Tetracycline labeling as a measure of humeral head viability after 3- or 4-part proximal humerus fracture

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.

Shoulder Osteonecrosis: Pathogenesis, Causes, Clinical Evaluation, Imaging, and Classification

The humeral head is the second most common site for nontraumatic osteonecrosis after the femoral head, yet it has attracted relatively little attention. Osteonecrosis is associated with many conditions, such as traumatism, corticosteroid use, sickle cell disease, alcoholism, dysbarism (or caisson disease), and Gaucher's disease. The diagnosis is clinical and radiographic with MRI, with radiographs being the basis for staging. Many theories have been proposed to decipher the mechanism behind the development of osteonecrosis, but none have been proven. Because osteonecrosis may affect patients with a variety of risk factors, it is important that caregivers have a heightened index of suspicion. Early detection may affect prognosis because prognosis is dependent on the stage and location of the disease. In particular, the disease should be suspected in patients with a history of fractures, steroid usage, or sickle cell disease, and in divers. This report reviews osteonecrosis of the humeral head, with an emphasis on causes, clinical evaluation, imaging, and classification.

Open Reduction and Internal Fixation with a Locking Plate Via Deltopectoral Approach for the Treatment of Three and Four-Part and Proximal Humeral Fractures

Open reduction and internal fixation (ORIF) via the deltopectoral approach is the gold standard for operatively treated proximal humeral fractures when joint preservation is desired. Indications include an unacceptable deformity, need for stability and early mobilization, and osteoporotic bone. (1) A 12 to 14-cm incision is made in the deltopectoral groove. The fracture is reduced. (2) Pins and tension sutures are placed for provisional fixation. (3) The locking plate is placed with unicortical screws in the metaphysis of the proximal part of the humerus and bicortical screws in the shaft. (4) The rotator cuff tendon is sutured into the open suture holes of the plate. (5) The surgical wound is then closed in a layered fashion. Hertel et al. reported that calcar length <8 mm, disruption of the medial hinge, and complex fracture patterns are more predictive of future osteonecrosis. In a series of 34 patients managed with ORIF, Neviaser et al. showed that the length of the posteromedial hinge was not predictive of osteonecrosis. Additionally, with use of tetracycline labeling, Crosby et al. demonstrated that perfusion to the humeral head is maintained in more complex 3 and 4-part fractures following anatomic reduction. Although they are useful for surgical planning, the criteria proposed by Hertel et al. cannot accurately predict osteonecrosis. The most important predictor of ischemia is the length of the dorsomedial metaphyseal extension and the integrity of the medial hinge. Including medial support in the fixation greatly decreases the incidence of screw cutout and migration into the articular surface and increases functional outcomes. Proper and complete reduction is of the utmost importance because varus malreduction contributes to the loss of fixation and to technical complications, such as improper plate positioning, improper screw length, and screw cutout, that influence outcomes.

Management and Prognostic Factors for Delayed Reconstruction of Neglected Posterior Shoulder Fracture-Dislocation

Introduction:

Posterior fracture-dislocations of the shoulder are rare conditions. Misdiagnosis can occur in 50% - 80% of the patients. Due to the size of the lesion, stability of the joint could not be achieved with transfer of subscapular tendon or tuberosity.

Case Presentation:

A 54-year-old male patient was referred to our hospital with a neglected posterior shoulder fracture-dislocation. Functional results of the patient, and technical informations were explained in this case report. The reverse Hill-Sachs lesion involved 40% of the articular surface. Depressed and malunited fragment was elevated, and fixated to the humeral head.

Conclusions:

Glenohumeral joint reduction with reconstruction of the humeral head seems to be possible even in a neglected locked posterior shoulder fracture-dislocation. If the depressed osteochondral fragment is still spheric, signs of the avascular necrosis are absent on CT, and malunion of the fragment has occurred, it is quite possible to reconstruct the head. Although results of the case are good, it is worthwhile to follow these patients for long-term complications.

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.

Biomechanical considerations for surgical stabilization of osteoporotic fractures

The incidence of osteoporotic fractures has been steadily rising along with the aging of the population. Surgical management of these fractures can be a challenge to orthopedic surgeons. Diminished bone mass and frequent comminution make fixation difficult. Advancements in implant design and fixation techniques have served to address these challenges and when properly applied, can improve overall outcome. The purpose of this review is to describe fixation challenges of common osteoporotic fractures and provide options for successful treatment.

Open reduction internal fixation of proximal humerus fractures

The treatment of proximal humerus fractures continues to evolve. While the many of these injuries can be managed nonoperatively, a certain percentage require operative treatment. Open reduction internal fixation can offer excellent outcomes when performed in the appropriate patient and utilizing proper techniques. This article reviews the most up-to-date literature regarding all phases of proximal humerus fracture osteosynthesis, including diagnosis, imaging, anatomic considerations, surgical indications, fixation, and surgical outcomes.

Rate of avascular necrosis following proximal humerus fractures treated with a lateral locking plate and endosteal implant

INTRODUCTION

Treatment of displaced proximal humerus fractures remains challenging. The introduction of locking plates has renewed interest in treating these fractures with joint-preserving techniques rather than hemiarthroplasty, but high complication rates are still reported. Avascular necrosis is not solely dependent on the initial fracture pattern, but can also result from intraoperative and postoperative vascular insults.

METHOD

We describe a technique to minimize disruption of humeral head blood supply and maximize fracture fixation. A total of 34 patients with complex proximal humerus fractures were treated with a locking plate and endosteal implant through an anterolateral approach and followed for an average of 66 weeks to determine the rates of avascular necrosis.

RESULTS

No patient suffered complete osteonecrosis (0%) and only one patient suffered partial necrosis (2.8%) of the humeral head. The length of the posteromedial hinge was not predictive of this complication.

CONCLUSION

Use of the anterolateral approach and endosteal augment of a lateral locking plate can minimize avascular necrosis following proximal humerus fracture.