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Saber AY, Said UN, Abdelmonem AH, Elsayed H, Taha M, Hussein W, Al-Hashimi K, El-Omar O, Elbeshbeshy M. Surgical Fixation of Three- and Four-Part Proximal Humeral Fractures Using the Proximal Humeral Interlocking System Plate. Cureus 2022; 14:e25348. [PMID: 35774694 PMCID: PMC9236683 DOI: 10.7759/cureus.25348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction The management of proximal humeral fractures ranges greatly from conservative management to surgical treatment. For those fractures requiring surgical treatment, internal fixation is the primary method. The aim of internal fixation is to achieve rigid fracture fixation until union occurs, return of shoulder range of motion, and minimise intra-and postoperative complications. The aim of this study was to evaluate the results of the Proximal Humeral Interlocking System Plate (PHILOS) used for the treatment of three-and four-part proximal humeral fractures. Materials and methods This study included 30 patients with a mean age of 54 years (range 20-80 years). Results were checked post-operatively with standard radiographs and clinical evaluation according to the Constant-Murley shoulder score. All patients were followed up for 12 months. Results Union was achieved in all patients with a mean neck/shaft angle of 130° (range 108°-150°). The mean Constant-Murley score at the final follow-up was 82.28 (range 67-96) correlating with good results. No patients developed an intraoperative or postoperative vascular injury, wound complications, or avascular necrosis of the humeral head. Conclusion Our study has shown that the surgical treatment of three- and four-part proximal humeral fractures with the use of the PHILOS plate leads to a good functional outcome. It has also demonstrated the PHILOS plate and is an effective system for fracture stabilisation provided the correct surgical technique is used with awareness of potential hardware complications.
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KOKKALIS ZINONT, BAVELOU EKATERINI, PAPANIKOS EFSTRATIOS, PANAGOPOULOS ANDREAS, MEGAS PANAGIOTIS. AVOIDING COMPLICATIONS OF LOCKING PLATING FOR PROXIMAL HUMERUS FRACTURES. J Long Term Eff Med Implants 2022; 32:73-81. [DOI: 10.1615/jlongtermeffmedimplants.2022040229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Howard L, Berdusco R, Momoli F, Pollock J, Liew A, Papp S, Lalonde KA, Gofton W, Ruggiero S, Lapner P. Open reduction internal fixation vs non-operative management in proximal humerus fractures: a prospective, randomized controlled trial protocol. BMC Musculoskelet Disord 2018; 19:299. [PMID: 30121091 PMCID: PMC6098830 DOI: 10.1186/s12891-018-2223-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Proximal humerus fractures are the third most common fracture in the elderly population and are expected to increase due to the aging population. Surgical fixation with locking plate technology has increased over the last decade despite a lack of proven superiority in the literature. Three previous randomized controlled trials have not shown a difference in patient-centered outcomes when comparing non-operative treatment with open reduction and internal fixation. Low patient enrollment and other methodological concerns however limit the generalizability of these conclusions and as a result, management of these fractures remains a controversy. By comparing the functional outcomes of locked plate surgical fixation versus non-operative treatment of displaced three and four-part proximal humerus fractures in the elderly population with a large scale, prospective, multi-centered randomized controlled trial, the optimal management strategy for this common injury may be determined. METHODS We will conduct a prospective, single blind randomized controlled parallel arm trial to compare non-operative management of proximal humerus fractures with open reduction and internal fixation using locked plating technology. One-hundred and sixty patients > age 60 with acute 3- or 4- part proximal humerus fractures will be randomized to either open reduction and internal fixation with locked plating technology or non-operative management treatment arms. The primary outcome measure is the Constant Score at 24 months post-operative. Secondary outcome measures include the American Shoulder and Elbow Surgeon's Score (ASES), EuroQol EQ-5D-5 L Health Questionnaire Score, short form PROMIS upper extremity score and IPAQ for the elderly score. Further outcome measures include assessment of the initial classification, displacement and angulation and the quality of surgical reduction via a standard computed tomography (CT) scan; rates of non-union, malunion, arthrosis, osteopenia or other complications including infection, nerve injury, intra-articular screw penetration, reoperation rates and hospital re-admission rates. DISCUSSION The results of this trial will provide Level 1 evidence to guide decision-making in the treatment of proximal humerus fractures in the elderly population. TRIAL REGISTRATION ClinicalTrials.gov NCT02362100 . Registered 5 Feb 2015.
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Affiliation(s)
- Lisa Howard
- Division of Orthopaedic Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON Canada
| | - Randa Berdusco
- Orthopaedic Sports Medicine & Upper Extremity Reconstruction, Fellowship, University of Manitoba, Winnipeg, MB Canada
| | - Franco Momoli
- Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health, and Preventive Medicine, University of Ottawa, Ottawa, Canada
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - J. Pollock
- Division of Orthopaedic Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON Canada
| | - Allan Liew
- Division of Orthopaedic Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON Canada
| | - Steve Papp
- Division of Orthopaedic Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON Canada
| | - Karl-Andre Lalonde
- Division of Orthopaedic Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON Canada
| | - Wade Gofton
- Division of Orthopaedic Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON Canada
| | - Sara Ruggiero
- Division of Orthopaedic Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON Canada
| | - Peter Lapner
- Division of Orthopaedic Surgery, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON Canada
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Dheerendra SK, Khan WS, Barber J, Goddard NJ, Ahrens PM. Outcomes of Locking Plates in Proximal Humeral Fractures: A Systematic Review. Shoulder Elbow 2017. [DOI: 10.1111/j.1758-5740.2011.00106.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A systematic review of the clinical and radiological outcomes of locking plates in proximal humeral fractures in the current English literature was performed using Medline, CINAHL, AMED and EMBASE electronic databases to July 2009 via Ovid. There were 1266 proximal humeral fractures included in the review. The mean age of the patients was 61.7 years and there were 70.3% women. Based on the Neer classification, the review included 27% two-part, 39.5% three-part and 23.6% four-part fractures. At final follow-up, the Constant score was in the range 59 to 80, and the Disabilities of the Arm, Shoulder and Hand scores were in the range 15.2 to 51.8. The most frequent postoperative complication described was intra-articular screw perforation in 8.5% of fractures. Other complications included avascular necrosis (5.1%), subacromial impingement (3.1%), loss of reduction (3.7%) and implant failure (3.15%). Unplanned secondary surgical procedures were undertaken in 14.2% of cases. This systematic review has demonstrated that locking plate systems are suitable for stabilizing proximal humeral fractures. The current evidence base presents a number of methodological weaknesses and randomized controlled trials at independent centres reporting long-term results are required to compare locking plate systems with alternative fixation techniques used in the treatment of proximal humeral fractures.
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Affiliation(s)
| | - Wasim S. Khan
- Department of Statistical Science, University College London, London, UK
| | - Julie Barber
- Department of Statistical Science, University College London, London, UK
| | | | - Philip M. Ahrens
- Department of Trauma and Orthopaedics, Royal Free Hospital, London, UK
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Haasters F, Siebenbürger G, Helfen T, Daferner M, Böcker W, Ockert B. Complications of locked plating for proximal humeral fractures-are we getting any better? J Shoulder Elbow Surg 2016; 25:e295-303. [PMID: 27079217 DOI: 10.1016/j.jse.2016.02.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 01/24/2016] [Accepted: 02/12/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Complication rates reported after locking plate fixation of proximal humeral fractures still range up to 40%. Whether modifications of surgical techniques, use of primary shoulder arthroplasty, or a fracture-specific management resulted in decreased complication rates during recent years remains unclear. Therefore, the aim of this long-term observation study was to analyze the incidence of complications and revision surgery after locked plating. METHODS Between February 2002 and December 2013, 788 patients (aged 67.4 ± 17.3 years) with displaced proximal humeral fractures were treated with locking plate, primary hemiarthroplasty (HA), or reverse shoulder arthroplasty (RSA). Standardized follow-up included radiographs at 1 day, 6 weeks, and 3, 6, and 12 months. Complications and unplanned revision surgery were prospectively recorded over the complete follow-up. RESULTS Of 788 patients, 646 (82%) were treated with locking plate, 82 (10.4%) with HA, and 60 (7.6%) with RSA. Mean follow-up was 14.8 ± 3.8 months. The mean complication rate associated with locked plating was 12.8%, and revision surgery was necessary in 11.6%. Within the last 5 years, the loss of fixation rate markedly decreased from 14.3% to 4.8%; simultaneously, an increased use of RSA was observed. CONCLUSION The overall complication rate of locking plate osteosynthesis for proximal humeral fractures has been decreasing considerably within the last years. Among others, this might be due to an increased use of primary RSA for complex fracture types. In addition to a precise surgical technique, choosing the adequate treatment for each individual fracture to avoid complications and revision surgery is of utmost importance.
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Affiliation(s)
- Florian Haasters
- Department of Trauma Surgery, Ludwig-Maximilians-Universität, Munich, Germany; Department of Knee, Hip and Shoulder Surgery, Schön-Klinik Munich-Harlaching, Munich, Germany.
| | - Georg Siebenbürger
- Department of Trauma Surgery, Ludwig-Maximilians-Universität, Munich, Germany
| | - Tobias Helfen
- Department of Trauma Surgery, Ludwig-Maximilians-Universität, Munich, Germany
| | - Mark Daferner
- Department of Trauma Surgery, Ludwig-Maximilians-Universität, Munich, Germany
| | - Wolfgang Böcker
- Department of Trauma Surgery, Ludwig-Maximilians-Universität, Munich, Germany
| | - Ben Ockert
- Department of Trauma Surgery, Ludwig-Maximilians-Universität, Munich, Germany
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Abstract
OBJECTIVE We evaluated the clinical and long-term functional outcomes of humeral diaphyseal fractures treated with acute anterior plating in a trauma population. DESIGN Single-center, retrospective cohort analysis with long-term prospective follow-up. SETTING Urban, Level I trauma center. PATIENTS Ninety-six patients with high-energy fractures of the humeral shaft were treated over a 10-year period. INTERVENTION All patients were treated by a standard surgical protocol of open reduction through an anterior approach with small or large fragment fixation in the supine position. MAIN OUTCOME MEASUREMENTS Mechanism of injury, time to union, complications, and range of motion during clinical follow-up were obtained. We also prospectively assessed long-term strength, range of motion, and perceptions of disability using the Disabilities of the Arm, Shoulder and Hand questionnaire. RESULTS Mean time to surgery was 5 days (standard deviation, 11 days); 97.5% of patients achieved union in an average of 16.9 weeks (range, 6-56 weeks). Complications included two postoperative infections, two nonunions, and three implant failures. Long-term follow-up (n = 34) averaged 4.75 years (range, 1.4-10.8 years). On average, no significant differences between the injured and uninjured extremities were seen in range of motion at the shoulder and elbow with the exception of shoulder flexion. A modest loss of upper extremity strength in the injured arm was appreciated. The mean Disabilities of the Arm, Shoulder and Hand score was 25.9 (range, 0-79). CONCLUSIONS A standard anterior surgical approach with small fragment fixation is a safe and effective treatment for humeral shaft fractures in multiple trauma patients. We show a high union rate and few complications, although a modest loss of function and some perceived disability exists in the long-term.
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Brorson S, Frich LH, Winther A, Hróbjartsson A. Locking plate osteosynthesis in displaced 4-part fractures of the proximal humerus. Acta Orthop 2011; 82:475-81. [PMID: 21657970 PMCID: PMC3237040 DOI: 10.3109/17453674.2011.588856] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 03/08/2011] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE There is considerable uncertainty about the optimal treatment of displaced 4-part fractures of the proximal humerus. Within the last decade, locking plate technology has been considered a breakthrough in the treatment of these complex injuries. METHODS We systematically identified and reviewed clinical studies on the benefits and harms after osteosynthesis with locking plates in displaced 4-part fractures. RESULTS We included 14 studies with 374 four-part fractures. There were 10 case series, 3 retrospective observational comparative studies, 1 prospective observational comparative study, and no randomized trials. Small studies with a high risk of bias precluded reliable estimates of functional outcome. High rates of complications (16-64%) and reoperations (11-27%) were reported. INTERPRETATION The empirical foundation for the value of locking plates in displaced 4-part fractures of the proximal humerus is weak. We emphasize the need for well-conducted randomized trials and observational studies.
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Affiliation(s)
- Stig Brorson
- Department of Orthopaedic Surgery, Herlev University Hospital, Herlev, Denmark.
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Sproul RC, Iyengar JJ, Devcic Z, Feeley BT. A systematic review of locking plate fixation of proximal humerus fractures. Injury 2011; 42:408-13. [PMID: 21176833 DOI: 10.1016/j.injury.2010.11.058] [Citation(s) in RCA: 270] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 11/13/2010] [Accepted: 11/22/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE Technique for the fixation of two, three, and four part proximal humerus fractures has rapidly shifted towards the use of specially contoured proximal humerus locking plates. The purpose of this study is to evaluate the short to medium term functional results and common complications associated with the fixation of proximal humerus fractures with locking plates. METHODS The PubMed and EMBASE databases were used to perform a systematic review of the English literature to assess the functional results and complications associated with proximal humerus locking plates. Our inclusion criteria were proximal humerus fracture due to trauma (excluding pathologic fractures), patients greater than 18 years of age, more than 15 patients in the study or subgroup of interest, at least 18 months follow-up, at least one relevant functional outcome score, and quality outcome score of at least 5/10. Studies that did not meet these criteria were excluded. All institutional, author, and journal information was concealed to minimize reviewer bias. RESULTS Twelve studies including 514 patients met the inclusion criteria. At most recent follow-up patients achieved a mean Constant score of 74 and a mean DASH score of 27. The overall rate of complications was 49% including varus malunion, 33% excluding varus malunion, and reoperation rate was 14%. The most common complications included varus malunion 16%, AVN 10%, screw perforation of the humeral head into the joint 8%, subacromial impingement 6%, and infection 4%. DISCUSSION Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation. Further study is needed to determine what technical errors and patient characteristics are risk factors for failure of this now common fixation technique.
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Affiliation(s)
- Robert C Sproul
- University of California, San Francisco, Department of Orthopaedic Surgery, Sports Medicine and Shoulder Surgery Service, 1500 Owens Street, San Francisco, CA 94158, USA
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Abstract
Thirty-three peer-reviewed studies met the inclusion criteria for the Overview. Criteria were framed by three key questions regarding indications for the use of locking plates, their effectiveness in comparison with traditional nonlocking plates, and their cost-effectiveness. The studies were divided into seven applications: distal radius, proximal humerus, distal femur, periprosthetic femur, tibial plateau (AO/OTA type C), proximal tibia (AO/OTA type A or C), and distal tibia. Patient enrollment criteria were recorded to determine indications for use of locking plates, but the published studies do not consistently report the same enrollment criteria. Regarding effectiveness, there were no statistically significant differences between locking plates and nonlocking plates for patient-oriented outcomes, adverse events, or complications. The literature search did not identify any peer-reviewed studies that address the cost-effectiveness or cost-utility of locking plates.
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