Displaced proximal humeral fractures: an Indian experience with locking plates

Proximal Humerus Fractures Treated Using Locking Plate: A Comparison Between Anatomical Reduction and Valgus Bent Locking Plate Fixation After Valgus Reduction

Introduction

Plate osteosynthesis is preferred for the treatment of proximal humerus fractures (PHFs). However, applying the locking plate flush against the bone may lead to varus malreduction and medial displacement of the humeral head. We hypothesized that slight valgus reduction and valgus bent locking plate fixation against potential varus deformation would yield better results than the traditional plate fixation.

Methods

We retrospectively reviewed patients with PHFs treated with locking plate fixation between March 2014 and July 2019. We evaluated changes in the neck-shaft angle (NSA) and humeral head height, as well as the development of complications postoperatively. Clinical outcomes were measured at 1-year post-surgery and at the last follow-up using the American Shoulder and Elbow Surgeons, the Disabilities of the Arm, Shoulder and Hand, and the Constant-Murley scores.

Results

A total of 58 patients with PHFs were enrolled in this study. They were divided into the valgus-aligned group (n = 28) and the anatomical group (n = 30). According to radiographic evaluation, immediate postoperative NSA was significantly greater in the valgus-aligned group. Moreover, the NSA measured at the last follow-up was significantly greater the valgus-aligned group. In contrast, the NSA became considerably more varus-aligned in the anatomical group.

Conclusion

The appropriate valgus reduction and valgus bending plate fixation could lead to better short-term results and improve the ability of proximal humerus locking plates to prevent varus collapse and fixation failure.

Level of Evidence

Level III, retrospective cohort design.

Screw placement in two different implants for proximal humeral fractures regarding regional differences in bone mineral density: An anatomical study

BACKGROUND

The aim of this study was to investigate proximal humerus plating regarding drill depth and over penetration of the glenohumeral joint and to find a relation between these findings and different areas of bone mineral density (BMD) in the humeral head.

MATERIAL & METHODS

The study sample involved 45 upper extremities from human adult cadavers. Two different plates (HOFER; PHILOS) were applied to the proximal humerus. Each hole was drilled until the respective participant thought to have placed the drill bit subchondral. Next, penetration of the far cortex was conducted to determine the residual bone stock. Additionally, the point of screw penetration of the far cortex was identified for each hole of the plates and allocated to five regions with different bone mineral density as described by Tingart et al.

RESULTS

The screw penetration rate and the residual bone stock were compared within the 5 BMD regions. A significantly thicker residual bone stock was found at the central region (SD ± 13.1 mm) than in the anterior region (SD ± 9.5 mm) and in the posterior region (SD ± 8.5 mm). The anterior region revealed a significantly higher penetration rate than the posterior region (p = 0.01) and the central region (p = 0.03).

CONCLUSION

The anterior region of the humeral head was associated with a higher over penetration rate of the far cortex into the glenohumeral joint and a decreased bone stock after subchondral drilling representing a reduced bone mineral density (BMD).

LEVEL OF EVIDENCE

Cadaver Study.

Evaluation of screw placement in proximal humerus fractures regarding drilling manoeuvre and surgeon's experience

INTRODUCTION

Following proximal humeral plate osteosynthesis, mechanical complication rates ranging up to 40% have been reported. The study aims to determine the influence of surgeons' experience and the technique of drilling on the complication rate.

MATERIALS AND METHODS

The sample involved 45 cadaveric humeri. Six orthopaedic surgeons were divided into two groups with regard to their level of experience (novice versus expert group). On each humerus two different proximal humerus plates were applied. Drillings were performed either with a sharp or worn drill bit (to simulate either sharp or blunt drilling). The respective holes were drilled until the respective participant thought to have placed the drill bit subchondrally, followed by perforation of the cartilage of the humeral head. Both these values and cases of unintended penetration of the articular cavity were evaluated.

RESULTS

Fourteen holes (3.6%) were primary penetrated in the joint cavity in the worn-drill-bit-subgroup and 19 holes (5%) in the sharp-drill-bit-group. The latter had an average distance between the chosen subchondral position and the humeral articular surface of 8.3 mm and the worn-drill-bit-subgroup was at 10.6 mm. In the novice group 20 perforations (5.2%) of the joint space occurred and the mean interval between the chosen subchondral point and the humeral articular surface was 4.0 mm. The experienced surgeons showed a perforation rate of 3.4% and were at a mean of 14.9 mm. There were no significant differences regarding drilling manoeuvres and experience.

CONCLUSION

Although our results are satisfactory, they can be traced back to the relatively high interval between the respective chosen position of the drill bit and the humeral articular surface which may not guarantee screw stability during ORIF of all fracture patterns.

Surgical treatment of proximal humeral fractures with the transosseous suture fixation

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, retrospective study.

Osteosynthesis of proximal humeral fractures: a 1-year analysis of failure in a Belgian level-1 trauma centre

PURPOSE

Proximal humeral fractures are the third most common fractures affecting the elderly. Angular stable osteosynthesis has become indispensable in the operative treatment. However, surgical fixation remains challenging. The aim of this retrospective study was to analyse the failure rate after osteosynthesis of proximal humeral fractures over a year in a level-1 trauma centre. Furthermore, parameters that are presumed to be related to osteosynthesis failure will be investigated and discussed.

METHODS

After meeting the exclusion criteria, 134 patients were operatively treated with angular stable osteosynthesis between January 2017 and January 2018 at the University Hospitals of Leuven.

RESULTS

Circa 16% of the proximal humeral osteosyntheses failed. Our study showed that the most significant parameter for osteosynthesis failure was smoking. The odds of failure were significantly lower if treated by a shoulder surgeon compared to another trauma surgeon in the plate and nail group combined.

CONCLUSION

The management of proximal humeral fracture osteosynthesis remains a controversial subject. In this retrospective analysis, a failure rate of 15.7% was calculated. Smoking is a statistically significant parameter related to osteosynthesis failure. The subspecialty of the treating trauma surgeon affected the failure rate significantly. A lower failure rate was noted after osteosynthesis by a shoulder surgeon compared to another trauma surgeon.

Axillary nerve elongation in humeral fracture plating: A cadaveric study for comparison between straight and helical Philos plates

Helical plating is a known concept in humeral fracture treatment. Attention should be paid to the axillary nerve when inserting a plate underneath the deltoid muscle. The purpose of this cadaveric study was to estimate axillary nerve stretching when introducing the plate.

METHODS

On 42 fresh frozen human humeri, an 8-, 10- and 12-hole Philos plate in a straight and a helical shape were compared measuring the maximum plate-bone-distance.

RESULTS

For all three plate lengths, the helical plates had a significantly lower plate-bone-distance.

CONCLUSION

Indirectly, this suggests a lower axillary nerve elongation and hence less chance of nerve damage.

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.

The Photodynamic Bone Stabilization System in the Treatment of Humerus Fractures: A Prospective Clinical Trial

Background

Fractures of the proximal humerus are among the most common long-bone fractures and present unique challenges to surgeons. Traditional internal fixation methods, such as intramedullary nails, are associated with drawbacks such as an inability to fully fill the trabecular space and a limited ability to utilize supplemental hardware in many cases. We evaluated the safety and effectiveness of a novel fracture fixation device that utilizes a light-cured monomer to stabilize the fracture in a cohort of patients suffering from humerus fractures.

Methods

We prospectively collected data from patients being treated surgically for humerus fractures. Fractures were treated using the photodynamic bone stabilization system (PBSS) consisting of a balloon and light-cured monomer. Patients were evaluated at 7-14, 30, 60, 90, 180, and 360 days post-procedure. Primary outcomes included normal and complete radiographic fracture healing. Secondary outcomes included pain (via visual analog scale), function (via the disability of the arm, shoulder, and hand (DASH) and constant shoulder scales), and the rate of complications.

Results

A total of 33 patients were included in the intent-to-treat analysis (mean age: 76.6 yrs). Of these patients, 88% demonstrated normal radiographic healing at their 90-, 180-, and 360-day visits. Complete radiographic healing was observed in 81%, 88%, and 96% of patients at 90, 180, and 360 days, respectively. Pain scores decreased significantly at day seven when compared with baseline (28.2+20.9 vs.53.6+32.2, p<0.001) and continued to decrease at the 90-day (24.7+15.5, p<0.001), 180-day (17.8+12.5, p<0.001) and 360-day (6.6+6.7, p<0.001) evaluations. DASH scores demonstrated statistically significant improvements over baseline (65.5+31.5) at 90 (37.0+14.9, p<0.001), 180 (30.6+15.7, p<0.001), and 360 days (23.9+15.0, p<0.001) post-procedure. The procedure-related event rate was 36.4%, with 5 (11.4%) device-related adverse events reported at the one-year follow-up.

Conclusions

Our study demonstrates the ability of a novel internal fixation device to safely and effectively treat fractures of the humerus in the elderly population.

Complications Associated with Locking Plate of Proximal Humerus Fractures

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

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

OBJECTIVE

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

METHODS

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

SETTING

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

IV.

Fracture Severity Based on Classification Does Not Predict Outcome Following Proximal Humerus Fracture

This study was conducted to determine whether proximal humerus fracture patterns as defined by the Orthopaedic Trauma Association (AO/OTA) classification and the Neer 4-part system predicted functional outcomes for patients treated with open reduction and internal fixation with locked plates and, if so, which system correlated better with outcomes. During a 12-year period, 213 patients with a displaced proximal humerus fracture who underwent surgical treatment with a locking plate at 1 academic institution were prospectively followed. All patients were treated in a similar way and were followed by the operating surgeon at routine intervals. Functional outcomes were measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Of these patients, 164 were available for analysis. Functional outcomes based on DASH scores did not differ significantly by Neer system, AO/OTA classification, or varus/valgus humeral head alignment at more than 12 months postoperatively. However, patients with Neer 4-part fracture and AO/OTA type 11-C fracture had worse shoulder range of motion in terms of forward elevation and external rotation. Time to healing and complication rates also were not significantly different based on either classification system. Fracture classification can predict shoulder range of motion 12 months after surgical fixation, but its use is limited in predicting functional outcome scores, time to healing, and complication rates. Patients who undergo surgical repair of a proximal humerus fracture can expect good functional results independent of the initial injury pattern, but more severe fracture patterns may lead to decreased shoulder range of motion. [Orthopedics. 2017; 40(6):368-374.].

Treatment of Proximal Humerus Fractures using PHILOS Plate

INTRODUCTION

Treatment of proximal humerus fractures always holds a dilemma for the treating surgeon.

AIM

To assess the functional outcome of proximal humerus fractures treated with Proximal Humerus Internal Locking System (PHILOS) plating.

MATERIAL AND METHODS

Fifty three consecutive patients were treated with PHILOS plating between August 2013 and August 2014. The inclusion criteria were skeletally matured patients with closed fracture proximal humerus with displacement >1 cm and varus angulation of >45⁰. Severely comminuted fractures, open fractures and valgus impacted fractures were excluded from the study. The outcome was assessed using Neer's scoring system.

RESULTS

The average age was 54.3±5.8 years. As per the Neers classification system, there were 6 (11.32%) 1-part, 19 (35.85%) 2-part, 17 (32.085) and 11 (20.75%) 3 and 4-part fracture respectively. Average surgical duration was 94±10.2 minutes. Radiological union was seen at 12±4.6 weeks. There were 2 (3.77%) cases of varus collapse. Three (5.66%) cases had screw back out, which was later revised and had a favourable outcome. As per the Neer's scoring system, 7 (13.21%) cases had excellent results, 37 (69.81%) had satisfactory, 6 (11.32%) had unsatisfactory while 3 (05.66%) cases had poor outcomes.

CONCLUSION

PHILOS plating has a good functional outcome. However, proper patient selection, thorough knowledge of the anatomy and biomechanical principles are the pre-requisites for a successful surgery.

Operative repair of proximal humerus fractures in septuagenarians and octogenarians: Does chronologic age matter?

BACKGROUND

With an expected doubling of the geriatric population within the next thirty years it is becoming increasingly important to determine who among the elderly population benefit from orthopaedic interventions. This study assesses post-operative outcomes in patients aged seventy or greater who sustained a proximal humerus fracture and were treated surgically as compared to a younger geriatric cohort to determine if there is a chronologic age after which post-operative outcomes significantly decline.

METHODS

A retrospective chart review was conducted for 201 patients who sustained fractures of the proximal humerus (OTA 11A-C) and were treated operatively by open reduction and internal fixation. Data from 132 independent, active patients aged fifty-five or older was identified and analyzed. Forty-seven patients age 70 or older were compared to 78 patients aged 55-69. Average length of follow-up was 19.5 months. All complications were recorded. Univariate and multivariate analysis was conducted to assess for differences between groups.

RESULTS

95% of patients achieved fracture union within 6 months. No significant differences were found between cohorts with regard to gender, fracture severity, or CCI (p = 0.197, p = 0.276, p = 0.084, respectively). Functional outcome scores, shoulder range of motion, and complications rates for patients aged 70 and older were not significantly different from patients aged 55-69. There were 10 complications in the older elderly cohort (21%), 6 of which required re-operation and 13 complications in the young elderly cohort (17%), 8 of which required re-operation.

CONCLUSIONS

Operative fracture repair using locked plating of the proximal humerus in septuagenarians and octogenarians can provide for excellent long-term outcomes in appropriately selected patients. These patients tend to have long term functional outcome scores, post-operative range of motion, and complication rates that are comparable to younger geriatric patients. Physicians should not exclude patients for repair of proximal humerus fractures based on chronological age cutoffs.

Initial varus displacement of proximal humerus fractures results in similar function but higher complication rates

PURPOSE

To investigate the effect of initial varus or valgus surgical neck alignment on outcomes of patients who sustained proximal humerus fractures treated with open reduction and internal fixation (ORIF).

METHODS

An institutional review board approved database of proximal humerus fractures treated with locked plates was reviewed. Of 185 fractures in the database, 101 fractures were identified and met inclusion criteria. Initial varus displacement was seen in 47 fractures (OTA types 11.A2.2, A3.1, A3.3, B1.2, B2.2, C1.2, C2.2, or C2.3) and initial valgus displacement was observed in 54 fractures (OTA types 11.A2.3, B1.1, C1.1, or C2.1). All patients were treated in a similar manner and examined by the treating physician at standard intervals. Functional outcomes were quantified via the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and physical examination data at 12 months. Radiographs were reviewed for complications of healing. Additionally, complication rate and reoperation rate were investigated.

RESULTS

Patients who presented with initial varus displacement had an average age of 59.3 years, while patients in the valgus group had an average age of 62.4 years. Overall, there was no statistically significant difference in age, sex distribution, BMI, fracture parts, screws used, or implant plate type between the two groups. At a minimum 12 months follow up, there was no significant difference in DASH scores between those presenting with varus versus valgus fracture patterns. In addition, no significant differences were seen in final shoulder range of motion in any plane. Overall, 30 patients included in this study developed a complication. A significantly greater number of patients in the initial varus cohort developed complications (40.4%), as compared to 20.3% of patients in the initial valgus cohort (P=0.03). Fourteen patients in this study underwent reoperation. Nine of these patients were in the varus cohort, while 5 were in the valgus cohort (P=0.15).

CONCLUSIONS

In this study, initial surgical neck displacement in varus or valgus was found to not significantly affect functional outcome. Based upon our findings, patients with varus displaced proximal humerus fractures are at a greater risk of developing postoperative complications than those who present with initial valgus displaced fracture patterns.

Timing of surgery for open reduction and internal fixation of displaced proximal humeral fractures

BACKGROUND

Open reduction and internal fixation is one established method for treatment of displaced fractures of the proximal humerus. However, the timing of surgery and its effect on complications have not yet been investigated in the literature. Hence, aim of this study was to analyze the occurrence of complication following locked plating of proximal humeral fractures when surgery was delayed in comparison to early intervention.

METHODS

Between February 2002 and November 2010, 497 patients with displaced proximal humeral fractures were treated by open reduction and locked plating. 329 patients were available for follow-up with a minimum of 12 months after surgery. Outcome analysis included radiographic evidence of loss of fixation (> 10° of secondary displacement), screw-cutout and avascular head necrosis. Outcomes were analyzed with regards to age, gender and fracture pattern and were compared between time intervals in which the primary surgery had been conducted; early intervention (< 48 h), timely scheduled for surgery (3-5 days) and delayed intervention (>5 days).

RESULTS

Of 329 patients (68.4% women; median age at time of surgery: 69.9 years, 95% Confidence Interval (CI) 68.2, 71.2) the median time between fracture incident and surgical intervention was 3.2 days (95%CI: 3.1, 3.3). Surgery was performed in a 2-part fracture at a median of 3.3 days (95%CI: 3.2, 3.4) after trauma, in a 3-part fracture after 3.3 days (95%CI: 3.1, 3.4), in a 4-part fracture 2.9 days (95%CI: 2.8, 3.0), in head split type fracture 2.2 days (95%CI: 2.0, 2.4) and in dislocation type fracture 0.8 days after trauma (95%CI: 0.7, 0.9, p = 0.40). Loss of fixation was observed in 12.8% (n = 42 patients), of which in 4.9% (n = 16) screw cutout was evident and in 6.8% of cases (n = 20) avascular head necrosis was diagnosed. Patients in which complication was observed were treated at median 2.5 days after trauma (95% CI, 1.8, 3.2), in comparison, patients without evidence of complications were treated at a median of 3.2 days (95% CI, 2.8-3.8, p = 0.35). The odds ratio regarding occurrence of complications for patients treated <48 hours was 0,924, for patients in which surgery was performed 3-5 days after the incident the odds ratio was 0,836 and in patients treated > 5 days the odds ratio was 1,637.

CONCLUSIONS

Loss of fixation following open reduction and internal fixation of proximal humeral fractures was not more frequently observed when surgery was performed 3-5 days after the incident in comparison to early intervention (< 48 h). However, a delay of intervention > 5 days is related to significant increase of complications. Thus, if open reduction and internal fixation is indicated, reconstruction of the proximal humerus should be performed within 5 days of the fracture event. In head split and dislocated fracture types anatomic reconstruction completed within 48 h from the incident may be beneficial with regards to risk of avascular necrosis.

Evolving trends in surgically managed patients with proximal humerus fracture: are we different after ten years?

INTRODUCTION

New knowledge, and improved surgical hardware and fixation techniques have changed surgical management. We review the evolving trends of surgically managed proximal humerus fractures.

METHODS

Patients who underwent surgery for proximal humerus fractures from 1 January 2001 to 31 December 2010 were identified from the hospital's electronic diagnosis and operative coding database. Data extracted from the database included patient demographics, comorbidities, clinical and radiological findings, operative techniques, and complications.

RESULTS

In total, 95 patients with 97 surgically managed proximal humerus fractures were identified. The median age of the patients was 50 (range 12-85) years, and the male to female ratio was 1.2:1.0. Male patients tended to present at a younger age than female patients (peak age 30-39 years vs. 70-79 years, p < 0.001). Two-part surgical neck fracture was the most common type of fracture (n = 33, 34.0%). Plate osteosynthesis was predominantly used for two- and three-part surgical neck fractures involving the greater tuberosity (p = 0.03, p = 0.0002, respectively). Hemiarthroplasty was commonly performed for four-part fractures (p < 0.001). Wound infections, implant failure, avascular necrosis of the humeral head and nonunion were seen in 8 (8.3%) cases. Minimally invasive plate osteosynthesis (MIPO) had been in use since 2007 (p < 0.001).

CONCLUSION

Surgically managed proximal humerus fractures predominantly involved young men following high velocity injury and elderly women following osteoporotic fractures. Open plating was most commonly used for two- and three-part fractures, and hemiarthroplasty for four-part fractures. MIPO techniques have been practised in our institution since 2007.

Operative versus nonoperative treatment for complex proximal humeral fractures: a meta-analysis of randomized controlled trials

Whether operative treatment for complex proximal humeral fractures has a greater benefit over nonoperative treatment is uncertain. The authors conducted a meta-analysis to include all randomized controlled trials (RCTs) to determine the advantages and disadvantages of operative vs nonoperative treatment. Multiple databases, online registries of RCTs, and proceedings from major meetings were systematically searched up to November 2012. Randomized controlled trials comparing operative and non-operative treatment for 3- and 4-part proximal humeral fractures were included. Two authors independently assessed methodological quality and extracted data. Seven articles with a total of 286 patients met inclusion criteria. No significant differences were found between operative and nonoperative treatment regarding Constant score, the Disabilities of the Arm, Shoulder and Hand score, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, 15 Dimensions, and complications. Health-related quality of life according to the EuroQol-5D score in operative treatment showed statistically, but not clinically, significant improvement compared with nonoperative treatment. Operative treatment could significantly increase the incidence of additional surgery at 12- and 24-month follow-up compared with nonoperative treatment. However, sensitivity analysis showed a higher additional surgery rate at 12-month follow-up remained unstable. On the basis of current evidence, both operative and nonoperative treatment can achieve a similar treatment effect on complex proximal humeral fractures, but operative treatment may increase the occurrence of additional surgery. However, due to some limitations, the result of this meta-analysis should be cautiously interpreted, and further studies are needed.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

Open reduction and locking plate fixation of displaced proximal humerus fractures

BACKGROUND

Treatment of proximal humerus fractures is controversial and various operative modalities have been tried in the literature. The aim of the present study was to evaluate functional outcome and complication rate after open reduction and internal fixation of displaced proximal humerus fractures by proximal humerus locking plate.

MATERIALS AND METHODS

52 patients with displaced proximal humerus fractures treated with proximal humerus locking plate between May 2008 and October 2010 were included in the study. Fractures were classified according to Neer's classification into displaced 2-part, 3-part, and 4-part fractures. Patients were followed for a minimum period of 1 year. 11 patients had less than 1 year of followup and were not considered in the evaluation of final results. Forty one patients were considered for final evaluation. Functional evaluation was done according to the Constant-Murley scoring system. Constant score was compared between 2-part, 3-part, and 4-part fractures at final up and also between young (≤60 yrs) and old (>60 yrs).

RESULTS

11 patients had 2-part fractures, 22 patients had 3-part fractures, and 19 patients had 4-part fractures. The mean followup period was 15.21 ± 2.59 months. 65.8% (n = 27) patients had good to excellent result, 19.5% (n = 8) had fair, and 14.7% (n = 6) had poor result. Constant scores for 2-part (79.83 ± 6.95) and 3-part fractures (74.22 ± 12.53) were significantly superior to those of 4-part fractures (61.09 ± 14.29) (P value = 0.002 and 0.018, respectively). Difference between 2-part and 3-part fractures was not significant (P value = 0.623). There was no significant difference between younger (≤60) and older patients (>60). Complications encountered in this series were varus malreduction in 17% (n = 7), screw perforation in 10% (n = 4), plate impingement in 12% (n = 5), infection in 2% (n = 1), and nonunion in 2% (n = 1) of cases.

CONCLUSION

Proximal humerus locking plate gives reliable fixation for 2-part and 3-part fractures. Its use in more complicated fracture patterns of 4-part fractures is associated with poor clinical outcome.

Fractures of the acetabulum in elderly patients: an update

The incidence of acetabular fractures in elderly patients is increasing. Poor bone quality and concomitant diseases are the main features of these patients. Fracture patterns are marked by a high degree of variability in terms of patient and fracture characteristics. Preoperative planning with plain radiographs and computed tomography, including 3-dimensional reconstructions, is recommended. Treatment remains challenging because of precarious general health, severe osteopenia, comminution, and associated femoral head damage. Treatment options available include closed management, open reduction with internal fixation, percutaneous fixation in situ, and acute or staged total hip arthroplasty (THA) whether alone or combined with osteosynthesis. In the case of significant destruction of the articular cartilage, primary THA may provide the best solution. Whichever surgical method is chosen, the objective is rapid mobilisation of the patient on a walker or crutches. Late local complications that may occur after nonoperative or operative treatment include posttraumatic arthritis, nonunion, malunion, wound infection, dislocation, intrusive hardware, nerve palsy, and heterotopic bone formation. In this article an overview of the current trends in the management of acetabulum fractures in the elderly is presented.

Benefits and harms of locking plate osteosynthesis in intraarticular (OTA Type C) fractures of the proximal humerus: a systematic review

INTRODUCTION

Locking plate osteosynthesis of proximal humeral fractures are widely recommended and used, even in complex intraarticular fracture patterns such as AO/OTA Type C fractures. We systematically reviewed clinical studies assessing the benefits and harms of osteosynthesis with angle stable plates in AO/OTA Type C fractures of the proximal humerus.

METHODS

We conducted an iterative search in PubMed, Embase, Cochrane Library, Web of Science, Cinahl, and PEDro in all languages from 1999 to November 2010. Eligible studies should study the outcome for Type C fractures after primary osteosynthesis with locking plate within two weeks of injury, and a follow-up period of six months or more. Patients should be evaluated with the Constant-Murley Score (CS). Two observers extracted data independently.

RESULTS

Twelve studies and 282 Type C fractures were included. Results were categorised according to study type and synthesised qualitatively. No randomised clinical trials were identified. Two comparative, observational studies reported a mean CS of 71 (relative to contralateral shoulder) and 75 (non-adjusted Constant Score) for Type C fractures. For all studies mean non-adjusted CS ranged from 53 to 75. Mean age- and sex-adjusted CS ranged from 60 to 88. Mean CS relative to the contralateral shoulder ranged from 71 to 85. The most common complications were avascular necrosis (range, 4-33%), screw perforations (range, 5-20%), loss of fixation (range, 3-16%), impingement (range, 7-11%) and infections range 4-19%. Reoperation rate ranged from 6 to 44%.

CONCLUSIONS

Insufficient study designs and unclear reporting preclude safe treatment recommendations. Complication and reoperation rates were unexpected high. Based on the studies included we cannot routinely recommend the use of locking plates in AO/OTA Type C fractures.

Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus

INTRODUCTION

Angular stable osteosynthesis has become the gold standard in the operative treatment of proximal humeral fractures. The aim of this article is to determine the indications for osteosynthesis versus primary arthroplasty based on clinical and radiological parameters.

METHODS

A total of 368 surgically treated proximal humeral fractures were reviewed. Preoperative X-rays were used to evaluate the displacement and vascularity of the humeral head (according to the Hertel criteria) and the AO (Arbeitsgemeinschaft für Osteosynthesefragen) fracture type. Postoperative X-rays were analysed to assess the quality of the reduction, the reconstruction of the medial hinge and the displacement of the tuberosities. Follow-up X-rays were used to evaluate healing progress, the occurrence of avascular necrosis, loss of reduction and implant related failures. The American Shoulder and Elbow Surgeons score (ASES score) was used to evaluate the functional outcome. Correlations between a set of variables, type of treatment and eventual outcome were verified in both univariate and multivariate settings, with the significance rate set at p<0.05.

RESULTS

In total, 307 shoulders were evaluated. Mean follow-up was 4.3 years and showed a 15.3% failure rate, a 23.8% re-operation rate and a mean ASES score of 75.3. Better results were noted in patients who were younger at the time of surgery. More displaced fractures, AO type C fractures, varus fracture configuration and reduced head vascularity all led to a worse outcome. Anatomical reduction correlated with better results. Articular fractures had better results when treated with a plate.

CONCLUSION

Surgical treatment of proximal humeral fractures remains difficult, with a failure rate of 15.3% and a re-operation rate of 23.8% at 4.3 years. A significantly displaced varus articular fracture in the older patient results in the worst outcome.

Comparison of two different locking plates for two-, three- and four-part proximal humeral fractures--results of an international multicentre study

PURPOSE

The aim of this study was to compare the functional outcome, quality of restoration, and complication rate after open reduction and internal fixation (ORIF) of displaced or unstable 2-, 3- and 4-part humeral fractures using two different locking plates.

METHODS

The data used in this analysis was prospectively collected in two large multicentre studies in 15 European Level 1 trauma centres. A total of 318 patients with proximal humeral fractures were treated with ORIF using either the locking proximal humerus plate (LPHP) or proximal humeral internal locking system (PHILOS). Outcome measurements included Constant and Neer scores, evaluation of local pain at the fracture site and complications, and radiographic assessment at one year.

RESULTS

At one year, the mean Constant scores (relative to the contralateral shoulder) improved significantly for both groups and were above 80% for 2-, 3-, and 4-part fractures. A significantly shorter surgical time, less pain at the fracture site, and better functional outcome was achieved by PHILOS-treated patients with 2-part fractures throughout the one-year follow-up month and with 3-part fractures at three months (p < 0.05). There was no difference between the treatment outcomes for 4-part fractures, and no difference in the complication rates (p > 0.05).

CONCLUSIONS

PHILOS and LPHP can be considered as useful implants for ORIF of displaced and unstable proximal humeral fractures. There was a slight advantage of the PHILOS system with regard to operative time and functional outcome, especially for the treatment of 2- and 3-part fractures.