Nailing of three- and four-part fractures of the humeral head -- long-term results

Straight intramedullary MultiLoc nails for displaced proximal humeral fractures: health status, radiographic results, clinical outcome, and complications

BACKGROUND

The treatment of the displaced proximal humerus fractures (PHF) still facing a lot of unsolved problems. The aim of this study was to evaluate the clinical effect of MultiLoc nails for the treatment of PHF and present outcomes of patients with different Neer's classification and reduction quality.

METHODS

Adult patients with PHFs were recruited and treated with MultiLoc nail. Intraoperative data, radiographic and functional outcomes, as well as occurrence of postoperative complications were assessed.

RESULTS

48 patients met inclusion and exclusion criteria and were included in this study. The DASH Score were 32.2 ± 3.1 points at 12 months, and 37.3 ± 2.5 points at the final follow-up. The mean ASES score at 12 months and final follow-up were 74.4 ± 6.2 and 78.8 ± 5.1, respectively. The mean CM Score in all 48 patients reached 68 ± 6.4 points at the final follow-up, relative side related CM Score 75.2 ± 7.7% of contralateral extremity. The incidence rate of complications was 20.8%. Patients with fracture mal-union, adhesive capsulitis were observed but no secondary surgeries were performed. There was no significantly difference of DASH Score 12 months after surgery and at the last follow-up among patients with different Neer's classification or reduction quality. However, functional outcomes such as ASES score and CM score were significantly influenced by severity of fracture and the quality of fracture reduction.

CONCLUSIONS

Our study demonstrated that MultiLoc nails is well suited for proximal humeral fractures, with satisfactory health status recovery, good radiographic results, positive clinical outcomes and low rates of complications. The treatment for four part PHF still faces great challenges. Accurate fracture reduction was an important factor for good functional result.

Comparison of clinical outcomes and complications in 2-part vs. 3- or 4-part proximal humerus fractures treated using an intramedullary nail designed to capture the tuberosities

Background

Intramedullary nail fixation for proximal humerus fractures has been shown to provide satisfactory results. The quality of reduction correlates with clinical outcomes, the rate of complications, avascular necrosis, and postoperative loss of fixation. The purpose of this study was to evaluate the clinical outcomes and complications of 2-part proximal humerus fractures compared to 3- or 4-part proximal humerus fractures.

Methods

A single-center retrospective review was carried out of patients who underwent an intramedullary nail for a proximal humerus fracture by one of three surgeons between the years of 2009 and 2022, and who had a minimum of 12-months follow-up. Fracture pattern, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, satisfaction, pain score, range of motion, and complications were recorded. The mechanism of injury (high energy vs. low energy), method of reduction (open vs. percutaneous), and evidence of radiographic healing were assessed. A P value of <.05 was considered to be statistically significant.

Results

The study included 78 patients (62 female, 16 male). The number of patients in each group (2-part, N = 32 vs. 3- or 4-part, N = 46), mean age (2-part, 64 vs. 3- or 4-part,61), follow-up (2-part, 42.5 months vs. 3- or 4-part, 34.5 months), injury type (2-part, 88% low energy vs. 3- or 4-part, 78% low energy), and method of reduction (2-part, 81% percutaneous vs. 3- or 4-part 72% percutaneous) were similar among the two groups. There was fracture union in all patients. All patients demonstrated satisfactory patient-reported outcome measures. However, 2-part fractures did have a significantly lower pain score, higher Single Assessment Numeric Evaluation score, and higher percentage of patients being satisfied or very satisfied when compared to 3- or 4-part fractures. The rate of subsequent procedures was 13% (n = 4) in 2-part fractures compared to 19% (n = 9) in 3- or 4-part fractures but was not statistically significant (P = .414). The overall rate of conversion to arthroplasty was 3.2% in 2-part fractures and 10.4% in 3- or 4-part fractures.

Conclusion

Multipart proximal humerus fractures remain difficult to treat. However, this study demonstrates an overall acceptable outcome with improvement in range of motion, patient-reported outcomes, and similar complication rates between 2-part and 3- or 4-part proximal humerus fractures treated with an intramedullary nail. However, the improvement in certain parameters is not as marked in 3- or 4-part fractures as 2-part fractures.

Risk factors for osteonecrosis of the humeral head after internal fixation of proximal humeral fractures: a systematic review and meta-analysis

BACKGROUND

Osteonecrosis of the humeral head (ONHH) is a severe complication after the internal fixation of proximal humeral fractures (IFPHF). The risk factors remain controversial though many studies have reported. In this research, meta-analysis was used to evaluate which surgeon-level factors can be modified to lower the risk and we hope to provide evidence-based support for preventing ONHH.

METHODS

Literature was retrieved from PubMed, Cochrane Library, Embase, Web of Science, and Scopus for eligible studies published up to January 2023. The pooled odds ratios (ORs) were calculated with their corresponding 95% confidence intervals (CIs) to evaluate. STATA 15.1 software was applied for data synthesis, sensitivity synthesis, and publication bias.

RESULTS

45 articles were published between 2000 and 2022, and 2482 patients were finally included. All articles were observational research, with 7 case-control studies and 38 cohort studies, and the Newcastle Ottawa Scale (NOS) score ranged from 7 to 9. The pooled results suggested that age (OR 0.32, 95% CI 0.14-0.74, P = 0.01), reduction quality (OR 0.08, 95% CI 0.01-0.44, P = 0.00), fracture type (OR 0.44, 95% CI 0.25-0.78, P = 0.01), surgical approach (OR: 4.06, 95% CI 1.21-13.61, P = 0.02) and fixation implant (OR = 0.68, 95% CI = 0.34-1.33, P = 0.02) were risk factors for ONHH after IFPHF. According to sensitivity analysis, Begg (P = 0.42) and Egger (P = 0.68) tests, the results were stable and exhibited no publication bias.

CONCLUSIONS

The study showed that age, reduction quality, fracture type, surgical approach and fixation implant were risk factors for ONHH after IFPHF, while gender, varus or valgus, timely operation, injured side, and the existence of medial support have little influence on ONHH, as they could not be considered risk factors and still need further investigations.

Risk Factors and Clinical Outcomes after Antegrade Intramedullary Nailing in Proximal Humeral Fractures: Insights and Implications for Patient Satisfaction

BACKGROUND

Proximal humeral fractures (PHFs) are common injuries that can lead to significant functional impairment. This retrospective cohort study aimed to evaluate the clinical outcomes and complications associated with the use of the Targon PH+ (Fa. Aesculap, Germany) intramedullary nail for the treatment of PHFs.

METHODS

A subgroup consisting of 70 patients with a mean follow-up of 4.91 years out of 479 patients who underwent treatment with the Targon PH+ intramedullary nail for PHFs at a single center between 2014 and 2021 were included. Patient-reported outcome measures (PROMs) and health-related quality of life (HRQoL) were assessed using validated German versions of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and EuroQol 5-Dimension 5-Level (EQ-5D-5L). Radiographic assessment was performed using pre- and postoperative imaging.

RESULTS

Among the 70 patients of the subgroup who completed follow-up, 21.4% experienced complications, including major complications in 15.7% of cases, all of which were revised (revision rate of 15.7%). Anatomical reduction was achieved in 48,5% of cases. The mean DASH, ASES, and OSS scores were 25.4 ± 22.0, 76.2 ± 21.1, and 38.8 ± 10.3, respectively. Significant correlations were observed among the PROMs, indicating their convergent validity. Additionally, a significant correlation of all used PROMs and patient well-being (HRQoL) was observed. Severe complications and revisions were associated with significantly lower ASES scores (-11.1%, p = 0.013). There was a tendency for PROM scores to slightly decline with increasing fracture complexity, although this trend did not reach statistical significance. Our findings indicate that patients over the age of 65 years tend to exhibit lower scores in PROMs and HRQoL measures.

CONCLUSION

The use of the Targon PH+ intramedullary nail for the treatment of PHFs resulted in satisfactory clinical outcomes and acceptable complication and revision rates. The PROMs and HRQoL measures indicated varying levels of disability and symptoms, with major complications, revision surgery, and age negatively impacting shoulder function after midterm follow-up.

Short-term clinical and radiographic outcomes in patients treated with a modern intramedullary nailing system for 2-part proximal humerus fractures

OBJECTIVES

The optimal surgical treatment of displaced proximal humerus fractures (PHFs) remains controversial. There are advocates for both open reduction and internal fixation with plate and screws (ORIF) and intramedullary nailing (IMN). The purpose this study was to evaluate the early-term clinical and radiographic outcomes of IMN for isolated, displaced 2-part surgical neck PHFs using a modern, straight nail system and to determine the effect of preoperative patient and fracture characteristics on outcome.

METHODS

This was a case series of 23 patients with displaced 2-part surgical neck PHFs who were treated with ORIF using a straight IMN with minimum follow-up of 1 year (mean 2.5 years [range, 1.1-4.6]). Patients were identified retrospectively and contacted for measurement of active range of motion (AROM) and patient reported outcome measures (PROMs) including the American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and Single Assessment Numeric Evaluation (SANE), EuroQol-5D (EQ-5D), and Visual Analog Scale Pain score (VAS Pain). Plain radiographs were evaluated to assess the quality of the reduction and failure of fixation. Complications and reoperations were identified.

RESULTS

Reduction was anatomic in 12 (52%) patients, acceptable in 9 (39%), and 2 (9%) were malreduced. There were no differences in reduction quality based on sex (p = 0.37), age at surgery (p = 0.68), calcar comminution (p = 0.68), number of screws in the head (p = 0.99), or medial hinge disruption (p = 0.06). At final follow-up, the mean ASES score was 92 ± 10, OSS was 45 ± 4, SANE was 93 ± 7, EQ-5D of 0.85 ± 0.17, and VAS Pain was 0 ± 1. The mean active forward flexion was 143° ± 16°, active external rotation was 68° ± 20°, and internal rotation was T11 ± 4 vertebrae. Two (9%) patients underwent reoperation and 2 (9%) patients experienced clinical failure not requiring reoperation.

CONCLUSIONS

Straight IMN is a reliable treatment for displaced 2-part surgical neck PHFs with excellent radiographic and clinical outcomes in early follow-up. The implant facilitated anatomic or acceptable alignment of the fracture in the vast majority of patients.

The Role of Intramedullary Nailing for Proximal Humerus Fractures: What Works and What Does Not

PURPOSE OF REVIEW

The evaluation of proximal humerus fractures (PHFs) should be aimed to answer the following four questions: (1) does the fracture need surgery in each particular patient? (2) if surgery is recommended, is it better to proceed with internal fixation or shoulder arthroplasty, (3) if internal fixation is recommended, what is the ideal fixation device strategy, and (4) how can outcomes be optimized? This review article tries to answer these questions and provides some clarity regarding what works and what does not in PHFs treated with intramedullary nailing.

RECENT FINDINGS

According to published articles on the treatment of PHFs with intramedullary nails, it is difficult to draw conclusions about outcomes and complications due to great variation in age, type of fracture, and nail designs included in the studies. However, the literature seems to support the use of modern nail designs for PHFs, especially in fractures of the surgical neck as well as varus posteromedial and valgus fractures with no tuberosity involvement. Although the results of IMN in PHF seem to be better in two-part fractures, in more complex fractures, the quality of the reduction achieved seems to influence functional outcomes. Tuberosity malreduction leads to poor clinical outcomes, high rate of complications, and an increased risk of avascular necrosis. Malreduction of the humeral head increases the risk of postoperative loss of reduction, especially for varus posteromedial impacted fractures. A medial nail entry point decreases the risk of postoperative varus malunion, preserves the rotator cuff tendon, and avoids iatrogenic fractures of the GT. To decrease the risk of postoperative stiffness, fracture fixation should be stable enough to allow early mobilization.

Predictors of outcomes of proximal humerus fractures in children and adolescents: A systematic review

PURPOSE

Minimally displaced pediatric proximal humerus fractures can be reliably managed non-operatively; however, there is considerable debate regarding the appropriate management of severely displaced proximal humerus fractures, particularly in older children and adolescents with limited remodeling potential. The purpose of this study was to perform a systematic review to answer the questions: "What are the functional and quality-of-life outcomes of pediatric proximal humerus fractures?" and "What factors have been associated with a poorer outcome?"

METHODS

A review of Medline and Embase was performed on 4 July 2021 using search terms relevant to proximal humerus fractures, surgery, non-operative management, pediatrics, and outcomes. Studies including ≥10 pediatric patients with proximal humerus fractures, which assessed clinical outcomes by use of an established outcome measure, were selected. The following clinical information was collected: participant characteristics, treatment, complications, and outcomes.

RESULTS

Twelve articles were selected, including four prospective cohort studies and eight retrospective cohort studies. Favorable outcome scores were found for patients with minimally displaced fractures, and for children aged less than 10 years, irrespective of treatment methodology or grade of fracture displacement. Older age at injury and higher grade of fracture displacement were reported as risk factors for a poorer patient-reported outcome score.

CONCLUSION

An excellent functional outcome can be expected following non-operative management for minimally displaced pediatric proximal humerus fractures. Prospective trials are required to establish a guideline for the management of severely displaced proximal humerus fractures in children and adolescents according to fracture displacement and the degree of skeletal maturity.

LEVEL OF EVIDENCE

level V.

Surgical treatment of proximal humeral fractures with the transosseous suture fixation

BACKGROUND

The surgical treatment of displaced proximal humeral fractures is commonly affected by implant-related complications. We evaluated the functional and radiographic results of transosseous suture fixation in a series of displaced proximal humeral fractures (PHF).

METHODS

Sixty-four patients were retrospectively classified by age, sex, and the Neer fracture classification. Two-part greater tuberosity (2pGT) displaced fractures and 3-part (varus and valgus) and 4-part valgus impacted fractures were managed with fragment reduction and transosseous suture fixation. Patients with minimum follow-up of 24 months and assessed with the Constant-Murley score (CMS) were included. Radiological and medical complications, as well as reinterventions were also recorded.

RESULTS

Forty-six patients with a mean follow-up of 58 (24-132) and a mean age of 58 years old were analyzed. Patients with 2pGT (n = 10) fractures had a CMS of 76 points (59-89); patients with 3-part fractures (n = 22) had a score of 67 points (13-91); and those with 4-part fractures (n = 14) had a score of 64 (24-76) points. The overall complication rate was 6 out of 46, and 4 patients required reintervention for different reasons. Patients presenting with 3-part varus fractures had significantly lower functional outcomes scores (p = 0.007). Humeral head osteonecrosis was present in 9 patients and significantly affected the functional outcomes (p < 0.05). However, only three out of nine patients with osteonecrosis required subsequent surgery at the indicated follow-up.

CONCLUSIONS

The fracture reduction and transosseous fixation technique represents a safe technique with low complication and reintervention rates. The presence of humeral head necrosis did not lead to subsequent surgical intervention because no hardware had protruded.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Humeral Head Replacement in the Treatment of Comminuted Proximal Humeral Fracture

Objective

To investigate the outcomes of humeral head replacement in the treatment of patients with comminuted proximal humeral fracture.

Methods

Between February 2013 and September 2016, 56 patients underwent humeral head replacement in our hospital. Of them, 18 cases were diagnosed as comminuted proximal humeral fracture before the operation. The mean age of the patients was 69.5 years old (ranging from 61 to 79 years old). Of them, there were six males and 12 females. All the patients in this group had fresh fractures. They were all treated by artificial humeral head replacements. After the prosthesis was fixed by bone cement reliably, the greater or lesser trochanter and prosthesis handle were sutured and fixed firmly. The interval time from injury to operation ranged from 1 to 5 days. The Constant Functional Score, operation time, blood loss, nerve injury, joint dislocation rate, and infection rate were recorded at the final follow‐up. The clinical data of these patients were retrospectively studied. All of the data were recorded in average form.

Results

In this study, the mean duration of follow‐up was 4 years, ranging from 3 to 6 years. The operation time ranged from 75 to 120 min, with the average of 82 min. The blood loss ranged from 100 to 400 mL, with the average of 210 mL. The mean score of Constant Functional Score was 83.5 ± 3.1. Of them, 14 cases achieved excellent and good (scores of more than 80), and four cases achieved moderate and poor (scores of less than 80). No patient suffered from joint dislocation, unstable joint, or infection after the operation. There were two patients with axillary nerve injury before the operation. However, the function could be recovered within 3–6 weeks after the surgery.

Conclusion

The artificial humeral head replacement could be applied for the treatment of patients with comminuted proximal humeral fracture. During the surgery process, the stable structure of shoulder joint could be completely restructured, and the rehabilitation plan should be adjusted reasonably and timely after the operation.

Anatomic evaluation of radiographic landmarks for accurate straight antegrade intramedullary nail placement in the humerus

Background

Neurovascular insult, nonunion, and iatrogenic rotator cuff injury are concerns when using an intramedullary nail (IMN) for proximal humerus fracture. The purpose of this study was to identify a reproducible starting point and intraoperative imaging for nail insertion optimizing nail depth, tuberosity screw position, and protecting the axillary nerve and rotator cuff insertion. Our hypothesis was that a more medialized starting point would protect soft tissue structures and improve locking screw positioning.

Methods

Ten fresh-frozen cadavers underwent antegrade IMN with Grashey and modified lateral “precipice” view imaging. A guidewire was positioned medial to the coracoacromial ligament (CAL) in 5 cadavers and lateral to the CAL in 5. Distances from the nail entry point to anatomic landmarks were measured. Anatomic and histologic evaluations were performed, characterizing the nail perforation zone. Radiographs were compared between groups.

Results

The medial CAL group had a greater distance of screw fixation to the axillary nerve, a shorter distance of greater tuberosity (GT) screw fixation at the rotator cuff insertion on the infraspinatus and teres minor tubercles, and greater screw spread with improved lesser tuberosity capture. Two laterally placed implants violated the rotator cuff tendon. Imaging demonstrated that the ideal starting pin position was medial to the articular margin at a distance equal to the width of the rotator cuff insertion footprint.

Conclusions

Medial placement optimized fixation of the GT, avoided violation of the rotator cuff tendon and footprint, and was associated with an increased distance of proximal locking screw to the axillary nerve.

Proximal humeral nail for treatment of 3- and 4-part proximal humerus fractures in the elderly population: effective and safe in experienced hands

BACKGROUND

Optimal treatment of 3- and 4-part proximal humerus fractures (PHFs) remains controversial. Although commonly recommended for less comminuted PHFs, the outcomes of treatment with proximal humerus nailing (PHN) are more equivocal. The purpose of this study was to report on radiographic and clinical outcomes of patients undergoing PHN fixation of 3- and 4-part PHFs at minimum one-year follow-up. Our hypothesis was that the findings would demonstrate satisfactory radiographic and clinical outcomes, with low rates of complications and revision surgeries.

METHODS

Between 2008 and 2016, 121 patients with comminuted, low-energy, osteoporotic, PHFs underwent fixation via Targon PHN (Aesculap, Tuttlingen, Germany). Of these, 60 patients met inclusion and exclusion criteria and were included in this analysis (mean age 72; range 65-85). All completed a minimum 1-year follow-up (range 12.5-82 months). Patients with 3-part PHFs were compared to patients with 4-part PHFs. Clinical, radiographic, and functional outcomes were assessed at postoperative visits. Patient reported outcomes included pain, the American Shoulder and Elbow Surgeons (ASES) score and the Simple Shoulder Test (SST). Radiographic union and revision and complication rates were assessed.

RESULTS

Overall, 37 (62%) fractures were classified as Neer 3 and 23 (38%) were classified as Neer 4. Both groups achieved similar postoperative range of motion. Patients with 3-part fractures reported significantly lower postoperative pain (0.76 ± 1.8 vs. 1.65 ± 2.2, p = 0.0047). Patients with 3-part fractures reported significantly better ASES scores (82.4 ± 19.2 vs. 70.8 ± 21.9, p = 0.02) and non-statistically significant higher SST scores (8.4 ± 3.2 vs. 7.43 ± 3.8, p = 0.14). Adequate fracture union was achieved in 53 fractures (88.3%). Three patients (5%) had varus malunion or greater tuberosity displacement, one (1.7%) had mechanical failure, and three (5%) had radiographic evidence of avascular necrosis. Between groups, there was no difference in failure rates.

CONCLUSION

Proximal humeral nails can successfully be used by experienced surgeons in fixation of comminuted and displaced proximal humeral fractures in selected patients with osteoporosis. While patients with both 3- and 4-part fractures demonstrate fracture union with satisfactory outcomes, patients with 3-part fractures demonstrate significantly higher postoperative functional scores.

The Current State of the Problem of Treatment of Patients with Proximal Humeral Fractures against the Background of Osteoporosis

This study focuses on problems of treatment of proximal humeral fractures occurring against the background of osteoporosis. It presents statistics on osteoporosis and lower energy trauma among patients in the Russian Federation and abroad. The high susceptibility to osteoporotic changes in the bone structure of the male population of Russia compared to the global statistics of osteoporosis among men was emphasized. The main classifications used in the clinical practice of orthopedists and traumatologists allow to identify the type of fracture by clinical and anatomical basis and to structure the existing patient management tactics to achieve the most optimal result of treatment and restoration of limb function. There is an analysis of publications representing various methods of fracture treatment, which helps to use the most optimal methods of relevant fractures treatment.

Complication rate after operative treatment of three- and four-part fractures of the proximal humerus: locking plate osteosynthesis versus proximal humeral nail

PURPOSE

There is still disagreement regarding the optimal surgical treatment of three- and four-part fractures of the proximal humerus. The aim of this monocentric, retrospective study was to compare the complication rate of internal fixation with a locking plate versus proximal humeral nailing after a one-year follow-up.

METHODS

From 2005 to 2016, 292 patients suffered a fracture of the proximal humerus and were treated surgically at our level-I trauma center. According to the inclusion criteria, 50 patients were included in this study: 19 of these (11 three-part fractures and 8 four-part fractures) were treated with a proximal humeral nail (HN) and 31 (12 three-part fractures and 19 four-part fractures) with a locking plate (LP) osteosynthesis. Classification was performed according to the Hertel classification. At a 1-year follow-up, the complication rate of the two treatment methods was compared.

RESULTS

Twenty patients (40%) suffered at least one complication. Of these, six patients (12%) were treated with a HN and 14 (28%) with a LP (p = 0.39). The most frequent complication was screw perforation (22%), followed by non-union (16%). Humeral head necrosis (10%) occurred only in the LP cohort. One wound infection occurred in a patient treated with a HN. Four-part fractures were treated more frequently with a LP. However, the difference was non-significant in this sample (p = 0.186).

CONCLUSIONS

The results of our study provide some evidence that in terms of complication rate, both treatment options are comparable for internal fixation of three- and four-part fractures of the proximal humerus. The type of fracture seems to be decisive for the choice of implant.

Intramedullary Fixation for Proximal Humeral Fractures

Proximal humeral fractures are a commonly encountered injury; however, no consensus has been reached for the ideal treatment. Current surgical fixation options include plate, plate with fibular strut allograft, intramedullary fixation, pinning, suture constructs, and external fixation. Each of these options possesses distinct advantages and disadvantages. With the evolution of implant design, a greater understanding of the mechanisms of failure of fixation, and the ability to preserve fracture biology, the management of proximal humeral fractures with intramedullary fixation has become an accepted treatment option. From a biomechanical perspective, intramedullary fixation may have advantages over laterally based fixation, in particular with fractures associated with significant calcar comminution. The ability to insert the implant from a superior starting point may help preserve vascular supply to the humeral head and tuberosities. With reported outcomes comparable with the aforementioned techniques and an evolving understanding of fracture characteristics and failures of fixation, intramedullary fixation represents an alternative treatment option for proximal humeral fractures with specific fixation and biologic advantages.

Intramedullary nailing of displaced four-part fractures of the proximal humerus

BACKGROUND

Intramedullary nailing is already established technique for the treatment of two and three-part fractures of proximal humerus. The aim of the study was to prospectively evaluate the efficacy and functional outcome after treatment of four-part fractures of proximal humerus with Multiloc proximal humeral nail.

DESIGN

prospective monocentric cohort study.

SETTING

single level 1 traumacenter.

MATERIALS AND METHODS

From February 2011 to March 2016, 40 patients with displaced four-part proximal humeral fractures were treated with intramedullary nail inserted through anterolateral approach. Minimum one year follow up completed 35 patients and were involved into the study.

RESULTS

After mean follow up period of 25.8 months 29 of 35 fractures healed. Average absolute Constant score in all 35 patients reached 57.7 points, relative side related Constants score 66.8% of contralateral extremity. Together there were 20 complications. in 6 cases (17%) developed complete avascular necrosis of the head. One deep infection was treated by implantation of antibiotic cement discs. Twelve secondary surgeries were performed, mostly for avascular necrosis development. Function and pain were significantly influenced by the quality of fracture reduction (p < 0.05) and development of complete AVN (p = 0.001). Group of 29 patients without AVN reached relative Constant score 73% of contralateral extremity.

CONCLUSIONS

Intramedullary nailing can be used as possible fixation technique for the treatment of four-part fractures of proximal humerus. In experienced hands provides nailing osteosynthesis similar results as reconstruction with locking plates. Appropriate reduction of fracture fragments is the key for good functional result.

LEVEL OF EVIDENCE

Level 2b - monocentric prospective cohort study.

Cement augmentation of the proximal humerus internal locking system in elderly patients: a multicenter randomized controlled trial

INTRODUCTION

Cement augmentation of the proximal humerus internal locking system (PHILOS) screws might reduce complication rates in osteoporotic bones. This study compared the risk of mechanical failure during the first year after PHILOS™ treatment of proximal humerus fractures (PHF) without (control group) and with (augmented group) screw augmentation. Secondary objectives were to report shoulder functions, quality of life (QoL), adverse events (AEs), and reoperation rates.

MATERIALS AND METHODS

This multicenter randomized trial enrolled patients aged ≥ 65 years with displaced/unstable PHF from eight European centers. Randomization was performed during surgery through sealed opaque envelopes. Mechanical failures were assessed by two independent reviewers via radiographs, shoulder function by Quick DASH, SPADI, and Constant Murley scores, and QoL by EQ-5D. Follow-ups were planned at postoperative 6 weeks, 3, 6, and 12 months.

RESULTS

The preliminary analysis of 6-week radiographs of the first 59 enrolled patients suggested a mechanical failure rate lower than expected and the difference between groups was too small to be detected by the planned sample size of 144. The trial was prematurely terminated after 67 patients had been enrolled: 34 (27 eligible) in the control group and 33 (29 eligible) in the augmented group. Follow-ups were performed as planned. Nine patients had mechanical failures and the failure rates (95% CI) were: augmented group, 16.1% (5.5; 33.7); control group, 14.8% (4.2; 33.7); the relative risk (95% CI) for the augmented group was 1.09 (0.32; 3.65) compared to the control group (p = 1.000). No statistically significant differences in shoulder function, QoL, and AEs were observed between study groups at 1 year. Nine patients (15.8%) underwent a revision.

CONCLUSIONS

Due to premature termination, the study was underpowered. A larger study will be necessary to determine if cement augmentation lowers the risk of mechanical failure rate.

Reverse shoulder arthroplasty for proximal humerus fractures: Is the glenoid implant problematic?

INTRODUCTION

Reverse shoulder arthroplasty (RSA) is a key tool in the orthopedic trauma surgeon's arsenal, especially when faced with a proximal humerus fracture in older patients. However, few studies have focused on the glenoid side of RSA in this indication as the implant is placed in a generally healthy scapula.

HYPOTHESIS

Glenoid implants for RSA after trauma are well positioned and do not often cause complications.

MATERIAL AND METHODS

Retrospective multicenter study of 513 patients who underwent RSA because of a proximal humerus fracture. The mean follow-up was 55 months. Radiographs were used to assess the height and tilt of the glenoid implant, along with the development of scapular notching or loosening. The clinical outcomes were determined based on the Constant score.

RESULTS

At the last follow-up, 44% of shoulders had scapular notching, 7% of which were severe (stages 3-4). This notching was progressive, with two resulting in loosening. The rate of severe notching was higher in patients with a high glenoid implant (62.5% vs. 42.3%, p=0.03) or glenosphere with superior tilt (58.3% vs. 37.8%, p=0.02). Nine patients had confirmed loosening and 63 had potential loosening. This was more common in cases with superior tilt (9.3% vs. 0.4%, p<0.001). Patients with a high glenoid implant had a lower Constant score (57 vs. 45, p<0.001). There fewer cases of severe notching when a lateralized glenoid implant was used (0% vs. 7%, p<0.05) and/or the humeral implant had a smaller neck-shaft angle (implants<155°: 3% vs. implants at 155°: 8.5%, p=0.03).

DISCUSSION AND CONCLUSION

Glenoid loosening and severe scapular notching are related to poor positioning and/or incorrect orientation of the glenosphere. Implant selection is important, as there is little to no notching when less-angled humeral implants and lateralized glenoid implants are used.

LEVEL OF EVIDENCE

IV.

Calcar screws and adequate reduction reduced the risk of fixation failure in proximal humeral fractures treated with a locking plate: 190 patients followed for a mean of 3 years

Background

Fixation of proximal humeral fractures (PHF) with locking plates has gained popularity over conservative treatment, but surgery may be complicated with infection, non-union, avascular necrosis (AVN) of the humeral head and fixation failure. Failure to achieve structural support of the medial column has been suggested to be an important risk factor for fixation failure. The aims of this study were to examine the effect of calcar screws and fracture reduction on the risk of fixation failure and to assess long-term shoulder pain and function.

Methods

This was a single-centre retrospective study of 190 adult PHF patients treated with a locking plate between 2011 and 2014. Reoperations due to fixation failure were the primary outcome. Risk factors for fixation failure were assessed using the Cox regression analysis. Postoperative shoulder pain and function were assessed by the Oxford Shoulder Score (OSS).

Results

Thirty-one of 190 (16%) patients underwent a reoperation: 14 (7%) due to fixation failure, 10 (5%) due to deep infection and 2 (1%) due to AVN. The absence of calcar screws and fixation with residual varus malalignment (head-shaft angle < 120°) both increased the risk of fixation failure with an adjusted hazard ratio (95% CI) of 8.6 (1.9–39.3; p = 0.005) and 4.9 (1.3–17.9; p = 0.02), respectively. The median (interquartile range) OSS was 40 (27–46).

Conclusion

The use of calcar screws, as well as the absence of postoperative varus malalignment, significantly reduced the risk of fixation failure. We, therefore, recommend the use of calcar screws and to avoid residual varus malalignment to improve the medial support of proximal humeral fractures treated with a locking plate.

Biomechanical testing to evaluate the cut-through resistance of intramedullary nails for the proximal humerus

Intramedullary nailing for stabilization of proximal humeral fractures is well-established. Complications as part of a cut-through, such as backing out of locking screws, loss of reduction, and perforation of the screws into the glenoid, are equally well-known. The test bench presented in this study enables testing of the cut-through behavior of multiple intramedullary implants on a simulated osteoporotic three-part fracture configuration with three different loading circumstances (A, B and C). In situation A, the glenohumeral dynamic force with progressive loadings entered at an angle of 15° to the humeral shaft. In situation B the force entered at an angle of 35° and in situation C the angle measured 55°. Three different types of nails were tested: the Targon PH with the optimal proximal screw length (T) and with all four proximal screws shortened (Tshort), the Synthes MultiLoc PHN with (S5) and without (S4) the additional calcar screw and, lastly, the PolyAxNail PH, a polyaxial intramedullary nail, in a neutral screw configuration (PAN) and a version with diametrically opposed crossed first and fourth locking screws (PAN10). Significant differences in the three cases were found with the evaluation of the failure load, which represents the cut-through resistance. Case A: Tshort (245.4 ± 18.7 N) - S4 (346.8 ± 18.0 N) (adjusted p = 0.002); Tshort (245.4 ± 18.7 N) - S5 (368.5 ± 12.0 N) (adjusted p = < 0.001); Tshort (245.4 ± 18.7 N) - T (323.5 ± 38.2 N) (p = 0.004); Case B: no significant differences between the study groups (adjusted significance). Case C: PAN (412.5 ± 16.0 N) - S5 (471.5 ± 21.5 N) (adjusted p = 0.007); T (414.0 ± 33.5 N) - S5 (471.5 ± 21.5 N) (adjusted p = 0.008). The optimal screw length has a strong influence on the failure load. Choosing proximal screws that are too short, produces a negative impact on the cut-through resistance. The additional calcar screw of the MultiLoc PHN and the polyaxiality of the PolyAxNail showed a positive effect with regard to the failure load reached.

Humeral head necrosis after proximal humeral nailing: what are the reasons for bad outcomes?

INTRODUCTION

Humeral head necrosis (HHN) remains a major problem in fracture care. Neither its occurrence, its extend, nor its impact on clinical outcomes is predictable on the long term. This study was designed to evaluate clinical and radiological outcomes in patients depending on the influence of HHN.

PATIENTS AND METHODS

32 patients with a 3-6 year follow up participated in this study. Their humeral fractures had been stabilized with a standard Targon PH nail (Aesculap, Tuttlingen, Germany) for an acute humeral head fracture. Constant score (CS), DASH score, UCLA shoulder rating scale, and Neer score were assessed. Range of motion (ROM) as well as pain during exercise was documented (VAS). HHN was detected radiologically and graded in stages 0-5.

RESULTS

All fractures had healed. HHN was found in 10 cases (31.3%). 4 patients (12.5%) showed interlocking screw perforation as part of the head collapse caused by HHN. Median CS was 73 (range: 24-85). There was no association detectable between number of fracture fragments and CS (p ≥ 0.631). The median DASH score was 16.4 (range: 0-74.1), UCLA score 30 (range: 9-35), Neer score 80 (range: 29-100). Three (37.5%) of the patients with a stage IV or V osteonecrosis reported about pain (twice VAS grade 4, once VAS grade 5). All patients suffering from pain were affected by high grade HHN and screw perforation. CS was nonsignificantly affected by HHN (75.5 vs. 63.5; p = 0.12), however massively diminished if additional implant protrusion was present (63.5 vs. 25; p = 0.02). Findings for normalised CS, relative CS, DASH score, UCLA shoulder rating scale, Neer score, and ROM were analogous.

DISCUSSION

Whereas HHN itself seems to contribute only mildly to functional outcome, we identified screw protrusion as major predictor for bad clinical results. The high rate of HHN found in our study (31.3%) may be attributed to the inclusion of mild HHN and our long follow-up period, as it is known that late-onset HHN may occur more than 3 years after trauma.

CONCLUSIONS

HHN may lead to screw perforation, resulting in poorest outcomes. We recommend regular clinical and radiographic follow-up for at least five years in order to detect impending screw perforation and plan screw removal in time.

Multifragmentary dislocated humeral head fracture-A case report of a successful head preserving treatment strategy despite delayed presentation

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Case report of multifragmentary and luxated humeral head fracture treated headpreserving despite delayed surgery (120 h).

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“Avoiding arthroplasty inspite of extrmely high risk of avascular necrosis due to compromised blood supply in luxation oft he humeral head.

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The headpreserving treatment showed excellent functional and radiologic results keeping a high “quality of life level”.

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Divergent from the recommended standard−treatment (trauma arthroplasty) of luxated humeral headsplit fractures in a “delayed situation” a head preserving option should be taken into consideration.

Introduction

Head preserving, delayed osteosynthesis five days after a luxated, multifragmentary humeral head fracture is rarely seen and a challenge for the surgeon.

Presentation of case

This case history describes the case of a 69-year-old female with delayed head preserving treatment of a dislocated multifragmentary humeral head fracture using intramedullary nailing, avoiding a primary trauma arthroplasty after strict refusal of the patient despite poor prognosis and high risk of avascular humeral head necrosis.

Discussion

The treatment of the humeral head fracture is still a matter of debate, the “golden standard” does not exist, especially in the deferred luxated situation. With the use of modern implants head preserving treatment is reasonable and possible. It should therefore always be taken into account as an alternative for arthroplasty.

Conclusion

Excellent postoperative outcome can be achieved by joint reconstruction eliminating the possible side effects of shoulder endoprosthesis.

Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial

BACKGROUND

Previous studies have shown good clinical results in patients with proximal humeral fractures (PHFs) treated with locking intramedullary nails or locking plates. Our study compared the clinical and radiographic outcomes in patients with 2- and 3-part surgical neck fractures.

METHODS

In this prospective, randomized controlled trial, 72 patients with 2- or 3-part surgical neck PHFs were randomly assigned to receive fixation with locking intramedullary nails (nail group) or locking plates (plate group). The primary outcome was the 12-month Constant-Murley score. The secondary outcomes included the Disabilities of the Arm, Shoulder and Hand score, the visual analog scale pain score, the shoulder passive range of motion, the neck-shaft angle, and complication rates.

RESULTS

There was no significant mean treatment group difference in the Constant-Murley score at 12 months (70.3 points for the nail group vs. 71.5 points for the plate group; P = .750) or at individual follow-up assessments. There were no differences in the 3-, 6- and 12-month Disabilities of the Arm, Shoulder and Hand scores, visual analog scale scores, and range of motion, except for the medial rotation at 6 months. The neck-shaft angle was equivalent between the groups at 12 months. There were significant differences over 12 months in total complication rates (P = .002) and reoperation rates (P = .041). There were no significant differences for the rotator cuff tear rate (P = .672).

CONCLUSION

Fixation of PHFs with locking plates or locking intramedullary nails produces similar clinical and radiologic results. Nevertheless, the complication and reoperation rates were higher in the nail group.

Outcomes of intramedullary nailing for acute proximal humerus fractures: a systematic review

Background

While proximal humerus fractures remain common within the elderly population, the optimal treatment method remains controversial. Intramedullary nailing has been advocated as an effective and less invasive surgical technique. The purpose of this study is to elucidate the demographics, outcomes, and complications of intramedullary nailing for acute, displaced proximal humerus fractures.

Materials and methods

Multiple computerized literature databases were used to perform a systematic review of English-language literature. Studies that met our stated criteria were further assessed for the requisite data, and when possible, similar outcome data were combined to generate frequency-weighted means.

Results

Fourteen studies with 448 patients met our inclusion criteria. The frequency-weighted mean age was 64.3 years, and mean follow-up was 22.6 months. Females accounted for 71 % of the included patients. Three-part fractures (51 %) were most commonly treated. The overall frequency-weighted mean Constant score was 72.8, and American Shoulder and Elbow Surgeons (ASES) score was 84.3. Frequency-weighted mean forward elevation, abduction, extension, and external rotation were 137.3°, 138.4°, 33.8°, and 43.1°, respectively. The Constant score for two- and three-part fractures was significantly higher than for four-part fractures (p = 0.007 and p = 0.0009, respectively). The reoperation rate for two-, three-, and four-part fractures was 13.6, 17.4, and 63.2 %, respectively.

Conclusions

Intramedullary nailing of acute, displaced two- and three-part proximal humerus fractures yields satisfactory clinical outcomes, although reoperation and complication rates remain high. Use of this implant for four-part fractures cannot be recommended until further clinical studies with larger patient numbers are available.

Level of evidence

Level IV, Systematic review.

Post-traumatic osteonecrosis of the proximal humerus

Post-traumatic osteonecrosis of the proximal humerus represents a challenging problem to the surgeon. It is commonly seen following multi-fragmentary fractures of the proximal humerus which may affect the long-term functional recovery after such injuries. This review summarises the current evidence on risk factors, reasons why estimating its epidemiology is difficult, the vascular supply of the humeral head, classification, and management options.