Transosseous suture fixation of proximal humeral fractures

Novel calcaneal plate versus traditional philos plate for treating split fractures of humeral greater tuberosity

Purpose

To compare the effect of two internal fixation methods of calcaneal plate fixation and Philos plate fixation in treating split fractures of humeral greater tuberosity.

Patients and methods

A total of 37 patients with split fractures of humeral greater tuberosity were retrospectively analyzed from September 2016 to April 2021. Enrolled patients were divided into Group A (calcaneal anatomical locking plates), and Group B [Proximal Humeral Internal Locking System (PHILOS)]. The demographics, injury-related variables, surgery-related variables, Constant-Murley score, and postoperative complication between the two groups were compared.

Results

There were 16 in Group A and 21 in Group B. Fracture union was achieved in all patients, with an average of 11.9 months. The mean length of incision was significantly different between groups (Group A, 6.16 cm ± 1.07 cm; Group B, 9.09 cm ± 1.30 cm, p < 0.05). Significant difference was observed by comparing bleeding loss between Group A and Group B (Group A, 45.41 ± 11.19 ml; Group B, 106.06 ± 11.12 ml, p < 0.05). After 6 months of treatment, the average Constant-Murley score of Group A was significantly higher than that of Group B (p < 0.05). In terms of operation, no significant difference was observed between groups. In addition, two patients had shoulder impingement syndrome in Group B, and none in Group A.

Conclusion

Calcaneal anatomical locking plate fixation is superior to Philos plate fixation in surgical trauma and bleeding loss. Our study provides an alternative technique for treating split fractures of humeral greater tuberosity.

Risk factors for osteonecrosis of the humeral head after internal fixation of proximal humeral fractures: a systematic review and meta-analysis

BACKGROUND

Osteonecrosis of the humeral head (ONHH) is a severe complication after the internal fixation of proximal humeral fractures (IFPHF). The risk factors remain controversial though many studies have reported. In this research, meta-analysis was used to evaluate which surgeon-level factors can be modified to lower the risk and we hope to provide evidence-based support for preventing ONHH.

METHODS

Literature was retrieved from PubMed, Cochrane Library, Embase, Web of Science, and Scopus for eligible studies published up to January 2023. The pooled odds ratios (ORs) were calculated with their corresponding 95% confidence intervals (CIs) to evaluate. STATA 15.1 software was applied for data synthesis, sensitivity synthesis, and publication bias.

RESULTS

45 articles were published between 2000 and 2022, and 2482 patients were finally included. All articles were observational research, with 7 case-control studies and 38 cohort studies, and the Newcastle Ottawa Scale (NOS) score ranged from 7 to 9. The pooled results suggested that age (OR 0.32, 95% CI 0.14-0.74, P = 0.01), reduction quality (OR 0.08, 95% CI 0.01-0.44, P = 0.00), fracture type (OR 0.44, 95% CI 0.25-0.78, P = 0.01), surgical approach (OR: 4.06, 95% CI 1.21-13.61, P = 0.02) and fixation implant (OR = 0.68, 95% CI = 0.34-1.33, P = 0.02) were risk factors for ONHH after IFPHF. According to sensitivity analysis, Begg (P = 0.42) and Egger (P = 0.68) tests, the results were stable and exhibited no publication bias.

CONCLUSIONS

The study showed that age, reduction quality, fracture type, surgical approach and fixation implant were risk factors for ONHH after IFPHF, while gender, varus or valgus, timely operation, injured side, and the existence of medial support have little influence on ONHH, as they could not be considered risk factors and still need further investigations.

Osteomyelitis with abscess associated with acute closed upper humerus fracture in an adult: A case report

A 64-year-old female presented with malaise and fever 11 days after a closed, minimally displaced humerus surgical neck fracture. MR imaging revealed an abscess around the fracture, which is a very rare occurrence in adults. Two open debridements and IV antibiotics eradicated the infection. Reverse total shoulder arthroplasty was eventually performed for fracture nonunion.

Suture Augmentation Neutralizes Deforming Muscular Forces in a Simulated 2-Part Osteoporotic Proximal Humeral Fracture Model

OBJECTIVES

To evaluate the contribution that tension-relieving sutures, placed between a proximal humeral locking plate and the rotator cuff muscles, had on preventing varus malalignment in an osteoporotic 2-part proximal humerus fracture model.

METHODS

A 2-part fracture model was created in 8 cadaveric specimens and then fixed with a lateral locking plate. A custom shoulder testing system was used to increase loading through the supraspinatus (SS) tendon to drive varus deformity. Trials were performed with no suture placement; SS only; SS and subscapularis (SB); and SS, SB, and infraspinatus. The primary outcome was contribution of each point of suture fixation to prevention of varus collapse.

RESULTS

Suture augmentation to the SS, SB, and infraspinatus significantly decreased humeral head varus collapse when compared with the plate alone at nearly all loads ( P < 0.05). There were no significant differences in humeral head varus collapse between the 3 suture constructs.

CONCLUSIONS

In our biomechanical evaluation of a simulated osteoporotic 2-part proximal humerus fracture with incompetent medial calcar, tension-relieving sutures placed between a lateral locked plate and the rotator cuff tendons prevented varus malalignment.

Reverse Shoulder Arthroplasty for Failed Operative Treatment of Proximal Humeral Fractures

Introduction

Failure after operative treatment of complex proximal humeral fractures (PHF) can prove challenging even for experienced surgeons. Reverse shoulder arthroplasty (RSA) seems to offer a satisfactory revision procedure with good clinical outcomes.

Materials and Methods

We present a case series of 14 patients, who were treated during a 3.5 years period (from 01/2016 until 06/2019). They all underwent revision surgery with RSA for failed operative treatment of PHF. Their mean age was 68 years (range, 51-84 years). 2 patients (14.3%) had been primarily treated with open reduction and internal fixation (ORIF), 5 patients (35.7%) with hemiarthroplasty, 3 patients (21.4%) with closed reduction and percutaneous fixation and 4 patients (28.6%) with transosseous suture fixation (TSF). We evaluated their absolute Constant score (CS), Visual Analogue Scale (VAS) score, and Range of Motion at their final follow-up, and we made a full clinical and radiological assessment to detect any postoperative complications.

Results

The mean absolute CS, VAS score, active anterior elevation, active abduction significantly improved compared with the preoperative status. Less significant difference was found in external rotation when comparing with the preoperative status (P = .0304). No significant differences were found when comparing RSA for different failed primary techniques (P > .05). No complications were detected following the revision surgeries of all patients.

Conclusion

RSA is an appropriate treatment as a revision technique for failed primary surgical treatment of PHFs. Though challenging it can offer good clinical results and pain relief.

The Efficacy of Suture Fixation of the Greater Trochanter in Unstable Intertrochanteric Fractures

Backgroud

Intertrochanteric fractures are one of the most common fractures in the elderly, especially those having osteoporosis. Stable intertrochanteric fractures may be fixed with implants including the dynamic hip screw and proximal femoral nail antirotation; however, this method is difficult to apply to unstable fractures. Bipolar hemiarthroplasty can be applied to unstable fractures and it prevents complications by facilitating early ambulation in the elderly. Many studies reported on how to fix the greater trochanter in unstable fractures during arthroplasty. We suggest that suture fixation alone can be a useful, effective, and affordable method.

Methods

We retrospectively enrolled 294 patients who underwent hemiarthroplasty for an unstable intertrochanteric fracture, and 225 patients were included in this study after excluding 69 patients who had not been available for follow-up until 1 year after surgery or died. The patients were divided into suture fixation and wiring fixation groups. Relationships of operation time, estimated blood loss, tip-to-stem distance, union rate, and physical performance in the groups of suture fixation and wiring were analyzed respectively.

Results

Changes in the tip-to-stem distance between the initial assessment at 1 year after surgery were statistically significantly different between the suture fixation group and wiring group (p < 0.001). There was no significant difference in change of the Koval score between the suture fixation and wiring groups (p = 0.362). The operation time and estimated intraoperative blood loss were statistically significantly lower in the suture group than in the wiring group (p < 0.001). There was no significant difference in the union rate between the groups (p = 0.470).

Conclusions

Compared to tension-band wiring, the suture fixation technique demonstrated an effective fixing force. In addition to the clinical results, it had an advantage of preventing complications due to shortening of the operation time and estimated intraoperative blood loss. Suture fixation of the greater trochanter is recommended for elderly patients with unstable intertrochanteric fractures.

Surgical fixation of isolated greater tuberosity fractures of the humerus- systematic review and meta-analysis

OBJECTIVES

A systematic review was undertaken based on PRISMA guidelines to study the results of surgical treatment of Greater Tuberosity fractures of the Humerus by different techniques (Open, Percutaneous or Arthroscopic) and using different fixation devices (Sutures, Screws and Plates).

DATA SOURCES

Literature searches were performed for studies in English on four online databases (MEDLINE®, Embase®, Ovid® Emcare and CINAHL®) using a pre-planned search strategy.

STUDY SELECTION

Studies were screened against pre-decided inclusion and exclusion criteria. 24 articles were eligible for inclusion involving 562 patients in all.

DATA EXTRACTION

A template was used for collection of relevant data regarding the study design, demographics, fracture characteristics, surgical techniques and implants used, outcomes, complications and re-operations. Methodological quality was assessed using a modified Coleman Methodology Score.

DATA SYNTHESIS

Pooled analysis was conducted for (1) complications/reoperations of different devices; and (2) reported results using standard outcome measures of various techniques. Results were pooled using inverse variance method. When pooling proportions, we used arcsine transformation to account for zero events.

CONCLUSION

Use of screws was associated with higher rates of total complications (23.7%) as well as reoperations (13.2%), compared to sutures (14.2%; 2.6%) and plates (10.6%; 4.1%). In a subgroup analysis, use of low-profile plates (LPPs) was associated with the lowest rates of total complications (4.97%). The superiority of any surgical technique could not be established using the pooled Constant or ASES scores because there was lack of uniformity in the reporting of outcome measures. Our analysis of complications of the various fixation devices dissuades the use of screws and favours the use of low-profile plates. There is a need for prospective studies comparing arthroscopic suture fixation with open low-profile plate fixation of GT fractures.

Surgical treatment of proximal humeral fractures with the transosseous suture fixation

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, retrospective study.

Dual Locking Plate Osteosynthesis for 3- or 4-Part Proximal Humeral Fractures Combined with Multiple Fractures of the Greater Tuberosity

BACKGROUND

This retrospective study was conducted to evaluate the efficacy of dual locking plate osteosynthesis for treating 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity.

METHODS

From January 2012 to December 2018, 19 skeletally mature patients, who suffered 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity, were treated with open reduction and internal fixation using a dual locking plate technique through a delto-pectoral approach. Indexes for evaluation included fracture healing, quality of reduction, and incidence of complications (infections, screw perforation into the glenohumeral joint, subacromial impingement, hardware failure, avascular necrosis, and loss of reduction). Shoulder function was evaluated using Constant-Murley scoring.

RESULTS

The patients were assessed at a mean time of 25.3 months after surgery. Union of fractures was radiographically confirmed for all 19 patients. The mean Constant-Murley patient score was 85.2 points, and complications were identified in two patients during follow-up evaluations.

CONCLUSIONS

The method of using dual locking plate osteosynthesis through a delto-pectoral approach resulted in a satisfactory union rate, excellent fracture reduction, low complication rate and good shoulder function for patients with complex proximal humeral fractures. The method is effective for treating 3- or 4-part proximal humeral fractures combined with multiple fractures of the greater tuberosity.

Transosseous Suture Fixation of True 4-part Valgus Impacted Fractures of the Proximal Humerus: Clinical and Radiological Outcome in 49 Patients

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.

Arthroscopic reduction and fixation for displaced greater tuberosity fractures using the modified suture-bridge technique

PURPOSE

The aim of this study was to evaluate the early clinical outcomes of arthroscopic treatment of avulsion or comminuted fractures of the greater tuberosity (GT) using a modified suture-bridge technique.

METHODS

Between February 2013 and November 2015, 14 patients with displaced or comminuted fractures of GT were arthroscopically treated using a modified suturebridge technique. Displacement of the GT fragments was > 3 mm in any plane. An analysis of follow-up results including the University of California, Los Angeles (UCLA) shoulder scale; the shoulder index of the American Shoulder and Elbow Surgeons (ASES); the simple shoulder test (SST); and shoulder range of motion (ROM), is presented.

RESULTS

Mean duration of follow up is 18.9 months (range, 6-30). Mean age of patients was 62.9 years (range, 49-74). Postoperatively, the outcomes were rated as excellent, good and fair in two, 11 and one patient, respectively based on the UCLA score. At the most recent follow-up, the average UCLA score increased to 32 points, the ASES score increased to 97.5 points, and the SST score increased to 11 points. Average forward flexion was 153.6°, average abduction was 158.6°, average external rotation in the neutral position was 38.6°, and internal rotation increased to the 12th thoracic vertebral level.

CONCLUSION

Early follow-up outcomes of the arthroscopic modified suture-bridge technique used for avulsion or comminuted GT fractures are promising. The technique can be used as one of the therapeutic modalities for GT fractures.

A Case Report about Early Major Postoperative Ossifications of the Shoulder

INTRODUCTION

Ossifications after osteosynthesis of the proximal humerus are poorly described. We report a case of major and early ossifications after synthesis of a fracture dislocation of the shoulder.

CASE REPORT

A 57-year-old man, right-handed, bipolar schizophrenic, presented after a fall, a fracture of the head and metaphysis of the humerus from the anterior notch of posterior dislocation of the right humerus. An osteosynthesis was performed after reduction on the tenth posttraumatic day. The postoperative period was complicated because of early ossifications and painless stiffness of the shoulder.

CONCLUSION

The importance of local trauma, the long consultation period, the operative difficulties and the heparin therapy are factors that could have favored the occurrence of ossifications. Preventive treatment could have prevented them or limited their extent.

Is Arthroscopic Technique Superior to Open Reduction Internal Fixation in the Treatment of Isolated Displaced Greater Tuberosity Fractures?

BACKGROUND

Arthroscopic double-row suture-anchor fixation and open reduction and internal fixation (ORIF) are used to treat displaced greater tuberosity fractures, but there are few data that can help guide the surgeon in choosing between these approaches.

QUESTIONS/PURPOSES

We therefore asked: (1) Is there a difference in surgical time between arthroscopic double-row suture anchor fixation and ORIF for isolated displaced greater tuberosity fractures? (2) Are there differences in the postoperative ROM and functional scores between arthroscopic double-row suture anchor fixation and ORIF for isolated displaced greater tuberosity fractures? (3) Are there differences in complications resulting in additional operations between the two approaches?

METHODS

Between 2006 and 2012, we treated 79 patients surgically for displaced greater tuberosity fractures. Of those, 32 (41%) were considered eligible for our study based on inclusion criteria for isolated displaced greater tuberosity fractures with a displacement of at least 5 mm but less than 2 cm. During that time, we generally treated patients with displaced greater tuberosity fractures with a displacement greater than 1 cm or with a fragment size greater than 3×3 cm with open treatment, and patients with displaced greater tuberosity fractures with a displacement less than 1 cm or with a fragment size less than 3×3 cm with arthroscopic treatment. Fifty-three underwent open treatment based on those indications, and 26 underwent arthroscopic treatment, of whom 17 (32%) and 15 (58%) were available for followup at a mean of 34 months (range, 24-28 months). All patients with such fractures identified from our institutional database were treated by these two approaches and no other methods were used. Surgical time was defined as the time from initiation of the incision to the time when suture of the incision was finished, and was determined by an observer with a stopwatch. Patients were followed up in the outpatient department at 6, 12, and 24 weeks, and every 6 month thereafter. Radiographs showed optimal reduction immediately after surgery and at every followup. Radiographs were obtained to assess fracture healing. Patients were followed up for a mean of 34 months (range, 24-48 months). At the last followup, ROM, VAS score, and American Shoulder and Elbow Surgeons (ASES) score were used to evaluate clinical outcomes. All these data were retrieved from our institutional database through chart review. Complications were assessed through chart review by one observer other than the operating surgeon.

RESULTS

Patients who underwent arthroscopic double-row suture anchor fixation had longer surgical times than did patients who underwent ORIF (mean, 95.3 minutes, SD, 10.6 minutes vs mean, 61.5 minutes, SD, 7.2 minutes; mean difference, 33.9 minutes; 95% CI, 27.4-40.3 minutes; p < 0.001). All patients achieved bone union within 3 months. Compared with patients who had ORIF, the patients who had arthroscopic double-row suture anchor fixation had greater ranges of forward flexion (mean, 152.7°, SD, 13.3° vs mean, 137.7°, SD, 19.2°; p = 0.017) and abduction (mean, 146.0°, SD, 16.4° vs mean, 132.4°, SD, 20.5°; p = 0.048), and higher ASES score (mean, 91.8 points, SD, 4.1 points vs mean, 87.4 points, SD, 5.8 points; p = 0.021); however, in general, these differences were small and of questionable clinical importance. With the numbers available, there were no differences in the proportion of patients experiencing complications resulting in reoperation; secondary subacromial impingement occurred in two patients in the ORIF group and postoperative stiffness in one from the ORIF group. The two patients experiencing secondary subacromial impingement underwent reoperation to remove the implant. The patient with postoperative stiffness underwent adhesion release while receiving anesthesia, to improve the function of the shoulder. These three patients had the only reoperations.

CONCLUSIONS

We found that in the hands of surgeons comfortable with both approaches, there were few important differences between arthroscopic double-row suture anchor fixation and ORIF for isolated displaced greater tuberosity fractures. Future, larger studies with consistent indications should be performed to compare these treatments; our data can help inform sample-size calculations for such studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Least Possible Fixation Techniques of 4-Part Valgus Impacted Fractures of the Proximal Humerus: A Systematic Review

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.

Transosseous braided-tape and double-row fixations are better than tension band for avulsion-type greater tuberosity fractures

INTRODUCTION

The optimal treatment for avulsion-type greater tuberosity fractures is yet to be determined. Three fixation methods are tested: tension band with #2 wire suture (TB), double-row suture bridge with anchors (DR), and simple transosseous fixation with braided tape (BT).

MATERIALS AND METHODS

Twenty-four porcine proximal humeri were randomised into three groups: TB, DR and BT. A standardised greater tuberosity (GT) osteotomy was performed at 90° to the humeral diaphysis axis. A mechanical testing machine was used to simulate supraspinatus contraction. The force required to produce 3mm and 5mm displacement, as well as complete failure was measured with an axial load cell. Also, three cycles of shoulder flexion/extension with 25 N of supraspinatus contraction were performed. Maximum GT fragment translation and rotation amplitude during one cycle were measured.

RESULTS

During supraspinatus contraction, DR and BT groups (p < 0.05) were superior to TB group for both displacements. The BT technique had the strongest maximal load to failure (BT = 466 N; DR = 386 N; TB = 320 N). For the flexion/extension, DR and BT groups had less displacement and rotation than TB group (anterio-posterior displacement: BT = 2.0mm, DR = 1.9 mm, TB = 5.8 mm; anterio-posterior angular displacement: BT = 1.4°, DR = 1.0°, TB = 4.8°). No significant difference was observed between DR and BT groups, except for the medio-lateral rotation favouring the DR group.

CONCLUSION

In conclusion, BT and DR are good fixation methods to treat displaced avulsion-type greater tuberosity fractures. They have similar mechanical properties, and are stronger and more stable that the TB construct. Potential advantages of the BT over the DR may be a lower cost and easier surgery.

LEVEL OF EVIDENCE

Basic science study (LEVEL II).

[Morbidity and mortality of surgically treated proximal humerus fractures]

BACKGROUND

The aim of the present study is to analyse the factors associated with mortality and the capacity to perform daily life activities (DLA) in patients with surgically treated proximal humeral fractures.

METHODS

A retrospective study was conducted on 94 patients with a surgically treated proximal humeral fracture, with a mean follow-up of 8 years (2 - 12 years). A correlation analysis was performed to determine the relationship between the type of fracture, surgical technique, comorbidities and mortality and DLA. The Student t test was used for statistical analysis.

RESULTS

A total of 72 patients were identified, 18.6% of them died during follow-up, all diagnosed with some comorbidity. There was no correlation between mortality, type of fracture or the technique used. Most of the patients (85.4%) had comorbidities, and 79.5% were completely independent for DLA. Although there was no relationship with the type of fracture, there was a significant reduction in the performing of DLA in patients treated with hemiarthroplasty, and in patients with neurological disorders.

CONCLUSIONS

There was a mortality of 18.6% among patients with surgically treated proximal humerus fractures. The majority of surgically treated patients were fully independent for DLA at long-term follow-up.

Proximal humeral fractures: a review of current concepts

The majority of proximal humerus fractures are sustained via low energy falls in the elderly population. These patients can attain an acceptable level of function via non-operative treatment. There is yet to be a clear consensus on treatment options suitable for those that fall outside of this majority group. Open reduction internal fixation, intra medullary nailing and arthroplasty surgery have all been used to varying effects. Good results are achievable if complications such as mal-union, non-union and avascular necrosis can be avoided. This review aims to clarify the options available to the current day trauma surgeon.

AO X-shaped midfoot locking plate to treat displaced isolated greater tuberosity fractures

Although various implants exist for 3- and 4-part fractures, few implants are appropriate for isolated greater tuberosity fractures. This retrospective study evaluated the efficacy of AO X-shaped midfoot locking plates for greater tuberosity fractures. Between May 2008 and September 2009, nineteen patients with displaced greater tuberosity fractures were treated with open reduction and internal fixation using AO X-shaped midfoot locking plates. Postoperatively, radiographs, functional results, and complications were evaluated. All patients were followed up for a mean 33.2 months (range, 24-42 months). Mean healing time was 9.4 weeks (range, 8-14 weeks). Mean Constant score was 90.6±4.0 points (range, 77-95 points). Excellent results were obtained in 16 cases, good in 2 cases, moderate in 1 case, and poor in 0 cases. The excellent-good rate was 94.7%. No recurrence of dislocation occurred in the 11 cases with shoulder dislocation. All fractures healed without the complications of wound infection, skin numbness, subacromial impingement syndrome, nonunion, secondary displacement, and implant loosening. The described technique is an effective, simple, and inexpensive method with a short learning curve.

Proximal humerus fractures

Proximal humeral fractures are extremely common injuries, and are one of the true osteoporotic fractures. Most fractures can be effectively treated nonoperatively, as the rich vascularity and broad cancellous surfaces impart a high propensity for healing. Additionally, many fracture patterns result in adequate bone contact and minimal displacement with acceptable alignment. Open reduction and internal fixation of displaced fractures can improve outcomes, depending on the pre-injury functional status of the patient. If operative treatment is selected, unique treatment challenges must be overcome, including obtaining and maintaining reduction of small bone fragments with strong muscle forces, often in osteoporotic bone. Many options are feasible, including plates, nails, sutures, and other novel devices. Locking plates are the most common device used, but technical detail is critical to minimize the risk of implant failure, loss of reduction, and reoperation.

Review of fixation techniques for the four-part fractured proximal humerus in hemiarthroplasty

Introduction

The clinical outcome of hemiarthroplasty for proximal humeral fractures is not satisfactory. Secondary fragment dislocation may prevent bone integration; the primary stability by a fixation technique is therefore needed to accomplish tuberosity healing. Present technical comparison of surgical fixation techniques reveals the state-of-the-art approach and highlights promising techniques for enhanced stability.

Method

A classification of available fixation techniques for three- and four part fractures was done. The placement of sutures and cables was described on the basis of anatomical landmarks such as the rotator cuff tendon insertions, the bicipital groove and the surgical neck. Groups with similar properties were categorized.

Results

Materials used for fragment fixation include heavy braided sutures and/or metallic cables, which are passed through drilling holes in the bone fragments. The classification resulted in four distinct groups: A: both tuberosities and shaft are fixed together by one suture, B: single tuberosities are independently connected to the shaft and among each other, C: metallic cables are used in addition to the sutures and D: the fragments are connected by short stitches, close to the fragment borderlines.

Conclusions

A plurality of techniques for the reconstruction of a fractured proximal humerus is found. The categorisation into similar strategies provides a broad overview of present techniques and supports a further development of optimized techniques. Prospective studies are necessary to correlate the technique with the clinical outcome.

A simple and effective implant for displaced fractures of the greater tuberosity: the "Bamberg" plate

Displaced fractures of the greater tuberosity are common findings in trauma surgical patients. Nevertheless, osteosynthesis of these fractures impairs the risk of secondary dislocation or secondary impingement due to the implant (e.g., 4.5 mm cancellous screws with spiked washers). We present an easy and simple technique/implant to perform an osteosynthesis of multiple-fractured greater tuberosity fractures. We use a self-adjusted calcaneus titanium plate (Litos) which is cut into a 6 or more holed small plate. In ten patients we had excellent postoperative outcomes with no complications and no secondary loss of reduction. The surgical technique is easy and efficient.

New trends in fixation of proximal humeral fractures: a review

Surgical treatment of proximal humeral fractures continues to be a challenge especially in osteoporotic patients. Locking plates and intramedullary nails have been used with satisfactory results but the previous reported complications have not been substantially reduced. Most of the existing studies involve a small number of patients followed up for a rather short period of time. Since proximal humeral fractures constitute a heterogenous group of complex fractures in an even more heterogenous population, no single fixation method is a panacea. Choice of implant and method of fixation should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. Based on the findings of the existing clinical studies the authors propose a treatment algorithm.

Proximal humeral fractures: current concepts in classification, treatment and outcomes

Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery. This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.

The hybrid technique: potential reduction in complications related to pins mobilization in the treatment of proximal humeral fractures

BACKGROUND

Proximal humeral fracture fixation has a high incidence of complications especially when pins are used in elderly patients. In 2005, we introduced a new technique that augmented osteosutures by using 2.5-mm fully threaded pins and an external fixator (hybrid technique). The purpose of this study is to compare the outcomes of the hybrid technique (HT) with traditional pins fixation.

METHODS

A prospective nonrandomized study was organized on 2 consecutive series of patients: 51 patients treated with percutaneous fixation using 2.5-mm terminally threaded pins and 55 patients treated with the Hybrid technique. In both groups, an open reduction and osteosutures augmented with percutaneous fixation was used when closed reduction was insufficient to provide anatomical reduction. The patients were assessed at 6- and 12-month follows-ups using DASH score, Constant score, and Modified Constant score (MCS).

RESULTS

Sixteen patients treated with traditional pins experienced complications compared to 6 patients in the HT group (P = .006). The revision rate was 19% for the traditional pins group and 4% for the HT group (P = .04). Pins migration affected 8 patients in the traditional pins group and 1 case in the hybrid group (P = .01). The MCS at the 12-month follow-up was 89 ± 9 in the HT group and 77 ± 14 in the traditional pins group (P = .03). The MCS was negatively affected by complications and malreduction (P = .001).

CONCLUSION

The study suggests that the HT is a valuable option for the treatment of proximal humeral fractures. It has benefits compared to the traditional technique.

Reliability of shoulder abduction strength measure for the Constant-Murley score

Reports using the Constant-Murley score often lack details regarding how strength measurement was performed, which may have an important impact on the results obtained. A description of the measurement is especially important when patients are unable to adopt the prescribed position of 90 degrees shoulder abduction, leading to invalid or highly discrepant scores. We investigated the influence of shoulder abduction and torso position on strength measurement with special emphasis on intraobserver reliability. Thirty-three healthy volunteers were examined using a handheld dynamometer (Isobex) in 30 degrees , 60 degrees , and 90 degrees abduction with or without stabilization of the torso. A linear correlation between strength measurements in different degrees of abduction was observed, with values at 90 degrees abduction on average 15% lower than at 60 degrees and 45% lower than at 30 degrees . In multivariate analysis, gender and weight had a substantial impact on the strength of individual measurement positions. Intraobserver reliability was related to arm and torso position (intraclass correlation coefficients, 0.71-0.93) and was highest for 90 degrees abduction without torso stabilization. These findings emphasize the importance of standardized torso and arm positions ensuring high reliability when performing the strength measurement of the Constant-Murley score.

Does fixed-angle plate osteosynthesis solve the problems of a fractured proximal humerus? A prospective series of 87 patients

BACKGROUND AND PURPOSE

There is considerable controversy about the treatment of complex, displaced proximal humeral fractures. Various types of head-preserving osteosynthesis have been suggested. This prospective case series was designed to evaluate the perioperative and early postoperative complications associated with fixed-angle implants and to record outcome after bone healing.

PATIENTS AND METHODS

Fractures of the proximal humerus were stabilized surgically in 87 patients (mean age 64 (16-93) years) by application of a fixed-angle plate (65 PHILOS, 22 T-LCP). There were 34 2-segment fractures, 42 3-segment fractures, and 11 4-segment fractures, including 7 dislocation fractures. Follow-up assessment after a minimum of 12 months was based on the Constant, UCLA, and DASH scores and on radiographs.

RESULTS

Postoperative complications included soft tissue problems (n = 9), humeral head necrosis (n = 9), screw perforation (n = 11), secondary displacements (n = 14), and delayed fracture healing (n = 4). Treatment outcomes recorded on the various scores were very good in 60-82% of the cases.

INTERPRETATION

Screw perforation of fixed-angle implants has replaced the complications of secondary displacement and implant loosening after using conventional plates. Even with the use of fixed-angle implants, fractures of the proximal humerus are associated with a high complication rate and sometimes poor outcome.