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Greenfield PT, Coble TJ, Bell JA, Calandruccio JH, Weller WJ. Surgical Considerations for Osteoporosis, Osteopenia, and Vitamin D Deficiency in Upper Extremity Surgery. Orthop Clin North Am 2024; 55:355-362. [PMID: 38782507 DOI: 10.1016/j.ocl.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Fragility fractures as a result of osteoporosis, osteopenia, or vitamin D deficiency are some of the most common injuries encountered in orthopedics and require careful consideration when determining the appropriate management and treatment options. A thorough perioperative evaluation can identify causes of low bone mineral density allowing for initiation of appropriate therapy. Surgical treatment of these fractures can be difficult, and techniques should be employed to ensure stable fixation. It is important to understand the potential pitfalls associated with treatment of fragility fractures to prevent avoidable complications. Postoperative management is key to preventing future injuries in this unique patient population.
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Affiliation(s)
- Paul T Greenfield
- Hand and Wrist Section of Orthopedic Clinics of North America, Campbell Clinic Department of Orthopedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 7887 Wolf River Boulevard, Germantown, TN 38138, USA
| | - Tori J Coble
- Hand and Wrist Section of Orthopedic Clinics of North America, Campbell Clinic Department of Orthopedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 7887 Wolf River Boulevard, Germantown, TN 38138, USA
| | - Jared A Bell
- Hand and Wrist Section of Orthopedic Clinics of North America, Campbell Clinic Department of Orthopedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 7887 Wolf River Boulevard, Germantown, TN 38138, USA
| | - James H Calandruccio
- Hand and Wrist Section of Orthopedic Clinics of North America, Campbell Clinic Department of Orthopedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 7887 Wolf River Boulevard, Germantown, TN 38138, USA
| | - William J Weller
- Hand and Wrist Section of Orthopedic Clinics of North America, Campbell Clinic Department of Orthopedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center, 7887 Wolf River Boulevard, Germantown, TN 38138, USA.
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Matheron G, Mahoney M, Domos P. Conservative treatment of 3- and 4-part proximal humeral fractures: Can poor outcomes be predicted? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2031-2040. [PMID: 38517527 DOI: 10.1007/s00590-024-03890-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/28/2024] [Indexed: 03/24/2024]
Abstract
PURPOSE 3- and 4-part proximal humeral fractures are frequently treated conservatively. This study aims to combine radiographic, and patient reported outcome data to identify factors leading to poor outcomes following conservative treatment. METHODS A retrospective local database analysis identified 3- and 4-part fractures. Radiographic and functional outcomes including Oxford Shoulder Score (OSS), QuickDash (QD), Subjective Shoulder Score (SSV) and VAS pain scores were collected. RESULTS 104 patients were included at mean follow-up of 55 months. Analysis highlighted significant OSS differences in 3- versus 4-part (p = 0.027), dominant arm injury (p = 0.046), age > 65 (p = 0.006), varus coronal neck-shaft angle < 115 versus 115-155 degrees (p = 0.008), posterior head tilt > 155 degrees (p = 0.005), greater tuberosity (GT) displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.032). According to QD scores; age > 65 (p = 0.012), varus neck-shaft angle (p = 0.01), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.006). SSV varied significantly with 3- versus 4-part fractures (p = 0.005), age > 65 (p = 0.04), varus neck-shaft angle (p = 0.001), posterior head tilt (p = 0.005), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.003), and medial calcar hinge displacement > 2 mm (p = 0.001). CONCLUSION We highlight risk factors for unfavourable outcomes following conservative management, aiding surgeons in shared decision-making and patient expectation management.
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Affiliation(s)
- George Matheron
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK.
| | - Melissa Mahoney
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK
| | - Peter Domos
- Barnet and Chase Farm Hospitals, Royal Free London NHS Foundation Trust, Wellhouse Lane Barnet, London, Hertfordshire, EN5 3DJ, UK
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Sapienza M, Pavone V, Muscarà L, Panebianco P, Caldaci A, McCracken KL, Condorelli G, Caruso VF, Costa D, Di Giunta A, Testa G. Proximal humeral multiple fragment fractures in patients over 55: Comparison between Conservative treatment and Plate Fixation. Heliyon 2024; 10:e25898. [PMID: 38375257 PMCID: PMC10875435 DOI: 10.1016/j.heliyon.2024.e25898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/21/2024] Open
Abstract
Proximal humerus fractures account for about 5% of fragility fractures. These involve a significant burden of disability and a reduced quality of life. This study aims to compare functional results and surgical outcomes (closed reduction and internal fixation with the internal closure system of the proximal humerus) and the conservative management of proximal humerus fractures by 2-, 3-, 4-parts, in patients older than 55 years. Between January 2017 and April 2019, 65 patients with 2, 3 or 4-part fractures were retrospectively analyzed: 29 patients (5 males and 24 females) with an average age of 70.8 ± 9.9 years treated non-surgically (conservative group (CG)) and 36 patients (11 males and 25 females) with an average age of 66.2 ± 7.1 years treated surgically with plate fixation (operating group (OG)). Using different evaluation scores, we compared the OG and the CG. Through the DASH score we have seen how at 12 months there is a satisfactory result in patients with conservative treatment (p = 0.0019). Constant-Murley scale shows no difference between the two treatments (p = 0.2300). BARTHEL scale and SST score did not give statistically satisfactory results. Also, after one year of follow-up, patients treated with conservative therapy had a higher improvement in their Range of Motion (ROM) values than patients treated with surgical treatment. The results in terms of pain in NPRS at 3, 6, 12 months are better for conservative groups (p = 0,0000). Our findings suggest that conservative treatment in proximal humeral fractures, particularly in multi-fragmented fractures in patients over 55 years of age, designs an excellent alternative to the surgical option.
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Affiliation(s)
- Marco Sapienza
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Vito Pavone
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Liliana Muscarà
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Pierpaolo Panebianco
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Alessia Caldaci
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | | | - Giuseppe Condorelli
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Vincenzo Fabrizio Caruso
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
| | - Danilo Costa
- Orthopaedic Division of Policlinico “G.B. Morgagni”, 95125, Catania, Italy
| | - Angelo Di Giunta
- Orthopaedic Division of Policlinico “G.B. Morgagni”, 95125, Catania, Italy
| | - Gianluca Testa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, P.O. “Policlinico Gaspare Rodolico”, University of Catania, Catania, Italy
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Hu C, Qiu B, Cen C, Luo Q, Cao Y. 3D printing assisted MIPO for treatment of complex middle-proximal humeral shaft fractures. BMC Musculoskelet Disord 2024; 25:93. [PMID: 38267894 PMCID: PMC10809673 DOI: 10.1186/s12891-024-07202-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 01/13/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND This study was designed to explore the clinical efficacy of 3-dimensional (3D) printing assisted minimally invasive percutaneous plate osteosynthesis (MIPO) technique by comparing the clinical outcomes with traditional open reduction and internal plating fixation (ORIF) for treating complex middle-proximal humerus fractures (AO 12C fracture type). MATERIALS AND METHODS The data of 42 participants who received a complicated middle-proximal humerus fracture from the beginning of 2018 to the end of 2022 were retrospectively analyzed. All patients were assigned to two groups: MIPO with detailed preoperative planning assisted by 3D printing technique (MIPO group), and traditional ORIF (ORIF group). RESULTS This study included 21 patients in the ORIF group and 21 patients in the MIPO group. All patients were followed-up for at least one year (mean: 16.12 ± 4.13 months), and no difference was observed in the range of shoulder joint motion (ROM), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores and Constant scores between the two groups. However, the occurrence of complications (surgical incision site infection, implant loosening, bone nonunion and radial nerve palsy) in ORIF group was remarkably higher compared to the MIPO group. All the cases achieved bone union within the MIPO group. Significant differences were found in surgical time, intraoperative blood loss and fracture healing time between the two groups. CONCLUSION Preoperative 3D printing assisted MIPO technique exhibits obvious advantages in high operational efficiency and low occurrence of complications, which is worthy of clinical application for treating complex middle-proximal humeral shaft fractures.
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Affiliation(s)
- Chaoran Hu
- Department of Orthopedics, The Beijing Jishuitan Hospital Guizhou Hospital, Guiyang, 550014, Guizhou, China
| | - Bing Qiu
- Department of Orthopedics, The Beijing Jishuitan Hospital Guizhou Hospital, Guiyang, 550014, Guizhou, China
| | - Chaode Cen
- Department of Orthopedics, The Beijing Jishuitan Hospital Guizhou Hospital, Guiyang, 550014, Guizhou, China
| | - Qin Luo
- Department of Orthopedics, The Beijing Jishuitan Hospital Guizhou Hospital, Guiyang, 550014, Guizhou, China
| | - Yongfei Cao
- Department of Orthopedics, The Beijing Jishuitan Hospital Guizhou Hospital, Guiyang, 550014, Guizhou, China.
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Buchmann L, van Lieshout EMM, Zeelenberg M, den Hartog D, Pfeifer R, Allemann F, Pape HC, Halvachizadeh S. Proximal humerus fractures (PHFs): comparison of functional outcome 1 year after minimally invasive plate osteosynthesis (MIPO) versus open reduction internal fixation (ORIF). Eur J Trauma Emerg Surg 2022; 48:4553-4558. [PMID: 34216222 PMCID: PMC9712325 DOI: 10.1007/s00068-021-01733-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/11/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Osteosynthetic treatment strategies of PHFs include MIPO or ORIF techniques. The aim of this study was to compare the 1 year outcome following either technique in type B PHFs. METHODS This study was designed as a retrospective cohort study of patients treated at one academic Level 1 trauma center. Patients from 2009 to 2019 who required surgical treatment of a type B PHF were eligible to be included in this study. Patients with A- or C-type fractures or patients requiring arthroplasty were excluded. All patients were treated with Proximal Humerus Interlocking System (PHILOS) and stratified according the approach into Group MIPO or Group ORIF. Outcome measures include local complications that occurred during hospitalization, nonunion after 12 months, and range of motion after 1 year follow-up. RESULTS This study included 149 (75.3%) patients in Group ORIF, and 49 (24.7%) in Group MIPO. The fracture morphology and concomitant injuries were comparable amongst these groups. When compared with Group MIPO, Group ORIF had a 2.6 (95% CI 0.6-11.7) higher risk of suffering from local complications. The rate of postoperative nerve lesions was comparable (OR 0.9, 95% CI 0.1-9.7) as was the rate of soft tissue complications (OR 2.0, 95% CI 0.2-17.2). The risk for nonunion was 4.5 times higher (95% 1.1-19.5) in Group ORIF when compared with Group MIPO. Group MIPO had a higher chance of flexion above 90° (OR 8.2, 95% CI 2.5-27.7). CONCLUSION This study provides indications that patients following surgical treatment of PHFs in MIPO technique might have favourable outcome. Large-scale and high-quality studies are warranted to confirm these results.
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Affiliation(s)
- Laura Buchmann
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Raemistrasse 75, 8006, Zurich, Switzerland
| | - Esther M M van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Miliaan Zeelenberg
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Dennis den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Raemistrasse 75, 8006, Zurich, Switzerland
| | - Florin Allemann
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Raemistrasse 75, 8006, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Raemistrasse 75, 8006, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
- Faculty of Medicine, University of Zurich, Raemistrasse 75, 8006, Zurich, Switzerland.
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Effect of Calcar Screw in Locking Compression Plate System for Osteoporotic Proximal Humerus Fracture: A Finite Element Analysis Study. BIOMED RESEARCH INTERNATIONAL 2022; 2022:1268774. [PMID: 36158892 PMCID: PMC9499776 DOI: 10.1155/2022/1268774] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/22/2022] [Accepted: 08/22/2022] [Indexed: 11/18/2022]
Abstract
This study proposes a finite element analysis (FEA) model for complex fractures at the osteoporotic proximal humerus and investigates the relevance of using a calcar screw in surgical treatments using this model. Two types of three-dimensional (3D) fracture models of patients with osteoporotic humerus were constructed reflecting the mechanical properties of the osteoporotic humerus, such as the Young’s modulus and Poisson’s ratio, and two load conditions mimicking the clinical environment were applied for simulation. Using the 3D models and the conditions, the FEA software calculated the concentration and distribution of stresses developing in the humerus, locking compression plate (LCP), and screws. Then, we evaluated and predicted the fixed state of a LCP system depending on whether the maximum stress value exceeded tensile strength. When axial force was applied, insertion of the calcar screw led to significant reduction of stress applied on screws in the fracture model having a medial gap by approximately 61%, from 913.20 MPa to 351.84 MPa. Based on the results, it was clearly confirmed that using of calcar screws improved the stability of a three-part fractures and simultaneously reinforced medial support.
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Hiramatsu Y, Takegami Y, Katsuhiro T, Matsuura Y, Makihara K, Kanemura T, Imagama S. Displaced Humeral Head After Intramedullary Nailing for Proximal Humeral Fracture is Associated With the Worse Short-term Outcomes -multicenter (TRON) study-. JSES Int 2022; 6:374-379. [PMID: 35572435 PMCID: PMC9091743 DOI: 10.1016/j.jseint.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background In recent years, complex and unstable proximal humeral fractures (PHFs) are treated with intramedullary nails (IMNs) in the elderly; however, the postoperative radiographic findings related to the clinical outcome are not clear. This study evaluated the association of clinical outcomes with the radiographic findings of PHFs treated with IMNs. Methods We collected data of patients aged >60 years with PHFs treated with IMNs from 2015 to 2019 in 13 associated centers' database (named TRON). We excluded patients lost to follow-up of <6 months postoperatively (PO6M). We evaluated clinical outcomes with the University of California at Los Angeles (UCLA) score at PO6M and defined a score of <27 as poor. We assessed the radiographic findings on the anteroposterior view of the humeral head postoperatively, and each radiographic finding such as humeral head height (HHH), head shaft angle, and cranialization of the greater tuberosity was divided into two groups: poor and good. Factors associated with poor UCLA at PO6M were extracted by logistic regression analysis, and the factors were divided into two groups (poor and good) and matched for age, sex, and fracture type. The UCLA score at PO6M between the groups was examined by the Mann-Whitney U test, and the significance level was set at 0.05. The minimal clinical important difference in the UCLA score was set 2 points. Results The study included 243 patients (mean age, 76 years; range, 60-95 years). The mean follow-up period was 12 months (range, 6-56 months). The correlation coefficients indicated that there was either no or only a weak correlation between HHH, head shaft angle, and cranialization of the greater tuberosity. A poor HHH (HHH <0 or >10 mm) was extracted as a factor associated with a poor UCLA score at PO6M by logistic regression analysis (odds ratio: 5.78, 95% confidence interval = 1.2-27.7, P = .0287). In matched pair analysis, the UCLA score at PO6M was significantly lower in the poor HHH group (26 [range: 9-33] vs. 24 [range: 10-35], P = .0458). Conclusion We revealed that the HHH was an independent risk factor for poor short-term outcomes. There was a significant difference in the UCLA score between groups divided by the HHH in cases treated with IMNs. The HHH can be used intraoperatively or postoperatively as a reliable parameter to predict clinical outcomes in PHFs treated with IMNs.
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Xing B, Zhang Y, Hou X, Li Y, Li G, Han G. Digital analysis of external fixation area of proximal humerus fractures in elderly patients. BMC Musculoskelet Disord 2021; 22:991. [PMID: 34836534 PMCID: PMC8626931 DOI: 10.1186/s12891-021-04826-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/25/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction The purpose is based on anatomical basis, combined with three-dimensional measurement, to guide the clinical repositioning of proximal humeral fractures, select the appropriate pin entry point and angle, and simulate surgery. Methods 11 fresh cadaveric specimens were collected, the distance of the marked points around the shoulder joint was measured anatomically, and the vertical distance between the inferior border of the acromion and the superior border of the axillary nerve, the vertical distance between the apex of the humeral head and the superior border of the axillary nerve, the vertical distance between the inferior border of the acromion and the superior border of the anterior rotator humeral artery, and the vertical distance between the apex of the humeral head and the superior border of the anterior rotator humeral artery were marked on the 3D model based on the anatomical data to find the relative safety zone for pin placement. Results Contralateral data can be used to guide the repositioning and fixation of that side of the proximal humerus fracture, and uniform data cannot be used between male and female patients. For lateral pining, the distance of the inferior border of the acromion from the axillary nerve (5.90 ± 0.43) cm, range (5.3-6.9) cm, was selected for pining along the medial axis of the humeral head, close to the medial cervical cortex, and the pining angle was measured in the coronal plane (42.84 ± 2.45)°, range (37.02° ~ 46.31°), and in the sagittal plane (28.24 ± 2.25)°, range (19.22° ~ 28.51°). The pin was advanced laterally in front of the same level of the lateral approach point to form a cross-fixed support with the lateral pin, and the pin angle was measured in the coronal plane (36.14 ± 1.75)°, range (30.32° ~ 39.61°), and in the sagittal plane (28.64 ± 1.37)°, range (22.82° ~ 32.11°). Two pins were taken at the greater humeral tuberosity for fixation, with the proximal pin at an angle (159.26 ± 1.98) to the coronal surface of the humeral stem, range (155.79° ~ 165.08°), and the sagittal angle (161.76 ± 2.15)°, with the pin end between the superior surface of the humeral talus and the inferior surface of the humeral talus. The distal needle of the greater humeral tuberosity was parallel to the proximal approach trajectory, and the needle end was on the inferior surface of the humeral talus. Conclusion Based on the anatomical data, we can accurately identify the corresponding bony structures of the proximal humerus and mark the location of the pin on the 3D model for pin placement, which is simple and practical to meet the relevant individual parameters.
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Affiliation(s)
- Baorui Xing
- Cangzhou Hospital of integrated traditional Chinese medicine and Western medicine, No.31, West Huanghe Road, Yunhe District, Cangzhou, 061000, Hebei Province, China
| | - Yadi Zhang
- Cangzhou Hospital of integrated traditional Chinese medicine and Western medicine, No.31, West Huanghe Road, Yunhe District, Cangzhou, 061000, Hebei Province, China.
| | - Xiuxiu Hou
- Cangzhou Hospital of integrated traditional Chinese medicine and Western medicine, No.31, West Huanghe Road, Yunhe District, Cangzhou, 061000, Hebei Province, China
| | - Yunmei Li
- Cangzhou Hospital of integrated traditional Chinese medicine and Western medicine, No.31, West Huanghe Road, Yunhe District, Cangzhou, 061000, Hebei Province, China
| | - Guoliang Li
- Cangzhou Hospital of integrated traditional Chinese medicine and Western medicine, No.31, West Huanghe Road, Yunhe District, Cangzhou, 061000, Hebei Province, China
| | - Guangpu Han
- Cangzhou Hospital of integrated traditional Chinese medicine and Western medicine, No.31, West Huanghe Road, Yunhe District, Cangzhou, 061000, Hebei Province, China
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Maluta T, Amarossi A, Dorigotti A, Bagnis F, Samaila EM, De Luca L, Pezze L, Magnan B. External fixation can be an option for proximal humerus fractures Neer 3-4. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020017. [PMID: 33559622 PMCID: PMC7944700 DOI: 10.23750/abm.v91i14-s.10979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 11/23/2020] [Indexed: 11/23/2022]
Abstract
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)
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Soler-Peiro M, García-Martínez L, Aguilella L, Perez-Bermejo M. Conservative treatment of 3-part and 4-part proximal humeral fractures: a systematic review. J Orthop Surg Res 2020; 15:347. [PMID: 32831119 PMCID: PMC7444241 DOI: 10.1186/s13018-020-01880-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/11/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Although there are numerous publications about surgical treatment of proximal humeral fractures (PHFs), few assess conservative treatment, which is the most common approach. The aim of this systematic literature review was to assess criteria for indications, treatment protocols, and outcomes obtained with the conservative treatment of 3-part and 4-part PHF. METHODS We searched the PubMed and Cochrane databases for clinical studies published between 2000 and 2019 on conservative treatment for 3-part and 4-part PHF that included patients older than 18 years, a minimum follow-up of 1 year, fracture classification, and description of outcomes with assessment scales. RESULTS The search yielded 26,660 records. We reviewed 44 of them in full, and finally 6 studies were included. We obtained a population of 133 patients (79% women), with a mean age of 74.3 years (range 25 to 98) and mean follow-up of 32 months (range 12 to 68.8). According to the Neer classification system, there were 41% (55) three-part fractures and 59% (78) four-part fractures; 5.81% of the patients were lost to follow-up. The mean Constant score was 64.5 for three-part fractures and 54.9 patients with four-part fractures. Consolidation was achieved in 95% of the three-part fractures and 91% of the four-part fractures. Loss of mobility varied according to the type of fracture. Regarding complications, the most frequent was malunion (21%), followed by avascular necrosis (9%). CONCLUSIONS Our data show that most three-part PHFs treated conservatively achieve fracture consolidation even noting a negligible rate of malunion got fair-good functional results with few complications, while the orthopedic four-part PHF treatment presents high rate of consolidation with less rate of malunion than the three-part PHF but achieve poor functional results with few complications. LEVEL OF EVIDENCE Level IV, Systematic Review.
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Affiliation(s)
- Manuel Soler-Peiro
- Upper Extremity Unit, Orthopaedic Surgery Service, Hospital Universitario de La Ribera, Alzira, Valencia, Spain.
| | - Lorena García-Martínez
- Upper Extremity Unit, Orthopaedic Surgery Service, Hospital Universitario de La Ribera, Alzira, Valencia, Spain
| | - Luis Aguilella
- Upper Extremity Unit, Orthopaedic Surgery Service, Hospital Universitario de La Ribera, Alzira, Valencia, Spain
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Simionato IF, Brunelli JPF, Ferreira MT, Matsumoto FY, Britto AG, Mothes FC. Radiographic Evaluation of the Consolidation of Humerus Surgical Neck Fractures Treated With Percutaneous Fixation. Rev Bras Ortop 2020; 55:347-352. [PMID: 32616981 PMCID: PMC7316538 DOI: 10.1055/s-0039-3402463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 05/02/2019] [Indexed: 12/03/2022] Open
Abstract
Objective
To evaluate radiographically the postoperative results of patients with fracture of the proximal humerus in two parts of the surgical neck treated with threaded percutaneous fixation.
Methods
We evaluated the radiographic results of percutaneous fixation with threaded pins on the treatment of proximal humerus fractures in our service. Preoperative and postoperative images of 42 patients were evaluated, evaluating radiographs until 8 weeks postoperatively. We considered on evaluation the fracture deviation on preoperative images, the loss of reduction and no consolidation.
Results
Our consolidation rate was 90.4%, with loss of reduction in 16.6% of the cases and no consolidation rates in just 4 operated cases. We observed a predominance of a specific fracture pattern in the cases with loss of reduction.
Conclusion
The present study allows us to consider the percutaneous fixation technique with threaded pins as an alternative in our therapeutic arsenal for the proximal humerus fracture of the surgical neck. Contraindications are considered for low fracture trait on the metaphysis and with medial/lateral cortical impairment.
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Affiliation(s)
| | | | - Marco Tonding Ferreira
- Grupo de Cirurgia do Ombro e Cotovelo, Santa Casa de Misericórdia de Porto Alegre, RS, Brasil
| | | | - Almiro Gerszon Britto
- Grupo de Cirurgia do Ombro e Cotovelo, Santa Casa de Misericórdia de Porto Alegre, RS, Brasil
| | - Fernando Carlos Mothes
- Grupo de Cirurgia do Ombro e Cotovelo, Santa Casa de Misericórdia de Porto Alegre, RS, Brasil
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Dauwe J, Walters G, Holzer LA, Vanhaecht K, Nijs S. Failure after proximal humeral fracture osteosynthesis: a one year analysis of hospital-related healthcare cost. INTERNATIONAL ORTHOPAEDICS 2020; 44:1217-1221. [PMID: 32342142 PMCID: PMC7260263 DOI: 10.1007/s00264-020-04577-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 04/17/2020] [Indexed: 11/29/2022]
Abstract
Purpose The issue of rising healthcare costs and limited resources is a topic of worldwide discussion over the last several decades. We hypothesized that failure of proximal humeral fracture osteosynthesis is presumed to be an important determinant in healthcare resources and related costs. The aim of this study was to calculate the total hospital-related healthcare cost of proximal humeral fracture osteosynthesis over one year focusing on failure. Methods A total of 121 patients with a proximal humeral fracture treated by angular stable osteosynthesis were included in this retrospective study. All hospital-related healthcare costs were investigated. Five main hospital-related cost categories were defined: hospitalization cost, honoraria, day care admission, materials, and pharmaceuticals. Results A total healthcare cost of € 1,139,448 was calculated for the whole patient group. Twelve patients needed revision surgery due to complications or fixation-related failure. This failure rate alone costed € 190,809 of the healthcare resources. In other words, failure after proximal humeral fracture osteosynthesis costed 17% of the total healthcare expenditure inone year. Conclusion This study demonstrates that a high amount of hospital-related healthcare resources is spent because of failure after proximal humeral fracture osteosynthesis. Further research is necessary and should investigate on how to prevent failure. This is not only in the patient’s interest, but it is also of great importance for maintaining a healthy healthcare system.
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Affiliation(s)
- Jan Dauwe
- AO Research Institute, Davos, Switzerland
- Department of Orthopedic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Gregory Walters
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lukas A Holzer
- Department of Orthopaedic Surgery, AUVA Trauma Center Klagenfurt, Waidmannsdorferstraße 35, 9020, Klagenfurt am Wörthersee, Austria.
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria.
| | - Kris Vanhaecht
- Institute for Healthcare Policy, University of Leuven, Leuven, Belgium
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
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Kim YG, Park KH, Kim JW, Oh JK, Yoon JP, Kim HJ, Oh CW. Is minimally invasive plate osteosynthesis superior to open plating for fixation of two-part fracture of the proximal humerus? J Orthop Surg (Hong Kong) 2020; 27:2309499019836156. [PMID: 30885047 DOI: 10.1177/2309499019836156] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Displaced two-part fractures of the proximal humerus are generally treated with open plate (OP) fixation. Recently, minimally invasive plate osteosynthesis (MIPO) has been increasingly favored for fracture healing and functional recovery. We aimed to compare OP and MIPO for two-part fractures of the proximal humerus to identify outcome differences. METHODS All patients who underwent OP or MIPO for a displaced two-part fracture of the proximal humerus at a single level I trauma center between 2007 and 2013 were retrospectively evaluated. Of the patients, 17 were treated using the OP method through the delto-pectoral approach and 19 with MIPO through deltoid splitting. Radiographic results were evaluated to determine the union rate, time to union, and alignment. Functional outcomes were measured with Constant and UCLA scores. Radiation exposure and operative time were also evaluated. RESULTS All patients achieved bone union without complication. In the OP and MIPO groups, no significant difference was observed in the neck shaft angles, constant scores, or UCLA scores. The OP group required less radiation exposure time than the MIPO group ( p < 0.001). However, the OP group showed more operation time than the MIPO group ( p < 0.001). CONCLUSIONS Both techniques showed satisfactory radiographic and functional outcomes in two-part fractures of the proximal humerus. Although MIPO technique offers advantages, including minimal soft tissue damage and short operation time, surgeons and patients should be warned of the invisible risk from the radiation hazard.
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Affiliation(s)
- Young-Gun Kim
- 1 Department of Orthopedic Surgery, Cha University Gumi Medical Center, Gumi, South Korea
| | - Kyeong-Hyeon Park
- 2 Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Joon-Woo Kim
- 2 Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Jong-Keon Oh
- 3 Department of Orthopedic Surgery, Korea University Guro Hospital, Seoul, South Korea
| | - Jong-Pil Yoon
- 2 Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Hee-June Kim
- 2 Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Chang-Wug Oh
- 2 Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
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Dauwe J, Walters G, Van Eecke E, Vanhaecht K, Nijs S. Osteosynthesis of proximal humeral fractures: a 1-year analysis of failure in a Belgian level-1 trauma centre. Eur J Trauma Emerg Surg 2020; 47:1889-1893. [PMID: 32076785 DOI: 10.1007/s00068-020-01323-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/04/2020] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Jan Dauwe
- Department of Orthopedic Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Gregory Walters
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Eduard Van Eecke
- Department of Orthopedic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, Catholic University of Leuven, Leuven, Belgium
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
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15
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Johnson NA, Pandey R. Proximal humerus fracture-dislocation managed by mini-open reduction and percutaneous screw fixation. Shoulder Elbow 2019; 11:353-358. [PMID: 31534485 PMCID: PMC6739749 DOI: 10.1177/1758573218791815] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/20/2018] [Accepted: 07/09/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND We describe a minimally open reduction and percutaneous fixation technique for three- and four-part proximal humeral fracture-dislocations which preserves soft tissues. METHODS Eleven consecutive patients with three-and four-part proximal humeral fracture-dislocations (eight anterior, three posterior dislocations) were treated this way. The dislocation is reduced using a mini-open deltopectoral approach with a horizontal split in subscapularis. Fracture fragments are fixed with percutaneous screws. Constant and Oxford Shoulder Score were collected prospectively. RESULTS Mean age was 51 years (range 32-65). Mean follow-up was 36 months (range 24-72 months). At last follow-up mean Constant score was 75 (range 64-86) compared to 88 (range 85-92) for the uninjured shoulder. Mean Oxford shoulder score was 41 (range 34-46). One patient developed avascular necrosis. Screw back out was seen in three patients. These were removed under local anaesthesia. There were no screw penetrations of articular surface. One patient suffered a radial nerve neuropraxia which resolved. CONCLUSION These results are promising and comparable to published literature with other means of fixation for this complex problem. Due to minimal soft tissue dissection the complications rate is low.
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Affiliation(s)
- NA Johnson
- NA Johnson, Leicester Royal Infirmary,
Infirmary Square, Leicester, LE1 5WW.
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16
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Vicenti G, Antonella A, Filipponi M, Conserva V, Solarino G, Carrozzo M, Moretti B. 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. Injury 2019; 50 Suppl 2:S80-S88. [PMID: 30926138 DOI: 10.1016/j.injury.2019.01.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2019] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Giovanni Vicenti
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs University of Bari, Italy
| | - Abate Antonella
- Orthopedics and Traumatology, Di Venere Hospital, Bari, Italy
| | - Marco Filipponi
- Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
| | - Vito Conserva
- Orthopedics and Traumatology, Lorenzo Bonomo Hospital, Andria, Italy
| | - Giuseppe Solarino
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs University of Bari, Italy
| | - Massimiliano Carrozzo
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs University of Bari, Italy.
| | - Biagio Moretti
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs University of Bari, Italy
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Huang H. Treatment of the surgical neck fracture of the humerus with a novel external fixator in the elderly with osteoporosis: biomechanical analysis. BMC Musculoskelet Disord 2019; 20:218. [PMID: 31092231 PMCID: PMC6521449 DOI: 10.1186/s12891-019-2599-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 04/30/2019] [Indexed: 11/16/2022] Open
Abstract
Background No consensus exists on the treatment of proximal humerus fractures, especially in the elderly patients with osteoporosis. This study was aimed to evaluate the biomechanical characteristics of a novel external fixator in treating two-part surgical neck fracture of the proximal humerus in the elderly patients with osteoporosis. Methods Sixteen female elderly humeral shaft specimens with osteoporosis were randomized into 2 groups. Models with the surgical neck two-part fracture of the proximal humerus were built, in which a novel external fixator (test group) and a clover plate (control group) were applied separately. In the test group, the fracture was firstly fixed with intersection pinning using 3 Schanz pins (3.5 mm), followed by the novel external fixation frame. In the control group, a clover plate and 6 cortical bone screws were applied. Biomechanical testing of the specimens was performed to assess the resistance to load bearing and torsional stress. The parameters of the two groups were compared using independent t-test. Results Ultimate bearing capacity and load bearing at different parts with the humerus rotation were higher (P < 0.05) in the external fixator group (145.16 ± 17.42 N and 140 N respectively) than those in the plate group (120.21 ± 13.15 N and 69.63 ± 25.16–90.78 ± 17.18 N respectively). As for resistance to torsional stress, plate’s torque fluctuated between 1 Nm and 5 Nm, while the external fixator’s torque values were more evenly (P < 0.01) distributed with the fluctuation within 1 Nm. Conclusions In the fixation of two-part humeral fracture in elderly patients with osteoporosis, the new external fixator seemed to be superior to plate fixation in load bearing and resistance to torsional stress.
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Affiliation(s)
- Haijing Huang
- Department of trauma Orthopedic, Tianjin Hospital, No. 406, Jiefang south Road, Hexi District, Tianjin, 300021, China.
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18
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Outcomes following fixation for proximal humeral fractures. J Clin Orthop Trauma 2019; 10:468-473. [PMID: 31061571 PMCID: PMC6491912 DOI: 10.1016/j.jcot.2019.01.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 01/30/2019] [Indexed: 11/23/2022] Open
Abstract
Fractures of the proximal humerus are a very common presentation in modern Trauma and Orthopaedic practice. In an ever-aging population, the incidence has dramatically increased resulting in a large socioeconomical burden. The surgical management of these injuries has evolved over the years. Patient outcomes are variable and there is no consensus on treatment approach. This review article focuses on the outcomes following fracture fixation using common surgical techniques.
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19
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Acklin YP, Zderic I, Inzana JA, Grechenig S, Schwyn R, Richards RG, Gueorguiev B. Biomechanical evaluation of a new gliding screw concept for the fixation of proximal humeral fractures. Bone Joint Res 2018; 7:422-429. [PMID: 30034796 PMCID: PMC6035359 DOI: 10.1302/2046-3758.76.bjr-2017-0356.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Aims Plating displaced proximal humeral fractures is associated with a high rate of screw perforation. Dynamization of the proximal screws might prevent these complications. The aim of this study was to develop and evaluate a new gliding screw concept for plating proximal humeral fractures biomechanically. Methods Eight pairs of three-part humeral fractures were randomly assigned for pairwise instrumentation using either a prototype gliding plate or a standard PHILOS plate, and four pairs were fixed using the gliding plate with bone cement augmentation of its proximal screws. The specimens were cyclically tested under progressively increasing loading until perforation of a screw. Telescoping of a screw, varus tilting and screw migration were recorded using optical motion tracking. Results Mean initial stiffness (N/mm) was 581.3 (sd 239.7) for the gliding plate, 631.5 (sd 160.0) for the PHILOS and 440.2 (sd 97.6) for the gliding augmented plate without significant differences between the groups (p = 0.11). Mean varus tilting (°) after 7500 cycles was comparable between the gliding plate (2.6; sd 1.9), PHILOS (1.2; sd 0.6) and gliding augmented plate (1.7; sd 0.9) (p = 0.10). Similarly, mean screw migration(mm) after 7500 cycles was similar between the gliding plate (3.02; sd 2.85), PHILOS (1.30; sd 0.44) and gliding augmented plate (2.83; sd 1.18) (p = 0.13). Mean number of cycles until failure with 5° varus tilting were 12702 (sd 3687) for the gliding plate, 13948 (sd 1295) for PHILOS and 13189 (sd 2647) for the gliding augmented plate without significant differences between the groups (p = 0.66). Conclusion Biomechanically, plate fixation using a new gliding screw technology did not show considerable advantages in comparison with fixation using a standard PHILOS plate. Based on the finding of telescoping of screws, however, it may represent a valid approach for further investigations into how to avoid the cut-out of screws. Cite this article: Y. P. Acklin, I. Zderic, J. A. Inzana, S. Grechenig, R. Schwyn, R. G. Richards, B. Gueorguiev. Biomechanical evaluation of a new
gliding screw concept for the fixation of proximal humeral fractures. Bone Joint Res 2018;7:422–429. DOI: 10.1302/2046-3758.76.BJR-2017-0356.R1.
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Affiliation(s)
- Y P Acklin
- AO Research Institute Davos, Davos, Switzerland
| | - I Zderic
- AO Research Institute Davos, Davos, Switzerland
| | - J A Inzana
- AO Research Institute Davos, Davos, Switzerland
| | - S Grechenig
- Universitätsklinikum, Regensburg, Klinik und Poliklinik für Unfallchirurgie, Regensburg, Germany
| | - R Schwyn
- AO Research Institute Davos, Davos, Switzerland
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Panagopoulos A, Tatani I, Yannis S, Aikaterini B, Kouzelis A, Tyllianakis M, Dimakopoulos P. Transosseous Suture Fixation of True 4-part Valgus Impacted Fractures of the Proximal Humerus: Clinical and Radiological Outcome in 49 Patients. Open Orthop J 2018. [PMID: 29515680 PMCID: PMC5827299 DOI: 10.2174/1874325001812010041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background The valgus-impacted (VI) 4-part fractures are a subset of fractures of the proximal humerus with a unique anatomic configuration characterized by a relatively lower incidence of avascular necrosis after operative intervention. Objectives The present study reports the midterm clinical and radiological results of a large series of consecutive patients with 4-part VI fractures treated with a minimal invasive technique of internal fixation. Methods Over a ten-year period (2004-2014), we treated 56 patients with a true 4-part valgus impacted fracture of the proximal part of the humerus. Four patients were lost to follow-up and three died, leaving 49 patients (33 female, 16 males, average age 60,1 years) available for the study. Fracture fixation was achieved through the lateral transdeltoid approach with transosseous suturing of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head avoiding gross disimpaction of the humeral head from the valgus position. Functional outcome assessment was performed using the parameters of the Constant-Murley score within a mean follow up period of 43,8 months (range, 24 to 115 months). Results All fractures were united within the first 3 months except one that showed late displacement and finally nonunion. The median Constant score was 81,7 points and the functional score in comparison with the unaffected shoulder was 86.2%. There were three patients with total Avascular Necrosis (AVN) of the head revised to hemiarthroplasty. The nonunion case was revised to reverse shoulder arthroplasty 12 months after surgery. In five cases, absorption of the greater tuberosity was noted in the last radiographic control without any serious consequences to the shoulder function. Conclusion Advantages of this minimally invasive technique can be summarized as shorter operative time, no use of hardware, minimal soft tissue damage, low incidence of avascular necrosis, stable osteosynthesis with "tension band effect" and adequate rotator cuff repair allowing for early joint motion.
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Affiliation(s)
| | - Irini Tatani
- Shoulder & Elbow Department - University Hospital of Patras, Patras, Greece
| | - Seferlis Yannis
- Shoulder & Elbow Department - University Hospital of Patras, Patras, Greece
| | - Bavelou Aikaterini
- Shoulder & Elbow Department - University Hospital of Patras, Patras, Greece
| | - Antonis Kouzelis
- Shoulder & Elbow Department - University Hospital of Patras, Patras, Greece
| | - Minos Tyllianakis
- Shoulder & Elbow Department - University Hospital of Patras, Patras, Greece
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Schumaier A, Grawe B. Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient. Geriatr Orthop Surg Rehabil 2018; 9:2151458517750516. [PMID: 29399372 PMCID: PMC5788098 DOI: 10.1177/2151458517750516] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/29/2017] [Accepted: 11/23/2017] [Indexed: 12/20/2022] Open
Abstract
Introduction: Proximal humerus fractures are common in the elderly. The evaluation and management of these injuries is often controversial. The purpose of this study is to review recent evidence and provide updated recommendations for treating proximal humerus fractures in the elderly. Methods: A literature review of peer-reviewed publications related to the evaluation and management of proximal humerus fractures in the elderly was performed. There was a focus on randomized controlled trials and systematic reviews published within the last 5 years. Results: The incidence of proximal humerus fractures is increasing. It is a common osteoporotic fracture. Bone density is a predictor of reduction quality and can be readily assessed with anteroposterior views of the shoulder. Social independence is a predictor of outcome, whereas age is not. Many fractures are minimally displaced and respond acceptably to nonoperative management. Displaced and severe fractures are most frequently treated operatively with intramedullary nails, locking plates, percutaneous techniques, or arthroplasty. Discussion: Evidence from randomized controlled trials and systematic reviews is insufficient to recommend a treatment; however, most techniques have acceptable or good outcomes. Evaluation should include an assessment of the patient’s bone quality, social independence, and surgical risk factors. With internal fixation, special attention should be paid to medial comminution, varus angulation, and restoration of the calcar. With arthroplasty, attention should be paid to anatomic restoration of the tuberosities and proper placement of the prosthesis. Conclusion: A majority of minimally displaced fractures can be treated conservatively with early physical therapy. Treatment for displaced fractures should consider the patient’s level of independence, bone quality, and surgical risk factors. Fixation with percutaneous techniques, intramedullary nails, locking plates, and arthroplasty are all acceptable treatment options. There is no clear evidence-based treatment of choice, and the surgeon should consider their comfort level with various procedures during the decision-making process.
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Affiliation(s)
- Adam Schumaier
- Department of Orthopaedics and Sports Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Brian Grawe
- Department of Orthopaedics and Sports Medicine, University of Cincinnati, Cincinnati, OH, USA
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Biomechanical comparison of pin and tension-band wire fixation with a prototype locking plate fixation in a transverse canine patellar fracture model. Vet Comp Orthop Traumatol 2017; 29:20-8. [DOI: 10.3415/vcot-15-07-0115] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 07/30/2015] [Indexed: 11/17/2022]
Abstract
Summary
Objective: To compare a locking plate (LP) with pin and tension-band wire (pin/TBW) for fixation of mid-patellar transverse fractures.
Materials and methods: Cadaveric canine stifle joints from 10 adult mixed breed dogs (23–36 kg) were used. Mid-patellar transverse osteotomies were randomly stabilized (in pairs) with either pin/TBW or a prototype LP. Cyclic loads (1 Hz, 500 cycles) at 100% body weight (90°-135° stifle joint extension), were applied. Survival or failure of constructs was defined as <2 mm fracture gap distraction at 500 cycles, or ≥ 2 mm fracture gap distraction at the number of cycles sustained, respectively. Number of cycles at failure and distraction gap were compared with a paired Student’s t-test, and a survival analysis performed with a Mantel-Cox test. All constructs that survived cyclic testing were tested in single cycle load to failure (1.0 mm/sec; 110° stifle joint extension); yield strength was compared with a Wilcoxon rank sum test. Significance was set at p <0.05.
Results: All 10/10 LP and three out of 10 pin/ TBW fixations survived cyclic testing. Survival analysis, number of cycles at failure, and distraction gap all were significantly different between the two groups (p = 0.0011, p = 0.0013, and p <0.0001, respectively). Construct yield strength was not significantly different (p = 0.1273).
Conclusions: The failure mode with pin/TBW was consistently similar to failures observed clinically. The LP demonstrated consistent, reliable and stable fixation.This work was performed at the Biomechanics Orthopedic Research Laboratory, Cummings School of Veterinary Medicine at Tufts University, North Grafton, MA, USA.
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Chen ACY, Chiu CH, Hsu KY, Chan YS. Influence of age, gender, and radiographic features on the deltoid splitting approach for surgical osteosynthesis in displaced proximal humerus fractures: a comparison study. BMC Musculoskelet Disord 2017; 18:495. [PMID: 29179714 PMCID: PMC5704527 DOI: 10.1186/s12891-017-1840-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 11/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The deltoid splitting approach has recently been widely adopted to facilitate less invasive procedures for proximal humerus fractures. However, there are still concerns regarding its effectiveness in aging people and in cases involving complex fractures. This study was conducted to evaluate the efficacy of a proximal humeral locking plate using the anterolateral deltoid splitting approach and to specifically examine the effect of patient age, gender, and fracture pattern on surgical outcomes. METHODS Forty-two cases of proximal humeral fractures treated using the deltoid splitting approach and locking plate fixation were reviewed. Outcome differences were evaluated in terms of age, gender distribution, and radiographic analysis based on the Neer Classification. The influence of the surgical approach was further investigated by age-matched paired analysis after subdividing patients into two age groups (younger than 60 years vs. older than 60 years; N = 21, in each group). RESULTS In total, 41 patients (98%) demonstrated fracture union. The average Constant score was 80.4. No significant differences were found between patients younger than 60 years, and the older patients. Higher mean scores were found in men than in women (p = 0.448) and in simple fractures than in complex fractures (p = 0.454), without any significant differences. Better postoperative functional outcomes were observed when the humeral head-neck angle was greater than 105°, with a significant difference (p = 0.000). Surgical complications were found in 16 patients (38%) without significant difference between two age groups (p = 0.268). The most common complication was screw penetration. CONCLUSIONS Anterolateral deltoid splitting using locking plate fixation provided a feasible alternative for surgery of proximal humerus fractures in different age groups and yielded comparable outcomes when the neck-shaft angle was properly restored. Surgeons must be cautious regarding potential complications, especially with screw penetration when using the locking plate through a less invasive approach. TRIAL REGISTRATION ISRCTN75494532 . Trial Date: 2017/01/31.
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Affiliation(s)
- Alvin Chao-Yu Chen
- Bone and Joint Research Center, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital-Linkou and University College of Medicine, 333, 5th, Fu-Hsin St., Kweishan Dist., Taoyuan, 333, Taiwan, Republic of China.
| | - Chih-Hao Chiu
- Bone and Joint Research Center, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital-Linkou and University College of Medicine, 333, 5th, Fu-Hsin St., Kweishan Dist., Taoyuan, 333, Taiwan, Republic of China
| | - Kuo-Yau Hsu
- Bone and Joint Research Center, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital-Linkou and University College of Medicine, 333, 5th, Fu-Hsin St., Kweishan Dist., Taoyuan, 333, Taiwan, Republic of China
| | - Yi-Sheng Chan
- Bone and Joint Research Center, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital-Linkou and University College of Medicine, 333, 5th, Fu-Hsin St., Kweishan Dist., Taoyuan, 333, Taiwan, Republic of China
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Minimally Invasive Treatment of Displaced Proximal Humeral Fractures in Patients Older Than 70 Years Using the Humerusblock. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6451849. [PMID: 27981050 PMCID: PMC5131233 DOI: 10.1155/2016/6451849] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/25/2016] [Indexed: 11/17/2022]
Abstract
Background. Surgical treatment of proximal humeral fractures (PHF) in osteoporotic bone of elderly patients is challenging. The aim of this retrospective study was to evaluate the clinical and radiological outcome after percutaneous reduction and internal fixation of osteoporotic PHF in geriatric patients using the semirigid Humerusblock device. Methods. In the study period from 2005 to 2010, 129 patients older than 70 years were enrolled in the study. After a mean follow-up of 23 months, a physical examination, using the Constant-Murley score and the VAS pain scale, was performed. Furthermore radiographs were taken to detect signs of malunion, nonunion, and avascular necrosis. Results. The recorded Constant-Murley score was 67.7 points (87.7% of the noninjured arm) for two-part fractures, 67.9 points (90.8%) for three-part fractures, and 43.0 points (56.7%) for four-part fractures. In ten shoulders (7.8%) loss of reduction and in four shoulders (3.1%) nonunion were the reason for revision surgery. Avascular humeral head necrosis developed in eight patients (6.2%). Conclusions. In two- and three-part fractures postoperative results are promising. Sufficient ability for the activities of daily living was achieved. In four-part fractures the functional results were less satisfying regarding function and pain with a high postoperative complication rate. In those patients other treatment strategies should be considered. Study design. Therapeutic retrospective case series (evidence-based medicine (EBM) level IV).
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D'Ambrosi R, Palumbo F, Barbato A, Facchini RM. A prospective study for the treatment of proximal humeral fractures with the Galaxy Fixation System. Musculoskelet Surg 2016; 101:11-17. [PMID: 27822870 DOI: 10.1007/s12306-016-0434-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 10/27/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fractures of the proximal humerus represent a common problem in clinical practice; in particular for three- or four-part fractures, there is no consensus regarding which is the best treatment. The aim of our study was to report clinical and radiological outcomes in patients treated with the Galaxy Fixation System™ for a proximal humerus fracture. MATERIALS AND METHODS Thirty-two patients of which 18 (56.25%) women, and 14 (43.75%) men suffering from proximal humerus fractures were treated using the Galaxy Fixation System™. Fractures were classified according to Neer and only patients with a three- or four-part fracture with two-thirds of the methaphysis intact were included. Clinical examination included the Constant-Murley score, UCLA score and Quick DASH evaluated at 6, 12 and 24 months after surgery. In addition, at the final follow-up, patients were asked to complete the SF-12 questionnaire. The humeral head-shaft angle was evaluated by radiographs the day after surgery, as well as after 12 and 24 months. RESULTS All 32 patients were available for the 6th, 12th and 24th month follow-up examination. The mean interval between trauma and surgery was 2.7 days (range 0-6 days). The period of hospital stay ranged from 2 to 8 days with an average of three days. The time of healing ranged from 4 to 10 weeks with an average of 7 weeks. The mean Constant score increased from 72.9 after 6 months to a mean of 82.8 at 12 months (p < 0.05) to 88.9 at 24 months (p < 0.05). UCLA score ranged from 27.5 at 6 months to 29.5 at 12 months (p < 0.05) and finally improved to 32.3 at final follow-up (p < 0.05). Quick DASH varied from 7.2 at 6 months after surgery to 5.2 at 12 months after surgery (p > 0.05) and reached the value of 3.1 after 24 months (p > 0.05). Mean Mental Component (MCS) resulted in a value of 48.1, while the Physical Component (PCS) was 52.7. The mean head-shaft angulation was 137.6° the day after surgery compared with 137.5° (p > 0.05) measured 12 months later, and 137.2° measured 24 months later (p > 0.05). CONCLUSIONS Galaxy Fixation System™ is a safe and efficient procedure for the treatment of three- or four-part proximal humerus fractures, providing an excellent outcome. LEVEL OF EVIDENCE Prospective case series, Level IV.
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Affiliation(s)
- R D'Ambrosi
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy. .,Centro Traumatologico Ortopedico, U.O. Clinica Ortopedica e Traumatologica, Milan, Italy.
| | - F Palumbo
- Centro Traumatologico Ortopedico, U.O. Clinica Ortopedica e Traumatologica, Milan, Italy
| | - A Barbato
- Centro Traumatologico Ortopedico, U.O. Clinica Ortopedica e Traumatologica, Milan, Italy
| | - R M Facchini
- Centro Traumatologico Ortopedico, U.O. Clinica Ortopedica e Traumatologica, Milan, Italy
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Panagopoulos A, Tatani I, Ntourantonis D, Seferlis I, Kouzelis A, Tyllianakis M. Least Possible Fixation Techniques of 4-Part Valgus Impacted Fractures of the Proximal Humerus: A Systematic Review. Orthop Rev (Pavia) 2016; 8:6211. [PMID: 27114810 PMCID: PMC4821228 DOI: 10.4081/or.2016.6211] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 10/30/2015] [Accepted: 11/02/2015] [Indexed: 11/25/2022] Open
Abstract
The valgus-impacted (VI) 4-part fractures are a subset of fractures of the proximal humerus with a unique anatomic configuration characterized by a relatively lower incidence of avascular necrosis after operative intervention. We systematically reviewed clinical studies assessing the benefits and harms of least possible fixation techniques (LPFT) for this unique fracture type. Such information would be potentially helpful in developing an evidence-based approach in the management of these complex injuries. We performed analytic searches of PubMed, Embase, Web of Science, Google Scholar and the Cochrane Library, restricting it to the years 1991-2014. Included studies had to describe outcomes and complications after primary osteosynthesis with any type of LPFT apart from plate-screws and intramedullary nailing. Eligibility criteria were also included English language, more than 5 cases, minimum follow up of one year and report of clinical outcome using at least one relevant score (Constant, Neer or ASES). Based on 292 database hits we identified 12 eligible studies including 190 four-part valgus impacted fractures in 188 patients. All eligible studies were case series composed of min 8 to max 45 patients per study. The gender distribution was 60% (112) female and 40% (76) male. The average age of the patients at the time of injury was 54.5 years. In 8/12 studies an open reduction was used for fracture fixation using different surgical techniques including KW, cerclage wires, cannulated screws and osteosutures. Closed reduction and percutaneous fixation was used in 4 studies. Mean follow-up time ranged from 24 to 69 months. A good functional outcome (constant score >80) was reported in 9/12 studies. The most common complication was avascular necrosis of the humeral head with an overall incidence of 11% (range, 0-26.3%). Total avascular necrosis (AVN) was found in 15/188 patients (7.9%) and was more common in percutaneous techniques and partial AVN in 6/188 (3.1%) being more common in open techniques. The overall re-operation rate was very low (3.7%). Insufficient study designs cannot provide definite treatment recommendations and quantitative data synthesis of outcome. In general, LPFT for 4-part VI fractures leads to satisfactory outcomes with low incidence of complications. A considerable risk of biases can be attributed to fracture classification, proper radiological control, mean age of patients, mixed types of fixation methods, nonage adjusted clinical scoring and small follow up periods. These factors are discussed in detail. Level of evidence: systematic review of literature (level IV) as most of the studies were level IV.
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Affiliation(s)
- Andreas Panagopoulos
- Department of Shoulder and Elbow Surgery, University Hospital of Patras , Greece
| | - Irini Tatani
- Department of Shoulder and Elbow Surgery, University Hospital of Patras , Greece
| | | | - Ioannis Seferlis
- Department of Shoulder and Elbow Surgery, University Hospital of Patras , Greece
| | - Antonis Kouzelis
- Department of Shoulder and Elbow Surgery, University Hospital of Patras , Greece
| | - Minos Tyllianakis
- Department of Shoulder and Elbow Surgery, University Hospital of Patras , Greece
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Classification of proximal humeral fractures based on a pathomorphologic analysis. J Shoulder Elbow Surg 2016; 25:455-62. [PMID: 26475635 DOI: 10.1016/j.jse.2015.08.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 08/05/2015] [Accepted: 08/09/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to analyze the pathomorphology of proximal humeral fractures to determine relevant and reliable parameters for fracture classification. METHODS A total of 100 consecutive acute proximal humeral fractures in adult patients were analyzed by 2 non-independent observers from a single shoulder department using a standardized protocol based on biplane radiographs and 3-dimensional computed tomography scans. A fracture classification system based on the most reliable key features of the pathomorphologic analysis was created, and its reliability was tested by 6 independent shoulder experts analyzing another 100 consecutive proximal humeral fractures. RESULTS The head position in relation to the shaft (varus, valgus, sagittal deformity) and the presence of tuberosity fractures showed a higher interobserver reliability (κ > 0.8) than measurements for medial hinge, shaft, and tuberosity displacement, metaphyseal extension, fracture impaction, as well as head-split component identification (κ < 0.7). These findings were used to classify nondisplaced proximal humeral fractures as type 1, fractures with normal coronal head position but sagittal deformity as type 2, valgus fractures as type 3, varus fractures as type 4, and fracture dislocations as type 5. The fracture type was further combined with the fractured main fragments (G for greater tuberosity, L for lesser). Interobserver and intraobserver reliability analysis for the fracture classification revealed a κ value (95% confidence interval) of 0.700 (0.631-0.767) and 0.917 (0.879-0.943), respectively. CONCLUSION The new classification system with emphasis on the qualitative aspects of proximal humeral fractures showed high reliability when based on a standardized imaging protocol including computed tomography scans.
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Moroder P, Tauber M, Scheibel M, Habermeyer P, Imhoff AB, Liem D, Lill H, Buchmann S, Wolke J, Guevara-Alvarez A, Salmoukas K, Resch H. Defect Characteristics of Reverse Hill-Sachs Lesions. Am J Sports Med 2016; 44:708-14. [PMID: 26747848 DOI: 10.1177/0363546515621286] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Little scientific evidence regarding reverse Hill-Sachs lesions (RHSLs) in posterior shoulder instability exists. Recently, standardized measurement methods of the size and localization were introduced, and the biomechanical effect of the extent and position of the defects on the risk of re-engagement was determined. PURPOSE To analyze the characteristics and patterns of RHSLs in a large case series using standardized measurements and to interpret the results based on the newly available biomechanical findings. STUDY DESIGN Case series; Level of evidence, 4. METHODS In this multicenter study, 102 cases of RHSLs in 99 patients were collected from 7 different shoulder centers between 2004 and 2013. Patient- as well as injury-specific information was gathered, and defect characteristics in terms of the size, localization, and depth index were determined on computed tomography or magnetic resonance imaging scans by means of standardized measurements. Additionally, the position (gamma angle) of the posterior defect margin as a predictor of re-engagement was analyzed. RESULTS Three types of an RHSL were distinguished based on the pathogenesis and chronicity of the lesion: dislocation (D), locked dislocation (LD), and chronic locked dislocation (CLD). While the localization of the defects did not vary significantly between the subgroups (P = .072), their mean size differed signficantly (D: 32.6° ± 11.7°, LD: 49.4° ± 17.2°, CLD: 64.1° ± 20.7°; P < .001). The mean gamma angle as a predictor of re-engagement was similarly significantly different between groups (D: 83.8° ± 14.5°, LD: 96.5° ± 17.9°, CLD: 108.7° ± 18.4°; P < .001). The orientation of the posterior defect margin was consistently quite parallel to the humeral shaft axis, with a mean difference of 0.3° ± 8.1°. CONCLUSION The distinction between the 3 different RHSL types based on the pathogenesis and chronicity of the defect helps identify defects prone to re-engagement. The gamma angle as a measurement of the position of the posterior defect margin and therefore a predictor of re-engagement varies significantly between the defect types.
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Affiliation(s)
- Philipp Moroder
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Salzburg, Austria
| | - Mark Tauber
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Salzburg, Austria Department of Shoulder and Elbow Surgery, ATOS Clinic Munich, Munich, Germany
| | - Markus Scheibel
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Habermeyer
- Department of Shoulder and Elbow Surgery, ATOS Clinic Munich, Munich, Germany
| | - Andreas B Imhoff
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Dennis Liem
- Department of Orthopedics and Tumor Orthopedics, University Hospital Muenster, Muenster, Germany
| | - Helmut Lill
- Department of Trauma and Reconstructive Surgery, Friederikenstift Hospital Hanover, Hanover, Germany
| | - Stefan Buchmann
- Department for Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany
| | - Julia Wolke
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Katharina Salmoukas
- Department of Trauma and Reconstructive Surgery, Friederikenstift Hospital Hanover, Hanover, Germany
| | - Herbert Resch
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Salzburg, Austria
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Carbone S, Papalia M. The amount of impaction and loss of reduction in osteoporotic proximal humeral fractures after surgical fixation. Osteoporos Int 2016; 27:627-33. [PMID: 26323331 DOI: 10.1007/s00198-015-3304-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 08/21/2015] [Indexed: 11/26/2022]
Abstract
UNLABELLED After surgical fixation, osteoporotic proximal humeral fractures often show high impaction and loss of reduction. This study aims at assessing the amount of impaction and loss of reduction at a short and medium follow-up. We found an alarming percentage of cases showing these complications in the first postoperative months. INTRODUCTION This study seeks to quantify the amount of humeral head impaction and loss of reduction in a consecutive series of osteoporotic proximal humerus fractures treated with a locking plate. METHODS A series of displaced proximal humerus fractures were prospectively treated with minimally invasive reduction and ostheosynthesis using a locking plate. Diagnosis and classification of fractures were based on X-ray examination and CT scan. Proximal humerus cortical bone thickness (CBTAVG) was studied to assess osteoporosis. Amount of loss of reduction and head fragment impaction were noted at 3 and 18 months of follow-up. Constant score was calculated at 6 and 18 months of follow-up. RESULTS Thirty-one osteoporotic fractures were studied. Most of the fractures (21, 67.7 %) had a CBTAVG of less than 4 mm. At 3 months of follow-up, 7 cases (22.5 %) had significant loss of reduction and the mean amount of impaction was 2.8 mm. At 18 months of follow-up, only 1 additional fracture showed loss of reduction and mean impaction was 3 mm (p < 0.05). At 6 months follow-up, the mean Constant score was 58 %; while at 18 months, it was 70 % (p = 0.02). Amount of impaction was significantly correlated to age of patients (p = 0.031), female sex (p = 0.011), CBTAVG (p = 0.019), and metaphyseal comminution (p = 0.013). CONCLUSIONS Osteoporotic proximal humerus fractures may present an important impaction and loss of reduction in the first 3 months after surgery even if treated with a rigid device and multiple head screws. Surgeons treating these osteoporotic fractures should be aware of these complications even when using a rigid device.
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Affiliation(s)
- S Carbone
- Department Of Molecular Medicine, Sapienza University of Rome, Rome, Italy.
| | - M Papalia
- Department Of Orthopaedics and Traumatology, Clinica Nuova Itor, Rome, Italy
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Boesmueller S, Wech M, Gregori M, Domaszewski F, Bukaty A, Fialka C, Albrecht C. Risk factors for humeral head necrosis and non-union after plating in proximal humeral fractures. Injury 2016; 47:350-5. [PMID: 26706457 DOI: 10.1016/j.injury.2015.10.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 09/27/2015] [Accepted: 10/02/2015] [Indexed: 02/02/2023]
Abstract
AIM The aim of this study was to evaluate risk factors for the development of humeral head necrosis and non-union after proximal humeral fractures-in particular, general risk factors that exist independent of fracture type. MATERIALS AND METHODS This study included patients (n=154) treated for proximal humeral fracture by means of open reduction and internal fixation (ORIF) using the Philos plate at a single level I trauma centre between January 2005 and December 2013. Follow-up monitoring included radiographic examination before hospital discharge, and again at 6 weeks, 12 weeks, and 6 months after surgery. At a minimum follow-up time of 6 months, radiographs taken in the anteroposterior and axial projection were evaluated in regard to the development of humeral head necrosis, non-union, and secondary screw cut out. RESULTS A total of 154 patients (61 males, 93 females) were available for radiological checkup. Mean age was 55.8 years (range: 19-91 years). There were statistically significant correlations between the development of avascular necrosis (AVN) and fracture type, non-union and smoking, and screw cut out - as well as overall complication rate - and age. The time to surgery did not influence the risk for AVN or non-union, independent of fracture type. In this study population, the risk of developing non-union after ORIF was 3.9-fold higher in heavy smokers (i.e., >20 cigarettes per day). The risk for screw cut out was 4.1-fold higher in patients over 60 years of age, and the overall risk for complications was 3.3-fold higher. CONCLUSION The older the patient, the more carefully one must consider the decision between conservative and operative treatments. If surgical treatment is performed, screw length should be selected depending on the patient's age. Heavy smokers must be informed preoperatively of the increased risk for bony non-union after ORIF.
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Affiliation(s)
- Sandra Boesmueller
- Medical University of Vienna, Department of Trauma Surgery, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
| | - Margit Wech
- Medical University of Vienna, Department of Trauma Surgery, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Markus Gregori
- Medical University of Vienna, Department of Trauma Surgery, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Florian Domaszewski
- Medical University of Vienna, Department of Trauma Surgery, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Adam Bukaty
- Medical University of Vienna, Division of General Anaesthesia and Intensive Care Medicine, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Christian Fialka
- AUVA Trauma Center Vienna Meidling, Kundratstraße 37, A-1120 Vienna, Austria
| | - Christian Albrecht
- Medical University of Vienna, Department of Trauma Surgery, Waehringer Guertel 18-20, A-1090 Vienna, Austria
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Augmentation in proximal humeral fractures. CURRENT ORTHOPAEDIC PRACTICE 2015. [DOI: 10.1097/bco.0000000000000304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ortmaier R, Filzmaier V, Hitzl W, Bogner R, Neubauer T, Resch H, Auffarth A. Comparison between minimally invasive, percutaneous osteosynthesis and locking plate osteosynthesis in 3-and 4-part proximal humerus fractures. BMC Musculoskelet Disord 2015; 16:297. [PMID: 26467533 PMCID: PMC4607011 DOI: 10.1186/s12891-015-0770-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 10/08/2015] [Indexed: 02/03/2023] Open
Abstract
Background The ideal method for the surgical treatment of proximal humeral fractures has not yet been found. We therefore conducted a retrospective matched-pair analysis and compared osteosynthesis with open reduction and internal fixation and that with an angular stable plate with minimally invasive, closed reduction, percutaneous fixation with the Humerusblock. Methods During a study period of 3 years, we matched 30 patients treated with angular stable plates (group 1) for age, gender, fracture type and handedness (dominant or nondominant) to 30 patients treated using the Humerusblock (group 2). At a minimal follow-up of 24 months, clinical evaluation included the Constant-Murley score, the UCLA score and the Simple Shoulder Test. Subjective pain was evaluated using the VAS pain scale. Patients were asked to rate their subjective satisfaction of final outcome as excellent, good, satisfied or dissatisfied. Results The mean CMS, UCLA score and SST differed significantly between groups 1 and 2 (60.9 vs 71.9, p < 0.01), (25.1 vs 29.5, p < 0.01) and (8.1 vs 9.4, p < 0.05), respectively. The VAS pain score was significantly lower in group 2 than in group 1 (1.2 vs 2.4; p < 0.01). The mean abduction (109.7° vs 133.7°; p < 0.01) and anterior flexion (128.3° vs 145.7°; p < 0.01) were significantly worse in group 1. The mean operation time was significantly shorter in group 2 (117.3 vs 72.1, p < 0.01). Complications occurred in 30 % (group 1) and 23 % (group 2) of patients. Conclusions In this study, the functional outcome is superior in the Humerusblock group. However, the general outcome after surgical treatment of 3-and 4-part fractures is moderate, and the complication rate has to be considered, even though it can be lowered with the use of minimally invasive implants.
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Affiliation(s)
- Reinhold Ortmaier
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria.
| | - Verena Filzmaier
- Department of Traumatology, Diakonissenkrankenhaus Schladming, Salzburgerstraße 777, A-8970, Schladming, Austria.
| | - Wolfgang Hitzl
- Department of Biostatistics, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria.
| | - Robert Bogner
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria.
| | - Thomas Neubauer
- Landeskrankenhaus Horn and Paracelsus Medical University, Spitalgasse 10, A-3580 Horn, Salzburg, Austria.
| | - Herbert Resch
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria.
| | - Alexander Auffarth
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria.
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Tauber M, Hirzinger C, Hoffelner T, Moroder P, Resch H. Midterm outcome and complications after minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock. Injury 2015; 46:1914-20. [PMID: 26071323 DOI: 10.1016/j.injury.2015.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 04/22/2015] [Accepted: 05/02/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The Humerusblock (HB) represents a minimally invasive implant allowing for the stabilisation of proximal humeral fractures after closed or percutaneous reduction. The aim of the study was to perform a general clinical and radiological midterm follow-up focusing on the quality and complications in a large series of patients of younger age (<70 years). PATIENTS AND METHODS A total of 126 patients with an average age of 53.6 years treated surgically using the HB device were evaluated clinically using the Constant score (CS) and radiologically by biplanar radiographs after a mean follow-up time of 59 months. Thirty-three patients had a two-part fracture, 58 a three-part fracture and 35 a four-part fracture. Ultrasound imaging for bilateral rotator cuff evaluation was performed, and complications regarding implant failure, revision rate and post-traumatic avascular necrosis (AVN) were analysed. RESULTS The average CS was 77.3 points for the affected shoulder and 86.5 points for the unaffected shoulder (P=0.001). The subjective shoulder value was 84.2%. Two-part fractures achieved 77.5 points, three-part fractures 81.7 points and four-part fractures 69.8 points. Surgical neck non-union was observed in 1.3% and AVN was observed in 11% associated with a CS of 46.4 points. Implant failure occurred in 9.6%. Varus malposition was present in 36%, and it was clinically relevant when exceeding 25°. CONCLUSION Percutaneous fracture treatment using the HB achieves good functional outcomes with an acceptable complication rate. The rate of AVN was surprisingly high, especially in four-part fractures (26%), which presumably is due to the longer follow-up period. Varus malalignment was clinically relevant when exceeding 25°. STUDY DESIGN Retrospective case series (evidence-based medicine (EBM) level IV).
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Affiliation(s)
- Mark Tauber
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Salzburg, Austria; Shoulder and Elbow Service, ATOS Clinic Munich, Effnerstrasse 38, 81925 Munich, Germany.
| | - Corinna Hirzinger
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Salzburg, Austria
| | - Thomas Hoffelner
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Salzburg, Austria
| | - Philipp Moroder
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Salzburg, Austria
| | - Herbert Resch
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Salzburg, Austria
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Handford C, Nathoo S, Porter K, Kalogrianitis S. A review of current concepts in the management of proximal humerus fractures. TRAUMA-ENGLAND 2015. [DOI: 10.1177/1460408614555069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Fracture of the proximal humerus is a common orthopaedic injury and is likely to increase in incidence. This fracture type is associated with a wide variety in fracture morphology and as a direct result there are many treatment options available. It is often not clear what treatment modality should be utilised. This article reviews the current literature on proximal humerus fractures offering evidence for care pathways and management strategies from presentation to rehabilitation.
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Abstract
OBJECTIVES This study was performed to identify the risk factors for reduction loss after locking plate fixation of proximal humerus fractures. DESIGN Retrospective study. SETTING University trauma center. PATIENTS AND INTERVENTION We retrospectively evaluated 252 patients who had been surgically treated for proximal humeral fractures with locking plates between January 2004 and December 2011. MAIN OUTCOME MEASUREMENTS Charts and standardized x-rays (true anteroposterior and axillary lateral views) were used to evaluate the Neer and AO OTA fracture types, initial neck-shaft angle (NSA, varus displacement), medial comminution, postoperative NSA (reduction adequacy), medial support restoration, healing progress, reduction loss, and implant-related problems immediately after surgery and at 2 weeks, 1 month, 3 months, 6 months, 9 months, and at least 1 year after surgery. Reduction loss was defined as (1) ≥10 of angulation in any direction, (2) ≥5 mm of height loss of the humeral head from the plate, and (3) fixation failure. RESULTS Reduction loss occurred in 6.7% (17 of 252) of cases; revision surgeries were performed in all cases. Univariable logistic regression analysis revealed that older age (P = 0.023), osteoporosis (P = 0.001), varus displacement (P = 0.001), medial comminution (P = 0.001), reduction adequacy (P = 0.036), and insufficient medial support (P = 0.001) had significant correlations with reduction loss. CONCLUSIONS Multivariable regression analysis revealed that osteoporosis (less than -2.5 bone mineral density, P = 0.015), displaced varus fracture (less than 110° of NSA, P = 0.025), medial comminution (more than 1 fragment, P = 0.018), and insufficient medial support (no cortical or screw support, P = 0.001) were independent risk factors for reduction loss in the proximal humerus fractures surgery. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Proximal fractures of the humerus in patients older than 75 years of age: should we consider operative treatment? J Orthop Traumatol 2015; 15:111-5. [PMID: 24233865 PMCID: PMC4033798 DOI: 10.1007/s10195-013-0273-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 09/25/2013] [Indexed: 11/21/2022] Open
Abstract
Background Over 75 % of patients presenting with a proximal humerus fracture are 70 years or older. Very little is known about the outcome after operative treatment of these fractures in very old patients. This study was performed to gain more insight in safety and functional outcome of surgical treatment of proximal humerus fractures in the elderly. Materials and methods In this observational study, we analyzed all operatively treated patients, aged 75 or older, with a proximal humerus fracture between January 2003 and December 2008 in our center. Patient selection was on clinical grounds, based on physical, mental, and social criteria. Complications were evaluated. We used the DASH Questionnaire to investigate functional outcome, pain, and ADL limitations. Results Sixty-four patients were treated surgically for a displaced proximal fracture of the humerus: 15 two-part, 32 three-part, and 17 four-part fractures. Mean DASH scores were 37.5, 36.9, and 48.6, respectively. Regarding the operative methods, overall good results were obtained with the modern locked plate osteosynthesis (mean DASH 34.4). Prosthetic treatment, mostly used in highly comminuted fractures, often resulted in poor function (mean DASH 72.9). Persistent pain and ADL limitations were more present in more comminuted fractures (64 and 50 % in patients with 4-part fractures vs. 14 % in 2-part fractures). There were no postoperative deaths within 3 months of surgery, and fracture-related and non-fracture-related complication rates were low (non-union 3 %; 1 myocardial infarction). Conclusion This study shows that it is safe and justifiable to consider surgical treatment of a severely dislocated proximal humerus fracture in selected patients aged 75 and older. Level of evidence According to OCEBM Working Group, Level IV.
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Clinical investigation for displaced proximal humeral fractures in the elderly: a randomized study of two surgical treatments: reverse total prosthetic replacement versus angular stable plate Philos (The DELPHI-trial). BMC Musculoskelet Disord 2014; 15:323. [PMID: 25261913 PMCID: PMC4247153 DOI: 10.1186/1471-2474-15-323] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 09/16/2014] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Treatment for displaced proximal humeral fractures is still under debate. Few studies exist at the highest level of evidence. Although reversed total shoulder prosthesis has gained popularity and showed promising results in the treatment for proximal humeral fractures in the elderly patients, no randomized controlled trials exist to the authors' knowledge. METHODS/DESIGN This study is a randomized semi-blinded controlled multicenter trial designed according to the Consort statement and the recommendations given by the Cochrane reviewers for proximal humeral fractures. The study will investigate whether a reversed total shoulder prosthetic replacement gain better functional outcome compared to open reduction and internal fixation using an angular stable plate in displaced three- and four parts proximal humeral fractures after two and five years follow-up.Participants are aged 65-85 admitted in seven different hospitals with a displaced proximal humeral fracture according to AO-OTA type 11-B2 or 11-C2. The intervention group is surgical treatment using a reversed total shoulder prosthesis (Delta X-tend) compared to open reduction and internal fixation with an angular stable plate (Philos) and thread cerclage in the control group. 60 patients will be randomized to each group.The primary outcome is shoulder function (Constant score). Secondary outcomes will be patient self-assessment form (Oxford shoulder score), a quality of life questionnaire (15D score) and resource implications (cost-effectiveness). Follow-ups take place at 3, 6, 12 and 24 months, and five years. The trial design is semi-blinded with blinded physiotherapists performing the functional testing of patients at all follow-ups.Randomization to treatment groups is electronic online, by independent supervisor (web-CRF). The recruitment of patients started at January 1.st 2013. Inclusion of 120 patients during three years is expected. DISCUSSION This semiblinded trial include a high number of patients compared to existing randomized trials in this field. To our knowledge and according to ClinicalTrials.gov, this is the first study that compare these two treatments for a displaced proximal humeral fracture in elderly patients. This may provide important information to help the surgeon to decide the best treatment in the future. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT01737060.
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Zhang W, Zeng L, Liu Y, Pan Y, Zhang W, Zhang C, Zeng B, Chen Y. The mechanical benefit of medial support screws in locking plating of proximal humerus fractures. PLoS One 2014; 9:e103297. [PMID: 25084520 PMCID: PMC4118867 DOI: 10.1371/journal.pone.0103297] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 06/28/2014] [Indexed: 11/26/2022] Open
Abstract
Background The purpose of this study was to evaluate the biomechanical advantages of medial support screws (MSSs) in the locking proximal humeral plate for treating proximal humerus fractures. Methods Thirty synthetic left humeri were randomly divided into 3 subgroups to establish two-part surgical neck fracture models of proximal humerus. All fractures were fixed with a locking proximal humerus plate. Group A was fixed with medial cortical support and no MSSs; Group B was fixed with 3 MSSs but without medial cortical support; Group C was fixed with neither medial cortical support nor MSSs. Axial compression, torsional stiffness, shear stiffness, and failure tests were performed. Results Constructs with medial support from cortical bone showed statistically higher axial and shear stiffness than other subgroups examined (P<0.0001). When the proximal humerus was not supported by medial cortical bone, locking plating with medial support screws exhibited higher axial and torsional stiffness than locking plating without medial support screws (P≤0.0207). Specimens with medial cortical bone failed primarily by fracture of the humeral shaft or humeral head. Specimens without medial cortical bone support failed primarily by significant plate bending at the fracture site followed by humeral head collapse or humeral head fracture. Conclusions Anatomic reduction with medial cortical support was the stiffest construct after a simulated two-part fracture. Significant biomechanical benefits of MSSs in locking plating of proximal humerus fractures were identified. The reconstruction of the medial column support for proximal humerus fractures helps to enhance mechanical stability of the humeral head and prevent implant failure.
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Affiliation(s)
- Wen Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Langqing Zeng
- Department of Orthopaedics, Zhuhai People's Hospital, Jinan University Affiliated Zhuhai Hospital, Guangdong, China
| | - Yanjie Liu
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yao Pan
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Changqing Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bingfang Zeng
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yunfeng Chen
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Comparison between reverse shoulder arthroplasty and Humerusblock in three- and four-part proximal humerus fractures in elderly patients. INTERNATIONAL ORTHOPAEDICS 2014; 39:335-42. [DOI: 10.1007/s00264-014-2433-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 06/17/2014] [Indexed: 10/25/2022]
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Functional and quality-of-life results of displaced and nondisplaced proximal humeral fractures treated conservatively. J Orthop Trauma 2014; 28:e178. [PMID: 24740114 DOI: 10.1097/bot.0000000000000136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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The amount of humeral head impaction of proximal humeral fractures fixed with the Humerusblock device. INTERNATIONAL ORTHOPAEDICS 2014; 38:1451-9. [PMID: 24695976 DOI: 10.1007/s00264-014-2327-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Accepted: 03/15/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The Humerusblock is a minimally invasive device allowing fixation of proximal humeral fractures. A drawback of the device is possible K-wire perforation of the head with the need for early removal of the implant. We assessed the amount of humeral head impaction and its role in the postoperative varus/valgus deviation of the humeral head in fractures of the upper humerus treated with Humerusblock. METHODS Fractures were classified according to the Codman-Lego system. The length of the posteromedial metaphyseal extension and integrity of medial hinge were measured; metaphyseal comminution was assessed. Accuracy of fracture reduction was classified as excellent to poor. An original method of measurement of amount of postoperative impaction of the humeral head was developed. The impaction and varus/valgus inclination of the heads were measured comparing postoperative and three-month follow-up radiographs. Constant score and its relation to sintering was calculated at 12-month follow-up. RESULTS Forty-three fractures were available for follow-up. The amount of humeral head impaction was 3.9 mm on average and was directly correlated with patient's age, sex, Codman-Lego classification, varus inclination and mataphyseal comminution. The postoperative cervico-diaphyseal angle was restored in 35 cases, with 81 % good results. The Humerusblock was removed in 41 % of cases because of K-wire perforation of the humeral head. A negative correlation was found between impaction and Constant score. CONCLUSIONS The amount of humeral head impaction is related to patients' age, sex, and fracture patterns, being the most prone to compaction those with metaphyseal comminution. Humeral head impaction negatively affects final Constant score.
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Abstract
BACKGROUND AND PURPOSE Long term outcome of the treatment of displaced complex fractures of humeral head is rare in the literature especially in greater cohorts. Main purpose of our study was the assessment of long term results of intramedullary nailing of 3-4 part fractures. PATIENTS AND METHODS 137 patients with 137 three or four-part fractures of the humeral head treated by intramedullary nailing were reassessed after an average follow-up time of 57 (27-93) months. The whole cohort consisted of 85 three-part fractures, 38 four-part fractures and 14 fracture-dislocations. Radiographic and clinical outcome - absolute Constant score (CS(abs)) and relative Constant score (compared to the contralateral side - CS(rel)) were evaluated. The rate of complications was recorded. Analysis of the influence of quality of achieved reduction on final functional result and on the development of complications was performed. RESULTS 125 fractures healed uneventfully. Mean long term CS(rel) was 81% of the unaffected side. Mean CS(rel) was 85% in 3-part fractures, 73% in four-part fractures, 80% in three-part fracture-dislocations and 70% in four-part fracture-dislocations. 96 (70%) patients achieved excellent or good results (CS(rel) higher than 80%), 17 (12.4%) satisfactory results and 24 (17.5%) poor results (CS(rel) less than 60%). No significant difference was observed in functional results between different age groups. No incidence of non-union was observed, 4 losses of reduction were encountered. We observed 17 cases of complete humeral head necrosis, 14 of them in the group of 4-part fractures. Reduction quality strongly influenced functional result and development of head necrosis. In the group of excellent reduction mean CS(rel) was 88% and the rate of necrosis was 2%. Moderate reduction quality deteriorated CS(rel) to 70% and head necrosis rate rose up to 28%. If reduction was poor, mean CS(rel) was 52% and the rate of complete necrosis rose to 60%. CONCLUSION Long term results confirmed nailing as appropriate treatment strategy for all types of humeral head fractures with limitation of excellent reduction in every age group. Moderate or even poor reduction significantly deteriorates functional results and increases rate of complete necrosis of the humeral head. If good reduction cannot be achieved, treatment strategy should be changed.
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Affiliation(s)
- Martin Kloub
- Department of Traumatology, Hospital Ceske Budejovice, Czech Republic.
| | - Karel Holub
- Department of Traumatology, Hospital Ceske Budejovice, Czech Republic
| | - Simona Polakova
- Daphne CR-Institute of Applied Ecology, Ceske Budejovice, Czech Republic
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Abstract
Arthroscopy has become increasingly more established in the treatment of proximal humeral fractures. In addition to the known advantages of minimally invasive surgery fracture and implant positioning can be optimized and controlled arthroscopically and relevant intra-articular concomitant pathologies (e.g. biceps tendon complex and rotator cuff) can be diagnosed and treated. Arthroscopic techniques have proven to be advantageous in the treatment of various entities of greater tuberosity fractures, lesser tuberosity fractures (suture bridging technique) and subcapital humeral fractures (arthroscopic nailing). This article presents an overview on innovative arthroscopic modalities for treating proximal humeral fractures, describes the surgical techniques and the advantages compared to open procedures as well as initial clinical results.
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Kogan PG, Vorontsova TN, Shubnyakov II, Voronkevich IA, Lasunskiy SA. Evolution of treatment of of the proximal humerus fractures (review). TRAUMATOLOGY AND ORTHOPEDICS OF RUSSIA 2013. [DOI: 10.21823/2311-2905-2013--3-154-161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The article in generalized form acquaints with the publications devoted to the bases of proximal humeral fractures treatment. A brief digression on anatomy and biomechanics of the humeral joint allows to consider the main morphological features of it. The most commonly used classification of proximal humeral fractures concisely classify many types of damage. According to the clinical and anatomical characteristics of fractures tracked the historical aspect, the development and the current state of the most common methods of treatment. In his review collected works authors share their experience in the application of methods. It allows to further the perspective directions.
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Burkhart KJ, Dietz SO, Bastian L, Thelen U, Hoffmann R, Müller LP. The treatment of proximal humeral fracture in adults. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:591-7. [PMID: 24078839 DOI: 10.3238/arztebl.2013.0591] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 04/29/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND The incidence of proximal humeral fractures lies between 105 and 342 per 100 000 persons per year. Around the world, this type of fracture remains a major challenge for treating surgeons. While non-displaced fractures can be managed conservatively, displaced ones are often treated surgically. METHODS Selective literature review. RESULTS There are still no evidence-based schemes or guidelines for the treatment of proximal humeral fractures, and very few prospective randomized trials are available. The few that have been published recently show a trend in favor of conservative treatment, but they were carried out on small groups of patients and their findings are not directly generalizable. For younger patients, the goal of treatment is generally anatomical repositioning and osteosynthetic stabilization; for older patients, primary treatment with a prosthesis is a further option. Depending on the mode of treatment, complications can arise such as shoulder stiffness, necrosis of the humeral head, pain, infection, loss of reposition, and "cutting out." CONCLUSION Current evidence supports the individualized treatment of proximal humeral fractures. Treatment decisions must always be made jointly with the patient in consideration of his or her individual needs and characteristics. Particularly for elderly patients, the possibility of conservative treatment should be carefully considered. If conservative treatment is not possible, then the type of operation performed should also be a function of the surgeon's individual skills and experience with particular types of implant.
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Affiliation(s)
- Klaus J Burkhart
- Department of Orthopedics and Trauma Surgery, University Hospital of Cologne
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Innocenti M, Carulli C, Civinini R, Matassi F, Tani M, Muncibì F. Displaced fragility fractures of proximal humerus in elderly patients affected by severe comorbidities: percutaneous fixation and conservative treatment. Aging Clin Exp Res 2013; 25:447-52. [PMID: 23760947 DOI: 10.1007/s40520-013-0063-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 02/04/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Proximal humerus is a common site of fracture in elderly patients, mainly related to bone fragility. Comorbidities are often present in these patients and may limit the surgical options. Not or minimal invasive treatments are commonly indicated however with variable results. The authors present their experience with conservative approach and percutaneous fixation by K-wires, focusing on their indications and main advantages on this population: mini-invasivity, acceptable reduction and recovery, and low costs. METHODS A study group of 51 consecutive patients with a mean age of 75.5 and affected by severe comorbidities (mainly cardiac, circulatory, pneumologic, neurologic, metabolic, and nephrologic pathologies) were evaluated clinically (ASA score, VAS, muscular strength, Constant-Murley score), and with radiologic analysis: 28 patients were treated by percutaneous fixation, while 23 subjects were treated conservatively. RESULTS Fractures treated by K-wires fixation healed after a mean interval of 8.2 weeks in all fractures but one, with improvements in mean Constant-Murley score (up to 80.6 points), in mean VAS (2.9), in muscular strength (4.1), and in range of motion. Fractures treated by brace healed in a mean time of 10.2 weeks. Mean Constant-Murley score improved to 76.4 points, VAS to 3.0, muscular strength to 3.8 points, and significant recovery of range of motion. CONCLUSIONS Results of the study confirm that both percutaneous fixation and conservative treatment may represent suitable options for proximal humerus fragility fractures in elderly patients, not candidated to open surgery for severe associated comorbidities. LEVEL OF EVIDENCE IV (case series study).
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Affiliation(s)
- Massimo Innocenti
- Orthopaedic Clinic, University of Florence, Largo P. Palagi 1, 50139 Florence, Italy
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Investigation of metallic and carbon fibre PEEK fracture fixation devices for three-part proximal humeral fractures. Med Eng Phys 2013; 35:712-22. [DOI: 10.1016/j.medengphy.2012.07.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 07/23/2012] [Accepted: 07/29/2012] [Indexed: 11/19/2022]
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Jung SW. Indirect reduction maneuver and minimally invasive approach for displaced proximal humerus fractures in elderly patients. Clin Orthop Surg 2013; 5:66-73. [PMID: 23467431 PMCID: PMC3582873 DOI: 10.4055/cios.2013.5.1.66] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 07/05/2012] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND This study examined the clinical outcomes of indirect reduction maneuver and minimally invasive approach for treating displaced proximal humerus fractures in patients older than 60. METHODS Thirty-two patients (11 male and 21 female) who had undergone treatment for displaced proximal humerus fracture were evaluated. The mean age of the patients was 72.4 years (range, 60 to 92 years). All cases were followed up for at least 12 months. All patients were interviewed and evaluated on the visual analog scale, with gender-specific constant score correction for age, standardized X-rays to check the neck-shaft angle (NSA) and the presence of medial support, and bone mineral density. Statistical analysis was performed with a multiple regression analysis. RESULTS The average visual analog scale score was 2.4, and the average gender-specific constant score correction for age was 80.6 points. Final functional outcomes were 8 excellent, 15 good, 7 fair, and 2 poor. The average NSA was 122.8°; and the radiological results were 20 good, 11 fair, and 1 poor. There was significant difference of the gender-specific constant score for age between the group of NSA more than 110° and the group of NSA less than 110° (p = 0.00). There were 26 cases with and 6 cases without medial support, with significant difference between the gender-specific constant score correction for age of these groups (p = 0.01). Complications occurred in 4 patients (12.5%). CONCLUSIONS The indirect reduction maneuver and minimally invasive approach were safe and reliable options for the treatment of displaced proximal humerus fractures in the elderly patients. An inadequate reduction (i.e., less than 110° NSA) or lack of medial support (e.g., no cortical or screw support) were significant factors contributing to poor functional outcomes.
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Affiliation(s)
- Sung-Weon Jung
- Department of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea.
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Surgical treatment of three and four-part proximal humeral fractures. Orthop Traumatol Surg Res 2013; 99:S197-207. [PMID: 23333125 DOI: 10.1016/j.otsr.2012.12.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 11/24/2012] [Indexed: 02/08/2023]
Abstract
Three- and four-part fractures of the proximal humerus are usually treated surgically. Open reduction with internal fixation (ORIF) is the method of choice in younger patients. Anatomic reduction of the tuberosities is crucial to ensure that, in the event of poorly tolerated avascular necrosis of the humeral head, hemiarthroplasty can be performed under optimal conditions. Suboptimal outcomes may occur after ORIF, as less-than-perfect reduction and fixation is poorly tolerated at the shoulder. Preoperative computed tomography must be performed routinely to analyse fragment displacement and comminution, classify the fracture, assess humeral head vitality, and evaluate the mechanical properties of the underlying bone. Fracture reduction relies on principles that are shared by the various available techniques. Reduction of each fragment should be assessed separately. Reduction of the humeral head to the shaft should be performed before reduction of the tuberosities. The fixation technique should ensure stability of the anatomic reduction, with secure fixation of the tuberosities and a minimal risk of material migration into the joint. Here, we provide a detailed discussion of the various techniques, with their advantages and drawbacks, to help surgeons select the method that is most appropriate to each individual patient.
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