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Suture Augmentation Neutralizes Deforming Muscular Forces in a Simulated 2-Part Osteoporotic Proximal Humeral Fracture Model. J Orthop Trauma 2022; 36:312-317. [PMID: 35166268 DOI: 10.1097/bot.0000000000002351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the contribution that tension-relieving sutures, placed between a proximal humeral locking plate and the rotator cuff muscles, had on preventing varus malalignment in an osteoporotic 2-part proximal humerus fracture model. METHODS A 2-part fracture model was created in 8 cadaveric specimens and then fixed with a lateral locking plate. A custom shoulder testing system was used to increase loading through the supraspinatus (SS) tendon to drive varus deformity. Trials were performed with no suture placement; SS only; SS and subscapularis (SB); and SS, SB, and infraspinatus. The primary outcome was contribution of each point of suture fixation to prevention of varus collapse. RESULTS Suture augmentation to the SS, SB, and infraspinatus significantly decreased humeral head varus collapse when compared with the plate alone at nearly all loads ( P < 0.05). There were no significant differences in humeral head varus collapse between the 3 suture constructs. CONCLUSIONS In our biomechanical evaluation of a simulated osteoporotic 2-part proximal humerus fracture with incompetent medial calcar, tension-relieving sutures placed between a lateral locked plate and the rotator cuff tendons prevented varus malalignment.
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Kim H, Chung YG, Jang JS, Kim Y, Park SB, Song HS. Why locking plates for the proximal humerus do not fit well. Arch Orthop Trauma Surg 2022; 142:219-226. [PMID: 33170353 DOI: 10.1007/s00402-020-03676-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 10/28/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION We compared the angle of the humerus and plate and to assess compatibility of a plate to the proximal humerus using three-dimensional (3D) printed models. MATERIALS AND METHODS A total of 120 cases were included, who underwent anteroposterior shoulder radiographs. From these, 30 cases with 3D shoulder computed tomography scans were randomly selected to print 3D model. The lateral angle between the lateral cortex of the humeral shaft and lateral border of the greater tuberosity (GT), neck-shaft angle, and height from the most proximal point of the GT to the angular point were measured. When the plates were applied on the 3D models, the gap from the most proximal point of the GT to the proximal rim of the plate was measured. RESULTS The mean lateral angle in plain radiographs was 12.9 ± 2.2° and height from the most proximal point of the GT to the angular point was 44.4 ± 4.7 mm. The bending angles of the three plates were 8° and 10°. Height from the proximal rim of the plate to the bending point was 42.4, 42.0 and 43.8 mm. In 98% of cases, the lateral angle of the humerus was larger than all three plates. In 43% of cases, height of the GT was smaller than height of plates. When plates were applied to the 3D model, the mean gap from GT to plate was 4.8 ± 2.8 mm. CONCLUSIONS There was large variation in the lateral angle of the proximal humerus, which was not correlated with the neck-shaft angle. The lateral angle of the humerus was larger than the plates and prone to varus reduction and medial collapse. LEVEL OF EVIDENCE OR CLINICAL RELEVANCE Basic science study.
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Affiliation(s)
- Hyungsuk Kim
- Department of Orthopedic Surgery, College of Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, 1021 Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea
| | - Yang-Guk Chung
- College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Ji Seok Jang
- Department of Orthopedic Surgery, College of Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, 1021 Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea
| | - Yongdeok Kim
- Department of Orthopedic Surgery, College of Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, 1021 Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea
| | - Soo Bin Park
- Department of Orthopedic Surgery, College of Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, 1021 Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea
| | - Hyun Seok Song
- Department of Orthopedic Surgery, College of Medicine, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, 1021 Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea.
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Xiang H, Wang Y, Yang Y, Liu F, Lu Q, Kong L, Li M, Han Y, Wang F. Anatomical study for the treatment of proximal humeral fracture through the medial approach. J Orthop Surg Res 2022; 17:35. [PMID: 35039046 PMCID: PMC8764758 DOI: 10.1186/s13018-021-02897-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/30/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The treatment of complex 3- and 4-part proximal humeral fractures has been controversial due to numerous postoperative complications. With the further study of medial support and blood supply of humeral head, new techniques and conception are developing. The study aims to illustrate the medial approach of the proximal humeral fracture through cadaver autopsy. METHOD Upper limbs from 19 cadavers have been dissected to expose the shoulder joint. We selected the coracoid process as the bony reference. Vernier caliper will be used to measure the following data, including distance from coracoid process to circumflex brachial artery, distance between anterior humeral circumflex artery (ACHA) and posterior circumflex brachial artery (PCHA) and their diameters. Assessment included the characteristics of the vascular supply around the humeral head, identification of the structures at risk, quality of exposure of the bony structures, and feasibility of fixation. RESULTS The medial approach is appropriate in 86.84% anatomical patterns. Between the lower part of the shoulder capsule and the insertion of conjoined tendon, the bony surface exposed was limited by the interval between ACHA and PCHA. An interval of 2 to 3 cm (24.29 ± 3.42 mm) was available for medial plate. ACHA (49.35 ± 8.13 mm, 35.14-68.53 mm) and PCHA (49.62 ± 7.82 mm, 37.67-66.76 mm) were about 5 cm away from the coracoid process. Risk structures including ACHA and PCHA originate in common, PCHA originated from the deep brachial artery (DBA), the presence of perforator vessels, musculocutaneous nerve intersects with ACHA, the diameter of PCHA: ACHA < 1.5. In 13.15% anatomical patterns, this risk structure should be taken seriously. CONCLUSION The medial approach opens a new perspective in the optimal management of complex fractures of proximal humerus. Anatomical research proves that the medial approach is feasible. The interval between ACHA and PCHA is suitable for placement. Anatomical pattern and indication have been discussed, and we hypothesized that ACHA has been destroyed in complex PHFs. With further studies on the anatomy and mechanism of injury, the development of more clinical cases will be an important work of our institution in the future.
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Affiliation(s)
- Hao Xiang
- Department of Orthopedics, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, No. 324, Jing Wu Road, Jinan, 250021, China
| | - Yan Wang
- Medical Laboratory Diagnosis Center, Jinan Central Hospital, 105 Jie Fang Road, Jinan, 250013, China
| | - Yongliang Yang
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China
| | - Fanxiao Liu
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China
| | - Qingsen Lu
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China
| | - Lingpeng Kong
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China
| | - Mingzhen Li
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China
| | - Yong Han
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China.
| | - Fu Wang
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jing Wu Road, Jinan, 250021, China.
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Kim YK, Kang SW, Jung KH, Oh YK. The potential of locking plate with intramedullary fibular allograft to manage proximal humeral fracture with an unstable medial column. Arch Orthop Trauma Surg 2022; 142:91-97. [PMID: 32948917 DOI: 10.1007/s00402-020-03604-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the potential of locking compression plate with intramedullary fibular allograft in managing proximal humeral fractures with an unstable medial column. METHODS Between March 2007 and March 2015, we retrospectively analyzed 63 patients who underwent locking plate fixation for proximal humeral fracture with an unstable medial column. All patients were assigned into group 1 (patients treated with locking plate) and group 2 (patients treated with locking plate with intramedullary fibular allograft). Groups 1 and 2 were composed of 29 and 34 patients, respectively. We analyzed bone union, the neck-shaft angle, the Constant score, the range of motion, and complications. RESULTS The mean average bone union time of the patients was 13.9 weeks in group 1 and 11.3 weeks in group 2. The average Constant score was 67.4 in group 1 and 73.6 in group 2 (p < 0.05). The mean preoperative NSA, postoperative NSA, and NSA at the last follow-up were 104.4°, 125.8°, and 115.8°, respectively, in group 1, and 109.0°, 130.3°, and 127.1°, respectively, in group 2. The mean forward flexion, abduction, external rotation, and internal rotation were 109.0°, 48.2°, 34.0°, and L5, respectively, in group 1, and 127.5°, 118.2°, 38.7°, and L1, respectively, in group 2. In group 1, avascular necrosis occurred in one patient and screw cutout in two patients. In group 2, screw cutout occurred in one patient. CONCLUSION In patients aged over 65 years with proximal humeral fractures, an unstable medial column was associated with poor clinical results owing to varus collapse. To prevent this, an intramedullary fibular allograft was used, and radiologic and clinical results were better with this approach than with a locking plate alone. Therefore, locking plate fixation using a fibular allograft is one of the possible treatments for patients with an unstable medial column.
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Affiliation(s)
- Young-Kyu Kim
- Department of Orthopaedic Surgery, Gil Medical Center, Gachon University, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Suk-Woong Kang
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan, 626-770, Republic of Korea.
| | - Kyu-Hak Jung
- Department of Orthopaedic Surgery, Gil Medical Center, Gachon University, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Young-Kwang Oh
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan, 626-770, Republic of Korea
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RUSPI MARIALUISA, MARRAS DANIELE, CRISTOFOLINI LUCA. DOES CEMENT CURING CAUSE CONCERNING INCREASE OF THE TEMPERATURE WHEN DELIVERED IN THE HUMAN HUMERUS? J MECH MED BIOL 2021. [DOI: 10.1142/s0219519421500603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
For the treatment of humeral fractures, numerous strategies exist to improve the clinical outcome of the reconstruction and to reduce the incidence of fixation failure. Injection of acrylic-based cements to reinforce the bone and/or augment the screws is one option. The heat generated during cement polymerization raises some concerns, as it could cause tissue damage. The first aim of this study was to measure the temperature over time during polymerization when acrylic cements are delivered inside the bone to treat fracture. The second aim was to assess if the ISO-5833:2002 standard can predict what happens in a real bone. Different tests were performed using two acrylic-based cements (Mendec and Cal-Cemex): (i) the ISO-5833:2002 standard (Annex C); (ii) tests on human bones (humeral diaphysis and humeral head) injected with cement to simulate fracture treatment. In the humeri, the highest temperature was measured in the diaphysis (68.6∘C for Mendec, 62.7∘C for Cal-Cemex). These values are comparable with the temperature reached in other consolidated applications (vertebroplasty). Exposure to high temperature was shorter for the diaphysis than for the head. For both cements, in both the diaphysis and the head, temperatures exceeded 48∘C for less than 10[Formula: see text]min. This is within the threshold for tissue necrosis. The ISO-5833:2002 yielded significantly different results in terms of maximum temperature (difference exceeding 15∘C) and exposure to temperature above 48∘C and 45∘C. This discrepancy is probably due to a combination of factors affecting the amount of heat produced and dissipated (e.g., amount and shape of the cement, thermal conductivity).
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Affiliation(s)
- MARIA LUISA RUSPI
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum, University of Bologna, Via Umberto Terracini 24-28, 40131 Bologna, Italy
| | - DANIELE MARRAS
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum, University of Bologna, Via Umberto Terracini 24-28, 40131 Bologna, Italy
| | - LUCA CRISTOFOLINI
- Department of Industrial Engineering, School of Engineering and Architecture, Alma Mater Studiorum, University of Bologna, Via Umberto Terracini 24-28, 40131 Bologna, Italy
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A nomogram for predicting reduction loss risk after locking plate fixation for proximal humeral fractures. Injury 2021; 52:2947-2951. [PMID: 34399985 DOI: 10.1016/j.injury.2021.07.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 07/20/2021] [Accepted: 07/27/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of our study was to determine the risk factors for reduction loss in patients with proximal humeral fractures after locking plate fixation and establish a nomogram prediction model. METHODS We retrospectively analyzed the clinical data of proximal humeral fractures patients who had been surgically treated for locking plate in our institution from January 2016 to December 2018. Perioperative information was obtained through the electronic medial record system, univariate and multivariate analyzes were performed to determine the risk factors of reduction loss, and a nomogram model was constructed to predict the risk of reduction loss. The predictive performance and consistency of the model were evaluated by the consistency coefficient (C-index) and the calibration curve, respectively. RESULTS 115 patients were finally enrolled in our study. Multivariate analysis results showed that age, fracture classification, medial comminution, and calcar screw status were independent risk factors for reduction loss. The accuracy of the contour map for predicting transfusion risk was 0.944. CONCLUSION We found a correlation between reduction loss and age, fracture classification, medial comminution, and calcar screw status after locking plate fixation for proximal humeral fractures patients. Our nomogram is helpful for clinicians to identify high-risk patients, early intervention and reduce the incidence of reduction loss.
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Porschke F, Bockmeyer J, Nolte PC, Studier-Fischer S, Guehring T, Schnetzke M. More Adverse Events after Osteosyntheses Compared to Arthroplasty in Geriatric Proximal Humeral Fractures Involving Anatomical Neck. J Clin Med 2021; 10:jcm10050979. [PMID: 33801182 PMCID: PMC7957872 DOI: 10.3390/jcm10050979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 12/11/2022] Open
Abstract
The purpose of this study was to compare adverse events and clinical outcomes of geriatric proximal humerus fractures (PHF) involving the anatomical neck (type C according to AO classification) treated with open reduction and internal fixation (ORIF) using locking plate vs. arthroplasty. In this retrospective cohort study, geriatric patients (>64 years) who underwent operative treatment using ORIF or arthroplasty for type C PHFs were included. Complications, revisions and clinical outcomes using Constant Murley Score (CMS) and Disabilities of the Arm, Shoulder and Hand (DASH) Score were assessed and compared between groups. At a mean follow up of 2.7 ± 1.7 years, 59 patients (mean age 75.3 ± 5.5 years) were included. In 31 patients ORIF was performed and 29 patients underwent arthroplasty. Complications and revision surgeries were significantly more frequent after ORIF (32.6% vs. 7.1%, p = 0.023 and 29.0% vs. 7.1%, p = 0.045). In contrast, clinical outcomes showed no significant differences (DASH 39.9 ± 25.7 vs. 39.25 ± 24.5, p = 0.922; CMS 49.7 ± 29.2 vs. 49.4 ± 25.2, p = 0.731). ORIF of type C PHFs in geriatric patients results in significantly more complications and revision surgery when compared to arthroplasty. Therefore, osteosynthesis of geriatric intraarticular fractures of the proximal humerus must be critically evaluated.
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Affiliation(s)
- Felix Porschke
- BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen, Germany; (J.B.); (P.-C.N.); (S.S.-F.); (M.S.)
- Correspondence: ; Tel.: +49-6210-68100
| | - Julia Bockmeyer
- BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen, Germany; (J.B.); (P.-C.N.); (S.S.-F.); (M.S.)
| | - Philip-Christian Nolte
- BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen, Germany; (J.B.); (P.-C.N.); (S.S.-F.); (M.S.)
| | - Stefan Studier-Fischer
- BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen, Germany; (J.B.); (P.-C.N.); (S.S.-F.); (M.S.)
| | - Thorsten Guehring
- Department of Orthopedic Surgery, Paulinenhilfe, Diakonieklinikum Stuttgart, Rosenbergstraße 38, 70176 Stuttgart, Germany;
| | - Marc Schnetzke
- BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwig-Guttmann-Straße 13, 67071 Ludwigshafen, Germany; (J.B.); (P.-C.N.); (S.S.-F.); (M.S.)
- German Joint Center, Atos Clinic Heidelberg, Bismarckstraße 9-15, 69115 Heidelberg, Germany
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Zhao Y, Pu S, Yin H, Lü Q, Xu Y, Zhu Y. [Application of suspensory external fixation technique in treatment of proximal humeral fracture]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:144-148. [PMID: 33624464 DOI: 10.7507/1002-1892.202009016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the effectiveness of suspensory external fixation technique in treatment of proximal humeral fractures. Methods Between August 2013 and October 2018, 14 patients with proximal humeral fractures were treated with suspensory external fixation technique. There were 10 males and 4 females with an average age of 55.9 years (range, 43-76 years). There were 10 cases of falling injury and 4 cases of traffic accident injury. Among them, there were 9 cases of Neer type Ⅲ and 5 cases of Neer type Ⅳ. The time from injury to operation was 3-7 days (mean, 4.6 days). Nine cases were complicated with osteoporosis. The preoperative visual analogue scale (VAS) score was 6.1±1.2. The effectiveness was comprehensively evaluated by hospital stay, fracture healing time, removal time of external fixator, postoperative complications, VAS score, and Neer score of shoulder joint function. Results All operations were successfully completed, and the hospital stay was 6-14 days, with an average of 9.4 days. All the incisions healed by first intention, and no infection or other complications occurred. All patients were followed up 16-60 months (mean, 35.4 months). X-ray films examination showed that all fractures healed, the healing time was 4-7 months (mean, 4.9 months). The removal time of external fixator was 5-8 months (mean, 6.3 months). VAS scores were 1.5±0.8 at 1 month after operation and 1.0±0.9 at last follow-up, both of which were significantly improved when compared with preoperative score, the differences were significant between different time points ( P<0.05). Neer score of shoulder joint function was 75-100 (mean, 91.1); 9 cases were excellent, 4 cases were good, and 1 case was fair. The excellent and good rate was 92.9%. During follow-up, there was no adverse events such as acromion impingement, nonunion, or pseudoarthrosis. Conclusion For proximal humeral fractures, the suspensory external fixation technique is a simple and reliable treatment method that can significantly improve joint function.
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Affiliation(s)
- Yonghui Zhao
- Department of Orthopedics, the 920th Hospital of Joint Logistics Support Force, Kunming Yunnan, 650032, P.R.China;Department of Orthopedics, the First People's Hospital of Yunnan Province/the Affiliated Hospital of Kunming University of Science and Technology, Kunming Yunnan, 650032, P.R.China
| | - Shaoquan Pu
- Department of Orthopedics, the 920th Hospital of Joint Logistics Support Force, Kunming Yunnan, 650032, P.R.China
| | - Hao Yin
- Department of Clinical Medical College of Fudan University, Shanghai, 200032, P.R.China
| | - Qian Lü
- Department of Orthopedics, the 920th Hospital of Joint Logistics Support Force, Kunming Yunnan, 650032, P.R.China
| | - Yongqing Xu
- Department of Orthopedics, the 920th Hospital of Joint Logistics Support Force, Kunming Yunnan, 650032, P.R.China
| | - Yueliang Zhu
- Department of Orthopedics, the 920th Hospital of Joint Logistics Support Force, Kunming Yunnan, 650032, P.R.China
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Wang F, Wang Y, Dong J, He Y, Li L, Liu F, Dong J. A novel surgical approach and technique and short-term clinical efficacy for the treatment of proximal humerus fractures with the combined use of medial anatomical locking plate fixation and minimally invasive lateral locking plate fixation. J Orthop Surg Res 2021; 16:29. [PMID: 33422119 PMCID: PMC7796622 DOI: 10.1186/s13018-020-02094-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/11/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND HYPOTHESIS The typical anterolateral approach is widely used to treat proximal humerus fractures with lateral locking fixation. However, lateral fixation cannot completely avoid medial reduction loss and varus deformity especially in the cases of an unstable medial column. We present a novel medial surgical approach and technique together with a minimally invasive lateral locking plate to fix proximal humerus fractures with an unstable medial column. MATERIALS AND METHODS We performed an anatomical study and reported 8 cases of proximal humerus fractures with unstable medial columns treated with plate fixation through a minimally invasive anterolateral approach and medial approach. All surgeries were performed by the same single surgeon. Patients were followed clinically and radiographically at 1, 3, 6, and 12 months postoperatively. RESULTS There was a safe region located at the medial part of the proximal humerus just beneath the articular surface. An anatomical medial locking proximal humerus plate could be placed in the medial column and did not affect the axillary nerve, blood supply of the humeral head, or stability of the shoulder joint. Successful fracture healing was achieved in all 8 cases. The function and range of motion of the shoulder joint were satisfactory 24 months postoperatively, with an average Constant score (CS) of 82.8. No reduction loss (≥ 10° in any direction), screw cutout, nonunion, or deep infection occurred. CONCLUSIONS The combined application of medial anatomical locking plate fixation and minimally invasive lateral locking plate fixation is effective in maintaining operative reduction and preventing varus collapse and implant failure in proximal humerus fractures with an unstable medial column.
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Affiliation(s)
- Fu Wang
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jing Wu Road, Jinan, 250021, People's Republic of China
| | - Yan Wang
- Medical Laboratory Diagnosis Center, Jinan Central Hospital, 105 Jiefang Road, Jinan, 250013, People's Republic of China
| | - Jinye Dong
- Department of Ultrasound, Weifang People's Hospital, Weifang, 261041, Shandong, People's Republic of China
| | - Yu He
- Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, 33 Badachu Road, Shijingshan District, Beijing, 100144, People's Republic of China
| | - Lianxin Li
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jing Wu Road, Jinan, 250021, People's Republic of China
| | - Fanxiao Liu
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jing Wu Road, Jinan, 250021, People's Republic of China.
| | - Jinlei Dong
- Department of Orthopedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Shandong Provincial Hospital Affiliated to Shandong University, 324 Jing Wu Road, Jinan, 250021, People's Republic of China.
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Chen H, Zhu ZG, Li JT, Chang ZH, Tang PF. Finite element analysis of an intramedulary anatomical strut for proximal humeral fractures with disrupted medial column instability: A cohort study. Int J Surg 2019; 73:50-56. [PMID: 31783165 DOI: 10.1016/j.ijsu.2019.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/17/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Lateral locking plate (LLP) fixation has gained popularity for the treatment of proximal humeral fractures (PHFs); however, complications can occur due to loss of the medial cortical buttress from fracture comminution. MATERIALS AND METHODS We designed a novel intramedullary anatomical medial strut with allograft bone (IAMSAB) using MIMICS software to specifically fill the intramedullary canal of the proximal humeral bone. We used finite element analysis to evaluate the biomechanical characteristics of a LLP, LLP-intramedullary fixation system (IFS), LLP-anatomical medial locking plate (AMLP), or the combined application of a LLP and IAMSAB (LLP-IAMSAB) fixation construct in patients with a PHF and an unstable medial column. RESULTS For axial or rotational loads, under (normal) Nor or osteoporotic (Ost) bone conditions, the LLP-IAMSAB fixation construct was significantly stiffer than the LLP-IFS fixation construct, and displacement at the fracture site after LLP-IAMSAB fixation was significantly less than after LLP or LLP-IFS fixation (P < 0.05). Stiffness of the LLP-IAMSAB and LLP-AMLP fixation constructs and displacement at the fracture site after LLP-IAMSAB and LLP-AMLP fixation were not significantly different. The IFS, AMLP, and IAMSAB shared the load in the LLP and decreased the risk of implant failure. There were no significant differences in von Mises stress and stress distribution after fixation with the LLP-IFS, LLP-AMLP, and LLP-IAMSAB constructs. CONCLUSION These data suggest that the IAMSAB can provide direct medial support or resistance to rotation and augment the biomechanics of the LLP. The combined application of the IAMSAB and LLP may achieve functional outcomes that are similar to the LLP-AMLP fixation construct.
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Affiliation(s)
- Hua Chen
- The Department of Orthopaedic Surgery, Chinese PLA General Hospital (301 Hospital), China.
| | - Zheng-Guo Zhu
- The Department of Orthopaedic Surgery, Chinese PLA General Hospital (301 Hospital), China
| | - Jian-Tao Li
- The Department of Orthopaedic Surgery, Chinese PLA General Hospital (301 Hospital), China
| | - Zu-Hao Chang
- The Department of Orthopaedic Surgery, Chinese PLA General Hospital (301 Hospital), China
| | - Pei-Fu Tang
- The Department of Orthopaedic Surgery, Chinese PLA General Hospital (301 Hospital), China.
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11
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Shi X, Liu H, Xing R, Mei W, Zhang L, Ding L, Huang Z, Wang P. Effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture: an update systematic review and meta-analysis. J Orthop Surg Res 2019; 14:285. [PMID: 31470878 PMCID: PMC6717341 DOI: 10.1186/s13018-019-1345-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 08/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate the effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture (PHF). METHODS China National Knowledge Infrastructure (CNKI), Chinese Scientific Journals Database (VIP), Wan-fang database, Chinese Biomedicine Database (CBM), PubMed, EMBASE, Web of Science, and Cochrane Library were searched until July 2018. The eligible references all show that the control group uses locking plates to treat PHF, while the experimental group uses intramedullary nails to do that. Two reviewers independently retrieved and extracted the data. Reviewer Manager 5.3 was used for statistical analysis. RESULTS Thirty-eight retrospective studies were referred in this study which involves 2699 patients. Meta-analysis results show that the intramedullary nails in the treatment of proximal humeral fractures are superior to locking plates in terms of intraoperative blood loss, operative time, fracture healing time, postoperative complications, and postoperative infection. But there is no significance in constant, neck angle, VAS, external rotation, antexion, intorsion pronation, abduction, NEER, osteonecrosis, additional surgery, impingement syndrome, delayed union, screw penetration, and screw back-out. CONCLUSIONS The intramedullary nail is superior to locking plate in reducing the total complication, intraoperative blood loss, operative time, postoperative fracture healing time and postoperative humeral head necrosis rate of PHF. Due to the limitations in this meta-analysis, more large-scale, multicenter, and rigorous designed RCTs should be conducted to confirm our findings. TRIAL REGISTRATION PROSPERO CRD42019120508.
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Affiliation(s)
- Xiaoqing Shi
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Hao Liu
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Runlin Xing
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Wei Mei
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Li Zhang
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Liang Ding
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Zhengquan Huang
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Peimin Wang
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China.
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12
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Mouraria GG, Zoppi Filho A, Kikuta FK, Moratelli L, Cruz MA, Etchebehere M. ANTEROLATERAL APPROACHES FOR PROXIMAL HUMERAL OSTEOSYNTHESIS: A SYSTEMATIC REVIEW. ACTA ORTOPEDICA BRASILEIRA 2019; 27:178-182. [PMID: 31452617 PMCID: PMC6699402 DOI: 10.1590/1413-785220192703215572] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Objective: Anterolateral approaches for proximal humerus osteosynthesis have great advantages because they allow direct exposure of the lateral aspect of the humerus without the muscular retraction seen in the deltopectoral approach. However, much resistance is found among surgeons due to the potential risk of iatrogenic injury to the axillary nerve. To identify the incidence of axillary nerve iatrogenic lesions and evaluate the functional results of proximal humerus osteosynthesis with locking plates using anterolateral approaches. Methods: The literature review followed the PRISMA protocol. Results: A total of 23 articles were selected from 786 patients submitted to anterolateral approaches. Three cases (0.38%) of iatrogenic axillary nerve lesions were confirmed. The results of the functional tests were similar to those of the deltopectoral approach. Conclusion: Anterolateral approaches are a viable and safe alternative for proximal humerus osteosynthesis with locking plate. Subacromial impingement was the most frequent complication. Level of Evidence II, Systematic Review.
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13
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Rusimov L, Zderic I, Ciric D, Barcik JP, Enchev D, Rashkov M, Hadzhinikolova M, Richards G, Gueorguiev B, Baltov A. Does Supplemental Intramedullary Grafting Increase Stability of Plated Proximal Humerus Fractures? J Orthop Trauma 2019; 33:196-202. [PMID: 30570617 DOI: 10.1097/bot.0000000000001376] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To investigate the biomechanical competence of locked plating augmented with supplemental intramedullary graft in comparison to conventional locked plate fixation in proximal humerus fractures (PHF). METHODS Complex four-part PHFs were set in 30 artificial humeri assigned to 3 study groups (n = 10 in each group). Group 1 was characterized by loss of medial support, group 2 by simulated severe cancellous bone damage due to osteoporosis, and group 3 by combination of the 2 features. After locked plating, each specimen underwent nondestructive quasi-static mechanical testing in 25 degrees lateral angulation under axial loading between 150 and 400 N in 50-N increments, accompanied by consecutive anteroposterior x-ray imaging. Subsequently, an additional 3D-printed intramedullary graft was inserted into each specimen and all tests were repeated. RESULTS Grafting resulted in significantly higher axial stiffness compared with no graft in groups 1 and 3 (P < 0.01) but not in group 2 (P = 0.12). Nongrafted specimens represented significantly higher stiffness in group 2 compared with groups 1 and 3 (P < 0.01), whereas no significant differences were detected among the 3 groups in the grafted state (P > 0.99). Varus deformation decreased significantly in each group after graft insertion (P ≤ 0.04). Nongrafted specimens in group 2 showed significantly lower varus deformation compared with groups 1 and 3 (P ≤ 0.04). No significant differences were registered among the 3 groups after grafting (P ≥ 0.65). CONCLUSIONS From a biomechanical perspective, locked plating augmented with intramedullary graft has the potential to increase significantly the stability against varus collapse in unstable PHFs when compared with conventional locked plate fixation.
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Affiliation(s)
- Lyubomir Rusimov
- AO Research Institute Davos, Davos, Switzerland.,Department of Trauma Surgery, University Multiprofile Hospital for Active Treatment and Emergency Medicine "N. I. Pirogov," Sofia, Bulgaria
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | - Daniel Ciric
- AO Research Institute Davos, Davos, Switzerland.,Flinders University, Tonesly, South Australia
| | | | - Dian Enchev
- Department of Trauma Surgery, University Multiprofile Hospital for Active Treatment and Emergency Medicine "N. I. Pirogov," Sofia, Bulgaria
| | - Mihail Rashkov
- Department of Trauma Surgery, University Multiprofile Hospital for Active Treatment and Emergency Medicine "N. I. Pirogov," Sofia, Bulgaria
| | - Mariya Hadzhinikolova
- AO Research Institute Davos, Davos, Switzerland.,Department of Trauma Surgery, University Multiprofile Hospital for Active Treatment and Emergency Medicine "N. I. Pirogov," Sofia, Bulgaria
| | | | | | - Asen Baltov
- Department of Trauma Surgery, University Multiprofile Hospital for Active Treatment and Emergency Medicine "N. I. Pirogov," Sofia, Bulgaria
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14
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Kuang GM, Wong TM, Wu J, Ouyang J, Guo H, Zhou Y, Fang C, Leung FKL, Lu W. Augmentation of a Locking Plate System Using Bioactive Bone Cement-Experiment in a Proximal Humeral Fracture Model. Geriatr Orthop Surg Rehabil 2018; 9:2151459318795312. [PMID: 30305979 PMCID: PMC6176529 DOI: 10.1177/2151459318795312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/10/2018] [Accepted: 07/21/2018] [Indexed: 12/17/2022] Open
Abstract
Introduction: The purpose of this study was to test whether local filling of a novel
strontium-containing hydroxyapatite (Sr-HA) bone cement can augment the fixation of a
locking plate system in a cadaveric proximal humeral facture model. Materials and Methods: Twelve pairs of formalin-treated cadaveric humeri were used. One side in each pair was
for cemented group, while the other side was for the control group. The bone mineral
density (BMD) of the samples was tested. A 3-part facture model was created and then
reduced and fixed by a locking plate system. In the cemented group, the most proximal 4
screw holes were filled with 0.5 mL bone cement. In the control group, the screw holes
were not filled by cement. Locking screws were inserted in a standard manner before the
cement hardened. X-ray was taken before all the specimens being subjected to mechanical
study, in which 6 pairs were used for axial loading (varus bending) test, while other 6
pairs were used for axial rotational test. Results: There is no difference in BMD between the cemented side and the control side. The X-ray
shows that the implant is in position. Cement filling was noted in the most proximal 4
screws in the cemented group. Better mechanical outcome was seen in the cemented groups,
in terms of less maximal displacement per cycle and higher failure point and stiffness
in varus bending test. However, no difference was found between the
cemented group and the control group in the axial rotation test. Discussion: In similarity with the previous studies, our results showed better mechanical results
in the cemented group. However, due to the limitations (e.g. sample size, fracture
model, testing protocol, etc), we still cannot directly extrapolate current mechanical
results to clinical practice at the present moment. Furthermore, it is still unknown
whether better primary outcome may lead to better long-term results, even though the
local release of strontium may enhance the local bone formation. Conclusion: The local filling of Sr-HA bone cement augments the fixation of the locking plate
system in current proximal humeral fracture model.
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Affiliation(s)
- Guan-Ming Kuang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Shenzhen Hospital, Shenzhen, China.,Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Tak Man Wong
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Jun Wu
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Shenzhen Hospital, Shenzhen, China.,Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jun Ouyang
- Department of Anatomy and Medical Biomechanical Key Laboratory of Guangdong Province, Southern Medical University, Guangzhou, China
| | - Haihua Guo
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Shenzhen Hospital, Shenzhen, China.,Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yapeng Zhou
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Shenzhen Hospital, Shenzhen, China.,Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Christian Fang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Frankie K L Leung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - William Lu
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Shenzhen Hospital, Shenzhen, China
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15
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Butler MA, Chauhan A, Merrell GA, Greenberg JA. Establishing the appropriate position of proximal humerus locking plates: a cadaveric study of five plating systems and their anatomic reference measurements. Shoulder Elbow 2018; 10:40-44. [PMID: 29276536 PMCID: PMC5734525 DOI: 10.1177/1758573217704816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 02/08/2017] [Accepted: 03/10/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND The present study aimed to determine anatomic references for the placement of five proximal humerus locking plates. METHODS Five proximal humerus locking-plate systems were placed on six human shoulder cadavers. Plates were positioned by fluoroscopic confirmation so that the inferior oblique screw was within 5 mm of the inferomedial cortex. Plate position was measured using the superior border of the pectoralis major tendon (PMT) to the bottom of the first slotted or nonlocking hole and top of the plate to the top of the greater tuberosity. The distance from the PMT insertion to the top of the humeral head was measured as a control. RESULTS There was consistency within each plating system for both the distance from the PMT insertion to the first hole and the top of the plate to the greater tuberosity: Synthes first-generation [mean (SD) 13.7 mm (3.1 mm); 10 mm (1.3) mm], Synthes second-generation [28.2 mm (2.2 mm); 18.5 mm (2.7 mm)], Biomet OptiLock® [25.5 mm (2.7 mm); 18.7 mm (2 mm)], Stryker AxSOS® [5 mm (2.8 mm); 12.3 mm (3.3 mm)] and Acumed Polarus® [9.5 mm (1.8 mm); 14.8 mm (1.6 mm)]. CONCLUSIONS The present study provides measurements that improve the accuracy of plate positioning for five plating systems.
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Affiliation(s)
| | - Aakash Chauhan
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Jeffrey A Greenberg
- Indiana Hand to Shoulder Center, Indianapolis, IN, USA,Jeffrey A Greenberg, Indiana Hand to Shoulder Center, 8501 Harcourt Road, Indianapolis, IN 46260, USA.
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16
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Beeres FJP, Hallensleben NDL, Rhemrev SJ, Goslings JC, Oehme F, Meylaerts SAG, Babst R, Schep NWL. Plate fixation of the proximal humerus: an international multicentre comparative study of postoperative complications. Arch Orthop Trauma Surg 2017; 137:1685-1692. [PMID: 28929389 DOI: 10.1007/s00402-017-2790-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The primary aim was to evaluate the number of complications following locking plate fixation of proximal humeral fractures in country X and in country Y. The secondary aim was to identify risk factors for complications. METHODS Multicentre retrospective case series of 282 consecutive patients with proximal humeral fractures, treated with a locking plate between 2010 and 2014. SETTING two level 1 trauma centres in country X and one in country Y. Data pertaining to demographics, postoperative complications and re-operations were collected. Fractures were classified according to the AO and Hertel classifications and experienced surgeons assessed the quality of reduction and plate fixation on the postoperative X-rays. Outcomes of the two different countries were compared and logistic regression analysis was performed to analyse the relationship between risk factors and complications. RESULTS During a median follow-up of 370 days, 196 complications were encountered in 127 patients (45%). The most frequent complications were: screw perforation in the glenohumeral joint (23%), persistent shoulder complaints (16%), avascular necrosis of the humeral head (10%) and secondary fracture displacement (5%). In 80 patients (28%), 132 re-operations were performed. The patients operated in country X had significantly more complications compared with the patients operated in country Y. For implant-related complications, advanced age, non-anatomic reduction of the greater tuberosity, and country of operation were risk factors. CONCLUSION The use of locking plates for proximal humeral fractures was associated with a high number of complications in both countries; the patients operated in country Y, however, had better results compared with the patients operated in country X. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Frank J P Beeres
- Klinik Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Lucerne, Switzerland.
| | - N D L Hallensleben
- Trauma Unit, Department of Surgery, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - S J Rhemrev
- Department of Surgery, Haaglanden Medical Centre, The Hague, The Netherlands
| | - J C Goslings
- Trauma Unit, Department of Surgery, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - F Oehme
- Klinik Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Lucerne, Switzerland
| | - S A G Meylaerts
- Department of Surgery, Haaglanden Medical Centre, The Hague, The Netherlands
| | - R Babst
- Klinik Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Lucerne, Switzerland
| | - N W L Schep
- Department of Surgery, Maasstad Medical Centre, Rotterdam, The Netherlands
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17
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Abstract
PURPOSE It is known that shoulder surgery may cause iatrogenic injury to the axillary nerve as a serious complication, but there is little evidence to indicate whether the axillary nerve is at risk of injury during an anterolateral acromial approach for minimally-invasive plate osteosynthesis (MIPO) of proximal humerus fractures. We hypothesised that this surgical method is safe for the axillary nerve and would preserve it from iatrogenic injury. MATERIALS AND METHODS We conducted a prospective follow-up cohort study on 49 consecutive patients with proximal humerus fractures who were managed with MIPO through an anterolateral approach. All patients underwent standardised electroneurographic testing, with assessment of amplitudes of evoked compound muscle action potentials (CMAP) and distal motor latencies (DML) of the axillary nerves, pre- and post-operatively. Six weeks after injury, all patients underwent needle electromyographic (EMG) testing of anterior, middle, posterior deltoid, teres minor and paraspinal muscles for detecting abnormal muscle activity as a sign of acute denervation. After six months of physical rehabilitation, patients with axillary nerve injury underwent control electroneurographic testing to check the recovery of neurographic features (CMAP, DML). All nerve measurements were compared to reference values, and between right and left side. RESULTS Five patients had a mild-to-moderate traumatic axillary nerve injury before surgery. There were no significant differences between amplitudes of CMAP (p = 0.575) and DML (p = 0.857) pre- and post-surgical procedure. CONCLUSIONS These results confirmed safety of this surgical method in the preservation of axillary nerve from iatrogenic injury, but the course of the axillary nerve must be kept in mind.
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18
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Laux CJ, Grubhofer F, Werner CML, Simmen HP, Osterhoff G. Current concepts in locking plate fixation of proximal humerus fractures. J Orthop Surg Res 2017; 12:137. [PMID: 28946902 PMCID: PMC5613450 DOI: 10.1186/s13018-017-0639-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 09/17/2017] [Indexed: 12/27/2022] Open
Abstract
Despite numerous available treatment strategies, the management of complex proximal humeral fractures remains demanding. Impaired bone quality and considerable comorbidities pose special challenges in the growing aging population. Complications after operative treatment are frequent, in particular loss of reduction with varus malalignment and subsequent screw cutout. Locking plate fixation has become a standard in stabilizing these fractures, but surgical revision rates of up to 25% stagnate at high levels. Therefore, it seems of utmost importance to select the right treatment for the right patient. This article provides an overview of available classification systems, indications for operative treatment, important pathoanatomic principles, and latest surgical strategies in locking plate fixation. The importance of correct reduction of the medial cortices, the use of calcar screws, augmentation with bone cement, double-plate fixation, and auxiliary intramedullary bone graft stabilization are discussed in detail.
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Affiliation(s)
- Christoph J Laux
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Florian Grubhofer
- Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Clément M L Werner
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hans-Peter Simmen
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Georg Osterhoff
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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19
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Shukla DR, McAnany S, Pean C, Overley S, Lovy A, Parsons BO. The results of tension band rotator cuff suture fixation of locked plating of displaced proximal humerus fractures. Injury 2017; 48:474-480. [PMID: 28063677 DOI: 10.1016/j.injury.2016.12.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 12/17/2016] [Accepted: 12/26/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to assess 1-year outcomes of patients with displaced proximal humerus fractures who underwent treatment with locked plate fixation with rotator cuff suture augmentation. METHODS A total of 86 patients who had sustained 2, 3 and 4-part displaced proximal humerus fractures underwent locked plate fixation with multiple sutures placed in the cuff tendons. Clinical outcome variables included active forward elevation (AFE), active external rotation (AER), and Constant and American Shoulder and Elbow Surgeons (ASES) scores. Post-operative variables included the following complications: varus re-collapse, loss of fixation, osteonecrosis of the humeral head (AVN), screw cut out, hardware failure and infection. RESULTS Forty-one patients were available with minimum of 1-year follow-up. Mean AFE was 142±17.0° and AER was 41±13.0°. The overall complication rate was 14.6%, with osteonecrosis being the most common (12.2%). Of the 21 patients (51.2%) that initially had varus displacement, all but one maintained anatomic reduction and fixation. Mean ASES score was 78.2±20.0 and average Constant score was 72.7±17.6. Bivariate analyses demonstrated that pre-operative medial comminution (p=0.297) or varus collapse (p=0.95) were not associated with an increased likelihood of sustaining a complication. CONCLUSIONS Follow-up of patients in this series demonstrated a low overall complication rate and excellent functional outcomes. We believe suture augmentation of the rotator cuff can counteract varus forces on proximal humerus fractures fixed with locked plates, and should be performed routinely in displaced 2, 3 and 4 part fractures.
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Affiliation(s)
- Dave R Shukla
- Leni & Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, United States.
| | - Steven McAnany
- Leni & Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, United States
| | - Christian Pean
- Icahn School of Medicine at Mount Sinai, 50 East 98th Street, Apt 2B, New York, NY 10029, United States
| | - Samuel Overley
- Leni & Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, United States
| | - Andrew Lovy
- Leni & Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, United States
| | - Bradford O Parsons
- Leni & Peter May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, United States
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20
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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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21
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Schnetzke M, Bockmeyer J, Porschke F, Studier-Fischer S, Grützner PA, Guehring T. Quality of Reduction Influences Outcome After Locked-Plate Fixation of Proximal Humeral Type-C Fractures. J Bone Joint Surg Am 2016; 98:1777-1785. [PMID: 27807109 DOI: 10.2106/jbjs.16.00112] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this study was to determine if fracture reduction, fracture pattern, and patient-related factors influence clinical outcome after locked-plate fixation of displaced proximal humeral fractures. METHODS Ninety-eight patients (mean age, 61.1 ± 11.2 years) with a proximal humeral fracture involving the anatomical neck (type C according to the OTA/AO classification system) were included. Clinical outcome was determined by age and sex-adjusted Constant score (CS%) and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Fracture reduction was quantitatively determined by 3 parameters (head-shaft displacement, head-shaft alignment, and cranialization of the greater tuberosity), and patients were divided into groups according to anatomical reduction, acceptable reduction, or malreduction. Relative risk (RR) for complications, revision surgery, and inferior clinical outcome (CS of <50%) was determined according to the quality of fracture reduction and fracture pattern (disruption of the medial hinge; type-C3 fracture) and patient-related factors (age; comorbidities). RESULTS After a mean of 3.1 ± 1.5 years, the mean CS% and DASH score were 54.8% ± 28.0% and 31.9 ± 24.8, respectively. The complication rate was 32.7% (n = 32), and 27 patients (27.6%) required revision surgery. Anatomical or acceptable fracture reduction was achieved in 40 (40.8%) of the patients. This resulted in a significantly lower complication rate (20.0% compared with 41.4% among the patients with malreduction; p = 0.027), a trend of lower revision rate (20% compared with 32.8%; p = 0.165), and better clinical outcome (mean CS% of 65.4% ± 28.2% compared with 47.6% ± 25.7%; p = 0.002) without a higher risk for osteonecrosis of the humeral head (5% compared with 10.3%). Cranialization of the greater tuberosity of >5 mm (n = 25), head-shaft displacement of >5 mm (n = 50), and valgus head-shaft alignment (n = 12) all increased the RR for inferior clinical outcome by twofold to threefold. Conversely, a patient age of >65 years (n = 31) and an OTA/AO type-C3 fracture pattern (n = 38) were not significantly associated with complications and inferior clinical outcome (RR, 0.9 to 1.8). CONCLUSIONS Anatomical fracture reduction with a locked plate significantly improved the clinical outcome of unstable and displaced proximal humeral fractures involving the anatomical neck. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Marc Schnetzke
- Department of Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwigshafen on the Rhine, Germany
| | - Julia Bockmeyer
- Department of Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwigshafen on the Rhine, Germany
| | - Felix Porschke
- Department of Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwigshafen on the Rhine, Germany
| | - Stefan Studier-Fischer
- Department of Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwigshafen on the Rhine, Germany
| | - Paul-Alfred Grützner
- Department of Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwigshafen on the Rhine, Germany
| | - Thorsten Guehring
- Department of Trauma and Orthopaedic Surgery, BG Trauma Center Ludwigshafen at the University of Heidelberg, Ludwigshafen on the Rhine, Germany
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He Y, He J, Wang F, Zhou D, Wang Y, Wang B, Xu S. Application of Additional Medial Plate in Treatment of Proximal Humeral Fractures With Unstable Medial Column: A Finite Element Study and Clinical Practice. Medicine (Baltimore) 2015; 94:e1775. [PMID: 26469918 PMCID: PMC4616805 DOI: 10.1097/md.0000000000001775] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The purpose of this study was to use finite element analysis to compare the biomechanical characteristics after lateral locking plate (LLP) or LLP with a medial anatomical locking plate (LLP-MLP) fixation of proximal humeral fractures with an unstable medial column.First, a 3-dimensional, finite element analysis model was developed. Next, LLP and LLP-MLP implants were instrumented into the proximal humeral fracture models. Compressive and rotational loads were then applied to the humerus model to determine the biomechanical characteristics. Both normal and osteoporotic proximal humerus fractures were simulated using 2 internal fixation methods each under 7 loading conditions. To assess the biomechanical characteristics, the construct stiffness, fracture micromotion, and stress distribution on the implants were recorded and compared.The LLP-MLP method provided both lateral and medial support that reduced the stress on the LLP and the amount of displacement in the fracture region. In contrast, the LLP method resulted in more instability in the medial column and larger magnitudes of stress. In osteoporotic bone, the LLP was more inclined to fail than LLP-MLP.The LLP-MLP method provides a strong support for the medial column and increases the stability of the region surrounding the fracture.
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Affiliation(s)
- Yu He
- From the Department of Orthopedic Surgery, Shandong Provincial Hospital Affiliated to Shandong University (YH, JH, FW, DZ, BW, SX); and Department of Medical Laboratory Diagnosis Center, Jinan Central Hospital, Ji'nan, Shandong, People's Republic of China
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Della Rocca GJ, Uppal HS, Copeland ME, Crist BD, Volgas DA. Geriatric Patients With Fractures Below the Hip are Medically Similar to Geriatric Patients With Hip Fracture. Geriatr Orthop Surg Rehabil 2015; 6:28-32. [PMID: 26246950 DOI: 10.1177/2151458514565662] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The objective of this study was to compare a cohort of geriatric patients with operatively managed isolated fractures below the hip to a cohort of geriatric patients with operatively managed isolated hip fractures. All patients greater than 59 years of age admitted to our institution for surgical care of an isolated lower extremity fracture during a 3-year period were included. Patients were divided into 2 cohorts: BTH (fracture below the subtrochanteric region of the femur) and HIP (proximal femoral fracture at subtrochanteric region or proximal). We identified 141 patients included in cohort BTH and 205 patients included in cohort HIP. HIP patients were older (P < .01) and less obese (P < .01) but were otherwise very similar. An extensive comorbidity review revealed that the 2 cohorts were similar, with the exception of an increased incidence of dementia (P = .012) or glaucoma (P = .04) in HIP patients and of peripheral neuropathy (P = .014) in BTH patients. HIP patients were more likely to be under active antiosteoporotic medication management and were more likely to be receiving pharmacological anticoagulation at the time of admission. HIP patients and BTH patients were similar with regard to necessity of assistance with ambulation preinjury, but HIP patients were less likely to reside independently at home than were BTH patients (P < .001). HIP patients were also less likely to be discharged directly home from the hospital (P < .001). Geriatric patients with fractures below the hip are medically similar to geriatric patients with hip fracture. Medical comanagement protocols have been extensively published that improve care of geriatric patients with hip fracture; consideration should be given to similar protocol-driven medical comanagement programs for geriatric patients with fractures below the hip.
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Affiliation(s)
- Gregory J Della Rocca
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Harmeeth S Uppal
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Marilyn E Copeland
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - David A Volgas
- Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, MO, USA
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Shin DJ, Byun YS, Cho YH, Park KH, Yoo HS. An Anterosuperior Deltoid Splitting Approach for Plate Fixation of Proximal Humeral Fractures. Clin Shoulder Elb 2015. [DOI: 10.5397/cise.2015.18.1.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Oh HK, Cho DY, Choo SK, Park JW, Park KC, Lee JI. Lessons learned from treating patients with unstable multifragmentary fractures of the proximal humerus by minimal invasive plate osteosynthesis. Arch Orthop Trauma Surg 2015; 135:235-242. [PMID: 25552395 DOI: 10.1007/s00402-014-2138-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The authors present clinical and radiographic results of minimal invasive plate osteosynthesis (MIPO) for three- or four-part fractures of the proximal humerus. PATIENTS AND METHODS Twenty-six patients with three- or four-part proximal humeral fractures treated with the MIPO technique through the deltoid splitting approach were clinically and radiographically evaluated at a minimum of 12 months with an average of 20.1 months. The valgus-impacted type of three-part fracture was excluded to verify the results of the MIPO with unstable multifragmentary fractures of the proximal humerus. RESULTS Twenty female patients and six male patients were included (mean age 67 years; range 18-90 years). No cases of nonunion were seen. The mean forward flexion, abduction, and external rotation were 145°, 119°, and 48°, respectively. The mean visual analog scale (VAS) for pain was 1.47 points. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 14.5 points, and the mean UCLA score was 29.6 points. The mean neck-shaft angle was 134°. Twenty-three patients had adequate medial support, and three patients did not have adequate medial support on initial postoperative radiographs. Five shoulders (19 %) developed complicated results. Two cases of proximal malposition of the plate (7.7 %) and two intra-articular screw penetrations (7.7 %) were observed. One case of osteonecrosis of the humeral head was identified at the final follow-up (3.8 %). CONCLUSION The MIPO technique provides reliable radiologic and functional outcomes for three- and four-part proximal humeral fractures. Our results might support the use of MIPO for treating unstable multi fragmentary fractures of proximal humerus such as three- or four-part fractures to decrease osteonecrosis of humeral head.
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Affiliation(s)
- Hyoung Keun Oh
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Dae Yeon Cho
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Suk Kyu Choo
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Jong Woong Park
- Department of Orthopedic Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Ki Chul Park
- Department of Orthopedic Surgery, Hanyang University Guri Hospital, 153, Gyeongchunro, Guri, 471-701, Korea
| | - Jung Il Lee
- Department of Orthopedic Surgery, Hanyang University Guri Hospital, 153, Gyeongchunro, Guri, 471-701, Korea.
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Proximal fractures of the humerus in patients older than 75 years of age: should we consider operative treatment? J Orthop Traumatol 2015; 15:111-5. [PMID: 24233865 PMCID: PMC4033798 DOI: 10.1007/s10195-013-0273-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 09/25/2013] [Indexed: 11/21/2022] Open
Abstract
Background Over 75 % of patients presenting with a proximal humerus fracture are 70 years or older. Very little is known about the outcome after operative treatment of these fractures in very old patients. This study was performed to gain more insight in safety and functional outcome of surgical treatment of proximal humerus fractures in the elderly. Materials and methods In this observational study, we analyzed all operatively treated patients, aged 75 or older, with a proximal humerus fracture between January 2003 and December 2008 in our center. Patient selection was on clinical grounds, based on physical, mental, and social criteria. Complications were evaluated. We used the DASH Questionnaire to investigate functional outcome, pain, and ADL limitations. Results Sixty-four patients were treated surgically for a displaced proximal fracture of the humerus: 15 two-part, 32 three-part, and 17 four-part fractures. Mean DASH scores were 37.5, 36.9, and 48.6, respectively. Regarding the operative methods, overall good results were obtained with the modern locked plate osteosynthesis (mean DASH 34.4). Prosthetic treatment, mostly used in highly comminuted fractures, often resulted in poor function (mean DASH 72.9). Persistent pain and ADL limitations were more present in more comminuted fractures (64 and 50 % in patients with 4-part fractures vs. 14 % in 2-part fractures). There were no postoperative deaths within 3 months of surgery, and fracture-related and non-fracture-related complication rates were low (non-union 3 %; 1 myocardial infarction). Conclusion This study shows that it is safe and justifiable to consider surgical treatment of a severely dislocated proximal humerus fracture in selected patients aged 75 and older. Level of evidence According to OCEBM Working Group, Level IV.
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Jaura G, Sikdar J, Singh S. Long Term Results of PHILOS Plating and Percutaneous K-Wire Fixation in Proximal Humerus Fractures in The Elderly. Malays Orthop J 2014; 8:4-7. [PMID: 25279077 PMCID: PMC4093541 DOI: 10.5704/moj.1403.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
ABSTRACT This is a report of a study on the long term results of PHILOS plating and percutaneous K-wire fixation in a prospective series of proximal humerus fractures in elderly patients. We reviewed a total of 60 patients with proximal humerus fractures in 30 patients (Group 1), who were treated by open reduction and internal fixation with Proximal Humeral Internal Locking System (PHILOS) plate and 30 patients (Group 2) who were treated with percutaneous K-wire fixation. Functional outcome was assessed using Visual Analogue Scale(VAS) and Constant-Murley Score. Mean Constant-Murley score was 84.6 points (range: 61- 100) in Group 1 and - 76.4 points(range:56-100) in Group 2 at final follow up. Values varied depending upon the fracture type with worst in 4-part fractures. Mean VAS Score was 2.6(range:0-10) in Group 1 and 3.8(range:0-10) in Group 2. We obtained satisfactory results in both the groups, with each procedure having its advantages and shortcomings. We found that PHILOS plate fixation provided stable fixation with minimal implant problems and enabled early range-ofmotion exercises to achieve acceptable functional results. Fixation with percutaneous K-wires presented an efficient treatment option with the advantages of minimal invasiveness and soft tissue dissection. KEY WORDS Proximal humerus fractures, PHILOS plate and K-wires.
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Affiliation(s)
- Gs Jaura
- Department of Orthopaedics, Maharishi Markandeshwar Institute of Medical Sciences and Research Mullana Ambala, India
| | - J Sikdar
- Department of Orthopaedics, Maharishi Markandeshwar Institute of Medical Sciences and Research Mullana Ambala, India
| | - S Singh
- Department of Orthopaedics, Maharishi Markandeshwar Institute of Medical Sciences and Research Mullana Ambala, India
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Effect of Calcar Screw Use in Surgical Neck Fractures of the Proximal Humerus With Unstable Medial Support: A Biomechanical Study. J Orthop Trauma 2014; 28:452-7. [PMID: 24662994 DOI: 10.1097/bot.0000000000000057] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the effect of calcar screw use in proximal humeral fractures with unstable medial support treated with locked plates. METHODS Standard osteotomies were performed in 36 cadaveric humeri to create a surgical neck fracture proximal humeral model. For static testing, 12 pairs of humeri were divided into 4 groups: normal alignment and varus deformity groups with and without 5-mm medial deficiencies. Calcar screw function was measured in each group by axial, shear, and torsion stiffness tests. Another 6 pairs of humeri with 5-mm medial deficiencies were subjected to cyclic loading tests in the normal alignment model with and without calcar screw application. RESULTS Calcar screws improved rotational stability in the normal alignment (P = 0.007) and varus (P = 0.002) groups. Calcar screws improved static and cyclic axial (P = 0.004) and shear (P = 0.017) stability in the normal alignment group with medial deficiency. In specimens with normal alignment and intact medial cortex, calcar screws provided no advantage in axial (P = 0.535) or shear (P = 0.537) stiffness. Calcar screws did not provide sufficient axial (P = 0.782) or shear (P = 0.772) stability to avoid reduction loss in humeri with varus malreduction. CONCLUSIONS In humeri with normal alignment, calcar screws can provide additional stability even when a medial deficiency exists. The use of calcar screws in humeri with varus deformity showed no biomechanical superiority.
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No Contribution of Tension-Reducing Rotator Cuff Sutures on Locking Plate Fixation in a 2-Part Proximal Humerus Fracture Model. J Orthop Trauma 2014; 28:458-63. [PMID: 24375272 DOI: 10.1097/bot.0000000000000051] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Varus failure is a well-known complication of open reduction internal fixation of proximal humeral fractures. The addition of tension-reducing sutures from the plate to the rotator cuff may attenuate the deforming forces of the rotator cuff resulting in decreased varus failure. In this study, we investigate the biomechanical contributions of tension-reducing sutures to a locked plate construct in a 2-part proximal humerus fracture model. METHODS Two fixation techniques were tested in 12 matched fresh frozen humeri in which standard 2-part fractures of the surgical neck were created with a gap simulating surgical neck medial comminution. In group 1, fractures were fixed with a standard proximal humerus locking plate. In group 2, the plate fixation was similar, and additionally, tension-reducing sutures were applied from the plate to the rotator cuff. Active abduction was simulated for 400 cycles with force applied through the rotator cuff tendons. Intercyclic fracture motion, change in displacement, and load to failure were recorded. RESULTS The addition of tension-reducing sutures did not lead to significant differences in intercyclic fracture motion. The mean change in displacement and load to failure were similar in both groups. Failure typically occurred in both groups at the rotator cuff testing clamp interface. CONCLUSIONS Tension-relieving rotator cuff sutures added to locking plate fixation did not lead to a change in fracture gap with cyclic loading or an increase in ultimate failure load in a 2-part surgical neck proximal humerus fracture model without medial support.
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Frich LH, Jensen NC. Bone properties of the humeral head and resistance to screw cutout. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2014; 8:21-6. [PMID: 24926160 PMCID: PMC4049036 DOI: 10.4103/0973-6042.131851] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Surgical treatment of fractures involving the proximal humeral head is hampered by complications. Screw cutout is the major pitfall seen in connection with rigid plating. We have exploited a bony explanation for this phenomenon.
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Affiliation(s)
- Lars Henrik Frich
- Department of Orthopaedics, Odense University Hospital, Odense, Denmark
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Bai L, Fu ZG, Wang TB, Chen JH, Zhang PX, Zhang DY, Jiang BG. Radiological evaluation of reduction loss in unstable proximal humeral fractures treated with locking plates. Orthop Traumatol Surg Res 2014; 100:271-4. [PMID: 24709305 DOI: 10.1016/j.otsr.2013.12.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 12/10/2013] [Accepted: 12/31/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to radiologically evaluate the risk of reduction loss after locking plate fixation of proximal humerus fractures. METHODS From September 2007 to April 2009, 71 patients (28 males, 43 females) with unstable proximal humeral fracture were treated with open reduction and internal fixation by locking plate. The mean follow-up time was 31.2 months (range: 26-47). The head-shaft angulation (HSA) and the humeral head height (HHH) in true anteroposterior (AP) were recorded and compared over time. All complications were noted. Shoulder function was measured by the Constant score. RESULTS Patients with ΔHSA >10° (t=2.740, P=0.008) and ΔHHH >5mm (t=2.55, P=0.019) were more likely to have impaired shoulder function. Varus collapse occurred most frequently in patients with initial reduction of HSA <125° (χ(2)=19.17, P<0.001, Fisher's exact test F<0.001). Patients with >5mm HHH decrease were strongly associated with loss of reduction (χ(2)=24.23, P<0.001, F<0.001). CONCLUSIONS Dynamic change of HSA >10° and HHH >5mm were radiological factors that indicated poor shoulder function. Intra-operative HSA >125° should be achieved to avoid reduction loss following locking plate fixation of proximal humerus fracture. LEVEL OF EVIDENCE level IV.
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Affiliation(s)
- L Bai
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China
| | - Z-G Fu
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China
| | - T-B Wang
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China
| | - J-H Chen
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China
| | - P-X Zhang
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China
| | - D-Y Zhang
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China.
| | - B-G Jiang
- Department of Orthopedics and Traumatology, Peking University People's Hospital, Traffic Medicine Center, XiZhiMen South Avenue 11#, 100044 Beijing, PR China.
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Kammerlander C, Erhart S, Doshi H, Gosch M, Blauth M. Principles of osteoporotic fracture treatment. Best Pract Res Clin Rheumatol 2013; 27:757-69. [DOI: 10.1016/j.berh.2014.02.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Rose DM, Sutter EG, Mears SC, Gupta RR, Belkoff SM. Proximal humeral fractures: a biomechanical comparison of locking plate constructs in a cadaveric 3-part fracture model. Geriatr Orthop Surg Rehabil 2013; 1:73-7. [PMID: 23569665 DOI: 10.1177/2151458510388179] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The purpose of our study was to biomechanically compare, under cyclic loading conditions, fracture site motion, humeral head collapse, and intra-articular hardware penetration in simulated 3-part osteoporotic proximal humeral fractures stabilized with 1 of 2 locking-plate constructs. We performed fixation on simulated 3-part proximal humeral fractures in 10 pairs of cadaveric osteoporotic humeri with a Hand Innovations S3 Proximal Humerus Plate (S3 plate) or an LCP Proximal Humerus Plate (LCP plate; 1 each for each pair). The specimens were potted, mounted on a materials testing machine, and subjected to 5000 cycles of abduction in the scapular plane, loading through the supraspinatus tendon. Interfragmentary displacement at 2 virtual points (the most medial aspect of the calcar and the most superior aspect of the osteotomy line between the greater tuberosity and humeral head) was measured using an optical tracking system. Humeral head rotation was also measured. We used a generalized linear latent and mixed model to check for an effect of cyclic loading and treatment on the parameters of interest (significance, P < .05). After cyclic loading, the S3 plate humeri showed significantly greater displacement of the greater tuberosity fragment and rotation of the humeral head and a trend (not a significant difference) toward greater displacement at the calcar. No hardware penetration was noted for either repair. Although the S3 plate repairs resulted in significantly more fracture site motion, it is unknown whether the magnitude of the motion is clinically significant.
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Affiliation(s)
- David M Rose
- International Center for Orthopaedic Advancement, Department of Orthopaedic Surgery, The Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Biomechanical considerations for surgical stabilization of osteoporotic fractures. Orthop Clin North Am 2013; 44:183-200. [PMID: 23544823 DOI: 10.1016/j.ocl.2013.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The incidence of osteoporotic fractures has been steadily rising along with the aging of the population. Surgical management of these fractures can be a challenge to orthopedic surgeons. Diminished bone mass and frequent comminution make fixation difficult. Advancements in implant design and fixation techniques have served to address these challenges and when properly applied, can improve overall outcome. The purpose of this review is to describe fixation challenges of common osteoporotic fractures and provide options for successful treatment.
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Namdari S, Voleti PB, Mehta S. Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment. J Shoulder Elbow Surg 2012; 21:1787-95. [PMID: 22748925 DOI: 10.1016/j.jse.2012.04.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 03/22/2012] [Accepted: 04/01/2012] [Indexed: 02/01/2023]
Abstract
Fractures of the proximal humerus are relatively common injuries in the elderly population. Given the association between proximal humeral fractures and osteoporosis, elderly patients who sustain these injuries should always undergo a fragility fracture workup. Furthermore, a preoperative assessment of local bone quality can be critical in facilitating decision making regarding surgical and nonsurgical treatment. Modalities for quantifying osteoporosis in the proximal humerus include plain radiography and spiral computed tomography imaging. Optimal management of osteoporotic proximal humeral fractures has evolved and may now includes use of locking plates and augmentation with intramedullary fibular grafts, calcium phosphate or sulfate cement, and iliac crest bone graft. This article reviews the demographics of patients who sustain proximal humerus fractures, the appropriate postinjury fragility fracture workup, modalities for quantifying osteoporosis in the proximal humerus, techniques for augmenting fixation of proximal humerus fractures, and the authors' preferred approach to the treatment of these injuries.
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Affiliation(s)
- Surena Namdari
- Department of Orthopaedic Surgery, Hospital of University of Pennsylvania, Philadelphia, PA 19104, USA
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Barco R, Barrientos I, Encinas C, Antuña SA. Minimally invasive poly-axial screw plating for three-part fractures of the proximal humerus. Injury 2012; 43 Suppl 2:S7-11. [PMID: 23622997 DOI: 10.1016/s0020-1383(13)70173-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The purpose of this study was to evaluate the poly-axial locked plating system inserted through a minimally invasive approach for the treatment of three-part fractures of the proximal humerus. Twenty-three patients with a three-part fracture of the proximal humerus treated with a poly-axial locking plate through a percutaneous approach were available for clinical and radiological analysis at a minimum of 2 years follow up (average 36 months; range, 24-54 months). To assess objective and subjective outcomes the Constant Score (CS) and the Disabilities of the Arm, Shoulder, and Hand (DASH) score were obtained. All complications were recorded. There were 17 women and 6 men, with a mean age of 62 years (range, 18-86). All fractures healed. At final follow up, the mean forward flexion, external rotation and internal rotation were 126°, 44° and L1, respectively; the mean CS was 64 and the mean DASH score was 23. Twelve patients (52%) had a postoperative complication, which included screw cut-out, stiffness and infection. The poly-axial locked plating system through a minimally-invasive approach may be an appropriate treatment for three-part fractures of the proximal humerus and may reduce the biological aggression of conventional plate fixation.
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Affiliation(s)
- R Barco
- Shoulder and Elbow Unit, Orthopedic Department, Hospital La Paz, Madrid, Spain.
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Kim SH, Lee YH, Chung SW, Shin SH, Jang WY, Gong HS, Baek GH. Outcomes for four-part proximal humerus fractures treated with a locking compression plate and an autologous iliac bone impaction graft. Injury 2012; 43:1724-31. [PMID: 22819250 DOI: 10.1016/j.injury.2012.06.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Revised: 06/13/2012] [Accepted: 06/25/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The study aims to evaluate outcomes of autologous iliac bone impaction grafts (AIBIGs) with locking-compression plates (LCPs) in four-part proximal humeral fracture. METHODS Between October 2004 and October 2008, 21 AIBIG with LCP osteosyntheses were done for four-part proximal humeral fractures. Patients included seven males and 14 females. Their mean age at the time of the operation was 66.3±16.9 years (range: 24-87 years). Five patients had high-energy fractures other than fall from standing height. There were two fracture-dislocation cases, and three valgus-impacted fractures. The length of the calcar segment attached to the articular segment was 7.04±6.10mm; 13 of the 21 cases had lengths less than 8mm. Medial-hinge displacement was 16.77±15.84mm; 19 of the 21 cases had displacements more than 2mm. RESULTS There was no avascular necrosis of the humeral head and union was achieved in all cases. Varus collapse and hardware-related complications were not observed. Postoperative neck-shaft angles were found to be 129±9° (range: 109-146°). Neer scores were 92.0±6.3 (range: 81-100). CONCLUSION The results of using AIBIG with LCP for four-part proximal humeral fractures are excellent. There are significant bone defects in osteoporotic or comminuted fractures and LCP alone does not always provide reliable fixation. Therefore, meticulous technique and use of AIBIG in this complicated type of fracture can ensure a favourable outcome.
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Affiliation(s)
- Sae Hoon Kim
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Sun JC, Li YL, Ning GZ, Wu Q, Feng SQ. Treatment of three- and four-part proximal humeral fractures with locking proximal humerus plate. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 23:699-704. [PMID: 23412173 DOI: 10.1007/s00590-012-1040-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Accepted: 06/27/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the effectiveness and complications of the locking proximal humerus plate to treat proximal humerus fractures. DESIGN A retrospective clinical trial. SETTING Department of Orthopaedics, Tianjin Medical University General Hospital. PATIENTS Sixty-eight consecutive patients with three- or four-part fractures of the proximal humerus were treated with locking proximal humerus plates. INTERVENTION The deltopectoral anterolateral acromial approach was used to the proximal humerus; open reduction and locking proximal humerus plate were applied. MAIN OUTCOME MEASUREMENTS Constant Score was used to measure the shoulder functional recovery, and Visual Analog Scale (VAS) was used to measure subjective evaluation of pain. The radiology was observed. RESULTS After average 26.7 months, the average Constant Score was 72.6 ± 13.2 points and the average VAS was 1.2 ± 0.8 points. All the complications such as screw perforation into the glenohumeral joint, screws loosening, soft tissue infections, avascular necrosis and delayed union occurred in eight cases (11.8 %). CONCLUSIONS The effectiveness of the locking proximal humerus plate was similar to other published literatures on treating fractures of the proximal humerus; however, a lower complications rate in short follow-up time was observed in this study. It may potentially provide a favorable option for treating three- or four-part fractures of the proximal humerus. Dealing with each particular fracture pattern, surgeons should have a decision of appropriate way to internal fixation.
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Affiliation(s)
- Jing-Cheng Sun
- Department of Orthopaedics, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin 300052, PR China
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Lynde MJ, Sautter T, Hamilton GA, Schuberth JM. Complications after open reduction and internal fixation of ankle fractures in the elderly. Foot Ankle Surg 2012; 18:103-7. [PMID: 22443995 DOI: 10.1016/j.fas.2011.03.010] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 03/24/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Open reduction with internal fixation for unstable ankle fractures is relatively predictable with excellent outcomes. However, the management of ankle fractures in the elderly remains less predictable secondary to the various co-morbidities associated with advanced age. METHODS A retrospective chart review of 216 patients over the age of 60 that sustained an ankle fracture, was performed to determine the incidence of complications after ORIF of ankle fractures in an elderly population in the perioperative course. Secondly, the incidence of complications in patients that had locking plate fixation compared to those that had non-locking plate fixation was determined. Lastly, the effect of early weight bearing on the incidence of complications was analyzed. RESULTS There was not a statistically significant difference in the complication rates between the group with co-morbidities (19.01%) and those without (11.96%). The postoperative complication with the highest incidence was wound dehiscence (9.7%), and only diabetes significantly predicted wound dehiscence. The fixation construct and weight-bearing protocol failed to significantly predict any of the indexed complications. CONCLUSIONS Overall, the results suggest that surgical treatment of unstable ankle fractures in the elderly is fairly predictable with an acceptable complication rate. The complication rates are higher with increased age and diabetes, but they failed to reach statistical significance. Conventional plating appears to provide adequate stability without increased risk of hardware failure. In addition patients that were allowed to walk within the first 2 weeks postoperatively did not experience a higher rate of hardware failure.
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Affiliation(s)
- Michael J Lynde
- San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics and Podiatric Surgery, Kaiser Permanente Medical Center, Oakland, CA 94118, USA
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Relationship of cortical thickness of the proximal humerus and pullout strength of a locked plate and screw construct. J Orthop Trauma 2012; 26:222-5. [PMID: 22207205 DOI: 10.1097/bot.0b013e31822421f7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND No study to date has evaluated cortical thickness as it relates to locking plate failure or screw pullout in the proximal humerus. The purpose of this study is to determine the relationship between proximal humerus cortical thickness and locked plate hardware failure in a cadaveric proximal humerus fracture model. METHODS Twelve humerus specimens were placed into two groups based on the proximal humerus cortical thickness on an anteroposterior radiograph: less than 4 mm and greater than 4 mm. The specimens were plated with a six-hole proximal humerus locking plate and a 15-mm resection osteotomy at the surgical neck was performed. The specimens were tested in a materials testing machine at a displacement of 5 mm/min to failure. RESULTS Load at failure, stiffness, maximum load, failure, and fracture gap closure were all statistically similar (P > 0.05) between the groups. CONCLUSION Our biomechanical study used modern locked plate-screw construct fixation of a simulated two-part proximal humerus fracture. The mechanical strength was unaffected based on a threshold combined proximal humerus cortical thickness of 4 mm.
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Krappinger D, Roth T, Gschwentner M, Suckert A, Blauth M, Hengg C, Kralinger F. Preoperative assessment of the cancellous bone mineral density of the proximal humerus using CT data. Skeletal Radiol 2012; 41:299-304. [PMID: 21509434 DOI: 10.1007/s00256-011-1174-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 04/04/2011] [Accepted: 04/06/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Osteoporotic fractures of the proximal humerus show an increasing incidence. Osteoporosis not only influences the fracture risk after low-energy trauma, but also affects the mechanical stability of internal fixation. Preoperative assessment of the local bone quality may be useful in the surgical treatment of patients sustaining these injuries. The aim of the present study was to present a method for the preoperative assessment of the local cancellous bone mineral density (BMD) of the proximal humerus using CT data. METHODS In the first part of the study, CT scans of 30 patients with unilateral fractures of the proximal humerus after low-energy trauma were used. The local BMD was assessed on the contralateral uninjured side. All 30 patients additionally underwent dual-emission X-ray absorptiometry (DXA) of the lumbar spine, proximal femur, and forearm of the side of the uninjured proximal humerus within 6 weeks after trauma. Three independent trauma surgeons performed measurements on the uninjured proximal humerus twice with a time interval of 4 weeks in order to assess the inter- and intraobserver reliability of the method. In the second part of the study, the local BMD of 507 patients with either proximal humerus fractures or chronic shoulder instability was assessed by a single trauma surgeon. In both parts, the average HU values in standardized ROIs of the humeral head were automatically calculated after correcting for HU values below the water equivalent. A linear calibration equation was computed for the calculation from HU to BMD using a calibration device (EFP). RESULTS The intra- and interobserver reliability was high (ICC > 0.95). Correlation coefficients between the local BMD of the proximal humerus and other anatomical sites were between 0.35 (lumbar spine) and 0.64 (forearm). We found a high correlation between the local BMD and age. The BMD in the fracture group was significantly lower than in the instability group. These patients were significantly older and more likely to be female. CONCLUSION Our method may provide a preoperative tool for the assessment of the local bone quality of the proximal humerus using CT data. Therapeutic adjustments such as augmentation or primary arthroplasty may be considered in patients with very low local BMD.
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Affiliation(s)
- Dietmar Krappinger
- Department of Trauma Surgery and Sports Medicine, Innsbruck Medical University, Anichstraße 35, 6020, Innsbruck, Austria.
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Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients: a randomized controlled trial. J Orthop Trauma 2012; 26:98-106. [PMID: 21804410 DOI: 10.1097/bot.0b013e31821c2e15] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of the study was to evaluate functional outcome, patient self-assessment, and radiographic outcome at 1 year in displaced three- and four-part proximal humeral fractures (OTA group 11-B2 and 11-C2). DESIGN Randomized controlled trial. SETTING Academic medical center. PATIENTS/PARTICIPANTS Fifty patients aged 60 years or older with displaced three- or four-part proximal humeral fractures and no previous shoulder injuries were randomized either to surgical treatment or to conservative closed treatment. Twenty-five patients were included in each group. Forty-eight patients completed 12-month follow-up. Two surgical patients died within 3 months. INTERVENTION The surgically treated group had a standardized surgical treatment with open reduction and internal fixation using an angular stable plate and cerclages. Instructed physical therapy started the third postoperative day. The conservative treatment group had a standardized nonoperative treatment that included closed reduction if displacement between the head and metaphyseal shaft fragment exceeded 50% of the diaphyseal diameter. Physical therapy started on the fifteenth postoperative day. MAIN OUTCOME MEASUREMENTS The main outcome was the mean difference in Constant score between the injured and noninjured shoulder at 12 months. The secondary outcomes were patient self-assessment (American Shoulder and Elbow Surgeons score) and radiographic ratings at 12 months. RESULTS At 12 months, mean Constant scores favored conservative treatment by 2.4 points (nonsignificant; P = 0.62). There was no significant difference in mean patient self-assessment. However, radiographic outcomes were significantly better for surgically treated patients. CONCLUSION There is no evidence of a difference in functional outcome at 1-year follow-up between surgical treatment and conservative treatment of displaced proximal humeral fractures in elderly patients.
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Muncibì F, Paez DC, Matassi F, Carulli C, Nistri L, Innocenti M. Long term results of percutaneous fixation of proximal humerus fractures. Indian J Orthop 2012; 46:664-7. [PMID: 23325969 PMCID: PMC3543884 DOI: 10.4103/0019-5413.104203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Proximal humerus fracture in elderly osteoporotic patients usually leads to severe displaced and multifragmentary fractures. Associated comorbidities may limit surgical options and conservative treatment is commonly indicated, however, with variable results. In most cases, surgery is the treatment of choice in order to restore anatomical integrity, and allow early functional recovery. Several techniques were used over the years, each with specific indication. Percutaneous pinning after closed reduction, a mini-invasive technique and fixation by use of K-wires is not preferred commonly. We present our experience with this approach, focusing on its indications and advantages. PATIENTS AND METHODS A study group of 41 consecutive patients with a mean age of 65.5 years were evaluated clinically (VAS, Constant-Murley score, range of motion), and with radiological analysis: 35 patients finally completed a minimum followup of 24 months. RESULTS K-wires were removed after a mean interval of 4 weeks. Clinical and radiographic healing occurred in a mean time of 8.2 weeks in all fractures but one, with improvements in mean Constant-Murley score of 87.6 points, mean VAS of 2.3. In 33 patients, the reduction was considered satisfactory. In two cases, reduction was poor, but the patients however presented acceptable functional outcome. CONCLUSIONS Percutaneous pinning may represent a suitable option of treatment for 2-or 3-part proximal humerus fractures in selected subjects.
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Affiliation(s)
- Francesco Muncibì
- Orthopaedic Clinic, University of Florence (Chief: Prof. M. Innocenti), Largo P. Palagi, 1 – 50139 Florence, Italy
| | - Diana Chicon Paez
- Orthopaedic Clinic, University of Florence (Chief: Prof. M. Innocenti), Largo P. Palagi, 1 – 50139 Florence, Italy
| | - Fabrizio Matassi
- Orthopaedic Clinic, University of Florence (Chief: Prof. M. Innocenti), Largo P. Palagi, 1 – 50139 Florence, Italy
| | - Christian Carulli
- Orthopaedic Clinic, University of Florence (Chief: Prof. M. Innocenti), Largo P. Palagi, 1 – 50139 Florence, Italy,Address for correspondence: Dr. Christian Carulli, Orthopaedic Clinic, University of Florence, Largo P. Palagi, 1 – 50139, Florence, Italy E-mail:
| | - Lorenzo Nistri
- Orthopaedic Clinic, University of Florence (Chief: Prof. M. Innocenti), Largo P. Palagi, 1 – 50139 Florence, Italy
| | - Massimo Innocenti
- Orthopaedic Clinic, University of Florence (Chief: Prof. M. Innocenti), Largo P. Palagi, 1 – 50139 Florence, Italy
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Sanders RJ, Thissen LG, Teepen JC, van Kampen A, Jaarsma RL. Locking plate versus nonsurgical treatment for proximal humeral fractures: better midterm outcome with nonsurgical treatment. J Shoulder Elbow Surg 2011; 20:1118-24. [PMID: 21481614 DOI: 10.1016/j.jse.2011.01.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 12/29/2010] [Accepted: 01/09/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND Since its introduction, there has been controversy about the use of locking plates in the treatment of proximal humeral fractures. Have they really improved the functional outcome after a proximal humeral fracture or should nonsurgical treatment have a more prominent role? In order to evaluate our hypothesis that nonsurgical treatment for proximal humerus fractures should be the first choice of treatment, a matched controlled cohort study was conducted to compare the midterm (>1 year) functional and radiologic outcome of a group of patients treated with a locking plate and a matched group of patients treated nonsurgically. Complications in each group of patients were evaluated. MATERIALS AND METHODS Through direct matching, 17 patients (1 bilateral fracture) treated with a locking plate were matched to 18 patients treated nonsurgically. Medical records and radiographs were reviewed retrospectively to obtain relevant patient related data and fracture type according to Neer classification (i.e. 2-, 3- and 4-part fractures). At the time of clinical follow-up, EQ-5D, American Shoulder and Elbow Surgeons (ASES) score, visual analog pain (VAS) pain and VAS satisfaction scores were completed. Active range of motion was tested. New radiographs were made to evaluate fracture healing, complications and, in the locking plate group, the position of the plate and screws. RESULTS No significant differences were found in the characteristics of the patient groups. A significant difference in range of motion was found in favor of the nonsurgically treated patients. Results of ASES and patient satisfaction scores were also tending toward nonsurgical treatment. Furthermore, the complication rate was higher with locking plate treatment. Patients treated with a locking plate needed significantly more additional treatment on their injured shoulder (P = 0.005). DISCUSSION This study's main limitation was the fact that the choice of initial fracture management was based on clinical judgement, as well as patient's fitness for surgery and therefore not randomized. By matching for fracture type this bias was largely overcome. Surgical treatment had a higher complication rate, requiring more additional treatment, which was often related to the initial surgery. Improving surgical technique could possibly lead to better outcomes for the surgically treated patients. In addition to the more favorable outcomes, nonsurgical treatment is also a more cost effective treatment. CONCLUSION Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures.
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Affiliation(s)
- Rick J Sanders
- Department of Orthopaedics, Flinders Medical Centre, Adelaide, Australia
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Johanson NA, Litrenta J, Zampini JM, Kleinbart F, Goldman HM. Surgical treatment options in patients with impaired bone quality. Clin Orthop Relat Res 2011; 469:2237-47. [PMID: 21384210 PMCID: PMC3126955 DOI: 10.1007/s11999-011-1838-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bone quality should play an important role in decision-making for orthopaedic treatment options, implant selection, and affect ultimate surgical outcomes. The development of decision-making tools, currently typified by clinical guidelines, is highly dependent on the precise definition of the term(s) and the appropriate design of basic and clinical studies. This review was performed to determine the extent to which the issue of bone quality has been subjected to this type of process. QUESTIONS/PURPOSES We address the following issues: (1) current methods of clinically assessing bone quality; (2) emerging technologies; (3) how bone quality connects with surgical decision-making and the ultimate surgical outcome; and (4) gaps in knowledge that need to be closed to better characterize bone quality for more relevance to clinical decision-making. METHODS PubMed was used to identify selected papers relevant to our discussion. Additional sources were found using the references cited by identified papers. RESULTS Bone mineral density remains the most commonly validated clinical reference; however, it has had limited specificity for surgical decision-making. Other structural and geometric measures have not yet received enough study to provide definitive clinical applicability. A major gap remains between the basic research agenda for understanding bone quality and the transfer of these concepts to evidence-based practice. CONCLUSIONS Basic bone quality needs better definition through the systematic study of emerging technologies that offer a more precise clinical characterization of bone. Collaboration between basic scientists and clinicians needs to improve to facilitate the development of key questions for sound clinical studies.
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Affiliation(s)
- Norman A. Johanson
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th Street, MS 420, Philadelphia, PA 19102 USA
| | - Jody Litrenta
- Drexel University College of Medicine, Philadelphia, PA USA
| | - Jay M. Zampini
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th Street, MS 420, Philadelphia, PA 19102 USA
| | - Frederic Kleinbart
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th Street, MS 420, Philadelphia, PA 19102 USA
| | - Haviva M. Goldman
- Department of Orthopaedic Surgery, Drexel University College of Medicine, 245 N 15th Street, MS 420, Philadelphia, PA 19102 USA ,Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA USA
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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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Bae JH, Oh JK, Chon CS, Oh CW, Hwang JH, Yoon YC. The biomechanical performance of locking plate fixation with intramedullary fibular strut graft augmentation in the treatment of unstable fractures of the proximal humerus. ACTA ACUST UNITED AC 2011; 93:937-41. [DOI: 10.1302/0301-620x.93b7.26125] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We evaluated the biomechanical properties of two different methods of fixation for unstable fractures of the proximal humerus. Biomechanical testing of the two groups, locking plate alone (LP), and locking plate with a fibular strut graft (LPSG), was performed using seven pairs of human cadaveric humeri. Cyclical loads between 10 N and 80 N at 5 Hz were applied for 1 000 000 cycles. Immediately after cycling, an increasing axial load was applied at a rate of displacement of 5 mm/min. The displacement of the construct, maximum failure load, stiffness and mode of failure were compared. The displacement was significantly less in the LPSG group than in the LP group (p = 0.031). All maximum failure loads and measures of stiffness in the LPSG group were significantly higher than those in the LP group (p = 0.024 and p = 0.035, respectively). In the LP group, varus collapse and plate bending were seen. In the LPSG group, the humeral head cut out and the fibular strut grafts fractured. No broken plates or screws were seen in either group. We conclude that strut graft augmentation significantly increases both the maximum failure load and the initial stiffness of this construct compared with a locking plate alone.
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Affiliation(s)
- J.-H. Bae
- Department of Orthopaedic Surgery, Korea University College of Medicine, Ansan Hospital, Gojan 1 Dong, Danwon-gu, Ansan-si, Gyeonggi-do, 425-707, Korea
| | - J.-K. Oh
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, 97 Gurodong-gil, Guro-gu, Seoul, 152-703, Korea
| | - C.-S. Chon
- SOLCO Biomedical Institute, 34-36 Geumam, Seotan, Pyungtaek, Gyeonggi-do, 451-852, Korea
| | - C.-W. Oh
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, 50, 2-Ga, Samdok, Chunggu, Daegu, 700-721, Korea
| | - J.-H. Hwang
- Division of Pediatric, Orthopaedics, Yonsei University College of Medicine, Severance Children’s Hospital, 250 Seongsanno, Seodaemun-gu, Seoul, 120-752, Korea
| | - Y.-C. Yoon
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, 97 Gurodong-gil, Guro-gu, Seoul, 152-703, Korea
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