Mid-term results of minimally invasive deltoid-split versus standard open deltopectoral approach for PHILOS™ (proximal humeral internal locking system) osteosynthesis in proximal humeral fractures

The Application of Bidirectional Rapid Reductor in Minimally Invasive Plate Osteosynthesis for the Treatment of Proximal Humeral Fractures: A Case Series

OBJECTIVE

Rapid and effective reduction is difficult for minimally invasive plate osteosynthesis (MIPO) surgery. This study aims to introduce a bidirectional rapid reductor (BRR) designed to assist in the reduction during MIPO surgery for proximal humeral fractures (PHFs).

METHODS

This retrospective study was conducted between June 2021 and February 2022 in the Third Hospital of Hebei Medical University, involving patients diagnosed with PHFs. A detailed technical approach of BRR in MIPO surgery was described, and the patients' outcomes based on postoperative radiographic results including x-ray postoperative follow-up, and clinical outcome parameters including visual analogue scale (VAS) and constant-Murley score at last follow-up were reported.

RESULTS

A total of 12 patients were included in this study, comprising three males and nine females, with an average age of 67.58 years. The mean operative time was 70.92 min (range 63-80 min). The mean blood loss was 102.27 mL (range 50-300 mL). The mean VAS and constant-Murley scores at final follow-up were 0.33 and 88, respectively. All patients had their fractures healed without secondary displacement at last follow-up. One patient experienced shoulder stiffness post-operation. There were no adverse events or complications following the use of this technique, such as acromion fracture, nerve or blood vessel injury.

CONCLUSION

The BRR can assist MIPO for good reduction of PHFs. However, the efficacy should be validated with a large-sample randomized controlled trial and longer follow-up.

Risk factors for osteonecrosis of the humeral head after internal fixation of proximal humeral fractures: a systematic review and meta-analysis

BACKGROUND

Osteonecrosis of the humeral head (ONHH) is a severe complication after the internal fixation of proximal humeral fractures (IFPHF). The risk factors remain controversial though many studies have reported. In this research, meta-analysis was used to evaluate which surgeon-level factors can be modified to lower the risk and we hope to provide evidence-based support for preventing ONHH.

METHODS

Literature was retrieved from PubMed, Cochrane Library, Embase, Web of Science, and Scopus for eligible studies published up to January 2023. The pooled odds ratios (ORs) were calculated with their corresponding 95% confidence intervals (CIs) to evaluate. STATA 15.1 software was applied for data synthesis, sensitivity synthesis, and publication bias.

RESULTS

45 articles were published between 2000 and 2022, and 2482 patients were finally included. All articles were observational research, with 7 case-control studies and 38 cohort studies, and the Newcastle Ottawa Scale (NOS) score ranged from 7 to 9. The pooled results suggested that age (OR 0.32, 95% CI 0.14-0.74, P = 0.01), reduction quality (OR 0.08, 95% CI 0.01-0.44, P = 0.00), fracture type (OR 0.44, 95% CI 0.25-0.78, P = 0.01), surgical approach (OR: 4.06, 95% CI 1.21-13.61, P = 0.02) and fixation implant (OR = 0.68, 95% CI = 0.34-1.33, P = 0.02) were risk factors for ONHH after IFPHF. According to sensitivity analysis, Begg (P = 0.42) and Egger (P = 0.68) tests, the results were stable and exhibited no publication bias.

CONCLUSIONS

The study showed that age, reduction quality, fracture type, surgical approach and fixation implant were risk factors for ONHH after IFPHF, while gender, varus or valgus, timely operation, injured side, and the existence of medial support have little influence on ONHH, as they could not be considered risk factors and still need further investigations.

Minimally invasive lateral plating for diaphyseal fractures with extension into the proximal humerus and its implications for the deltoid muscle and its distal insertion: functional analysis and MR-imaging

BACKGROUND

In minimally invasive lateral plate osteosynthesis of the humerus (MILPOH) the plate is introduced through a deltoid split proximally and advanced through the central portion of the deltoid insertion and between bone and brachial muscle to the distal aspect of the humerus. The fracture is then indirectly reduced and bridged by the plate. Whereas it has been shown that the strong anterior and posterior parts of the distal deltoid insertion remain intact with this maneuver, its impact on deltoid muscle strength and muscular morphology remains unclear. It was the aim of this study to evaluate deltoid muscle function and MR-morphology of the deltoid muscle and its distal insertion after MILPOH.

METHODS

Six patients (median age 63 years, range 52-69 years, f/m 5/1) who had undergone MILPOH for diaphyseal humeral fractures extending into the proximal metaphysis and head (AO 12B/C(i)) between 08/2017 and 08/2020 were included. Functional testing was performed for the injured and uninjured extremity including strength measurements for 30/60/90° shoulder abduction and flexion at least one year postoperatively. Constant-Murley-Score (CMS) including an age-and gender-adjusted version, were obtained and compared to the uninjured side. Oxford Shoulder Score (OSS) and the Disability of the Arm, Shoulder and Hand (DASH) questionnaire were acquired for the affected extremity. Quality of life was measured using the EQ visual analogue scale (EQ-5D-5 L VAS). MR imaging was performed for both shoulders accordingly at the time of follow-up to assess the integrity of the distal insertion, muscle mass and fatty degeneration of the deltoid muscle. Muscle mass was determined by measuring the area of the deltoid muscle on the axial MR image at the height of the center of the humeral head.

RESULTS

Median follow-up was 29 months (range 12-48 months). Median difference of abduction strength after MILPOH was + 13% for 30°, 0% for 60° and - 22% for 90°. For flexion, the difference to the uninjured side was measured 5% for 30°, -7% for 60° and - 12% for 90°. Median CMS was 75 (66-82) for the operated extremity compared to 82 (77-90) for the uninjured side. Age- and gender-adapted CMS was calculated 88 (79-99) vs. 96 (89-107). Median OSS was 47 (40-48). DASH was 26 (15-36). EQ-5D-5 L VAS ranged from 81 to 95 with a median of 90. The median difference of the deltoid muscle area on MRI was 2% (-21% to + 53%) compared to the uninjured side. No fatty degeneration of the deltoid muscle was observed. The weaker central part of the distal deltoid insertion was exclusively perforated by the plate, leaving the strong anterior and posterior parts of the insertion intact in all patients.

CONCLUSIONS

MILPOH was associated with good functional and subjective outcome. Minor impairment of abduction strength was observed with increasing abduction angles. The reason for this impairment is unclear since MILPOH did not affect the structural quality of the deltoid muscle and the integrity of the strong anterior and posterior parts of its insertion remained intact.

TRIAL REGISTRATION

26/05/2023: ISRCTN51786146.

An updated systematic review and meta‑analysis comparing deltoid‑split approach with deltopectoral approach for proximal humerus fractures

The present review and meta-analysis aimed to summarize the currently available data and to compare the important clinical and functional outcomes in patients with proximal humerus fractures who were treated using deltoid split (DS) or deltopectoral (DP) surgical approaches. The PubMed, EMBASE, Scopus and Cochrane Central Register of Controlled Trials databases were systematically searched for randomized controlled trials or observational studies that reported functional outcome data of patients with fracture of proximal humerus who were surgically treated using DS and DP approaches. A total of 14 studies were included in the present meta-analysis. The duration of surgery [min; weighted mean difference (WMD), -16.44; 95% CI, -(25.25-7.63)], amount of blood loss [ml; WMD, -57.99; 95% CI, -(102.74-13.23)] and time to bone union [weeks WMD, -1.66; 95% CI, -(2.30-1.02)] was comparatively lower in patients that underwent DS. There were no statistically significant differences in the pain and quality of life scores, range of movement and risk of complications between the DS and the DP groups. Patients in the DS group had improved shoulder function and constant shoulder score (CSS) at 3 months post-surgery (WMD, 6.36; 95% CI, 1.06-11.65). No differences were observed between the two groups in terms of CSS and disabilities of the arm, shoulder and hand scores at 12 and 24 months post-operatively. The activity of daily living (ADL) score was significantly improved in the DS group at 3 (WMD, 1.23; 95% CI, 0.40-2.06), 6 (WMD, 0.99; 95% CI, 0.72-1.25) and 12 months (WMD, 0.83; 95% CI, 0.18-1.47) after the surgery. The present results suggested that DS and DP surgical approaches were associated with similar clinical outcomes. The DS approach was associated with certain perioperative benefits, as well as reduced time to bone union, improved shoulder function in the early postoperative period and improved ADL scores. These benefits may be considered while choosing between these two surgical approaches.

Plate osteosynthesis for proximal humerus fractures through a deltoid-split approach under traction in lateral decubitus position: preliminary results

Aim: We aimed to present deltoid split approach under traction in lateral decubitus position that we perform for the treatment of proximal humerus fractures (PHFs) and to present the preliminary surgical and clinical outcomes of our patients. Material and Method: Twelve patients who underwent plate osteosynthesis through a deltoid split approach under traction in lateral decubitus position between May 2019 and January 2021 were evaluated. Patient demographics, Neer classification, and time from injury to surgery were collected in all patients preoperatively. Radiation exposure time and operating time was recorded intraoperatively. Radiological outcomes were assessed, including time to union, and neck-shaft angle. Functional outcomes were evaluated using the Constant score at the minimum 12-month follow-up. Results: Twelve patients (5 male, 7 female) were evaluated with a mean age 58.6±10.7 years (range, 32 to 72 years) at the time of surgery. The mean follow-up period was 117.4±3.8 months). The mean operation time was 60.7±15.2 min (range, 44 to 92 min). The mean radiation exposure time was 6.1±3.0 s (range, 3.3 to 14.2 s). Fracture union was observed in all patients at mean 14.6±2.5 weeks (range, 8 to 20 weeks). The mean neck-shaft angle after the union was 134.5±3.4 degrees (range, 124 to 143 degrees). The mean Constant score was at the final follow-up was 76.4±8.7 (range, 63 to 90). Conclusion: Patient positioning in the lateral decubitus position under traction can be considered as a safe, reliable, and reproducible method in selected patients with PHFs.

Displaced proximal humerus fractures treated with ORIF via the deltoid interfascicular approach vs the deltopectoral approach: A prospective case-control study

BACKGROUND

The purpose of this study was to evaluate the clinical outcomes and complications of displaced proximal humeral fractures treated with proximal humeral internal locking system (PHILOS) plate fixation via a deltoid interfascicular (DI) vs a deltopectoral (DP) approach.

METHODS

This prospective case-control study was conducted with patients admitted to our hospital from May 2015 to June 2018 who suffered from unilateral displaced proximal humerus fractures. Patients were treated with PHILOS plate fixation via a DI (DI group) or DP approach (DP group). The clinical outcomes and complication data were collected for comparison between the 2 groups. The patients were followed up at 3, 6, and 12 months; and every 6 months thereafter. The patients' functional recoveries were evaluated according to the normalized Constant-Murley score, range of motion of the shoulder (flexion, abduction, external/internal rotation) and disabilities of the arm, shoulder and hand score.

RESULTS

A total of 77 patients, followed for an average of 15 ± 2.2months (range, 12-21), were enrolled (36 in DI group and 41 in DP group) for final analysis. No significant differences in age, sex, affected side, fracture type, injury mechanism or time from injury to operation were found between the 2 groups (all P > .05). The incision length, intra-operative blood loss, and duration of operation in the DI group were significantly less than those in the DP group, respectively (all P < .05). The functional outcomes assessed by the normalized Constant-Murley score and range of motion of flexion and internal rotation in the DI group were superior to those in the DP group at 3 and 6months after the operation (P < .05); however, no significant differences were observed at the 12-month and subsequent follow-ups (all P > .05). There was no significant difference in the range of shoulder external rotation and abduction during the postoperative follow-ups (P > .05). At the last follow-up, the mean disabilities of the arm, shoulder, and hand score was 14.0 (6.6) points in the DI group and 14.4 (6.9) points in the DP group (P = .793). Complications occurred in 1 patient in the DI group and 8 patients in the DP group (P = .049).

CONCLUSION

The current study demonstrates that DI approach is a safe and effective alternative for the treatment displaced proximal humerus fractures. The DI approach rather than DP approach was recommended when lateral and posterior exposure of the proximal humerus is required, especially when fixed with PHILOS plate.

PHILOS Synthesis for Proximal Humerus Fractures Has High Complications and Reintervention Rates: A Systematic Review and Meta-Analysis

Purpose: The aim of this study was to quantify the rate of complications and reinterventions in patients treated with PHILOS plate for proximal humerus fractures (PHFs) synthesis. Methods: A comprehensive literature search was performed on the PubMed, Web of Science, Embase, and Cochrane databases up to 7 October 2021. Studies describing medium and long-term complications in PHF synthesis using the PHILOS plate were included. A systematic review and meta-analysis were performed on complications and causes of reinterventions. Assessment of risk of bias and quality of evidence was performed with the Downs and Black’s “Checklist for Measuring Quality”. Results: Seventy-six studies including 4200 patients met the inclusion criteria. The complication rate was 23.8%, and the main cause was screw cut-out (4.1%), followed by avascular necrosis (AVN) (3.1%) and subacromial impingement (1.5%). In patients over 55 years, the complication rate was 29.5%. In the deltopectoral (DP) approach the complication rate was 23.8%, and in the delto-split (DS) it was 17.5%, but no difference between the two approaches was seen when considering the type of fracture. The overall reintervention rate was 10.5% in the overall population and 19.0% in older patients. Conclusions: Proximal humerus synthesis with a PHILOS plate has high complications and reintervention rates. The most frequent complication was screw cut-out, followed by humeral head AVN and subacromial impingement. These results need to be further investigated to better understand both the type of patient and fracture that is more at risk of complications and reintervention and to compare pros and cons of the PHILOS plate with respect to the other solutions to manage PHFs.

Shoulder-specific Outcome after Proximal Humerus Fracture Influences Medium-term Overall Quality of Life

BACKGROUND

Surgical treatment of proximal humerus fracture is an established procedure. Postoperative complications have been shown to have a significant impact on shoulder-specific outcome. Little is known to date about an influence on injury-independent quality of life.

AIM OF THE WORK

The aim of this retrospective study is to analyse whether patients with a poor functional outcome after surgically treated proximal humerus fracture also show a reduced general quality of life in the medium term. Emphasis is placed on the analysis of patients with poor functional outcome due to postsurgical complications.

MATERIAL AND METHODS

Evaluation of all patients operated at one level 1 trauma centre with a proximal humerus fracture in the period 01.01.2005 to 31.12.2015 and follow-up using validated scores (Constant-Murley Score [CMS], EQ-5D). Two groups, group A with good outcome (∆CMS ≤ 15P.) and group B with poor outcome (∆CMS ≥ 16P.), were defined. Furthermore, descriptive variables including definition of a complication were defined in advance.

RESULTS

138 patients were included in the study (group A: 91, group B: 47). The mean follow-up was 93.86 months ± 37.33 (36-167). Group B had significantly more complications. Furthermore, patients with poor outcome regarding the shoulder (group B) were also found to have significantly lower EQ-VAS (78.9 ± 19.2 [20.0-100] vs. 70.4 ± 19.5 [15.0-98.0]; p = 0.008) and EQ index (0.91 ± 0.14 [0.19-1.00] vs. 0.82 ± 0.17 [0.18-1.00]; p < 0.001).

DISCUSSION

In conclusion, in the present study, the patients with poor outcome of shoulder function in CMS have significantly lower overall quality of life after a mean of more than 6 years of follow-up. The poor outcome was due to a significantly higher postoperative complication rate. This was independent of the fracture morphology present and the surgical procedure used.

Treatment of 2-Part Proximal Humeral Fractures in Osteoporotic Patients With Medial Calcar Instability Using a PHILOS Plate Plus an Allogeneic Fibula Inserted Obliquely - A Retrospective Study

INTRODUCTION

To date, there is little research assessing the efficacy of a proximal humeral internal locking system (PHILOS) plate plus an allogeneic fibula inserted obliquely in the treatment of 2-part proximal humerus fractures (PHFs) with calcar comminution in patients >60 years old with severe osteoporosis. The aim of this study was to retrospectively evaluate the outcomes of elderly patients with osteoporotic 2-part PHFs combined with medial column (calcar) instability or disruption who experienced a PHILOS plate plus an allogeneic fibula inserted obliquely.

MATERIALS AND METHODS

One hundred and twelve consecutive elderly patients with severe osteoporotic 2-part PHFs combined with calcar instability or disruption who were treated with a PHILOS plate plus an allogeneic fibula inserted obliquely were retrospectively identified from 3 tertiary medical centres during 2014-2019. The primary outcomes were the Constant scores and American Shoulder and Elbow Surgeons (ASES) scores; secondary outcome was the rate of key orthopaedic complications.

RESULTS

Median follow-up was 24 (15.3-27.6) months. Significant improvements in the median Constant scores were observed (39 [26-58 points] prior to surgery vs 81 [67-95 points] at final follow-up). The median ASES scores improved from 43 (26-64 points) prior to surgery to 83 (65-96 points) at final follow-up. The percentage of key orthopaedic complications was 25.6% (22/86). Four (4.7%) cases had loss of reduction, 4 (4.7%) experienced aseptic loosening, 1 (.8%) had non-union, 4 (4.7%) suffered a periprosthetic fracture, 3 (3.5%) experienced a revision surgery, 1 (.8%) had a dislocation and 5 (5.8%) suffered an unbearable shoulder pain.

CONCLUSION

For elderly patients with osteoporotic 2-part PHFs combined with calcar instability or disruption, PHILOS plate combined with an allogeneic fibula inserted obliquely might have recognisable advantages in decreasing the loss of fixation and preventing medial calcar collapse.

Long head of biceps in proximal fractures of the humerus: an underestimated problem?

Background and aim of the work:

The long head of biceps (LHB) is one of the tendons of the rotator cuff that runs strictly close to the humeral head. In case of pathology, it can be responsible for pain and shoulder impairment: in such cases, surgical options include tenotomy or tenodesis. The management of LHB along with surgery of the rotator cuff or during shoulder prosthetic replacement has been widely discussed in the literature. Conversely, the possibility of acute impingement and incarceration of LHB in proximal humerus fractures, as well as its role in shoulder pain in outcomes of these fractures, has been poorly considered.

Methods:

The following aspects in the literature on LHB and proximal humerus fractures have been analysed: its management during fixation of fractures, the possibility of interference of the tendon with reduction of fractures or dislocations of the shoulder and its possible role in chronic pain after fixation of proximal humerus fractures.

Results:

LHB can be an obstacle in the reduction of fractures, dislocations and fracture-dislocations. Only a few papers take into account acute surgery to LHB (tenotomy or tenodesis); most of the studies on fixation of proximal humerus fractures simply ignore the problem of LHB. The tendon can be a source of pain and a cause of disability in sequelae of these fractures.

Conclusions:

LHB should be taken into consideration both in the acute phase of fractures of the proximal humerus and in the outcomes. Other studies are needed to better understand its optimal management during fracture surgery. (www.actabiomedica.it)