Clinical longer-term results after internal fixation of proximal humerus fractures with a locking compression plate (PHILOS)

Clinical Outcome and Quality of Life after Modular Reverse Total Shoulder Arthroplasty in Comparison with Joint-Preserving Locking Plate Osteosynthesis in Aged Patients: A Retrospective Comparison Study

OBJECTIVES

Proximal humeral fractures (PHFs) show a high incidence in aged patients. While nondisplaced fractures achieve good results by conservative treatment, surgical procedures are discussed controversially. Next to open reduction and internal fixation (ORIF), the primary use of reverse shoulder arthroplasty (RSA) has become increasingly important. The aim of this study was to investigate the clinical function, activities of daily living (ADL), as well as pain assessment in patients with PHFs, treated by ORIF or RSA.

METHODS

A retrospective comparison study was assessed. From November 2011 to March 2016, 34 patients (17 matched pairs) that had undergone either ORIF or RSA of the proximal humerus, were included in this study. Pain was measured by numeric rating scale (NRS). ADL were obtained by Katz-Index and SF-12. Moreover, shoulder function was assessed using the Oxford Shoulder Score (OSS). The maximum range of motion (ROM) was also recorded. From November 2011 to March 2016, 34 patients (17 matched pairs) that had undergone either ORIF (Figure or RSA of the proximal humerus) were included in this study. For statistical analyses, Student's t-test, Wilcoxon test, and Chi-Quadrat test were used. Statistical significance was indicated with p < 0.05.

RESULTS

Totally 34 patients with an average age of 76.6 years were included. Surgical treatment was performed on average 5.2 days after diagnosis, differing significantly between the two groups (RSA/ORIF: 6.9/3.5 days) The operation time of RSA (97 min) was significantly longer than for ORIF (78 min). Pain assessment, as well as the Katz-Index and the SF-12, showed no significant differences. Moreover, clinical shoulder function showed no significant discrepancies between the two surgical techniques.

CONCLUSIONS

Aged patients with PHFs treated with RSA display similar results regarding clinical function, ADL as well as pain perception compared with ORIF. However, revision surgery rate was lower in patients who underwent RSA. Thus, the surgical treatment of PHFs by RSA represents an excellent alternative, especially with regard to an aging patient population.

Patient satisfaction after removal of locking plates in proximal humeral fractures - worth the surgery under functional and cosmetic aspects?

Background

Locking plates are one of the most frequently used implants in surgical treatment of displaced proximal humeral fractures. In spite of this established implant and a standardized approach, reduced shoulder function might remain a mid-to long-term issue, furthermore scars may influence patient satisfaction as a cosmetic issue. Indications for a second surgery to remove implant and/or scar revision are common questions in this context.The aim of the present study was to assess the benefit of a second surgery, including implant removal and scar revision surgery, on patients' satisfaction under functional and cosmetic aspects.

Methods

Patients following displaced proximal humeral fractures treated by open reduction and internal fixation with a locking plate osteosynthesis via a delto-pectoral approach following implant removal were included retrospectively. A follow-up took place anamnestically before the incident or the primary surgery [A], before second surgery [B], and after second surgery (scar revision/implant removal) [C]. Functional outcome (Constant Score (CS)) of both shoulders was obtained using a patient-reported outcome measure to evaluate the contralateral side as well as percentage CS (%CS). Furthermore, the cosmetic outcome was evaluated for color, contour, and size.

Results

The clinical data of n = 81 patients with displaced proximal humeral fractures and the consecutive open reduction and internal fixation with a locking plate (51 women = 63.0% and 30 men = 37.0%; mean age: 53.7 ± 16.6 years) via a standardized deltopectoral approach could be included. The mean CS) before sustaining the humeral fracture or primary surgery [A] was anamnestically 85.8 ± 8.5 points and %CS 99.4 ± 8.4%. After open reduction and internal with a locking plate osteosynthesis [B], the mean CS was 72.2 ± 9.1 points and %CS 84.5 ± 8.7%. Following the scheduled implant removal and scar revision [C], the CS was 80 ± 13.1 points and %CS 92.3 ± 14.1%. After primary surgery, 26 patients (32.1%) complained about the scar because of color, contour, or size before the second surgery, and 23 patients (28.4%) afterwards.

Conclusion

Implant removal after locking plate osteosynthesis in proximal humeral fractures via a delto-pectoral approach leads to an improved outcome both functionally and cosmetically. CS as well as scar situation and patients' overall satisfaction could be improved with a second surgery. Nevertheless, the need for a second surgery depends on the patients' functional and cosmetic demands.

Assessing complications and functional outcomes in proximal humerus fracture management: a retrospective comparison between conservative and intramedullary nailing treatments

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.

Locking plate fixation versus intramedullary nail fixation for the treatment of multifragmentary proximal humerus fractures (OTA/AO type 11C): a preliminary comparison of clinical efficacy

BACKGROUND

This study aimed to compare the clinical efficacy of locking plate and intramedullary nail fixations in the treatment of patients with OTA/AO type 11C proximal humerus fractures.

METHODS

We retrospectively analyzed the data of patients with OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures who underwent surgery at our institution from June 2012 to June 2017. Perioperative indicators, postoperative morphological parameters of the proximal humerus, and Constant-Murley scores were evaluated and compared.

RESULTS

Sixty-eight patients with OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures were enrolled in this study. Overall, 35 patients underwent open reduction and plate screw internal fixation, and 33 patients underwent limited open reduction and locking of the proximal humerus with intramedullary nail internal fixation. The total cohort had a mean follow-up duration of 17.8 months. The mean operation time of the locking plate group was significantly longer than that of the intramedullary nail group (P < 0.05), while the mean bleeding volume was significantly higher in the locking plate group than that in the intramedullary nail group (P < 0.05). The initial neck-shaft angles, final neck-shaft angles, forward flexion ranges, or Constant-Murley scores did not show significant differences between the two groups (P > 0.05). Complications, including screw penetrations, acromion impingement syndrome, infection, and aseptic necrosis of the humeral head, occurred in 8 patients (8/35, 22.8%) in the locking plate group and 5 patients in the intramedullary nail group (5/33, 15.1%; including malunion and acromion impingement syndrome), with no significant difference between the groups (P > 0.05).

CONCLUSIONS

Similar satisfactory functional results can be achieved with locking plates and intramedullary nailing for OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures, with no significant difference in the number of complications between these two techniques. However, intramedullary nailing has advantages over locking plates for OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures in terms of operation time and bleeding volume.

Mid-term functional outcome (minimum 24 months, mean 4 years) after locking plate osteosynthesis for displaced fractures of the proximal humerus in 557 cases

BACKGROUND

The best surgical management of displaced proximal humeral fractures remains a matter of considerable debate. This study presents mid-term functional outcome (median 4 years) after locking plate osteosynthesis for displaced proximal humeral fractures.

METHODS

Between February 2002 and December 2014 1031 patients with 1047 displaced proximal humeral fractures were treated by open reduction and locking plate fixation with the same implant and received consecutive prospective follow up at least 24 months after surgical treatment. Clinical follow-up consisted of Constant Murley score (CS), Disabilities of the Arm, Shoulder and Hand score (DASH), and Short Form 36 questionnaire (SF-36). Complete follow-up could be performed in 557 (53.2%) cases, with a mean follow-up of 4.0 ± 2.7 years.

RESULTS

Of 557 patients (67% women; mean age at time of osteosynthesis: 68.3 ± 15.5 years) absolute CS of all patients 4 ± 2.7 years after surgery was 68.4 ± 20.3 points. Normalized CS according to Katolik was 80.4 ± 23.8 points, and CS in percentage to the contralateral side (%CS) was 87.2 ± 27.9%. DASH score was at 23.8 ± 20.8 points. Osteosynthesis related complications (secondary displacement, screw cutout, avascular necrosis (n = 117 patients) were associated with lower functional scores (mean CS was 54.5 ± 19.0 p.; nCS 64.5 ± 22.9 p.;%CS 71.2 ± 25.0%; DASH score 31.9 ± 22.4 p.). The SF 36 was 66.5 points in the case cohort and a vitality mean of 69.4 points. Patients with a complication showed lower results (SF 36 56.7; vitality mean 64.9 points).

CONCLUSIONS

Overall, patients following locking plate osteosynthesis of displaced proximal humeral fractures showed good to moderate outcomes four years after surgery. Mid-term functional outcomes correlate significantly with those at 1 year postoperatively. Furthermore, there is a significant negative correlation of midterm functional outcome with the occurrence of complications.

LEVEL OF EVIDENCE

Level III, prospective nonconsecutive patients.

Role of Fibular Allograft in Proximal Humerus Fractures: A Systematic Review

OBJECTIVES

To analyze the outcomes and complication rates of fibular allografts (FA) as an augmentation technique for proximal humeral fractures and determine their appropriate indications.

DATA SOURCES

English- and Spanish-language articles in PubMed, MEDLINE, Embase, Web of Science (Core Collection), and Google Scholar databases were systematically reviewed with the Preferred Reporting Items for Systematic Reviews guidelines on April 10, 2020.

STUDY SELECTION

Studies of patients with proximal humeral fractures treated primarily with FA and locking compression plates and with a minimum follow-up of 6 months were included, and presenting results with standardized clinical scales, radiological values, and operative complications.

DATA EXTRACTION

Two authors independently extracted data from the selected studies with a standardized data collection form. Subsequently, each extracted data set was consolidated on the agreement of authors.

DATA SYNTHESIS

From the initial screening of 361 articles, 5 case series and 6 retrospective cohort studies were included. A meta-analysis was not performed.

CONCLUSIONS

FA improved the clinical and radiological results, thereby reducing complications. The optimal indication for this procedure may be a 4-part fracture with medial column disruption in younger adults.

LEVEL OF EVIDENCE

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

Renal disease is a risk factor for complications and mortality after open reduction internal fixation of proximal humerus fractures

Background

Renal osteodystrophy predisposes renal disease patients to fracture. Proximal humerus fractures (PHFs) frequently undergo open reduction internal fixation (ORIF); however, the effect of renal disease on outcomes is unknown.

Methods

A retrospective review of the Nationwide Readmissions Database used International Classification of Diseases, 9th Revision, codes to identify patients who underwent ORIF for closed PHF from 2010 to 2014 with no renal disease, predialysis chronic renal disease (CRD), and end-stage renal disease (ESRD).

Results

A total of 85,433 patients were identified, including 5498 (6.4%) CRD and 636 (0.7%) ESRD. CRD and ESRD patients had increased age, comorbidities, and rates of Medicare insurance. After adjusting for differences, CRD and ESRD patients were at increased risk of any complication (odds ratio [OR] 2.48, 1.66), blood transfusion (OR 1.85, 3.31), respiratory complications (OR 1.14, 1.59), acute renal failure (OR 4.80, 1.67), systemic infection (OR 2.00, 3.14), surgical site infection (OR 1.52, 3.87), longer length of stay (7.1 and 12.9 days vs. 5.9 days), and higher cost ($21,669 and $35,413 vs. $20,394) during index hospitalization, as well as surgical site infection (OR 1.43, 3.03) and readmission (OR 1.61, 3.69) within 90 days of discharge, respectively, compared with no renal disease patients. During index hospitalization, CRD patients also had increased risk for periprosthetic fracture (OR 4.97) and cardiac complications (OR 1.47), whereas ESRD patients had increased risk of mortality (OR 5.79), wound complication (2.67), and deep vein thrombosis (OR 16.70).

Conclusion

These findings suggest renal patients are at increased risk for complications after PHF ORIF, highlighting the importance of close perioperative monitoring and appropriate patient selection in this population, including strong consideration of nonoperative management.

The Proximal Humerus Outcome Score at One Year (POSY) Predicts Which Patients Have Poor Functional Outcomes Following Operative Fixation of Proximal Humerus Fractures

Background: The ability to predict long-term outcomes following surgical fixation of proximal humerus fractures would help identify patients at risk of poor functional outcomes. The purpose of this study was to develop a simple score based on preoperative data that can accurately predict functional outcomes for patients following operative management of proximal humerus fractures.

Methods: Over a 12-year period, all proximal humerus fractures surgically treated with a locked proximal humerus plate at a single institution were enrolled in a prospective database. Inclusion criteria in this analysis were any patient with a minimum of a one-year functional outcome score. Patients were assigned to the poor outcome cohort if their Disabilities of the Arm, Shoulder, and Hand (DASH) score at that time point was greater than 10 points above the mean DASH score. Logistic regression was used to build a predictive formula for cohort membership using p < 0.15 and an area under the receiver operator characteristic curve (AUROC) value was calculated to define the overall predictive capacity.

Results: A total of 165 patients with an average age of 60.91±13.5 years met the inclusion criteria, with 47 (28.5%) patients assigned to the poor outcome group and 118 (71.5%) patients assigned to the good outcome group. Older age (p = 0.088), BMI (p = 0.019), age-adjusted CCI (p = 0.001), non-Caucasian race (p = 0.017), no college degree (p < 0.0005), unemployed (p < 0.0005), and worker’s compensation case (p = 0.002) were found to be significant predictors of poorer outcome and were used to create a final formula through logistic regression which predicted the probability of a poor outcome (Nagelkerke R Square = 0.403; Hosmer and Lemeshow = 0.902; AUROC = 0.839 [CI: 0.762-0.917]). Once each patient was assigned a score, cutoff values were defined that divided the cohort into three groups. High-risk patients had a score above 50%, and 19 (73.1%) of these patients had a poor outcome.

Conclusions: The POSY score is a tool that can predict the functional outcome at one year or greater following surgical intervention for a proximal humerus fracture. Patients who score above 50% are considered at high risk for a poor functional outcome. In the era of value-based care, the POSY score may be used to direct resource utilization while improving outcomes.

The influence of fracture severity on postoperative outcome and quality of life after locking plate fixation of proximal humeral fractures

Objective:

For proximal humeral fractures open reduction und internal fixation (ORIF) with a fixed-angle plate is considered the gold standard for surgical management. However, it can lead to poor functional outcomes and is associated with postoperative complications. Therefore, the purpose of this study was to investigate the influence of fracture severity by applying a new classification (simple versus complex) on clinical outcome and quality of life after ORIF of proximal humerus fractures.

Methods:

We conducted a prospective clinical study with an average follow-up period of 12 (SD 1) months after ORIF of proximal humeral fractures with a fixed-angle plate. The postoperative function and quality of life was measured using the Oxford Shoulder Score (OSS) and the Constant Score. Data was tested for statistical significance with the Mann-Whitney test and Fisher's exact test. Based on the findings of this study a simplified fracture classification system has been developed.

Results:

Seventy-two patients with a mean age of 65 years (SD 12) with 69% being males were included. According to the Neer classification, 35% (n=25) non-displaced (“one-part fractures”), 19% (n=14) two-part fractures, 15% (n=11) three-part fractures and 31% (n=22) four-part fractures were detected. Regarding the AO/OTA classification, 18% (n=13) were type A fractures, 43% (n=31) type B and 39% (n=28) type C fractures. From these criteria we derived our own fracture classification, including 50% (n=36) simple and 50% (n=36) severe fractures. Patients with simple fracture types achieved significantly higher total values in the Constant Score as well as the OSS (p=0.008; p=0.013). The cumulative incidence of complications in the entire patient collective was 14% (n=10) with humeral head necrosis (n=5) occurring only in the severe fracture group.

Conclusions:

The postoperative clinical outcome as well as the incidence of humeral head necrosis after ORIF of proximal humeral fractures with a fixed-angle plate correlates with the fracture type and severity. The newly derived fracture classification into simple and severe fractures is suitable with regard to clinical results and complication rate. However, prospective studies comparing ORIF vs. conservative treatment of proximal humeral fractures of the same severity are required.

Level of Evidence:

III

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

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

PHILOS Synthesis for Proximal Humerus Fractures Has High Complications and Reintervention Rates: A Systematic Review and Meta-Analysis

Purpose: The aim of this study was to quantify the rate of complications and reinterventions in patients treated with PHILOS plate for proximal humerus fractures (PHFs) synthesis. Methods: A comprehensive literature search was performed on the PubMed, Web of Science, Embase, and Cochrane databases up to 7 October 2021. Studies describing medium and long-term complications in PHF synthesis using the PHILOS plate were included. A systematic review and meta-analysis were performed on complications and causes of reinterventions. Assessment of risk of bias and quality of evidence was performed with the Downs and Black’s “Checklist for Measuring Quality”. Results: Seventy-six studies including 4200 patients met the inclusion criteria. The complication rate was 23.8%, and the main cause was screw cut-out (4.1%), followed by avascular necrosis (AVN) (3.1%) and subacromial impingement (1.5%). In patients over 55 years, the complication rate was 29.5%. In the deltopectoral (DP) approach the complication rate was 23.8%, and in the delto-split (DS) it was 17.5%, but no difference between the two approaches was seen when considering the type of fracture. The overall reintervention rate was 10.5% in the overall population and 19.0% in older patients. Conclusions: Proximal humerus synthesis with a PHILOS plate has high complications and reintervention rates. The most frequent complication was screw cut-out, followed by humeral head AVN and subacromial impingement. These results need to be further investigated to better understand both the type of patient and fracture that is more at risk of complications and reintervention and to compare pros and cons of the PHILOS plate with respect to the other solutions to manage PHFs.

Why locking plates for the proximal humerus do not fit well

INTRODUCTION

We compared the angle of the humerus and plate and to assess compatibility of a plate to the proximal humerus using three-dimensional (3D) printed models.

MATERIALS AND METHODS

A total of 120 cases were included, who underwent anteroposterior shoulder radiographs. From these, 30 cases with 3D shoulder computed tomography scans were randomly selected to print 3D model. The lateral angle between the lateral cortex of the humeral shaft and lateral border of the greater tuberosity (GT), neck-shaft angle, and height from the most proximal point of the GT to the angular point were measured. When the plates were applied on the 3D models, the gap from the most proximal point of the GT to the proximal rim of the plate was measured.

RESULTS

The mean lateral angle in plain radiographs was 12.9 ± 2.2° and height from the most proximal point of the GT to the angular point was 44.4 ± 4.7 mm. The bending angles of the three plates were 8° and 10°. Height from the proximal rim of the plate to the bending point was 42.4, 42.0 and 43.8 mm. In 98% of cases, the lateral angle of the humerus was larger than all three plates. In 43% of cases, height of the GT was smaller than height of plates. When plates were applied to the 3D model, the mean gap from GT to plate was 4.8 ± 2.8 mm.

CONCLUSIONS

There was large variation in the lateral angle of the proximal humerus, which was not correlated with the neck-shaft angle. The lateral angle of the humerus was larger than the plates and prone to varus reduction and medial collapse.

LEVEL OF EVIDENCE OR CLINICAL RELEVANCE

Basic science study.

Treatment of 2-Part Proximal Humeral Fractures in Osteoporotic Patients With Medial Calcar Instability Using a PHILOS Plate Plus an Allogeneic Fibula Inserted Obliquely - A Retrospective Study

INTRODUCTION

To date, there is little research assessing the efficacy of a proximal humeral internal locking system (PHILOS) plate plus an allogeneic fibula inserted obliquely in the treatment of 2-part proximal humerus fractures (PHFs) with calcar comminution in patients >60 years old with severe osteoporosis. The aim of this study was to retrospectively evaluate the outcomes of elderly patients with osteoporotic 2-part PHFs combined with medial column (calcar) instability or disruption who experienced a PHILOS plate plus an allogeneic fibula inserted obliquely.

MATERIALS AND METHODS

One hundred and twelve consecutive elderly patients with severe osteoporotic 2-part PHFs combined with calcar instability or disruption who were treated with a PHILOS plate plus an allogeneic fibula inserted obliquely were retrospectively identified from 3 tertiary medical centres during 2014-2019. The primary outcomes were the Constant scores and American Shoulder and Elbow Surgeons (ASES) scores; secondary outcome was the rate of key orthopaedic complications.

RESULTS

Median follow-up was 24 (15.3-27.6) months. Significant improvements in the median Constant scores were observed (39 [26-58 points] prior to surgery vs 81 [67-95 points] at final follow-up). The median ASES scores improved from 43 (26-64 points) prior to surgery to 83 (65-96 points) at final follow-up. The percentage of key orthopaedic complications was 25.6% (22/86). Four (4.7%) cases had loss of reduction, 4 (4.7%) experienced aseptic loosening, 1 (.8%) had non-union, 4 (4.7%) suffered a periprosthetic fracture, 3 (3.5%) experienced a revision surgery, 1 (.8%) had a dislocation and 5 (5.8%) suffered an unbearable shoulder pain.

CONCLUSION

For elderly patients with osteoporotic 2-part PHFs combined with calcar instability or disruption, PHILOS plate combined with an allogeneic fibula inserted obliquely might have recognisable advantages in decreasing the loss of fixation and preventing medial calcar collapse.

No change in outcome ten years following locking plate repair of displaced proximal humerus fractures

PURPOSE

To assess longer-term (> 5 years) function and outcome in patients treated with anatomic locking plates for proximal humerus fractures.

METHODS

This retrospective cohort study was conducted at an urban, academic level 1 trauma center and an orthopedic specialty hospital. Patients treated operatively for proximal humerus fractures with an anatomic locking plate by three orthopedic trauma surgeons and two shoulder surgeons from 2003 to 2015 were reviewed. Patient demographics and injury characteristics, disabilities of the arm, shoulder, and hand (DASH) scores, complications, secondary surgeries, and shoulder range of motion were compared at 1 year and at latest follow-up.

RESULTS

Seventy-five of 173 fractures were eligible for analysis. At a minimum 5 years and a mean of 10.0 ± 3.2 years following surgery, DASH scores did not differ from one-year compared to long-term follow-up (16.3 ± 17.4 vs. 15.1 ± 18.2, p = 0.555). Shoulder motion including: active forward flexion (145.5 vs. 151.5 degrees, p = 0.186), internal rotation (T10 vs. T9, p = 0.204), and external rotation measurements (48.4 vs. 57.9, p = 0.074) also did not differ from one year compared to long-term follow-up. By one year, all fractures had healed. After 1-year post-operatively, four patients underwent reoperation, but none for AVN or screw penetration.

CONCLUSIONS

Patient-reported functional outcome scores and shoulder range of motion are stable after one year following proximal humerus fracture fixation, and outcomes do not deteriorate thereafter. After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms.

Epiphyseal fragment as a predictive factor of failure in fixation of proximal fractures of the humerus

INTRODUCTION

Fractures of the proximal humerus are frequent and are widely studied with regards to their treatment indications. The aim of this article is to establish a correlation between the size of the epiphyseal fragment in fractures of the proximal humerus and the probability of loss of reduction after a surgical procedure.

METHODS

A total of 47 surgically treated proximal humeral fractures were reviewed. Preoperative CT scans were used to evaluate the size of the epiphyseal fragment of the fracture. Postoperative X-rays were analyzed to assess complications, especially loss of reductions. Mean age was 61 years old (29-91 years).

RESULTS

In total, 42 shoulders were evaluated. The average size of the epiphyseal fragment was 38.3 mm (32-50 mm) the largest longitudinal length; and 19.9 mm (12-30 mm) the largest cross-sectional length. The most frequent complication observed was loss of reduction. The statistical analysis showed significance that patients with smaller cross-sectional size of the epiphyseal fragment presented more complications (p = 0.034), and based on the graph and ROC curve, a value of 15.5 mm was considered as the cutoff value for failure.

CONCLUSION

A cross-sectional length of the epiphyseal fragment of less than 15.5 mm indicates a higher probability of loss of reduction in fractures of the proximal end of the humerus after extra-medullary osteosynthesis.

Outcomes following fracture fixation with the Equinoxe® proximal humerus plate: an improvement over PHILOS®?

INTRODUCTION

The purpose of this study is to compare patient outcomes between the Equinoxe® (Exactech, Gainesville, Fla) proximal humerus locking plate and the PHILOS® (Synthes, Paoli, PA) proximal humerus locking plate.

METHODS

Two hundred and seventy-one patients with a displaced proximal humerus fracture presented to our academic medical center between February 2003 and October 2020. Functional outcomes assessed included the Disabilities of the Arm, Shoulder, and Hand questionnaire and shoulder range of motion. Radiographs were utilized to determine fracture healing and development of posttraumatic osteoarthritis or osteonecrosis.

RESULTS

Overall, 108 Equinoxe® and 87 PHILOS® patients treated by a single surgeon with complete clinical, functional, and radiographic follow-up were included in the study. Demographics were similar between groups. One hundred and eight Equinoxe® patients healed at a mean time to union by 3.7 ± 2.2 months, and 86 PHILOS® patients healed (p = 0.24) by 4.1 ± 2.3 months after surgery (p = 0.31). Shoulder external rotation was greater in Equinoxe® patients by 7 degrees (p = 0.044), and forward elevation was greater by 16 degrees (p = 0.005) at one-year follow-up. DASH scores were similar between patients at the 3-, 6-, and 12-month follow-up (p = 0.86, p = 0.77, p = 0.64). Fewer Equinoxe® patients experienced complications (p = 0.043).

CONCLUSION

Fixation of a proximal humerus fracture can safely be performed with both Equinoxe® and PHILOS® proximal humerus locking plates. Patients fixed with Equinoxe® plates achieved a slightly greater degree of external rotation, forward elevation, and experienced fewer complications. This difference may be due to surgeon experience rather than the implant itself.

PHILOS Plate Plus Oblique Insertion of Autologous Fibula for 2-Part Proximal Humerus Fractures With Medial Column Disruption: A Retrospective Study

Introduction:

The aim of this retrospective study was to evaluate the outcomes of older patients with 2-part proximal humerus fractures (PHFs) with medial column disruption stabilized using a proximal humeral internal locking system (PHILOS) plate plus oblique insertion of autologous fibula as a primary procedure.

Materials and Methods:

Data involving 112 patients (112 shoulders) sustaining 2-part PHFs with medial column disruption treated with PHILOS plate plus oblique insertion of autologous fibula as a primary procedure during 2012-2019 were identified. The median follow-up was 36 months (range: 11.2-43.5 months). The primary endpoint was the Constant scores and American Shoulder and Elbow Surgeons (ASES) scores. The secondary endpoint was the main orthopedic complication rate.

Results:

The median Constant and ASES scores were 78 (range, 52-95) and 77 (range, 62-96) at the final follow-up, respectively. The main orthopedic complication rate was 10.7% (12/112). Twelve orthopedic complications in 8 patients were detected, and they involved loss of reduction, varus collapse, aseptic loosening, mal-union, revision, and intolerable shoulder pain. Of these complications, 3 (2.6%) involved loss of reduction, 2 (1.7%) involved varus collapse, 3 (2.6%) involved aseptic loosening, 1 (0.8%) involved mal-union, 2 (1.7%) required revision surgery, and 1 (0.8%) presented intolerable shoulder pain.

Conclusion:

PHILOS plate plus oblique insertion of autologous fibula as a primary procedure may yield good functional outcomes and a low rate of the main orthopedic complications.

Nail Versus Plate: A Biomechanical Comparison of a Locking Plate Versus an Intramedullary Nail With an Angular Stable Locking System in a Shoulder Simulator With Active Muscle Forces Using a Two-Part Fracture Model

OBJECTIVES

To compare a locking compression plate versus an intramedullary nail with an angular stable locking system (ASLS) using a 2-part fracture model in a shoulder test bench.

METHODS

Twelve fresh frozen humeri were used for biomechanical testing in a shoulder simulator. A 2-part fracture model, with and without medial cortical support, was used to compare the locking plate and a nail with an ASLS. The varus impaction, varus per cycle motion, tilt, and tilt per cycle were analyzed.

RESULTS

No significant differences for the resulting forces in the glenoid fossa were evaluated. The stable fracture model showed no significant differences for the 2 groups. The median varus impaction was -0.96 degrees (range -0.55 to -4.26 degrees) in the plate group and 0.5 degrees (range -3.06 to 0.98 degrees) in the nail group, after 500 cycles of cyclic loading in the unstable fracture model. The plate group showed a significantly higher median varus impaction per cycle motion and median varus impaction at the 200th, 300th, and 400th cycle of physiological loading.

CONCLUSIONS

The intramedullary nail with the ASLS could be an alternative for patients suffering from osteoporosis and comorbidities.

Comparison of "Bilboquet" device and locking plate for surgical treatment of proximal humerus complex fractures at two years follow-up

PURPOSE

Surgical treatment of three or four part fractures of the proximal humerus is complex. Different conservative techniques have been described. The main goal of this study was to compare the clinical and radiological outcomes of Bilboquet and locking plate at two year follow-up.

METHODS

This is a retrospective, comparative study, with a continuous series of 41 patients. Bony fixation was achieved with a Bilboquet device in 22 patients or a locking plate in 19 patients. Patient evaluation included clinical data: shoulder range of motion, Constant-Murley shoulder score and DASH (Disabilities of the Arm, Shoulder and Hand) score, and imaging using standard shoulder X-rays.

RESULTS

Of the 41 patients included, 1 patient was lost to follow-up in the locking plate group. At a mean follow-up of 24 months patients in Bilboquet group showed a Constant score higher than in locking plate (p = 0.02). Range of motion and DASH score were not significantly different between the two groups. avascular necrosis occured in three patients of Bilboquet group (14%) versus in two patients in the locking plate group (11%) (p > 0.5). Complication and reintervention rate were non-significantly higher in the locking plate group than in the Bilboquet group (37 vs 14%).

CONCLUSION

Bilboquet and locking plate give good functional outcomes in complex proximal humerus fractures. However, the Bilboquet device appears to provide better functional results than locking plate at mid-term follow-up.

External fixation can be an option for proximal humerus fractures Neer 3-4

Background:

Proximal humeral fractures (PHF) account for 4-6% of all fractures and 25% of humeral fractures. While conservative treatment is the gold standard for simple fractures, there is no consensus about the best treatment choice for complex PHF in the elderly. Recently a new external fixator was introduced in clinical practice for treatment of complex PHF. Aim of the study was to evaluate the functional results of this therapeutic approach.

Methods:

Data were retrospectively analyzed. Inclusion criteria were: three- and four-part PHF according to Neer, treatment with closed reduction and external fixation, normal Abbreviated Mini Mental Test score, independence in the daily living, non-pathological fracture, glenohumeral joint with moderate osteoarthritic changes and availability of clinical and radiological follow-up. For each patient demographic data, comorbidities, surgery time and estimated blood loss were recorded. Clinical and radiological evaluation were performed at 1, 2, 6, 12 months.

Results:

17 patients were enrolled. Mean age was 69.7 years. Fractures were classified according to Neer as type III in 10 cases and type IV in 7 cases. The mean operating time was 22 minutes. Mean Constant score value at follow up was 74 ± 11,52 at 2 months, 82 ± 11,16 at 6 months and 85 ± 9,86 at 12 months.

Conclusion:

These preliminary results show that the studied system is easy to use, minimally invasive, effective in reducing surgical and hospitalization time. The results in terms of functional recovery are encouraging, showing a reduced number of complications. (www.actabiomedica.it)

Cement augmentation of calcar screws may provide the greatest reduction in predicted screw cut-out risk for proximal humerus plating based on validated parametric computational modelling: Augmenting proximal humerus fracture plating

Aims

Fixation of osteoporotic proximal humerus fractures remains challenging even with state-of-the-art locking plates. Despite the demonstrated biomechanical benefit of screw tip augmentation with bone cement, the clinical findings have remained unclear, potentially as the optimal augmentation combinations are unknown. The aim of this study was to systematically evaluate the biomechanical benefits of the augmentation options in a humeral locking plate using finite element analysis (FEA).

Methods

A total of 64 cement augmentation configurations were analyzed using six screws of a locking plate to virtually fix unstable three-part fractures in 24 low-density proximal humerus models under three physiological loading cases (4,608 simulations). The biomechanical benefit of augmentation was evaluated through an established FEA methodology using the average peri-screw bone strain as a validated predictor of cyclic cut-out failure.

Results

The biomechanical benefit was already significant with a single cemented screw and increased with the number of augmented screws, but the configuration was highly influential. The best two-screw (mean 23%, SD 3% reduction) and the worst four-screw (mean 22%, SD 5%) combinations performed similarly. The largest benefits were achieved with augmenting screws purchasing into the calcar and having posteriorly located tips. Local bone mineral density was not directly related to the improvement.

Conclusion

The number and configuration of cemented screws strongly determined how augmentation can alleviate the predicted risk of cut-out failure. Screws purchasing in the calcar and posterior humeral head regions may be prioritized. Although requiring clinical corroborations, these findings may explain the controversial results of previous clinical studies not controlling the choices of screw augmentation.

Glenohumeral joint lavage does not affect clinical outcomes in open reduction and internal fixation of displaced intracapsular proximal humeral fractures: a prospective, randomized, double-blinded trial

BACKGROUND

This prospective, randomized, and double-blinded trial evaluates the effect of intraoperative glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures.

METHODS

Between January 2016 and April 2018, 86 patients (mean age: 65.2 ± 16.3 years) with a displaced intracapsular proximal humeral fracture were treated by open reduction and internal fixation using locking plates. Patients were randomized to either locked plating followed by intraoperatively performed glenohumeral joint lavage (group L, n = 36) or locked plating without the lavage (group NL, n = 36). Functional outcome assessment included range of shoulder motion, strength, and the Constant score, obtained 6 weeks, 3 months, 6 months, and 12 months postoperatively. A total of 62 shoulders could be reviewed for final investigation (86% follow-up).

RESULTS

One year after open reduction and internal fixation, the mean Constant score was 70 ± 14 (group L, n = 31) compared with 73 ± 14 (group NL, n = 31, P = .272). The mean forward flexion and abduction in group L was 134 ± 33 and 128 ± 33 as compared with 139 ± 32 and 135 ± 32 in group NL, respectively (P = .538, P = .427). The mean external rotation was 40 ± 16 (group L) compared with 44 ± 16 (group NL) (P = .210). The overall complication rate was 9.6% and did not differ significantly between the groups (P = .321). In group L, there were 2 cases of avascular necrosis (6.5%) and 1 case of secondary displacement (3.2%). In group NL, 1 case of avascular necrosis (3.2%) and 1 case of secondary displacement were noted (3.2%, P = .742).

CONCLUSION

The results of this study do not demonstrate a need for glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures with regard to shoulder function at 1-year follow-up.

Comparison between MIPO and the deltopectoral approach with allogenous fibular bone graft in proximal humeral fractures

BACKGROUND

The purpose of this study was to investigate the clinical differences between open reduction and plate fixation via a deltopectoral approach with allogenous fibular bone graft and a minimally invasive plate osteosynthesis (MIPO), in Neer's classification two-, three- part proximal humeral fractures.

METHODS

In this retrospective study, 77 patients with two-, three-part proximal humeral fractures were treated at two different institutions. Clinical and radiological evaluations were performed in 39 patients, who underwent MIPO at one institution (group A), and 38 patients, who underwent a deltopectoral approach with allo-fibular bone graft (group B) at another institution. The results between the groups were compared.

RESULTS

The MIPO technique was significantly less time consuming and caused less bleeding than the deltopectoral approach with allo-fibular bone graft (P<0.05). The duration of the fracture union was significantly reduced in group A (14.5±3.4; range, 10-22 weeks) compared to group B (16.4±4.3; range, 12-28) weeks (P<0.05). There were no statistically significant differences between the two groups when evaluating the visual analog scale and Constant scores between the two groups, 1 year postoperatively. In radiological evaluation, there was no difference in radiological outcomes between the two groups. There were no statistically significant differences in malunion between the two groups.

CONCLUSIONS

The MIPO technique and deltopectoral approach with allo-fibular bone graft for two-, three-part proximal humeral fractures, show similar clinical and radiological results. However, allogenous fibular grafts require longer surgery, cause more bleeding, and result in longer fracture healing time than MIPO technique.

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.

Treatment of proximal humerus fractures in geriatric patients - Can pathological DEXA results help to guide the indication for allograft augmentation?

INTRODUCTION

Reconstruction of proximal humerus fracture continues to represent a challenge, especially in severe osteopenia. However, there still is a lack of consensus and clear indication on use of allograft augmentation. Therefore, this study aims to investigate outcome after osteosynthesis with and without allograft augmentation. It focuses on bone density results obtained by DEXA as potential examination that might help decision-making.

METHODS

This study included patients aged 65 years and older that were treated at one Level 1 trauma center between 2007 and 2018. Inclusion criteria: Proximal humerus fracture treated with or without allograft, conclusive data-sets. Exclusion criteria: prior surgical treatment of the proximal humerus, open fracture with bone loss, neurological damage. Patients were stratified according to the use of allograft augmentation in two groups: Group NA (no allograft augmented PHILOS) and Group A (PHILOS with allograft augmentation). Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Fractures were graded according to the classification by Neer. Radiographic union was analyzed at 6 weeks, 12 weeks, and at year follow up. Complications include surgical site infection, implant failure, humeral head necrosis, or delayed union. Allograft was used in cases of 1inch/3cm3 bone-loss or an egg-shell situation, where the patient refused arthroplasty.

RESULTS

This study included 167 patients, with 143 (85%) in the Group NA, and 24 (15%) in the Group A. There were no significant differences in age, gender, injury distribution, and distribution of Neer classification or CCI. Patients in Group A had significantly lower T-scores preoperatively (-2.87 ± 1.08 versus -0.9 ± 2.12, p = 0.003). No difference occurred in any of the complications. At one-year follow-up, the range of motion was comparable in both groups.

CONCLUSION

In patients with allograft augmentation and severe osteopenia, similar clinical and radiological results were obtained when compared with patients with better preoperative bone density scores (T-scores, DEXA). In view of a lack of guidelines indicating the indication for the use of allograft, this difference may be worth further study.

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.

Mid-term results after proximal humeral fractures following angular stable plate fixation in elderly patients-which scores can be evaluated by a telephone-based assessment?

BACKGROUND

The aim was to evaluate postsurgical outcome in elderly patients (> 70 years) after open reduction and internal fixation (ORIF) of proximal humeral fractures and compare the test-retest agreement of scores which are frequently used to assess the outcome of upper extremity disorders.

METHODS

Ninety patients (78.1 ± 5.2 years) with a minimum follow-up of 2 years (3.7 ± 0.9 years) following angular stable plate fixation of a proximal humeral fracture (2-part: 34, 3-part: 41, 4-part: 12) were enrolled. Two telephone-based interviews assessed Disabilities of the Arm, Shoulder and Hand Score (DASH), Oxford Shoulder Score (OSS), and Constant Score adjusted for interview assessment (CS) by two independent interviewers. Correlations, Bland-Altman analyses, Cross tabulation, and weighted Kappa measure of agreement (k) were calculated to assess differences and the test-retest agreement between the categories of each score.

RESULTS

In the first and second interview, we could state fair outcomes: CS 91 (range 40-100) and 65.5 (23-86), DASH 12.5 (0-64.2) and 18.3 (0-66.7), and OSS 58 (33-60) and 55 (25-60) points. The test-retest correlations were r = 0.67, r = 0.77, and r = 0.71 for CS, DASH, and OSS. Bland-Altman analyses showed absolute mean individual score differences of - 22.3, 4.9, and - 3.0 for CS, DASH, and OSS. Limits of agreement represented possible differences of 21.6%, 15.5%, and 9.0% of CS, DASH, and OSS. The category agreements were medium to high: CS 55.9% (k = 0.08), DASH 87.2% (k = 0.62), and OSS 99.3% (k = 0.74).

CONCLUSION

Patients showed good subjective outcomes. The test-retest agreement of the interview-adjusted CS was low, but telephone-based assessment of OSS and DASH present as an alternative to collect outcomes in elderly patients.

TRIAL REGISTRATION

(250/2011BO2).

Late screw-related complications in locking plating of proximal humerus fractures: A systematic review

Locking plating is a common surgical treatment of proximal humeral fractures with satisfactory clinical results. Implant-related complications, especially screw-related, have been reported, however, the lack of information regarding their onset, used surgical technique, complexity of the fracture, bone quality etc., prevents from understanding the causes for them. The aim of this systematic review is to identify the potential risk factors for late screw complications by gathering information about the patient characteristics, comorbidities, fracture types, surgical approaches and implant types. A PubMed search was performed using humerus, fractures, bone and locking as keywords in clinical papers written in English. All abstracts and manuscripts on distal or humerus shaft fractures, and those on proximal humerus fractures without any or with only iatrogenic complications were excluded. One hundred studies met the inclusion criteria, resulting in 33% of the reported cases having at least one complication, with 11% of all complications being screw-related. Most of the latter were secondary screw perforations and screw cut-outs, being predominantly linked to poor bone quality, while screw loosening and retraction were found less frequently as a result of locking mechanism failure. Overall, the amount of information for complications was limited and screw perforation was the most frequent screw-related complication, mostly reported in female patients older than 50 years, following four-part or AO/OTA type C fractures and detected four weeks postoperatively. The sparse information in the literature could be an indicator that the late screw complications might have been under-reported and under-described, making the understanding of the screw-related complications even more challenging.

Comparison between minimally invasive plate osteosynthesis and open reduction-internal fixation for proximal humeral fractures: a meta-analysis based on 1050 individuals

BACKGROUND

This meta-analysis aimed to compare the clinical outcomes and complications of minimally invasive plate osteosynthesis (MIPO) and open reduction-internal fixation (ORIF) in patients with proximal humeral fractures.

METHODS

We searched PubMed, EMBASE, Ovid, and the Cochrane Library to identify all relevant studies from inception to April 2019. Cochrane Collaboration's Review Manage 5.3 was used for meta-analysis.

RESULTS

Sixteen studies involving 1050 patients (464 patients in the MIPO group and 586 patients in the ORIF group) were finally included. According to the meta-analysis, MIPO was superior to ORIF in operation time, blood loss, postoperative pain, fracture union time, and constant score. However, MIPO was associated with more exposure to radiation and axillary nerve injury. No significant differences were found in length of hospital stays and complication except for axillary nerve injury.

CONCLUSION

The present evidence indicates that compared to ORIF, MIPO had advantages in functional outcomes, operation time, blood loss, postoperative pain, and fracture union time for the treatment of PHFs. However, the MIPO technique had a higher rate of axillary nerve injury and longer radiation time compared to ORIF.

The Treatment of Proximal Humerus Fracture Using Internal Fixation with Fixed-angle Plates

BACKGROUND

Implants made of various types of material can be used for the internal fixation of fractures. Carbon fiber reinforced polyetheretherketone (CFR-PEEK) is a radiolucent material that may have advantageous handling properties compared with titanium implants.

METHODS

Seventy-six patients with proximal humerus fractures requiring surgery were randomized to receive a fixed-angle plate made out of either titanium or CFR- PEEK. To measure the functional outcome, the DASH score (Disabilities of Arm, Shoulder, and Hand; primary endpoint), the Simple Shoulder Test (SST), and the Oxford Shoulder Score (OSS) were determined in 63 patients at 6 weeks, 12 weeks, and 6 months after surgery, accompanied at each time point by radiological evaluation.

RESULTS

Both groups displayed improvement in DASH scores 6 months after surgery (CFR-PEEK: 27.5 ± 20.5; titanium: 28.5 ± 17.9; p = 0.82). Sensitivity analysis with multiple imputations confirmed this result (27.4 ± 19.2 versus 28.5 ± 16.6). The OSS and SST scores were likewise improved in both groups. All patients displayed full bony consolidation 12 weeks after surgery. In no case was material failure, secondary dislocation, or screw perforation seen. No difference was seen in the maintenance of postoperative reposition between the CFR-PEEK group and the titanium group.

CONCLUSION

The internal fixation of proximal humerus fractures with either CFR-PEEK or titanium led to clinical improvement 6 months after surgery. No clinical or radiological difference in outcomes was seen between the two groups. Because of the study design, however, the equivalence of the two interventions was not con- clusively demonstrated; a non-inferiority study would have been needed for this purpose.

Intramedullary nailing of displaced four-part fractures of the proximal humerus

BACKGROUND

Intramedullary nailing is already established technique for the treatment of two and three-part fractures of proximal humerus. The aim of the study was to prospectively evaluate the efficacy and functional outcome after treatment of four-part fractures of proximal humerus with Multiloc proximal humeral nail.

DESIGN

prospective monocentric cohort study.

SETTING

single level 1 traumacenter.

MATERIALS AND METHODS

From February 2011 to March 2016, 40 patients with displaced four-part proximal humeral fractures were treated with intramedullary nail inserted through anterolateral approach. Minimum one year follow up completed 35 patients and were involved into the study.

RESULTS

After mean follow up period of 25.8 months 29 of 35 fractures healed. Average absolute Constant score in all 35 patients reached 57.7 points, relative side related Constants score 66.8% of contralateral extremity. Together there were 20 complications. in 6 cases (17%) developed complete avascular necrosis of the head. One deep infection was treated by implantation of antibiotic cement discs. Twelve secondary surgeries were performed, mostly for avascular necrosis development. Function and pain were significantly influenced by the quality of fracture reduction (p < 0.05) and development of complete AVN (p = 0.001). Group of 29 patients without AVN reached relative Constant score 73% of contralateral extremity.

CONCLUSIONS

Intramedullary nailing can be used as possible fixation technique for the treatment of four-part fractures of proximal humerus. In experienced hands provides nailing osteosynthesis similar results as reconstruction with locking plates. Appropriate reduction of fracture fragments is the key for good functional result.

LEVEL OF EVIDENCE

Level 2b - monocentric prospective cohort study.

A comparative retrospective study of locking plate fixation versus a dedicated external fixator of 3- and 4-part proximal humerus fractures: Results after 5 years

INTRODUCTION

Fractures of the proximal humerus (PHF) represent a common injury among orthopedic department; especially for three- and four-part fractures no consensus about the best treatment is still achieved. The aim of our study was to compare clinical and radiological outcomes in patients alternatively treated with plates and screws or external fixation system for a type III-IV proximal humerus fracture.

MATERIAL AND METHODS

Sixty-nine patients went surgery for type III-IV PHF between January 2011 and January 2014. According to the Neer classification, fractures were classified as type III in 50 cases (72,46%) and type IV in 19 cases (24,56%). 45 patients were treated with plates (65%) and 24 external fixators (35%). The patients' mean age was 62 years (range, 31-87 y). At five years, 60 patients (86,9%) were assessed using the visual analog scale (VAS) pain score, Constant Score (CS), the range of motion, and radiological evaluation. The CS at five years was the primary outcome measure. Results were evaluated and compared with the contralateral unaffected side to avoid bias related to different ages.

RESULTS

At the final follow up, we found no clinical differences when comparing the two procedures. Moreover, when age was considered as a variable, a significative difference of the CS was observed in the group of patients younger than 65 years treated with a plate (Plate Group Mean: 79; SD: +/- 15. Ex Fi Mean: 58; SD:+/- 4. P = 0,008). In the group of patients older than 65 years, the two procedures did not show significative differences in outcomes (Plate Group Mean: 69; SD: +/- 15. Ex Fi Mean: 63; SD:+/- 7. P = 0,032). External fixation procedure was overall associated with a reduction in blood loss, surgical time, length of hospital stay.

CONCLUSION

Percutaneous techniques have a long tradition in PHF treatment; the introduction of dedicated external fixation system has the advantage to improve the stability and allow early rehabilitation when compared to the classical pinning technique. In our experience, the indication elderly patients with osteoporosis and comorbidities may benefit by this type of mini-invasive surgery with low soft tissue damages.

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

Introduction

Proximal humeral fracture is a common cause of morbidity in the elderly and poses a challenge for the orthopedic surgeon. Open reduction and internal fixation (ORIF) with a locking plate is associated with high rate of secondary implant-related complications (IRC). Early implant removal could potentially reduce the risk of IRC and further improve the outcome in relatively asymptomatic patients. The purpose of this study was to evaluate the clinical and radiologic outcomes following implant removal.

Methods

A total of 56 patients with an average age of 63 ± 13 years and a mean follow-up of 29 months were evaluated retrospectively following removal of a locking plate in the proximal humerus. Postoperative functional outcomes were evaluated with the Constant-Score, Subjective shoulder value and Quick-DASH score.

Results

Early implant removal resulted in high functional outcomes with 96% of the patients reporting an improvement of their shoulder function following implant removal. No intraoperative complications were reported. Avascular necrosis (AVN) of the humeral head occurred in 12.5% of the patients, but no secondary screw cut-out was reported.

Conclusion

Early implant removal might be a safe option to avoid secondary IRC with significant subjective functional improvement also in asymptomatic patients. Although early implant removal cannot reverse the process of AVN, it could potentially prevent secondary IRC and subsequent glenohumeral cartilage destruction.

PROXIMAL HUMERUS FRACTURE WITH LOCKING PLATE: FUNCTIONAL AND RADIOGRAPHIC RESULTS

OBJECTIVE

To correlate the functional outcome and radiographic indices of proximal humerus fractures treated with locking plate.

METHODS

Seventy patients with proximal humerus fractures treated with locking plate, with mean follow-up of 30 months. These patients were analyzed for the score of the University of California, Los Angeles (UCLA) for the operated shoulder, range of motion measurements and radiography of both shoulders. After that, a graphical correlation was established between the radiographic measurements and the functional outcomes.

RESULTS

78% good and excellent results according to the UCLA score, with mean130° elevation; 45° lateral rotation; and thumb-T10 medial rotation. The type of fracture according to the Neer classification and age had a significant correlation with the range of motion. An association was found between the lowest mean elevation and the UCLA score when the neck-shaft angle variation in the antero-posterior plane was greater than 15° varus (p <0.001).

CONCLUSION

The variation of the neck-shaft angle measurement in the anteroposterior plane showed significant correlation with the range of motion and can be one of the predictors of functional results in proximal humerus fractures treated with locking plate. Level of evidence III, Retrospective Study.

Results measured by means of a motion capture system in proximal humerus fractures treated by osteosynthesis with locking plate

OBJECTIVE

To evaluate the results after locking plate internal fixation of proximal humerus fractures by means of a motion capture system, and functional scales.

MATERIAL AND METHOD

Retrospective study of a cohort of 47 elderly patients undergoing surgery from January 2010 to December 2014. After a minimum follow-up of two years, two functional scales (Constant-Murley and Quick DASH), and a quality of life scale (EQ-5D) were used for clinical evaluation. For objective evaluation of the range of motion a kinematic marker-free analysis with cameras was performed.

RESULTS

The average age was 74.85 years. Average functional scores were: Constant-Murley 70.06 points, Quick DASH 35.74 points and EQ-5D 6.79 points. The average range of motion was: flexion, 111.49°; extension: 24.13°; abduction: 109.40°; adduction: 15.13°; external rotation: 38.96°, and internal rotation: 49.28°. Correlation was found between the two functional scales, between them and the EQ-5D, and between range of motion and functional scales (except for external rotation) as well as between range of motion and EQ-5D (except for flexion and external rotation).

CONCLUSION

Locking plate osteosynthesis in proximal humerus fragility fractures achieved good functional and quality of life scores. Motion capture systems can be a useful tool for the functional assessment of shoulder pathology allowing an objective evaluation of range of motion.

Detection of Intra-Articular Screw Penetration of Proximal Humerus Fractures: Is Postoperative Computed Tomography the Necessary Imaging Modality?

RATIONALE AND OBJECTIVE

Screw penetration is the common complication of proximal humerus fractures treated with locking plates. This study compared postoperative plain radiography to computed tomography (CT) for their abilities in determining screw penetration, and was to evaluate whether advanced imaging modalities (two-dimensional [2D] CT; three-dimensional [3D] CT) could increase surgeons' level of confidence regarding their diagnoses.

MATERIALS AND METHODS

Two observers reviewed radiological images of 134 patients who sustained proximal humerus fractures treated with locking plates. The observers were asked to answer two questions: (1) Is there screw penetrating into glenohumeral joint for this patient (Yes/No)? and (2) On a scale from 0 to 10, how confident are you about this diagnosis: (0-10) (0 = not at all confident; 10 = very confident)? Three evaluations were performed: (1) plain radiography alone, (2) radiography and 2D CT 4 weeks later, and (3) radiography in combination with 2D and 3D CT after that. This process was then repeated for intraobserver analysis.

RESULTS

CT obtained almost perfect interobserver and intraobserver agreement (0.818-0.961), which was higher than radiography (0.377-0.655). For incidence of screw penetration, the significant difference was found between radiographs and CT images (P< .0125), but not between 2D and 3D CT images (P > .05). For confidence of diagnosis, the differences between imaging modalities were significant (all P< .001).

CONCLUSIONS

We suggest that postoperative CT scans (especially 3D CT images) should be used to evaluate the intra-articular screw penetration of proximal humerus fractures, especially when surgeons have not enough confidence in determining screw penetration using radiography alone.

Long-term follow-up after MIPO Philos plating for proximal humerus fractures

INTRODUCTION

Minimally invasive plate osteosynthesis (MIPO) has been described as a suitable technique for the treatment of proximal humerus fractures, but long-term functional results have never been reported. The aim of this study was to describe the long-term functional outcome and implant-related irritation after MIPO for proximal humerus fractures.

METHODS

A long-term prospective cohort analysis was performed on all patients treated for a proximal humerus fracture using MIPO with a Philos plate (Synthes, Switzerland) between December 2007 and October 2010. The primary outcome was the QuickDASH score. Secondary outcome measures were the subjective shoulder value (SSV), implant related irritation and implant removal.

RESULTS

Seventy-nine out of 97 patients (81%) with a mean age of 59 years were available for follow-up. The mean follow-up was 8.3 years (SD 0.8). The mean QuickDASH score was 5.6 (SD 14). The mean SSV was 92 (SD 11). Forty out of 79 patients (50.6%) had implant removal, and of those, 27/40 (67.5%) were due to implant-related irritation. On average, the implant was removed after 1.2 years (SD 0.5). In bivariate analysis, there was an association between the AO classification and the QuickDASH (p = 0.008).

CONCLUSION

Treatment of proximal humerus fractures using MIPO with Philos through a deltoid split approach showed promising results. A good function can be assumed due to the excellent scores of patient oriented questionnaires. However, about one-third of the patients will have a second operation for implant removal due to implant-related irritation.

Does an early mobilization and immediate home-based self-therapy exercise program displace proximal humeral fractures in conservative treatment? Observational study

BACKGROUND

Nonoperative management of proximal humeral fractures (PHFs) is the most common treatment, but its functional outcome may improve with early mobilization. In frail osteoporotic patients, quick recovery of prefracture independency is mandatory. This study assessed fracture displacement in PHFs managed with conservative treatment after early mobilization and a home-based self-exercise program.

METHODS

We retrospectively analyzed the radiologic displacement of fracture fragments of PHFs treated conservatively with early mobilization and a home-based self-exercise program.

RESULTS

Included were 99 patients with 26 one-part, 32 two-part, 32 three-part, and 9 four-part PHFs managed conservatively, followed by early mobilization and a home-based self-exercise program. In the x-ray examinations, the head displaced from varus into valgus 55° ± 23° to 42° ± 22°, in the normal range of anatomic values. The medial hinge displaced from medial to the diaphysis (+1 ± 6 mm) to lateral to the head (-0.6 ± 6 mm). The greater tuberosity displaced cranially from -1 ± 7 mm to 2 ± 5 mm. The Constant score at the 1-year follow-up was 79.69 ± 16.3.

DISCUSSION AND CONCLUSIONS

The home-based self-exercise program for conservative treatment of PHFs displaces the head-diaphysis angle and the medial hinge toward anatomic reduction, but there is a risk of greater tuberosity cranial displacement. Functional results are fairly good, allowing frail patients to keep on with their independency and life style. Because a large number of patients might need further physiotherapy, the quality of the home-based self-exercises should be supervised.

Augmentation of a Locking Plate System Using Bioactive Bone Cement-Experiment in a Proximal Humeral Fracture Model

Introduction:

The purpose of this study was to test whether local filling of a novel strontium-containing hydroxyapatite (Sr-HA) bone cement can augment the fixation of a locking plate system in a cadaveric proximal humeral facture model.

Materials and Methods:

Twelve pairs of formalin-treated cadaveric humeri were used. One side in each pair was for cemented group, while the other side was for the control group. The bone mineral density (BMD) of the samples was tested. A 3-part facture model was created and then reduced and fixed by a locking plate system. In the cemented group, the most proximal 4 screw holes were filled with 0.5 mL bone cement. In the control group, the screw holes were not filled by cement. Locking screws were inserted in a standard manner before the cement hardened. X-ray was taken before all the specimens being subjected to mechanical study, in which 6 pairs were used for axial loading (varus bending) test, while other 6 pairs were used for axial rotational test.

Results:

There is no difference in BMD between the cemented side and the control side. The X-ray shows that the implant is in position. Cement filling was noted in the most proximal 4 screws in the cemented group. Better mechanical outcome was seen in the cemented groups, in terms of less maximal displacement per cycle and higher failure point and stiffness in varus bending test. However, no difference was found between the cemented group and the control group in the axial rotation test.

Discussion:

In similarity with the previous studies, our results showed better mechanical results in the cemented group. However, due to the limitations (e.g. sample size, fracture model, testing protocol, etc), we still cannot directly extrapolate current mechanical results to clinical practice at the present moment. Furthermore, it is still unknown whether better primary outcome may lead to better long-term results, even though the local release of strontium may enhance the local bone formation.

Conclusion:

The local filling of Sr-HA bone cement augments the fixation of the locking plate system in current proximal humeral fracture model.

Comparison of CFR-PEEK and conventional titanium locking plates for proximal humeral fractures: a retrospective controlled study of patient outcomes

BACKGROUND

Metal plates are the fixation devices used most frequently to proximal humeral fractures (PHFs). However, in recent years carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates have become increasingly common. This study compares the clinical and radiographic outcomes of 42 Neer three- and four-part PHFs treated with CFR-PEEK or metal (titanium) plates.

MATERIALS AND METHODS

Forty-two PHF patients were managed with CFR-PEEK plates (n = 21, males/females 9/12; mean age 57.4 years; mean follow-up 30.7 months; CFR-PEEK group) or metal plates (n = 21; males/females 7/14; mean age 55.8 years; mean follow-up 52.7 months; Metal group). Active shoulder mobility (anterior elevation, lateral elevation, external rotation, and internal rotation), the Constant-Murley Score, the Simple Shoulder Test Score, and the pain score were recorded. Preoperative computed tomography scans and X-rays were obtained. Postoperative fracture healing and displacement, tuberosity resorption and/or malposition, hardware position, and cortical thinning (CT) under the plate were assessed radiographically.

RESULTS

Shoulder mobility, clinical, and pain scores were similar in both patient groups. CT was significantly greater in CFR-PEEK patients (mean difference, 1.14 mm; p = 0.0003). In both groups, incomplete or poor calcar reduction was associated to a significantly higher complication rate, especially stiffness and muscle weakness (p = 0.016). The rate of tuberosity resorption was significantly higher in the Metal group (p = 0.040). Two patients required revision to a hemiarthroplasty (CFR-PEEK) and reverse arthroplasty (Metal group).

CONCLUSIONS

CFR-PEEK plates provide a viable alternative to conventional titanium plates in PHFs, ensuring similar clinical outcomes and a lower rate of tuberosity resorption, but they involve higher stress shielding under the plate.

Cadaveric study of the anatomical reference points for proximal humeral plate positioning

BACKGROUND

Complications following locking plate fixation in proximal humeral fractures often related to malposition plates and inadequate screw fixation. However, literature did not define the best anatomical reference point for plate positioning. We conducted a study to assess the occurrence of subacromial impingement and screw perforation with two anatomical reference points for proximal humeral plate positioning.

METHOD

Sixty shoulders of 30 cadavers were dissected, and proximal humeral locking plate was placed in two different levels in the coronal plane of the upper tip of plate: (1) the proximal portion of bicipital groove group and (2) the most prominent of lesser tuberosity group. Subacromial impingement during passive forward elevation and screw perforation were assessed in relation to the plate positioning.

RESULTS

No subacromial impingement during passive motion contacted to the plate in both groups. The calcar screw perforation rate was significantly lower in the proximal portion of the bicipital groove group (2 of 60 specimens, 3.33%) than the most prominent of lesser tuberosity group (52 of 60 specimens, 86.67%). The most proximal screws of the plate were no humeral head perforation in all specimens.

CONCLUSION

Our study would suggest that two anatomical reference points could be used to be the landmark to avoid the subacromial impingement and the most proximal screw perforation. However, the placement of the locking plate using the proximal portion of bicipital groove reference is better for calcar screw insertion.

Biomechanics-Hot Topics Part I

This study summarizes presentations of a symposium on biomechanically related hot topics of the 2015 Basic Science Focus Forum. Each topic emphasizes a biomechanical challenge common to all 4 of these presentations: an ideal fixation technique should deliver ample stability and sufficient flexibility to prevent fixation failure and to restore normal function.

Assessment of Screw Length of Proximal Humerus Internal Locking System (PHILOS) Plate for Proximal Humeral Fractures Using Three-Dimensional Computed Tomography Scan

Background

Screw perforation and varus collapse are common complications of treatment with a PHILOS (proximal humerus internal locking system) plate for proximal humerus fractures, which are associated with improper screw length selection and lack of medial column support. The purposes of this study were: (1) to measure the proper length of periarticular screws of the PHILOS plate in the humeral head, and (2) to determine what factors influence the screw length and implantation of the inferomedial support screw.

Material/Methods

Computed tomography (CT) images of the normal proximal humerus in 134 cases were retrospectively reviewed. The length of periarticular screws was measured using three-dimensional (3D) techniques. Intraobserver and interobserver reliability of measurement were evaluated using intraclass correlation coefficients (ICCs). Sex and body height influences on screw length and implantation of the inferomedial screw were analyzed.

Results

All measurements had excellent agreement (ICC>0.75). The screw length and implantation rate of the inferomedial screw were greater in males than in females. Positive correlations were observed between body height and screw length and implantation of the inferomedial screw (all P<0.001).

Conclusions

The screws were longer and the implantation rate was higher for inferomedial screws in males than in females, and were positively correlated with body height. Our data can be used as a reference for surgeons to reduce the number of times screws are changed intraoperatively and to reduce operation duration and minimize use of intraoperative fluoroscopy for proximal humerus fractures treated with the PHILOS plate.

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.

Establishing the appropriate position of proximal humerus locking plates: a cadaveric study of five plating systems and their anatomic reference measurements

BACKGROUND

The present study aimed to determine anatomic references for the placement of five proximal humerus locking plates.

METHODS

Five proximal humerus locking-plate systems were placed on six human shoulder cadavers. Plates were positioned by fluoroscopic confirmation so that the inferior oblique screw was within 5 mm of the inferomedial cortex. Plate position was measured using the superior border of the pectoralis major tendon (PMT) to the bottom of the first slotted or nonlocking hole and top of the plate to the top of the greater tuberosity. The distance from the PMT insertion to the top of the humeral head was measured as a control.

RESULTS

There was consistency within each plating system for both the distance from the PMT insertion to the first hole and the top of the plate to the greater tuberosity: Synthes first-generation [mean (SD) 13.7 mm (3.1 mm); 10 mm (1.3) mm], Synthes second-generation [28.2 mm (2.2 mm); 18.5 mm (2.7 mm)], Biomet OptiLock® [25.5 mm (2.7 mm); 18.7 mm (2 mm)], Stryker AxSOS® [5 mm (2.8 mm); 12.3 mm (3.3 mm)] and Acumed Polarus® [9.5 mm (1.8 mm); 14.8 mm (1.6 mm)].

CONCLUSIONS

The present study provides measurements that improve the accuracy of plate positioning for five plating systems.

Functional and quality of life outcome after non-operatively managed proximal humeral fractures

BACKGROUND

Fractures of the proximal humerus are common and most often treated non-operatively. However, long-term follow-up studies focusing on functional results and quality of life in patients after this type of fracture are scarce. The primary aim of this study is to report the long-term functional and quality of life outcome in patients with a proximal humeral fracture.

MATERIALS AND METHODS

A retrospective analysis of all consecutive patients undergoing non-operative treatment for a proximal humeral fracture in a level 2 trauma centre between January 2000 and December 2013 was performed. A database consisting of all relevant demographic, patient and fracture characteristics was created. Subsequently, a questionnaire containing the DASH (Disabilities of the Arm, Shoulder and Hand) score, EuroQol-5D (EQ-5D), VAS (visual analogue scale) score, and subjective questions was sent to all patients.

RESULTS

A total of 410 patients (65 male, 345 female) were included for analyses. Average follow-up was 90 ± 48 months. DASH-scores <15 were considered as good. A median DASH-score of 6.67 [0.83-22.50] was found. A significant lower DASH-score was seen in patients under the age of 65 compared to older patients (p < 0.001). In comparison to an age-matched general Dutch population, Health related Quality of Life (HrQoL) on the EQ-us was not significantly worse in our study population (difference 0.02). Strong (negative) correlation was found between DASH-score and VAS-score, and DASH-score and HrQoL, respectively ρ = -0.534 and ρ = -0.787.

CONCLUSION

Long-term functional and quality of life outcomes are good in most patients after proximal humeral fractures, but negatively correlated to each other.

LEVEL OF EVIDENCE

Level III.

Surgical Technique for Open Reduction-Internal Fixation of an Unstable Displaced 3-Part Proximal Humeral Fracture Using a Proximal Humeral Locking Plate

The proximal humeral locking plate (PHLP) is a recently developed fixed-angle implant that is an option for open reduction-internal fixation of an unstable displaced proximal humeral fracture. Various articles have reported successful outcomes using the PHLP when compared with other implant designs. However, many complications still occur with use of the PHLP, such as avascular necrosis of the humeral articular fragment, malreduction (particularly varus malalignment), and screw penetration. These complications are related to the difficulty in fixation of this particular type of fracture, as well as ineffective surgical technique. We have therefore proposed a step-by-step surgical technique for open reduction-internal fixation of an unstable displaced 3-part proximal humeral fracture using a PHLP. This technique focuses on the precise placement of the PHLP according to the plate design, as well as an effective intraoperative assessment, to improve surgical outcomes and prevent the various complications of proximal humeral fractures.

Clinical comparison between open plating and minimally invasive plate osteosynthesis for displaced proximal humeral fractures: A prospective randomized controlled trial

BACKGROUND

Recently, minimally invasive plate osteosynthesis (MIPO) has been widely used for the treatment of proximal humeral fractures. However, there is concern about whether the MIPO in comminuted proximal humeral fractures is also comparable to open plating. The purpose of this study was to compare the clinical and radiographic outcomes of open plating and MIPO for acute displaced proximal humeral fractures.

MATERIALS AND METHODS

In this prospective, randomized controlled study, 107 patients who had an acute proximal humeral fracture were randomized to either the open plating or MIPO techniques. Forty-five patients treated with open plating and 45 with the MIPO technique who were followed up at least 1year were evaluated. Shoulder functional assessment, operating time, several radiographic parameters, and complications were evaluated at final follow-up.

RESULTS

The mean follow-up period was 15.0 months in the open plating and 14.3 months in the MIPO technique. There were no statistically significant differences in functional assessment scores and radiographic parameters between the two groups. High complications rates were found in 4-part fracture in both surgical methods The average operation time in the MIPO group were significantly lower compared to the open plating group (p<0.05).

CONCLUSION

This study showed MIPO in proximal humerus fractures had similar clinical and radiographic outcomes compared to the open plating. However, the MIPO technique in proximal humerus fracture provided significantly shorter operation time than the open plating.

Postoperative Evaluation of Reduction Loss in Proximal Humeral Fractures: A Comparison of Plain Radiographs and Computed Tomography

OBJECTIVE

To compare postoperative CT images with plain radiographs for measuring prognostic factors of reduction loss of fractures of the proximal part of the humerus.

METHODS

A total of 65 patients who sustained fractures of the proximal humerus treated with locking plates from June 2012 to October 2015 were retrospectively analyzed. There were 24 men and 41 women, with a mean age of 60.0 years (range, 22-76 years). According to the Neer classification system of proximal humeral fracture, there were 26 two-part, 27 three-part and 12 four-part fractures of the proximal part of the humerus, and all fractures were treated with open reduction and internal fixation (ORIF) using locked plating. All postoperative CT images and plain radiographs of the patients were obtained. Prognostic factors of the reduction loss were the change of neck shaft angle (NSA) and the change of humeral head height (HHH). The change of NSA and HHH were evaluated by the difference between postoperative initial and final follow-up measurement. Reduction loss was defined as the change ≥10° for NSA or ≥5 mm for HHH. The NSA and HHH were measured using plain radiographs and 3-D CT images, both initially and at final follow-up. The paired t-test was used for comparison of NSA, change of NSA, HHH, and change of HHH between two image modalities. The differences between two image modalities in the assessment of reduction loss were examined using the χ² -test (McNemar test). Intraclass correlation coefficients (ICC) were used to assess the intra-observer and inter-observer reliability.

RESULTS

3-D CT images (ICC range, 0.834-0.967) were more reliable in all parameters when compared with plain radiographs (ICC range, 0.598-0.915). Significant differences were found between the two image modalities in all parameters (plain radiographs: initial NSA = 133.6° ± 3.8°, final NSA = 130.0° ± 1.9°, initial HHH = 17.9 ± 0.9 mm, final HHH = 15.8 ± 1.5 mm; 3-D CT: initial NSA = 131.4° ± 3.4°, final NSA = 128.8° ± 1.7°, initial HHH = 16.8 ± 1.2 mm, final HHH = 14.5 ± 1.1 mm; all P < 0.05). In the assessment of reduction loss, the percentage was 16.9% (11/65) for the plain radiographs and 7.7% (5/65) for the 3-D CT scans (P < 0.05). For the 5 patients with reduction loss, which were observed by two imaging modalities, the mean Constant-Murley score was 61.0 ± 1.6. The patients with reduction loss, observed only in plain radiographs but not CT images, had good shoulder function (Constant-Murley score: 82.7 ± 1.0).

CONCLUSIONS

Our data reveal that 3-D CT images are more reliable than plain radiographs in the assessment of the prognostic factors of reduction loss of fractures of the proximal part of the humerus with treatment of locking plates; this reliable CT technique can serve as an effective guideline for the subsequent clinical management of patients.