1
|
Lim JH, Ahn YS, Kim S, Kim MS. Novel Use of a Fibular Strut Allograft with Fibular Head in an Elderly Patient with Proximal Humeral Fracture and Severe Metaphyseal Comminution: An Alternative to Shoulder Arthroplasty. J Clin Med 2024; 13:2200. [PMID: 38673473 PMCID: PMC11050512 DOI: 10.3390/jcm13082200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/01/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
Treatment of a comminuted proximal humerus fracture (PHF) in elderly patients with severe osteoporosis is challenging, often leading to arthroplasty (such as hemiarthroplasty or reverse shoulder arthroplasty) as the treatment of choice. However, arthroplasty does not always guarantee favorable outcomes. In contrast, the use of intramedullary fibular strut allografts provides additional reduction stability during locking plate fixation; however, to our knowledge, there is limited literature on the use of fibular strut allografts, including the fibular head. Here we aim to report the advantages of using a fibular strut containing the fibular head in severe osteoporotic PHFs. We present the case of an 88-year-old female patient with severe osteoporosis diagnosed with a left PHF accompanied by severe metaphyseal comminution following a fall from a chair. Rather than shoulder arthroplasty, we performed osteosynthesis using a fibular strut allograft containing the fibular head. At the one-year follow-up after surgery, we observed excellent bony union and a favorable functional outcome without major complications, such as reduction loss. The novel use of a fibular strut allograft containing the fibular head could be promising for PHFs with severe metaphyseal comminution, potentially avoiding the need for arthroplasty.
Collapse
Affiliation(s)
- Jun-Hyuk Lim
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, Dong-gu, Gwangju 61469, Republic of Korea; (J.-H.L.); (S.K.)
| | - Yeong-Seub Ahn
- Department of Orthopedic Surgery, Good Morning General Hospital, Pyeongtaek 17874, Republic of Korea;
| | - Sungmin Kim
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, Dong-gu, Gwangju 61469, Republic of Korea; (J.-H.L.); (S.K.)
| | - Myung-Sun Kim
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, Dong-gu, Gwangju 61469, Republic of Korea; (J.-H.L.); (S.K.)
| |
Collapse
|
2
|
Opperman FLJ, Blaas LS, Pape M, Buijs N, Sterkenburg MV, Yuan JZ, Lameijer CM, Derksen RJ. Fibula allograft in complex three-part and four-part proximal humeral fractures in active patients, a matched case-control study. JSES Int 2024; 8:21-26. [PMID: 38312278 PMCID: PMC10837717 DOI: 10.1016/j.jseint.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background About 20% of proximal humerus fractures (PHFs) are unstable and/or markedly displaced and therefore require surgery. Locking plate fixation after anatomical reduction has become the current treatment of choice for these fractures in the active population. However, studies have shown complication rates up to 36%, such as loss of reduction and avascular necrosis. To date, data from literature are inconclusive on outcomes following the use of an intramedullary fibula allograft in PHFs, possibly due to the case mix. It is hypothesized that the use of a fibula allograft is beneficial to prevent secondary displacement of the fracture in cases where the medial hinge is markedly displaced and unstable, resulting in better clinical and patient reported outcomes. Methods In this multicenter matched cohort study, patients with an unstable, displaced PHF, including anatomic neck fractures and significantly displaced surgical neck fractures, were included. Patients that were treated with a locking plate augmented with a fibula allograft were matched to patients who had undergone locking plate reconstruction without the allograft. The matches were made based on fracture characteristics, age, and performance status. Functional outcomes, Patient Reported Outcome Measures, complications, and radiographic results were compared. Results Twelve patients with fibula allograft augmented osteosyntheses were included and matched to 12 control patients. The mean age was 58 years in the fibula allograft group compared to 62 years in the control group. Minimum follow-up was 12 months. Disability of the Arm Shoulder and Hand score, Constant Shoulder score, abduction, and external rotation were significantly better in the fibula allograft group (17.4 ± 8.6 vs. 26.1 ± 19.2, P = .048; 16.5 ± 11.5 vs. 19.8 ± 16.5 P = .040; mean 127° ± 38° vs. mean 92° ± 49° P = -.045; 50° ± 21° vs. mean 26° ± 23°, P = .004). There was no statistically significant difference in the Oxford Shoulder score between groups (P = .105). The Visual Analog Scale was not significantly different between groups (3.1 ± 1.8 vs. 1.6 ± 1.9, P = .439). Radiographic union was reached in 11 patients of the fibula allograft group compared to 8 in the control group (P = .317). The complication rate was twice as high in the control group (3 vs. 7). Conclusion Additional support of the medial hinge in unstable PHFs with a locking plate in combination with a fibula allograft appears to create a more stable construct without compromising the viability of the articular surface of the head. The use of a fibula allograft in selected complex cases could therefore result in better clinical outcomes with lower complication rates.
Collapse
Affiliation(s)
| | - Leanne S. Blaas
- Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
- Department of Surgery, Zaandam Medical Center, Zaandam, The Netherlands
| | - Merel Pape
- Department of Surgery, Zaandam Medical Center, Zaandam, The Netherlands
| | - Nikki Buijs
- Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | | | - Jian Zhang Yuan
- Department of Surgery, Zaandam Medical Center, Zaandam, The Netherlands
| | | | | |
Collapse
|
3
|
Pop H, Morcovescu A, Mihai MM, Constantinescu AS, Bica F. Open Reduction and Internal Fixation With Proximal Humerus Locking Plate, Screws, and Fibular Strut Graft: An Alternative to Shoulder Arthroplasty and Solution to Medial Instability and Varus Collapse in Comminuted Proximal Humerus Fractures. Cureus 2024; 16:e53164. [PMID: 38304640 PMCID: PMC10831780 DOI: 10.7759/cureus.53164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 02/03/2024] Open
Abstract
Fractures of the proximal humerus are a frequent ailment in the senior population. One concern with such a case that presented in our emergency room was the risk of varus collapse following open reduction and internal fixation (ORIF) in a patient with marked calcar comminution. The surgical method used in this case of a NEER four-part fracture with medial column instability proved effective in terms of good surgery outcome, patient satisfaction, good range of motion, and low or no pain at post-surgical follow-ups. ORIF with a locking plate and fibular strut graft proved to be a viable alternative to solo plating or shoulder arthroplasty. We conducted upper extremity patient-reported functional outcome scales (ASES, CONSTANT, and Neer's "limited goals") with this particular patient. At the last visit, two years after the first surgical intervention, the patient had a normal range of motion, was pain-free, and was generally satisfied with the results of the surgery. We concluded that ORIF of the proximal humerus with locking plate and fibular strut graft was, in our case, a good solution for preventing varus malalignment in a patient with severe comminution of medial calcar.
Collapse
Affiliation(s)
- Horea Pop
- Orthopedics and Traumatology, Bagdasar-Arseni Emergency Clinical Hospital, Bucharest, ROU
| | - Andrei Morcovescu
- Orthopedics and Traumatology, Bagdasar-Arseni Emergency Clinical Hospital, Bucharest, ROU
| | - Maria M Mihai
- Orthopedics and Traumatology, Bagdasar-Arseni Emergency Clinical Hospital, Bucharest, ROU
| | | | - Florin Bica
- Orthopedics and Traumatology, Bagdasar-Arseni Emergency Clinical Hospital, Bucharest, ROU
| |
Collapse
|
4
|
Iwata H, Takada N, Kuroyanagi G, Yamamoto N, Usami T, Sekiya I, Murakami H. Endosteal strut using a hydroxyapatite/poly-L-lactide mesh tube with a proximal humeral locking plate for the treatment of proximal humeral fractures. Eur J Orthop Surg Traumatol 2024; 34:217-223. [PMID: 37421450 DOI: 10.1007/s00590-023-03638-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/25/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE Proximal humeral fractures cause large intramedullary bone defects after humeral-head reduction. Hydroxyapatite/poly-L-lactide (HA/PLLA) materials are widely used for various fractures. However, the efficacy of endosteal strut using a HA/PLLA mesh tube (ES-HA/PLLA) with a locking plate for treating proximal humeral fractures was not reported. The purpose of this study is to examine the efficacy of ES-HA/PLLA with a proximal humeral locking plate in proximal humeral fractures. METHODS Seventeen patients with proximal humeral fractures treated using ES-HA/PLLA with a locking plate from November 2017 to November 2021 were evaluated. The range of motion of the shoulder and postoperative complications were assessed at the final follow-up. Radiographs were evaluated to assess bone union and loss of reduction by measuring humeral-head height (HHH) and humeral neck-shaft angle (NSA). RESULTS The average flexion and external rotation of the shoulder at the final follow-up were 137° (range, 90-180°) and 39° (range, - 10 to 60°), respectively. All fractures were united. The average HHH and NSA just after the surgery and final follow-up were 12.5 mm and 11.6 mm and 129.9° and 127.4°, respectively. Two patients presented screw perforation of the humeral head. One patient underwent implant removal due to infection. Avascular necrosis of the humeral head was observed in one patient with arthritis mutilans. CONCLUSIONS The use of ES-HA/PLLA with a proximal humeral locking plate resulted in bone union in all patients and prevented postoperative loss of reduction. ES-HA/PLLA is one of the treatment options for proximal humeral fractures.
Collapse
Affiliation(s)
- Hidetoshi Iwata
- Department of Orthopedic Surgery, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Yatomi, Japan
| | - Naoya Takada
- Department of Orthopedic Surgery, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Yatomi, Japan
| | - Gen Kuroyanagi
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan.
| | - Norio Yamamoto
- Department of Orthopedic Surgery, Miyamoto Orthopedic Hospital, Okayama, 773-8236, Japan
| | - Takuya Usami
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan
| | - Isato Sekiya
- Department of Orthopedic Surgery, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, Yatomi, Japan
| | - Hideki Murakami
- Department of Orthopedic Surgery, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan
| |
Collapse
|
5
|
Panchal S, Gawhale S, Yadav AK, Gupta D, Akshay KS. Fibular Autograft as Medial Support with Proximal Humerus Locking Plate Construct in Comminuted Proximal Humerus Fractures: A Retrospective Analysis. Indian J Orthop 2023; 57:1443-1451. [PMID: 37609012 PMCID: PMC10441945 DOI: 10.1007/s43465-023-00946-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/24/2023] [Indexed: 08/24/2023]
Abstract
Background Varus collapse is one of the pivotal mechanisms of failure following surgical fixation of proximal humerus fractures. The aim of the present study was to evaluate functional and radiological outcomes of non-vascularized fibular autograft as medial support with locking plate construct for comminuted proximal humerus fractures (PHF's). Materials and methods We retrospectively evaluated 18 patients with unstable PHF's in the age group 50-70 years with a minimum follow-up of two years. All the fracture patterns were classified according to Resch, Neer's and AO classification and either medial calcar compromise or comminution were present in all. Open reduction internal fixation (ORIF) with a locking plate was performed for all the patients along with intramedullary fibular autograft to support medial calcar. Radiological outcome was assessed by neck-shaft angle (NSA) graded according to the Paavolainen grading method and difference in the humeral head height (HHH). Functional outcome was assessed by shoulder range of motion (ROM), University of California-Los Angeles (UCLA) score and American shoulder and elbow surgeons score (ASES). Results Radiological union at the fracture site was achieved in all the patients at mean of 8 months (range 6-12 months). Range of movements were mean flexion of 123.89, extension 35.28, internal rotation 66.94, external rotation 57.78 and abduction of 115° at final follow-up. The average NSA was in the range of 120°-130° and none of the patients showed difference in HHH of ≥ 4 mm in the immediate post-operative radiograph and that taken on final follow-up. The functional outcome assessed by ASES score (mean 89.44) and UCLA score (mean 29.61) suggested fair to good results. None of the patients has shown varus collapse and avascular necrosis. Neither there were any complications related to the donor area. Conclusions In unstable proximal humerus fractures with calcar comminution or void, PHILOS plate fixation augmented with fibular autograft as a medial support reduces varus collapse and promotes early radiological union.
Collapse
Affiliation(s)
- Sameer Panchal
- Department of Orthopaedics, Sir HN Reliance Foundation Hospital and Research Centre, Mumbai, 400004 India
| | - Sangeet Gawhale
- Department of Orthopaedics, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, 400008 India
| | - Amit Kumar Yadav
- Department of Orthopaedics, Sir HN Reliance Foundation Hospital and Research Centre, Mumbai, 400004 India
| | - Devanshu Gupta
- Department of Orthopaedics, Lokmanya Tilak Municipal Medical College and Sion Hospital, Mumbai, 400022 India
| | - K. S. Akshay
- Department of Orthopaedics, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, 400008 India
| |
Collapse
|
6
|
Marsalli M, De La Paz J, Córdova C, Fritis D, Errázuriz JDD. Complications of Locked Plating for Proximal Humeral Fractures in Active Patients in a Level One Trauma Center. Shoulder Elbow 2023; 15:181-187. [PMID: 37035615 PMCID: PMC10078815 DOI: 10.1177/17585732221079588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 11/16/2022]
Abstract
Background The incidence of complications associated with locked plating of proximal humerus fractures (PHF) has been reported in up to 40% of surgeries. This study aimed to analyze the incidence and risk factors of complications and re-intervention associated with locked plating of PHF in a an young active working population. Methods This retrospective cohort study included patients indicated for locked plating of displaced PHF at a dedicated workers' accident trauma center. The variables analyzed were patient comorbidities, fracture characteristics, and immediate radiologic surgical outcomes. Postoperative complications and risk factors were determined. Results A total of 127 patients with a median follow-up of 31 months and a median age of 52 years were included. The complication and reintervention rates were 13.4% and 12.6%, respectively. The main cause of reintervention was post-traumatic stiffness. The incidence of other complications was 4% screw protrusion, 1.6% avascular necrosis, 1.6% varus collapse. Complications were not associated with age, comorbidity, fracture classification, bone mineral density, Hertel's risk factors, presence of calcar comminution, reduction quality, and calcar screw position. Discussion The incidence of complications and reintervention was low. The main cause of reintervention was persistent stiffness, and no risk factors for complications were found in this study.
Collapse
Affiliation(s)
- Michael Marsalli
- Orthopaedic and Trauma Surgery, Clínica Universidad de los Andes, Chile
| | - Joaquín De La Paz
- Orthopaedic and Trauma Surgery, Hospital del Trabajador de Santiago, Santiago, Chile
| | - Carlos Córdova
- Orthopaedic and Trauma Surgery, Hospital del Trabajador de Santiago, Santiago, Chile
| | - Diego Fritis
- Orthopaedic and Trauma Surgery, Clínica Universidad de los Andes, Chile
- Orthopaedic and Trauma Surgery, Hospital del Trabajador de Santiago, Santiago, Chile
| | - Juan De Dios Errázuriz
- Orthopaedic and Trauma Surgery, Hospital del Trabajador de Santiago, Santiago, Chile
- Orthopaedic and Trauma Surgery, Clínica Dávila, Santiago, Chile
| |
Collapse
|
7
|
Siebenbürger G, Neudeck R, Daferner MP, Fleischhacker E, Böcker W, Ockert B, Helfen T. It Is Always the Same—A Complication Classification following Angular Stable Plating of Proximal Humeral Fractures. J Clin Med 2023; 12:jcm12072556. [PMID: 37048639 PMCID: PMC10095119 DOI: 10.3390/jcm12072556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/19/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023] Open
Abstract
Introduction: The aim of this study was to create a novel complication classification for osteosynthesis-related complications following angular stable plating of the proximal humerus subsuming the influence of these complications on clinical outcome in relation to fracture morphology and consequent revision strategies. A total of 1047 proximal humerus fractures with overall 193 osteosynthesis-associated complications (24.5%) were included. The following complication types could be clarified: complication Type 1 is defined by mild varus (<20°) or valgus displacement of the humeral head without resulting in a screw cutout through the humeral head cortex. Type 2a is defined by varus displacement (<20°) of the humeral head associated with screw cutout through the humeral head cortex. Type 2b complication is limited to displacement of the greater tuberosity, lesser tuberosity, or both tuberosities. Complication Type 2c is defined by severe varus dislocation (>20°) of the humeral head with screw cutout at the humeral head cortex. Complication Type 3 describes a displacement of the angular stable plate in the humeral shaft region with associated shaft-sided screw cutout, while the position of the humeral head remains static. Complication Type 4 is characterized by the occurrence of AVN with or without glenoidal affection (4a/b). Clinical outcome according to the constant score was mainly affected by type 2–4, leading to a deteriorated result. Depending on the type of complication, specific revision strategies can be considered. Additionally, more complex fracture patterns fostered the incidence of complications.
Collapse
Affiliation(s)
- Georg Siebenbürger
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munchen, Germany
- Correspondence:
| | - Rouven Neudeck
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munchen, Germany
| | | | - Evi Fleischhacker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munchen, Germany
| | - Wolfgang Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munchen, Germany
| | - Ben Ockert
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munchen, Germany
| | - Tobias Helfen
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munchen, Germany
| |
Collapse
|
8
|
Muacevic A, Adler JR, Abdeljaouad N, Yacoubi H. Irreducible Posterior Fracture Dislocation of the Shoulder: A Case Report. Cureus 2023; 15:e33819. [PMID: 36819390 PMCID: PMC9930172 DOI: 10.7759/cureus.33819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 01/19/2023] Open
Abstract
Posterior shoulder fracture-dislocation is a rare traumatic entity. Early diagnosis results in the adequate treatment of these lesions and prevents serious complications, such as avascular necrosis. Several therapeutic options have been proposed depending on the size of the humeral defect, duration of the dislocation, age of the patient, associated comorbidities, and functional requirements. For this kind of injury, early open anatomical reduction and stable internal fixation remain the optimum treatment option. Arthroplasty is often the last resort for active young patients, particularly in cases of avascular necrosis, humeral head complex fracture, or undiagnosed posterior shoulder dislocation. Here, we report a case of a complex posterior shoulder fracture-dislocation in a young man, which was treated surgically with open reduction and locked plate osteosynthesis using a deltopectoral approach.
Collapse
|
9
|
Abstract
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.
Collapse
|
10
|
Nie W, Wang Z, Gu F, Xu S, Yue Y, Shao A, Sun K. Effects of fibular strut augmentation for the open reduction and internal fixation of proximal humeral fractures: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:322. [PMID: 35729668 PMCID: PMC9210738 DOI: 10.1186/s13018-022-03211-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is still a lack of remarkable consensus regarding the clinical efficacy of the application of fibular strut augmentation (FSA) combined with a locking plate for proximal humeral fractures. A systematic review and meta-analysis to assess the effect of the use of FSAs in open reduction and internal fixation of proximal humeral fractures was conducted. METHODS A literature search was conducted in PubMed, Embase, Cochrane, Web of Science Core Collection, and ClinicalTrials.gov to identify trials that compared the clinical outcomes of proximal humeral fractures treated using a locking plate with or without FSA. The primary outcome measures were postoperative complications, radiographical findings, functional recovery scores, and postoperative range of motion (ROM). Data were pooled and analysed using a random-effects model based on the Der Simonian and Laird method. RESULTS Eight studies involving 596 participants were included for further analysis. Compared with using a locking plate independently, the additional application of FSA was associated with the likelihood of lower risk of overall complications (OR 0.37; 95% CI 0.22-0.65; I2 = 12.22%; 95% PI 0.14-0.98) and the rate of patients with orthopaedic complications (OR 0.48; 95% CI 0.25-0.92; I2 = 7.52%; 95% PI 0.16-1.45), less changes in postoperative humeral head height (MD - 2.40; 95% CI - 2.49 to - 2.31; I2 = 0.00%; 95% PI - 2.61 to - 2.20) and the neck-shaft angle (MD - 6.30; 95% CI - 7.23 to - 5.36; I2 = 79.32%; 95% PI - 10.06 to - 2.53), superior functional outcomes (Constant-Murley score: MD 5.07; 95% CI 3.40 to 6.74; I2 = 0.00%; 95% PI 2.361-7.78; American Shoulder and Elbow Surgeons Score: MD 5.08; 95% CI 3.67 to 6.49; I2 = 0.00%; 95% PI 1.98-8.18), and better postoperative ROM in terms of forward elevation and external rotation. However, the evidence regarding postoperative abduction was insufficient. CONCLUSION Meta-analytic pooling of current evidence showed a significant association between the application of FSAs and favourable clinical outcomes in terms of postoperative complications, radiographical findings, functional recovery, and postoperative elevation and external rotation.
Collapse
Affiliation(s)
- Wei Nie
- Department of Orthopedic Surgery, Lianyungang 2nd People's Hospital, No. 41 Hailian East Road, Haizhou District, Lianyungang, 222000, Jiangsu, China
| | - Zhaojun Wang
- Department of Orthopedic Surgery, Lianyungang 2nd People's Hospital, No. 41 Hailian East Road, Haizhou District, Lianyungang, 222000, Jiangsu, China
| | - Fei Gu
- Department of Orthopedic Surgery, Lianyungang 2nd People's Hospital, No. 41 Hailian East Road, Haizhou District, Lianyungang, 222000, Jiangsu, China
| | - Shizhuang Xu
- Department of Orthopedic Surgery, Lianyungang 2nd People's Hospital, No. 41 Hailian East Road, Haizhou District, Lianyungang, 222000, Jiangsu, China
| | - Yang Yue
- Department of Orthopedic Surgery, Lianyungang 2nd People's Hospital, No. 41 Hailian East Road, Haizhou District, Lianyungang, 222000, Jiangsu, China
| | - Anze Shao
- Department of Orthopedic Surgery, Lianyungang 2nd People's Hospital, No. 41 Hailian East Road, Haizhou District, Lianyungang, 222000, Jiangsu, China
| | - Kefu Sun
- Department of Orthopedic Surgery, Lianyungang 2nd People's Hospital, No. 41 Hailian East Road, Haizhou District, Lianyungang, 222000, Jiangsu, China.
| |
Collapse
|
11
|
Hao KA, Patch DA, Reed LA, Spitler CA, Horneff JG, Ahn J, Strelzow JA, Hebert-Davies J, Little MTM, Krause PC, Johnson JP, King JJ. Factors influencing surgical management of proximal humerus fractures: do shoulder and trauma surgeons differ? J Shoulder Elbow Surg 2022; 31:e259-e269. [PMID: 34973423 DOI: 10.1016/j.jse.2021.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/19/2021] [Accepted: 11/25/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal humerus fractures (PHFs) are managed with open reduction and internal fixation (ORIF), hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), or nonoperatively. Given the mixed results in the literature, the optimal treatment is unclear to surgeons. The purpose of this study was to survey orthopedic shoulder and trauma surgeons to identify the patient- and fracture-related characteristics that influence surgical decision-making. METHODS We distributed a 23-question closed-response email survey to members of the American Shoulder and Elbow Surgeons and Orthopaedic Trauma Association. Questions posed to respondents included demographics, surgical planning, indications for ORIF and arthroplasty, and the use of surgical augmentation with ORIF. Numerical and multiple-choice responses were compared between shoulder and trauma surgeons using unpaired t-tests and χ2 tests, respectively. RESULTS Respondents included 172 shoulder and 78 trauma surgeons. When surgery is indicated, most shoulder and trauma surgeons treat 2-part (69%) and 3-part (53%) PHFs with ORIF. Indications for managing PHFs with arthroplasty instead of ORIF include an intra-articular fracture (82%), bone quality (76%), age (72%), and previous rotator cuff dysfunction (70%). In patients older than 50 years, 90% of respondents cited a head-split fracture as an indication for arthroplasty. Both shoulder and trauma surgeons preferred RSA for treating PHFs presenting with a head-split fracture in an elderly patient (94%), pre-existing rotator cuff tear (84%), and pre-existing glenohumeral arthritis with an intact cuff (75%). Similarly, both groups preferred ORIF for PHFs in young patients with a fracture dislocation (94%). In contrast, although most trauma surgeons preferred to manage PHFs in low functioning patients with a significantly displaced fracture or nonreconstructable injury nonoperatively (84% and 86%, respectively), shoulder surgeons preferred either RSA (44% and 46%, respectively) or nonoperative treatment (54% and 49%, respectively) (P < .001). Similarly, although trauma surgeons preferred to manage PHFs in young patients with a head-split fracture or limited humeral head subchondral bone with ORIF (98% and 87%, respectively), shoulder surgeons preferred either ORIF (54% and 62%, respectively) or HA (43% and 34%, respectively) (P < .001). CONCLUSIONS ORIF and HA are preferred for treating simple PHFs in young patients with good bone quality or fracture dislocations, whereas RSA and nonoperative management are preferred for complex fractures in elderly patients with poor bone quality, rotator cuff dysfunction, or osteoarthritis. The preferred management differed between shoulder and trauma surgeons for half of the common PHF presentations, highlighting the need for future research.
Collapse
Affiliation(s)
- Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - David A Patch
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Logan A Reed
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John G Horneff
- Department of Orthopaedic Surgery, The Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jason A Strelzow
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, USA
| | - Jonah Hebert-Davies
- Department of Orthopedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Milton T M Little
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Peter C Krause
- Department of Orthopaedic Surgery, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Joey P Johnson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joseph J King
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA.
| |
Collapse
|
12
|
Shermetaro J, Valk J, Sosnoski D, Brossy K. An Irreducible Posterior Fracture-Dislocation of the Shoulder: A Case Report. Cureus 2022; 14:e24535. [PMID: 35651412 PMCID: PMC9142166 DOI: 10.7759/cureus.24535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 11/05/2022] Open
Abstract
Posterior fracture-dislocations of the shoulder are exceedingly rare orthopedic injuries. The management of these rare and complex injuries can be challenging from initial presentation through definitive management. Timely diagnosis of these injuries is critical to prevent devastating complications, yet the diagnosis is often delayed. Delays in surgery and poor fracture reduction are associated with a high risk of complications such as avascular necrosis. Additionally, these injuries have the potential to be irreducible. This may occur secondary to osteochondral humeral defects, soft tissue interposition, or entrapment. The long head of the biceps tendon incarceration is one potential block to reduction. Definitive surgical treatment options include open reduction and internal fixation (ORIF) and shoulder arthroplasty. While reoperation rates are higher in patients undergoing ORIF, arthroplasty longevity is a concern among young, active patients with high functional demands. Fibular strut allograft is a useful adjunct when reconstructing complex proximal humerus fractures. We present a case of a 28-year-old male who sustained a significantly comminuted four-part left proximal humerus fracture with an irreducible posterior humeral head dislocation requiring urgent ORIF following a motor vehicle accident.
Collapse
|
13
|
Skura B, Glazier MT, Schuette HB, Passias BJ, Chang IR, Verre J, Mehta S, Taylor BC. The Corkscrew Technique for Removing a Fibular Strut Allograft From the Proximal Humerus. Cureus 2022; 14:e23233. [PMID: 35449668 PMCID: PMC9012660 DOI: 10.7759/cureus.23233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/05/2022] Open
|
14
|
Kane SM, Tanaka S, Smith M. Delivery Technique for Fibular Strut Bone Grafting to Proximal Humerus Nonunion Fractures. Tech Orthop 2021; 36:464-8. [DOI: 10.1097/bto.0000000000000489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
15
|
Rogers D, Raad M, Srikumaran U, Shafiq B. Proximal Humerus Fracture-Open Reduction Internal Fixation With an Expandable Intramedullary Nitinol Scaffold. J Orthop Trauma 2021; 35:S1-S2. [PMID: 34227586 DOI: 10.1097/bot.0000000000002177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY For the treatment of proximal humerus fractures, the intramedullary nitinol scaffold is a novel implant that has gained popularity and demonstrated promising 1-year outcomes as an alternative to bone grafting for providing intramedullary structural support to the humeral head. The aim of this video is to demonstrate the insertion of this device safely, while highlighting potential pitfalls, in a 67-year-old patient with a displaced, varus angulated 2-part proximal humerus fracture.
Collapse
Affiliation(s)
- Davis Rogers
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | | | | | | |
Collapse
|
16
|
Polykandriotis E, Zschiegner A, Horch RE, Schürmann M. Bone Allograft and Locking Plate for Severe Proximal Humeral Fractures: Early and Late Outcomes. Med Sci Monit 2021; 27:e928982. [PMID: 34006820 PMCID: PMC8142705 DOI: 10.12659/msm.928982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Early failure of osteosyntheses is common even with use of locking plates. In patients with comminuted fractures and epiphyseal osseous defects, we performed a series of osteosyntheses by locking plate in combination with an allograft bone augmentation. Because of encouraging short-term results in the literature, we assumed that the method could be a potential alternative to a reverse shoulder prosthesis. Material/Methods Twenty-six patients with a dislocated proximal humeral fracture (Neer IV/V/VI) were studied. A lyophilized allogeneic bone graft was used to reinforce the humeral head fragments before locking plate osteosynthesis. The outcomes of fractures were assessed with Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley (Constant) scores, range of motion, a visual analog scale, and with radiological testing. The Constant-Murley scores were the endpoint of our study. Results The Neer classification of the fractures was type IV in 4 patients, type V in 20 patients, and type VI in 2 patients. The mean DASH score was 52.85 (range, 4.17–79.3) and the mean Constant score was 39.26 (range, 17–88). We observed late necrosis of the humeral head in 15 of 24 patients (62.5%), although early radiological follow-up showed that the humeral head had been anatomically reconstructed. Conclusions Long-term follow-up demonstrated inferior functional results, as displayed by poor Constant scores. There was a high incidence of necrosis, in spite of initial anatomical reconstruction. Biointegration of the allogeneic bone graft and revascularization of the humeral head fragments could be impaired in geriatric patients who have gross dislocation. Therefore, augmentation of the humeral head with allogeneic bone grafts cannot be recommended in these patients.
Collapse
Affiliation(s)
- Elias Polykandriotis
- Department of Plastic, Hand, and Microsurgery, Sana Hospital Hof, Hof/Saale, Germany.,Department of Plastic and Hand Surgery, University of Erlangen, Erlangen, Germany
| | | | - Raymund E Horch
- Department of Plastic and Hand Surgery, University of Erlangen, Erlangen, Germany
| | - Matthias Schürmann
- Department of Trauma and Orthopedic Surgery, Sana Hospital Hof, Hof/Saale, Germany
| |
Collapse
|
17
|
Blaas LS, Lameijer CM, Derksen RJ. Letter to the editor regarding Barlow et al: "Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate". J Shoulder Elbow Surg 2021; 30:e256-e257. [PMID: 33493623 DOI: 10.1016/j.jse.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/18/2020] [Indexed: 02/01/2023]
Affiliation(s)
- Leanne S Blaas
- Department of Trauma Surgery, Zaandam Medical Center, Zaandam, The Netherlands; Department of Trauma Surgery, Amsterdam University Medical Center Location Boelelaan, Amsterdam, The Netherlands.
| | - Charlotte M Lameijer
- Department of Trauma Surgery, Amsterdam UMC Location Boelelaan, Amsterdam, The Netherlands
| | - Robert Jan Derksen
- Department of Trauma Surgery, Zaandam Medical Center, Zaandam, The Netherlands
| |
Collapse
|
18
|
Li B, Xiong W, Chang S. [Research progress on intra-articular screw penetration in proximal humeral fracture treated with locking plate]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2021; 35:403-408. [PMID: 33855821 DOI: 10.7507/1002-1892.202010099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To review the research progress on intra-articular screw penetration in proximal humeral fracture treated with locking plate. Methods The domestic and foreign literature about the proximal humeral fracture treated with locking plate was extensively reviewed. The incidence of screw penetration and risk factors were summarized from both primary and secondary screw penetrations, and the reasons of the intra-articular screw penetration and the technical solutions to avoid the penetration were analyzed. Results The incidence of intra-articular screw penetration is about 11%-30%, which includes primary and secondary screw penetrations. The primary screw penetration is related to improper operation, inaccurate measurement, and "Steinmetz solid" effect, which results in inadequate fluoroscopy and blind zone. The secondary screw penetration is related to the loss of reduction and varus, collapse, and necrosis of the humeral head. The risk factors for intra-articular screw penetration include the bone mass density, the fracture type, the quality of fracture reduction, the applied location, number, and length of the plate and screws, and whether medial column buttress is restored. Improved fracture reduction, understanding the geometric distribution of screws, good intraoperative fluoroscopy, and reconstruction of medial column buttress stability are the key points for success. Conclusion The risk of the intra-articular screw penetration in the proximal humeral fractures treated with locking plates is still high. Follow-up studies need to further clarify the cause and mechanism of screw penetration, and the risk factors that lead to screw penetration, in order to effectively prevent the occurrence of this complication.
Collapse
Affiliation(s)
- Bo Li
- Department of Orthopaedics, Yangpu Hospital, Tongji University, Shanghai, 200090, P.R.China
| | - Wenfeng Xiong
- Department of Orthopaedics, Yangpu Hospital, Tongji University, Shanghai, 200090, P.R.China
| | - Shimin Chang
- Department of Orthopaedics, Yangpu Hospital, Tongji University, Shanghai, 200090, P.R.China
| |
Collapse
|
19
|
Abstract
Proximal humerus fractures (PHF) are a common orthopedic injury; however, their treatment remains largely controversial with evidence supporting a wide array of treatments. Although many injuries can be treated nonoperatively, there has been much debate about surgical management of PHF. A detailed review of the literature was performed relative to operative management options specifically related to implant choices. Although no definitive answers are available regarding best practice, there is literature to guide operative decision-making and implant selection based on both patient- and surgeon-specific factors.
Collapse
Affiliation(s)
- Adeshina Adeyemo
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA
| | - Nicholas Bertha
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA
| | - Kevin J Perry
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA
| | - Gary Updegrove
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA.
| |
Collapse
|
20
|
Erickson BJ, Shishani Y, Bishop ME, Romeo AA, Lederman E, Gobezie R. Tuberosity Repair in Reverse Total Shoulder Arthroplasty for Fracture Using a Stem-based Double-row Repair: A Cadaveric Biomechanical Study. J Am Acad Orthop Surg 2020; 28:e1059-65. [PMID: 32195827 DOI: 10.5435/JAAOS-D-19-00667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 02/23/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The optimal tuberosity repair method in reverse total shoulder arthroplasty for fracture is unknown. METHODS Eight matched pairs of cadaver shoulders were randomly assigned to a stem-based tuberosity repair technique or a nonstem-based repair (Boileau technique) and mechanically tested with a 10 kN load cell. Cyclic loading was performed between 10 and 100 N for 500 cycles at 1 Hz, followed by static pull to failure at 33 mm/s. Ultimate load was determined from the maximum load reached during the pull to failure. A paired Student t-test was used to compare the means of the ultimate load and average cyclic displacement of the two sample groups. RESULTS The ultimate load to failure for the stem-based tuberosity repair technique was significantly higher than the nonstem-based technique (668 ± 164 N versus 483 ± 67 N; P = 0.032). The average cyclic displacement for the stem-based tuberosity repair technique was significantly less than the nonstem-based technique 0 (0.83 ± 0.67 mm versus 3.36 ± 2.36 mm; P = 0.017). CONCLUSION The stem-based tuberosity repair technique afforded higher ultimate load to failure with less average cyclic displacement than the nonstem-based technique. Consideration to the stem-based technique should be given when performing a tuberosity repair in the setting of reverse total shoulder arthroplasty for fracture. LEVEL OF EVIDENCE Level III.
Collapse
|
21
|
Richard GJ, Denard PJ, Kaar SG, Bohsali KI, Horneff JG, Carpenter S, Fedorka CJ, Mamelson K, Garrigues GE, Namdari S, Abboud JA, Paxton ES, Kovacevic D, Hebert-Davies J, Ponce BA, King JJ. Outcome measures reported for the management of proximal humeral fractures: a systematic review. J Shoulder Elbow Surg 2020; 29:2175-2184. [PMID: 32951643 DOI: 10.1016/j.jse.2020.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The American Shoulder and Elbow Surgeons multicenter taskforce studying proximal humerus fractures reached no consensus on which outcome measures to include in future studies, and currently no gold standard exists. Knowledge of commonly used outcome measures will allow standardization, enabling more consistent proximal humerus fracture treatment comparison. This study identifies the most commonly reported outcome measures for proximal humerus fracture management in recent literature. METHODS A systematic review identified all English-language articles assessing proximal humerus fractures from 2008 to 2018 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Review articles, meta-analyses, revision surgery, chronic injuries, studies with <15 patients, studies with <12 month follow-up, anatomic/biomechanical studies, and technique articles were excluded. Included studies were assessed for patient demographics and outcome scores, patient satisfaction, complications, range of motion, and strength. RESULTS Of 655 articles, 74 met inclusion criteria. The number of proximal humerus fractures averaged 74.2 per study (mean patient age, 65.6 years). Mean follow-up was 30.7 months. Neer type 1, 2, 3, and 4 fractures were included in 8%, 51%, 81%, and 88% of studies, respectively. Twenty-two patient-reported outcome instruments were used including the Constant-Murley score (65%), Disabilities of the Arm, Shoulder, and Hand score (31%), visual analog scale pain (27%), and American Shoulder and Elbow Surgeons score (18%). An average of 2.2 measures per study were reported. CONCLUSION Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging. We recommend that future literature on proximal humerus fractures use at least 3 outcomes measures and 1 general health score until the optimal scores are determined.
Collapse
Affiliation(s)
- George J Richard
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | | | - Scott G Kaar
- Department of Orthopaedic Surgery, Saint Louis University, St. Louis, MO, USA
| | - Kamal I Bohsali
- Jacksonville Orthopaedic Institute-Beaches Division, Jacksonville, FL, USA
| | - J Gabriel Horneff
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Shannon Carpenter
- Department of Orthopaedic Surgery, Dwight D. Eisenhower VAMC, Leavenworth, KS, USA
| | - Catherine J Fedorka
- Cooper Bone and Joint Institute, Cooper Medical School at Rowan University, Camden, NJ, USA
| | - Kelly Mamelson
- Florida State University College of Medicine, Tallahassee, FL, USA
| | - Grant E Garrigues
- Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph A Abboud
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - E Scott Paxton
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, East Providence, RI, USA
| | - David Kovacevic
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Jonah Hebert-Davies
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Brent A Ponce
- Department of Orthopaedic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Joseph J King
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA.
| |
Collapse
|
22
|
Galler M, Zellner J. Komplikationsmanagement in der operativen Versorgung der Humeruskopffraktur. Arthroskopie 2020; 33:120-126. [DOI: 10.1007/s00142-020-00339-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
23
|
Goodnough LH, Campbell ST, Githens TC, DeBaun MR, Bishop JA, Gardner MJ. Intramedullary Cage Fixation for Proximal Humerus Fractures Has Low Reoperation Rates at 1 Year: Results of a Multicenter Study. J Orthop Trauma 2020; 34:193-8. [PMID: 31809419 DOI: 10.1097/BOT.0000000000001712] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine reoperation rates after treatment of a proximal humerus fracture with cage fixation. DESIGN Retrospective case series. SETTING Eleven U.S. hospitals. PATIENTS Fifty-two patients undergoing surgical treatment of proximal humerus fractures. INTERVENTION Open reduction and internal fixation of a proximal humerus fracture with a proximal humerus cage. MAIN OUTCOME MEASUREMENTS Reoperation rate at 1 year. RESULTS At a minimum follow-up of 1 year, reoperations occurred in 4/52 patients (7.7%). Avascular necrosis (2/41) occurred in 4.9% of patients. CONCLUSION Standard locked plating remains an imperfect solution for proximal humerus fractures. Proximal humerus cage fixation had low rates of revision surgery at 1 year. Proximal humerus cage fixation may offer reduced rates of complication and reoperation when compared with conventional locked plating for the management of proximal humerus fractures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
24
|
Tilton M, Armstrong A, Sanville J, Chin M, Hast MW, Lewis GS, Manogharan GP. Biomechanical Testing of Additive Manufactured Proximal Humerus Fracture Fixation Plates. Ann Biomed Eng 2019; 48:463-476. [PMID: 31555983 DOI: 10.1007/s10439-019-02365-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 09/12/2019] [Indexed: 01/24/2023]
Abstract
Achieving satisfactory fracture fixation in osteoporotic patients with unstable proximal humerus fractures remains a major clinical challenge. Varus collapse is one of the more prominent complications that may lead to screw cutout. This aim of this study was to compare the fixation provided by conventional locking plates with novel design concepts that are only feasible through additive manufacturing (AM) techniques. In addition to reversed engineered implants, two novel implant designs with integrated struts were included in the study to provide medial support to humeral head. The medial strut was either solid or included a porous lattice structure intended to promote bone ingrowth. Biomechanical tests were performed using low density synthetic bones with simulated 3-part comminuted fractures. Nondestructive torsion and compression were performed, followed by increasing cyclic loading. The relative displacements between the bone fragments were determined using a 3D motion capture system. The AM manufactured implants with medial strut showed significant reduction of varus displacement during the increasing cyclic loading when compared to conventional designs. AM reversed-engineered locking plates showed similar mechanical behavior to conventional plates with identical geometry. This study demonstrates the feasibility and potential of employing alternative design via AM for fixation of unstable comminuted proximal humerus fractures to reduce fragment displacement.
Collapse
Affiliation(s)
- Maryam Tilton
- Department of Mechanical Engineering, Pennsylvania State University, 232 Reber Bldg, University Park, PA, 16802, USA
| | - April Armstrong
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Jennifer Sanville
- Biedermann Lab for Orthopaedic Research, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew Chin
- Biedermann Lab for Orthopaedic Research, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael W Hast
- Biedermann Lab for Orthopaedic Research, Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory S Lewis
- Department of Orthopaedics and Rehabilitation, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Guha P Manogharan
- Department of Mechanical Engineering, Pennsylvania State University, 232 Reber Bldg, University Park, PA, 16802, USA.
| |
Collapse
|
25
|
Abstract
Augmentation of proximal humeral fracture fixation with an endosteal fibular allograft has increased in popularity because it biomechanically improves construct stability and potentially may lead to a lower rate of humeral head collapse. However, the potential need for arthroplasty after proximal humeral fracture fixation may still arise. Placing a humeral stem in the presence of an existing intramedullary fibular graft is challenging because the fibula is dense cortical bone and is typically well-integrated by the time an arthroplasty would be performed. Some have proposed burring the proximal humerus open to receive a stem, or using cannulated intramedullary reamers until a humeral stem can be placed. These steps are tedious and inefficient. We have found the most efficient technique as treating the fibula as if it were a well-fixed humeral stem: freeing it up from the native bone and removing it in its entirety.
Collapse
|
26
|
Spross C, Meester J, Mazzucchelli RA, Puskás GJ, Zdravkovic V, Jost B. Evidence-based algorithm to treat patients with proximal humerus fractures-a prospective study with early clinical and overall performance results. J Shoulder Elbow Surg 2019; 28:1022-1032. [PMID: 31003888 DOI: 10.1016/j.jse.2019.02.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/10/2019] [Accepted: 02/15/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND On the basis of patients' demands, bone quality, and fracture type, we developed an evidence-based treatment algorithm for proximal humerus fractures (PHF) that includes all treatment modalities from open reduction and internal fixation, hemiprosthesis, to reverse total shoulder arthroplasty. This study was done to assess its feasibility and early clinical outcome. MATERIALS AND METHODS Patients with isolated PHF in 2014 and 2015 were included in this prospective study. The quality of life (EQ-5D) and the level of autonomy before injury were recorded. The fractures were classified and local bone quality was measured. When possible, patients were treated according to the algorithm. Radiographic and clinical follow-up-Constant score, subjective shoulder value, and EQ-5D-took place after 3 months and 1 year. The rate of unplanned surgery was analyzed. RESULTS A total of 192 patients (mean age 66 years; 58 male, 134 female) were included. Of these, 160 (83%) were treated according to the algorithm. In total, 132 patients were treated conservatively, 36 with open reduction and internal fixation and 24 with reverse total shoulder arthroplasty or hemiarthroplasty. Generally, the mean EQ-5D before trauma and 1 year after treatment was equal to 0.88 to 0.9 points. After 1 year, the overall mean relative Constant score was 95% and mean subjective shoulder value 84%. Unplanned surgery was necessary in 21 patients. CONCLUSION This comprehensive algorithm is designed as a noncompulsory treatment guideline for PHF, which prioritize the patient's demands and biology. The high adherence proves that it is a helpful tool for decision making. Furthermore, this algorithm leads to very satisfying overall results with low complication and revision rates.
Collapse
Affiliation(s)
- Christian Spross
- Department of Orthopaedic Surgery and Traumatology, St. Gallen, Switzerland.
| | - Jan Meester
- Department of Orthopaedic Surgery and Traumatology, St. Gallen, Switzerland
| | | | - Gábor J Puskás
- Department of Orthopaedic Surgery and Traumatology, St. Gallen, Switzerland
| | - Vilijam Zdravkovic
- Department of Orthopaedic Surgery and Traumatology, St. Gallen, Switzerland
| | - Bernhard Jost
- Department of Orthopaedic Surgery and Traumatology, St. Gallen, Switzerland
| |
Collapse
|
27
|
Hudgens JL, Jang J, Aziz K, Best MJ, Srikumaran U. Three- and 4-part proximal humeral fracture fixation with an intramedullary cage: 1-year clinical and radiographic outcomes. J Shoulder Elbow Surg 2019; 28:S131-S137. [PMID: 31196507 DOI: 10.1016/j.jse.2019.05.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/30/2019] [Accepted: 05/04/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Reverse total shoulder arthroplasty is a treatment option for 3- and 4-part proximal humeral fractures in elderly patients. However, arthroplasty has drawbacks in younger patients because of their greater activity level and more likely need for revision surgery. In such patients, an intramedullary cage may allow for reconstruction of the proximal humerus. METHODS We reviewed the outcomes of patients with proximal humeral fractures treated with expandable intramedullary cages from 2016 to 2017. We included patients with closed 3- or 4-part fractures (Neer classification), no osteoarthritis of the glenohumeral joint, and minimum 12-month follow-up. We assessed range of motion, pain, the American Shoulder and Elbow Surgeons score, and the Subjective Shoulder Value. RESULTS Eleven patients (mean follow-up, 54 weeks [range, 49-61 weeks]) were included. Two patients had 3-part fractures, and nine had 4-part fractures. At final follow-up, the mean visual analog scale score for pain was 1.4 (range, 0-6), the mean Subjective Shoulder Value was 69 (range, 20-90), and the mean American Shoulder and Elbow Surgeons score was 80 (range, 27-98). Mean forward flexion was 123° (range, 45°-160°), mean abduction was 82° (range, 30°-90°), and mean external rotation in 90° of abduction was 71° (range, 30°-90°). At final radiographic evaluation, all fractures were healed. No wound-related or neurologic complications were noted. Avascular necrosis developed in 1 patient; conversion to shoulder arthroplasty was performed. CONCLUSION Treatment of 3- and 4-part proximal humeral fractures with an expandable intramedullary cage produced good clinical outcomes and a 100% union rate.
Collapse
Affiliation(s)
- Joshua L Hudgens
- Department of Orthopaedic Surgery, St. Peter's Health, Helena, MT, USA
| | - Jessica Jang
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Keith Aziz
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
28
|
Lee SJ, Hyun YS, Baek SH. Strut Support with Tricortical Iliac Allografts in Unstable Proximal Humerus Fractures: Surgical Indication and New Definition of Poor Medial Column Support. Clin Shoulder Elb 2019; 22:29-36. [PMID: 33330191 PMCID: PMC7713880 DOI: 10.5397/cise.2019.22.1.29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/20/2018] [Accepted: 01/21/2019] [Indexed: 11/25/2022] Open
Abstract
Background The execution of fibular allograft augmentation in unstable proximal humerus fractures (PHFs) was technically demanding. In this study, the authors evaluated the clinical and radiographic outcomes after tricortical iliac allograft (TIA) augmentation in PHFs. Methods We retrospectively assessed 38 PHF patients treated with locking-plate fixation and TIA augmentation. Insertion of a TIA was indicated when an unstable PHF showed a large cavitary defect and poor medial column support after open reduction, regardless of the presence of medial cortical comminution in preoperative images. Radiographic imaging parameters (humeral head height, HHH; humeral neck-shaft angle, HNSA; head mediolateral offset, HMLO; and status of the union), Constant score, and range of motion were evaluated. Patients were grouped according to whether the medial column support after open reduction was poor or not (groups A and B, respectively); clinical outcomes were compared for all parameters. Results All fractures healed radiologically (average duration to complete union, 5.8 months). At final evaluation, the average Constant score was 73 points and the mean active forward flexion was 148°. Based on the Paavolainen assessment method, 33 patients had good results and 5 patients showed fair results. The mean loss of reduction was 1.32 mm in HHH and 5.02% in HMLO. None of the parameters evaluated showed a statistically significant difference between the two groups (poor and not poor medial column support). Conclusions In unstable PHFs, TIA augmentation can provide good clinical and radiological results when there are poor medial column support and a large cavitary defect after open reduction.
Collapse
Affiliation(s)
- Seung-Jin Lee
- Department of Orthopadic Surgery, Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Yoon-Suk Hyun
- Department of Orthopadic Surgery, Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Seung-Ha Baek
- Department of Orthopadic Surgery, Kangdong Sacred Heart Hospital, Seoul, Korea
| |
Collapse
|
29
|
Antonios T, Bakti N, Nzeako O, Mohanlal P, Singh B. Outcomes following fixation for proximal humeral fractures. J Clin Orthop Trauma 2019; 10:468-73. [PMID: 31061571 DOI: 10.1016/j.jcot.2019.01.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 01/30/2019] [Indexed: 11/23/2022] Open
Abstract
Fractures of the proximal humerus are a very common presentation in modern Trauma and Orthopaedic practice. In an ever-aging population, the incidence has dramatically increased resulting in a large socioeconomical burden. The surgical management of these injuries has evolved over the years. Patient outcomes are variable and there is no consensus on treatment approach. This review article focuses on the outcomes following fracture fixation using common surgical techniques.
Collapse
|
30
|
Kakazu R, Wyrick JD. Management of Complex Proximal Humerus Fractures: What Is the Role of Open Reduction and Internal Fixation? Curr Geri Rep 2018. [DOI: 10.1007/s13670-018-0261-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
31
|
Levack AE, Gadinsky N, Gausden EB, Klinger C, Helfet DL, Lorich DG. The Use of Fibular Allograft in Complex Periarticular Fractures Around the Knee. ACTA ACUST UNITED AC 2018; 28:141-151. [PMID: 30853772 DOI: 10.1053/j.oto.2018.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although the use of fibular strut allografts in proximal humerus fractures has gained popularity, their use in other types of fractures is less well described. Fibular allografts have recently been used in the repair of complex periarticular fractures of the proximal tibia and distal femur. Fibular allografts can be inserted in a variety of manners to achieve goals specific to each individual fracture pattern. In the proximal tibia, insertion through a fracture line or cortical window facilitates joint surface elevation, prevents subsidence and enhances overall construct stability. In distal femoral fractures, including complex periarticular fractures, insertion through the fracture or cortical window permits indirect reduction of the medial cortex and provides necessary medial column support. An additional option in distal femur fractures includes fibula insertion as an intramedullary nail, allowing enhanced fixation in short distal fracture segments. In all cases, the use of a fibular allograft augments poor bone stock and provides improved screw purchase and construct stability when combined with conventional plating methods. Here we present a series of cases at our institution illustrating an array of novel techniques utilizing endosteal fibular allografts in the fixation of complex periarticular fractures about the knee.
Collapse
Affiliation(s)
- Ashley E Levack
- Resident Physician, Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY, USA
| | - Naomi Gadinsky
- Research Fellow, Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY, US
| | - Elizabeth B Gausden
- Resident Physician, Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY, USA
| | - Craig Klinger
- Research Coordinator, Orthopaedic Trauma Service, Hospital for Special Surgery, New York, NY, USA
| | - David L Helfet
- Chief Emeritus, Orthopedic Trauma Service, Hospital for Special Surgery and Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Dean G Lorich
- Associate Director, Orthopaedic Trauma Service, Hospital for Special Surgery and Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| |
Collapse
|
32
|
Carbone S, Mezzoprete R, Papalia M, Arceri V, Carbone A, Gumina S. Radiographic patterns of osteoporotic proximal humerus fractures. Eur J Radiol 2018; 100:43-48. [DOI: 10.1016/j.ejrad.2017.12.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 11/01/2017] [Accepted: 12/31/2017] [Indexed: 10/18/2022]
|
33
|
Schumaier A, Grawe B. Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient. Geriatr Orthop Surg Rehabil 2018; 9:2151458517750516. [PMID: 29399372 PMCID: PMC5788098 DOI: 10.1177/2151458517750516] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/29/2017] [Accepted: 11/23/2017] [Indexed: 12/20/2022] Open
Abstract
Introduction: Proximal humerus fractures are common in the elderly. The evaluation and management of these injuries is often controversial. The purpose of this study is to review recent evidence and provide updated recommendations for treating proximal humerus fractures in the elderly. Methods: A literature review of peer-reviewed publications related to the evaluation and management of proximal humerus fractures in the elderly was performed. There was a focus on randomized controlled trials and systematic reviews published within the last 5 years. Results: The incidence of proximal humerus fractures is increasing. It is a common osteoporotic fracture. Bone density is a predictor of reduction quality and can be readily assessed with anteroposterior views of the shoulder. Social independence is a predictor of outcome, whereas age is not. Many fractures are minimally displaced and respond acceptably to nonoperative management. Displaced and severe fractures are most frequently treated operatively with intramedullary nails, locking plates, percutaneous techniques, or arthroplasty. Discussion: Evidence from randomized controlled trials and systematic reviews is insufficient to recommend a treatment; however, most techniques have acceptable or good outcomes. Evaluation should include an assessment of the patient’s bone quality, social independence, and surgical risk factors. With internal fixation, special attention should be paid to medial comminution, varus angulation, and restoration of the calcar. With arthroplasty, attention should be paid to anatomic restoration of the tuberosities and proper placement of the prosthesis. Conclusion: A majority of minimally displaced fractures can be treated conservatively with early physical therapy. Treatment for displaced fractures should consider the patient’s level of independence, bone quality, and surgical risk factors. Fixation with percutaneous techniques, intramedullary nails, locking plates, and arthroplasty are all acceptable treatment options. There is no clear evidence-based treatment of choice, and the surgeon should consider their comfort level with various procedures during the decision-making process.
Collapse
Affiliation(s)
- Adam Schumaier
- Department of Orthopaedics and Sports Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Brian Grawe
- Department of Orthopaedics and Sports Medicine, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
34
|
McMillan TE, Johnstone AJ. Primary screw perforation or subsequent screw cut-out following proximal humerus fracture fixation using locking plates: a review of causative factors and proposed solutions. International Orthopaedics (SICOT) 2017; 42:1935-1942. [DOI: 10.1007/s00264-017-3652-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/24/2017] [Indexed: 10/18/2022]
|
35
|
|