Minimally invasive plate osteosynthesis in the treatment of proximal humeral fracture

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.

[Effectiveness comparison of two minimally invasive plate osteosynthesis techniques for proximal humeral shaft fractures]

Objective

To compare the effectiveness of lateral approach minimally invasive plate osteosynthesis (MIPO) and helical plate MIPO in the treatment of proximal humeral shaft fractures.

Methods

The clinical data of patients with proximal humeral shaft fractures who underwent MIPO via lateral approach (group A, 25 cases) and MIPO with helical plate (group B, 30 cases) between December 2009 and April 2021 were retrospectively analyzed. There was no significant difference in gender, age, injured side, cause of injury, American Orthopaedic Trauma Association (OTA) fracture classification, and time from fracture to operation between the two groups ( P>0.05). The operation time, intraoperative blood loss, fluoroscopy times, and complications were compared between two groups. The angular deformity and the fracture healing were evaluated according to anteroposterior and lateral X-ray films postoperatively. The modified University of California Los Angeles (UCLA) score for shoulder and the Mayo Elbow Performance (MEP) score for elbow were analyzed at last follow-up.

Results

The operation time in group A was significantly shorter than that in group B ( P<0.05). However, the intraoperative blood loss and fluoroscopy times presented no significant difference between the two groups ( P>0.05). All patients were followed up 12-90 months, with an average of 19.4 months. There was no significant difference in follow-up time between the two groups ( P>0.05). In terms of the quality of postoperative fracture reduction, there were 4 (16.0%) and 11 (36.7%) patients with angulation deformity in group A and group B, respectively, and there was no significant difference in the incidence of angulation deformity ( χ 2=2.936， P=0.087). All fractures achieved bony union, there was no significant difference in fracture healing time between group A and group B ( P>0.05); delayed union occurred in 2 cases and 1 case in group A and group B, respectively (healing time was 30, 42, and 36 weeks after operation, respectively). In group A and group B, 1 patient had superficial infection of incision, respectively; 2 patients and 1 patient had subacromial impact after operation, respectively; and 3 patients in group A had symptoms of radial nerve paralysis of different degrees; all of them were cured after symptomatic treatment. The overall complication incidence of group A (32%) was significantly higher than that of group B (10%) ( χ 2=4.125, P=0.042). At last follow-up, there was no significant difference in the modified UCLA score and MEPs score between the two groups ( P>0.05).

Conclusion

Both lateral approach MIPO and helical plate MIPO can achieve satisfied effectiveness in the treatment of proximal humeral shaft fractures. Lateral approach MIPO may be beneficial to shorten the operation time, while the overall complication incidence of helical plate MIPO is lower.

Anatomical analysis of different helical plate designs for proximal humeral shaft fracture fixation

OBJECTIVES

Helical plates are preferably used for proximal humeral shaft fracture fixation and potentially avoid radial nerve irritation.

AIMS

Safety of applying four different long plate designs (straight, 45°-, 90°-helical and ALPS) with MIPO technique as well as assessment and comparison of their distances to adjacent anatomical structures.

METHODS

MIPO was performed in 16 human cadaveric humeri using either a straight (group 1), a 45°-helical (group 2), a 90°-helical (group 3) plate, or an ALPS (group 4). Applying CT angiography, distances between brachial arteries and plates were evaluated. All specimens were dissected and distances to the axillary, radial and musculocutaneous nerve were evaluated.

RESULTS

No specimens demonstrated injuries of the anatomical structures at risk after MIPO with all investigated plate designs. Closest overall distance (mean (range); mm) between each plate and the radial nerve was 1 (1-3) in group 1, 7 (2-11) in group 2, 14 (7-25) in group 3 and 6 (3-8) in group 4. It was significantly bigger in group 3 and significantly smaller in group 1 compared to all other groups, p < 0.001. Closest overall distance between each plate and the musculocutaneous nerve was 16 (8-28) in group 1, 11 (7-18) in group 2, 3 (2-4) in group 3 and 6 (3-8) in group 4. It was significantly bigger in group 1 and significantly smaller in group 3 compared to all other groups, p < 0.001.

CONCLUSIONS

MIPO with 45°- and 90°-helical plates as well as with ALPS is safely feasible and demonstrates significantly bigger distances to the radial nerve compared to straight plates. However, the distances remain small and attention must be paid to the musculocutaneous nerve and the brachial artery when MIPO is applied using ALPS, 45°- and 90°-helical implants.

Treatment of humeral shaft fractures: a new minimally-invasive plate osteosynthesis versus open reduction and internal fixation: a case control study

Background

To evaluate the feasibility and safety of a new minimally-invasive surgical approach–anteromedial minimally-invasive plate osteosynthesis (MIPO)–in the treatment of middle and distal humeral shaft fractures.

Methods

Fourteen patients with humeral shaft fracture treated with anteromedial MIPO from November 2016 to March 2020 (MIPO Group) were selected as the study subjects. Open reduction and internal fixation (ORIF) were used to treat 14 patients with humeral shaft fractures as the control group (ORIF group). The two groups were fixed with a locking compression plate (LCP) or LCP + multi-directional locking screw system (MDLS). The incision length, intraoperative blood loss, intraoperative fluoroscopy time, operation time, length of hospital stay, fracture healing time, QuickDASH score and Constant score were observed and compared between the two groups.

Results

Fourteen patients were enrolled in each group. The incision length (7.79 ± 2.39 cm), intraoperative blood loss (96.07 ± 14.96 mL), operative time (110.57 ± 21.90 min), hospital stay (6.29 ± 1.49 days) and fracture healing time (14.94 ± 0.99 weeks) in the MIPO group were all lower than those in the ORIF group, and the difference was statistically significant for each parameter (P < 0.05). The intraoperative fluoroscopy time (20.07 ± 3.22) in the MIPO group was significantly higher than that in the ORIF group (P < 0.05). There were no significant differences in age (P = 0.078), QuickDASH score (P = 0.074) or Constant score (P = 0.293) between the two groups and no postoperative complications occurred in any of the patients.

Conclusion

The anteromedial approach MIPO technique has the advantages of less trauma, less bleeding, low risk of nerve injury and high rate of fracture healing. It is one of the most effective methods for the treatment of middle and middle–distal humeral shaft fractures.

Time until union in absolute vs. relative stability MIPO plating in simple humeral shaft fractures

PURPOSE

The objective of this study is to evaluate the effect of absolute stability (AS) versus relative stability (RS) performed through a minimally invasive plate osteosynthesis (MIPO) in AO/OTA 12A1 and 12A2 fractures on healing and the time to radiographic union.

METHODS

This was a retrospective cohort study of all patients treated with plate fixation for AO/OTA type 12A1-A2 fractures at a single institution. Patients were grouped according to the type of stability used in their surgery. Time until radiographic union was estimated using the Kaplan-Meier method, which was compared by long-rank test between both types of surgical techniques.

RESULTS

A total of 70 patients were included in this study with 35 patients in each group. The median follow-up was 9 (IQR 6-14) months. The median time to radiographic union was significantly lower in the AS group than in the RS group: 12 (interquartile range (IQR) 10-14) weeks versus 18 (IQR 16-19) weeks, respectively (p < 0.001). Non-union was seen in two cases (7%) in the relative stability group. Three patients in the RS group developed a post-operative radial nerve palsy.

CONCLUSION

The main finding of this study is that the median time to radiographic union was significantly shorter in the patients treated with AS compared to those with a RS technique. These findings support the recommendations of the AO foundation in that simple metaphyseal fractures (type A) that require surgical treatment should be treated with an AS construct. RS techniques should be reserved to multifragmentary fractures where fragment preservation of blood supply is paramount.

Radial nerve palsy associated with closed humeral shaft fractures: a systematic review of 1758 patients

BACKGROUND AND PURPOSE

Humeral shaft fractures are often associated with radial nerve palsy (RNP) (8-16%). The primary aim of this systematic review was to assess the incidence of primary and secondary RNP in closed humeral shaft fractures. The secondary aim was to compare the recovery rate of primary RNP and the incidence of secondary RNP between operative and non-operative treatment.

METHODS

A systematic literature search was performed in 'Trip Database', 'Embase' and 'PubMed' to identify original studies reporting on RNP in closed humeral shaft fractures. The Coleman Methodology Score was used to grade the quality of the studies. The incidence and recovery of RNP, fracture characteristics and treatment characteristics were extracted. Chi-square and Fisher exact tests were used to compare operative versus non-operative treatment.

RESULTS

Forty studies reporting on 1758 patients with closed humeral shaft fractures were included. The incidence of primary RNP was 10%. There was no difference in the recovery rate of primary RNP when comparing operative treatment with radial nerve exploration (98%) versus non-operative treatment (91%) (p = 0.29). The incidence of secondary RNP after operative and non-operative treatment was 4% and 0.4%, respectively (p < 0.01).

INTERPRETATION

One-in-ten patients with a closed humeral shaft fracture has an associated primary RNP, of which > 90% recovers without the need of (re-)intervention. No beneficial effect of early exploration on the recovery of primary RNP could be demonstrated when comparing patients managed non-operatively with those explored early. Patients managed operatively for closed humeral shaft fractures have a higher risk of developing secondary RNP.

LEVEL OF EVIDENCE

Level IV; Systematic Review.

Open Reduction and Long Locking Plate Fixation of Complex Proximal Humeral Metadiaphyseal Fractures

BACKGROUND

A minority of proximal humeral fractures extend into the diaphysis and their optimal treatment remains controversial. We evaluated the outcomes and risk of complications in patients with these injuries, treated by a protocol of open reduction and long locking plate fixation (LPF).

METHODS

Between 2007 and 2014, all locally resident patients with a proximal humeral fracture extending into the diaphysis were referred to a specialist shoulder clinic. Operative treatment using a protocol of open reduction and LPF was offered to medically fit patients. Those with 2-year radiographic follow-up were included in the study, and standardized assessments of clinical and radiographic outcomes were performed during the first 2 years postoperatively. At a mean of 8.8 years (range, 5 to 12 years) after LPF, the functional outcomes and satisfaction of surviving, cognitively intact patients were assessed with a questionnaire study.

RESULTS

One hundred and two patients met the inclusion criteria; the majority were older women who had incurred the injury during a simple fall. Fractures were divided into 2 types depending on the pattern of diaphyseal extension. The pain levels, functional scores, and satisfaction with treatment were satisfactory both at the 2-year follow-up and at the longer-term follow-up at a mean of 8.8 years postsurgery. Complications were predominantly due to postsurgical stiffness (in 7 patients, with 3 undergoing additional surgery) and nonunion or fixation failure (in 7 patients, with 6 undergoing additional surgery).

CONCLUSIONS

Proximal humeral fractures with diaphyseal extension are rare. The results of our study support the use of LPF in medically stable patients in centers with the expertise to perform these procedures.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Minimally invasive percutaneous plate osteosynthesis for treatment of proximal humeral shaft fractures

PURPOSE

The objective of this study was to evaluate the feasibility and safety of a minimally invasive percutaneous plate osteosynthesis (MIPPO) procedure for proximal humeral shaft fractures using lateral minimal proximal and distal approaches and lateral bridge plating with primary radial nerve control, and to assess its clinical and radiographic outcomes.

METHODS

A retrospective review was done for the medical records of adult patients admitted for fracture of the proximal humeral shaft without associated injury to the ipsilateral upper limb and who consented to undergo a novel MIPPO technique herein reported. Patients were reviewed at regular follow-up periods and assessed at a final follow-up for evaluation of Constant, normalized Constant, and QuickDASH scores.

RESULTS

There were 21 adult patients with mean age of 56 years. Three patients were lost from early follow-up; one of them had post-operative radial nerve paralysis. Eighteen patients were reviewed for the purpose of this study at a mean of 20 months of final follow-up; among them, one patient developed post-operative radial nerve paralysis with complete recovery after three months. Bone healing was achieved without any malalignment in 17 patients at a mean of 15 weeks, and one patient developed nonunion. At final assessment (mean, 20 months), the mean values of Constant, normalized Constant, and QuickDASH scores were 84 (range, 59 to 100), 95 (range, 73 to 100), and 5 (range, 0 to 18.2) respectively.

CONCLUSION

Compared to pre-reported methods of MIPPO, this technique of lateral proximal and distal mini-approaches with lateral bridge plating after primary control of the radial nerve seems safe and feasible for proximal humeral shaft fractures. It gives good clinical and radiographic results with excellent restoration of upper limb function, very low incidence of post-operative radial nerve injury, and high rate of bone union in good alignment.

Is minimally invasive plate osteosynthesis superior to open plating for fixation of two-part fracture of the proximal humerus?

PURPOSE

Displaced two-part fractures of the proximal humerus are generally treated with open plate (OP) fixation. Recently, minimally invasive plate osteosynthesis (MIPO) has been increasingly favored for fracture healing and functional recovery. We aimed to compare OP and MIPO for two-part fractures of the proximal humerus to identify outcome differences.

METHODS

All patients who underwent OP or MIPO for a displaced two-part fracture of the proximal humerus at a single level I trauma center between 2007 and 2013 were retrospectively evaluated. Of the patients, 17 were treated using the OP method through the delto-pectoral approach and 19 with MIPO through deltoid splitting. Radiographic results were evaluated to determine the union rate, time to union, and alignment. Functional outcomes were measured with Constant and UCLA scores. Radiation exposure and operative time were also evaluated.

RESULTS

All patients achieved bone union without complication. In the OP and MIPO groups, no significant difference was observed in the neck shaft angles, constant scores, or UCLA scores. The OP group required less radiation exposure time than the MIPO group ( p < 0.001). However, the OP group showed more operation time than the MIPO group ( p < 0.001).

CONCLUSIONS

Both techniques showed satisfactory radiographic and functional outcomes in two-part fractures of the proximal humerus. Although MIPO technique offers advantages, including minimal soft tissue damage and short operation time, surgeons and patients should be warned of the invisible risk from the radiation hazard.

Minimally invasive percutaneous plate osteosynthesis versus intramedullary nail fixation for distal tibial fractures: a systematic review and meta-analysis

Background

The treatment for distal tibial fractures remains controversial to date. Minimally invasive percutaneous plate osteosynthesis (MIPPO) and intramedullary nailing (IMN) are well-accepted and effective methods for distal tibial fractures, but these methods were associated with complications. This study aimed to assess and compare the clinical and functional outcomes in patients with distal tibial fractures treated with MIPPO or IMN.

Methods

We systematically reviewed randomized controlled trials (RCTs) that compared MIPPO with IMN in patients with distal tibial fractures from inception till 15 August 2019. Also, quantitative summaries of time to reunion, rate of complications, and functional outcomes were evaluated.

Results

The pooled results suggested that patients in the MIPPO group had a longer time to reunion with a mean difference of 1.21 weeks [P = 0.02; 95% confidence interval (CI) 0.16–2.26)] than those in the IMN group. The overall union complications and deep infection between IMN and MIPPO were similar (P > 0.05). IMN had a significantly low risk of wound complications [risk ratio (RR) = 0.51, P = 0.00, 95% CI 0.34–0.77)]. The pooled functional outcomes of the two groups remained controversial by different evaluating scores.

Conclusions

Compared to MIPPO, IMN had a significantly low risk of wound complications and associated with limited time for reunion. Although the pooled functional outcomes of the two groups were controversial due to different evaluating scores, IMN was the preferred surgical technique than MIPPO for treating distal tibial fractures.

Complex Proximal Humeral Fracture Fixation with PHILOS Plate using Minimal Invasive Percutaneous Plate Osteosynthesis (MIPPO) Technique: A Series of 30 Patients

Introduction: Proximal humerus fracture fixation using plate osteosynthesis depends on the quality of the bone, design of the fixation devices and intra-operative soft tissue dissection. This study evaluates the functional outcome of minimally invasive percutaneous plate osteosynthesis using locking compression plate in proximal humerus fracture treatment.

Materials and Methods: The study was conducted on 30 patients with complex proximal humerus fractures treated by minimally invasive percutaneous plate osteosynthesis using locking compression plate (PHILOS). There were 21 males and 9 females. The average age of our study group was 58.8 years. All the patients were evaluated at six weeks, three months, four months, six months and 12 months following surgery.

Results: All patients had fracture union at an average of 13.2 weeks. The mean DASH score at the follow-up was 8.69 (2.5 to 17.16), the average range of flexion was 143.83 degrees (100 to 170 degrees) and abduction was 121.49 degrees (90 to 160 degrees). We had superficial infection in three patients which resolved with a short course of antibiotics. There was excellent outcome in 26 patients, good and fair in two patients each.

Conclusion: Proximal humerus fractures treated with minimally invasive percutaneous plate osteosynthesis using locking compression plate with minimal soft tissue dissection, provides good functional outcome and early return of shoulder function.

Management of AO type 12C humerus proximal metadiaphyseal fractures with minimally invasive plate osteosynthesis in geriatric patients

Background

To evaluate the treatment efficacy and complications of the lateral minimally invasive plate osteosynthesis (MIPO) method in geriatric patients with a humerus diaphyseal fracture with proximal extension.

Patients and methods

The study included a total of 21 patients (18 females, 3 males; mean age 74±6.3 years, range 65–89 years) who underwent surgery with the lateral MIPO technique for a humerus diaphyseal fracture with proximal extension during the period January 2011 to December 2016. None of the patients had additional injuries and all completed regular follow-up. According to the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation classification system, the fractures were evaluated as 12C1 in 17 cases and 12C3 in 4 cases. All patients were evaluated radiologically and functionally at 6 months and 1 year. In the follow-up evaluations, the Constant–Murley score and the Quick Disabilities of the Arm, Shoulder, and Hand (Q-DASH) score were used.

Results

No non-union, avascular necrosis or infection was seen in any patient. The mean time to union was 15.7 weeks. Impingement syndrome was seen in 2 patients and radial nerve palsy in 2 patients. The mean Constant–Murley score was 70.6±10.2 at 6 months and 84±7.6 at the end of 1 year. The mean Q-DASH score was 38.6±15.1 at 6 months and 21.9±13.1 at the end of 1 year. The increase in the Constant–Murley scores from 6 months to 1 year was statistically significant (p<0.0001). The decrease in the Q-DASH scores between 6 months and 1 year was determined to be statistically significant. In the 2 patients with radial nerve palsy, the functions were seen to completely recover during follow-up. No axillary nerve palsy was seen in any patient.

Conclusion

Metadiaphyseal humerus fractures with proximal extension in the elderly can be successfully treated with the lateral MIPO technique. When applied correctly, it is a method with high rates of union and low rates of complications.

Influence of age, gender, and radiographic features on the deltoid splitting approach for surgical osteosynthesis in displaced proximal humerus fractures: a comparison study

BACKGROUND

The deltoid splitting approach has recently been widely adopted to facilitate less invasive procedures for proximal humerus fractures. However, there are still concerns regarding its effectiveness in aging people and in cases involving complex fractures. This study was conducted to evaluate the efficacy of a proximal humeral locking plate using the anterolateral deltoid splitting approach and to specifically examine the effect of patient age, gender, and fracture pattern on surgical outcomes.

METHODS

Forty-two cases of proximal humeral fractures treated using the deltoid splitting approach and locking plate fixation were reviewed. Outcome differences were evaluated in terms of age, gender distribution, and radiographic analysis based on the Neer Classification. The influence of the surgical approach was further investigated by age-matched paired analysis after subdividing patients into two age groups (younger than 60 years vs. older than 60 years; N = 21, in each group).

RESULTS

In total, 41 patients (98%) demonstrated fracture union. The average Constant score was 80.4. No significant differences were found between patients younger than 60 years, and the older patients. Higher mean scores were found in men than in women (p = 0.448) and in simple fractures than in complex fractures (p = 0.454), without any significant differences. Better postoperative functional outcomes were observed when the humeral head-neck angle was greater than 105°, with a significant difference (p = 0.000). Surgical complications were found in 16 patients (38%) without significant difference between two age groups (p = 0.268). The most common complication was screw penetration.

CONCLUSIONS

Anterolateral deltoid splitting using locking plate fixation provided a feasible alternative for surgery of proximal humerus fractures in different age groups and yielded comparable outcomes when the neck-shaft angle was properly restored. Surgeons must be cautious regarding potential complications, especially with screw penetration when using the locking plate through a less invasive approach.

TRIAL REGISTRATION

ISRCTN75494532 . Trial Date: 2017/01/31.

Minimally invasive lateral plate placement for metadiaphyseal fractures of the humerus and its implications for the distal deltoid insertion- it is not only about the radial nerve. A cadaveric study

INTRODUCTION

Minimally invasive lateral placement of plates on the humerus may be associated with a risk of injury to the radial nerve. Whereas this potential complication has been investigated in several studies, there is no data regarding potential injuries to the distal insertion of the deltoid muscle when the plates are passed distally in a submuscular tunnel.

METHODS

Minimally invasive plate placement was performed on eight arms in fresh cadavers. A lateral deltoid split approach was made and the plates were introduced in an antegrade submuscular manner from proximal to distal. A lateral distal incison was made to adjust the position of the plate at the lateral aspect of the humerus without formal exploration of the radial nerve. The arms were dissected to identify the seven intramuscular tendons of the deltoid and their insertions at the humerus. The position of the plate and its relation to the intramuscular tendons of the deltoid was explored. Furthermore, potential injuries to the axillary and radial nerve were investigated. Damage to the brachialis muscle its interference with plate positioning were explored.

RESULTS

The distal deltoid insertion was affected in all eight examined arms. The two most anterior and two most posterior segments were intact in all. In two arms, the third intramuscular tendon was perforated. In three specimens, the insertion of the fourth segment was damaged. The fifth segment was partially disrupted in three arms. Overall, injuries to the intramuscular tendons were limited to one tendon in all arms. Partial brachial muscle entrapment underneath the plate was observed in four specimens. The axillary nerve was not damaged in any of the examined arms. The radial nerve was entrapped between plate and humeral shaft in one case.

CONCLUSIONS

Lateral plate placement in MIPO technique damages central parts of the distal deltoid muscle insertion. However, the most anterior and posterior tendons are not involved and the clinical significance on muscle function remains unclear. Introduction of the plate without prior distal incision and elevation of the brachial muscle may be associated with partial entrapment of the brachial muscle and a higher risk of injuring the radial nerve.

LEVEL OF EVIDENCE

Experimental study.

Open vs. closed reduction combined with minimally invasive plate osteosynthesis in humeral fractures

Aim To explore a more effective surgical procedure, the outcomes of closed manipulative reduction (CMR) combined with minimally invasive plate osteosynthesis (MIPO) and conventional open reduction and internal fixation (ORIF) for treating proximal humeral fractures were compared. Material and methods In a retrospective study of patients operated for humerus shaft fractures from April 2008 to July 2011, the outcomes of 33 patients treated with CMR/MIPO were compared with the outcomes of 42 patients treated with ORIF. The fractures were classified, and the incision length, blood transfusion, operating time, as well as the VAS (Visual Analog Scale) pain scores were analyzed. The neck-shaft angles of the proximal humerus were detected, and the postoperative function of the shoulder was evaluated. Results The mean values of incision length, blood transfusion, and VAS pain scores at the 1st and 3rd day after CMR/MIPO and operation time were lower than that of ORIF. The postoperative radiographs verified good position of all screws and satisfactory bone fracture reduction in both groups. Meanwhile, in the ORIF group, nonunion (three cases) and humeral head necrosis (four cases) were detected. Conclusions The MR/MIPO technique showed smaller incisions, easier operation, less blood transfusion and more effective recovery of shoulder joint function for treating proximal humeral fractures than ORIF.

Comparison of retrograde nailing and minimally invasive plating for treatment of periprosthetic supracondylar femur fractures (OTA 33-A) above total knee arthroplasty

INTRODUCTION

Retrograde intramedullary (IM) nailing and minimally invasive plate osteosynthesis (MIPO) using locking plate are typically considered the gold standards of treatment for periprosthetic supracondylar femoral fractures above total knee arthroplasty (TKA).

METHODS

Forty-one consecutive patients treated with either retrograde nailing (nail group, n = 20) or minimally invasive plating (plate group, n = 21) for periprosthetic supracondylar femoral fractures between March 2003 and January 2014 were retrospectively reviewed. Clinical functions [arc range of motion and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score] and bony outcomes (bony union and malunion) were evaluated.

RESULTS

There was no statistical difference between the nail and plate groups in age (p = 0.665), one-year postoperative arc range of motion (p = 0.642), preoperative WOMAC score (p = 0.076), postoperative one-year WOMAC score (p = 0.135), and union time (p = 0.081). The mean union time of the nail group and the plate group was 4.3 months (range 3-12 months) and 3.6 months (range 3-5 months), respectively. There were three cases of malalignment in the nail group, whereas there was one case of malalignment in the plate group (p = 0.343). One case of nailing using a short nail demonstrated nail breakage.

CONCLUSIONS

Although retrograde nailing was found to have a slightly higher rate of malunion compared to minimally invasive plating, there was no statistically significant difference between both treatment options in terms of clinical outcomes. Regardless of which implant is used, the proper application is essential in management of periprosthetic supracondylar femoral fractures above TKA.

Clinic research on the treatment for humeral shaft fracture with minimal invasive plate osteosynthesis: a retrospective study of 128 cases

INTRODUCTION

Minimal invasive plate osteosynthesis (MIPO) is one of the most important techniques in the treatment for humeral shaft fractures. This study was performed to evaluate the efficacy of MIPO technique for the treatment for humeral shaft fractures.

MATERIALS AND METHODS

We retrospectively evaluated 128 cases with humeral shaft fractures that were treated with MIPO technique from March 2005 to August 2008. All the patients were followed up by routine radiological imaging and clinical examinations. Constant-Murley score and HSS elbow joint score were used to evaluate the treatment outcome.

RESULTS

The average duration of the surgery was 60 min (range 40-95 min) without blood transfusion. All fractures healed without infection. All cases recovered carrying angle except four cases with 10°-15° cubitus varus. After the average follow-up of 23 (13-38) months, satisfactory function was achieved according to Constant-Murley score and HSS elbow joint score. Constant-Murley score was 80 on average (range 68-91). According to HSS elbow joint score, there were 123 cases of excellent clinical outcome and five cases of effective outcome.

CONCLUSION

It seems to be a safe and effective method for managing humeral shaft fractures with MIPO technique.

Minimally invasive plate osteosynthesis for proximal humeral fractures

PURPOSE

To report the outcome after minimally invasive plate osteosynthesis (MIPO) through the deltoid-splitting approach for proximal humeral fractures.

METHODS

10 men and 30 women aged 37 to 88 years underwent MIPO through the deltoid-splitting approach using the Proximal Humerus Internal Locking System or the Locking Proximal Humerus Plate for 2-part (n=18), 3-part (n=20), and 4-part (n=2) proximal humeral fractures. The rehabilitation protocol was standardised.

RESULTS

All 40 patients were followed up at 3 months, 34 (85%) at 6 months, 30 (75%) at one year, and 13 (33%) at 2 years. Two patients had malunion. No patient had avascular necrosis, infection, nerve palsy, or nonunion. The mean Constant score at one year and 2 years was 75 and 87.5, respectively. The Constant score at 6 months correlated to that at one year (r=0.926, p<0.0001) and at 2 years (r=0.874, p=0.0001). In younger patients, improvement in the range of motion was faster. The early plateau group (those with no further improvement after 6 months) and the late plateau group (those with no further improvement after one year) did not differ significantly in age, fracture grade, or hand dominance.

CONCLUSION

MIPO for fixation of proximal humeral fractures using a locking plate is safe and effective in enabling an early return of shoulder function.

Evolving trends in surgically managed patients with proximal humerus fracture: are we different after ten years?

INTRODUCTION

New knowledge, and improved surgical hardware and fixation techniques have changed surgical management. We review the evolving trends of surgically managed proximal humerus fractures.

METHODS

Patients who underwent surgery for proximal humerus fractures from 1 January 2001 to 31 December 2010 were identified from the hospital's electronic diagnosis and operative coding database. Data extracted from the database included patient demographics, comorbidities, clinical and radiological findings, operative techniques, and complications.

RESULTS

In total, 95 patients with 97 surgically managed proximal humerus fractures were identified. The median age of the patients was 50 (range 12-85) years, and the male to female ratio was 1.2:1.0. Male patients tended to present at a younger age than female patients (peak age 30-39 years vs. 70-79 years, p < 0.001). Two-part surgical neck fracture was the most common type of fracture (n = 33, 34.0%). Plate osteosynthesis was predominantly used for two- and three-part surgical neck fractures involving the greater tuberosity (p = 0.03, p = 0.0002, respectively). Hemiarthroplasty was commonly performed for four-part fractures (p < 0.001). Wound infections, implant failure, avascular necrosis of the humeral head and nonunion were seen in 8 (8.3%) cases. Minimally invasive plate osteosynthesis (MIPO) had been in use since 2007 (p < 0.001).

CONCLUSION

Surgically managed proximal humerus fractures predominantly involved young men following high velocity injury and elderly women following osteoporotic fractures. Open plating was most commonly used for two- and three-part fractures, and hemiarthroplasty for four-part fractures. MIPO techniques have been practised in our institution since 2007.

Complications and outcomes of minimally invasive percutaneous plating for proximal humeral fractures

BACKGROUND

The minimally invasive plate osteosynthesis (MIPO) technique using periarticular locking plates may be a good option for the repair of displaced proximal humeral fractures. However, axillary nerve complications related to this technique may be underestimated. The purpose of this study is to evaluate the outcomes of the minimally invasive plating, focusing on the complications.

METHODS

The records of 21 consecutive patients treated for proximal humerus fractures using the MIPO technique with locking plates were retrospectively reviewed. These patients were treated between March 2009 and March 2011 with a minimum one-year follow-up. The clinical function, complications, and radiological bony union were evaluated.

RESULTS

All of the patients, with one exception, showed at least 90 degrees of flexion and abduction at the shoulder joint six months postoperatively. The average Constant scores at three months, six months, and one year follow-ups were 74.0 (range, 62 to 90), 79.4 (range, 64 to 91), and 82.7 (range, 66 to 92), respectively. All of the patients achieved bony union within the average of 3.2 months (range, 2 to 6 months). There was one case of delayed union, one case of intra-articular screw penetration, and one case of axillary nerve paresis (incomplete injury), which did not completely recover during the one year of follow-up.

CONCLUSIONS

The MIPO technique using periarticular locking plates is a useful option for the treatment of selected cases of displaced proximal humeral fractures. However, nerve complications such as axillary nerve paresis should be considered along with implant-related complications when choosing patients for minimally invasive plating.

Open reconstruction of complex proximal metadiaphyseal fragility fractures of the humerus

PURPOSE

A proactive surgical and rehabilitation protocol was implemented to manage humeral fractures involving both the proximal end and shaft in an older patient population. Primary treatment goals were early return to function and reliable fracture union with minimal complications.

METHODS

From 2008 to 2012, 21 such operations were performed; 18 were considered "fragility" fractures based on mechanism, patient age, and evidence of osteopenia or osteoporosis. Open reduction and internal fixation (ORIF) was employed using direct reduction and fixation with a long periarticular locking plate. Physiotherapy was commenced 2 weeks postoperatively. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was used to assess functional outcome at a time point greater than 1 year postoperative.

RESULTS

The study group consisted primarily of elderly females (83% with a median age of 69 years) whom sustained complex metadiaphyseal proximal humeral fractures after simple mechanical fall (78%). Uneventful union occurred in all cases. Local complications included 1 case of partial radial nerve palsy, which had resolved completely by 1 year. No cases of infection were identified. Long-term return to functionality was evident with a median DASH score of 12 (mean = 21, standard deviation = 20, n = 13). Seventy five percent of patients reported minimal or no pain (question [Q] 24), and 75% achieved return of overhead function (Q6, 12, and 15).

CONCLUSION

Treatment of complex metadiaphyseal fragility fractures with anatomic reduction, fixed angle plating, and early physiotherapy returns the older patient to optimized functionality with minimal risk of complication. The DASH outcomes are equivalent to ORIF of isolated proximal humerus fractures and clinically indistinguishable from the general population.

Minimally invasive plate osteosynthesis for distal radius fractures

BACKGROUND

Fractures of distal radius are common injury in all age groups. Cast treatment with or without close reduction is a viable option. However, the results are often unsatisfactory with restricted function. The open reduction and internal fixation often results in extensive soft tissue dissection and associated high rates of infect and delayed/nonunion. The distractor/external fixator have reported good functional and anatomical results but the incidence of pin traction infection nerve injury and cosmedic deformity are high. We introduced a modified operative technique for minimally invasive plate osteosynthesis (MIPO) for distal radial fracture and evaluated the functional outcomes and complications.

MATERIALS AND METHODS

22 distal radial fractures (10 left, 12 right) were treated using the MIPO technique and two small incisions with a palmar locking plate from August 2009 to August 2010. The wrist function was assessed according to Dienst wrist rating system, and postoperative complications were recorded.

RESULTS

According to Dienst wrist rating system, 13 patients showed excellent results, 6 cases showed good results and 3 patients had moderate results. No patient had poor results. Thus, the excellent and good rate was 86.4%. One patient had anesthesia in the thenar eminence and this symptom disappeared after 3 months. One patient had delayed healing in the proximal wrist crease. Two patients had mild pain on the ulnar side of the wrist and two patients had limited wrist joint function.

CONCLUSION

The MIPO technique by using two small palmar incisions is safe and effective for treatment of distal radial fractures.

Digital photography for assessment of shoulder range of motion: A novel clinical and research tool

Purpose:

Maintenance of a pain-free functional range of motion is the aim of surgery for shoulder trauma. The aim of this study was to show that the range of motion can be accurately assessed using digital photographs.

Materials and Methods:

We reviewed 17 patients who had undergone surgery for shoulder trauma. Each patient's range of motion was assessed by two physicians and two physiotherapists. Digital photographs were taken of each patient at their functional limit. Photographs were assessed by two physicians and two physiotherapists, and by an external physician who had no previous contact with the patients.

Results:

Inter-observer and intra-observer reliability trials showed excellent correlation of results. There was no significant difference between observer's results, or between results of physical examination and photographic examination.

Conclusions:

Digital photography is a viable adjunct to assessment of range of motion of the shoulder. This has positive implications both clinically, and for shoulder research.

Level of Evidence:

Level 3.

Indirect reduction maneuver and minimally invasive approach for displaced proximal humerus fractures in elderly patients

BACKGROUND

This study examined the clinical outcomes of indirect reduction maneuver and minimally invasive approach for treating displaced proximal humerus fractures in patients older than 60.

METHODS

Thirty-two patients (11 male and 21 female) who had undergone treatment for displaced proximal humerus fracture were evaluated. The mean age of the patients was 72.4 years (range, 60 to 92 years). All cases were followed up for at least 12 months. All patients were interviewed and evaluated on the visual analog scale, with gender-specific constant score correction for age, standardized X-rays to check the neck-shaft angle (NSA) and the presence of medial support, and bone mineral density. Statistical analysis was performed with a multiple regression analysis.

RESULTS

The average visual analog scale score was 2.4, and the average gender-specific constant score correction for age was 80.6 points. Final functional outcomes were 8 excellent, 15 good, 7 fair, and 2 poor. The average NSA was 122.8°; and the radiological results were 20 good, 11 fair, and 1 poor. There was significant difference of the gender-specific constant score for age between the group of NSA more than 110° and the group of NSA less than 110° (p = 0.00). There were 26 cases with and 6 cases without medial support, with significant difference between the gender-specific constant score correction for age of these groups (p = 0.01). Complications occurred in 4 patients (12.5%).

CONCLUSIONS

The indirect reduction maneuver and minimally invasive approach were safe and reliable options for the treatment of displaced proximal humerus fractures in the elderly patients. An inadequate reduction (i.e., less than 110° NSA) or lack of medial support (e.g., no cortical or screw support) were significant factors contributing to poor functional outcomes.

Operative treatment of clavicle midshaft fractures using a locking compression plate: comparison between mini-invasive plate osteosynthesis (MIPPO) technique and conventional open reduction

HYPOTHESIS

The goal of the present study was to compare minimally invasive percutaneous plate osteosynthesis (MIPPO) technique and conventional open reduction with LCP for the treatment of clavicle midshaft fractures in adults in a randomized, controlled, clinical trial with a minimum of 1-year follow-up.

MATERIALS AND METHODS

Between June 2006 and May 2008, 64 cases of open reduction and internal plate fixation were performed for clavicle midshaft fractures. The operative indications were complete displacement, severe comminution and marked shortening of the clavicle (>2cm). MIPPO and conventional open reduction surgery procedures with LCP were used in 32 and 32 cases, respectively.

RESULTS

The mean time to union was 13 weeks in the open reduction group compared to 12 weeks in MIPPO group (P>0.05). The MIPPO group had no significantly superior Constant shoulder scores or DASH scores at all time-points (P>0.05). However, the complications in the open reduction group were dysesthesia in the area of the incision and directly below in 10 cases, hypertrophic scarring in five cases, painful shoulder in two cases and a limitation of shoulder motion in one case (P>0.05). The complications in the MIPPO group were dysesthesia in two cases, no hypertrophic scarring, no painful shoulder, no limitation of shoulder motion were noted (P<0.05). Patients in this operative group were more satisfied with cosmetic appearance and overall outcome than those in the conventional open reduction group.

CONCLUSIONS

Operative treatment with a LCP for clavicle shaft fractures can be used to obtain stable fixation. Particularly, MIPPO of displaced midshaft clavicular fractures resulted in a lower rate of dysesthesia, hypertrophic scarring, and a better cosmetic than conventional open reduction, although the functional outcomes (Constant and DASH) were no different between the two groups. Overall satisfaction was higher in the MIPPO group than conventional open reduction group.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

Minimally invasive percutaneous osteosynthesis for proximal humeral shaft fractures with the PHILOS through the deltopectoral approach

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.

Minimally invasive plate osteosynthesis for distal radius fractures with a palmar locking plate

PURPOSE

Since 2006, we have been performing minimally invasive plate osteosynthesis with a palmar locking plate and without division of the pronator quadratus muscle for repairing distal radial fractures. The purpose of this study was to present the surgical technique we have developed and to retrospectively evaluate the clinical outcomes.

METHODS

Twenty patients were treated with this technique between January and December 2007. The range of motion of the wrist and forearm, grip strength, and the quick disability of the arm, shoulder, and hand score were assessed at the latest follow-up examination, and postoperative complications were evaluated.

RESULTS

The average ranges of flexion and extension of the wrist were 55° and 60°, respectively. The average ranges of supination and pronation of the forearm were 88° and 86°, respectively. The average grip strength of the treated side was 71 % of that of the uninjured side. The average quick disability of the arm, shoulder, and hand score was 13.4 points. No patient had loss of fracture reduction, implant failure, deep infection, or tendon or nerve problems.

CONCLUSIONS

The small skin incisions of this technique are advantageous from the aesthetic viewpoint. Minimally invasive plate osteosynthesis is one of the options for the treatment of distal radial fractures.

Minimally invasive plate osteosynthesis in the treatment of isolated ulnar bone fractures

ABSTRACT

BACKGROUND

Minimally invasive internal fixation is also called "biological internal fixation". This concept is used widely in the treatment of various fractures but to date, there have been no report about such application in the repair of isolated ulnar bone fractures.

METHODS

Eleven patients with fracture of isolated ulnar bone (four AO type 22A11 and seven AO type 22A12), mean age 43.16 (range, 24- 59y), were treated using closed reduction and locking compression plate with minimally invasive plate osteosynthesis (MIPO) with the aim of minimising soft tissue damage.

RESULTS

Fractures healed at an average of 7.8 weeks with good to excellent clinical outcomes. There were no complications such as nonunion, implant failure or neurovascular injuries.

CONCLUSIONS

MIPO seems to be advantageous for soft tissue and bone biology. Good union was seen and fracture complications were also prevented by early mobilisation.

KEY WORDS

Locking compression plate (LCP), closed reduction, isolated ulnar bone fracture, minimally invasive plate osteosynthesis (MIPO).

Minimally invasive helical plating for shaft of humerus fractures: technique and outcome

INTRODUCTION

The humerus is subjected to substantial amount of torsional stress. Conventional plating may not address this sufficiently and may lead to fixation failure or non-union. A helical plate may offer the solution. We present the surgical technique and functional outcome of 5 cases of humeral shaft fractures treated with this technique in a minimally invasive way.

MATERIALS AND METHODS

The operations were performed between 2004 and 2010, by three surgeons. All the patients had closed humeral shaft fractures, either simple transverse or with mild comminution. Two small incisions were made. The proximal incision was placed along the deltopectoral groove over the shaft, and the distal incision was placed as in an antero-lateral approach. The radial nerve was identified and protected. A pre-selected plate was contoured and introduced in the submuscular plane. The plate was placed in a proximal-lateral and distal-anterior position. Screws were inserted through stab incisions. The patients were followed for an average of 6 months. Functional recovery of the shoulder and elbow was assessed using the Constant and Mayo elbow performance score systems.

RESULTS

All incisions healed by first intention without complications and all the fractures went on to unite. All patients achieved good to excellent shoulder and elbow function.

CONCLUSION

The helical plate technique is a safe and effective method of treating humeral shaft fractures and has good functional outcome.

Minimal Invasive Plate Osteosynthesis (MIPO) Technique Using Anterolateral Approach for Treating Closed Proximal Humerus Fracture

ABSTRACT

Proximal humerus fracture is the second most common fracture of the upper extremity and presents several unique problems such as anatomical complexity, high risk of avascular necrosis, minimal bone stock for purchase, significant morbidity, and lack of a universally accepted treatment. Recent treatments for proximal humerus fractures include use of minimally invasive plate osteosynthysis (MIPO). The aim of this cross-sectional study was to evaluate the outcomes of our less invasive technique using a modified anterolateral approach for treatment of proximal humerus fractures. Ten such operative procedures were performed in patients of varying age and with varied mechanism of injury from 2002-2011. All cases were conducted in an acute setting. There were no cases of infection and the functional outcome scores were good. This approach represents an alternative treatment for closed proximal humerus fracture but more extensive studies are needed.

KEY WORDS

Proximal humerus fracture, MIPO, less invasive,anterolateral approach.

Treatment of proximal and middle one-third humeral fractures with lateral distal tibial helical plate

OBJECTIVE

To evaluate the outcomes of treating patients with proximal and middle one-third humeral fractures treated with lateral distal tibial helical plate.

MATERIALS AND METHODS

From June 2004 to January 2009, 12 patients (8 men, 4 women: average age: 46.8 years, range: 25-63) with proximal and middle one-third humeral fractures were treated with open reduction and internal fixation using lateral distal tibial helical plate. Standard anterior-posterior and lateral radiographs were obtained and evaluated. Shoulder function was assessed according to the Constant-Murley score.

RESULTS

At follow-up (average: 18 months), all fractures had healed (average: 15 weeks, range: 9-23). There were no cases of intraoperative complications, implant failures, infections, or iatrogenic intra- or post-operative nerve lesions. All patients achieved at least 100° of abduction by 3 months post-surgery and full range of movement by 12 months post-surgery, with the exception of one patient who had an impingement symptom with moderate loss of abduction and external rotation. The average Constant-Murley score was 88 points at 12-month follow-up. According to Constant-Murley score, 28% of patients had excellent functional outcome, 64% had good outcome, 8% had moderate outcome, and none had failure. According to self-reporting, all patients had returned to the pre-injury level of activity.

CONCLUSIONS

The lateral distal tibial helical plate promotes bone healing and minimizes the damage to the deltoid muscle insertion region, thereby facilitating rapid and good functional recovery. In addition, the helical plate design avoids affecting sliding of the biceps tendon and maintains good reduction position. The lateral distal tibial helical plate is an effective surgical option for proximal and middle one-third humeral fractures.

Minimal invasive long PHILOS®-plate osteosynthesis in metadiaphyseal fractures of the proximal humerus

Minimal invasive plate osteosynthesis (MIPO) not only meets the criteria of a "biological" osteosynthesis by minimising invasivity as well as iatrogenic soft tissue damage, but can also provide adequate stability for fracture healing and early functional aftertreatment. Up to date, only few publications report on MIPO of humeral shaft fractures mainly using the anterolateral deltopectoral approach for proximal plate insertion. Objective of the present study was to assess the feasibility and clinical outcome of MIPO for metadiaphyseal fractures of the proximal humerus through a lateral approach using angular stable long PHILOS(®)-plates. We retrospectively evaluated 29 patients (mean age 77 years, range 48-95 years) with displaced metadiaphyseal fractures of the proximal humerus treated with MIPO technique. For the first time, an angular stable long PHILOS(®)-plate through a lateral deltoid-split approach proximally and a brachialis/brachioradialis intermuscular approach with exposure of the radial nerve distally, were used. There were no infections and no iatrogenic injuries to the axillary and radial nerve. One patient showed subacromial impingement and one patient had to be reoperated for redislocation of the distal fragment with screw breakage, which was most likely due to incorrect screw placement. This patient was successfully operated using the same method and implant. Besides one patient who refused further follow-up, 28 patients could be followed up to a mean of 8 months (range 3-12 months) each with an entirely healed fracture. Furthermore, patient's quality of life was documented using the SF-36 questionnaire. Comparison with published United States normative data showed no significant deficits in the physical as well as in the mental domains 8 months after MIPO. Minimal invasive long PHILOS(®)-plate osteosynthesis using a combined lateral deltoid-split and brachialis/brachioradialis intermuscular approach proved to be a safe procedure for the treatment of metadiaphyseal fractures of the proximal humerus with low morbidity and full restoration of quality of life in these elderly patients.

Sub-muscular plating of the humerus: an emerging technique

OBJECTIVE

The purpose of the present study was to evaluate percutaneous sub-muscular internal fixation using a locked screw methodology for treatment of diaphyseal humeral fractures.

METHODS

Inclusion criteria were multiple extremity fractures, open fractures, neurovascular injuries,additional ipsilateral upper extremity fractures, the inability to obtain a satisfactory closed reduction and isolated fractures with circumstances that prevented effective bracing. Exclusion criteria were immaturity, neoplasm, infection and intra-articular extensions in the same bone. Outcome measures included clinical and radiographic healing, complications, elbow and shoulder symptoms, range of motion (ROM) and Constant–Murley (CM) scores.

RESULTS

Thirty-one patients with 32 fractures were evaluated with a mean follow-up of 16 months (3–38 months). There was radiographic healing in 31 out of the 32 fractures; the non-union was revised to open plating at 6 months and healed uneventfully. Hardware complications included two construct disengagements; one patient was revised and healed, and the other achieved union with bracing.Neurovascular complications included one preoperative nerve palsy that recovered by 3 months, two partial to complete postoperative nerve palsies that recovered by 6 months, and one intact-to-complete nerve palsy due to a bone fragment that required decompression with full recovery by 3 weeks. All patients had functional ROM with a mean CM score of 88. There were no elbow complaints and minor shoulder dysfunction occurred in two patients with ipsilateral shoulder injuries. The rate of neurovascular complications was comparable to open plating techniques and all patients had full recovery.

CONCLUSION

We feel sub-muscular anterior plating of the humerus using locking screw technology is a viable and useful method for diaphyseal humeral fractures.

Long-term results after non-plate head-preserving fixation of proximal humeral fractures

A retrospective study was conducted to evaluate displaced proximal humeral fractures treated with a non-plate head-preserving fixation and to detect factors predicting functional outcome. After a median follow-up period of 79.7 months, 105 patients with nine A-fractures, 36 B-fractures and 60 C-fractures (nine two-part-fractures, 41 three-part fractures and 55 four-part fractures) were assessed. Functional outcome was measured based on the Constant and UCLA scores. Of all patients, 70-75% had excellent or good Constant and UCLA scores. In 74% a good or satisfactory quality of initial reduction fracture was achieved. About one-fifth (21%) of the fractures showed a secondary displacement. Twenty-seven percent of the patients had signs of humeral head necrosis and 22% had implant related problems. There were significant correlations between a high final score and young age, low AO fracture severity, good quality of fracture reduction and residual osseous deformity, absence of secondary fracture displacement, implant-related complications, shoulder arthrosis and humeral head necrosis at the time of follow-up. In conclusion, the non-plate head-preserving fixation of proximal humeral fractures is an alternative treatment for displaced proximal humeral fractures. Especially in severely displaced C-fractures in older patients, non-anatomical reduction leads to a high rate of secondary displacement, residual osseous deformity and only a fair shoulder function. For these cases alternative methods such as prosthetic replacement should be chosen.

Minimally invasive percutaneous plate osteosynthesis (MIPPO) technique applied in the treatment of humeral shaft distal fractures through a lateral approach

The minimally invasive percutaneous plate osteosynthesis (MIPPO) technique through the anterior approach has been successfully used in the treatment of humeral shaft fractures and has gained satisfactory clinical outcome. An anatomical study and a preliminary clinic report were performed to evaluate the feasibility of applying the MIPPO technique in the treatment of humeral shaft distal fractures through the lateral approach. This study was done on 14 arms from seven fresh cadavers. The results of this study showed that it is possible to treat humeral shaft distal fractures by using the MIPPO technique through the lateral approach. The results of using the MIPPO technique through the lateral approach in the treatment of humeral shaft fractures in 22 patients were also reviewed.

Philos plate fixation for proximal humeral fractures

PURPOSE

To evaluate the efficacy of Philos plate fixation for proximal humerus fractures.

METHODS

Functional outcomes of 31 men and 27 women aged 36 to 73 (mean, 61) years who underwent Philos plate fixation for proximal humeral fractures were retrospectively reviewed. Indications for surgery were 3-part (n=33) or 4-part (n=25) closed proximal humeral fractures with angulation of more than 45 degrees or displacement of more than 1 cm. Functional outcomes and shoulder range of movement were assessed based on the Constant scoring system.

RESULTS

Patients were followed up for 12 to 18 (mean, 15) months. All fractures healed satisfactorily, except in one patient with a valgus 4-part fracture who had malunion. No wound infections, vascular injuries, avascular necrosis, or loss of fixation ensued. Two patients with axillary nerve palsy recovered spontaneously within 3 months. Functional outcome was excellent in 13 patients, good in 36, moderate in 8, and poor in 1. The mean Constant score was 80 (range, 40-100).

CONCLUSION

The Philos plate fixation is appropriate treatment for proximal humeral fractures.

Shape memory Ni-Ti alloy swan-like bone connector for treatment of humeral shaft nonunion

From August 1990 to December 2007, 156 patients with humeral shaft nonunion were treated with our patented Ni-Ti shape memory alloy swan-like memory pressure connector (SMC). The SMC device cooled with ice before implantation was warmed to 40-50 degrees C after implantation to produce balanced axial and compression forces to stabilise the fracture three-dimensionally. This combined with autologous bone grafting achieved bone tissue regeneration in the fracture and promoted smooth recovery of joint function, with a nonunion healing rate of 98.7% after a single SMC implantation. Failure of nonunion healing occurred in only two cases but was successfully managed by a further operation. Complications were not found in any of these patients apart from four with pre-existing radial nerve injuries. These results demonstrate the effectiveness of the SMC device for the management of humeral shaft nonunion. The device provides continuous compression of the fracture with minimal trauma to the local blood supply.

Locking plate fixation for proximal humerus fractures: a comparison with other fixation techniques

Various traditional surgical treatment methods for displaced proximal humerus fractures were compared with locking plates. Ninety-eight patients were reviewed and functional outcomes were obtained. After a mean 45-month follow-up, trends were noted toward better fracture reduction with locking plates and greater range of motion (ROM) with percutaneous pinning. Complications occurred in 22 patients, unrelated to treatment type. Method of fixation did not correlate with outcome scores, but functional ROM was associated with better American Shoulder and Elbow Surgeons (ASES) scores. Locking plates are comparable to traditional fixation methods. Functional ROM is associated with better outcome scores.

Is MIPO in humeral shaft fractures really safe? Postoperative ultrasonographic evaluation

In the last few years there has been great interest in minimally invasive plate osteosynthesis (MIPO) in the treatment of humeral shaft fractures. None of these studies showed the anatomical relationship between the radial nerve and the material of the implant in vivo. We performed postoperative ultrasonographic measurement of the distance between the radial nerve and the material implanted using the MIPO technique. Nineteen patients underwent postoperative ultrasound examinations. Group A comprised midshaft fractures and group B distal third fractures. The point of greatest proximity between the radial nerve and the implant was measured. In group A the distance was between 1.6 and 19.6 mm (mean: 9.3 mm) and in group B between 1.0 and 8.1 mm (mean: 4.0 mm). The ultrasound findings reveal that the radial nerve is quite close to the implant material, especially in the transition between the third and fourth quarters of the humeral shaft.

Plating in Proximal Humeral Fractures

Improved imaging, updated knowledge regarding humeral head perfusion and adapted fixation techniques with implants having better purchase also in osteopenic bone, have influenced the treatment of proximal humeral fractures in recent years. Demographic evolution and a more active population even among the older age groups will increase the incidence of this fracture, which is already the third most frequent fracture after hip and distal radius fractures in elderly patients. Long-term morbidity related to the treatment of these fractures like avascular humeral head necrosis, non-union, malunion, shoulder stiffness, persistent pain and functional disability are the challenging factors to be overcome. Plate osteosynthesis with angular stable implants have shown to address some of these problems and to broaden the spectrum of indication towards anatomic fracture stabilization even for severely displaced three- and four-part fractures instead of replacing the humeral head with an endoprosthesis, as long as a stable fixation is possible. Open access surgery is often needed for anatomic reconstruction of complex and displaced fractures. This calls for immediate postoperative mobilization with active-assisted ROM exercise to prevent subdeltoidal adhesions. Even though plating of proximal humeral fractures with angular stable implants has shown promising first clinical results, there still remain elevated complication rates especially in the elderly osteoporotic patient population. Recent clinical reports using angular stable plates provided only data with a low level of evidence to help in decision-making. The comparison with historical series using non-angular stable plates in respect to the long-term morbidity should help to better evaluate the value of locked plates inserted with less-extensive soft-tissue exposure.