Treatment of proximal humerus fractures with locking plates: a systematic review

[Update on shoulder surgery 2010: current treatment strategies for traumatic lesions of the shoulder]

The article summarizes the basic literature findings and innovations in the treatment of traumatic shoulder lesions published during the last 3 years. It covers trends in acromioclavicular joint dislocation, traumatic shoulder instability, rotator cuff tears as well as fractures of the humeral head. In particular prospective clinical studies with a high level of evidence are cited, which concern about the outcome of surgical and non-surgical treatment methods and the optimal point for treatment. The aim of this review is therefore to provide direct implications for the clinical treatment algorithm of such lesions.

Da Vinci System: clinical experience with complex proximal humerus fractures

The purpose of this study is to report the clinical and radiographic outcomes after open reduction and internal fixation of displaced proximal humerus fractures with the "Da Vinci System". It is a triangle-shaped cage whose opposite faces are pierced, and it represents the evolution of a triangle-shaped bone block technique performed in a previous series of 33 patients. The new device is an interesting innovation to treat the difficult problem of fracture fragments reconstruction and stability, metaphyseal bone loss and proximal humerus revascularization. According to the technique, authors position the correct size titanium cage into the metaepiphysis, so that the fragments are reduced upon the cage, and they are stabilized with a minimal osteosynthesis by Kirschner wires, titanium screws or transosseous sutures. If the fracture line involves the proximal portion of the diaphysis, it is possible to use a short low profile plate. Between May 2005 and November 2009, we treated 71 patients (34 men and 37 women), even though we included in our study only 59 patients, who had a minimum follow-up of 12 months. The first patient has been treated in May 2005 and the last one in September 2008. The mean age was 60.8 years (minimum 27, maximum 78). There were 8 displaced 3-part fractures, 20 displaced 4-part fractures, 10 4-part fracture-dislocations, 5 head splitting, 12 unclassified multifragmentary fractures, 1 2-part fracture with multifragmentary calcar and 3 malunions of 4-part fracture. The functional results were evaluated by the Constant score. With a mean follow-up of 24 months (minimum 12, maximum 36 months), the mean Constant score was 80.25. The results were excellent or good in 48 cases, bad in 2 cases and satisfactory in 9; the mean active anterior elevation (AAE) was 160 degrees . All fractures but one healed; in one case, we had a deep infection after 80 days since the operation, treated with a preformed cement spacer.

Results of 131 consecutive operated patients with a displaced proximal humerus fracture: an analysis with more than two years follow-up

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.