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Gumina S, Candela V. Humeral Head Three-Part Posterior Fracture-Dislocation Reduced through a Posterior Approach and Fixed with Blocked Threaded Wires: A Consecutive Case Series. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040772. [PMID: 37109730 PMCID: PMC10144646 DOI: 10.3390/medicina59040772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: Posterior fracture dislocations are rare. There is currently no uniformity regarding treatment. Therefore, outcomes are difficult to compare. We evaluated clinical and radiological outcomes of patients with humeral head posterior fracture dislocation treated with an open posterior reduction and then fixed with a biomechanically validated configuration of blocked threaded wires. Materials and Methods: 11 consecutive patients with humeral head three-part posterior fracture dislocation were treated by reduction through a posterior approach and fixed with blocked threaded wires. All patients were clinically and radiographically evaluated after a mean follow-up of 50 months. Results: The mean irCS was 86.1% (range: 70.5-95.3%). No significant difference was found between irCS at 6 and 12 months postoperatively and the final follow-up. Six patients noted their pain intensity as 0/10, three as 1/10, and two as 2/10. The postoperative reduction was considered as excellent in eight patients (Bahr's criteria) and good in the remaining three; at the final follow-up, reduction was excellent and good in seven and four patients, respectively. The mean neck-shaft angles at FU 0 and at the final FU were 137° and 132°, respectively. No signs of avascular necrosis, non-union, and arthritis progression were seen. No recurrence of dislocation or posterior instability symptoms were reported. Conclusions: We believe that our very satisfactory results stem from: (1) the manual reduction of the dislocation through a vertical posterior surgical approach, which does not produce further osteocartilaginous damage of the humeral head; (2) no multiple perforations of the humeral head are performed; (3) the threaded wires have a smaller diameter than the screws, therefore they preserve the bone tissue of the humeral head; (4) deperiostization or further detachment of soft tissues are not expected; (5) the adopted and validated system is stable and limits translation, torsion, and the collapse of the humeral head.
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Affiliation(s)
- Stefano Gumina
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Vittorio Candela
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences, Sapienza University of Rome, 00185 Rome, Italy
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Bue M, Bright E, Thillemann TM, Mosegaard SB, Hansen TB, Klebe T, Mechlenburg I, Stilling M. Osteoporosis does not affect bone mineral density change in the proximal humerus or the functional outcome after open reduction and internal fixation of unilateral displaced 3- or 4-part fractures at 12-month follow-up. J Shoulder Elbow Surg 2023; 32:292-301. [PMID: 35998782 DOI: 10.1016/j.jse.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 06/17/2022] [Accepted: 07/07/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this prospective study was to investigate bone mineral density (BMD) changes in the proximal humerus of the shoulder during a healing period of 12 months after displaced 3- or 4-part proximal humerus fractures treated with open reduction and internal fixation (ORIF) with an anatomic angular stable locking plate and the influence on fracture healing and functional outcomes. METHODS In a prospective multicenter study, 36 patients (29F and 7M, age range: 38-83) with unilateral displaced 3- or 4-part proximal humerus fractures were included for ORIF. Dual-energy x-ray absorptiometry for osteoporosis status was employed. Postoperative and 6-week, 3-, 6-, and 12-month shoulder radiographs and dual-energy x-ray absorptiometry of the shoulder with BMD measures in 4 templated regions of interest (ROIs) were performed. Functional outcomes, Western Ontario Osteoarthritis of the Shoulder index, Constant score, visual analog scale pain (VAS), and 36-Item Short Form Survey, were collected. RESULTS A total of 17 of 36 patients had osteoporosis. We found no differences in BMD changes, functional outcomes, radiology, or need for revision surgery between the osteoporosis and nonosteoporosis groups. The BMD values gradually declined from baseline to 3-month follow-up in all 4 ROIs of the operated shoulders. All 4 ROIs in the operated shoulder presented with a reduction in BMD at 3, 6, and 12 months compared with baseline, whereas no significant BMD changes were seen in the healthy shoulder during the study period. The functional outcomes displayed an increase in Constant score from 3 to 12 months, but a decrease in domains of the 36-Item Short Form Survey from preinjury to 12 months (physical functioning, general health, and bodily pain). Preinjury and 12-month Western Ontario Osteoarthritis of the Shoulder index, VAS pain at rest, and VAS pain at activity were comparable. CONCLUSION BMD changes appeared swiftly in the proximal humerus, after the treatment of displaced 3- or 4-part fractures with ORIF, particularly affecting the proximal diaphysis of the humerus. Shoulder function was restored to preinjury levels for most of the patients. Osteoporosis may not be regarded as a contraindication for the treatment of displaced 3- or 4-part fractures with ORIF.
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Affiliation(s)
- Mats Bue
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Elisabeth Bright
- Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Theis Muncholm Thillemann
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Sebastian Breddam Mosegaard
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Orthopaedic Surgery, University Clinic for Hand, Hip and Knee Surgery, Holstebro Regional Hospital, Holstebro, Denmark
| | - Torben Bæk Hansen
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Orthopaedic Surgery, University Clinic for Hand, Hip and Knee Surgery, Holstebro Regional Hospital, Holstebro, Denmark
| | - Thomas Klebe
- Department of Orthopaedic Surgery, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Inger Mechlenburg
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Maiken Stilling
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Orthopaedic Surgery, University Clinic for Hand, Hip and Knee Surgery, Holstebro Regional Hospital, Holstebro, Denmark.
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Hung CY, Yeh CY, Wen PC, Yeh WL, Lin SJ. The effect of medial calcar support on proximal humeral fractures treated with locking plates. J Orthop Surg Res 2022; 17:467. [PMID: 36307815 PMCID: PMC9617439 DOI: 10.1186/s13018-022-03337-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background Studies have reported mixed results on the importance of medial calcar support for the treatment of proximal humeral fractures. The purpose of this study was to compare radiographic and functional outcomes of patients who had displaced proximal humeral fractures with varying levels of medial support. Methods We performed a retrospective comparative cohort study. The study was conducted at a Level III trauma center in Taiwan. Seventy patients with proximal humeral fractures were collected retrospectively from 2015 to 2019. Only patients with two-, three-, or four-part types (Neer type I, II, or III) of displaced proximal humeral fractures were included in this study. However, patients with head-split fracture patterns, shoulder dislocation, prior shoulder trauma, and poor fracture reduction present in postoperative films were excluded. We assessed the radiographic outcomes, including the reduction score and amount of impaction in the humeral head. The functional outcome was evaluated based on the Constant score. Results Patients were grouped into the intact medial calcar group and the medial calcar deficiency group. In a subgroup analysis, the group with intact medial support had a significantly lower amount of impaction and a higher Constant score compared with the medial calcar deficiency group. Additionally, the groups with intact medial support had a nonsignificant difference in the Constant score between the affected side and the contralateral side. Conclusion The amount of impaction and the reduction score in the humeral head at the 12-month radiographic follow-up were significantly higher in the group with medial support deficiency. However, the reduction score after surgery exhibited no difference. This implies that the inherent nature of medial comminution of proximal humeral fracture may lead to inferior radiographic outcomes.
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Affiliation(s)
- Chun-Yu Hung
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Yunlin, Taiwan.,Department of Orthopaedic Surgery, Jen-Ai Hospital, Taichung, Taiwan
| | - Chia-Yi Yeh
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Po-Chong Wen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Yunlin, Taiwan
| | - Wen-Ling Yeh
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Orthopaedic Surgery, Lotung Poh-Ai Hospital, Yilan, Taiwan
| | - Shih-Jie Lin
- Department of Orthopaedic Surgery, New Taipei Municiple TuCheng Hospital, Chang Gung Memorial Hospital, New Taipei City, Taiwan. .,Department of Chemical Engineering, National Tsing Hua University, Hsinchu, Taiwan.
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Simionato IF, Brunelli JPF, Ferreira MT, Matsumoto FY, Britto AG, Mothes FC. Radiographic Evaluation of the Consolidation of Humerus Surgical Neck Fractures Treated With Percutaneous Fixation. Rev Bras Ortop 2020; 55:347-352. [PMID: 32616981 PMCID: PMC7316538 DOI: 10.1055/s-0039-3402463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 05/02/2019] [Indexed: 12/03/2022] Open
Abstract
Objective
To evaluate radiographically the postoperative results of patients with fracture of the proximal humerus in two parts of the surgical neck treated with threaded percutaneous fixation.
Methods
We evaluated the radiographic results of percutaneous fixation with threaded pins on the treatment of proximal humerus fractures in our service. Preoperative and postoperative images of 42 patients were evaluated, evaluating radiographs until 8 weeks postoperatively. We considered on evaluation the fracture deviation on preoperative images, the loss of reduction and no consolidation.
Results
Our consolidation rate was 90.4%, with loss of reduction in 16.6% of the cases and no consolidation rates in just 4 operated cases. We observed a predominance of a specific fracture pattern in the cases with loss of reduction.
Conclusion
The present study allows us to consider the percutaneous fixation technique with threaded pins as an alternative in our therapeutic arsenal for the proximal humerus fracture of the surgical neck. Contraindications are considered for low fracture trait on the metaphysis and with medial/lateral cortical impairment.
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Affiliation(s)
| | | | - Marco Tonding Ferreira
- Grupo de Cirurgia do Ombro e Cotovelo, Santa Casa de Misericórdia de Porto Alegre, RS, Brasil
| | | | - Almiro Gerszon Britto
- Grupo de Cirurgia do Ombro e Cotovelo, Santa Casa de Misericórdia de Porto Alegre, RS, Brasil
| | - Fernando Carlos Mothes
- Grupo de Cirurgia do Ombro e Cotovelo, Santa Casa de Misericórdia de Porto Alegre, RS, Brasil
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Falez F, Papalia M, Carbone S, Teti A, Favetti F, Panegrossi G, Casella F, Mazzotta G. Low complication rates in Minimally Invasive Plate Osteosynthesis (MIPO) for proximal humeral fractures at 5 years of follow-up. Injury 2019; 50 Suppl 2:S34-S39. [PMID: 30799100 DOI: 10.1016/j.injury.2019.01.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Purpose of this study was to analyse the medium term follow-up of minimally invasive plate osteosynthesis (MIPO) for proximal humeral fractures in terms of postoperative shoulder function, radiological outcome and complications. METHODS 76 consecutive patients with unstable proximal humeral fractures were treated using locking plate with a minimally invasive antero-lateral approach in two surgical centers. Constant score and radiographic evaluation of 74 patients were available at mean follow up of 5 years (minimum 4 years). RESULTS Mean Constant score was 74 (range to 28-100). Results were comparable in the two centers. Younger patients registered significantly higher scores (p < 0.05). 20 patients (27%) developed complications. Subacromial impingement occurred in 16,2% of cases for varus malreduction (6,7%) and for too proximal plate positioning (9,5%). Primary screws perforation (2,7%), secondary perforation due to cut-out (1,4%), avascular necrosis (AVN) of humeral head (1,4%), partial resorption of greater tuberosity (2,7%), secondary displacement of the greater tuberosity (2,7%) and stiffness (2,7%) were observed. DISCUSSION AND CONCLUSIONS Even at a medium term follow-up, MIPO for proximal humeral fractures ensured good and reproducible results for most common pattern of fractures. Major complications were lower respect to open procedures, because of soft tissue, deltoid muscle and circumflex vessels sparing.
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Affiliation(s)
- F Falez
- Orthopaedic and Traumatology Department, S. Spirito Hospital, Rome, Italy.
| | - M Papalia
- Orthopaedic and Traumatology Department, Nuova Itor Clinic, Rome, Italy
| | - S Carbone
- Orthopaedic and Traumatology Department, San Camillo De Lellis Hospital, Rieti, Italy
| | - A Teti
- Orthopaedic and Traumatology Department, S. Spirito Hospital, Rome, Italy
| | - F Favetti
- Orthopaedic and Traumatology Department, S. Spirito Hospital, Rome, Italy
| | - G Panegrossi
- Orthopaedic and Traumatology Department, S. Spirito Hospital, Rome, Italy
| | - F Casella
- Orthopaedic and Traumatology Department, S. Spirito Hospital, Rome, Italy
| | - G Mazzotta
- Orthopaedic and Traumatology Department, Nuova Itor Clinic, Rome, Italy
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Gumina S, Candela V, Giannicola G, Orsina L, Passaretti D, Villani C. Complex humeral head fractures treated with blocked threaded wires: maintenance of the reduction and clinical results with two different fixation constructs. J Shoulder Elbow Surg 2019; 28:36-41. [PMID: 30220496 DOI: 10.1016/j.jse.2018.06.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/16/2018] [Accepted: 06/23/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Locking plates are the gold standard for treatment of 3-part humeral head fractures, although major complications range from 9% to 36%. Percutaneous techniques may allow vascular supply preservation, maintenance of fracture hematoma, scarce blood loss. Many configurations with Kirschner wires can be performed, generating confusion on result interpretation. We studied the correlation between system configuration, stability, and clinical results in patients with 3-part humeral head fractures treated with the same fixation system but with 2 different biomechanical constructs. MATERIALS AND METHODS There were 52 consecutive patients (19 men, 33 women; mean age, 63.1 [standard deviation, 5.6] years; range, 48-82 years) with Hertel 7 humeral head fractures. Two fixation constructs composed of 3 couples (construct A) or 4 couples (construct B) of blocked threaded wires were used in 17 and 35 patients, respectively. At the final follow-up, the individual relative Constant Score (irCS) and visual analog scale were measured. Radiographic evaluation according to the Bahr criteria was performed. Statistical analysis was performed. RESULTS The mean follow-up was 22 months. The mean irCS at the final follow-up was 89.7%. The mean irCS in patients treated with construct A and construct B was 86% and 93%, respectively (P = .043). One nonunion and 2 superficial infections occurred (6%). The postoperative reduction was excellent in 97% of patients and remained excellent in 89%. The mean postoperative neck shaft angle was 135.0° (construct A: 134.7°; construct B: 135.1°), and the final neck shaft angle was 132.9° (construct A: 131.3°; construct B: 133.8°; P = .047). CONCLUSIONS The functional and radiologic outcomes obtained with percutaneous fixation or locking plates are similar; however, the percentage of major complications after percutaneous treatment is lower. Results of percutaneous fixation depend on the biomechanical construct.
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Affiliation(s)
- Stefano Gumina
- Department of Anatomy, Histology, Legal Medicine and Orthopedics, Sapienza, University of Rome-Polo Pontino (ICOT), Latina, Italy
| | - Vittorio Candela
- Department of Anatomy, Histology, Legal Medicine and Orthopedics, Sapienza, University of Rome-Polo Pontino (ICOT), Latina, Italy.
| | - Giuseppe Giannicola
- Department of Anatomy, Histology, Legal Medicine and Orthopedics, Sapienza, University of Rome-Policlinico Umberto I, Rome, Italy
| | - Luigi Orsina
- Department of Mathematic Science, Sapienza, University of Rome, Italy
| | - Daniele Passaretti
- Department of Anatomy, Histology, Legal Medicine and Orthopedics, Sapienza, University of Rome-Policlinico Umberto I, Rome, Italy
| | - Ciro Villani
- Department of Anatomy, Histology, Legal Medicine and Orthopedics, Sapienza, University of Rome-Policlinico Umberto I, Rome, Italy
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Chen JL, Chang FC, Lin SJ, Chuang PY, Peng KT, Huang KC, Huang TW. The outcome of surgical management of proximal humeral fractures using locking plates: comparison between locking plates with different geometry. J Shoulder Elbow Surg 2018; 27:2159-2166. [PMID: 30017232 DOI: 10.1016/j.jse.2018.05.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 05/18/2018] [Accepted: 05/21/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Locking plate fixation appears to be a standard treatment for proximal humeral fracture. Different locking plate designs might result in different radiographic and functional outcomes. The original version of the Proximal Humeral Internal Locking System (PHILOS; DePuy Synthes, Warsaw, IN, USA) occupied the largest volume of the humeral head by screw distribution, whereas the Zimmer Periarticular Locking Plate (ZPLP) system (Zimmer Biomet, Warsaw, IN, USA) occupied the smallest. METHODS We enrolled 50 patients undergoing ZPLP treatment and 50 undergoing PHILOS treatment. RESULTS The postoperative amount of impaction was significantly higher using the ZPLP System than using the PHILOS. Subgroup analysis showed that medial calcar support was another critical factor that affected surgical outcomes, especially when using the ZPLP System. CONCLUSION The amount of postoperative impaction was significantly higher when the ZPLP was used compared with the PHILOS locking plate. Medial calcar support is another critical factor that affects surgical outcomes. However, no significant differences in functional outcomes (Constant-Murley score) between the ZPLP System and the PHILOS were noted at the 12-month follow-up.
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Affiliation(s)
- Jiun-Liang Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Fu-Chun Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Shih-Jie Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan.
| | - Po-Yao Chuang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Kuo-Ti Peng
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Kuo-Chin Huang
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Tsan-Wen Huang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan; Chang Gung University, Taoyuan, Taiwan
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Titanium mini locking plate with trans-osseous sutures for the treatment of humeral greater tuberosity fracture osteosynthesis versus PHILOS: a retrospective view. INTERNATIONAL ORTHOPAEDICS 2018; 42:2467-2473. [PMID: 29500554 DOI: 10.1007/s00264-018-3823-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/31/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Greater tuberosity fractures (GTFs) account for 17 to 21% of proximal humerus fractures, most of these fractures are treated conservatively, but treatment for displaced fractures is still controversial. The aim of this study is to compare intra-operative clinical conditions and post-operative outcomes when displaced GTFs are treated with either proximal humeral internal locking system (PHILOS) or mini locking plate with trans-osseous sutures. METHODS This is a retrospective study conducted in Shanghai Tenth People's Hospital. A total of 60 patients (22 males and 38 females) with displaced humeral GTF between May 2013 and March 2017 were included, of whom 43 underwent PHILOS implant treatment and 17 underwent titanium mini plate implant with trans-osseous suture treatment. Intra-operative (incision size, intra-operative blood loss, operative duration) and postoperative (Constant-Murley score (CMS) and implant cost) variables were recorded for the comparison. RESULTS Mini locking plate with trans-osseous sutures shows better results. Operative duration (PHILOS mean 77.0 minutes vs mean 63.7 minutes, p value < 0.05), blood loss during surgery (PHILOS mean 111.5 vs 66.5 ml, p value < 0.05), incision size (PHILOS mean 7.2 vs 4.6 cm, p value < 0.05), CMS (PHILOS mean 81.0 vs 87.3, p value < 0.05), and implant costs (PHILOS mean 26,192.6 renminbi (RMB) vs mean 21,358.8 RMB, p value < 0.05). On the other hand, 9.30% of impingement in the PHILOS group was observed to have no complications compared to the mini locking plate group. CONCLUSIONS Mini locking plate with trans-osseous sutures shows better efficacy in reducing the incision size, operative duration, intraoperative blood loss, and implant cost and in improving CMS. No complication was found with its use. Our data can provide rationale and inform sample- size calculations for such studies. Larger, control studies are needed for better understanding.
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Carbone S, Mezzoprete R, Papalia M, Arceri V, Carbone A, Gumina S. Radiographic patterns of osteoporotic proximal humerus fractures. Eur J Radiol 2018; 100:43-48. [DOI: 10.1016/j.ejrad.2017.12.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 11/01/2017] [Accepted: 12/31/2017] [Indexed: 10/18/2022]
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Carbone S, Razzano C, Albino P, Mezzoprete R. Immediate intensive mobilization compared with immediate conventional mobilization for the impacted osteoporotic conservatively treated proximal humeral fracture: a randomized controlled trial. Musculoskelet Surg 2017; 101:137-143. [PMID: 28770512 DOI: 10.1007/s12306-017-0483-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/05/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE To select in a 2-year survey of proximal humerus fractures accessing the emergency department, a population of osteoporotic stable impacted fractures and to randomize them into two groups, one with an immediate intensive mobilization program and the other with an immediate conventional mobilization program. METHODS In emergency department, patients with clinical signs of shoulder girdle fracture were submitted to standard X-ray examination and CT scan. Patients with stable (absence of metaphyseal comminution or fifth fragment) osteoporotic (cortical bone thickness lower than 6 mm) impacted (Is any part of metaphysis or head impacted into the shaft? YES/NO) proximal humerus fractures were selected for randomization in one of the two groups. Group 1: early intensive mobilization; Group 2: early conventional mobilization. Functional and radiographic assessment was recorded at 3, 6 and 12 months of follow-up. RESULTS In the considered period, 120 patients were affected by a stable impacted osteoporotic proximal humerus fracture. At the final follow-up, 36 patients in group 1 and 39 patients in group 2 were available for statistical analysis. Functional and radiographic scores were comparable, with a trend of significance in favor of group 2. No fracture in any of the group showed significant loss of reduction respect to 6 months of follow-up. 4 (10%) and 1 (2.5%) patients in groups 1 and 2 were not compliant with the rehabilitation program (p = 0.037). CONCLUSIONS This randomized controlled trial showed that impacted osteoporotic proximal humerus fractures can be managed non-operatively with an early conventional rehabilitation program composed by 10 sessions of passive motion twice a week, followed by recovery of active range of motion for further 10 sessions thrice a week, while no advantage is given by a more aggressive rehabilitation regimen. Self-assisted exercises should be explained to patients to maximize the effects of the assisted program. LEVEL OF EVIDENCE Level 1, randomized controlled double-blinded trial.
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Affiliation(s)
- S Carbone
- Orthopaedic and Traumatology Department, Ospedale San Camillo de Lellis, Rieti, Italy.
- FIMAC Onlus, Via Giulio Pittarelli 114, 00166, Rome, Italy.
| | - C Razzano
- Department of Physical Medicine and Rehabilitation, Sapienza University of Rome, P.le Aldo Moro, 5, 00185, Rome, Italy
- Department of Physical Medicine and Rehabilitation, Centro Medico Erre, Via Pennino Traversa Mustilli, Sant'Agata dei Goti, BN, Italy
- MED.IT.A Onlus, Naples, Italy
| | - P Albino
- Casa di Cura Città di Aprilia, Aprilia, Italy
| | - R Mezzoprete
- Orthopaedic and Traumatology Department, Ospedale San Camillo de Lellis, Rieti, Italy
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Minimally Invasive Treatment of Displaced Proximal Humeral Fractures in Patients Older Than 70 Years Using the Humerusblock. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6451849. [PMID: 27981050 PMCID: PMC5131233 DOI: 10.1155/2016/6451849] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/25/2016] [Indexed: 11/17/2022]
Abstract
Background. Surgical treatment of proximal humeral fractures (PHF) in osteoporotic bone of elderly patients is challenging. The aim of this retrospective study was to evaluate the clinical and radiological outcome after percutaneous reduction and internal fixation of osteoporotic PHF in geriatric patients using the semirigid Humerusblock device. Methods. In the study period from 2005 to 2010, 129 patients older than 70 years were enrolled in the study. After a mean follow-up of 23 months, a physical examination, using the Constant-Murley score and the VAS pain scale, was performed. Furthermore radiographs were taken to detect signs of malunion, nonunion, and avascular necrosis. Results. The recorded Constant-Murley score was 67.7 points (87.7% of the noninjured arm) for two-part fractures, 67.9 points (90.8%) for three-part fractures, and 43.0 points (56.7%) for four-part fractures. In ten shoulders (7.8%) loss of reduction and in four shoulders (3.1%) nonunion were the reason for revision surgery. Avascular humeral head necrosis developed in eight patients (6.2%). Conclusions. In two- and three-part fractures postoperative results are promising. Sufficient ability for the activities of daily living was achieved. In four-part fractures the functional results were less satisfying regarding function and pain with a high postoperative complication rate. In those patients other treatment strategies should be considered. Study design. Therapeutic retrospective case series (evidence-based medicine (EBM) level IV).
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Carbone S, Papalia M. The amount of impaction and loss of reduction in osteoporotic proximal humeral fractures after surgical fixation. Osteoporos Int 2016; 27:627-33. [PMID: 26323331 DOI: 10.1007/s00198-015-3304-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 08/21/2015] [Indexed: 11/26/2022]
Abstract
UNLABELLED After surgical fixation, osteoporotic proximal humeral fractures often show high impaction and loss of reduction. This study aims at assessing the amount of impaction and loss of reduction at a short and medium follow-up. We found an alarming percentage of cases showing these complications in the first postoperative months. INTRODUCTION This study seeks to quantify the amount of humeral head impaction and loss of reduction in a consecutive series of osteoporotic proximal humerus fractures treated with a locking plate. METHODS A series of displaced proximal humerus fractures were prospectively treated with minimally invasive reduction and ostheosynthesis using a locking plate. Diagnosis and classification of fractures were based on X-ray examination and CT scan. Proximal humerus cortical bone thickness (CBTAVG) was studied to assess osteoporosis. Amount of loss of reduction and head fragment impaction were noted at 3 and 18 months of follow-up. Constant score was calculated at 6 and 18 months of follow-up. RESULTS Thirty-one osteoporotic fractures were studied. Most of the fractures (21, 67.7 %) had a CBTAVG of less than 4 mm. At 3 months of follow-up, 7 cases (22.5 %) had significant loss of reduction and the mean amount of impaction was 2.8 mm. At 18 months of follow-up, only 1 additional fracture showed loss of reduction and mean impaction was 3 mm (p < 0.05). At 6 months follow-up, the mean Constant score was 58 %; while at 18 months, it was 70 % (p = 0.02). Amount of impaction was significantly correlated to age of patients (p = 0.031), female sex (p = 0.011), CBTAVG (p = 0.019), and metaphyseal comminution (p = 0.013). CONCLUSIONS Osteoporotic proximal humerus fractures may present an important impaction and loss of reduction in the first 3 months after surgery even if treated with a rigid device and multiple head screws. Surgeons treating these osteoporotic fractures should be aware of these complications even when using a rigid device.
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Affiliation(s)
- S Carbone
- Department Of Molecular Medicine, Sapienza University of Rome, Rome, Italy.
| | - M Papalia
- Department Of Orthopaedics and Traumatology, Clinica Nuova Itor, Rome, Italy
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Ortmaier R, Filzmaier V, Hitzl W, Bogner R, Neubauer T, Resch H, Auffarth A. Comparison between minimally invasive, percutaneous osteosynthesis and locking plate osteosynthesis in 3-and 4-part proximal humerus fractures. BMC Musculoskelet Disord 2015; 16:297. [PMID: 26467533 PMCID: PMC4607011 DOI: 10.1186/s12891-015-0770-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 10/08/2015] [Indexed: 02/03/2023] Open
Abstract
Background The ideal method for the surgical treatment of proximal humeral fractures has not yet been found. We therefore conducted a retrospective matched-pair analysis and compared osteosynthesis with open reduction and internal fixation and that with an angular stable plate with minimally invasive, closed reduction, percutaneous fixation with the Humerusblock. Methods During a study period of 3 years, we matched 30 patients treated with angular stable plates (group 1) for age, gender, fracture type and handedness (dominant or nondominant) to 30 patients treated using the Humerusblock (group 2). At a minimal follow-up of 24 months, clinical evaluation included the Constant-Murley score, the UCLA score and the Simple Shoulder Test. Subjective pain was evaluated using the VAS pain scale. Patients were asked to rate their subjective satisfaction of final outcome as excellent, good, satisfied or dissatisfied. Results The mean CMS, UCLA score and SST differed significantly between groups 1 and 2 (60.9 vs 71.9, p < 0.01), (25.1 vs 29.5, p < 0.01) and (8.1 vs 9.4, p < 0.05), respectively. The VAS pain score was significantly lower in group 2 than in group 1 (1.2 vs 2.4; p < 0.01). The mean abduction (109.7° vs 133.7°; p < 0.01) and anterior flexion (128.3° vs 145.7°; p < 0.01) were significantly worse in group 1. The mean operation time was significantly shorter in group 2 (117.3 vs 72.1, p < 0.01). Complications occurred in 30 % (group 1) and 23 % (group 2) of patients. Conclusions In this study, the functional outcome is superior in the Humerusblock group. However, the general outcome after surgical treatment of 3-and 4-part fractures is moderate, and the complication rate has to be considered, even though it can be lowered with the use of minimally invasive implants.
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Affiliation(s)
- Reinhold Ortmaier
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria.
| | - Verena Filzmaier
- Department of Traumatology, Diakonissenkrankenhaus Schladming, Salzburgerstraße 777, A-8970, Schladming, Austria.
| | - Wolfgang Hitzl
- Department of Biostatistics, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria.
| | - Robert Bogner
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria.
| | - Thomas Neubauer
- Landeskrankenhaus Horn and Paracelsus Medical University, Spitalgasse 10, A-3580 Horn, Salzburg, Austria.
| | - Herbert Resch
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria.
| | - Alexander Auffarth
- Department of Traumatology and Sports Injuries, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria.
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