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Tan E, Lie D, Wong MK. Early outcomes of proximal humerus fracture fixation with locking plate and intramedullary fibular strut graft. Orthopedics 2014; 37:e822-7. [PMID: 25350626 DOI: 10.3928/01477447-20140825-60] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 01/30/2014] [Indexed: 02/03/2023]
Abstract
Proximal humerus fractures are commonly encountered in elderly patients. Surgical treatment demonstrates high complication rates, including varus construct collapse and screw cutout. In this study, the authors evaluate the clinical outcome of locking plate fixation with intramedullary fibular strut graft augmentation as a primary surgical treatment in the prevention of early collapse and screw cutout. A total of 9 patients were evaluated. Surgery was performed for displaced proximal humerus fractures between April and December 2011. Patients were either class 2, 3, or 4, according to Neer classification. Mean patient age was 75.4 years. Preoperative and immediate, 6-week, and 3-month postoperative radiographs were evaluated. Head-shaft angles were measured to assess for varus collapse and displacement. Range of motion, complication rates, and functional recovery were also evaluated. Patients underwent open reduction and internal fixation with placement of an intramedullary fibular strut graft. Fixation was achieved with a Philos plate (Synthes, Oberdorf, Switzerland). Reduction and fixation were evaluated with radiographs. Passive exercises and range of motion were allowed immediately postoperatively, and all patients achieved active abduction and forward flexion 6 weeks postoperatively. Shoulder radiographs taken 12 weeks postoperatively revealed no loss of reduction or screw cutout. The introduction of the locking plate has improved outcomes. The addition of an intramedullary strut graft has shown improved preliminary results. Maintained reduction was observed in all 9 patients in the early postoperative period, and good functional motion was achieved. No incidence of screw cutout was recorded.
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Computer-assisted preoperative planning for proximal humeral fractures by minimally invasive plate osteosynthesis. Chin Med J (Engl) 2014. [DOI: 10.1097/00029330-201409200-00016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Effect of Calcar Screw Use in Surgical Neck Fractures of the Proximal Humerus With Unstable Medial Support: A Biomechanical Study. J Orthop Trauma 2014; 28:452-7. [PMID: 24662994 DOI: 10.1097/bot.0000000000000057] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the effect of calcar screw use in proximal humeral fractures with unstable medial support treated with locked plates. METHODS Standard osteotomies were performed in 36 cadaveric humeri to create a surgical neck fracture proximal humeral model. For static testing, 12 pairs of humeri were divided into 4 groups: normal alignment and varus deformity groups with and without 5-mm medial deficiencies. Calcar screw function was measured in each group by axial, shear, and torsion stiffness tests. Another 6 pairs of humeri with 5-mm medial deficiencies were subjected to cyclic loading tests in the normal alignment model with and without calcar screw application. RESULTS Calcar screws improved rotational stability in the normal alignment (P = 0.007) and varus (P = 0.002) groups. Calcar screws improved static and cyclic axial (P = 0.004) and shear (P = 0.017) stability in the normal alignment group with medial deficiency. In specimens with normal alignment and intact medial cortex, calcar screws provided no advantage in axial (P = 0.535) or shear (P = 0.537) stiffness. Calcar screws did not provide sufficient axial (P = 0.782) or shear (P = 0.772) stability to avoid reduction loss in humeri with varus malreduction. CONCLUSIONS In humeri with normal alignment, calcar screws can provide additional stability even when a medial deficiency exists. The use of calcar screws in humeri with varus deformity showed no biomechanical superiority.
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Zhang W, Zeng L, Liu Y, Pan Y, Zhang W, Zhang C, Zeng B, Chen Y. The mechanical benefit of medial support screws in locking plating of proximal humerus fractures. PLoS One 2014; 9:e103297. [PMID: 25084520 PMCID: PMC4118867 DOI: 10.1371/journal.pone.0103297] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 06/28/2014] [Indexed: 11/26/2022] Open
Abstract
Background The purpose of this study was to evaluate the biomechanical advantages of medial support screws (MSSs) in the locking proximal humeral plate for treating proximal humerus fractures. Methods Thirty synthetic left humeri were randomly divided into 3 subgroups to establish two-part surgical neck fracture models of proximal humerus. All fractures were fixed with a locking proximal humerus plate. Group A was fixed with medial cortical support and no MSSs; Group B was fixed with 3 MSSs but without medial cortical support; Group C was fixed with neither medial cortical support nor MSSs. Axial compression, torsional stiffness, shear stiffness, and failure tests were performed. Results Constructs with medial support from cortical bone showed statistically higher axial and shear stiffness than other subgroups examined (P<0.0001). When the proximal humerus was not supported by medial cortical bone, locking plating with medial support screws exhibited higher axial and torsional stiffness than locking plating without medial support screws (P≤0.0207). Specimens with medial cortical bone failed primarily by fracture of the humeral shaft or humeral head. Specimens without medial cortical bone support failed primarily by significant plate bending at the fracture site followed by humeral head collapse or humeral head fracture. Conclusions Anatomic reduction with medial cortical support was the stiffest construct after a simulated two-part fracture. Significant biomechanical benefits of MSSs in locking plating of proximal humerus fractures were identified. The reconstruction of the medial column support for proximal humerus fractures helps to enhance mechanical stability of the humeral head and prevent implant failure.
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Affiliation(s)
- Wen Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Langqing Zeng
- Department of Orthopaedics, Zhuhai People's Hospital, Jinan University Affiliated Zhuhai Hospital, Guangdong, China
| | - Yanjie Liu
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yao Pan
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Changqing Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Bingfang Zeng
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yunfeng Chen
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Hospital readmissions after surgical treatment of proximal humerus fractures: is arthroplasty safer than open reduction internal fixation? Clin Orthop Relat Res 2014; 472:2317-24. [PMID: 24733446 PMCID: PMC4079887 DOI: 10.1007/s11999-014-3613-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 03/27/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND With technologic advances such as locked periarticular plating, hemiarthroplasty of the humeral head, and more recently reverse total shoulder replacement, surgical treatment of proximal humerus fractures has become more commonplace. However, there is insufficient information regarding patient outcomes after surgery, such as the frequency of unplanned hospital readmissions and factors contributing to readmission. QUESTIONS/PURPOSES We measured (1) the frequency of unplanned hospital readmissions after surgical treatment of proximal humerus fractures, (2) the medical and surgical causes of readmission, and (3) the risk factors associated with unplanned readmissions. METHODS The State Inpatient Database from seven different states was used to identify patients who underwent treatment for a proximal humerus fracture with open reduction and internal fixation (ORIF), hemiarthroplasty of the humeral head, or reverse total shoulder arthroplasty from 2005 through 2010. The database was used to measure the 30-day and 90-day readmission rates and identify causes and risk factors for readmission. Multivariate modeling and a Cox proportional hazards model were used for statistical analysis. RESULTS A total of 27,017 patients were included with an overall 90-day readmission rate of 14% (15% for treatment with ORIF, 15% for reverse total shoulder arthroplasty, and 13% for hemiarthroplasty). The majority of readmissions were associated with medical diagnoses (75%), but treatment with ORIF was associated with the most readmissions from surgical complications, (29%) followed by reverse total shoulder arthroplasty (20%) and hemiarthroplasty (16%) (p < 0.001). Risk of readmission was greater for patients who were female, African American, discharged to a nursing facility, or had Medicaid insurance. CONCLUSIONS As the majority of unplanned hospital readmissions were associated with medical diagnoses, it is important to consider patient medical comorbidities before surgical treatment of proximal humerus fractures and during the postoperative care phase. LEVEL OF EVIDENCE Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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56
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Shaw CR, Badhesha J, Ayana G, Abu-Rajab R. Use of a proximal humeral plate for a paediatric peri-prosthetic femoral fracture. J Surg Case Rep 2014; 2014:rju069. [PMID: 24986984 PMCID: PMC4077020 DOI: 10.1093/jscr/rju069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In this case an 18-year-old female with cerebral palsy sustained a peri-prosthetic femoral fracture adjacent to a blade plate previously inserted for a femoral varus osteotomy. The injury was treated using a long proximal humeral locking plate. The existing blade plate was removed. The fracture was reduced and held, and a 10-hole PHILOS™ plate applied with near anatomical reduction. There were no post-operative complications. Radiographic union was confirmed at 11 months. To our knowledge, this is the first reported use of a PHILOS™ plate in the management of a femoral peri-prosthetic fracture and successfully demonstrated a straightforward method for revision fixation.
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Affiliation(s)
- C R Shaw
- Department of Orthopaedics, Royal Alexandra Hospital, Paisley, Glasgow, UK
| | - J Badhesha
- Department of Orthopaedics, Royal Alexandra Hospital, Paisley, Glasgow, UK
| | - G Ayana
- Department of Orthopaedics, Royal Alexandra Hospital, Paisley, Glasgow, UK
| | - R Abu-Rajab
- Department of Orthopaedics, Royal Alexandra Hospital, Paisley, Glasgow, UK
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Lin T, Xiao B, Ma X, Fu D, Yang S. Minimally invasive plate osteosynthesis with a locking compression plate is superior to open reduction and internal fixation in the management of the proximal humerus fractures. BMC Musculoskelet Disord 2014; 15:206. [PMID: 24934152 PMCID: PMC4065576 DOI: 10.1186/1471-2474-15-206] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 06/12/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The use of minimally invasive plate osteosynthesis (MIPO) via anterolateral deltoid splitting has good outcomes in the management of proximal humerus fractures. While using this approach has several advantages, including minimal soft tissue disruption, preservation of natural biology and minimal blood loss, there is an increased risk for axillary nerve damage. This study compared the advantages and clinical and radiological outcomes of MIPO or open reduction and internal fixation (ORIF) in patients with proximal humerus fractures. METHODS A matched-pair analysis was performed, and patient groups were matched according to age (±3 years), sex and fracture type. Forty-three pairs of patients (average age: MIPO, 63 and ORIF, 61) with a minimum follow-up of 12 months were enrolled in the study group. The patients were investigated radiographically and clinically using the Constant score. RESULTS The MIPO technique required less surgery time and caused less blood loss compared to ORIF (p < 0.01). In addition, MIPO required a smaller incision, resulted in less scarring, and was cosmetically more appealing and acceptable to female patients than ORIF. Following MIPO, patients had better functional results at 3 and 6 months, with better outcomes, less pain, higher satisfaction in activities of daily living, and a higher range of motion when compared to ORIF (p < 0.05). Fracture configuration, according to the AO/ASIF(Association for the Study of Internal Fixation) fracture classification, did not significantly influence the functional results. The complication rate was comparable between both groups. CONCLUSION The use of MIPO with a locking compression plate in the management of proximal humerus fractures is a safe and superior option compared to ORIF.
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Affiliation(s)
- Tao Lin
- Department of Orthopedics, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Baojun Xiao
- Department of Orthopedics, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Xiucai Ma
- Department of Orthopedics, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Dehao Fu
- Department of Orthopedics, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Shuhua Yang
- Department of Orthopedics, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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McAnany S, Parsons BO. Treatment of Proximal Humeral Fractures: A Critical Analysis Review. JBJS Rev 2014; 2:01874474-201404000-00005. [PMID: 27490870 DOI: 10.2106/jbjs.rvw.m.00045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Steven McAnany
- Leni and Peter W. May Department of Orthopaedic Surgery, Mount Sinai School of Medicine, 5 East 98th Street, 9th Floor, New York, NY 10029
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Chowdary U, Prasad H, Subramanyam PK. Outcome of locking compression plating for proximal humeral fractures: a prospective study. J Orthop Surg (Hong Kong) 2014; 22:4-8. [PMID: 24781604 DOI: 10.1177/230949901402200104] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To evaluate the outcome of open reduction and internal fixation using locking compression plates for proximal humeral fractures. METHODS 54 men and 16 women aged 28 to 79 (mean, 54) years underwent open reduction and internal fixation using a locking compression plate for closed 2-part (n=22), 3-part (n=38), and 4-part (n=10) proximal humeral fractures. 10 of the patients also had dislocation of the humeral head; 4 had fractures extending to the shaft. Wound condition, functional outcome, bone union, amount of collapse, and malalignment were assessed. Functional outcome was assessed using the Constant-Murley score. RESULTS; The mean follow-up period was 15 (range, 6-24) months. All fractures achieved union after a mean of 9 (range, 6-12) weeks. The mean Constant-Murley scores for the injured and normal shoulders were 72 and 82, respectively (88% of normal). The final outcome was excellent in 14 patients, good in 28, moderate in 22, and poor in 6. In the latter 6 patients, 2 had screw penetration, 2 had plate impingement, one had a mal-reduced greater tuberosity, and one had adhesive capsulitis. All were preventable. In all, 18 patients had 20 complications: subacromial impingement of the plate (n=6), mal-reduction of the greater tuberosity (n=6), screw penetration (n=2), adhesive capsulitis (n=2), superficial infection (n=2), and haematoma (n=2); 12 of these complications were technique-related. CONCLUSION Locking proximal humeral plates enabled stable fixation in all Neer-type proximal humeral fractures. Most complications were technique-related.
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Affiliation(s)
- Umapathi Chowdary
- Department of Orthopaedics, Srinivas Institute of Medical Sciences & Research Center, Mukka, Mangalore, Karnataka, India
| | - Hari Prasad
- Department of Orthopaedics, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India
| | - P Krishna Subramanyam
- Department of Orthopaedics, Kamineni Hospitals, LB Nagar, Hyderabad, Andhra Pradesh, India
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Treatment of Proximal Humeral Nonunions With a Locked Plate and an Intramedullary Strut Autograft. Tech Orthop 2014. [DOI: 10.1097/bto.0b013e31827b9500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Results of open reduction and internal fixation of severe fractures of the proximal humerus in elderly patients. Rev Bras Ortop 2014; 49:25-30. [PMID: 26229768 PMCID: PMC4511769 DOI: 10.1016/j.rboe.2014.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 05/20/2013] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate clinical and radiological results with open reduction and internal fixation of severe fractures of the proximal humerus in the patients over the age of 60 years. METHODS Between June 1992 and February 2011, 21 patients with FGEPU over the age of 60 years were treated by open reduction and internal fixation at the Group of Shoulder and Elbow Department of Orthopaedics and Traumatology of Santa Casa de São Paulo Medical School. 18 patients were reviewed. RESULTS Two patients had excellent results, 12 good, three regular and one bad. Therefore, we find that 77.7% of these had good and excellent results. All patients were satisfied with the treatment and only three patients did not return to previous activities. Mean postoperative mobilities were 122° elevation (90-150°), 39 lateral rotation (20-60°) and medial rotation of T11 (T5 to sacro iliac joint). CONCLUSION Open reduction and internal fixation of FGEPU may also be indicated for elderly patients and obtained 77.7% of good and excellent results. Statistically (p < 0.05), the anatomical reduction of the fracture was found to be important for obtaining good results.
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Harnoss T, Felkel B, Döbele S, Schreiber U, Lenich A. Virtual morphological comparison of three intramedullary nailing systems for the treatment of proximal humeral fractures. Injury 2014; 45 Suppl 1:S24-8. [PMID: 24268131 DOI: 10.1016/j.injury.2013.10.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2013] [Indexed: 02/02/2023]
Abstract
Proximal humerus fractures treated with intramedullary nails show good results. However, the correct anatomical reconstruction of four-part fractures is demanding especially when using intramedullary nails. We therefore compared different intramedullary nail designs for the proximal humerus in a virtual morphological manner. Three commercially available nailing systems where virtually implanted in virtually generated reproducible four-part fractures of 25 digitised humeri. The objective of this study was to quantify and characterise the anatomical position of the proximal screws in the most vulnerable case of a four-part fracture. Taking into account a minimum distance of 5mm between the screw head and the fracture line, osteosynthesis was possible in 54 out of 75 cases. Difficulties placing the proximal screws could be observed at the localisation of the lower lesser tubercle or/and at the sulcus intertubercularis. This morphological analysis could be the basis for choosing the most sufficient implant intra operatively or even improving the nail design.
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Affiliation(s)
- Tobias Harnoss
- St. Vinzenz Clinic Pfronten, Department for Surgery and Orthopedics, Kirchenweg 15, 87459 Pfronten, Germany.
| | - Bernd Felkel
- Munich University of Applied Sciences, Lothstr. 34, 80335 Munich, Germany.
| | - Stefan Döbele
- Department of Traumatology and Reconstructive Surgery, BG Unfallklinik, Eberhard Karls Universität Tübingen, Schnarrenbergstraße 95, 72076 Tübingen, Germany.
| | - Ulrich Schreiber
- Munich University of Applied Sciences, Lothstr. 34, 80335 Munich, Germany.
| | - Andreas Lenich
- Clinic of Orthopedics and Traumatology, Department for Sport Orthopedics, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675 Munich, Germany.
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Miyazaki AN, Fregoneze M, Santos PD, Silva LAD, Sella GDV, Filho JMF, Ferreira MT, Filho PRD, Checchia SL. Avaliação dos resultados da redução aberta e da fixação interna das fraturas graves da extremidade proximal do úmero em idosos. Rev Bras Ortop 2014. [DOI: 10.1016/j.rbo.2013.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
BACKGROUND AND PURPOSE Long term outcome of the treatment of displaced complex fractures of humeral head is rare in the literature especially in greater cohorts. Main purpose of our study was the assessment of long term results of intramedullary nailing of 3-4 part fractures. PATIENTS AND METHODS 137 patients with 137 three or four-part fractures of the humeral head treated by intramedullary nailing were reassessed after an average follow-up time of 57 (27-93) months. The whole cohort consisted of 85 three-part fractures, 38 four-part fractures and 14 fracture-dislocations. Radiographic and clinical outcome - absolute Constant score (CS(abs)) and relative Constant score (compared to the contralateral side - CS(rel)) were evaluated. The rate of complications was recorded. Analysis of the influence of quality of achieved reduction on final functional result and on the development of complications was performed. RESULTS 125 fractures healed uneventfully. Mean long term CS(rel) was 81% of the unaffected side. Mean CS(rel) was 85% in 3-part fractures, 73% in four-part fractures, 80% in three-part fracture-dislocations and 70% in four-part fracture-dislocations. 96 (70%) patients achieved excellent or good results (CS(rel) higher than 80%), 17 (12.4%) satisfactory results and 24 (17.5%) poor results (CS(rel) less than 60%). No significant difference was observed in functional results between different age groups. No incidence of non-union was observed, 4 losses of reduction were encountered. We observed 17 cases of complete humeral head necrosis, 14 of them in the group of 4-part fractures. Reduction quality strongly influenced functional result and development of head necrosis. In the group of excellent reduction mean CS(rel) was 88% and the rate of necrosis was 2%. Moderate reduction quality deteriorated CS(rel) to 70% and head necrosis rate rose up to 28%. If reduction was poor, mean CS(rel) was 52% and the rate of complete necrosis rose to 60%. CONCLUSION Long term results confirmed nailing as appropriate treatment strategy for all types of humeral head fractures with limitation of excellent reduction in every age group. Moderate or even poor reduction significantly deteriorates functional results and increases rate of complete necrosis of the humeral head. If good reduction cannot be achieved, treatment strategy should be changed.
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Affiliation(s)
- Martin Kloub
- Department of Traumatology, Hospital Ceske Budejovice, Czech Republic.
| | - Karel Holub
- Department of Traumatology, Hospital Ceske Budejovice, Czech Republic
| | - Simona Polakova
- Daphne CR-Institute of Applied Ecology, Ceske Budejovice, Czech Republic
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Iris NSL, Ka-Chun I, Kin-Bong L, Wan-Yiu S, Ben C. Minimally Invasive Fixation for Proximal Humeral Fracture: A Review on the use of T2 Proximal Humeral Nail. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2013. [DOI: 10.1016/j.jotr.2013.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective and methodology A retrospective review of the outcome of patients who had proximal humeral fracture treated with T2 Proximal Humeral Nail from January 2007 to March 2011 was conducted. The demographics, union rate, and complications were reviewed. The patient outcome was assessed with the American Shoulder and Elbow Surgeons (ASES) score and Constant-Murley score. Results Thirty-two cases of traumatic proximal humeral fractures were included. The average follow-up period was 14.7 months. All fractures healed with an average of 3.97 months. The average forward flexion and lateral abduction of shoulder was 132° and 123°, respectively. The postoperative average Constant-Murley score was 67 (48-80) and ASES score was 82.9 (73-100). There was one case of avascular necrosis of humeral head. Six cases of minor screw complications required removal of screws later. No wound infection or neurovascular injury was found. Discussion and conclusion With the proper surgical technique high union rate, good functional recovery, and low complication rate can be achieved by using T2 Proximal Humeral Nail in managing traumatic proximal humeral fracture.
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Affiliation(s)
- Ngai Sze-Ling Iris
- Department of Orthopaedics and Traumatology, Trauma Service, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Ip Ka-Chun
- Department of Orthopaedics and Traumatology, Trauma Service, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Lee Kin-Bong
- Department of Orthopaedics and Traumatology, Trauma Service, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Shen Wan-Yiu
- Department of Orthopaedics and Traumatology, Trauma Service, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Chan Ben
- Department of Physiotherapy, Queen Elizabeth Hospital, Kowloon, Hong Kong
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Röderer G, Scola A, Schmölz W, Gebhard F, Windolf M, Hofmann-Fliri L. Biomechanical in vitro assessment of screw augmentation in locked plating of proximal humerus fractures. Injury 2013; 44:1327-32. [PMID: 23769470 DOI: 10.1016/j.injury.2013.05.008] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/05/2013] [Accepted: 05/13/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Proximal humerus fracture fixation can be difficult because of osteoporosis making it difficult to achieve stable implant anchorage in the weak bone stock even when using locking plates. This may cause implant failure requiring revision surgery. Cement augmentation has, in principle, been shown to improve stability. The aim of this study was to investigate whether augmentation of particular screws of a locking plate aimed at a region of low bone quality is effective in improving stability in a proximal humerus fracture model. MATERIALS AND METHODS Twelve paired human humerus specimens were included. Quantitative computed tomography was performed to determine bone mineral density (BMD). Local bone quality in the direction of the six proximal screws of a standard locking plate (PHILOS, Synthes) was assessed using mechanical means (DensiProbe™). A three-part fracture model with a metaphyseal defect was simulated and fixed with the plate. Within each pair of humeri the two screws aimed at the region of the lowest bone quality according to the DensiProbe™ were augmented in a randomised manner. For augmentation, 0.5 ml of bone cement was injected in a screw with multiple outlets at its tip under fluoroscopic control. A cyclic varus-bending test with increasing upper load magnitude was performed until failure of the screw-bone fixation. RESULTS The augmented group withstood significantly more load cycles. The correlation of BMD with load cycles until failure and BMD with paired difference in load cycles to failure showed that augmentation could compensate for a low BMD. DISCUSSION AND CONCLUSION The results demonstrate that augmentation of screws in locked plating in a proximal humerus fracture model is effective in improving primary stability in a cyclic varus-bending test. The augmentation of two particular screws aimed at a region of low bone quality within the humeral head was almost as effective as four screws with twice the amount of bone cement. Screw augmentation combined with a knowledge of the local bone quality could be more effective in enhancing the primary stability of a proximal humerus locking plate because the effect of augmentation can be exploited more effectively limiting it to the degree required.
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Affiliation(s)
- Götz Röderer
- Ulm University, Department of Orthopaedic Trauma, Ulm, Germany.
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Mechanisms of failure of locked-plate fixation of the proximal humerus: acoustic emissions as a novel assessment modality. J Orthop Trauma 2013. [PMID: 23187155 DOI: 10.1097/bot.0b013e31827934c1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Locking plates are the predominant implants used for proximal humerus fractures. Despite a preponderance of good clinical outcomes, failures continue to occur. The purpose of this study was to investigate the failure mechanism of locked proximal humeral plate fixation and its relationship with bone density and screw length. METHODS Human cadaveric humeri were subjected to cyclic bending loads after an unstable 2-part fracture (Orthopedic Trauma Association classification 11 A-3) was created and stabilized with a locking proximal humeral plate. Acoustic emission (AE) sensors were mounted on the specimens to detect fracture displacement and generation of microcracks. The data were analyzed to evaluate construct failure. RESULTS Eight of 10 locking plate constructs in cadaver specimens failed in varus collapse. The primary influences on failure were cancellous bone density and cancellous bone screw length. AE monitoring demonstrated patterns of microcrack progression, predominantly along the inferior screws. The progression trends according to AE were similar to their respective actuator displacement versus time curves. CONCLUSIONS Cancellous bone density and total cancellous screw depth penetration seem to be critical variables. Although the patients' bone density cannot be controlled, surgeons may decrease the risk of failure by maximizing the length of the screws within the cancellous bone. Analysis of microcrack formation revealed that failures begin at the midportion and tips of the inferior screws and at the bone-plate interface of the inferior screws.
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Bachelier F, Pizanis A, Schwitalla J, Pohlemann T, Kohn D, Wirbel R. Treatment for displaced proximal humerus fractures: comparison of interlocking plate fixation versus minimal invasive techniques. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 24:707-14. [PMID: 23728442 DOI: 10.1007/s00590-013-1235-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 05/10/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE The functional results and the complications following interlocking plate fixation of displaced proximal humerus fractures should be evaluated and compared with those following minimal invasive fixation techniques. PATIENTS AND METHODS Fifty patients (30 women, 20 men, mean age 62.7 (18-91) years) were treated for a displaced proximal humerus fracture using an interlocking plate fixation (PHILOS®) between 2003 and 2004. The mean follow-up time was 12 (9-36) months. Functional and radiographic results (Constant-Murley and Neer scores) were analyzed and compared with an equivalent historical control group of 53 patients operated for the same fracture types using minimal invasive techniques (K-wires and/or cannulated screws) between 1995 and 1997. According to the OTA/AO classification, there were 15 type A, 18 type B, and 17 type C fractures in the plate fixation group, and 23, 25, and 5 of these types in the control group, respectively. RESULTS The mean Neer score was 85.9, the mean Constant-Murley score 84, whereas 82.4 and 75.4 for the control group, respectively. Good and excellent results were seen in 78%, whereas in 70% in the control group. The results were dependent upon the fracture's type, sex, and patient's age. Complications were seen in 9 patients, whereas in 16 patients in the control group. INTERPRETATION Using an interlocking plate, the indication of fixation of displaced proximal humerus fractures had been expanded to type C fractures. The implant failure rate can be reduced. The functional results achieved are better compared with those following minimal invasive techniques.
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Affiliation(s)
- Felix Bachelier
- Department of Orthopaedics, University Hospital of Saarland, 66421, Homburg, Germany
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Grawe B, Le T, Lee T, Wyrick J. Open Reduction and Internal Fixation (ORIF) of Complex 3- and 4-Part Fractures of the Proximal Humerus: Does Age Really Matter? Geriatr Orthop Surg Rehabil 2013; 3:27-32. [PMID: 23569694 DOI: 10.1177/2151458511430662] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Treatment of complex fracture patterns of the proximal humerus continues to be a challenging and controversial clinical scenario. The aim of this study was to report on the outcomes of complex displaced 3- and 4-part fractures of the proximal humerus treated with locked plating and compare the functional results of patients on the basis of age at time of injury. METHODS A retrospective review was completed to identify patients whom had sustained a 3- or 4-part fracture of the proximal humerus (Neer classification), treated surgically with locked compression plating. Patients were recruited for a final follow-up, with clinical (Constant and Disabilities of the Arm, Shoulder, Hand [DASH] scores) and radiographic outcome analysis. Results were compared (t test and Wilcoxon test) with fracture type (3- vs 4-part) and patient age at time of fracture (<65 years vs >65years) as the primary outcome measure. The presence or absence of a complication and presence or absence of a concomitant osseous injury at the time of presentation were evaluated as secondary outcome measures, in regard to overall functional results of the treatment in question. Complications were defined as posttraumatic osteoarthritis, avascular necrosis of the humeral head, and screw cutout with chondrolysis. The null hypothesis being that age of the patient at the time of injury would not greatly affect functional outcome measurements. RESULTS Forty-five fractures were identified in 45 patients, with 31 three-part fractures and 14 four-part fractures, and 17 patients were available for final follow-up (9 three-part and 8 four-part). Twelve patients were identified as under the age of 65 years and were compared with 5 patients who were identified as older than 65 years of age. The relative Constant score, at final follow-up, for those under the age of 65 was 88.58, while the score for those above the age of 65 was 82.5. In a similar fashion, the DASH score for those younger than 65 was 11.67, while the score for those older than 65 was 12.5. Neither the Constant score nor the DASH score differed in a statistically significant manner, when comparing patients who were younger than 65 to those older than 65 years of age. CONCLUSION The current series of fractures was able to demonstrate similar and satisfactory outcomes following locked plating treatment of complex 3- and 4-part proximal humerus fractures in younger patients and patients older than the age of 65, while still accepting the null hypothesis.
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Affiliation(s)
- Brian Grawe
- Department of Orthopaedic Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
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Abstract
OBJECTIVE Most clinical evaluations after fracture treatment focus on pure functional and radiological outcome. However, this may not appreciate the impact on quality of life (QoL). The aim of this study was to assess QoL and its improvement during the first year of postoperative recovery after fracture treatment. DESIGN Prospective single-centre observational study. SETTING Trauma unit. City hospital. PATIENTS From March 2003 to June 2008 inclusion of 269 consecutive patients (72 years, 77% female) was possible. All were treated by open reduction and internal fixation (ORIF) with PHILOS because of isolated traumatic fractures of the proximal humerus. INTERVENTION Clinical follow-up examinations were performed at 6 weeks and 3, 6, and 12 months, postoperatively. MAIN OUTCOME MEASUREMENTS Constant-Murley score (CMS) and the QoL (SF-36 questionnaire) were used to assess outcome. All results were stratified according to length of follow-up, age, and fracture type. RESULTS CMS and SF-36, including the corresponding subgroups Physical Component Summary and Mental Component Summary, demonstrated continuing improvement during the period of observation. US norm values for the SF-36 were achieved after 6 months. However, speed of progress varied greatly between the scores and age groups. The fracture type significantly impacted CMS. Increasing age and complexity of fracture influenced the results negatively and cumulatively. CONCLUSION This study highlights and defines subjective improvements and changes of QoL up to 1 year after ORIF of these fractures. Increasing age and a more complex fracture type is correlated with a deceleration of functional improvement. The CMS shows a definite positive correlation with the unassisted self-evaluation of SF-36, but exchangeability could not be demonstrated.
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Graça ED, Okubo R, Shimano AC, Mazzer N, Barbieri CH. Biomechanics of four techniques for fixation of the four-part humeral head fracture. ACTA ORTOPEDICA BRASILEIRA 2013; 21:34-9. [PMID: 24453641 PMCID: PMC3862012 DOI: 10.1590/s1413-78522013000100007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 08/21/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE: To carry out a biomechanical study of four techniques for fixation of four-part humeral head fractures. METHODS: The fracture was reproduced in 40 plastic humeri, divided into groups of ten according to the fixation technique, each one employing different fixation resources, in different configurations. The humeral models were mounted on an aluminum scapula, with leather straps simulating the rotator cuff tendons, and submitted to bending and torsion tests in a universal testing machine, using relative stiffness as an evaluation parameter. Assemblies with intact humeri were analyzed for comparison. RESULTS: The biomechanical behavior of the fixation techniques varied within a wide range, where the assemblies including the DCP plate and the 4.5mm diameter screws were significantly more rigid than the assemblies with the Kirschner wires and the 3.5mm diameter screws. CONCLUSION: The four fixation techniques were able to bear loads compatible with the physiological demand, but those with higher relative stiffness should be preferred for clinical application. Laboratory investigation .
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Namdari S, Voleti PB, Mehta S. Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment. J Shoulder Elbow Surg 2012; 21:1787-95. [PMID: 22748925 DOI: 10.1016/j.jse.2012.04.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 03/22/2012] [Accepted: 04/01/2012] [Indexed: 02/01/2023]
Abstract
Fractures of the proximal humerus are relatively common injuries in the elderly population. Given the association between proximal humeral fractures and osteoporosis, elderly patients who sustain these injuries should always undergo a fragility fracture workup. Furthermore, a preoperative assessment of local bone quality can be critical in facilitating decision making regarding surgical and nonsurgical treatment. Modalities for quantifying osteoporosis in the proximal humerus include plain radiography and spiral computed tomography imaging. Optimal management of osteoporotic proximal humeral fractures has evolved and may now includes use of locking plates and augmentation with intramedullary fibular grafts, calcium phosphate or sulfate cement, and iliac crest bone graft. This article reviews the demographics of patients who sustain proximal humerus fractures, the appropriate postinjury fragility fracture workup, modalities for quantifying osteoporosis in the proximal humerus, techniques for augmenting fixation of proximal humerus fractures, and the authors' preferred approach to the treatment of these injuries.
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Affiliation(s)
- Surena Namdari
- Department of Orthopaedic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA 19104, USA
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Martetschläger F, Siebenlist S, Weier M, Sandmann G, Ahrens P, Braun K, Elser F, Stöckle U, Freude T. Plating of proximal humeral fractures. Orthopedics 2012; 35:e1606-12. [PMID: 23127451 DOI: 10.3928/01477447-20121023-17] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The optimal treatment for proximal humeral fractures is controversial. Few data exist concerning the influence of the surgical approach on the outcome. The purpose of this study was to evaluate the clinical and radiological outcomes of proximal humeral fractures treated with locking plate fixation through a deltopectoral vs an anterolateral deltoid-splitting approach. Of 86 patients who met the inclusion criteria, 70 were available for follow-up examination. Thirty-three patients were treated through a deltopectoral approach and 37 through an anterolateral deltoid-splitting approach. In all cases, open reduction and internal fixation with a PHILOS locking plate (Synthes, Umkirch, Germany) was performed. Clinical follow-up included evaluation of pain, shoulder mobility, and strength. Constant score and Disabilities of the Arm, Shoulder and Hand (DASH) score were assessed. A clinical neurological examination of the axillary nerve was also performed. Consolidation, reduction, and appearance of head necrosis were evaluated radiographically. After a mean follow-up of 33 months, Constant scores, DASH scores, and American Shoulder and Elbow Surgeons scores showed no significant differences between the groups. Clinical neurologic examination of the axillary nerve revealed no obvious damage to the nerve in either group. Deltopectoral and anterolateral detoid-splitting approaches for plate fixation of proximal humeral fractures are safe and provide similar clinical outcomes. The results of this study suggest that the approach can be chosen according to surgeon preference.
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Affiliation(s)
- Frank Martetschläger
- Clinic for Trauma Surgery, Emergency Department, University Hospital Rechts der Isar, Munich Technical University, Munich, Germany.
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Zhou ZB, Gao YS, Tang MJ, Sun YQ, Zhang CQ. Minimally invasive percutaneous osteosynthesis for proximal humeral shaft fractures with the PHILOS through the deltopectoral approach. INTERNATIONAL ORTHOPAEDICS 2012; 36:2341-5. [PMID: 22955676 DOI: 10.1007/s00264-012-1649-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 08/15/2012] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to evaluate clinical outcomes and complications following minimally invasive plate osteosynthesis (MIPO) with the proximal humeral internal locking system (PHILOS) for treating proximal humeral shaft fracture through the deltopectoral approach. METHODS Between November 2008 and March 2010, 74 patients with unilateral proximal humeral shaft fractures were treated using the MIPO technique with the PHILOS through the deltopectoral approach. Patients received an average follow-up of 16.9 (range, 12-24) months, and the final follow-up included anteroposterior and lateral imaging and recording of postoperative complications. The Constant-Murley shoulder score was used to evaluate function. RESULTS No intraoperative complications occurred. Postoperative complications included subacromial impingement in four patients. There was no deep infection, neurovascular damage, breakage or implant loosening. All fractures united in an average time of 17.4 (15-25) weeks. In terms of function, the Constant-Murley score was 85.8 points on average (range, 67-100). The range of motion of the involved shoulder was satisfactory, and pain-free in 83.8 % of patients. CONCLUSIONS Using the MIPO technique with the PHILOS through the deltopectoral approach is a valid and safe method of treating proximal humeral shaft fractures.
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Affiliation(s)
- Zu-Bin Zhou
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai 200233, China
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Pawaskar AC, Lee KW, Kim JM, Park JW, Aminata IW, Jung HJ, Chun JM, Jeon IH. Locking plate for proximal humeral fracture in the elderly population: serial change of neck shaft angle. Clin Orthop Surg 2012; 4:209-15. [PMID: 22949952 PMCID: PMC3425651 DOI: 10.4055/cios.2012.4.3.209] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 03/29/2012] [Indexed: 11/22/2022] Open
Abstract
Background We conducted this radiographic study in the elderly population with proximal humeral fracture aiming to evaluate 1) the serial changes of neck-shaft angle after locking plate fixation and 2) find relationship between change in neck shaft angle and various factors such as age, fracture pattern, severity of osteoporosis, medial support and initial reduction angle. Methods Twenty-five patients who underwent surgical treatment for proximal humeral fracture with locking plate between September 2008 and August 2010 are included. True anteroposterior and axillary lateral radiographs were made postoperatively and at each follow-up visit. Measurement of neck shaft angle was done at immediate postoperative, 3 months postoperative and a final follow-up (average, 11 months; range, 8 to 17 months). Severity of osteoporosis was assessed using cortical thickness suggested by Tingart et al. Results The mean neck shaft angles were 133.6° (range, 100° to 116°) at immediate postoperative, 129.8° (range, 99° to 150°) at 3 months postoperative and 128.4° (range, 97° to 145°) at final follow-up. The mean loss in the neck-shaft angle in the first 3 months was 3.8° as compared to 1.3° in the period between 3 months and final follow-up. This was statistically significant (p = 0.002), indicating that most of the fall in neck shaft angle occurs in the first three months after surgery. Relationship between neck shaft angle change and age (p = 0.29), fracture pattern (p = 0.41), cortical thickness (p = 0.21), medial support (p = 0.63) and initial reduction accuracy (p = 0.65) are not statistically significant. Conclusions The proximal humerus locking plate maintains reliable radiographic results even in the elderly population with proximal humerus fracture.
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Affiliation(s)
- Aditya C Pawaskar
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Dent-Acosta RE, Storm N, Steiner RS, San Martin J. The tactics of modern-day regulatory trials. J Bone Joint Surg Am 2012; 94 Suppl 1:39-44. [PMID: 22810446 DOI: 10.2106/jbjs.l.00194] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fractures are an important public health problem affecting patients of all ages. Although most fractures heal quickly, some heal poorly and some do not heal at all. To achieve an optimal healing outcome, the standard of care for most fractures consists of reduction followed by immobilization, with a myriad of options regarding the approach to fracture-healing. Currently, biopharmaceutical companies are sponsoring research with regard to products that aim to enhance or accelerate fracture-healing; however, as there are no approved and marketed systemic therapies for fracture-healing, the development and commercialization process for such products will require close collaboration between industry, academia, and regulators to determine how to bring these products to market in the most efficient manner. The following manuscript provides a brief overview of the regulatory process in the United States for systemic therapies in fracture-healing and discusses key issues that may arise in connection with the regulatory approval of these novel investigational treatments.
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Affiliation(s)
- Ricardo E Dent-Acosta
- Amgen Bone Therapeutic Area, Amgen Inc., One Amgen Center Drive, MS 38-2-C, Thousand Oaks, CA 91320, USA.
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Spross C, Platz A, Erschbamer M, Lattmann T, Dietrich M. Surgical treatment of Neer Group VI proximal humeral fractures: retrospective comparison of PHILOS® and hemiarthroplasty. Clin Orthop Relat Res 2012; 470:2035-42. [PMID: 22161081 PMCID: PMC3369075 DOI: 10.1007/s11999-011-2207-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Accepted: 11/21/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Neer Group VI proximal humeral fractures often are related to persistent disability despite surgical treatment. We retrospectively compared the outcome after open reduction and internal fixation with the PHILOS(®) plate or primary hemiarthroplasty in patients with Neer Group VI fractures focusing on complications, shoulder function, health-related quality of life (SF-36), and potential risk factors for complications. QUESTIONS/PURPOSES The aim of this study was to compare the PHILOS(®) plate with primary hemiarthroplasty for treatment of specific Neer Group VI fractures. We asked whether (1) both procedures have comparable clinical and radiologic complication rates; (2) one procedure is superior in terms of revision rate; (3) objective and subjective shoulder function (Constant-Murley score) and health-related quality of life (SF-36) were comparable in both groups at final followup; and (4) there are clinical or radiologic predictors for complications in any group? METHODS Between 2002 and 2007, 44 consecutive patients (mean, 75.2 years) with a Neer Group VI proximal humeral fracture were included. Twenty-two patients treated with a PHILOS(®) plate were compared with 22 patients treated by primary hemiarthroplasty. Both groups were similar in all criteria. At minimum followup of 12 months (mean, 30 months; range, 12-83 months), radiographic control, Constant-Murley score, and SF-36 were performed. RESULTS Fourteen patients with complications (63.6%) were counted in the PHILOS(®) plate group, of which 10 (45.4%) needed revision surgery, mostly as a result of avascular necrosis and screw cut-outs. In the primary hemiarthroplasty group, only one patient needed revision surgery (4.5%). Smoking and steroid therapy were substantially associated with complications in the PHILOS(®) plate group. There were no differences between the two groups regarding Constant-Murley or SF-36 scores. CONCLUSIONS Angular stable open reduction and internal fixation was associated with high complication and revision rates, especially in patients who smoked and those receiving steroid therapy. Primary hemiarthroplasty provides limited function, which had little influence on the quality of life in this elderly collective. There are predictive factors for complications after the treatment of Neer Group VI proximal humeral fractures with the PHILOS(®) plate. Primary hemiarthroplasty remains a good option, especially when treating elderly patients.
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Affiliation(s)
- Christian Spross
- Department of General Surgery, Trauma Division, Hospital Zurich-Triemli, Birmensdorferstrasse 497, CH-8063 Zurich, Switzerland
| | - Andreas Platz
- Department of General Surgery, Trauma Division, Hospital Zurich-Triemli, Birmensdorferstrasse 497, CH-8063 Zurich, Switzerland
| | - Matthias Erschbamer
- Department of Orthopedics, University of Zurich, Balgrist, Zurich, Switzerland
| | - Thomas Lattmann
- Department of General Surgery, Trauma Division, Hospital Zurich-Triemli, Birmensdorferstrasse 497, CH-8063 Zurich, Switzerland
| | - Michael Dietrich
- Department of General Surgery, Trauma Division, Hospital Zurich-Triemli, Birmensdorferstrasse 497, CH-8063 Zurich, Switzerland
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Abstract
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.
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Affiliation(s)
- Neil G Burke
- Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Dublin, Ireland.
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Verbeek PA, van den Akker-Scheek I, Wendt KW, Diercks RL. Hemiarthroplasty versus angle-stable locking compression plate osteosynthesis in the treatment of three- and four-part fractures of the proximal humerus in the elderly: design of a randomized controlled trial. BMC Musculoskelet Disord 2012; 13:16. [PMID: 22321162 PMCID: PMC3299658 DOI: 10.1186/1471-2474-13-16] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 02/09/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The optimal surgical management of dislocated three- and four-part fractures of the proximal humerus in elderly patients remains unclear. Most used techniques are hemiarthroplasty and angle-stable locking compression plate osteosynthesis. In the current literature there is no evidence available presenting superior results between hemiarthroplasty and angle-stable locking compression plate osteosynthesis in terms of speed of recovery, pain, patient satisfaction, functional outcome, quality of life or complications. METHODS/DESIGN A randomized controlled multicenter trial will be conducted. Patients older than 60 years of age with a dislocated three- or four-part fracture of the proximal humerus as diagnosed by X-rays and CT-scans will be included. Exclusion criteria are a fracture older than 14 days, multiple comorbidity, multitrauma, a pathological fracture, previous surgery on the injured shoulder, severely deranged function caused by a previous disease, "head-split" proximal humerus fracture and unwillingness or inability to follow instructions. Participants will be randomized between surgical treatment with hemiarthroplasty and angle-stable locking compression plate osteosynthesis. Measurements will take place preoperatively and 3 months, 6 months, 9 months, 12 months and 24 months postoperatively. Primary outcome measure is speed of recovery of functional capacity of the affected upper limb using the Disabilities of Arm, Shoulder and Hand score (DASH). Secondary outcome measures are pain, patient satisfaction, shoulder function, quality of life, radiological evaluation and complications. Data will be analyzed on an intention-to-treat basis, using univariate and multivariate analyses. DISCUSSION Both hemiarthroplasty and angle-stable locking compression plate osteosynthesis are used in the current treatment of dislocated three-and four-part fractures of the proximal humerus. There is a lack of level-1 studies comparing these two most-used surgical treatment options. This randomized controlled multicenter trial has been designed to determine which surgical treatment option provides the fastest recovery of functional capacity of the affected upper limb, and will provide better outcomes in pain, satisfaction, shoulder function, quality of life, radiological evaluation and complications. TRIAL REGISTRATION NUMBER The trial is registered in the Netherlands Trial Registry (NTR2461).
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Affiliation(s)
- Paul A Verbeek
- Department of Orthopedic Surgery University Medical Center Groningen P.O. Box 30.001 9700 RB Groningen, the Netherlands
| | - Inge van den Akker-Scheek
- Department of Orthopedic Surgery University Medical Center Groningen P.O. Box 30.001 9700 RB Groningen, the Netherlands
| | - Klaus W Wendt
- Department of Traumatology University Medical Center Groningen P.O. Box 30.001 9700 RB Groningen, the Netherlands
| | - Ron L Diercks
- Department of Orthopedic Surgery University Medical Center Groningen P.O. Box 30.001 9700 RB Groningen, the Netherlands
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Königshausen M, Kübler L, Godry H, Citak M, Schildhauer TA, Seybold D. Clinical outcome and complications using a polyaxial locking plate in the treatment of displaced proximal humerus fractures. A reliable system? Injury 2012; 43:223-31. [PMID: 22001506 DOI: 10.1016/j.injury.2011.09.024] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 09/19/2011] [Accepted: 09/23/2011] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The surgical treatment of displaced proximal humeral fractures (ORIF) is a perpetual challenge to the surgeon. For this reason, the principle of polyaxiality was developed to provide an improved primary stability of the fracture through better anchorage of the screws, especially in osteoporotic bone. The aim of this study was to present clinical results with the polyaxial locking plate in the operative treatment of proximal humerus fractures in order to determine whether the technique of polyaxiality leads to better functional outcome and lower complication rates in comparison to monoaxial plates in the literature. PATIENTS AND METHODS Seventy-three patients with displaced proximal humeral fractures were treated surgically with the polyaxial locking Suture Plate™ (Arthrex(®)) between 03/2007 and 06/2009. Fifty-two of the patients (mean age, 69.9 ± 12.1) were included in a radiographical and clinical examination using the Constant score (CS) and the Disabilities of the Arm, Shoulder and Hand score (DASH). RESULTS The follow-up examinations were on average 13.9 ± 4.5 months (10-27 months) after surgical treatment. The mean CS of the patients was 66.0 ± 13.7 points, the age- and gender-related CS was 90.9% ± 20.0% and the mean DASH score was 23.8 ± 19.8 points for the injured side. The patients with a nearly anatomical reduction of their fracture (n = 13) reached a significantly higher CS (75.1 ± 8.5; p = 0.004) and DASH-score (13.6 ± 11.6; p = 0.043) and none of these patients had a complication. The complications were identified in 12 (23.1%) cases, 5 of which involved loss of reduction. All of these 5 cases were lacking of initial medial column support and 4 of which were type C2.3 AO-Classification. CONCLUSION The data show that the combination of angular stability with the possibility of variable polyaxial screw direction is a good concept for reduction and fixation of displaced proximal humeral fractures, but anatomical reduction and medial support remain important preconditions for a good outcome. However, a significantly lower rate of complications or better clinical outcome than that reported in the literature could not be found.
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Affiliation(s)
- M Königshausen
- Department of General and Trauma Surgery, BG Universitätsklinikum Bergmannsheil, Ruhr-Universität Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany.
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Hatzidakis AM, Shevlin MJ, Fenton DL, Curran-Everett D, Nowinski RJ, Fehringer EV. Angular-stable locked intramedullary nailing of two-part surgical neck fractures of the proximal part of the humerus. A multicenter retrospective observational study. J Bone Joint Surg Am 2011; 93:2172-9. [PMID: 22159852 DOI: 10.2106/jbjs.j.00754] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The ideal fixation technique for the treatment of proximal humeral fractures remains unclear. In the present study, we evaluated the experience of three surgeons with the treatment of two-part surgical neck fractures with angular-stable intramedullary fixation. METHODS Forty-eight patients with forty-eight Neer two-part surgical neck proximal humeral fractures were managed with locked angular-stable intramedullary nail fixation by three surgeons. Shoulder pain and outcomes were quantified with Constant scores and standard radiographs. RESULTS Thirty-eight patients (including twenty-eight female patients and ten male patients) with a mean age of sixty-five years were followed for at least twelve months (mean, twenty months; range, twelve to thirty-six months). All fractures healed primarily. The mean follow-up Constant score (and standard deviation) was 71 ± 12 points (range, 37 to 88 points), with a mean age-adjusted Constant score of 97% (range, 58% to 119%). The mean Constant pain score was 13 ± 2.2 (possible range, 0 to 15 points, with 15 points representing no pain). The mean forward flexion was 132° ± 22°. All fractures but one healed with a neck-shaft angle of ≥125°. CONCLUSIONS Patients who were managed with locked angular-stable intramedullary nailing of two-part surgical neck proximal humeral fractures via an articular entry point had reliable fracture-healing, favorable clinical outcomes, and little residual shoulder pain.
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Widmer BJ, Bassora R, Warrender WJ, Abboud JA. Thromboembolic events are uncommon after open treatment of proximal humerus fractures using aspirin and compression devices. Clin Orthop Relat Res 2011; 469:3332-6. [PMID: 21656313 PMCID: PMC3210257 DOI: 10.1007/s11999-011-1942-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Thromboembolic phenomena have long been recognized as a major cause of morbidity and mortality in hospitalized patients, especially those undergoing reconstructive surgery. We have been empirically treating patients with aspirin, early ambulation, and mechanoprophylaxis after operative management of proximal humerus fractures. However, we have not established the incidence of postoperative deep vein thrombosis and pulmonary embolism in this population. QUESTIONS/PURPOSES We determined the incidence of deep vein thrombosis and pulmonary embolism in patients having surgery for displaced proximal humerus fractures treated with our thromboprophylactic regimen. PATIENTS AND METHODS We prospectively followed 50 patients with proximal humerus fractures who underwent fixation with plate osteosynthesis (n = 40) or hemiarthroplasty (n = 10) between August 2005 and December 2008. Deep vein thrombosis prophylaxis consisted of oral enteric-coated aspirin, pneumatic calf compression pumps, and early ambulation in all patients unless medically contraindicated. Color-flow Doppler ultrasound of the affected arm and both lower extremities was performed at a mean of 14 days (range, 7-21 days) postoperatively to evaluate for deep vein thrombosis. All patients clinically suspected to have suffered a pulmonary embolism underwent a CT angiogram. RESULTS We identified no patients with deep vein thrombosis or pulmonary embolism in this population. CONCLUSIONS Deep vein thrombosis and pulmonary embolism are not uncommon after major reconstructive surgery about the shoulder in untreated patients. Our data suggest these events can be low after surgery for proximal humerus fractures followed by a thromboprophylactic regimen including aspirin, mechanical devices, and early mobilization. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Benjamin J. Widmer
- University of Pennsylvania Health System, 3B Orthopaedics, Pennsylvania Hospital/Lankenau Hospital, 800 Spruce Street, 8th Floor Preston, Philadelphia, PA 19107 USA
| | | | - William J. Warrender
- University of Pennsylvania Health System, 3B Orthopaedics, Pennsylvania Hospital/Lankenau Hospital, 800 Spruce Street, 8th Floor Preston, Philadelphia, PA 19107 USA
| | - Joseph A. Abboud
- University of Pennsylvania Health System, 3B Orthopaedics, Pennsylvania Hospital/Lankenau Hospital, 800 Spruce Street, 8th Floor Preston, Philadelphia, PA 19107 USA
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84
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Jones CB, Sietsema DL, Williams DK. Locked plating of proximal humeral fractures: is function affected by age, time, and fracture patterns? Clin Orthop Relat Res 2011; 469:3307-16. [PMID: 21691910 PMCID: PMC3210268 DOI: 10.1007/s11999-011-1935-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Locking plate fixation of proximal humeral fractures improves biomechanical stability. It has expanded the indications of traditional open reduction internal fixation and become increasingly common for treating unstable, displaced proximal humeral fractures. Despite improved stability it is unclear whether these improve function and if so for which patients. QUESTIONS/PURPOSES We therefore determined patient function after a locked plating technique for the treatment of unstable proximal humeral fractures based on age, time, fracture pattern, and associated injures. PATIENTS AND METHODS We retrospectively reviewed 66 patients with 69 proximal humeral fractures treated with a locked proximal humeral plating technique from 2002-2006 using prospectively gathered data. Function was measured using the Short Musculoskeletal Function Assessment (SMFA), Disability of the Arm, Shoulder, and Hand (DASH), and SF-36 at 6, 12, and 24 months. Fracture healing was determined radiographically and complication rates were determined from the medical records. RESULTS At 2 years, DASH scores were 26.5 and 37.4 for isolated and polytrauma patients, respectively. For age differences, DASH scores were 33.1 and 28.9 for ages younger than 60 and 60 years old or older, respectively. At 2 years, SMFA scores were higher (worse) in older compared with younger patients. Function, but not bother continues to improve in younger patients up to 2 years. More severe fracture patterns performed worse in all SMFA indices at 2 years. Polytrauma patients consistently experienced worse mobility than isolated injury patients at each time interval. CONCLUSIONS With locked plating of unstable proximal humeral fractures, older patients function as well as younger patients; improvement continues until 1 year postoperatively, the Neer fracture classification differentiates function, and polytrauma patients perform worse clinically. Long-term functional deficits persist. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Clifford B. Jones
- Orthopaedic Associates of Michigan, Michigan State University, 230 Michigan Street NE, Suite 300, Grand Rapids, MI 49503 USA
| | - Debra L. Sietsema
- Orthopaedic Associates of Michigan, Michigan State University, Grand Rapids, MI USA
| | - Daniel K. Williams
- Grand Rapids Orthopaedic Surgical Residency Program, Grand Rapids, MI USA
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85
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Eid A, Osman M, Fekry HE. Percutaneous fixation with Schanz screws for displaced two- and three- part fractures of the proximal humerus in patients above fifty years of age. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2011; 5:38-43. [PMID: 21897582 PMCID: PMC3157096 DOI: 10.4103/0973-6042.83195] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PURPOSE The aim of this study is to evaluate whether two 3.0 mm Schanz screws in two-part proximal humeral fractures (plus one additional Schanz screw or K wire in three-part fractures) can provide enough stability to allow early mobilization until healing occurs in elderly patients. SETTINGS AND DESIGN This prospective study was performed in the Orthopaedic Department of our University Hospital. PATIENTS AND METHODS We performed closed reduction and percutaneous pinning for thirty-three patients with proximal humerus fractures. Twenty-seven patients were available for the final follow-up. Of those 27 patients, 17 had two-part surgical neck fractures; while 10 had three-part fractures. For fixation, we used two 3.0 mm Schanz screws in patients with two-part fractures plus one additional Schanz screw or K wire in the 10 patients with three-part fractures. RESULTS The mean Constant score modified according to the age and sex was 89.8% (range: 77.3-97.2%). Fifteen patients had excellent results, 11 patients had good results, and one patient had a fair result. CONCLUSION Closed reduction and percutaneous pinning with two Schanz screws for two-part surgical neck humeral fractures, plus an additional Schanz screw or K wire for three-part proximal humeral fractures is a useful and effective technique that provides enough stability to allow an early rehabilitation program till union occurs in elderly patients. LEVEL OF EVIDENCE IV; therapeutic study, case series.
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Affiliation(s)
- Abdelsalam Eid
- Department of Orthopaedic Surgery, Faculty of Medicine, Zagazig University, Egypt
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86
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Bae JH, Oh JK, Chon CS, Oh CW, Hwang JH, Yoon YC. The biomechanical performance of locking plate fixation with intramedullary fibular strut graft augmentation in the treatment of unstable fractures of the proximal humerus. ACTA ACUST UNITED AC 2011; 93:937-41. [DOI: 10.1302/0301-620x.93b7.26125] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We evaluated the biomechanical properties of two different methods of fixation for unstable fractures of the proximal humerus. Biomechanical testing of the two groups, locking plate alone (LP), and locking plate with a fibular strut graft (LPSG), was performed using seven pairs of human cadaveric humeri. Cyclical loads between 10 N and 80 N at 5 Hz were applied for 1 000 000 cycles. Immediately after cycling, an increasing axial load was applied at a rate of displacement of 5 mm/min. The displacement of the construct, maximum failure load, stiffness and mode of failure were compared. The displacement was significantly less in the LPSG group than in the LP group (p = 0.031). All maximum failure loads and measures of stiffness in the LPSG group were significantly higher than those in the LP group (p = 0.024 and p = 0.035, respectively). In the LP group, varus collapse and plate bending were seen. In the LPSG group, the humeral head cut out and the fibular strut grafts fractured. No broken plates or screws were seen in either group. We conclude that strut graft augmentation significantly increases both the maximum failure load and the initial stiffness of this construct compared with a locking plate alone.
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Affiliation(s)
- J.-H. Bae
- Department of Orthopaedic Surgery, Korea University College of Medicine, Ansan Hospital, Gojan 1 Dong, Danwon-gu, Ansan-si, Gyeonggi-do, 425-707, Korea
| | - J.-K. Oh
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, 97 Gurodong-gil, Guro-gu, Seoul, 152-703, Korea
| | - C.-S. Chon
- SOLCO Biomedical Institute, 34-36 Geumam, Seotan, Pyungtaek, Gyeonggi-do, 451-852, Korea
| | - C.-W. Oh
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, 50, 2-Ga, Samdok, Chunggu, Daegu, 700-721, Korea
| | - J.-H. Hwang
- Division of Pediatric, Orthopaedics, Yonsei University College of Medicine, Severance Children’s Hospital, 250 Seongsanno, Seodaemun-gu, Seoul, 120-752, Korea
| | - Y.-C. Yoon
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, 97 Gurodong-gil, Guro-gu, Seoul, 152-703, Korea
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87
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Röderer G, Sperfeld AD, Hansen P, Krischak G, Gebhard F, Kassubek J. Electrophysiological assessment of the deltoid muscle after minimally invasive treatment of proximal humerus fractures - a clinical observation. Open Orthop J 2011; 5:223-8. [PMID: 21760869 PMCID: PMC3134951 DOI: 10.2174/1874325001105010223] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 05/02/2011] [Accepted: 05/11/2011] [Indexed: 11/22/2022] Open
Abstract
The minimal anterolateral acromial approach offers a less invasive access to the proximal humerus. Functional impairment following this procedure may be caused by paresis of the deltoid muscle as a result of iatrogenic injury to the axillary nerve. It was addressed whether electromyography (EMG) of the deltoid muscle gives evidence for an axillary nerve lesion in association with the minimal anterolateral acromial approach. Twenty-three patients (14 men, 9 women; average age 58 years) with proximal humerus fractures were included in this clinical observation. Follow-up was performed 6 weeks (6w), 6 months (6m) and 12 months (12m) postoperatively. EMG changes indicating either lesion of the axillary nerve or direct muscle trauma were distinguished in “acute”, “chronic” and “combined” and semi quantified in “slight”, “moderate” and “severe”. Patients were examined clinically (standard neurological examination and Constant Score). Three cases of incomplete axillary nerve lesion with limited functional impairment were detected. Subclinical EMG signs of neural impairment of the deltoid muscle were observed frequently (6w, N = 8; 6m, N = 8; 12m, N = 7). Functional outcome did not show an association with EMG. Most patients presented with subclinical and most likely trauma- related neurogenic lesions of the deltoid muscle following the anterolateral acromial approach. Despite the fact that the axillary nerve does not function normally following this less-invasive approach for fixation of proximal humerus fractures, this does not appear to affect the clinical outcome. Prospective studies with larger sample sizes are required to determine the effect of axillary nerve retraction in the more commonly used deltopectoral approach.
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Affiliation(s)
- Götz Röderer
- University of Ulm, Department of Orthopaedic Trauma, Steinhövelstraße 9, D-89075 Ulm, Germany
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88
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Boileau P, Pennington SD, Alami G. Proximal humeral fractures in younger patients: fixation techniques and arthroplasty. J Shoulder Elbow Surg 2011; 20:S47-60. [PMID: 21281922 DOI: 10.1016/j.jse.2010.12.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 12/07/2010] [Accepted: 12/07/2010] [Indexed: 02/08/2023]
Affiliation(s)
- Pascal Boileau
- Department of Orthopaedic Surgery and Sports Traumatology, Hôpital de L'Archet, University of Nice, France.
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89
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The biomechanics of locked plating for repairing proximal humerus fractures with or without medial cortical support. ACTA ACUST UNITED AC 2011; 69:1235-42. [PMID: 20118814 DOI: 10.1097/ta.0b013e3181beed96] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Comminuted proximal humerus fracture fixation is controversial. Locked plate complications have been addressed by anatomic reduction or medial cortical support. The relative mechanical contributions of varus malalignment and lack of medial cortical support are presently assessed. METHODS Forty synthetic humeri divided into three subgroups were osteotomized and fixed at 0 degrees, 10 degrees, and 20 degrees of varus malreduction with a locking proximal humerus plate (AxSOS, Global model; Stryker, Mahwah, NJ) to simulate mechanical medial support with cortical contact retained. Axial, torsional, and shear stiffness were measured. Half of the specimens in each of the three subgroups underwent a second osteotomy to create a segmental defect simulating loss of medial support with cortex removed. Axial, torsional, and shear stiffness tests were repeated, followed by shear load to failure in 20 degrees of abduction. RESULTS For isolated malreduction with cortical contact, the construct at 0 degrees showed statistically equivalent or higher axial, torsional, and shear stiffness than other subgroups examined. Subsequent removal of cortical support in half the specimens showed a drastic effect on axial, torsional, and shear stiffness at all varus angulations. Constructs with cortical contact at 0 degrees and 10 degrees yielded mean shear failure forces of 12965.4 N and 9341.1 N, respectively, being statistically higher (p < 0.05) compared with most other subgroups tested. Specimens failed primarily by plate bending as the humeral head was pushed down medially and distally. CONCLUSIONS Anatomic reduction with the medial cortical contact was the stiffest construct after a simulated two-part fracture. This study affirms the concept of medial cortical support by fixing proximal humeral fractures in varus, if absolutely necessary. This may be preferable to fixing the fracture in anatomic alignment when there is a medial fracture gap.
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90
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Yang H, Li Z, Zhou F, Wang D, Zhong B. A prospective clinical study of proximal humerus fractures treated with a locking proximal humerus plate. J Orthop Trauma 2011; 25:11-7. [PMID: 21085030 DOI: 10.1097/bot.0b013e3181d2d04c] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this prospective study was to evaluate the safety, efficacy, and functional outcome of the locked proximal humerus plate (LPHP) to treat proximal humerus fractures. DESIGN Prospective clinical trial. SETTING University orthopedic center. PATIENTS Over a 25-month period, 64 consecutive patients were treated with a LPHP for an unstable or displaced proximal humerus fracture. INTERVENTION Demographic data, trauma mechanisms, surgical approaches, and postoperative complications were collected from medical records. Fracture classification according to the Neer classification, radiographic head-shaft angle, and screw tip-articular surface distance in true anteroposterior and axillary lateral radiographs of the shoulder were measured postoperatively. MAIN OUTCOME MEASUREMENTS The functional outcome was evaluated with a Constant-Murley (CM) evaluation. The CM score is a validated shoulder-specific scoring system in which patients report subjective findings. The physician reported the objective measurements of the shoulder. RESULTS Follow-ups were completed for all of the patients. The overall complication rate was 35.9%, with screw penetration into the glenohumeral joint as the most frequent problem (7.6%). Deep wound infections were observed in 3.1% (n = 2) of the cases and avascular necrosis in 3.1% (n = 2). All complications occurred in 4-part fractures. Subacromial impingement, frozen shoulder, rotator cuff rupture, and wound dehiscence were observed in 3.1% (n = 2), 3.1% (n = 2), 1.6% (n = 1), and 1.6% (n = 1) of the cases, respectively. Multivariate linear regression analysis revealed that the fracture pattern and the presence or absence of medial support were significant predictors of functional outcome (P = 0.026 and P = 0.003, respectively). Patient age (P = 0.581), sex (P = 0.325), and initial tuberosity displacement (varus/extension or valgus/impaction; P = 0.059) were not significantly associated with the CM score. CONCLUSIONS The LPHP seems to be a promising implant for the fixation of proximal humerus fractures. However, there are certain limitations that should be mentioned. The number of cases in our study was small, and no safe conclusions can be extracted regarding the rate of avascular necrosis. Additional studies with larger cohorts and longer follow-ups are necessary to better define the appropriate indications for and expected outcomes of this technology.
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Affiliation(s)
- Huiguang Yang
- Department of Orthopedics, Jiangyin People's Hospital, Medical School of Nantong University, No. 163 Shoushan Road, Jiangyin City, Jiangsu Province, China.
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91
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Shin SJ, Do NH, Song MH, Sohn HS. Minimal Invasive Plate Osteosynthesis in Proximal Humerus Fractures. Clin Shoulder Elb 2010. [DOI: 10.5397/cise.2010.13.2.202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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92
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Aggarwal S, Bali K, Dhillon MS, Kumar V, Mootha AK. Displaced proximal humeral fractures: an Indian experience with locking plates. J Orthop Surg Res 2010; 5:60. [PMID: 20731844 PMCID: PMC2933712 DOI: 10.1186/1749-799x-5-60] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 08/23/2010] [Indexed: 11/29/2022] Open
Abstract
Background The treatment of displaced proximal humerus fractures, especially in elderly, remains controversial. The objective of this study was to evaluate functional outcome of locking plate used for fixation of these fractures after open reduction. We also attempted to evaluate the complications and predictors of loss of fixation for such an implant. Methods Over two and a half years, 56 patients with an acute proximal humerus fracture were managed with locking plate osteosynthesis. 47 of these patients who completed a minimum follow up of 1 year were evaluated using Constant score calculation. Statistical analysis was done using SPSS 16 and a p value of less than 0.05 was taken as statistically significant. Results The average follow up period was around 21.5 months. Outcomes were excellent in 17%, good in 38.5%, moderate in 34% while poor in 10.5%. The Constant score was poorer for AO-OTA type 3 fractures as compared to other types. The scores were also inferior for older patients (> 65 years old). Complications included screw perforation of head, AVN, subacromial impingement, loss of fixation, axillary nerve palsy and infection. A varus malalignment was found to be a strong predictor of loss of fixation. Conclusion Locking plate osteosynthesis leads to satisfactory functional outcomes in all the patients. Results are better than non locking plates in osteoporotic fractures of the elderly. However the surgery has steep learning curve and various complications could be associated with its use. Nevertheless we believe that a strict adherence to the principles of locking plate use can ensure good result in such challenging fractures.
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Affiliation(s)
- Sameer Aggarwal
- Deptartment of Orthopaedics, PGIMER, Chandigarh Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012, India.
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93
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Abstract
OBJECTIVES To describe the minimally invasive treatment of fractures of the proximal humerus using the Non-Contact-Bridging (NCB) plate. The system allows secondary locking of screws to the plate with a locking cap and polyaxial (30 degrees radius) screw placement. DESIGN Prospective cohort study. SETTING University Level I trauma center. PATIENTS Fifty-four patients with unstable fractures of the proximal humerus. INTERVENTION Minimal anterolateral acromial approach to the proximal humerus, percutaneous fracture reduction, and minimally invasive application of the NCB plate. MAIN OUTCOME MEASUREMENTS Constant Score and radiologic follow-up (anteroposterior and transscapular). Visual Analog Scale for subjective evaluation of pain and function. RESULTS After 17 months, the average Constant Score was 66.8 points (87% of the age- and sex-related normal values). Implant-related complications (plate impingement, screw perforation into the glenohumeral joint, loosening of screws) occurred in nine cases (17%). The rate of avascular necrosis was low (5.5%) and no cases of nonunion were seen. CONCLUSIONS The effectiveness of the NCB is similar to other published methods of treatment for fractures of the proximal humerus and potentially provides a less invasive option for this problem. Complication rates and functional outcome in this series are comparable to the literature. An important factor in this technique is the process of percutaneous fracture reduction. The NCB plate is suitable for both a minimally invasive technique or standard open reduction and internal fixation through a deltopectoral approach; the surgeon must decide which approach is best for each particular fracture pattern and should be comfortable with both techniques.
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94
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[Biomechanical investigation of fixed-angle plate osteosynthesis of the proximal humerus]. Unfallchirurg 2010; 113:133-8. [PMID: 20024525 DOI: 10.1007/s00113-009-1672-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Proximal humeral fractures are common in the elderly population and are often associated with osteoporosis. Fixation of unstable proximal humeral fractures is problematic due to loss of fixation in osteoporotic bone. Fixed-angle devices are intended to provide superior mechanical stability due to the principle of an internal fixator. The NCB(R)-PH (non-contact-bridging proximal humerus) plate is a new fixed-angle device that locks the screws to the plate by secondary insertion of a locking cap. The aim of this study was to investigate if and to what extent NCB-PH plates applied in the locked mode provide higher mechanical stability in a proximal humerus fracture model. METHODS For this investigation 16 (8 pairs) fresh frozen cadaveric humeri were used. An AO/ASIF 11-B 1 fracture of the proximal humerus was created in each bone and fixed with the NCB-PH plate. In a paired setting one bone was fixed with the plate in the locked mode and the other with the plate in the non-locked mode. The bones were then subjected to 100 cycles of axial loading and interfragmentary motion was measured. Bones surviving this test were subjected to load-to-failure testing and the force at which failure occurred was recorded. RESULTS Bones fixed with the plate in the locked mode showed a statistically significant lower (51%) interfragmentary rotation compared to bones fixed with the plate in the non-locked mode. There was also a tendency for the bones fixed with the plate in the locked mode to fail first under higher forces (16%) during load-to-failure testing. CONCLUSION The NCB-PH plate provides superior interfragmentary stability when used in the locked mode in a human cadaveric proximal humerus fracture model. Therefore, we recommend that all screws should be inserted in the locked mode. The results suggest that the NCB-PH plate in the locked mode provides higher primary postoperative stability thus permitting early functional treatment of the patient.
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95
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Faraj D, Kooistra BW, Vd Stappen WAH, Werre AJ. Results of 131 consecutive operated patients with a displaced proximal humerus fracture: an analysis with more than two years follow-up. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2010; 21:7-12. [PMID: 21837232 PMCID: PMC3150824 DOI: 10.1007/s00590-010-0655-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Accepted: 05/13/2010] [Indexed: 01/05/2023]
Abstract
Objective The purpose of this study is to determine the efficacy of the open reduction and fixation of a dislocated proximal humerus fracture with a locking plate, also evaluating the incidence of complications and functional recovery of the shoulder. A retrospective study focusing on patients who had suffered a fracture of the proximal humerus and were treated by means of an open reduction and internal fixation with a locking plate, using either the Philos or the LPHP plate. We have also included a comparison of these two plates. Method Ninety-two patients were found to be eligible and were included in our study. These patients had all been treated for a proximal humerus fracture between 2002 and 2008. We included those patients who could be classified as a class 2, 3, or 4 according to the Neer classification. Demographic data, surgical technique, and peri/post-operative complications were collected from medical records. Patients were followed-up and the Oxford Shoulder Score (OSS) was filled in by phone. The mean age of our patient population was 66.2 (15–97), with a male: female ratio of 1:5 (15:77). (The median follow-up was 2.4 years (0.2–5.8). Fourteen of our patients died during follow-up, while 25 patients were otherwise lost to follow-up. For this study, out of the original 131 patients, this finally resulted in 92 patients whom we followed-up post-operatively. Results Ninety-two patients (70%, 92/131) were interviewed. The mean Oxford Shoulder Score (OSS) was 19.76 (11–54). The overall complication rate was 39.1% (36/92). The most frequently occurring complications in our patient population were hemorrhage 3.3%; dislocation of the caput humeri and/or tuberculum majus 2.2%; persistent pain 3.3%; Avascular necrosis (AVN) of the humeral head 0%; Loss of reduction and screw cutout 6.5%; Plate breakout 6.5%; Subacromial Impingement 11.9%; Frozen shoulder 3.3%; rotator cuff rupture 1.1%, and infection 1.1%. Of the entire group of patients originally included in this study, 29% was re-operated due to one of the above-mentioned complications. Conclusion In conclusion, the locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures. The incidence of complications and subsequent re-operation is relatively high, however, comparable to or slightly better when compared to data found in literature. Subacromial Impingement seems to occur more frequently when a Philos plate is implemented. We therefore suggest that randomized clinical trials determining the possible superiority of one specific type of plate in patients with a displaced proximal humerus fracture are to be performed in future.
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Affiliation(s)
- D Faraj
- Department of Surgery, Canisius Wilhelmina Hospital, P.O. Box 9015, 6500 GS Nijmegen, The Netherlands
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96
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Clavert P, Adam P, Bevort A, Bonnomet F, Kempf JF. Pitfalls and complications with locking plate for proximal humerus fracture. J Shoulder Elbow Surg 2010; 19:489-94. [PMID: 19995683 DOI: 10.1016/j.jse.2009.09.005] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Revised: 08/03/2009] [Accepted: 09/10/2009] [Indexed: 02/01/2023]
Abstract
PURPOSE The aim of this study was to identify specific complications of locking plate fixation of proximal humerus fractures. PATIENTS AND METHODS Seventy-three adult patients with a displaced 3- (24%) or 4-part (76%) fracture of the proximal humerus were treated over a period of 2 years under the supervision of a trauma surgeon. Fourty-four patients came back for a clinical and radiographic examinations at least 18 months after the trauma; the others were evaluated at 6 weeks and 3 and 6 months. RESULTS Out of the 73 patients (64.4% females, mean age of 65), 11 patients needed a second surgery and 18 were lost for follow-up after 6 months. Mean final constant score was 62.3 points. The incidence of secondary displacement was 8.2%. Nonunion rate was 5.5%, affecting the constant score (P = .018). 16.4% of the patients developed a partial necrosis of the humeral head at the latest follow-up, which influenced on the constant score (P = .029). Quality of the reduction of the greater tuberosity influenced final results (P = .037). Screw cutout rate was 13.7%, with an influence to the constant score (P = .001). A too high plate positioning influenced the constant score (P = .002). CONCLUSION Locked screw-plates provide more secure fixation of fractures, especially in weak bone. Complications rate remains high. Two complications are to be distinguished: 1) technical complications in plate positioning, length of the screws or secondary screw cutout strongly influence the final clinical result; and 2) specific complications related to this technology such as pseudarthrosis or plate fracture.
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Affiliation(s)
- Philippe Clavert
- Shoulder and Elbow Service, CCOM-CHU Strasbourg, Illkirch, France.
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97
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Biomechanical comparison of a proximal humeral locking plate using two methods of head fixation. J Shoulder Elbow Surg 2010; 19:495-501. [PMID: 20189837 DOI: 10.1016/j.jse.2009.11.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Revised: 11/01/2009] [Accepted: 11/06/2009] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS Locking plates have emerged as the implant of choice for stabilization of proximal humeral fractures. The biomechanical properties of a locked plating system using smooth pegs vs threaded screws for fixation of the humeral head were compared to test the hypothesis that there would be no biomechanical difference between pegs and threaded screws. MATERIALS AND METHODS Sixteen pairs of fresh frozen cadaveric humeri were randomized to have a surgical neck gap osteotomy stabilized with a locked plate using threaded screws (n=8) or smooth pegs (n=8). The intact contralateral humerus served as a control. Each specimen was tested with simultaneous cyclic axial compression (40 Nm) and torsion (both +/-2 Nm and +/-5 Nm) for 6000 cycles. All specimens were loaded to failure. Interfragmentary motion and load-displacement curves were analyzed to identify differences between the groups. Our data were then compared to previously published forces across the glenohumeral joint to provide evidence based recommendations for postoperative use of the shoulder. RESULTS There was a statistically significant difference between test specimens and their paired control (P < .001) in cyclic testing and load to failure. Differences between the smooth pegs and threaded screws were not statistically significant. DISCUSSION There is no biomechanical difference between locked smooth pegs and locked threaded screws for proximal fragment fixation in an unstable 2-part proximal humeral fracture model. CONCLUSION Our study contributes to the published evidence evaluating forces across the glenohumeral joint and suggests that early use of the affected extremity for simple activities of daily living may be safe. Use of the arm for assisted ambulation requiring a crutch, cane, walker, or wheelchair should be determined on a case-by-case basis.
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98
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Junior ACT, Ribeiro FR, Filho RB, Filho CSF, da Costa GL, Menniti EL. EVALUATION OF SURGICAL TREATMENT OF FRACTURES IN TWO OR THREE PARTS OF THE PROXIMAL HUMERUS WITH THE "PARACHUTE TECHNIQUE". Rev Bras Ortop 2010; 45:241-6. [PMID: 27022548 PMCID: PMC4799108 DOI: 10.1016/s2255-4971(15)30364-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objective: To evaluate the efficacy and safety of the surgical technique called the “parachute technique, as applied to adult patients who suffered displaced and unstable two or three-part fractures of the proximal humerus, through the clinical outcomes. Methods: Between January 1995 and June 2006, 59 adult patients with displaced and unstable two or three-part fractures underwent operations performed by the Shoulder and Elbow Group of the Orthopedics and Traumatology Service of Hospital do Servidor Público Estadual de São Paulo using the “parachute technique. This method consists of an intramedullary tension band and extramedullary fixation in a figure-of-eight to join the fragments of the fracture, using a 6.5-millimeter spongy screw with partial threading, a washer and two non-absorbable wires, thereby producing stable synthesis with minimal aggression to the surrounding soft tissue and not requiring any subsequent removal of material. The final shape of this synthesis is reminiscent of the shape of an open parachute. The patients had a minimum postoperative follow-up of six months. For the diagnosis, trauma series radiographic views of the shoulder were produced. The fractures were classified in accordance with the system proposed by Neer. We used the scale of the University of California, Los Angeles (UCLA), to evaluate the results. Results: The “parachute technique” produced good results in 47% and excellent results in 26% of the cases, according to the UCLA scores. Conclusion: The “parachute technique” is a safe and effective treatment for displaced and unstable two or three-part fractures of the proximal humerus.
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Affiliation(s)
| | - Fabiano Rebouças Ribeiro
- Attending physician in the Shoulder Group, Orthopedics and Traumatology Service, HSPE-IAMSPE, Sao Paulo
| | - Rômulo Brasil Filho
- Attending physician in the Shoulder Group, Orthopedics and Traumatology Service, HSPE-IAMSPE, Sao Paulo
| | | | | | - Eduardo Libório Menniti
- Collaborating Physician in the Shoulder Group, Orthopedics and Traumatology Service, HSPE-IAMSPE, Sao Paulo
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99
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Second generation locked plating of proximal humerus fractures--a prospective multicentre observational study. INTERNATIONAL ORTHOPAEDICS 2010; 35:425-32. [PMID: 20419453 DOI: 10.1007/s00264-010-1015-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 03/24/2010] [Accepted: 03/28/2010] [Indexed: 10/19/2022]
Abstract
Surgical treatment of most displaced proximal humerus fractures is challenging due to osteoporosis. Locking plates are intended to provide superior mechanical stability. In a prospective multicentre study 131 patients were treated with second generation locked plating (NCB-PH, Zimmer, Inc.). The open procedure (n = 78) was performed using a deltopectoral approach; the minimally invasive technique (n = 53) involved percutaneous reduction and an anterolateral deltoid split approach. Clinical and radiological follow-up was obtained. Improvement in function (ROM) was statistically significant. Fracture type (AO) had the most significant impact on the incidence of complications. The most frequent complications detected were intra-articular screw perforation (15%) and secondary displacement (8%). Complication rate and functional outcome of the NCB-PH are comparable to reports in the literature. Not all problems are likely to be solved by this new generation of implants, i.e. secondary dislocation still occurred in 8% of our patients.
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100
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Management of proximal humeral fractures: surgeons don't agree. J Shoulder Elbow Surg 2010; 19:446-51. [PMID: 19800259 DOI: 10.1016/j.jse.2009.06.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Revised: 06/24/2009] [Accepted: 06/29/2009] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The management options for proximal humeral fractures have expanded in recent years. Patients with displaced, unstable proximal humeral fractures may have improved outcomes if managed operatively. We investigated the decision making of fellowship-trained orthopedic surgeons when presented with the same group of cases. We hypothesized that interobserver and intraobserver agreement for surgical management would be poor and independent of fellowship training. METHOD Eight fellowship-trained orthopedic surgeons (3 shoulder, 5 trauma) viewed the preoperative plain radiographs of patients with proximal humeral fractures. All surgeons viewed the same 38 radiographs in a blinded fashion. Surgeons chose from 1 of 6 management options. Interobserver variability was calculated by using the weighted kappa coefficient. Intraobserver variability was calculated by comparing each surgeon's survey results with the operation they originally performed. RESULTS Overall interobserver agreement on management was moderate (weighted kappa=0.41) and did not differ significantly between trauma surgeons and shoulder surgeons. Reducing the number of management choices increased agreement between all surgeons. Testing for intraobserver agreement showed that surgeons picked the same operation in the survey as in the actual clinical setting only 56% of the time. CONCLUSION Interobserver agreement was moderate overall and improved when the number of management choices was reduced. Intraobserver agreement was less frequent, however, raising the question about consistent decision making by a given surgeon. Although surgeons agree in the method of treatment only to a modest degree, it remains for further outcomes research to establish if the choice of treatment actually influences the clinical outcome.
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