the proximal humerus. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:46-51. [PMID: 37588295 PMCID: PMC10426556 DOI: 10.1016/j.xrrt.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
A displaced surgical neck fracture can be a good indication for antegrade intramedullary nailing. However, nail insertion may result in malreduction and translational displacement of the humeral head fragment because of muscle traction and size discrepancies between the diameters of the medullary canal and the intramedullary nail. We used blocking screw augmentation in 20 fractures with residual medial displacement of the distal fragment after nail insertion to anatomically reduce displacement of the fracture and to maintain the reduced position before bone union. A blocking screw was placed percutaneously at the lateral side of the canal. Next, a straight intramedullary nail was reinserted medial to the blocking screw. Finally, the nail was locked both proximally and distally. All cases showed bone union without fixation failure at the time of the final follow-up. Blocking screw augmentation with intramedullary nailing is feasible for the treatment of humeral surgical neck fractures and is thought to be helpful for fracture reduction during surgery and stable fixation after surgery.
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Affiliation(s)
- Noboru Matsumura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Ryogo Furuhata
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takumi Nakamura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroo Kimura
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Taku Suzuki
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takuji Iwamoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
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Abstract
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.].
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Boileau P, d'Ollonne T, Bessière C, Wilson A, Clavert P, Hatzidakis AM, Chelli M. Displaced humeral surgical neck fractures: classification and results of third-generation percutaneous intramedullary nailing. J Shoulder Elbow Surg 2019; 28:276-287. [PMID: 30429058 DOI: 10.1016/j.jse.2018.07.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 06/28/2018] [Accepted: 07/03/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The high rates of complications and reoperations observed with the early designs of first-generation (unlocked) and second-generation (bent design) humeral intramedullary nail (IMNs) have discouraged their use by most surgeons. The purpose of this study was to report the results of a third-generation (straight, locking, low-profile, tuberosity-based fixation) IMN, inserted through a percutaneous approach, for the treatment of displaced 2-part surgical neck fractures. METHODS We performed a retrospective review of 41 patients who underwent placement of a third-generation IMN to treat a displaced 2-part surgical neck fracture (AO/OTA type 11A3). The mean age at surgery was 57 years (range, 17-84 years). After percutaneous insertion through the humeral head, the IMN was used as a reduction tool. Static locking fixation was achieved after axial fracture compression ("back-slap" hammering technique). Patients were reviewed and underwent radiography with a minimum of 1 year of follow-up; the mean follow-up period was 26 months (range, 12-53 months). RESULTS Preoperatively, 3 types of surgical neck fractures were observed: with valgus head deformity (Type A = 8 cases), shaft translation without head deformity (Type B = 19 cases), or with varus head deformity (Type C = 14 cases). At final follow-up, all fractures went on to union, and the mean humeral neck-shaft angle was 132° ± 5°. We observed 2 malunions and 1 case of partial humeral head avascular necrosis. No cases underwent screw migration or intra-articular penetration. At last review, mean active forward elevation was 146° (range, 90°-180°) and mean external rotation was 50° (range, 20°-80°). The mean Constant-Murley score and Subjective Shoulder Value were 71 (range, 43-95) and 80% (range, 50%-100%), respectively. CONCLUSIONS Antegrade insertion of a third-generation IMN through a percutaneous approach provides a high rate of fracture healing, excellent clinical outcome scores, and a low rate of complications. No morbidity related to the passage of the nail through the supraspinatus muscle and the cartilage was observed. The proposed A, B, and C classification allows choosing the optimal entry point for intramedullary nailing.
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Affiliation(s)
- Pascal Boileau
- Institut Universitaire Locomoteur & Sport, Hôpital Pasteur 2, Côted'Azur University, Nice, France.
| | - Thomas d'Ollonne
- Institut Universitaire Locomoteur & Sport, Hôpital Pasteur 2, Côted'Azur University, Nice, France
| | | | - Adam Wilson
- Institut Universitaire Locomoteur & Sport, Hôpital Pasteur 2, Côted'Azur University, Nice, France
| | - Philippe Clavert
- Orthopédique et de la Main, Medical University of Strasbourg, Illkirch, France
| | | | - Mikael Chelli
- Institut Universitaire Locomoteur & Sport, Hôpital Pasteur 2, Côted'Azur University, Nice, France
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Hao TD, Huat AWT. Surgical technique and early outcomes of intramedullary nailing of displaced proximal humeral fractures in an Asian population using a contemporary straight nail design. J Orthop Surg (Hong Kong) 2018. [PMID: 28625096 DOI: 10.1177/2309499017713934] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Despite being a common orthopedic injury, the optimal management of proximal humeral fractures remains a topic of debate. Although intramedullary nails have been used to treat these fractures, several complications have been reported with older nail devices. We describe our surgical technique and aim to evaluate the early functional and radiological outcomes of displaced Neer's two- to four-part proximal humeral fractures undergoing fixation with a contemporary straight intramedullary nail. METHODS A prospective cohort study of 22 consecutive patients (mean age 55.7 ± 18.0) with acute displaced proximal humeral fractures underwent intramedullary nailing (Depuy Synthes MultiLoc Humeral Nail) by a single surgeon in a single institution. According to Neer's classification, 11 had two-part fractures, 9 had three-part fractures, and 2 had four-part fractures. Functional and radiological outcomes, as well as occurrence of complications, were assessed at 12 months postoperatively. RESULTS The mean Constant-Murley score and American Shoulder and Elbow Surgeons score at 12 months were 75.5 ± 12.1 and 81.7 ± 6.2, respectively. Mean range of motion was forward flexion 144.3 ± 28.4, abduction 141.3 ± 30.5, external rotation 58.0 ± 13.9, and internal rotation 62.0 ± 15.2. Mean visual analog scale score was 1.7 ± 0.8. Radiographic fracture union was achieved at a mean of 3 months post-op. One patient underwent a second surgery for screw removal due to a proximal screw backing out. No other complications were found in our cohort. Notably, no patients had clinical signs and symptoms of subacromial impingement and/or rotator cuff tear. CONCLUSION Our study demonstrated that intramedullary nailing using the contemporary straight nail design is well suited for Neer's two- and three-part proximal humeral fractures, with good early outcomes and low rates of complications. Results for four-part fractures were, however, inferior in our cohort, suggesting that further studies with larger patient numbers are needed to determine the role of intramedullary nailing for four-part fractures.
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Affiliation(s)
- Toon Dong Hao
- 1 Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
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Inui H, Nobuhara K. Assessment of the restriction of arm elevation after intramedullary fixation for proximal humeral fractures. Shoulder Elbow 2017; 9:100-104. [PMID: 28405221 PMCID: PMC5384541 DOI: 10.1177/1758573216687265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 12/02/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Nail protrusion is suspected as a reason for the restriction of arm elevation after antegrade nailing of proximal humeral fractures, although assessment of the restriction of the glenohumeral joint during arm elevation has been insufficient. METHODS In this retrospective study, 30 shoulders with proximal humeral fractures in 29 cases were treated with Polarus short nails (Acumed, Beaverton, OR, USA). At a mean final follow-up of 14 months, clinical outcomes, bony union, alignment including retroversion of the head and entry points of the nails were evaluated. The ability of a subject to achieve maximum elevation above the zero position was also evaluated. RESULTS Constant and Japanese Shoulder Association scores were a mean (SD) of 54 (12) and 71 (8.9) points, respectively. Even though all cases achieved bony union without mal-alignment of the head and greater tuberosity height or protrusion of the nail at its entry point, only six subjects could achieve maximum elevation above the zero position. CONCLUSIONS Based on these findings, treatment of proximal humeral fractures with an antegrade humeral nail inserted from the top of the humeral head results in restricted arm elevation, even in patients without nail protrusion or fragment malalignment.
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Affiliation(s)
- Hiroaki Inui
- Hiroaki Inui, Nobuhara Hospital & Institute of Biomechanics, 720 Haze Issaicho, Tatsunoshi, Hyogo, 679-4017 Japan.
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Nobile F, Carta S, Fortina M, Santoro P, Meccariello L, Ferrata P. Displaced 3- and 4-part proximal humeral fractures: Evaluation and management with an intramedullary nail within 48 h, in the emergency department. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2015.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Lopiz Y, Garcia-Coiradas J, Garcia-Fernandez C, Marco F. Proximal humerus nailing: a randomized clinical trial between curvilinear and straight nails. J Shoulder Elbow Surg 2014; 23:369-76. [PMID: 24291047 DOI: 10.1016/j.jse.2013.08.023] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 07/16/2013] [Accepted: 08/12/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intramedullary nailing of displaced proximal humerus fractures is an attractive option in the elderly patient. However, in recent reports, some existing intramedullary nails have shown high rate of complications, so new designs are being developed. The objective of the present study is to report on outcomes and complications when comparing a straight to a curvilinear nail design. METHODS We prospectively include 54 patients with Neer's 2- or 3-part proximal humerus fractures. Two were lost to follow-up, 26 were surgically treated with a new straight humeral nail (MultiLoc, Synthes) mean age 69 (range, 47-87 years), and 26 with a curvilinear nail (Polarus, Acumed) mean age 71 (range, 38-89 years). At final follow-up (average 14 months), patients underwent a clinical and radiographic evaluation. Clinical outcome was assessed with the adjusted Constant score. RESULTS All but 1 fracture went on to radiographic union. Mean Constant score in the Polarus nail was 72.7 ± 16.0 and 83.3 ± 16.7 in the MultiLoc (P = .246). Symptoms related with rotator cuff disease were present in 19/26 patients (73%) and in 9/26 (34.6%), respectively (P = .001). The mean neck-shaft angle at final follow-up was 135° in the MultiLoc group and 130° in the Polarus group (P > .05). Reoperation rate was 42% for Polarus and 11.5% for MultiLoc. CONCLUSION Straight intramedullary nails had a comparable union rate to an accepted curvilinear design, with a much lower incidence of complications. Rotator cuff pain and dysfunction can be minimized with the use of newer generation straight nails.
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Affiliation(s)
- Yaiza Lopiz
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Clínico San Carlos Hospital. Complutense University of Madrid, Madrid, Spain.
| | - Javier Garcia-Coiradas
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Clínico San Carlos Hospital. Complutense University of Madrid, Madrid, Spain
| | - Carlos Garcia-Fernandez
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Clínico San Carlos Hospital. Complutense University of Madrid, Madrid, Spain
| | - Fernando Marco
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Clínico San Carlos Hospital. Complutense University of Madrid, Madrid, Spain
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Iris NSL, Ka-Chun I, Kin-Bong L, Wan-Yiu S, Ben C. Minimally Invasive Fixation for Proximal Humeral Fracture: A Review on the use of T2 Proximal Humeral Nail. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2013. [DOI: 10.1016/j.jotr.2013.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective and methodology A retrospective review of the outcome of patients who had proximal humeral fracture treated with T2 Proximal Humeral Nail from January 2007 to March 2011 was conducted. The demographics, union rate, and complications were reviewed. The patient outcome was assessed with the American Shoulder and Elbow Surgeons (ASES) score and Constant-Murley score. Results Thirty-two cases of traumatic proximal humeral fractures were included. The average follow-up period was 14.7 months. All fractures healed with an average of 3.97 months. The average forward flexion and lateral abduction of shoulder was 132° and 123°, respectively. The postoperative average Constant-Murley score was 67 (48-80) and ASES score was 82.9 (73-100). There was one case of avascular necrosis of humeral head. Six cases of minor screw complications required removal of screws later. No wound infection or neurovascular injury was found. Discussion and conclusion With the proper surgical technique high union rate, good functional recovery, and low complication rate can be achieved by using T2 Proximal Humeral Nail in managing traumatic proximal humeral fracture.
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Affiliation(s)
- Ngai Sze-Ling Iris
- Department of Orthopaedics and Traumatology, Trauma Service, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Ip Ka-Chun
- Department of Orthopaedics and Traumatology, Trauma Service, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Lee Kin-Bong
- Department of Orthopaedics and Traumatology, Trauma Service, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Shen Wan-Yiu
- Department of Orthopaedics and Traumatology, Trauma Service, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Chan Ben
- Department of Physiotherapy, Queen Elizabeth Hospital, Kowloon, Hong Kong
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Kogan PG, Vorontsova TN, Shubnyakov II, Voronkevich IA, Lasunskiy SA. Evolution of treatment of of the proximal humerus fractures (review). TRAUMATOLOGY AND ORTHOPEDICS OF RUSSIA 2013. [DOI: 10.21823/2311-2905-2013--3-154-161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The article in generalized form acquaints with the publications devoted to the bases of proximal humeral fractures treatment. A brief digression on anatomy and biomechanics of the humeral joint allows to consider the main morphological features of it. The most commonly used classification of proximal humeral fractures concisely classify many types of damage. According to the clinical and anatomical characteristics of fractures tracked the historical aspect, the development and the current state of the most common methods of treatment. In his review collected works authors share their experience in the application of methods. It allows to further the perspective directions.
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A new approach for the treatment of proximal humeral fractures using the TRIGEN proximal humeral nail. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 24:467-74. [PMID: 23689907 DOI: 10.1007/s00590-013-1229-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 04/28/2013] [Indexed: 10/26/2022]
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Giannoudis PV, Xypnitos FN, Dimitriou R, Manidakis N, Hackney R. "Internal fixation of proximal humeral fractures using the Polarus intramedullary nail: our institutional experience and review of the literature". J Orthop Surg Res 2012; 7:39. [PMID: 23253302 PMCID: PMC3554551 DOI: 10.1186/1749-799x-7-39] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 11/20/2012] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The purpose of this study is to evaluate the functional outcome, union and complication rates after surgical treatment of unstable or displaced proximal humeral fractures using the Polarus intramedullary nail, by reviewing our institutional experience and the relevant current literature. METHODS Twenty-seven patients were treated operatively for proximal humeral fracture using the Polarus nail. Fractures were classified according to Neer's classification. A number of parameters including patient demographics, mechanism of injury, operative time, time to union and complications were recorded. Functional outcome was evaluated using the Constant Shoulder Score. A comparison among functional outcomes in patients >60 years in relation to the younger ones was performed. Moreover, a review of the literature was carried out to evaluate the overall union and complication rates. RESULTS Two patients lost to follow-up were excluded from the analysis. For the twenty-five patients (mean age: 61 years), the mean follow-up was 36 months. There were 7 complications (28%), including one fixation failure, four protruded screws, one superficial infection and one case of impingement. The union rate was 96% (mean time to union: 4.2 months). The mean Constant score was 74.5 (range: 48-89). Patients under the age of 60 had a better functional outcome compared to patients >60 years of age (p<0.05). From the literature review and from a total of 215 patients treated with a Polarus nail, the mean union rate was 95.8%, the overall reported complication rate, including both minor and major complications, ranged widely from 9.3% up to 70%. CONCLUSIONS The Polarus nail was found to be an effective implant for stabilisation of proximal humeral fractures. Functional outcome is for the vast majority of the cases excellent or good, but in elderly patients a lower Constant score can be expected.
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Affiliation(s)
- Peter V Giannoudis
- Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon wing Level A, Great George Street, LS1 3EX, Leeds, UK.
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Brunner A, Resch H, Babst R, Kathrein S, Fierlbeck J, Niederberger A, Schmölz W. The Humerusblock NG: a new concept for stabilization of proximal humeral fractures and its biomechanical evaluation. Arch Orthop Trauma Surg 2012; 132:985-92. [PMID: 22446697 DOI: 10.1007/s00402-012-1503-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Humerusblock NG represents a new semi-rigid angular stable fixation device for minimally invasive stabilization of proximal humeral fractures. This study evaluates the function and stability of the Humerusblock NG and its biomechanical properties on the basis of two different fracture models under cyclic loading. METHODS Six fresh frozen human humeri were tested in a dynamic shoulder joint abduction motion test bench, simulating abduction between 15° and 45°. A stable wedge fracture with intact medial hinge and an unstable fracture with 5-mm gap were loaded for 500 cycles. Radiological measurement of implant migration was performed. RESULTS The stable fracture model showed a slow constant fracture settling. The unstable fracture model showed initial fracture settling with closure of the medial fracture gap during the first 20 cycles. Thereafter, a slow constant settling of the fracture was measured comparable to the stable fracture model. Maximum varus tilt was 3.17° for the stable and 3.68° for the unstable fracture pattern. Radiological analysis showed no change in the tip apex distance and a significant settling of the implants fixation pins in the unstable fracture model. None of the specimen failed during the testing. CONCLUSION The Humerusblock NG allows for angular stable dynamic fixation of two-part proximal humeral fractures. It enables closure of the fracture gap and maintains fracture compression during loading, a concept already established in the stabilization of femoral neck fractures (dynamic hip screw). Clinical trials will be necessary to evaluate the value of this device in daily practice. LEVEL OF EVIDENCE Basic science study.
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Affiliation(s)
- Alexander Brunner
- Department for Trauma Surgery and Sports Medicine, Medical University Innsbruck, Anichstrasse 35, Innsbruck, Austria.
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Nolan BM, Kippe MA, Wiater JM, Nowinski GP. Surgical treatment of displaced proximal humerus fractures with a short intramedullary nail. J Shoulder Elbow Surg 2011; 20:1241-7. [PMID: 21420325 DOI: 10.1016/j.jse.2010.12.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 12/06/2010] [Accepted: 12/08/2010] [Indexed: 02/01/2023]
Abstract
BACKGROUND The Polaris nail is an intramedullary device for treating displaced proximal humerus fractures with few published studies to support its use. Results of a consecutive series of patients treated with the Polaris nail are presented. METHODS Eighteen patients with a mean age of 71 years (range, 37-84) were treated for twelve 2- and six 3-part fractures. Radiographic results for all patients were evaluated. Thirteen patients with an average follow-up of 42 months (range, 24-84) were available for functional evaluation. RESULTS Seventeen of 18 patients healed. Postoperatively, the neck/shaft angle collapsed an average 11° (range, 5-30°) into varus. Nine of 18 patients had final neck/shaft angles <120° and were considered radiographic malunions. The mean Constant and American Shoulder and Elbow Surgeons (ASES) scores were 61 (range, 20-100) and 67 (range, 10-100), respectively. Forward elevation averaged 118°. Patients had an average 5/8 positive rotator cuff signs. Seven patients underwent reoperation for loss of fixation or prominent hardware, and 1 required revision to a hemiarthroplasty. CONCLUSION This study shows a higher than reported percentage of unsatisfactory results using the Polaris nail. The device violates the rotator cuff and is unable to resist the deforming forces that can lead to loss of fixation and varus collapse.
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Affiliation(s)
- Betsy M Nolan
- Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
Recent innovations have greatly increased the range of proximal humeral fractures that are amenable to open reduction and plate fixation.The optimum technique for some of the more complex fracture patterns is not yet fully refined.This article aims to describe the recent advances in the treatment of complex proximal humeral fractures by open reduction and locking plate fixation, focusing particularly on the indications for surgery, the operative techniques, and the expected outcomes after treatment.
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Noda M, Saegusa Y, Maeda T. Does the location of the entry point affect the reduction of proximal humeral fractures? A cadaveric study. Injury 2011; 42 Suppl 4:S35-8. [PMID: 21939801 DOI: 10.1016/s0020-1383(11)70010-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The selection of the correct entry point for stabilisation of long bone fractures and particularly of the humérus with intramedullary nailing is of paramount importance. The insertion of a nail from the correct entry point ensures anatomical alignment of the head and the shaft fragment. However, particularly for the humérus, the literature addressing this issue is obscure. Twenty cadaveric humeri without soft tissue attachment were studied. Two groups were studied: Group A (straight nail) and Group B (angled nail). A fracture of the surgical neck of the humérus was simulated. Then intramedullary nail was inserted through the correct entry hole. Displacement at the fracture site and force to reduce the displacement were measured. The average horizontal displacement was 2.5 ± 2.2 mm in Group A and 1.9 ± 1.1 mm in Group B. The humeral shaft tended to displace medially. The force required to reduce the produced displacement was usually less than 15 N. Anatomical reduction could not be obtained in 3/20 humeri even after applying a force of over 35 N. Our results of an average displacement of 2 mm following nail insertion, supports the significance of the entry point as a cause of loss of reduction at the fracture site post nail insertion. In most cases, anatomical reduction can be corrected with relative small forces, whereas in the rest the correction of the displacement is not feasible even with the application of substantial forces.
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Affiliation(s)
- Mitsuaki Noda
- Department of Orthopaedics, 1-5-16 Konan Hospital, Seikeigeka, Kobe Higashinada-ku Kamokogahara, Japan.
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Hamilton SW, Baird KS. The treatment of established non-union of the proximal humerus using the Polarus locking intramedullary nail. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2011; 3:53-6. [PMID: 20671865 PMCID: PMC2907000 DOI: 10.4103/0973-6042.59970] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Non-union following fracture of the proximal humerus is not uncommon, particularly in the elderly. This can be associated with significant morbidity due to pain, instability and functional impairment. The Polarus device (Acumed) is a locked, antegrade intramedullary nail designed to stabilize displaced 2-, 3- and 4-part fractures of the proximal humerus. We report our experience with the Polarus nail for the treatment of established non-union of the proximal humerus. MATERIALS AND METHODS A total of 7 Polarus nails were inserted for the treatment of non-union of the proximal humerus between June 2000 and July 2007. Each fracture site was opened, debrided, stabilized with a Polarus nail and then grafted with autologous cancellous iliac crest bone. The time between injury and surgery ranged from 6 to 102 months. One patient had undergone previous fixation of her fracture using Rush intramedullary rods. All patients were females, and mean age at surgery was 63.6 years (range, 49-78 years). A retrospective review of notes and radiographs was carried out. Patients were reviewed at varying intervals postoperatively (range, 13-68 months) and assessed using the Constant shoulder-scoring system. RESULTS All un-united fractures progressed to union. There were no wound complications and no postoperative nerve palsies. Functional outcome was good, even in those cases with a long interval between injury and surgery. The mean Constant score was 63 (range, 54-81). Migration of a single proximal locking screw was seen in 2 patients, and these screws required removal at 5 and 12 months, respectively, postoperatively. CONCLUSION In our experience, a locked proximal humeral nail used in conjunction with autologous bone grafting is an excellent device for the treatment of proximal humerus non-unions.
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Affiliation(s)
- Steven W Hamilton
- Department of Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, Scotland, U.K
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Abstract
Surgical treatment of proximal humeral fractures continues to be a challenge especially in osteoporotic patients. Locking plates and intramedullary nails have been used with satisfactory results but the previous reported complications have not been substantially reduced. Most of the existing studies involve a small number of patients followed up for a rather short period of time. Since proximal humeral fractures constitute a heterogenous group of complex fractures in an even more heterogenous population, no single fixation method is a panacea. Choice of implant and method of fixation should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. Based on the findings of the existing clinical studies the authors propose a treatment algorithm.
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Olerud P, Ahrengart L, Söderqvist A, Saving J, Tidermark J. Quality of life and functional outcome after a 2-part proximal humeral fracture: a prospective cohort study on 50 patients treated with a locking plate. J Shoulder Elbow Surg 2010; 19:814-22. [PMID: 20303288 DOI: 10.1016/j.jse.2009.11.046] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Revised: 10/20/2009] [Accepted: 11/08/2009] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of the study was to report the 2-year outcome after a displaced 2-part fracture of the proximal humerus in elderly patients treated with a locking plate, including an assessment of the health-related quality of life (HRQoL). MATERIAL AND METHODS We included 50 patients, mean age 75 (range, 55-93) years with 80% women. The fracture inclusion criteria were a displacement of the shaft of >50% of its width and/or >45 degrees of angulation. Follow-up examinations were performed at 4, 12, and 24 months. The main outcome measures were the Constant and DASH scores and HRQoL according to the EQ-5D. RESULTS Eight patients (16%) were re-operated upon during the study period. At the final follow-up the mean Constant score was 61 and the mean DASH score 32. The EQ-5D (index) score decreased from 0.86 before the fracture to 0.62 at 4 months. At 12 months the EQ-5D (index) score was 0.65 and at 24 months 0.68. The values at all follow-ups were significantly lower than before the fracture (P < .001 in all 3 comparisons). CONCLUSION Locking plates appear to be a good treatment alternative in elderly patients with a displaced 2-part fracture of the surgical neck of the proximal humerus with an acceptable complication rate and an acceptable functional outcome; however, rigorous attention has to be paid to avoid screw penetration. Despite the overall acceptable functional outcome, the patients reported a substantial negative effect upon their HRQoL.
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Affiliation(s)
- Per Olerud
- Karolinska Institutet, Department of Clinical Science and Education, Section of Orthopaedics, Stockholm Söder Hospital, Sweden.
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Sosef N, van Leerdam R, Ott P, Meylaerts S, Rhemrev S. Minimal invasive fixation of proximal humeral fractures with an intramedullary nail: good results in elderly patients. Arch Orthop Trauma Surg 2010; 130:605-11. [PMID: 20024568 DOI: 10.1007/s00402-009-1027-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To report on the results of a minimally invasive technique for the fixation of displaced proximal humeral fractures with a locked intramedullary nail. PATIENTS AND METHODS All consecutive patients treated with a T2 intramedullary nail between 2004 and 2007 were evaluated. Thirty-three patients were included [mean age 78, m:f ratio (1:4)]. Fracture characteristics were classified according to AO and Neer (eighteen 2-part, eleven 3-part, five 4-part fractures). RESULTS Functional outcome (Constant Score) was excellent in nine, satisfactory in eight and poor in three patients. Subjective outcome was satisfactory to good for patients with 2-part and 3-part fractures but poor for 4-part fractures. Major complications comprised four fixation failures, two cases of impingement and one deep infection. CONCLUSIONS Minimally invasive fixation of displaced 2-part and 3-part humeral fractures in an elderly population shows satisfactory to excellent results in 80% of patients.
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Affiliation(s)
- Nico Sosef
- Department of Surgery, Medical Center Haaglanden, The Hague, The Netherlands.
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Abstract
PURPOSE To evaluate the treatment outcome of Philos plate fixation for displaced proximal humeral fractures in 27 consecutive patients. METHODS 6 men and 21 women aged 22 to 85 (mean, 56) years underwent Philos plate fixation for displaced proximal humeral fractures. 11 patients were aged 60 years or younger and 16 older than 60 years. All fractures were closed with no associated injuries and classified as 2-part (n=13), 3-part (n=12), and 4-part (n=2), according to the Neer classification. Patients were assessed radiologically and functionally using the Constant shoulder score. RESULTS Patients were followed up for 6 to 24 (mean, 13) months. All the fractures united except in a 76- year-old woman with a 3-part fracture in whom there was fracture collapse and screw penetration of the humeral head at 6 weeks. She subsequently developed non-union and avascular necrosis. The mean Constant shoulder score was 70 (range, 28-88). 11 patients had a score exceeding 75, 13 were scored between 50 and 75, and 3 were below 50. CONCLUSION Philos plate fixation provided stable fixation, minimal metal work problems and enabled early range-of-motion exercises to achieve acceptable functional results.
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Affiliation(s)
- M A Fazal
- Department of Orthopaedics, Chase Farm Hospital, London, United Kingdom.
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Helwig P, Bahrs C, Epple B, Oehm J, Eingartner C, Weise K. Does fixed-angle plate osteosynthesis solve the problems of a fractured proximal humerus? A prospective series of 87 patients. Acta Orthop 2009; 80:92-6. [PMID: 19297792 PMCID: PMC2823244 DOI: 10.1080/17453670902807417] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND PURPOSE There is considerable controversy about the treatment of complex, displaced proximal humeral fractures. Various types of head-preserving osteosynthesis have been suggested. This prospective case series was designed to evaluate the perioperative and early postoperative complications associated with fixed-angle implants and to record outcome after bone healing. PATIENTS AND METHODS Fractures of the proximal humerus were stabilized surgically in 87 patients (mean age 64 (16-93) years) by application of a fixed-angle plate (65 PHILOS, 22 T-LCP). There were 34 2-segment fractures, 42 3-segment fractures, and 11 4-segment fractures, including 7 dislocation fractures. Follow-up assessment after a minimum of 12 months was based on the Constant, UCLA, and DASH scores and on radiographs. RESULTS Postoperative complications included soft tissue problems (n = 9), humeral head necrosis (n = 9), screw perforation (n = 11), secondary displacements (n = 14), and delayed fracture healing (n = 4). Treatment outcomes recorded on the various scores were very good in 60-82% of the cases. INTERPRETATION Screw perforation of fixed-angle implants has replaced the complications of secondary displacement and implant loosening after using conventional plates. Even with the use of fixed-angle implants, fractures of the proximal humerus are associated with a high complication rate and sometimes poor outcome.
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Affiliation(s)
- Peter Helwig
- 1Department of Orthopaedics and Traumatology, Albert Ludwigs UniversityFreiburgGermany
| | - Christian Bahrs
- 2Department of Trauma and Reconstructive Surgery, BG Trauma CenterTübingenGermany
| | - Björn Epple
- 2Department of Trauma and Reconstructive Surgery, BG Trauma CenterTübingenGermany
| | - Justus Oehm
- 2Department of Trauma and Reconstructive Surgery, BG Trauma CenterTübingenGermany
| | - Christoph Eingartner
- 3Department of Trauma and Reconstructive Surgery Unit, Caritas Hospital, Bad MergentheimGermany
| | - Kuno Weise
- 2Department of Trauma and Reconstructive Surgery, BG Trauma CenterTübingenGermany
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Young AA, Hughes JS. Locked intramedullary nailing for treatment of displaced proximal humerus fractures. Orthop Clin North Am 2008; 39:417-28, v-vi. [PMID: 18803972 DOI: 10.1016/j.ocl.2008.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Controversy surrounds the optimal technique for fixation of displaced fractures, although locked intramedullary nailing is emerging as a preferred technique in managing displaced proximal humerus fractures in appropriately selected patients. This technique provides stable fracture fixation allowing early postoperative mobilization critical in ensuring a pain-free shoulder with a functional range of motion. Additional advantages include the ability to insert by way of a minimally invasive approach with limited soft tissue dissection, achieve accurate anatomic reduction, provide a secure construct even in the situation of osteopenic bone or comminution, and manage fractures of the proximal humerus extending into the shaft.
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Affiliation(s)
- Allan A Young
- Department of Orthopaedic and Traumatic Surgery, Royal North Shore Hospital, Pacific Highway, St. Leonards, Sydney, NSW 2065, Australia
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