New trends in fixation of proximal humeral fractures: a review

Intramedullary nailing versus cemented plate for treating metastatic pathological fracture of the proximal humerus: a comparison study and literature review

BACKGROUND

Pathological fracture of the humerus causes severe pain, limited use of the hand, and decreased quality of life. This study aimed to compare the outcomes of intramedullary nailing and locking plate in treating metastatic pathological fractures of the proximal humerus.

METHODS

This retrospective comparison study included 45 patients (22 male, 23 female) with proximal humerus metastatic pathological fractures who underwent surgical treatment between 2011 and 2022. All data were collected from medical records and were analyzed retrospectively. Seventeen cases underwent intramedullary nailing plus cement augmentation, and 28 cases underwent locking plate plus cement augmentation. The main outcomes were pain relief, function scores, and complications.

RESULTS

Among 45 patients with mean age 61.7 ± 9.7 years, 23 (51.1%) had multiple bone metastases, and 28 (62.2%) were diagnosed with impending fractures. The nailing group had significantly lower blood loss [100 (60-200) versus 500 (350-600) ml, p < 0.001] and shorter hospital stay (8.4 ± 2.6 versus 12.3 ± 4.3 days, p < 0.001) than the plating group. Average follow-up time of the nailing group was 12 months and 16.5 months for the plating group. The nailing group had higher visual analog scale (VAS) scores than the plating group, indicating greater pain relief with nailing [7 (6-8) versus 6 (5-7), p = 0.01]. Musculoskeletal Tumor Society functional scores [28 (27-29) versus 27 (26.5-28.5), p = 0.23] were comparable between groups. No complications, local recurrence, or revision surgery were reported until the last follow-up in either group. However, one case in the plating group had a humeral head collapse and fragmentation without needing revision surgery.

CONCLUSIONS

Intramedullary nailing with cement augmentation is a viable option for treating proximal humerus metastatic pathological fracture, providing rigid fixation and better pain relief resulting in earlier mobility to optimize functional outcomes. Less invasive procedure with less blood loss and shorter hospital stay also benefits patients. Level of evidence Level II. Trial registration statement Not applicable.

An engineered dual function peptide to repair fractured bones

Targeted drug delivery, often referred to as "smart" drug delivery, is a process whereby a therapeutic drug is delivered to specific parts of the body in a manner that increases its concentration at the desired sites relative to others. This approach is poised to revolutionize medicine as exemplified by the recent FDA approval of Cytalux (FDA approves pioneering drug for ovarian cancer surgery - Purdue University News) which is a folate-receptor targeted intraoperative near infrared (NIR) imaging agent that was developed in our laboratories. Fracture-associated morbidities and mortality affect a significant portion of world population. United states, Canada and Europe alone spent $48 billion in treating osteoporosis related fractures although this number doesn't count the economic burden due to loss in productivity. It is estimated that by 2050 ca 21 million hip fractures would occur globally which will be leading cause of premature death and disability. Despite the need for improvement in the treatment for fracture repair, methods for treating fractures have changed little in recent decades. Systemic delivery of fracture-homing bone anabolics holds great promise as a therapeutic strategy in this regard. Here we report the design of a fracture-targeted peptide comprised of a payload that binds and activates the parathyroid hormone receptor (PTHR1) and is linked to a targeting ligand comprised of 20 D-glutamic acids (D-Glu20) that directs accumulation of the payload specifically at fracture sites. This targeted delivery results in reduction of fracture healing times to <1/2 while creating repaired bones that are >2-fold stronger than saline-treated controls in mice. Moreover, this hydroxyapatite-targeted peptide can be administered without detectable toxicity to healthy tissues or modification of healthy bones in dogs. Additionally, since similar results are obtained upon treatment of osteoporotic and diabetic fractures in mice, and pain resolution is simultaneously accelerated by this approach, we conclude that this fracture-targeted anabolic peptide displays significant potential to revolutionize the treatment of bone fractures.

Intramedullary nailing for pathological fractures of the proximal humerus caused by multiple myeloma: A case report and review of literature

BACKGROUND

Multiple myeloma (MM) bone disease is indicative of MM, and reduces patient life quality. In addition to oncological, antineoplastic systemic therapy, surgical therapy in patients with MM is an essential treatment within the framework of supportive therapy measures and involves orthopedic tumor surgery. Nevertheless, there are few reports on intramedullary (IM) nailing in the treatment of MM-induced proximal humeral fracture to prevent fixation loss. We here describe a case of pathological fracture of the proximal humerus caused by MM successfully treated with IM nailing without removal of tumors and a review of the current literature.

CASE SUMMARY

A 64-year-old male patient complaining of serious left shoulder pain and limited movement was admitted. The patient was finally diagnosed with MM (IgAλ, IIIA/II). After treatment of the pathological fracture with IM nailing, the patient's function recovered and his pain was rapidly relieved. Histopathological examination demonstrated plasma cell myeloma. The patient received chemotherapy in the Hematology Department. The humeral fracture displayed good union during the 40-mo follow-up, with complete healing of the fracture, and the clinical outcome was satisfactory. At the most recent follow-up, the patient's function was assessed using the Musculoskeletal Tumor Society score, which was 29.

CONCLUSION

Early surgery should be performed for the fracture of the proximal humerus caused by MM. IM nailing can be used without removal of tumors. Bone cement augmentation for bone defects and local adjuvant therapy can also be employed.

Assessment of the efficacy of the far cortical locking technique in proximal humeral fractures: a comparison with the conventional bi-cortical locking technique

Background

Locking plate fixation is one of the treatment strategies for the management of proximal humeral fractures. However, stiffness after locking plate fixation is a clinical concern. The mechanical stiffness of the standard locking plate system may suppress the interfragmentary motion necessary to promote secondary bone healing by callus formation. The far cortical locking (FCL) technique was developed to address this limitation in 2005. FCL increases construct flexibility and promotes callus formation. Our study aimed to evaluate the clinical and radiological outcomes of the FCL technique when implemented in proximal humeral fracture management. Furthermore, we compared the surgical outcomes of FCL with those of the conventional bicortical locking (BCL) screw fixation technique.

Methods

Forty-five consecutive patients who had undergone locking fixation for proximal humeral fractures were included in this study. A proximal humeral locking plate (PHILOS) system with BCL screw fixation was used in the first 27 cases, and the periarticular proximal humeral locking plate with FCL screw fixation was used in the final 18 consecutive cases. Functional capacity was assessed using the constant score, American Shoulder and Elbow Surgeons (ASES) score, and range of motion. Radiographic outcomes were evaluated using the Paavolainen method of measuring the neck-shaft angle (NSA).

Results

No significant differences in clinical outcomes (ASES score, constant score, and range of motion) were found between the two groups. The union rate at 12 weeks was significantly higher in the FCL group (94.4%) than in the BCL group (66.7%, p = 0.006). No significant differences in NSA were found between the two treatment strategies. The complication rate was not significantly different between the two groups.

Conclusions

When implemented in proximal humeral fractures, the FCL technique showed satisfactory clinical and radiological outcomes as compared with the conventional BCL technique. The bone union rate at 12 weeks after surgery was significantly higher in the FCL group than in the BCL group. However, no significant difference in the final bone union rate was found between the two groups.

Indications and results of osteosynthesis for proximal humerus fragility fractures in elderly patients

Proximal humerus fractures (PHF) are common injuries in the elderly population. Conservative treatment is indicated for undisplaced and stable fractures, which account for almost 80% of the cases. More complex fracture patterns might need surgery, with a wide variety of indication criteria and surgical techniques described in the literature. Surgical treatment should be reserved for patients in good clinical conditions, autonomous in daily living activities and able to adhere to postoperative rehabilitation protocols. In the elderly population with severe osteoporosis, cognitive impairment and clinical comorbidities, the risk of surgical failures is high. In these patients, the choice between surgical and conservative treatment, as well as for the type of procedure, is even more difficult, with no general consensus in the literature. Final indication is usually conditioned by surgeon’s experience and preference. Two independent reviewers (B.H and G.G) independently extracted studies on proximal humeral fractures. All selected studies were screened independently (B.H and G.G) based on title and abstract. Then the full text of any article that either judged potentially eligible was acquired and reviewed again. Any disagreement was resolved by discussing the full text manuscripts. Aim of the present paper is to review the literature about indications and results of osteosynthesis for proximal humerus fragility fractures in the elderly population.

Low complication rates in Minimally Invasive Plate Osteosynthesis (MIPO) for proximal humeral fractures at 5 years of follow-up

INTRODUCTION

Purpose of this study was to analyse the medium term follow-up of minimally invasive plate osteosynthesis (MIPO) for proximal humeral fractures in terms of postoperative shoulder function, radiological outcome and complications.

METHODS

76 consecutive patients with unstable proximal humeral fractures were treated using locking plate with a minimally invasive antero-lateral approach in two surgical centers. Constant score and radiographic evaluation of 74 patients were available at mean follow up of 5 years (minimum 4 years).

RESULTS

Mean Constant score was 74 (range to 28-100). Results were comparable in the two centers. Younger patients registered significantly higher scores (p < 0.05). 20 patients (27%) developed complications. Subacromial impingement occurred in 16,2% of cases for varus malreduction (6,7%) and for too proximal plate positioning (9,5%). Primary screws perforation (2,7%), secondary perforation due to cut-out (1,4%), avascular necrosis (AVN) of humeral head (1,4%), partial resorption of greater tuberosity (2,7%), secondary displacement of the greater tuberosity (2,7%) and stiffness (2,7%) were observed.

DISCUSSION AND CONCLUSIONS

Even at a medium term follow-up, MIPO for proximal humeral fractures ensured good and reproducible results for most common pattern of fractures. Major complications were lower respect to open procedures, because of soft tissue, deltoid muscle and circumflex vessels sparing.

Treatment of the surgical neck fracture of the humerus with a novel external fixator in the elderly with osteoporosis: biomechanical analysis

Background

No consensus exists on the treatment of proximal humerus fractures, especially in the elderly patients with osteoporosis. This study was aimed to evaluate the biomechanical characteristics of a novel external fixator in treating two-part surgical neck fracture of the proximal humerus in the elderly patients with osteoporosis.

Methods

Sixteen female elderly humeral shaft specimens with osteoporosis were randomized into 2 groups. Models with the surgical neck two-part fracture of the proximal humerus were built, in which a novel external fixator (test group) and a clover plate (control group) were applied separately. In the test group, the fracture was firstly fixed with intersection pinning using 3 Schanz pins (3.5 mm), followed by the novel external fixation frame. In the control group, a clover plate and 6 cortical bone screws were applied. Biomechanical testing of the specimens was performed to assess the resistance to load bearing and torsional stress. The parameters of the two groups were compared using independent t-test.

Results

Ultimate bearing capacity and load bearing at different parts with the humerus rotation were higher (P < 0.05) in the external fixator group (145.16 ± 17.42 N and 140 N respectively) than those in the plate group (120.21 ± 13.15 N and 69.63 ± 25.16–90.78 ± 17.18 N respectively). As for resistance to torsional stress, plate’s torque fluctuated between 1 Nm and 5 Nm, while the external fixator’s torque values were more evenly (P < 0.01) distributed with the fluctuation within 1 Nm.

Conclusions

In the fixation of two-part humeral fracture in elderly patients with osteoporosis, the new external fixator seemed to be superior to plate fixation in load bearing and resistance to torsional stress.

Surgical trends in elderly patients with proximal humeral fractures in South Korea: a population-based study

Background

It is known that there are large regional variations in treatment methods for the management of proximal humeral fractures. The objective of this study was to investigate the national surgical trends in elderly patients with proximal humeral fractures in South Korea.

Methods

We analyzed the Korean Health Insurance Review and Assessment Service database from 2008 to 2016. International Classification of Diseases, 10th revision codes and procedure codes were used to identify patients aged ≥65 years with proximal humeral fractures.

Results

A total of 69,120 proximal humeral fractures were identified from 2008 to 2016. The overall operative rate for proximal humeral fractures increased steadily from 24.6% in 2008 to 36.8% in 2016 (p < 0.001). The rate of cases treated with open reduction and internal fixation tended to increase each year, from 71.5% of the overall surgeries in 2008 to 85.6% in 2016; conversely, the rate of cases treated with closed reduction and internal fixation tended to decrease from 19.9% in 2008 to 4.5% in 2016. In terms of type of arthroplasty procedure, the rate of cases treated with reverse shoulder arthroplasty tended to increase significantly each year, from 8.2% of the overall arthroplasty procedures in 2008 to 52.0% in 2016 (p < 0.001). The proportion of reverse shoulder arthroplasty was shown to increase especially in patients aged 80 years or older.

Conclusion

Overall, our findings indicated that surgical treatment of proximal humeral fractures, particularly by open reduction and internal fixation, continues to increase; in terms of type of arthroplasty procedure, the rate of cases treated with reverse shoulder arthroplasty tended to increase.

Minimally Invasive Plate Osteosynthesis for Proximal Humerus Fractures: A Retrospective Study Describing Principles and Advantages of the Technique

BACKGROUND

The aim of this study was to evaluate the clinical and radiographic results after minimally invasive plate osteosynthesis (MIPO) for proximal humerus fractures. Potential advantages of this approach include the easier exposure of the greater tuberosity and the limited surgical dissection around the fracture site.

MATERIALS AND METHODS

From October 2011 to March 2016, thirty-nine patients (32 women, 7 men) with a mean age of 64.9 years (range: 48-80) were surgically treated with the MIPO technique for proximal humeral fractures. According to Neer classification, there were 12 two-part, 24 three-part, and 2 four-part fractures and 1 two-part fracture-dislocation; the AO/OTA system was also used to categorize the fractures. The Constant-Murley (CMS) and the Oxford Shoulder (OSS) Scores were used to evaluate shoulder function.

RESULTS

Thirty-four patients were available for clinical and radiographic evaluation at a mean follow-up of 31.8 months (range: 12-54 months). All fractures healed and no postoperative complications occurred. Full recovery of pretrauma activities was reported by 27 patients, while 7 patients presented mild functional limitations. The mean absolute CMS was 75.2 (range: 55-95), the mean normalized CMS was 90.5 (range: 69-107), and the mean OSS was 43.7 (range: 31-48). The only statistically significant correlation was found between the female gender and lower absolute CMS and OSS. Radiographic evaluation revealed varus malunion in 4 cases and valgus malunion in 1 case, while incomplete greater tuberosity reduction was detected in 4 cases. All malunions were related to inadequate reduction at time of surgery and not to secondary displacement.

CONCLUSIONS

MIPO for proximal humeral fractures is an effective and safe surgical procedure. The limited tissue dissection allows minimizing the incidence of nonunion, avascular necrosis, and infection. The technique is not easy, requires experience to achieve mastery, and should be reserved for selected fracture patterns. In our experience, the main advantage of this approach consists in the direct access to the greater tuberosity, thus facilitating its anatomic reduction and fixation.

Surgical technique and early outcomes of intramedullary nailing of displaced proximal humeral fractures in an Asian population using a contemporary straight nail design

BACKGROUND

Despite being a common orthopedic injury, the optimal management of proximal humeral fractures remains a topic of debate. Although intramedullary nails have been used to treat these fractures, several complications have been reported with older nail devices. We describe our surgical technique and aim to evaluate the early functional and radiological outcomes of displaced Neer's two- to four-part proximal humeral fractures undergoing fixation with a contemporary straight intramedullary nail.

METHODS

A prospective cohort study of 22 consecutive patients (mean age 55.7 ± 18.0) with acute displaced proximal humeral fractures underwent intramedullary nailing (Depuy Synthes MultiLoc Humeral Nail) by a single surgeon in a single institution. According to Neer's classification, 11 had two-part fractures, 9 had three-part fractures, and 2 had four-part fractures. Functional and radiological outcomes, as well as occurrence of complications, were assessed at 12 months postoperatively.

RESULTS

The mean Constant-Murley score and American Shoulder and Elbow Surgeons score at 12 months were 75.5 ± 12.1 and 81.7 ± 6.2, respectively. Mean range of motion was forward flexion 144.3 ± 28.4, abduction 141.3 ± 30.5, external rotation 58.0 ± 13.9, and internal rotation 62.0 ± 15.2. Mean visual analog scale score was 1.7 ± 0.8. Radiographic fracture union was achieved at a mean of 3 months post-op. One patient underwent a second surgery for screw removal due to a proximal screw backing out. No other complications were found in our cohort. Notably, no patients had clinical signs and symptoms of subacromial impingement and/or rotator cuff tear.

CONCLUSION

Our study demonstrated that intramedullary nailing using the contemporary straight nail design is well suited for Neer's two- and three-part proximal humeral fractures, with good early outcomes and low rates of complications. Results for four-part fractures were, however, inferior in our cohort, suggesting that further studies with larger patient numbers are needed to determine the role of intramedullary nailing for four-part fractures.

Radiographic and clinical results of tension suture fixation using two washers with PHILOS plate for proximal humeral fractures

INTRODUCTION

The purpose of this study was to evaluate the radiographic and clinical results of tension suture fixation using two washers with PHILOS plate (Synthes, West Chester, PA, USA) for proximal humeral fractures.

PATIENTS AND METHODS

Consecutive 39 patients were included and divided into two groups of adequate and inadequate medial support (MS (+) group vs MS (-) group). The mean follow-up period was 45months (range: 26-69 months). The mean age at the time of surgery was 59 years (range: 17-86 years) and there were 12 men and 27 women. The clinical results were evaluated using the visual analogue scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, and subjective shoulder value (SSV). The radiographic results were evaluated by serial radiographs and Paavolainen method, which measures the neck-shaft angle (NSA). We used the Paired T and Kruskal-Wallis test to compare radiographic and clinical results between the two groups.

RESULTS

Bony union was achieved in 37 cases (94.9%). The mean NSA was changed from 133.5° postoperatively to 131.0° at the final follow-up period, but this change was not statistically significant. Thirty-five cases (89.8%) had good radiographic results as determined by the Paavolainen method. The mean final VAS pain score, ASES score, and SSV were 1.3, 87.3, and 86.0%, respectively. There were no significant differences between the two groups with respect to radiographic and clinical outcomes. Eight cases (20.5%) had complications including 5 with shoulder stiffness, 1 experiencing nonunion by fixation failure, 1 malunion, and 1 migration of greater tuberosity.

CONCLUSION

Tension suture fixation using two washers with PHILOS plate for proximal humeral fractures yielded satisfactory radiographic and clinical results. It can be a treatment option that can reduce varus deformity and fixation loss.

Minimally invasive plate osteosynthesis with PHILOS plate for proximal humerus fractures

OBJECTIVES

The aim of the present study was to evaluate results, including clinical and radiological outcomes and number of complications, following minimally invasive plate osteosynthesis (MIPO) of proximal humerus fractures, using the PHILOS® proximal humerus internal locking system (Synthes Holding AG, Solothurn, Switzerland).

METHODS

Retrospectively evaluated were 31 patients treated with MIPO (12 male, 19 female; average age: 58.4 years). Four patients had 2-part fractures, 14 patients had 3-part fractures, and 13 patients had 4-part fractures, according to Neer classification. Healing, complications, and head-shaft angle (HSA) were radiographically evaluated. Clinical outcomes were assessed at 1-year follow-up with Constant score.

RESULTS

Average Constant scores for fractured and normal shoulders were 73.2 ± 10.9 and 84.8 ± 5.1, respectively. Varus progression, fracture type, and age had no significant effect on functional outcome. Average postoperative and follow-up HSA's were 130.80 ± 7.70 and 128.80 ± 10.00, respectively. Significant varus progression was observed during follow-up (p = 0.01). Varus progression was more prominent in patients with postoperative HSA < 130° (p < 0.001). Inferomedial calcar screw usage, fracture type, and age had no significant effect on varus progression. Complications included 2 implant failures, 1 case of avascular necrosis (AVN), 1 primary screw cut-out, 1 axillary nerve injury, and 1 radial nerve injury (22.6% overall).

CONCLUSION

MIPO is a safe and effective option for the treatment of proximal humerus fractures, with good functional recovery and fewer complications, which are typically technique dependent. Reduction may be difficult, resulting in varus progression. Another disadvantage is risk of axillary nerve injury. Careful surgical technique and correct implant selection is important in the prevention of nerve injury.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Intramedullary Nailing for Pathological Fractures of the Proximal Humerus

BACKGROUND

Endoprosthetic reconstruction is widely applied for pathological fractures of the proximal humerus; however, functional impairment is usually unsatisfactory. The aims of the current study are to evaluate the reliability of interlocking intramedullary (IM) nailing with cement augmentation as a fixation method in proximal humeral lesions and to assess functional outcomes.

METHODS

We reviewed 32 patients with pathological fractures of the proximal humerus who underwent interlocking IM nailing and cement augmentation. Functional scores and pain relief were assessed as outcomes.

RESULTS

The mean follow-up period was 14.2 months. The mean Musculoskeletal Tumor Society functional score and Karnofsky performance status scale score were 27.7 and 75.6, respectively. Improvement of pain assessed using the visual analogue scale was 6.2 on average. Thirty-one patients (97%) experienced no pain after surgery. The mean ranges of forward flexion and abduction were 115° and 112.6°, respectively. All patients achieved stability and had no local recurrence without failure of fixation until the last follow-up.

CONCLUSIONS

Proximal interlocking IM nailing with cement augmentation appears to be a reliable treatment option for pathological or impending fractures of the proximal humerus in selected patients with metastatic tumors, even with extensive bone destruction.

Operative versus non-operative treatment in complex proximal humeral fractures: a meta-analysis of randomized controlled trials

Whether operative treatment for complex proximal humeral fractures (CPHFs) has a greater benefit over non-operative treatment remains controversial. There is no consensus on the optimal treatment in elderly patients with CPHFs. This updated meta-analysis of randomized controlled trials (RCTs) aims to investigate whether operative treatment is superior to non-operative treatment in CPHFs. The authors searched RCTs in the electronic databases (Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Medline, Embase, Springer Link, Web of Knowledge, OVID and Google Scholar) from their establishment to July 2015. Researches on operative and non-operative treatment for CPHFs were selected in this meta-analysis. The quality of all studies was assessed and effective data was pooled for this meta-analysis. Outcome measurements were functional status include constant scores (CS scores) and disabilities of the arm, shoulder and hand scores (DASH scores), total complication rates and healthy-related quality of life. The meta-analysis was performed with software revman 5.3. Nine articles with a total 518 patients (average age 70.93) met inclusion criteria. Patients were followed up for at least 1 year in all the studies. No statistical differences were found between operative and non-operative treatment in CS scores at 12 mo (months) [MD 1.06 95 % CI (−3.51, 5.62)] and 24 mo [MD −0.61 95 % CI (−5.87, 4.65)]. There are also no statistical differences between operative and non-operative treatment in DASH scores at 12 mo [MD −4.51 95 % CI (−13.49, 4.47)] and 24 mo [MD −7.43 95 % CI (−16.14, 1.27)]. Statistical differences were found between operative and non-operative treatment in total complication rates [RR 1.55, 95 % CI (1.24, 1.94)]. Statistical differences in EQ-5D at 24 mo [MD 0.15, 95 % CI (0.05, 0.24)] were found between operative and non-operative treatment but no statistical differences were found in ED-5D at 12 mo [MD 0.08, 95 % CI (−0.01, 0.17)], 15D at 12 mo [MD 0.02, 95 % CI (−0.68, 0.73)] and 15D at 24 mo [MD 0.02, 95 % CI (−0.07, 0.83)]. Operative treatments did not significantly improve the functional outcome and healthy-related quality of life in elderly patients. Instead, Operative treatment for CPHFs led to higher incidence of postoperative complications.

Revisiting the outcome of displaced two-part fractures of the humeral neck in elderly patients after conservative treatment

The aim of this study was to evaluate our experience with regard to the outcome of displaced two-part fractures of the humeral neck in elderly patients that were treated conservatively.

Between July 2008 and June 2010, 53 consecutive patients (42 females and 11 males; mean age = 74; range = 60-92) with an acute, displaced, two-part fracture of the humeral neck were treated conservatively using a sling and swathe for two weeks, followed by a standard rehabilitation protocol. The inclusion criteria were a displacement of the shaft >50% of its width and/or angulation of the shaft >45 degrees on standard radiographs. The exclusion criteria were patients younger than 60 years of age and those with cognitive or systemic impairment that would preclude the recommended physiotherapy. Patients were followed-up for one year, and were assessed at 3, 6, and 12 months using the Constant- Murley Score (CMS) and the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH). Patients were divided into two groups, those below 70 years of age and those above 70-. Two-way repeated measures analysis of variance (ANOVA) was used to determine if there were significant differences between the results at 3, 6 and 12 months for both groups, and if the results were significantly different between the two groups.

Forty-eight out of 53 patients (91%) were able to complete the follow-up schedule, while five patients died. The mean CMS improved progressively at three (51.3), six (60.4), and 12 (61.3) months. The mean DASH also improved progressively at three (38.8), six (34.8), and 12 (32.6) months. For both groups, the CSS and DASH improved significantly from three to six months and from three to 12 months. However, the improvements were not significant from just six to 12 months. Between the two groups, the results at three, six, and 12 months were not significantly different from each other. On final follow-up, 42 out of 48 patients (88%) were satisfied with their outcome and reported that they would choose to undergo the same treatment if they had to do everything all over again.

Conservative management of displaced two-part fractures of the humeral neck in elderly patients is a safe, efficacious, and acceptable treatment.

Risk of injury to the axillary nerve during antegrade proximal humeral blade nail fixation - an anatomical study

INTRODUCTION

The antegrade intramedullary Locking Blade Nail (Marquardt, Germany) is a device aimed at improving purchase in the humeral head and reducing varus displacement by providing medial buttress support and triangular stability within the humeral head. The aim of this study is to measure the relationship of the proximal fixation screws to the axillary nerve.

METHODS

13 whole cadavers underwent insertion of an antegrade proximal humeral blade nail via a deltoid split approach to both shoulders. The anatomic proximity of the anterior branch of the axillary nerve to the screws was measured following soft tissue dissection and inspection of the nerve.

RESULTS

The mean distance of the nerve from the anterolateral acromion was 62 mm (range 45-81 mm). The nerve lay closest to the distal blade fixation screw 4.9 mm (range 0-19 mm). In three cases the nerve lay directly underneath the washer and in all three cases there was macroscopic evidence of damage to the nerve. In 5 cases the nerve travelled obliquely in a cranial direction to lie 1.8 mm (range 0-3 mm) from the distal blade fixation screw, in 2 of these cases the nerve lay beneath the washer.

CONCLUSION

The anterior branch of the axillary nerve is placed at risk during insertion of the locking screws despite use of protection sleeves and trocars. We advocate that when using antegrade intramedullary nails that incorporate an inferomedial calcar screw an extended anterolateral acromial approach is undertaken.

Minimally invasive plate osteosynthesis with a locking compression plate is superior to open reduction and internal fixation in the management of the proximal humerus fractures

BACKGROUND

The use of minimally invasive plate osteosynthesis (MIPO) via anterolateral deltoid splitting has good outcomes in the management of proximal humerus fractures. While using this approach has several advantages, including minimal soft tissue disruption, preservation of natural biology and minimal blood loss, there is an increased risk for axillary nerve damage. This study compared the advantages and clinical and radiological outcomes of MIPO or open reduction and internal fixation (ORIF) in patients with proximal humerus fractures.

METHODS

A matched-pair analysis was performed, and patient groups were matched according to age (±3 years), sex and fracture type. Forty-three pairs of patients (average age: MIPO, 63 and ORIF, 61) with a minimum follow-up of 12 months were enrolled in the study group. The patients were investigated radiographically and clinically using the Constant score.

RESULTS

The MIPO technique required less surgery time and caused less blood loss compared to ORIF (p < 0.01). In addition, MIPO required a smaller incision, resulted in less scarring, and was cosmetically more appealing and acceptable to female patients than ORIF. Following MIPO, patients had better functional results at 3 and 6 months, with better outcomes, less pain, higher satisfaction in activities of daily living, and a higher range of motion when compared to ORIF (p < 0.05). Fracture configuration, according to the AO/ASIF(Association for the Study of Internal Fixation) fracture classification, did not significantly influence the functional results. The complication rate was comparable between both groups.

CONCLUSION

The use of MIPO with a locking compression plate in the management of proximal humerus fractures is a safe and superior option compared to ORIF.

Operative versus nonoperative treatment in complex proximal humeral fractures

This updated meta-analysis investigated whether operative treatment is superior to nonoperative treatment in complex proximal humeral fractures. The authors searched the Cochrane Central Register of Controlled Trials, PubMed, and EMBASE. Randomized controlled trials that evaluated operative vs nonoperative treatment for exclusively 3- or 4-part proximal humeral fractures were considered. Six studies with a total of 287 patients who had proximal humeral fractures were included. According to the meta-analysis, no statistically significant differences were found between operative and nonoperative treatment in Constant-Murley shoulder scores (Constant scores); Disabilities of the Arm, Shoulder, and Hand scores; total complication events; mortality; infection; nonunion; avascular necrosis; osteoarthritis; redisplacement of fractures; or dislocation or resorption of tuberosity. For health-related quality of life, EuroQol-5D (EQ-5D) favored operative treatment, but 15D scores showed no significant difference. Compared with nonoperative treatment, open reduction and internal fixation required significantly more additional surgeries (risk ratio, 6.50; 95% confidence interval, 1.54-27.50; P=.01), and more penetrations into joint space occurred (risk ratio, 9.56; 95% confidence interval, 2.27-40.13; P=.002). The limited evidence suggests that no convincing findings support the use of either open reduction and internal fixation or hemiarthroplasty for the treatment of complex proximal humeral fractures. The findings of the current study should be interpreted cautiously because of the modest sample size and the short follow-up period.

Complications after interlocking intramedullary nailing of humeral shaft fractures

INTRODUCTION

IM nails have gained popularity for stabilization of humeral shaft fractures (HSF). The initial enthusiasm was tempered by a number of specific complications and thus indications need to be re-evaluated.

PATIENTS AND METHODS

This retrospective study includes 111 patients with HSF subjected to a treatment protocol of IM fixation with first and second generation of humeral nails. Antegrade approach was used in 105 (94.5%) and retrograde in 6 (5.5%) patients. Reaming was performed in 51 (45.9%) fractures. The study covers a period of 10 years. Mean follow-up time was 3.5 (1-6) years. This investigation is directed at technical errors and complications, especially those corrected by secondary surgery.

RESULTS

We registered 52 (46.85%) intra-operative complications in 40 (36.04%) patients, on average 1.3 per patient. The most common were: distraction n=5 (4.5%), long proximal locking screws n=9 (8.1%), additional diaphyseal fracture n=7 (6.3%) and countersinking of the nail in the humeral head n=8 (7.2%). The number of postoperative complications was 40 (36.0%) related to 19 (17.1%) patients. Technical errors, such as distraction, longer nail and additional fractures have affected time to union and resulted in chronic shoulder pain. 36 (32.5%) secondary surgeries were needed to address these problems. When first generation nails are used, the intra-operative complication related risk increases 1.58 times, and the postoperative complication related risk is 1.67 times higher compared to second generation nails. According to Constant-Murley score excellent and very good functional results were achieved in 93 (83.78%) patients. While reaming did not influence the clinical results for both nail generations, overall better results were achieved with second generation nails. Postoperative shoulder pain has been registered in 18 (16.2%) patients.

CONCLUSION

We registered a number of technical errors and complications, which we consider technique specific. The analysis and avoidance of these complications, related only to IM nailing of the humerus, will allow IM nails to successfully bridge the gap between functional bracing and plating.

BIOMECHANICAL COMPARISON OF THE ROLE OF INLAY GRAFT IN PROXIMAL HUMERUS FRACTURE FIXED WITH CONVENTIONAL PLATE AND LOCKING PLATE

With a varus deformity, repairs of proximal humeral fractures frequently fail after screws pull out due to lack of medial support. Indirect intramedullary grafts have been used to prevent such complications. A biomechanical study was performed to investigate the role of an intramedullary bone peg (strut) in fractures fixed with conventional and locking plates.

Twenty artificial proximal humerus specimens were divided into four groups. Group 1 specimens were fixed with convention plates and group 2 specimens were fixed with the addition of a bone peg. Groups 3 and 4 specimens were fixed using locking plate and additional bone peg, respectively. All specimens were tested with a static loading test, and the axial stiffness and maximal load were recorded.

Locking plates with inlay graft were the most rigid of the four groups. When an intramedullary graft was introduced, the maximal load increased by more than 200%, whether conventional or locking plates were used. The maximal load of a conventional plate with inlay graft was more than twice of that of the locking plate only.

Indirect medial support acts as an anti-bending device, reducing the tension on the plate. It also decreases varus deformity and loosening of screws. Locking plate stabilize the plate-bone interface. Locking plate with indirect medial support is thus recommended for patients withsevere osteoporotic or medial comminuted proximal humeral fractures.

Can the osteosynthesis with locking plates be a better treatment for unstable fractures of the proximal humerus?

PURPOSE

The purpose of this study is to review our experience with proximal humeral locking plates, including complications, functional outcomes, strength recovery and predictors of successful treatment.

METHODS

Seventy unstable proximal humeral fractures were treated with open reduction internal fixation (ORIF) with the use of locking proximal humerus plate. At an average follow-up of 31 months, the clinical and subjective outcomes were evaluated, and complication was analysed.

RESULTS

The average Constant score was 72. The mean disabilities of the arm, shoulder and hand score was 23. The average range of motion was as follows: mean range of anterior elevation and abduction 120°-150°; external rotation in abduction 64° and in adduction 44°; and internal rotation T12.

CONCLUSION

On the basis of the overall functional and clinical outcome obtained, it is possible to suggest that the ORIF of the proximal humerus fractures using locking plate represents a helpful option that can lead to a good clinical and functional outcome even in the most complex fractures.

Functional outcomes following locking plate fixation of complex proximal humeral fractures

The purpose of this study was to evaluate the functional outcome of patients with complex proximal humeral fractures fixated by locking plate technology. Eighty-nine patients (27 men, 62 women) older than 50 years with 3- and 4-part proximal humeral fractures were treated using locking plate fixation and followed up for more than 1 year. Functional outcomes were assessed by using the Disabilities of the Arm, Shoulder, and Hand (DASH) and Constant scores, and the complications were evaluated through physical and radiographic examinations. Mean DASH and Constant scores for all 89 patients were 19.6 and 66.6 points, respectively. No significant differences existed in the 2 scores between patients with 3- and 4-part fractures. Of the 71 patients without complications, 68 had an excellent functional outcome according to the DASH score, whereas 2 patients had an excellent outcome on the Constant score. For the 18 patients with complications, the functional outcomes were significantly poorer compared with patients without complications. According to the Constant score, all patients with complications were classified into a moderate or poor functional outcome, but the rate was 12% with the DASH score. In patients with 3- and 4-part proximal humeral fractures fixed with locking plate fixation, complications were the major cause of compromised functional outcomes. Based on these results, different conclusions would be reached when the functional outcome was assessed by using the DASH and Constant scores separately. Because the clinician-based Constant score may bias the results, patient-based assessments, such as the DASH score, are required for the evaluation of functional outcome after shoulder surgery.

Management of displaced surgical neck fractures of the humerus: health related quality of life, functional and radiographic results

INTRODUCTION

There is no controversy about the need for surgical treatment of the displaced surgical neck fractures of the humerus, but there are few studies comparing the results of the three preferred types of surgical treatment. To expand the knowledge needed in decision making, a patient series is reviewed using health related quality of life (HRQoL), functional and radiographic data from patients treated with percutaneous pinning, locking plates or intramedullary nails.

MATERIALS AND METHODS

Retrospective observational cohort study of patients who underwent internal fixation of fractures of the surgical neck of the humerus between 2004 and 2009 (mean follow-up 40.67 ± 17.93 months). Fifty patients fulfilled the inclusion criteria (mean age 70.04 ± 13.15 years). Nine had been treated by percutaneous pinning, fifteen with locking plates and twenty-six with intramedullary nails. We compared the results between the three groups of the HRQoL with the EuroQol5D questionnaire; the functional capacity of the operated and non-operated shoulder with the Constant score; and the radiographic result with plain X-rays.

RESULTS

Forty-eight patients had achieved fracture healing. The plating and nailing groups had a better fracture reduction compared with the pinning group (p <0.05). The EuroQol-5D did not discriminate between groups (mean 0.65 ± 0.26; p >0.05). The mean Constant score of the K-wire group (47.67 ± 22.42) was lower than those of the plating (82.45 ± 17.69) and nailing groups (72.72 ± 15.96) (p = 0.001), with no differences between plates and nails. There was positive correlation between the EuroQol-5D result and the Constant score (r = 0.490; p <0.005). The fractured shoulder was worse in each item of the Constant score than the non-operated one in patients treated with pins and nails. Patients treated with plates achieved similar results between operated and non-operated shoulder in three items: arm positioning, internal and external rotation. Seventeen patients (six re-operated) had some kind of complication during follow-up.

CONCLUSION

Patients treated with pinning achieved a worse radiographic and Constant score than patients treated with plates or nails. Although we did not find differences between the plating and nailing groups, patients treated with plates got a Constant score more similar to the non-operated shoulder.

Minimally invasive poly-axial screw plating for three-part fractures of the proximal humerus

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.

Treatment of three- and four-part proximal humeral fractures with locking proximal humerus plate

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.

Prospects of implant with locking plate in fixation of subtrochanteric fracture: experimental demonstration of its potential benefits on synthetic femur model with supportive hierarchical nonlinear hyperelastic finite element analysis

Background

Effective fixation of fracture requires careful selection of a suitable implant to provide stability and durability. Implant with a feature of locking plate (LP) has been used widely for treating distal fractures in femur because of its favourable clinical outcome, but its potential in fixing proximal fractures in the subtrochancteric region has yet to be explored. Therefore, this comparative study was undertaken to demonstrate the merits of the LP implant in treating the subtrochancteric fracture by comparing its performance limits against those obtained with the more traditional implants; angle blade plate (ABP) and dynamic condylar screw plate (DCSP).

Materials and Methods

Nine standard composite femurs were acquired, divided into three groups and fixed with LP (n = 3), ABP (n = 3) and DCSP (n = 3). The fracture was modeled by a 20 mm gap created at the subtrochanteric region to experimentally study the biomechanical response of each implant under both static and dynamic axial loading paradigms. To confirm the experimental findings and to understand the critical interactions at the boundaries, the synthetic femur/implant systems were numerically analyzed by constructing hierarchical finite element models with nonlinear hyperelastic properties. The predictions from the analyses were then compared against the experimental measurements to demonstrate the validity of each numeric model, and to characterize the internal load distribution in the femur and load bearing properties of each implant.

Results

The average measurements indicated that the constructs with ABP, DCPS and LP respectively had overall stiffness values of 70.9, 110.2 and 131.4 N/mm, and exhibited reversible deformations of 12.4, 4.9 and 4.1 mm when the applied dynamic load was 400 N and plastic deformations of 11.3, 2.4 and 1.4 mm when the load was 1000 N. The corresponding peak cyclic loads to failure were 1100, 1167 and 1600 N. The errors between the displacements measured experimentally or predicted by the nonlinear hierarchical hyperelastic model were less than 18 %. In the implanted femur heads, the principal stresses were spatially heterogeneous for ABP and DCSP but more homogenous for LP, meaning LP had lower stress concentrations.

Conclusion

When fixed with the LP implant, the synthetic femur model of the subtrochancteric fracture consistently exceeds in the key biomechanical measures of stability and durability. These capabilities suggest increased resistance to fatigue and failure, which are highly desirable features expected of functional implants and hence make the LP implant potentially a viable alternative to the conventional ABP or DCSP in the treatment of subtrochancteric femur fractures for the betterment of clinical outcome.

Tension suture fixation using 2 washers for proximal humeral fractures

The surgical treatment for proximal humeral fractures is challenging, especially in patients with osteoporosis. Locking plates and intramedullary nails have been widely used with satisfactory results, but previously reported complications have not been substantially reduced. Several authors have emphasized the importance of maintaining soft tissues around the proximal humerus with respect to limiting displacement and maintaining stability. To prevent postoperative complications, such as fixation failure and malunion, several supplementary suture techniques using nonabsorabable sutures that allow for the incorporation of the rotator cuff as a fixation point have been described.

Long term results of percutaneous fixation of proximal humerus fractures

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.