Treatment of proximal humeral fractures with a new intramedullary nail

Locking plate fixation versus intramedullary nail fixation for the treatment of multifragmentary proximal humerus fractures (OTA/AO type 11C): a preliminary comparison of clinical efficacy

BACKGROUND

This study aimed to compare the clinical efficacy of locking plate and intramedullary nail fixations in the treatment of patients with OTA/AO type 11C proximal humerus fractures.

METHODS

We retrospectively analyzed the data of patients with OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures who underwent surgery at our institution from June 2012 to June 2017. Perioperative indicators, postoperative morphological parameters of the proximal humerus, and Constant-Murley scores were evaluated and compared.

RESULTS

Sixty-eight patients with OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures were enrolled in this study. Overall, 35 patients underwent open reduction and plate screw internal fixation, and 33 patients underwent limited open reduction and locking of the proximal humerus with intramedullary nail internal fixation. The total cohort had a mean follow-up duration of 17.8 months. The mean operation time of the locking plate group was significantly longer than that of the intramedullary nail group (P < 0.05), while the mean bleeding volume was significantly higher in the locking plate group than that in the intramedullary nail group (P < 0.05). The initial neck-shaft angles, final neck-shaft angles, forward flexion ranges, or Constant-Murley scores did not show significant differences between the two groups (P > 0.05). Complications, including screw penetrations, acromion impingement syndrome, infection, and aseptic necrosis of the humeral head, occurred in 8 patients (8/35, 22.8%) in the locking plate group and 5 patients in the intramedullary nail group (5/33, 15.1%; including malunion and acromion impingement syndrome), with no significant difference between the groups (P > 0.05).

CONCLUSIONS

Similar satisfactory functional results can be achieved with locking plates and intramedullary nailing for OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures, with no significant difference in the number of complications between these two techniques. However, intramedullary nailing has advantages over locking plates for OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures in terms of operation time and bleeding volume.

Virtual morphological comparison of three intramedullary nailing systems for the treatment of proximal humeral fractures

Proximal humerus fractures treated with intramedullary nails show good results. However, the correct anatomical reconstruction of four-part fractures is demanding especially when using intramedullary nails. We therefore compared different intramedullary nail designs for the proximal humerus in a virtual morphological manner. Three commercially available nailing systems where virtually implanted in virtually generated reproducible four-part fractures of 25 digitised humeri. The objective of this study was to quantify and characterise the anatomical position of the proximal screws in the most vulnerable case of a four-part fracture. Taking into account a minimum distance of 5mm between the screw head and the fracture line, osteosynthesis was possible in 54 out of 75 cases. Difficulties placing the proximal screws could be observed at the localisation of the lower lesser tubercle or/and at the sulcus intertubercularis. This morphological analysis could be the basis for choosing the most sufficient implant intra operatively or even improving the nail design.

The importance of inferomedial support in the hot air balloon technique for treatment of 3-part proximal humeral fractures

HYPOTHESIS

Inferomedial support may affect the results of the hot air balloon technique for the treatment of displaced, 3-part fractures of the proximal humerus.

METHODS

Forty-three patients with displaced, 3-part fractures of the proximal humerus treated with the hot air balloon technique between 1995 and 2007 were included in the study. All patients were classified into 4 subgroups based on the presence or absence of medial buttress restoration and inferomedial screw insertion (R+, restored with inferomedial screw; R-, restored without inferomedial screw; NR+, non-restored with inferomedial screw; and NR-, non-restored without inferomedial screw). Assessment of radiologic and clinical outcome among subgroups was based on evaluation of neck-shaft angle, American Shoulder and Elbow Surgeons score, and Neer score.

RESULTS

The mean follow-up duration was 65 ± 29.7 months. The change in the neck-shaft angle in the R+, R-, NR+, and NR- groups was 3°, 2°, 3°, and 11°, respectively. The mean American Shoulder and Elbow Surgeons scores in the R+, R-, NR+, and NR- groups were 91 ± 4.8, 86 ± 5.4, 85 ± 1.9, and 77 ± 5.8, respectively. The mean Neer scores in the R+, R-, NR+, and NR- groups were 92 ± 4.3, 88 ± 4.0, 87 ± 2.1, and 76 ± 8.2, respectively.

CONCLUSIONS

Medial buttress restoration and inferomedial screw insertion affect bone-nail construct stability and clinical outcomes.

Biomechanical evaluation of two intramedullary nailing techniques with different locking options in a three-part fracture proximal humerus model

BACKGROUND

Osteosynthesis of unstable proximal humerus fractures still remains challenging. The aim of this study was to investigate two intramedullary nailing techniques with different locking options in a three-part fracture model and prove whether two new fixation concepts, introducing additional locking screw-in-screws inserted through the head of the proximal screws, and a calcar screw, provide better stability.

METHODS

A biomechanical testing model for three-part proximal humerus fractures including cyclic axial loading with increasing peak load and simultaneous pulling forces at the rotator cuff was used to test 12 pairs of human cadaver humeri, assigned to four groups and instrumented with either Targon PH (T1) or MultiLoc PHN in 3 different configurations (standard M1; two additional screw-in-screw M2; one additional calcar screw and two screw-in-screw M3).

FINDINGS

Initial range of motion in internal-external rotation and mediolateral translation was smallest in M3 (1.82°; 0.11mm), biggest in T1 (3.63°; 0.51mm) and significantly different between these two groups (p=0.02 and p=0.04, respectively). M3 showed minimum head migration along the nail and varus tilting after 5000 cycles (0.31mm; 0.20°) and 10000 cycles (1.59mm; 0.34°). M2 and M3 performed better than M1 and T1 regarding varus collapse. The highest number of cycles to failure was observed for M3 (20733) and the lowest for T1 (10083) with significant difference between these two groups (p=0.04).

INTERPRETATION

The configuration with two screw-in-screw and a calcar screw was superior in most aspects. The screw-in-screws were found to contribute against varus collapse. Both new fixation concepts could provide better stability in proximal humerus fractures.

Modern perspectives of open reduction and plate fixation of proximal humerus fractures

Recent innovations have greatly increased the range of proximal humeral fractures that are amenable to open reduction and plate fixation.The optimum technique for some of the more complex fracture patterns is not yet fully refined.This article aims to describe the recent advances in the treatment of complex proximal humeral fractures by open reduction and locking plate fixation, focusing particularly on the indications for surgery, the operative techniques, and the expected outcomes after treatment.

Biomechanical evaluation of two-part surgical neck fractures of the humerus fixed by an angular stable locked intramedullary nail

OBJECTIVE

The aim of the current study was to see how different interlocking mechanisms would affect construct stability and overall failure in the treatment of two-part surgical neck fractures in the proximal humerus in vitro.

METHODS

Left and right bones of eight pairs of fresh-frozen human cadaveric humeri were assigned to either a group with conventional or a group with angular stable distal interlocking. The different experimental interlocking mechanisms were used in a surgical neck fracture model of the humerus (Orthopaedic Trauma Association 11- A3) stabilized by a proximal humeral nail. The following variables were evaluated by biomechanical tests: hysteresis width in bending and torsion, stiffness, and fracture gap movement during cyclic axial loading until failure and the overall failure mechanism of the construct.

RESULTS

The angular stable group showed significantly less motion in initial bending and torsion and higher bending stiffness throughout the complete deformation cycle compared with the conventional interlocked group. Fracture gap movement was significantly less in the angular stable group. Higher stability was mainly observed in the early phase of the applied loading pattern; however, ultimate failure was not related to distal interlocking but occurred in the proximal fragment in both groups.

CONCLUSIONS

An experimental angular stable distal interlocking system of proximal humeral nails shows higher construct stability in the early phase of fracture fixation in vitro. In terms of overall failure, loss of fixation in the proximal fragment was crucial and not different between groups.

New trends in fixation of proximal humeral fractures: a review

Surgical treatment of proximal humeral fractures continues to be a challenge especially in osteoporotic patients. Locking plates and intramedullary nails have been used with satisfactory results but the previous reported complications have not been substantially reduced. Most of the existing studies involve a small number of patients followed up for a rather short period of time. Since proximal humeral fractures constitute a heterogenous group of complex fractures in an even more heterogenous population, no single fixation method is a panacea. Choice of implant and method of fixation should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. Based on the findings of the existing clinical studies the authors propose a treatment algorithm.

Is locking nailing of humeral head fractures superior to locking plate fixation?

The optimal surgical treatment of displaced proximal humeral fractures is controversial. New implants providing angular stability have been introduced to maintain the intraoperative reduction. In a multi-institutional study, we prospectively enrolled and followed 152 patients with unilateral displaced and unstable proximal humeral fractures treated either with an antegrade angular and sliding stable proximal interlocking nail or an angular stable plate. Fractures were classified according to the Neer four-segment classification. Clinical, functional, and radiographic followups were performed 3, 6, and 12 months after surgery. Absolute and relative (to the contralateral shoulder) Constant-Murley scores were used to assess postoperative shoulder function. Using age, gender, and fracture type, we identified 76 pairs (152 patients) for a matched-pairs analysis. Relative Constant-Murley scores 12 months after treatment with an angular and sliding stable nail and after plate fixation were 81% and 77%, respectively. We observed no differences between the two groups. Stabilization of displaced proximal humeral fractures with either an angular stable intramedullary or an extramedullary implant seems suitable with both surgical treatment options.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

PHN for treatment of proximal humerus fractures: evaluation of 80 cases

This paper analyses 80 cases of displaced proximal humerus fractures, with two or three fragments, treated by PHN nailing. The hold of the spiral blade was effective, and is particularly recommended for fractures with two fragments according to Neer's classification. The results, analysed with Constant's score and radiographic checkups, were satisfactory. Nearly all our patients (76 out of 80) had a mean age of 75 years and a total Constant score of 78.48. Only four (mean age 42.5 years) had a Constant score of 86. Shoulder articulation was good and only a few complications occurred.

Treatment of nonunions of humeral fractures with interlocking intramedullary nailing

OBJECTIVE

To introduce the experience of treating nonunions of humeral fractures with interlocking intramedullary nailing.

METHODS

Twelve patients with humeral nonunions were treated with interlocking intramedullary nailing. The time interval between trauma and surgery was 10.5 months on average. Open reduction with anterograde approach was performed. Axial compression was specially applied to the fracture site with humeral nail holder after insertion of distal locked screws. Iliac bone grafting was added.

RESULTS

The average follow-up period was 21 months (ranging 9-51 months). All patients achieved osseous union 5.8 months after treatment on average. Eleven patients had good functions of the shoulder joints and the upper extremities. No patient experienced any permanent neurological deficit. Refracture of the original ununited region occurred in one patient after removal of the internal fixator one year later, but union was achieved after closed re-intramedullary nailing fixation.

CONCLUSION

Humeral interlocking intramedullary nailing is an effective alternative treatment for humeral nonunion.

Angular and sliding stable antegrade nailing (Targon PH) for the treatment of proximal humeral fractures

INTRODUCTION

The optimal surgical treatment for displaced proximal humeral fractures continues to be controversial. Different treatment modalities are available. Mechanical implant-related problems, however, and the preservation of the biological integrity of the humeral head remain unsolved. New implants providing angular stability are expected to maintain the intraoperative result of reduction until definitive healing. The purpose of this study was to evaluate the functional outcome and the complication rate of an angular and sliding stable antegrade interlocking nail for the treatment of displaced proximal humeral fractures.

MATERIALS AND METHODS

In a prospective study, 112 consecutive patients with displaced proximal humeral fractures were treated. Complete 12 months postoperative follow-up was available for 74 patients. Fracture types were classified according to the Neer-classification. Clinical, functional and radiographic follow-up evaluations were performed 3, 6 and 12 months after surgery. The Constant Score (CS) was used to assess shoulder function.

RESULTS

All fractures were united. The CS (MV +/- SD) of the injured side 3, 6 and 12 months after surgery were 42.1 +/- 15.1, 56.1 +/- 20.1 and 70.9 +/- 19.3, respectively. Patients sustaining Neer III and VI/3 fractures revealed better shoulder function (68.8 +/- 14.7, 74.9 +/- 17.6) 12 months postoperatively than those with Neer IV/4 fractures (60.7 +/- 23.2), where most complications occurred. Complications requiring surgical therapy were seen in a total of 24 patients (30%) and included backing out of screws in nails without peak inlay (20%; 2000-2003), protrusion of screws into the gleno-humeral joint (5%), loss of reduction with malunion (9%) and major tubercle displacement (7%).

CONCLUSION

The treatment of displaced proximal humeral fractures with an angular and sliding stable antegrade nail (Targon-PH) led to good functional results, especially in 2- and 3-part fractures. There exists a substantial risk for postoperative complications and bad motor function in Neer IV/4 fractures. Lateral backing out of screws was abolished by implant modifications (PEEK-inlay) from 2003 onwards. Additional tension wire banding of the major tubercle may further reduce the risk of secondary displacement.

Treatment of proximal humerus fractures

The majority of proximal humerus fractures are treated nonoperatively with good functional results. Multiple options exist for treating displaced fractures, without a clear advantage of any one method for a given fracture type. Goals include an adequate reduction and stable fixation to initiate early motion and rehabilitation. Decision-making should be based on patient and injury specifics and surgeon's experience. Various types of fixation, including plates, nails, or percutaneous pins, can maintain sufficient stability to promote shoulder mobility and function. Any of these methods will have few complications when undertaken with appropriate patient selection and careful surgical technique. Preliminary results of locking plates in the proximal humerus suggest that this is a favorable treatment option for displaced, comminuted proximal humerus fractures, which compares well with established methods. Locked plating may improve fracture stability in some complex patterns and facilitate early rehabilitation. It is possible that some fractures previously treated with hemiarthroplasty may be managed successfully with locking plates. Prospective study to assess the complications, outcomes, and cost effectiveness of nonoperative management compared to various surgical treatment options is warranted.