Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Surgical technique

Quality of life, functional and radiological outcomes of treatment of three-part and four-part proximal humerus fractures with locking plates and comparison in young versus older than 70 years: a retrospective cohort study

PURPOSE

Verify if the use of locking plates in displaced three- and four-part proximal humerus fractures has meant an improvement even in patients over 70 years of age.

MATERIAL AND METHODS

We performed surgery with locking plate fixation in 56 consecutive patients with three- and four-part proximal humerus fractures according to Neer's classification between 1/1/15 and 12/31/20 at our Hospital. Patient satisfaction, quality of life, functionality and radiological variables, as well as the comparison between patients older and younger than 70 years were the main outcomes. Likewise, factors and complications that may have influenced these variables were analyzed as secondary outcomes. The analysis of all these variables was performed after a minimum follow-up time of 24 months after surgery.

RESULTS

51 patients (92%) ended up satisfied or very satisfied according to the SF-36 test and with no disability or mild disability according to the DASH Score questionnaire. 46 patients (82%) obtained a satisfactory or excellent result according to the Neer scale modified by Cofield and 38 (68%) a good or excellent function according to the Constant Murley questionnaire. In 47 cases (84%) good radiological alignment was observed. Complications occurred in 20 patients (36%). The complications and the results of the SF-36, DASH Score, Neer scale modified by Cofield and Constant Murley tests depended on the radiological alignment (p = 0.009, p = 0.006, p = 0.025, p = 0.0008 and p = 0.0004). There were 37 patients younger than 70 years and 19 older than 70 years with no statistically significant differences when comparing the two groups.

CONCLUSIONS

This study demonstrates that satisfactory results can be obtained with osteosynthesis with locking plates in displaced proximal humerus fractures even in patients older than 70 years of age.

LEVEL OF EVIDENCE III

Retrospective Cohort, Treatment Study.

Pectoralis major pedicle bone grafting vs. tricortical iliac grafting for Neer 4-part proximal humerus fractures: a randomized controlled trial

BACKGROUND

The risk of avascular necrosis, nonunion, or malunion is high in osteoporosis-related 4-part fractures. We evaluated the results of patients who underwent plate osteosynthesis with a vascularized pectoralis major graft compared with tricortical iliac grafting to treat 4-part proximal humerus fractures.

MATERIAL AND METHODS

Thirty-four patients aged 50-75 years with Neer 4-part proximal humerus fractures were studied. Group A (n = 17) underwent osteotomy of a 2.5 ± 1 cm pectoralis major pedicle bone graft and plate application, whereas group B (n = 17) underwent plate osteosynthesis using iliac autogenous grafts. Final follow-up assessments included evaluation using Constant and American Shoulder and Elbow Surgeons scoring systems, humeral neck-shaft angle (HNSA), humeral head height, and humeral head avascular necrosis.

RESULTS

Reduction loss was observed in 3 patients (17.6%) in group A, whereas it was observed in 10 patients (58.8%) in group B (P = .013). Humeral head avascular necrosis was found in 1 patient (5.8%) in group A, whereas it was found in 5 patients (29.4%) in the other group (P = .071). The HNSA was normal in 12 (70.5%) of group A patients, whereas it was normal in 6 (35.2%) of group B patients. The HNSA was weak or bad (<1200) in 29.4% of group A patients, whereas this rate was 64.7% in group B patients. Humeral head height was 2.64 ± 1.45 mm in group A and 3.66 ± 1.65 mm in group B. There were no statistically significant differences between the 2 groups in terms of Constant and American Shoulder and Elbow Surgeons scoring systems.

CONCLUSION

Pectoralis major bone pedicle graft in Neer 4-part proximal humerus fractures reduces the risk of avascular necrosis and nonunion rates. Our technique yielded excellent clinical and radiological results. We achieved recovery without creating additional donor site morbidity.

Clinical Outcome of Carbon Fiber Reinforced Polyetheretherketone Plates in Patients with Proximal Humeral Fracture: One-Year Follow-Up

BACKGROUND

Proximal humerus fractures are seen frequently, particularly in older patients. The development of new osteosynthesis materials is being driven by the high complication rates following surgical treatment of proximal humerus fractures. Plate osteosyntheses made of steel, titanium and, for several years now, carbon fiber-reinforced polyetheretherketone (CFR-PEEK) are used most frequently.

METHODS

A prospective, randomized study was conducted in order to evaluate whether there are differences in the functional postoperative outcome when comparing CFR-PEEK and titanium implants for surgical treatment of proximal humerus fractures. The primary outcome of shoulder functionality 1 year after surgery was measured with the DASH score, the Oxford Shoulder Score, and the Simple Shoulder Test.

RESULTS

Bony consolidation of the respective fracture was confirmed in all the patients included in the study within the scope of postoperative follow-up care. No significant differences in the DASH score, Oxford Shoulder Score, or Simple Shoulder Test were observed 1 year post-operatively when comparing the implant materials CFR-PEEK and titanium.

CONCLUSIONS

There are no differences in terms of the functional outcome between CFR-PEEK plates and titanium implants 1 year after surgery. Studies on the long-term outcomes using CFR-PEEK plates in osteoporotic bone should be the subject of further research.

Reverse Total Shoulder Arthroplasty Demonstrates Better Outcomes Than Angular Stable Plate in the Treatment of Three-part and Four-part Proximal Humerus Fractures in Patients Older Than 70 Years

BACKGROUND

Proximal humeral fractures are traditionally treated with open reduction and internal fixation (ORIF), but reverse total shoulder arthroplasty (RTSA) has emerged as an increasingly popular treatment option. Although ORIF with angular locking plates is a common treatment for proximal humerus fractures, prior reports suggest high failure and complication rates. Although RTSA has become an increasingly popular option for complex proximal humeral head fractures given its low complication rates, there are concerns it may lead to limited postoperative ROM. Thus, the optimal treatment for patients older than 70 years from a functional and radiographic perspective remains unclear.

QUESTIONS/PURPOSES

(1) In patients older than 70 years with three-part and four-part proximal humerus fractures, does RTSA result in better functional outcome scores (Constant, American Shoulder and Elbow Surgeons [ASES], and DASH scores) than ORIF with a locking plate? (2) Does RTSA result in greater ROM than ORIF? (3) Does RTSA result in a lower risk of complications than ORIF? (4) In patients with either procedure, what are the rates of negative radiographic outcomes in those treated with ORIF (such as malunion, bone resorption, malalignment, or avascular necrosis) or those with RTSA (such as resorption, notching, and loosening)? (5) At a minimum of 2 years of follow-up, does ORIF result in a greater number of revision procedures than RTSA?

METHODS

Between January 1, 2013, and June 30, 2018, we treated 235 patients for a proximal humeral fracture. We considered only patients without previous ipsilateral fracture or surgery, other fractures, or radial nerve injuries; age older than 70 years; and patients without neurologic disease or cognitive dysfunction as potentially eligible. Sixty-nine percent (162 patients) of the patients were eligible; a further 31% (73 patients) were excluded because 18% (13 of 73 patients) did not meet the inclusion criteria, 62% (45 patients) underwent nonoperative treatment, and 21% (15 patients) declined to participate. Patients were nonrandomly allocated to receive RTSA if they had supraspinatus Goutallier/Fuchs Grade 3 or 4 atrophy or ORIF if they had supraspinatus Goutallier/Fuchs Grade 1 or 2 atrophy. This left 81 patients who were treated with RTSA and another 81 patients who were treated with ORIF. Among the 81 patients treated with RTSA, 11% (nine patients) were lost to the minimum study follow-up of 2 years or had incomplete datasets, leaving 89% (72 patients) for analysis. Among the 81 patients treated with ORIF, 19% (15 patients) were lost before the minimal study follow-up of 2 years or had incomplete datasets, leaving 82% (66 patients) for analysis. The median follow-up for both groups was 53 months (range 24 to 72 months). The mean age was 76 ± 2.9 years in the RTSA group and 73 ± 2.9 years in the ORIF group. In the RTSA group, 27 patients had a three-part fracture and 45 patients had a four-part fracture. In the ORIF group, 24 patients had three-part fractures and 42 patients had four-part fractures (p = 0.48). Shoulder function was assessed using functional outcome questionnaires (ASES, DASH, and Constant) and active ROM measurements. A surgical complication was defined as any instance of dislocations, fractures, adhesive capsulitis, nerve injuries, or surgical site infections. Radiographic outcomes after ORIF (malunion, tuberosity resorption, or avascular necrosis) and RTSA (notching and osteolysis) were assessed. In calculating the revision rate, we considered unplanned revision procedures only.

RESULTS

Compared with patients treated with ORIF, patients treated with RTSA had superior improvements in Constant (85.0 ± 7.0 versus 53.0 ± 5.0; mean difference 32 [95% CI 30 to 34]; p < 0.01), ASES (46.3 ± 3.7 versus 30.0 ± 3.5; mean difference 16 [95% CI 15 to 18]; p < 0.01), and DASH scores (40.5 ± 4.2 versus 30.5 ± 2.6; mean difference 10 [95% CI 9 to 11]; p < 0.01). The mean elevation was 135° ± 7° for patients with RTSA and 100° ± 6° for patients with ORIF (mean difference 35 o [95% CI 33 to 37]; p < 0.01). The mean abduction was 131° ± 7° for patients with RTSA and 104° ± 6° for those with ORIF (mean difference 27 o [95% CI 25° to 29°]; p < 0.01). The mean external rotation was 85° ± 5° for patients with RTSA and 64° ± 5° for those with ORIF (mean difference 21° [95% CI 19° to 23°]; p < 0.01). The mean internal rotation was 45° ± 6° for patients with RTSA and 40° ± 6° for those with ORIF (mean difference 5° [95% CI 3° to 7°]; p < 0.01). The risk of complications was not different between patients with ORIF and those with RTSA (5% [three of 66] versus 1% [one of 72]; relative risk 3.3 [95% CI 0.3 to 30.7]; p = 0.30). Among patients with ORIF, 8% had varus malunions (five of 66), 6% had resorption of the greater tuberosity (four of 66), and 2% had avascular necrosis of the humeral head (one of 66). In the RTSA group, 24% (17 of 72 patients) demonstrated reabsorption of periprosthetic bone and 79% of patients (57 of 72) exhibited no notching. The risk of revision was not different between the RTSA and ORIF groups (0% [0 of 72] versus 9% [six of 66]; relative risk 0.07 [95% CI 0.0 to 1.2]; p = 0.07).

CONCLUSION

In patients older than 70 years with three-part and four-part proximal humerus fractures, primary RTSA resulted in better patient-reported outcome scores and better ROM than ORIF with an angular stable locking plate. Our findings might help surgeons decide between internal fixation and arthroplasty to surgically treat these injuries in older patients. Although RTSA seems to be a preferable treatment modality in view of these findings, longer follow-up is required to evaluate its longevity compared with ORIF with an angular locking plate. Dissimilar to ORIF, which is generally stable once healed, arthroplasties are at a continued risk for loosening and infection even after healing is complete.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Early Outcomes of Proximal Humerus Fractures in Adults Treated With Locked Plate Fixation Compared with Nonoperative Treatment: An Age-, Comorbidity-, and Fracture Morphology-Matched Analysis

OBJECTIVES

To compare patient-reported outcomes (PROs), range of motion (ROM), and complication rates for proximal humerus fractures managed nonoperatively or with open reduction internal fixation (ORIF).

DESIGN

Retrospective cohort.

SETTING

Academic level 1 trauma center.

PATIENTS/PARTICIPANTS

Four hundred thirty-one patients older than 55 years were identified retrospectively. 122 patients were excluded. 309 patients with proximal humerus fractures met inclusion criteria (234 nonoperative and 75 ORIF). After matching, 192 patients (121 nonoperative and 71 ORIF) were included in the analysis.

INTERVENTION

Nonoperative versus ORIF (locked plate) treatment of proximal humerus fracture.

MAIN OUTCOME MEASUREMENTS

Early Visual Analog Score (VAS), ROM, PROs, complications, and reoperation rates between groups.

RESULTS

At 2 weeks, ORIF showed lower VAS scores, better passive ROM, and patient-reported outcomes measurement information system (PROMIS) scores ( P < 0.05) compared with nonoperative treatment. At 6 weeks, open reduction internal fixation (ORIF) had lower VAS scores, better passive ROM, and PROMIS scores ( P < 0.05) compared with nonoperative treatment. At 3 months, ORIF showed similar PROMIS scores ( P > 0.05) but lower VAS scores and better passive ROM ( P < 0.05) compared with nonoperative treatment. At 6 months, ORIF showed similar VAS scores, ROM, and PROMIS scores ( P > 0.05) compared with nonoperative treatment. There was no difference in secondary operation rates between groups ( P > 0.05). ORIF patients trended toward a higher secondary reoperation rate (15.5% vs. 5.0%) than nonoperative patients ( P = 0.053).

CONCLUSIONS

In an age-, comorbidity-, and fracture morphology-matched analysis of proximal humerus fractures, ORIF led to decreased pain and improved passive ROM early in recovery curve compared with nonoperative treatment that normalized after 6 months between groups.

LEVEL OF EVIDENCE

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

Outcomes for type C proximal humerus fractures in the adult population: comparison of nonoperative treatment, locked plate fixation, and reverse shoulder arthroplasty

Background

This study compares patient-reported outcomes and range of motion (ROM) between adults with an AO Foundation/Orthopaedic Trauma Association type C proximal humerus fracture managed nonoperatively, with open reduction and internal fixation (ORIF), and with reverse shoulder arthroplasty (RSA).

Methods

This is a retrospective cohort study of patients >60 years of age treated with nonoperative management, ORIF, or RSA for AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures from 2015 to 2018. Visual analog scale pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, ROM values, and complication and reoperation rates were compared using analysis of variance for continuous variables and chi square analysis for categorical variables.

Results

A total of 88 patients were included: 41 nonoperative, 23 ORIF, and 24 RSA. At the 2-week follow-up, ORIF and RSA had lower visual analog scale scores and lower PROMIS pain interference scores (P < .05) than nonoperative treatment. At the 6-week follow-up, ORIF and RSA had lower visual analog scale, PROMIS pain interference, and PF scores and better ROM (P < .05) than nonoperative treatment. At the 3-month follow-up, ORIF and RSA had better ROM and PROMIS pain interference and PF scores (P < .05) than nonoperative treatment. At the 6-month follow-up, ORIF and RSA had better ROM and PROMIS PF scores (P < .05) than nonoperative treatment. There was a significantly higher complication rate in the ORIF group than in the non-operative and RSA groups (P < .05).

Conclusion

The management of AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures in older adults with RSA or ORIF led to early decreased pain and improved physical function and ROM compared to nonoperative management at the expense of a higher complication rate in the ORIF group.

Reduction and fixation of proximal humeral fracture with severe medial instability using a small locking plate

BACKGROUND

Currently, the reduction and support of comminuted medial cortex of humeral fracture remains a challenge, Therefore, a novel reduction and fixation technique that employs an anteromedial small locking plate was explored in this study, and its viability and the associated complications were assessed.

METHODS

Fifteen cases of proximal humeral fractures with medial instability (five cases were classified as three-part and ten as four-part by Neer classification) were treated by the proposed reduction technique using an anteromedial small locking plate. Subsequently, the radiological and clinical outcomes were evaluated over an average follow-up period of 18.53 months.

RESULTS

The average operation time was 108 min (range, 70-130 min), and the mean fracture union time in all patients was 12.13 weeks (range, 8-16 weeks). Complications such as infection and neurovascular injury were not observed. Postoperative X-ray showed avascular necrosis and screw penetration in one patient, while screw penetration, varus malunion, or significant reduction loss was not found in the other cases. The mean Constant score was 79.8 (range, 68-92) during the final visit.

CONCLUSIONS

The use of an anteromedial small locking plate improved the reduction efficiency, reconstructed the medial support, and alleviated the occurrence of complications in proximal humeral fractures with medial instability.

The role of minimally invasive plate osteosynthesis (MIPO) technique for treating 3- and 4-part proximal humerus fractures in the elderly - a case study

Background and aim of the work:

Proximal humeral fractures incidence in the elderly population is increasing. Treatment management is complicated by fracture complexity and patients’ comorbidities. The aim of our prospective study is the outcome evaluation of the role of minimally invasive plate osteosynthesis (MIPO) for elderly patients with a 3- or 4-parts proximal humeral fractures having an intact medial wall.

Methods:

N=45 patients were selected using inclusion criteria (>75yo, unilateral 3- or 4-parts proximal humeral fracture and with a surgical indication). We analyzed n=42 fractures treated with MIPO (3 patients had been reversed to ORIF and arthroplasty intraoperatively): n=20 4-parts fractures and n=22 were 3-parts. Of the 42 operated patients 17 identified as male and 25 as female (mean age 84yo). A trans-deltoid approach has been used with minimal surgical exposure and tissue damage to preserve the local tissue for early shoulder mobilization.

Results:

At follow-up, the DASH recorded mean value was 72, while the Constant mean score was 68. Complications have been recorded in 23,8% of patients with 4-parts fractures having the highest complication frequency. Mean shoulder joint ROM was recorded: anterior elevation 75°, lateral elevation 80°, abduction 90°, intra-rotation 50°, extra-rotation 25°. The following factors were identified influencing the outcome: >8mm calcar fragment, head valgus impaction and periosteal medial hinge preservation.

Conclusions:

The increase in population longevity matches the increase in complex humeral fracture frequency. We strongly for management consensus for proximal humerus fracture, in a similar way as for neck femoral fractures. MIPO is excellent in reducing soft tissue damage and complications for elderly patients with limited functional demand. (www.actabiomedica.it)

Hinge plate technique for osteosynthesis of comminuted proximal humeral fractures

BACKGROUND

Several surgical techniques of osteosynthesis have been described for treatment of proximal humeral fractures. There is evidence that the quality of reduction improves the clinical outcome and decreases the number of complications. Reduction of the medial calcar is tricky when standard manoeuvres are performed. We have therefore augmented our standard surgical technique with a low-profile medial hinge plate which aims at better reconstructing the medial metaphysis without extensile soft tissue dissection in combination with proximal humerus locked plating.

OBJECTIVE

Evaluate the radiological and clinical outcome after application of an augmented fixation with a low-profile medial hinge plate. We questioned: (i) The quality of reduction, (ii) The rate of complications, (iii) The clinical function in terms of the Oxford Shoulder Score (OSS).

METHODS

A retrospective single-centre case series. Between 2016 and 2019, patients who had undergone open reduction and osteosynthesis by an anatomical locking plate associated with a 2.0 mm locking compression plate used as a hinge to support the medial metaphysis. Thirty-four patients, with an average age of 64 years had a clinical and/or radiological average follow-up of 36 months.

RESULTS

The preoperative imaging identified three fractures in two parts, 19 fractures in three parts and 12 fractures in four parts. Seven cases with fracture-dislocation were identified, one head-split fracture, and 14 cases with a metaphyseal head extension of less than 8 mm. After comparing head-shaft displacement, cranialisation of the greater tuberosity as well as head-shaft alignment in the preoperative and postoperative radiographs, overall anatomical or near-anatomical fracture reduction was achieved in 27 of the patients. Only two cases presented postoperative complications. The two cases were complicated with nonunion without screw perforation requiring surgical intervention by re-osteosynthesis. The clinical outcome assessed by the OSS showed an average of 45/48. The age of the group with anatomical or near anatomical reduction and the group with at least one parameter of malreduction was significantly different, 65 and 74 years respectively (p<0.05). No significant differences were found when comparing the sex, surgical time, time to operation or the number of fracture parts.

CONCLUSION

The technique described provides a surgical treatment option with lower complication rates and a quality of reduction consistent with the current literature as well as a satisfactory clinical outcome.

Radiographic parameter(s) influencing functional outcomes following angular stable plate fixation of proximal humeral fractures

PURPOSE

Radiographic parameters which correlate with poor clinical outcome after proximal humeral fractures could be helpful indicators to answer the question which patients should be followed up closer. Moreover, during surgery, radiographic parameters correlating with unfavourable outcome should be avoided. The primary aim of the study was to compare radiographic measurements between the injured and the contralateral, uninjured shoulder. The secondary aim was to correlate these radiographic parameters with post-operative shoulder function.

METHODS

Fifty-eight patients (age: 55.6 ± 14.4 years, age at surgery) following angular stable plate fixation of a proximal humeral fracture (2-part fractures according to Neer: 24, 3-part: 25, 4-part: 9) were included in this retrospective cohort study. All patients were followed up at least six years (7.9 ± 1.4 after surgical intervention). During follow-up examination, the Constant score (CS) was assessed, and radiographs of both shoulders were taken. Radiographs were analyzed regarding lateral humeral offset, distance between tuberculum and head apex, head diameter, head height, perpendicular height, perpendicular center, vertical height, and angles between head and humeral shaft (CCD and HSA). These parameters were compared between the injured and uninjured shoulder. The cohort was divided in two groups: patients with a CS category of excellent/good and satisfying/worse. Both groups were tested regarding differences of demographic and radiographic parameters.

RESULTS

The distance between tuberculum and head apex (2.6 ± 3.4 mm vs. 4.3 ± 2.1 mm; p = 0.0017), the CCD (123.1 ± 12.9° vs. 130.1 ± 7.3°; p = 0.0005), and the HSA (33.1 ± 12.8° vs. 40.1 ± 7.3°; p = 0.0066) were significantly smaller on the treated shoulder compared to the uninjured side. Patients reached a Constant score of 80.2 ± 17.4 (95% CI 75.6-84.8) points. Regarding outcome categories of the Constant score, 46 patients had a good to excellent outcome, and 12 patients had a satisfying or bad outcome. The comparison of these groups revealed that patients with inferior outcome in the long-term follow-up were older, female, had a more complex fracture type (AO classification), smaller lateral humeral offset, smaller head diameter and height, lower perpendicular height, and lower CCD and HSA angles.

CONCLUSION

If the abovementioned parameters cannot be restored sufficiently during surgery, (reversed) shoulder arthroplasty might be a better solution to reach good post-operative outcome. Moreover, patients presenting these radiographic characteristics in the follow-up, older patients, and patients with a more complex fracture type should be followed up closer to possibly prevent poor shoulder function.

TRIAL REGISTRATION

83 250/2011BO2.

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

Introduction:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

[Application of suspensory external fixation technique in treatment of proximal humeral fracture]

Objective

To investigate the effectiveness of suspensory external fixation technique in treatment of proximal humeral fractures.

Methods

Between August 2013 and October 2018, 14 patients with proximal humeral fractures were treated with suspensory external fixation technique. There were 10 males and 4 females with an average age of 55.9 years (range, 43-76 years). There were 10 cases of falling injury and 4 cases of traffic accident injury. Among them, there were 9 cases of Neer type Ⅲ and 5 cases of Neer type Ⅳ. The time from injury to operation was 3-7 days (mean, 4.6 days). Nine cases were complicated with osteoporosis. The preoperative visual analogue scale (VAS) score was 6.1±1.2. The effectiveness was comprehensively evaluated by hospital stay, fracture healing time, removal time of external fixator, postoperative complications, VAS score, and Neer score of shoulder joint function.

Results

All operations were successfully completed, and the hospital stay was 6-14 days, with an average of 9.4 days. All the incisions healed by first intention, and no infection or other complications occurred. All patients were followed up 16-60 months (mean, 35.4 months). X-ray films examination showed that all fractures healed, the healing time was 4-7 months (mean, 4.9 months). The removal time of external fixator was 5-8 months (mean, 6.3 months). VAS scores were 1.5±0.8 at 1 month after operation and 1.0±0.9 at last follow-up, both of which were significantly improved when compared with preoperative score, the differences were significant between different time points ( P<0.05). Neer score of shoulder joint function was 75-100 (mean, 91.1); 9 cases were excellent, 4 cases were good, and 1 case was fair. The excellent and good rate was 92.9%. During follow-up, there was no adverse events such as acromion impingement, nonunion, or pseudoarthrosis.

Conclusion

For proximal humeral fractures, the suspensory external fixation technique is a simple and reliable treatment method that can significantly improve joint function.

Effectiveness of reverse total shoulder arthroplasty for primary and secondary fracture care: mid-term outcomes in a single-centre experience

BACKGROUND

The introduction of reverse total shoulder arthroplasty (RSA) as a treatment option in complex proximal humeral fractures, has significantly extended the surgical armamentarium. The aim of this study was to investigate the mid-term outcome following fracture RSA in acute or sequelae, as well as salvage procedures. It was hypothesized that revision RSA (SRSA) leads to similar mid-term results as primary fracture treatment by RSA (PRSA).

METHODS

This retrospective study describes the radiological and clinical mid-term outcomes in a standardized single-centre and Inlay design. Patients who underwent RSA in fracture care between 2008 and 2017 were included (minimum follow-up: 2 years, minimum age: 60 years). The assessment tools used for functional findings were range of motion (ROM), Visual Analogue Scale, absolute (CS) plus normative Constant Score, QuickDASH, and Subjective Shoulder Value. All adverse events as well as the radiological results and their clinical correlations were statistically analysed (using p < .05and 95% confidence intervals).

RESULTS

Following fracture RSA, 68 patients were included (mean age: 72.5 years, mean follow-up: 46 months). Forty-two underwent primary RSA (PRSA), and 26 underwent revision RSA (SRSA). Adverse advents were observed in 13% (n = 9/68). No statistically significant results were found for the scores of the PRSA and SRSA groups, while the failed osteosynthesis SRSA subgroup obtained statistically significantly negative values for ROM subzones (flexion: p = .020, abduction: p = .020). Decreased instances of tubercle healing were observed for the in PRSA group relative to the SRSA group (p = .006). The absence of bony healing of the tubercles was related to significant negative clinical and subjective outcomes (all scores: p < .05, external rotation: p= .019). Significant postoperative improvements were evaluated in the SRSA group (CS: 23 to 56 at mean, p = .001), the time from index surgery to operative revision revealed no associations in functional findings.

CONCLUSIONS

RSA is an effective option in severe shoulder fracture management with predictable results for salvage as well as first-line treatment. Promising mid-term functional results, reasonable implant survival rates, and high patient satisfaction can be achieved.

LEVEL OF EVIDENCE

Level III.

Long head of biceps in proximal fractures of the humerus: an underestimated problem?

Background and aim of the work:

The long head of biceps (LHB) is one of the tendons of the rotator cuff that runs strictly close to the humeral head. In case of pathology, it can be responsible for pain and shoulder impairment: in such cases, surgical options include tenotomy or tenodesis. The management of LHB along with surgery of the rotator cuff or during shoulder prosthetic replacement has been widely discussed in the literature. Conversely, the possibility of acute impingement and incarceration of LHB in proximal humerus fractures, as well as its role in shoulder pain in outcomes of these fractures, has been poorly considered.

Methods:

The following aspects in the literature on LHB and proximal humerus fractures have been analysed: its management during fixation of fractures, the possibility of interference of the tendon with reduction of fractures or dislocations of the shoulder and its possible role in chronic pain after fixation of proximal humerus fractures.

Results:

LHB can be an obstacle in the reduction of fractures, dislocations and fracture-dislocations. Only a few papers take into account acute surgery to LHB (tenotomy or tenodesis); most of the studies on fixation of proximal humerus fractures simply ignore the problem of LHB. The tendon can be a source of pain and a cause of disability in sequelae of these fractures.

Conclusions:

LHB should be taken into consideration both in the acute phase of fractures of the proximal humerus and in the outcomes. Other studies are needed to better understand its optimal management during fracture surgery. (www.actabiomedica.it)

Salvage reverse total shoulder arthroplasty for failed operative treatment of proximal humeral fractures in patients younger than 60 years: long-term results

HYPOTHESIS

Is salvage reverse total shoulder arthroplasty (RTSA) a justifiable treatment for failed operative treatment (open reduction-internal fixation [ORIF] or primary and secondary hemiarthroplasty) of proximal humeral fractures in patients younger than 60 years?

METHODS

Thirty patients (mean age, 52 years; age range, 30-59 years) were reviewed after a mean follow-up period of 11 years (range, 8-18 years). Of the patients, 7 (23%) underwent RTSA for failed ORIF and 23 (77%) for failed hemiarthroplasty. Clinical and radiographic outcomes were assessed longitudinally.

RESULTS

At final follow-up, the mean relative Constant score had improved from 25% (±12%) to 58% (±21%, P < .001). Significant improvements were seen in the mean Subjective Shoulder Value (20% to 56%), active elevation (45° to 106°), abduction (42° to 99°), pain scores, and strength (P < .001). Clinical outcomes did not significantly deteriorate over a period of 10 years. Patients with salvage RTSA for failed secondary hemiarthroplasty (n = 8) vs. those for failed ORIF (n = 6) showed significantly inferior active abduction (77° vs. 116°, P = .023). Patients with a healed greater tuberosity (n = 9) showed significantly better external rotation than patients with a resorbed/resected greater tuberosity (n = 13, 21° vs. 3°, P = .025). One or more complications occurred in 18 shoulders (60%), and 6 (20%) resulted in explantation of the RTSA.

CONCLUSIONS

Salvage RTSA in patients younger than 60 years is associated with a high complication rate. It leads nonetheless to substantial and durable improvement beyond 10 years, provided the complications can be handled with implant retention. Inferior shoulder function is associated with greater tuberosity resorption or resection and inferior overhead elevation with the diagnosis of failed hemiarthroplasty.

The impact of the AO Foundation on fracture care: An evaluation of 60 years AO Foundation

OBJECTIVES

Sixty years ago, the Association of Osteosynthesis (AO) was founded with the aim to improve fracture treatment and has since grown into one of the largest medical associations worldwide. Aim of this study was to evaluate AO's impact on science, education, patient care and the MedTech business.

DESIGN/METHODS

Impact evaluations were conducted as appropriate for the individual domains: Impact on science was measured by analyzing citation frequencies of publications promoted by AO. Impact on education was evaluated by analyzing the evolution of number and location of AO courses. Impact on patient care was evaluated with a health economic model analyzing cost changes and years of life gained through the introduction of osteosynthesis in 17 high-income countries (HICs). Impact on MedTech business was evaluated by analyzing sales data of AO-associated products.

RESULTS

Thirty-five AO papers and 2 major AO textbooks are cited at remarkable frequencies in high ranking journals with up to 2000 citations/year. The number of AO courses steadily increased with a total of 645'000 participants, 20'000 teaching days and 2'500 volunteer faculty members so far. The introduction of osteosynthesis saved at least 925 billion Swiss Francs [CHF] in the 17 HICs analyzed and had an impact on avoiding premature deaths comparable to the use of antihypertensive drugs. AO-associated products generated sales of 55 billion CHF.

CONCLUSION

AO's impact on science, education, patient care, and the MedTech business was significant because AO addressed hitherto unmet needs by combining activities that mutually enriched and reinforced each other.

Effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture: an update systematic review and meta-analysis

BACKGROUND

To evaluate the effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture (PHF).

METHODS

China National Knowledge Infrastructure (CNKI), Chinese Scientific Journals Database (VIP), Wan-fang database, Chinese Biomedicine Database (CBM), PubMed, EMBASE, Web of Science, and Cochrane Library were searched until July 2018. The eligible references all show that the control group uses locking plates to treat PHF, while the experimental group uses intramedullary nails to do that. Two reviewers independently retrieved and extracted the data. Reviewer Manager 5.3 was used for statistical analysis.

RESULTS

Thirty-eight retrospective studies were referred in this study which involves 2699 patients. Meta-analysis results show that the intramedullary nails in the treatment of proximal humeral fractures are superior to locking plates in terms of intraoperative blood loss, operative time, fracture healing time, postoperative complications, and postoperative infection. But there is no significance in constant, neck angle, VAS, external rotation, antexion, intorsion pronation, abduction, NEER, osteonecrosis, additional surgery, impingement syndrome, delayed union, screw penetration, and screw back-out.

CONCLUSIONS

The intramedullary nail is superior to locking plate in reducing the total complication, intraoperative blood loss, operative time, postoperative fracture healing time and postoperative humeral head necrosis rate of PHF. Due to the limitations in this meta-analysis, more large-scale, multicenter, and rigorous designed RCTs should be conducted to confirm our findings.

TRIAL REGISTRATION

PROSPERO CRD42019120508.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Failure Analysis of a Humeral Shaft Locking Compression Plate-Surface Investigation and Simulation by Finite Element Method

A case study of a failed humeral shaft locking compression plate is presented, starting with a clinical case where failure occurred and an implant replacement was required. This study uses finite element method (FEM) in order to determine the failure modes for the clinical case. Four loading scenarios that simulate daily life activities were considered for determining the stress distribution in a humeral shaft locking compression plate (LCP). Referring to the simulation results, the failure analysis was performed on the explant. Using fracture surface investigation methods, stereomicroscopy and scanning electron microscopy (SEM), a mixed mode failure was determined. An initial fatigue failure occurred followed by a sudden failure of the plate implant as a consequence of patient's fall. The fracture morphology was mostly masked by galling; the fractured components were in a sliding contact. Using information from simulations, the loading was inferred and correlated with fracture site and surface features.

Is the Charlson comorbidity index a good predictor of mortality and adverse effects in proximal humerus fractures?

INTRODUCTION

Proximal humerus fractures (PHF) are frequent in elderly patients. This population also suffers from a series of associated comorbidities, and PHF increases morbidity and mortality. The Charlson Comorbidity Index (CCI) is a tool used for calculating comorbidity and therefore the mortality risk.

HYPOTHESIS

Our hypothesis is that CCI is a good predictor of mortality in patients suffering from PHF, and that there is a relationship between CCI and the development of adverse events.

PATIENTS AND METHODS

A retrospective study with prospective data collection of 354 patients who had been diagnosed and treated for a single PHF between August 1st, 2013 and July 31st, 2015 was carried out at our hospital. The minimum follow-up was 24 months (mean 51.1 months). This study included all patients regardless the severity of the fracture, the treatment performed (surgical or conservative treatment) or whether the patient had been admitted to the hospital or was treated as an outpatient. Adverse effects and mortality data were collected and the CCI was calculated.

RESULTS

Patients with high CCI (>5) had a higher mortality risk 4.6 (95% CI [2.4-9.0]) compared to those with CCI<5. During follow-up, 40 (11%) patients died, being the mean follow-up of the patients overall 4.3 years 95% CI [4.1-4.4]. Patients suffering from systemic complications had a higher CCI average (p=0.001) compared to those who did not present adverse effects (HR=6.6; 95% CI [3.5-12.4]). No statistically significant relationship between the type of fracture (p=0.473) and mortality was found.

CONCLUSION

In our study CCI has proven to be a good predictor of mortality and there is a relationship between CCI and the development of adverse effects in patients suffering from PHF, which maybe should be taken into consideration in our therapeutic decision making.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Biomechanical evaluation of a novel dualplate fixation method for proximal humeral fractures without medial support

Background

Comminuted fractures of the proximal humerus are generally treated with the locking plate system, and clinical results are satisfactory. However, unstable support of the medial column results in varus malunion and screw perforation. We designed a novel medial anatomical locking plate (MLP) to directly support the medial column. Theoretically, the combined application of locking plate and MLP (LPMP) would directly provide strong dual-column stability. We hypothesized that the LPMP could provide greater construct stability than the locking plate alone (LP), locking plate combined with a fibular graft (LPSG), and locking plate combined with a distal radius plate (LPDP).

Methods

LP, LPMP, LPSG, and LPDP implants were instrumented into the finite element model of a proximal humeral fracture. Axial, shear, and rotational loads were applied to the models under normal and osteoporotic bone conditions. The whole simulation was repeated five times for each fixator. To assess the biomechanical characteristics, the construct stiffness, fracture micromotion, stress distribution, and neck-shaft angle (NSA) were compared.

Results

The LPMP group showed significantly greater integral and regional construct stiffness, and endured less von Mises stresses, than the other three fixation methods. The stresses on the lateral locking plate were dispersed by the MLP. The LPMP group showed the least change in NSA.

Conclusions

From the finite element viewpoint, the LPMP method provided both lateral and medial direct support. The LPMP system was effective in treating proximal humeral fracture with an unstable medial column.

Early results for treatment of two- and three-part fractures of the proximal humerus using Contours PHP (proximal humeral plate)

Background and aim of the work: The management of displaced 2- and 3-part fractures of the proximal humerus is controversial, both in younger and in elderly patients. The purpose of this paper is to evaluate the functional results of the Contours Proximal Humerus Plate (Orthofix^R, Bussolengo,Verona, Italy), for the treatment of displaced 2- and 3-part fractures of the proximal humerus. Methods: We retrospectively reviewed 55 patients with proximal humerus fractures, who underwent osteosynthesis with Contours Proximal Humerus Plate from December 2011 to March 2015. We had 21 patients with 2-part fractures and with an average age of 67.1 years and 34 patients with 3-part fractures, with average age of 63.6 years. Results: The average union time was 3 months. The mean Constant score was 67 for 2-part fracture group and 64.9 for 3-part fracture group. The difference was not statistically significant (p = 0.18). The overall complication rate was 14.5 %. Six patients underwent additional surgery (10.9%). Conclusions: The most frequent major complication was secondary loss of reduction following varus collapse of the fracture (2 cases). In these patients, there was loss of medial hinge integrity due to impaction and osteoporosis. The placement of the main locking screw in the calcar area to provide inferomedial support is the rational of the Contours Proximal Humerus Plate. Osteosynthesis with Contours Proximal Humerus Plate is a safe system for treating displaced 2- and 3-part fractures of the proximal humerus, with good functional results and complication rates comparable to those reported in the literature. (www.actabiomedica.it)

Reverse total shoulder arthroplasty for failed open reduction and internal fixation of fractures of the proximal humerus

BACKGROUND

Open reduction and internal fixation (ORIF) of complex fractures of the proximal humerus may yield unsatisfactory results. This study analyzed the results obtained after revision of failed ORIF of proximal humeral fractures using reverse total shoulder arthroplasty (RTSA).

METHODS

Fifty-four shoulders of 53 patients with a subjectively unacceptable outcome after ORIF of a complex fracture of the proximal humerus were revised with RTSA. At a minimum follow-up of 2 years (mean follow-up, 46 months; range, 24-108 months), 44 shoulders were clinically and radiographically reviewed for the purpose of this study. Six patients had been lost to follow-up, and 4 patients (7%) were excluded from functional analysis because of revision surgeries.

RESULTS

The mean absolute Constant score improved from 26 (range, 4-54) to 55 (range, 19-80) points; the mean relative Constant score improved from 32% (range, 4%-85%) to 67% (range, 27%-94%) of an age- and gender-matched, normal shoulder. The mean subjective shoulder value improved from 29% (range, 0%-90%) preoperatively to 67% (range, 5%-95%) at final follow-up. Nineteen patients rated their outcome excellent, 16 good, and 7 fair; 2 patients were dissatisfied.

CONCLUSION

RTSA is a valuable salvage procedure after failed ORIF of a proximal humeral fracture with relatively low revision rates. Shoulder function, patient satisfaction, and pain levels can be reliably improved.

A prospective study for the treatment of proximal humeral fractures with the Galaxy Fixation System

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.

Accurate application of a precontoured-locking plate for proximal humeral fractures in Asians: a cadaveric study

OBJECTIVES

The purpose of this study was to identify the optimal position for a precontoured-locking plating (PHILOS(®)) of the proximal humerus in Asians in terms of conformity and to determine the prevalence of screw exits in the position of the highest conformity.

METHODS

Twenty adult humeri and 14 cadaveric shoulders were included in this study. After placing the precontoured plate in the well-fitted position on the humerus, we measured the distance between the upper margin of the plate and the tip of greater tuberosity (GT) (distance A) and the distance between the anterior margin of the plate and lateral border of the bicipital groove (BG) (distance B). The prevalence of K-wire exits was assessed. In the 14 cadaver shoulders, the mutual relation between the most inferior locking sleeve of the optimally positioned plate and the axillary nerve was evaluated to assess the potential for axillary nerve injury.

RESULTS

The precontoured plate was well-fitted and remained in a relatively constant position in all specimens. Distance A was an average of 3.6 mm (range 1.4-5.5 mm), and distance B was an average of 2.5 mm (range 0-4.6 mm). The K wire closest to the BG pierced it in four cases (20 %), and most inferior K wires exited at an average distance of 3.8 mm (range 1.6-9.0 mm) from the inferior articular margin of the humeral head. Regarding involvement of the BG, articular width was the only significant variable in the logistic regression model, with an odds' ratio of 0.610. The axillary nerve was located at an average vertical distance of 59.7 mm (range 51.8-66.9 mm) from the tip of the GT in a vertically neutral position. The results did not differ between the left and right sides (t = 0.326, p = 0.755). Although the axillary nerve was slightly inferior to the most inferior locking holes of the proximal humerus, it was located in the path of their locking sleeves on the deltoid muscle.

CONCLUSION

The optimal position for the highest conformity led to ideal fixation of the proximal humerus and inferomedial support screw in Asians. However, the precontoured plate sometimes had screw exits that involved the BG, and articular width had a large impact on involvement of the BG. If locking sleeves for the most inferior holes were introduced on the deltoid muscle in a neutral position, there was high potential for injury to the axillary nerve in Koreans.

Outcome Analysis of Locking Plate Fixation in Proximal Humerus Fracture

INTRODUCTION

Proximal humerus fractures account for approximately 5% of all fractures. Stable minimally displaced fractures can be treated nonoperatively but the management of displaced fractures remain controversial with various modalities of treatment available. Locking plates provide stable fixation and enable early postoperative mobilization specially in osteoporotic proximal humerus fracture.

AIM

To evaluate the functional outcome of locking plate fixation and to compare the results of two approaches used for fixation.

MATERIALS AND METHODS

This prospective study was conducted at a tertiary level hospital between September 2011 to December 2013. PHILOS plates were used for internal fixation of displaced proximal humerus fractures Neer's type 2 part, 3 part and 4 part fractures on 26 patients (M/F ratio 1.36:1; mean age 46 years). According to Neer classification, 5,12 and 9 patients had displaced 2, 3 and 4 part fractures respectively. Deltopectoral and deltoid splitting approaches were used for fixation on 13 patients each. Functional outcome was assessed using Constant-Murley shoulder score. Graphpad software version 6.0 was used with Chi-square test and Fisher-exact test are used to compare data. The p-value< 0.05 is considered significant.

RESULTS

Of the 26 patients, all fractures united radiologically and clinically and average constant score at final follow-up was 72.5. At the final follow-up 8 patients had good score, 10 patients had moderate score, 6 patients had excellent outcome and 2 patients had poor outcome according to Constant score. Mean time to union was 12.3 weeks (9 -15 weeks). Four complications (15.4%) were encountered, 2 cases of varus malunion, 1 case of wound infection which required wound debridement and 1 case of screw cut-out in which screw removal was done. Mean constant score in delto splitting approach was 70.9 and 74 in deltopectoral group (p-value= 0.54). No significant difference existed in constant score in 2 approaches. No significant difference existed between groups in terms of complications (P > .05) and all fractures were united.

CONCLUSION

Our study demonstrates that locking plate fixation gives good functional outcomes in treatment of proximal humerus fractures. There was no significant difference in the two approaches used for exposure. Our results are comparable to various studies conducted by other authors which states that locking plates provide better functional and radiological outcomes as compared to other fixation methods like Tension band wiring, percutaneous K-wire fixation, non-locking plates, intramedullary nails.

Biomechanical Contribution of Tension-Reducing Rotator Cuff Sutures in 3-Part Proximal Humerus Fractures

OBJECTIVES

Using a cadaveric 3-part fracture model and cyclic loading protocol, our study objectives were to quantify the stabilizing effect of tension-reducing rotator cuff sutures in terms of fracture displacement across the surgical neck and greater tuberosity compared with a control group in which no sutures were used.

METHODS

Six matched pairs of fresh frozen specimens underwent a standardized, 3-part, proximal humerus fracture and were split into 2 groups. The control group had the fracture fixed with a plate and screw construct only while the experimental group had additional suture fixation through the plate to each rotator cuff tendon. Active abduction through the rotator cuff was simulated for 100, 200, 300, and 400 cycles and to failure at 1000 N. A Mann-Whitney U test compared cyclic displacement of the greater tuberosity and surgical neck fracture gaps and load to failure between the 2 groups.

RESULTS

There was no significant difference (P > 0.05) in fracture gap between fixation methods at the surgical neck at 100 (P = 0.13), 200 (P = 0.07), 300 (P = 0.49), and 400 (P = 0.07) cycles. There was no significant difference (P > 0.05) between fixation methods in the fracture gap at the greater tuberosity at 100 (P = 0.39), 200 (P = 1.00), 300 (P = 0.31), and 400 (P = 0.59) cycles. There was no significant difference (P > 0.5) at 1000 N at the surgical neck (P = 0.70) or the greater tuberosity (P = 0.39).

CONCLUSIONS

Tension-relieving rotator cuff sutures do not add stability to the repair of 3-part proximal humerus fractures. Varus collapse and greater tuberosity displacement are common complications associated with 3-part fractures. No mechanical data exist to demonstrate benefit of adding suture to a plate and screw construct for limiting fracture displacement.

A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2

Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.

Fractures and fracture-dislocations of the proximal humerus: A retrospective analysis of 82 cases treated with the Philos(®) locking plate

OBJECTIVE

To present the experience in a single institution of the management of 82 consecutive fractures and fracture-dislocations of the proximal humerus treated with the Proximal Humeral Internal Locking System (Philos(®)) plate.

MATERIALS AND METHODS

A total of 81 patients with 82 proximal humerus fractures (one patient had bilateral fracture) were treated at our institution with open reduction and internal fixation with Philos(®) plate from January 2008 to December 2012 and the clinico-radiological outcome was analysed. Twelve of these patients also had a dislocation of the proximal humerus. According to the Neer classification, there were seven two-part fractures, 40 three-part fractures and 35 four-part fractures. All patients received a similar physical therapy programme following internal fixation. Mean final follow-up was 32 months. Functional outcome was evaluated for each patient using the Constant-Murley score; radiographic evaluation was also conducted and complications were recorded.

RESULTS

At the end of the follow-up period, the mean Constant-Murley score for the injured side was 75 points (range 42-92); results were graded as excellent for eight patients, good for 52, moderate for 17 and poor for five. Twenty-three patients (28%) had complications during the follow-up period. Reoperation was required in 12 patients. Complications included avascular necrosis of the humeral head in 10 patients (12%), varus positioning of the head in four patients (4.8%), impingement syndrome in three patients (3.6%), secondary screw perforation in three patients (3.6%), non-union of the fracture in two patients (2.4%) and infection in one patient (1.2%).

CONCLUSIONS

Open reduction and internal fixation of proximal humeral fractures with the Philos(®) plate was associated with good clinical outcomes provided the correct surgical technique was used. To better evaluate the real incidence of complications, it is important to follow patients for more than one year after surgery as some complications may arise after this time.

Management of proximal humerus fractures in adults

The majority of proximal humerus fractures are low-energy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. Non-operative management has been associated with good functional outcomes in stable, minimally displaced and certain types of displaced fractures. Absolute indications for surgery are infrequent and comprise compound, pathological, multi-fragmentary head-splitting fractures and fracture dislocations, as well as those associated with neurovascular injury. A constantly expanding range of reconstructive and replacement options however has been extending the indications for surgical management of complex proximal humerus fractures. As a result, management decisions are becoming increasingly complicated, in an attempt to provide the best possible treatment for each individual patient, that will successfully address their specific fracture configuration, comorbidities and functional expectations. Our aim was to review the management options available for the full range of proximal humerus fractures in adults, along with their specific advantages, disadvantages and outcomes.

Locking plate fixation with and without inferomedial screws for proximal humeral fractures: a biomechanical study

PURPOSE. To compare the efficacy of locking plate fixation with and without inferomedial screws in maintaining the reduction of a proximal humeral fracture. METHODS. 22 synthetic humerus models were used. A standardised 3-part proximal humeral fracture with a 4-mm wedge segment was created and fixed with a locking plate and screws with (n=11) and without (n=11) inferomedial screws. The intrafragmentary motion of the construct at 250, 500, 750, and 1000 cycles of 532 N loading, and the load to failure of the 2 groups were compared. RESULTS. Locking plate fixation with inferomedial screws reduced the mean intrafragmentary motion in all cycles (p<0.01) and increased the load to failure (1452 N vs. 1159 N, p<0.001), compared to fixation without inferomedial screws. CONCLUSION. Additional inferomedial screws provide medial column support for fracture healing. This may reduce intrafragmentary motion and thus implant complications resulting from varus malalignment such as screw perforation or loss of reduction.

Bone properties of the humeral head and resistance to screw cutout

Surgical treatment of fractures involving the proximal humeral head is hampered by complications. Screw cutout is the major pitfall seen in connection with rigid plating. We have exploited a bony explanation for this phenomenon.

Is there any benefit in pre-operative urinary analysis before elective total joint replacement?

Whether patients with asymptomatic bacteriuria should be investigated and treated before elective hip and knee replacement is controversial, although it is a widespread practice. We conducted a prospective observational cohort study with urine analyses before surgery and three days post-operatively. Patients with symptomatic urinary infections or an indwelling catheter were excluded. Post-discharge surveillance included questionnaires to patients and general practitioners at three months. Among 510 patients (309 women and 201 men), with a median age of 69 years (16 to 97) undergoing lower limb joint replacements (290 hips and 220 knees), 182 (36%) had pre-operative asymptomatic bacteriuria, mostly due to Escherichia coli, and 181 (35%) had white cells in the urine. Most patients (95%) received a single intravenous peri-operative dose (1.5 g) of cefuroxime as prophylaxis. On the third post-operative day urinary analysis identified white cells in 99 samples (19%) and bacteriuria in 208 (41%). Pathogens in the cultures on the third post-operative day were different from those in the pre-operative samples in 260 patients (51%). Only 25 patients (5%) developed a symptomatic urinary infection during their stay or in a subsequent three-month follow-up period, and two thirds of organisms identified were unrelated to those found during the admission. All symptomatic infections were successfully treated with oral antibiotics with no perceived effect on the joint replacement.

We conclude that testing and treating asymptomatic urinary tract colonisation before joint replacement is unnecessary.

Cite this article: Bone Joint J 2014;96-B:390–4.

Proximal humeral nonunion treated with an intramedullary tantalum cylinder

Nonunion is uncommon after proximal humerus fracture surgery. There is no agreement about preferred method of treatment. Traditional approaches have included laterally based locking plates, autogenous grafting, and endosteal support to provide improved biomechanical stability. Open reduction and internal fixation (ORIF) of proximal humeral nonunion has been performed with various methods, including blade plates and bone grafting, as well as intramedullary support with autologous or allogenic grafts. Both malunion and nonunion have occurred after ORIF with locking plates. Endosteal support in the form of a fibular allograft incorporated into the locking plate construct can increase mechanical stability in selected cases. An ideal implant for proximal humeral nonunion provides medial column mechanical support and osteoconductive and osteoinductive properties. Porous intramedullary tantalum metal may play a role in nonunion surgery as an alternative to fibular allograft because of its versatility of use and salutary biological effects. It offers many material advantages for use in nonunion surgery. Tantalum is extensively porous (75%-80%), has a stiffness close to that of native bone, and offers the possibility of being a carrier for osteoinductive materials. It may also be suitable for patients who refuse allograft material. This article describes a 65-year-old woman with recalcitrant proximal humeral nonunion who was successfully treated with revision ORIF with intramedullary tantalum cylinder augmentation with a lateral-based locking plate and autogenous cancellous bone grafting. At 5-year follow-up, she had excellent motion and clinical and radiographic union.

Operative versus non-operative treatment for two-part surgical neck fractures of the proximal humerus

INTRODUCTION

Aim of this study was to evaluate outcomes of operative as compared to conserveative treatment for two-part humerus fractures at the surgical neck.

METHODS

Data from a prospective multi-centre cohort study on four treatment options (conservative treatment and three implants, i.e. LPHP, PHILOS and PHN) for proximal humerus fractures were evaluated in this post hoc analysis. All patients with two-part fractures of the surgical neck (AO types A2, n = 54 and A3, n = 110) were identified and included for the analysis. All operatively treated patients were gathered and compared to those receiving conservative treatment. Primary outcome parameters were pain, range of motion and absolute and relative Constant scores at 3, 6 and 12 months following injury and coronal plane alignment at 12 months.

RESULTS

Operative (n = 133) and non-operative (n = 31) groups were comparable with regard to all parameters assessed including mean age (62.9 vs. 65.6, P = 0.479), gender (27 vs. 29 % male, P = 0.826) and fracture distribution (65 vs. 77 % A3 type, P = 0.207). 26 of the 31 conservatively treated and 103 of the 133 operatively treated patients (84 and 77 %, respectively) were available for final follow-up. There was a continuous improvement for all outcome parameters in both treatment groups (P < 0.001). Operative treatment resulted in a more effective reduction of pain at 3 months (51 vs. 76 % reporting pain at fracture site, P = 0.03) and a reduction of coronal plane malalignment. Both range of motion and Constant scores were, however, comparable in both groups at all follow-up visits. Relative and absolute Constant scores were generally excellent at final follow-up (74 vs. 74, P = 0.528 and 89 vs. 91, P = 0.494, respectively).

CONCLUSIONS

Both non-operative treatment and operative treatment using modern implants (LPHP, PHILOS and PHN) can be considered safe and effective treatment options for two-part fractures of the proximal humerus. Operative treatment may result in better range of motion and reduced pain in the early postoperative course of treatment.

Effect of calcium triphosphate cement on proximal humeral fracture osteosynthesis: a finite element analysis

PURPOSE. To measure the effect of void-filling calcium triphosphate cement on the loads at the implant-bone interface of a proximal humeral fracture osteosynthesis using a finite element analysis. METHODS. Finite element models of a 3-part proximal humeral fracture fixed with a plate with and without calcium triphosphate cement augmentation were generated from a quantitative computed tomography dataset of an intact proximal humerus. Material properties were assigned to bone fragments using published expressions relating Young's modulus to local Hounsfield number. Boundary conditions were then applied to the model to replicate the physiological loads. The effect of void-filling calcium triphosphate cement was analysed. RESULTS. When the void was filled with calcium triphosphate cement, the pressure gradient of the bone surrounding the screws in the medial fracture fragment decreased 97% from up to 21.41 to 0.66 MPa. Peak pressure of the fracture planes decreased 95% from 6.10 to 0.30 MPa and occurred along the medial aspect. The mean stress in the screw locking mechanisms decreased 78% from 71.23 to 15.92 MPa. The angled proximal metaphyseal screw had the highest stress. CONCLUSION. Augmentation with calcium triphosphate cement improves initial stability and reduces stress on the implant-bone interface.

Effect of calcium triphosphate cement on proximal humeral fracture osteosynthesis: a cadaveric biomechanical study

PURPOSE. To evaluate the effect of filling a central humeral bone void with calcium triphosphate cement on the strength and stability of an osteosynthesis in elderly cadavers. METHODS. 14 fresh cadaveric shoulder specimens obtained from 11 donors (mean age, 91.5 years; mean body weight, 61 kg) were divided into 2 age- and sex-matched groups. A standardised 3-part proximal humeral fracture with a central bone void was created in each specimen. Each specimen was reduced and fixed with a locking plate. In half the specimens the central bone void was packed with calcium triphosphate cement. The intra-fragmentary motion and the load and mode of failure were recorded. RESULTS. Respectively in the test group and controls, the intra-fragmentary motion was 1.0 and 6.4 mm, and the peak displacement at the 500 N load was 1.8 and 9.1 mm. The Cohen's d was 1.6 to 2.7 for all load steps, indicating a large effect of the calcium triphosphate cement on strength and stability. The mean difference in the failure load was 300 N (p<0.05). CONCLUSION. Construct stability and failure load improved significantly when the central humeral bone void was filled with calcium triphosphate cement.

Functional outcomes following locking plate fixation of complex proximal humeral fractures

The purpose of this study was to evaluate the functional outcome of patients with complex proximal humeral fractures fixated by locking plate technology. Eighty-nine patients (27 men, 62 women) older than 50 years with 3- and 4-part proximal humeral fractures were treated using locking plate fixation and followed up for more than 1 year. Functional outcomes were assessed by using the Disabilities of the Arm, Shoulder, and Hand (DASH) and Constant scores, and the complications were evaluated through physical and radiographic examinations. Mean DASH and Constant scores for all 89 patients were 19.6 and 66.6 points, respectively. No significant differences existed in the 2 scores between patients with 3- and 4-part fractures. Of the 71 patients without complications, 68 had an excellent functional outcome according to the DASH score, whereas 2 patients had an excellent outcome on the Constant score. For the 18 patients with complications, the functional outcomes were significantly poorer compared with patients without complications. According to the Constant score, all patients with complications were classified into a moderate or poor functional outcome, but the rate was 12% with the DASH score. In patients with 3- and 4-part proximal humeral fractures fixed with locking plate fixation, complications were the major cause of compromised functional outcomes. Based on these results, different conclusions would be reached when the functional outcome was assessed by using the DASH and Constant scores separately. Because the clinician-based Constant score may bias the results, patient-based assessments, such as the DASH score, are required for the evaluation of functional outcome after shoulder surgery.

Biomechanical considerations for surgical stabilization of osteoporotic fractures

The incidence of osteoporotic fractures has been steadily rising along with the aging of the population. Surgical management of these fractures can be a challenge to orthopedic surgeons. Diminished bone mass and frequent comminution make fixation difficult. Advancements in implant design and fixation techniques have served to address these challenges and when properly applied, can improve overall outcome. The purpose of this review is to describe fixation challenges of common osteoporotic fractures and provide options for successful treatment.

Fractures of the acetabulum in elderly patients: an update

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

Outcomes for four-part proximal humerus fractures treated with a locking compression plate and an autologous iliac bone impaction graft

OBJECTIVES

The study aims to evaluate outcomes of autologous iliac bone impaction grafts (AIBIGs) with locking-compression plates (LCPs) in four-part proximal humeral fracture.

METHODS

Between October 2004 and October 2008, 21 AIBIG with LCP osteosyntheses were done for four-part proximal humeral fractures. Patients included seven males and 14 females. Their mean age at the time of the operation was 66.3±16.9 years (range: 24-87 years). Five patients had high-energy fractures other than fall from standing height. There were two fracture-dislocation cases, and three valgus-impacted fractures. The length of the calcar segment attached to the articular segment was 7.04±6.10mm; 13 of the 21 cases had lengths less than 8mm. Medial-hinge displacement was 16.77±15.84mm; 19 of the 21 cases had displacements more than 2mm.

RESULTS

There was no avascular necrosis of the humeral head and union was achieved in all cases. Varus collapse and hardware-related complications were not observed. Postoperative neck-shaft angles were found to be 129±9° (range: 109-146°). Neer scores were 92.0±6.3 (range: 81-100).

CONCLUSION

The results of using AIBIG with LCP for four-part proximal humeral fractures are excellent. There are significant bone defects in osteoporotic or comminuted fractures and LCP alone does not always provide reliable fixation. Therefore, meticulous technique and use of AIBIG in this complicated type of fracture can ensure a favourable outcome.

Biomechanical evaluation of suture-augmented locking plate fixation for proximal third fractures of the olecranon

OBJECTIVES

To describe a method of suture augmentation of locking plate fixation (PF) of proximal olecranon fractures and to evaluate the biomechanical effectiveness of the suture augmentation using a human cadaveric model.

METHODS

Six matched pairs of cadaveric elbows were used. Proximal one-third fractures of the olecranon were simulated via a transverse osteotomy. Identical locking PF was performed on each elbow using olecranon locking plates. One elbow of each pair was assigned to suture augmentation of the construct. The choice of left/right specimen for augmentation was performed in an alternating fashion. Augmentation was performed using a no. 2 ultra-high-molecular weight polyethylene-braided suture attaching the triceps to the plate via a modified Krackow stitch. The elbows were mounted into a custom jig and linearly loaded to failure using a hydraulic testing machine. Load to and modes of failure were recorded for each sample. The data were analyzed using the Wilcoxon signed-rank test for nonparametric distributions.

RESULTS

Suture augmentation improved the single load-to-failure strength in all pairs. One pair was excluded due to failure of the triceps attachment to the test machine. A median 398 N (P = 0.04 range, 197-633 N) or a median 48% (range, 30%-130%) improvement in strength was seen. The most common mode of failure was loss of fixation of the proximal olecranon fragment.

CONCLUSIONS

Suture augmentation can significantly increase the single load-to-failure strength of locking PF for proximal olecranon fractures.

Treatment of three- and four-part proximal humeral fractures with locking proximal humerus plate

OBJECTIVE

The purpose of this study was to evaluate the effectiveness and complications of the locking proximal humerus plate to treat proximal humerus fractures.

DESIGN

A retrospective clinical trial.

SETTING

Department of Orthopaedics, Tianjin Medical University General Hospital.

PATIENTS

Sixty-eight consecutive patients with three- or four-part fractures of the proximal humerus were treated with locking proximal humerus plates.

INTERVENTION

The deltopectoral anterolateral acromial approach was used to the proximal humerus; open reduction and locking proximal humerus plate were applied.

MAIN OUTCOME MEASUREMENTS

Constant Score was used to measure the shoulder functional recovery, and Visual Analog Scale (VAS) was used to measure subjective evaluation of pain. The radiology was observed.

RESULTS

After average 26.7 months, the average Constant Score was 72.6 ± 13.2 points and the average VAS was 1.2 ± 0.8 points. All the complications such as screw perforation into the glenohumeral joint, screws loosening, soft tissue infections, avascular necrosis and delayed union occurred in eight cases (11.8 %).

CONCLUSIONS

The effectiveness of the locking proximal humerus plate was similar to other published literatures on treating fractures of the proximal humerus; however, a lower complications rate in short follow-up time was observed in this study. It may potentially provide a favorable option for treating three- or four-part fractures of the proximal humerus. Dealing with each particular fracture pattern, surgeons should have a decision of appropriate way to internal fixation.

Where do locking screws purchase in the humeral head?

INTRODUCTION

One of the limiting factors in finding the best osteosynthesis approach in proximal humerus fractures is the current lack of information on the properties of the cancellous bone regions engaged by the implants fixing the epiphysis. The aim of this study is to assess the densitometric and mechanical characteristics of these regions when using a proximal humerus locking plate (PHLP).

MATERIALS AND METHODS

Nineteen PHLPs were mounted on cadaveric humeri using only their three most distal screws. Subsequently, the plates were removed and the bones were scanned using high-resolution peripheral quantitative computed tomography. Bone mineral density (BMD) was determined in the intact proximal epiphysis and in the exact locations where the six proximal screws would have been positioned concluding the instrumentation. Each plate was then repositioned on its bone and a minimally destructive local torque measurement was performed in the same six locations. A statistical analysis was performed to detect significant differences in the investigated parameters between screw positions, and to test the ability of local torque values to discriminate the bone mineral density of the entire humeral head (BMD(TOT)).

RESULTS

Novel data about the cancellous bone engaged by the screws of a PHLP are provided. Different epiphyseal locations showed statistically significant different properties. A local torque measurement was a good predictor of the BMD(TOT).

CONCLUSION

Position and direction of the epiphyseal screws on a locking implant are determinant to engage bone regions with significantly better bone quality. A breakaway torque measurement in a given screw position can distinguish between humeral heads with different densitometric properties.

Locking plate fixation for proximal humerus fractures

Locking plates are increasingly used to surgically treat proximal humerus fractures. Knowledge of the bone quality of the proximal humerus is important. Studies have shown the medial and dorsal aspects of the proximal humeral head to have the highest bone strength, and this should be exploited by fixation techniques, particularly in elderly patients with osteoporosis. The goals of surgery for proximal humeral fractures should involve minimal soft tissue dissection and achieve anatomic reduction of the head complex with sufficient stability to allow for early shoulder mobilization. This article reviews various treatment options, in particular locking plate fixation. Locking plate fixation is associated with a high complication rate, such as avascular necrosis (7.9%), screw cutout (11.6%), and revision surgery (13.7%). These complications are frequently due to the varus deformation of the humeral head. Strategic screw placement in the humeral head would minimize the possibility of loss of fracture reduction and potential hardware complications. Locking plate fixation is a good surgical option for the management of proximal humerus fractures. Complications can be avoided by using better bone stock and by careful screw placement in the humeral head.