Open reduction and internal fixation of three- and four-part proximal humeral fractures by intra-focal distraction: observational study of twenty five cases

A prognostic classification of proximal humerus fractures: the cephalic extension staging

PURPOSE

Recent publications emphasized the role of dorsomedial metaphyseal extension of humeral head as predictor of ischemia after complex proximal humerus fractures (PHFs). We evaluated on preoperative 3D CT scan of PHFs the surface of this metaphyseal extension and its prognostic value on the occurrence of avascular necrosis (AVN).

METHODS

We followed a series of 25 fixations of complex PHF which had a preoperative 3D CT scan and measured the surface area of the posterior metaphyseal extension (PME) of the head. Using approximations, we calculated the ratio between the PME surface area (PMS) and the articular surface area of the head (HS). The PMS/HS ratio was analyzed against the risk of AVN.

RESULTS

The measurement of the PMS/HS ratio emphasizes the significance of PME. The incidence of AVN is correlated with the magnitude of PME. Therefore, we include the PME as a fifth element in the characterization of complex PHFs and we propose a 4-stage prognostic classification based on the number of extensions of the humeral head. The head may have 3 extensions: posteromedial (PME), lesser tuberosity (LTE) and greater tuberosity (GTE). The risk of AVN decreases with the number of extensions of the head.

CONCLUSION

Our study demonstrates a correlation between the occurrence of AVN and the size of PME in complex PHF cases. We propose a four-stage classification system to facilitate treatment decision-making between fixation and prosthesis.

Comparison of "Bilboquet" device and locking plate for surgical treatment of proximal humerus complex fractures at two years follow-up

PURPOSE

Surgical treatment of three or four part fractures of the proximal humerus is complex. Different conservative techniques have been described. The main goal of this study was to compare the clinical and radiological outcomes of Bilboquet and locking plate at two year follow-up.

METHODS

This is a retrospective, comparative study, with a continuous series of 41 patients. Bony fixation was achieved with a Bilboquet device in 22 patients or a locking plate in 19 patients. Patient evaluation included clinical data: shoulder range of motion, Constant-Murley shoulder score and DASH (Disabilities of the Arm, Shoulder and Hand) score, and imaging using standard shoulder X-rays.

RESULTS

Of the 41 patients included, 1 patient was lost to follow-up in the locking plate group. At a mean follow-up of 24 months patients in Bilboquet group showed a Constant score higher than in locking plate (p = 0.02). Range of motion and DASH score were not significantly different between the two groups. avascular necrosis occured in three patients of Bilboquet group (14%) versus in two patients in the locking plate group (11%) (p > 0.5). Complication and reintervention rate were non-significantly higher in the locking plate group than in the Bilboquet group (37 vs 14%).

CONCLUSION

Bilboquet and locking plate give good functional outcomes in complex proximal humerus fractures. However, the Bilboquet device appears to provide better functional results than locking plate at mid-term follow-up.

Open reduction and internal fixation of three- and four-part proximal humeral fractures by intrafocal distraction: a clinical and radiographic study of thirty-two cases with five to ten years of follow-up

PURPOSE

The disadvantage of ORIF of proximal humerus fracture (PHF) by intrafocal distraction is that once the device is inserted, it cannot be removed. This study was designed to evaluate the tolerance of such a titanium alloy device at five years of minimal follow-up (FU) and secondarily to assess the relevance of the osteosynthesis of these fractures.

METHOD

Thirty-two patients operated for PHF and implanted with a titanium alloy device between 2009 and 2011 were reviewed: fifteen three-part fracture (3-PF) with mean age 65.2 ± seven years and mean FU at 86 months, and seventeen four-part (4-PF) with mean age 62.9 ± 12 years and mean FU at 88 months.

RESULTS

There were no signs of clinical or radiological incompatibility to the metal. The lateral cortex of the humeral shaft at the wedge component level of the device was thinner than pre-operatively in half of the cases. For the fifteen 3-PF, the median raw and weighted constant score (CS) were 75 and 100, respectively. Only one case presented avascular necrosis (AVN). For the seventeen 4-PF, the median raw and weighted CS were 64 and 88, respectively. Seven cases presented AVN and none of them seven had initially a dorsomedial metaphyseal extension of the humeral head. Kaplan-Meier survivorship analysis, with 95% confidence interval, was calculated at 89.7% (79.7-100%) survivorship at 7.18 years of follow-up.

CONCLUSIONS

This study shows no incompatibility of the titanium alloy device, radiological signs of localized stress shielding in half of the cases with no functional impact, excellent clinical and radiological evolution of the 3-PF, and AVN in all 4-PF without dorsomedial metaphyseal extension of the humeral head whereas most of cases without AVN had dorsomedial metaphyseal extension.