Minimally Invasive Percutaneous Plate Osteosynthesis via a Deltoidsplitting Approach with Strut Allograft for the Treatment of Displaced 3- or 4-part Proximal Humeral Fractures

Open reduction and internal fixation versus minimally invasive plate osteosynthesis of unstable proximal humerus fractures treated with locking plate and intramedullary allograft: A retrospective study

Background

This retrospective clinical study aims to compare the functional and radiological outcomes after open reduction and internal fixation versus minimally invasive plate osteosynthesis of unstable proximal humerus fractures treated with both locking plate and intramedullary graft.

Methods

Forty-seven patients with proximal humerus fractures were treated with either open reduction and internal fixation (25 cases) or minimally invasive plate osteosynthesis (22 cases) and evaluated retrospectively with a minimum follow-up of 12 months. Thirty-one fresh-frozen fibulae and 16 lyophilized tibia allografts were used for augmentation. Change of both neck-shaft angle and humeral head height were evaluated radiologically. Functional outcomes were assessed using Disabilities of the Arm, Shoulder and Hand Score (DASH), Absolute Constant-Murley Score (CSabs), Relative Constant-Murley Score (CSrel), and Individual Relative Constant-Murley Score (CSindiv).

Results

Follow-up period and age for open reduction and internal fixation/minimally invasive plate osteosynthesis were 27.4 ± 16.2/29.6 ± 17.6 months and 60.5 ± 13.7/66.3 ± 11.7 years. CSabs, CSrel, and CSindiv were 57.3 ± 21.2/52.4 ± 18.9, 73 ± 24.1/73.9 ± 23.4, and 69.6 ± 24.8/64 ± 25.5 for open reduction and internal fixation/minimally invasive plate osteosynthesis, p ≥ 0.409. DASH was 14.8 ± 12.5/18.7 ± 14.5 for open reduction and internal fixation/minimally invasive plate osteosynthesis, p = 0.324. Decrease of neck-shaft angle and humeral head height was 7.8 ± 9.4/8.2 ± 15.6° and 0.6 ± 5.5/1.4 ± 2.6 mm for open reduction and internal fixation/minimally invasive plate osteosynthesis, p ≥ 0.380. Surgical time was 165.8 ± 77.6/84.7 ± 38.1 min for open reduction and internal fixation/minimally invasive plate osteosynthesis, p < 0.001.

Conclusions

Locked plating with intramedullary graft augmentation of unstable proximal humerus fractures demonstrates similar functional and radiological outcomes when comparing open reduction and internal fixation with minimally invasive plate osteosynthesis. However, minimally invasive plate osteosynthesis is related to significantly shorter surgical time versus open reduction and internal fixation.

Advancements in the Management of Fragility Fractures in Orthopaedic Patients

Osteoporosis is a major risk factor for fragility fractures. The British Orthopaedics Association Standards for Trauma and Orthopaedics (BOAST) and Getting it Right First Time (GIRFT) guidelines on fragility fracture management highlight the need to initiate prompt, coordinated multidisciplinary care with a focus on early mobilisation to improve patient outcomes. Medical management of fragility fractures focuses on the prevention of progressive frailty. Advancements in medical therapy include romosozumab, recommended by the National Institute for Health and Care Excellence guidance in patients with imminent fracture risk, which improves overall bone mineral density. Regional nerve blocks are an increasingly common form of perioperative anaesthesia with fewer side effects than opioids and rates of postoperative delirium. Surgical management of osteoporotic fractures poses unique challenges, such as complex fracture patterns and increased risk of implant failure. The surgical approach to fragility fractures has undergone major advancements over the past 20 years, with developments such as polyaxial locking and far cortical locking systems that achieve secondary bone healing, as well as cement augmented screw fixation to provide stable fixation in osteoporotic bone. The development of minimally invasive surgical approaches has led to improved periosteal blood flow around a fracture site, as well as reduced operating time, hospital stay, and time to pain-free weight-bearing. In the future, we are likely to see a focus on minimally invasive surgical techniques for vertebral and pelvic fragility fractures to improve patients' mobility and independence before discharge, subsequently improving quality of life and preventing progressive frailty.

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

OBJECTIVES

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Why locking plates for the proximal humerus do not fit well

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE OR CLINICAL RELEVANCE

Basic science study.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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