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Boadi PJ, Da Silva A, Mizels J, Joyce CD, Anakwenze OA, Klifto CS, Chalmers PN. Intramedullary versus locking plate fixation for proximal humerus fractures: indications and technical considerations. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:615-624. [PMID: 39157214 PMCID: PMC11329022 DOI: 10.1016/j.xrrt.2024.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
Background The incidence of proximal humerus fractures (PHFs) continues to increase with an aging population, and intramedullary nailing (IMN) and locking plate fixation are two commonly employed techniques for the surgical management of PHF. However, the optimal fixation method can be a source of ongoing controversy. Some influencing factors include the extent of humeral head involvement, fracture complexity, patient age, and surgeon preference. There are many studies that provide a mix of data either when comparing the two techniques or analyzing them in isolation. The aim of this review is to further elucidate the indications and technical considerations involved specifically in IMN vs. locking plate fixation for PHF to further aid orthopedic surgeons when choosing surgical management. Methods A narrative approach was chosen for this review allowing for a comprehensive review of literature, including recent findings pertaining to the comparison of management options for PHF. A comprehensive literature search was conducted using the PubMed, Embase, and Cochrane Library databases. The inclusion criteria involved studies that discussed "proximal humerus fracture" and either "intramedullary nail" or "locking plate fixation." Results Complications such as avascular necrosis, hardware failure, additional surgical interventions, infection, fracture redisplacement, rotator cuff rupture, and nonunion did not show significant differences between the two groups. Newer generation humeral nails have minimized early complications. As both techniques undergo further refinement and utilization when specifically indicated, functional outcomes, potential complications, and postoperative pain continue to be improved. Conclusion The available evidence suggests that both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method. The choice of technique should be tailored to patient factors such as fracture type, age, bone quality, and functional expectations. Surgeon experience also plays a role. While certain presentations may exhibit trends that favor one fixation, no specific technique can be universally recommended. Both IMN and LP have shown comparable and satisfactory outcomes, and the final fixation method chosen should take into account the unique characteristics of each patient.
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Affiliation(s)
| | - Adrik Da Silva
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Josh Mizels
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Oke A. Anakwenze
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Christopher S. Klifto
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Peter N. Chalmers
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
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Kamikovski I, Wengle L, Sheth U, Nam D. Open reduction and internal fixation of the proximal humerus with femoral head allograft augmentation "the French fry technique". JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:438-448. [PMID: 39157223 PMCID: PMC11329033 DOI: 10.1016/j.xrrt.2023.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
Fractures of the proximal humerus account for 4%-8% of injuries to the appendicular skeleton. Most are stable, minimally displaced osteoporotic fractures in the elderly, and are the result of low-energy falls. A large majority of these patients regain adequate shoulder function without operative intervention. Surgery is considered in approximately 20% of patients because they require improved shoulder function for their activities of daily living or because of the significant deformity of their fracture and the need to restore functional alignment, length, and rotation in active, higher demand individuals. However, fixation of these fractures can pose a challenge due to poor bone quality and displacing forces of the rotator cuff. This is especially true in 3-part and 4-part fractures. These factors lead to the high failure rates seen with early attempts at osteosynthesis. In the last 2 decades, locking plate technology has been an innovation in treating these complex fractures. Despite the improvements in torsional strength and rigidity, outcome studies on locking plate technology demonstrate equivocal results with complication rates as high as 20%-30% and a revision rate of 10%. Specifically, these complications include avascular necrosis, varus collapse, intra-articular screw penetration, and postoperative stiffness. Varus collapse occurs when the weak osteoporotic bone fails around the implant. In turn, fibular strut endosteal augmentation was introduced to provide additional support and decrease implant failure rates in displaced fractures with varus coronal malalignment and significant metaphyseal bone loss. Although clinically successful and biomechanically superior to plate-only constructs, a few concerns remain. In turn, we introduce a novel technique of creating individual cancellous femoral head allograft struts or "French fries" that provides structural support for the humeral head but does not have the potential problems of a cortical fibular strut.
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Affiliation(s)
- Ivan Kamikovski
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Orthopedics, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Lawrence Wengle
- Division of Orthopedics, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ujash Sheth
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Orthopedics, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Diane Nam
- Division of Orthopedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Orthopedics, Department of Surgery, University of Toronto, Toronto, ON, Canada
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Le TGA, Bui KHT, Do HP, Phan NT, Hoang CM, Pham TT, Dinh MN, Nguyen TV, Diep QM, Le KM, Nguyen TV, Nguyen PD. Factors influencing surgical outcomes of fixation with locking plate for three- and four-part proximal humerus fractures in patients aged 50 Years and older. J Hand Microsurg 2024:100127. [DOI: 10.1016/j.jham.2024.100127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024] Open
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Delbast L, Koneazny C, Baroan C, Niéto H. Results of transosseous suture fixation in four-part valgus impacted fractures of the proximal humerus. Injury 2024; 55 Suppl 1:111345. [PMID: 39069340 DOI: 10.1016/j.injury.2024.111345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/13/2023] [Accepted: 01/14/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND The osteonecrosis ratio in valgus impacted fractures of the proximal humerus is low (<10 %), giving osteosynthesis all its meaning. However, the optimal fixation technique remains controversial. After recentering the humeral head, osteosuture is stable enough to allow bone healing in an adequate position as well as a good long-term shoulder functionality. METHODS Our cohort included 22 patients with a mean age of 65 (28-83). Patients were placed in a beach-chair position. Surgical exposure was done through an anterolateral, transdeltoid approach. Stay sutures were placed on both tuberosities. Elevation of the humeral head was obtained for 9 patients using iliac crest bone graft, for 7 patients using bone substitutes, for 6 without any graft needed. Both tuberosities were approximated and tied together using two horizontal non-absorbable double-threaded sutures. The whole head was also tied to the humeral metaphysis by cerclage wiring using the same suture. Patients were immobilized in a sling for 4 weeks with no passive or active mobilization; then began rehabilitation starting with passive and active-assisted mobilization. Functional outcome was assessed with the Constant score. Radiographic follow-up was used for fracture healing and osteonecrosis signs. RESULTS All fractures united within the first 3 months. One patient had radiographic signs of osteonecrosis and one had a secondary displaced fracture without osteonecrosis. At an average follow-up of 35 months, the median Constant score was 83.7 % (63-100) in comparison to the uninjured side. DISCUSSION A preserved posteromedial periosteal hinge in a valgus impacted fracture of the proximal humerus is key to the success of osteosuture. This hinge provides mechanical stability to the humeral head once elevated, as well as blood-supply from the branches of the posterior circumflex humeral artery. Computed Tomography with Three-Dimensional reconstructed images allow for a precise analysis of this hinge as well as the vascularity of the humeral head. Osteosuture being a minimally invasive surgical procedure plays a predominant role in sparing the remaining vascularization of the humeral head. CONCLUSION Osteosuture in four-part valgus impacted fractures of the proximal humerus is a minimally invasive procedure as well as a reliable technique yielding good long-term results.
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Affiliation(s)
- Laurent Delbast
- Department A of Orthopaedic Surgery and Traumatology, Niort Hospital, 40 avenue Charles de Gaulle BP 70600, 79021 Niort Cedex, France.
| | - Christopher Koneazny
- Department A of Orthopaedic Surgery and Traumatology, Niort Hospital, 40 avenue Charles de Gaulle BP 70600, 79021 Niort Cedex, France
| | - Célestin Baroan
- Department A of Orthopaedic Surgery and Traumatology, Niort Hospital, 40 avenue Charles de Gaulle BP 70600, 79021 Niort Cedex, France
| | - Hervé Niéto
- Department A of Orthopaedic Surgery and Traumatology, Niort Hospital, 40 avenue Charles de Gaulle BP 70600, 79021 Niort Cedex, France
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Fares MY, Boufadel P, Koa J, Vadhera AS, Singh J, Abboud JA. Top fifty cited articles on humeral fractures. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:153-160. [PMID: 38706674 PMCID: PMC11065750 DOI: 10.1016/j.xrrt.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Background Humeral fractures (HF) are common orthopedic pathologies. Reviewing the content and quality of influential literature over time is important to advance scientific research regarding a specific topic. This study aims to explore and appraise the fifty most cited HF studies that had been published in orthopedic literature. Methods The Web of Science database was used to conduct a systematic search for articles pertaining to HF. Articles were sorted out in descending order of citations and were included based on their relevance to HF. Data and metrics of the included studies were recorded. The methodological quality of the studies was assessed using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies criteria. Statistical analysis was conducted to explore any significant relationships between the date of publication and other relevant variables. Results Included articles (N = 50) were published between 1959 and 2015, with a total of 14,864 accumulated citations. Europe and North America contributed to all but one of the included studies. The Journal of Bone and Joint Surgery contributed to the highest number of included articles with 27 articles (54%). The proximal humerus was the most commonly explored HF location in our study (72%). The average MCMS and Methodological Index for Non-randomized Studies scores were reported to be 64.6 and 10.4, respectively, and the majority of articles (52%) were considered level four case series. Year of publication was found to have a positive correlation with increasing level of evidence(r = -0.301, P = .044), citation density (r = 0.734, P < .001), and MCMS score (r = 0.41, P = .01). Conclusion The level of evidence, MCMS scores, and citation density of influential HF literature has been increasing with time, reflecting the increasing effort and work being put in that field. While the findings seem encouraging, additional high-quality research is needed to help achieve better treatment strategies and outcomes.
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Affiliation(s)
- Mohamad Y. Fares
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Peter Boufadel
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Jonathan Koa
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Amar S. Vadhera
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Jaspal Singh
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Joseph A. Abboud
- Division of Shoulder and Elbow Surgery, Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Burkus M, Bruch A, Bergmann EM, Karahodzic-Franjic M, Zdichavsky M. Valgising angular stable plate fixation in the treatment of multifragmentary proximal humeral fractures in elderly patients. Arch Orthop Trauma Surg 2024; 144:1637-1645. [PMID: 38351348 DOI: 10.1007/s00402-024-05218-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/05/2024] [Indexed: 03/27/2024]
Abstract
INTRODUCTION The frequency of proximal humeral fractures shows an increasing tendency, especially in the elderly, who are frequently affected by osteoporosis. The adequate treatment of complex, displaced fractures poses a serious challenge. Among surgical treatment options, osteosynthesis with an angular stable plate is preferred, however, the implant-related complication rate may be exceptionally high. In our present study, we report the short-term outcomes of our new method of valgising angular stable plate fixation which we use for multifragmentary, displaced proximal humeral fractures in elderly patients. MATERIALS AND METHODS We retrospectively evaluated the clinical and radiological outcomes of 52 patients (46 female and 6 male, age: 71.9 ± 9.6) who suffered dislocated three- or four-part fractures and underwent valgising angular stable plate fixation. RESULTS Mean follow-up time was 17.3 months, while the functional outcomes were as following: excellent in 26, good in 18, moderate in 5 and poor in 3 patients. The mean Constant-Murley Score was 82.5 ± 11.2. Functional outcomes only showed significant correlation (p = 0.031) with age and were proven unrelated to fracture type, BMI and known primary diseases. The cumulative complication rate was 9.6% and revision rate was 5.8%. Neurological deficit, pseudoarthrosis or avascular humeral head necrosis did not occur during the follow-up period. CONCLUSIONS Valgising angular stable plate fixation that we apply for proximal humeral fractures provided favourable functional outcomes and a low postoperative complication rate due to the optimal head and plate placement. The method is especially effective for the treatment of displaced three- and four-part fractures with weakened, osteoporotic bone structure.
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Affiliation(s)
- Máté Burkus
- General, Visceral, Thoracic and Trauma Surgery, Surgical Orthopaedics, Die Filderklinik gGmbH, Im Haberschlai 7, 70794, Filderstadt-Bonlanden, Germany.
| | - A Bruch
- General, Visceral, Thoracic and Trauma Surgery, Surgical Orthopaedics, Die Filderklinik gGmbH, Im Haberschlai 7, 70794, Filderstadt-Bonlanden, Germany
| | - E M Bergmann
- General, Visceral, Thoracic and Trauma Surgery, Surgical Orthopaedics, Die Filderklinik gGmbH, Im Haberschlai 7, 70794, Filderstadt-Bonlanden, Germany
| | - M Karahodzic-Franjic
- General, Visceral, Thoracic and Trauma Surgery, Surgical Orthopaedics, Die Filderklinik gGmbH, Im Haberschlai 7, 70794, Filderstadt-Bonlanden, Germany
| | - M Zdichavsky
- General, Visceral, Thoracic and Trauma Surgery, Surgical Orthopaedics, Die Filderklinik gGmbH, Im Haberschlai 7, 70794, Filderstadt-Bonlanden, Germany
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Zdero R, Brzozowski P, Schemitsch EH. Biomechanical design optimization of proximal humerus locked plates: A review. Injury 2024; 55:111247. [PMID: 38056059 DOI: 10.1016/j.injury.2023.111247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/15/2023] [Accepted: 11/24/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Proximal humerus locked plates (PHLPs) are widely used for fracture surgery. Yet, non-union, malunion, infection, avascular necrosis, screw cut-out (i.e., perforation), fixation failure, and re-operation occur. Most biomechanical investigators compare a specific PHLP configuration to other implants like non-locked plates, nails, wires, and arthroplasties. However, it is unknown whether the PHLP configuration is biomechanically optimal according to some well-known biomechanical criteria. Therefore, this is the first review of the systematic optimization of plate and/or screw design variables for improved PHLP biomechanical performance. METHODS The PubMed website was searched for papers using the terms "proximal humerus" or "shoulder" plus "biomechanics/biomechanical" plus "locked/locking plates". PHLP papers were included if they were (a) optimization studies that systematically varied plate and screw variables to determine their influence on PHLP's biomechanical performance; (b) focused on plate and screw variables rather than augmentation techniques (i.e., extra implants, bone struts, or cement); (c) published after the year 2000 signaling the commercial availability of locked plate technology; and (d) written in English. RESULTS The 41 eligible papers involved experimental testing and/or finite element modeling. Plate variables investigated by these papers were geometry, material, and/or position, while screw variables studied were number, distribution, angle, size, and/or threads. Numerical outcomes given by these papers included stiffness, strength, fracture motion, bone and implant stress, and/or the number of loading cycles to failure. But, no paper fully optimized any plate or screw variable for a PHLP by simultaneously applying four well-established biomechanical criteria: (a) allow controlled fracture motion for early callus generation; (b) reduce bone and implant stress below the material's ultimate stress to prevent failure; (c) maintain sufficient bone-plate interface stress to reduce bone resorption (i.e., stress shielding); and (d) increase the number of loading cycles before failure for a clinically beneficial lifespan (i.e., fatigue life). Finally, this review made suggestions for future work, identified clinical implications, and assessed the quality of the papers reviewed. CONCLUSIONS Applying biomechanical optimization criteria can assist biomedical engineers in designing or evaluating PHLPs, so orthopaedic surgeons can have superior PHLP constructs for clinical use.
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Affiliation(s)
- Radovan Zdero
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
| | - Pawel Brzozowski
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada.
| | - Emil H Schemitsch
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada; Division of Orthopaedic Surgery, Western University, London, ON, Canada
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Ardebol J, Zuk NA, Kiliç AĪ, Pak T, Menendez ME, Denard PJ. Arthroscopic Lysis of Adhesions for Stiffness After Surgical Management of Proximal Humerus Fractures Leads to Satisfactory Outcomes in Most Patients. Arthrosc Sports Med Rehabil 2023; 5:100821. [PMID: 38023446 PMCID: PMC10661499 DOI: 10.1016/j.asmr.2023.100821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose To report patient-reported outcomes (PROs), range of motion (ROM), and satisfaction, in patients who underwent arthroscopic lysis of adhesions for stiffness after open reduction with internal fixation (ORIF) or reverse shoulder arthroplasty (RSA) for fracture. Methods A retrospective review was performed to identify patients with stiffness who underwent arthroscopic lysis of adhesions following ORIF or RSA for proximal humerus fracture at a single institution between 2012 and 2021 with minimum 1-year follow-up. PROs including visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES), and Subjective Shoulder Value (SSV), as well as active ROM including forward flexion (FF), external rotation (ER), internal rotation (IR), were collected pre- and postoperatively. Attempted nonoperative treatment before arthroscopic lysis of adhesions was documented. Complications and satisfaction were also recorded. Results A total of 21 patients met the study criteria (4 RSA, 17 ORIF), with an average age of 66.7 ± 8 years. The study sample comprised mostly of female patients (90%). The mean time from the index surgery to arthroscopy was 9 months, and mean follow-up post-lysis was 17 months. Patients with ORIF reported significant pain relief (VAS, Δ -3.2) and improvement in range of motion (FF, Δ 36°; ER, Δ 20°; IR Δ 3 spinal levels) and PROs (ASES, Δ 34.7; SSV Δ 44.8) (P < .01) after lysis. Patients with RSA had significant improvement in ASES (Δ 21.8; P = .04), SSV (Δ 8.8; P = .04), and FF (Δ 38; P = .02) but did not have significant improvement in VAS (Δ -2; P = .2), ER (Δ 0°; P = 1.0), and IR (Δ 1 spinal level; P = .2). Satisfaction was 100% in the RSA cohort and 82% in the ORIF cohort. No complications were observed. Conclusions Arthroscopic lysis of adhesions for stiffness after surgical management of proximal humerus fracture leads to satisfactory outcomes in most patients. Post-ORIF, patients may achieve improvement in PROs and global ROM, whereas post-RSA, patients may achieve improvement in PROs and FF but do not necessarily improve in rotational ROM. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
| | | | - Ali Īhsan Kiliç
- Oregon Shoulder Institute, Medford, Oregon, U.S.A
- Izmir Bakircay University, Izmir, Turkey
| | - Theresa Pak
- Oregon Shoulder Institute, Medford, Oregon, U.S.A
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Kimmeyer M, Schmalzl J, Rentschler V, Schieffer C, Macken A, Gerhardt C, Lehmann LJ. Correct positioning of the calcar screw leads to superior results in proximal humerus fractures treated with carbon-fibre-reinforced polyetheretherketone plate osteosynthesis with polyaxial locking screws. J Orthop Traumatol 2023; 24:54. [PMID: 37816859 PMCID: PMC10564686 DOI: 10.1186/s10195-023-00733-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/29/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Plate osteosynthesis with implants made of carbon-fibre-reinforced polyetheretherketone (CFR-PEEK) has recently been introduced for the treatment of fractures of the proximal humerus (PHFs). The advantages of the CFR-PEEK plate are considered to be its radiolucency, its favourable modulus of elasticity, and the polyaxial placement of the screws with high variability of the angle. The primary aim of this study is to investigate the influence of calcar screw positioning on the complication and revision rates after CFR-PEEK plating of PHFs. The secondary aim is to assess its influence on functional outcome. MATERIAL AND METHODS Patients were identified retrospectively. Minimum follow-up was 12 months. The cohort was divided into two groups depending on the distance of the calcar screw to the calcar (group I: < 12 mm, group II: ≥ 12 mm). The range of motion (ROM), Subjective Shoulder Value Score (SSV) and Constant-Murley Score (CS) were analysed at follow-up examination. Subjective complaints, complications (e.g. humeral head necrosis, varus dislocation) and the revision rate were evaluated. RESULTS 51 patients (33 female, 18 male) with an average age of 68.6 years were included after a period of 26.6 months (group I: 32 patients, group II: 19 patients). Apart from the gender distribution, no significant differences were seen in the patient characteristics. The outcome scores showed significantly better clinical results in group I: SSV 83.4 vs 71.2, p = 0.007; CS 79.1 vs 67.8, p = 0.013. Complications were seen less frequently in group I (18.8 % vs 47.4 %, p = 0.030). CONCLUSION This study shows that the positioning of the calcar screw is relevant for CFR-PEEK plate osteosynthesis in PHFs with a good reduction of the fracture. Optimal positioning of the calcar screw close to the calcar (< 12 mm) is associated with a lower rate of complications, resulting in significantly superior functional outcomes. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Michael Kimmeyer
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany.
- Alps Surgery Institute, Clinque Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France.
| | - Jonas Schmalzl
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, Oberduerrbacher Str. 6, 97080, Wuerzburg, Germany
| | - Verena Rentschler
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Christian Schieffer
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Arno Macken
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Alps Surgery Institute, Clinque Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
| | - Christian Gerhardt
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
| | - Lars-Johannes Lehmann
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeusserstr. 18, 76135, Karlsruhe, Germany
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Seok HG, Park SG. Dual-Plate Fixation for Proximal Humerus Fractures With Unstable Medial Column in Patients With Osteoporosis. J Orthop Trauma 2023; 37:e387-e393. [PMID: 37296091 DOI: 10.1097/bot.0000000000002645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To compare radiological and clinical outcomes between lateral locking plate (LLP) and dual-plate fixation (LLP and additional medial buttress plate) for proximal humerus fractures with medial column comminution and varus deformity in patients with osteoporosis. DESIGN Retrospective. SETTING Academic medical center. PATIENTS/PARTICIPANTS Overall, 52 patients were enrolled. Of these, 26 patients underwent dual-plate fixation. The control group (LLP) was matched to the dual-plate group for age, sex, injured side, and fracture type. INTERVENTION Patients in the dual-plate group were treated with LLP and medial buttress plate, whereas patients in the LLP group were treated with only an LLP. MAIN OUTCOME MEASUREMENTS Demographic factors, operative time, and level of hemoglobin of the 2 groups obtained from medical records. Changes in the neck-shaft angle and the development of postoperative complications were recorded. Clinical outcomes were measured based on the visual analog scale; American Shoulder and Elbow Surgeons; Disabilities of the Arm, Shoulder, and Hand; and Constant-Murley scores. RESULTS The operation time and hemoglobin loss did not differ significantly between the groups. Radiographic evaluation showed a significantly lower change in neck-shaft angle in the dual-=plate group than in the LLP group. The dual-plate group also showed better Disabilities of the Arm, Shoulder, and Hand; American Shoulder and Elbow Surgeons; and Constant-Murley scores than the LLP group. CONCLUSION Fixation using additional medial buttress plate with LLP may be considered for treating proximal humerus fractures in patients with an unstable medial column, varus deformity, and osteoporosis. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hyun-Gyu Seok
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Daegu, Republic of Korea
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Foruria AM. Plate Fixation of Proximal Humerus Fractures: How to Get It Right and Future Directions for Improvement. Curr Rev Musculoskelet Med 2023; 16:457-469. [PMID: 37572239 PMCID: PMC10497484 DOI: 10.1007/s12178-023-09853-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE OF REVIEW Open reduction and internal fixation with locking plates (ORIF-LP) has been used for decades for the surgical management of proximal humerus fractures. Despite good outcomes have been widely published in the literature, unacceptably high rates of complications (up to 40%), many of them yielding poor outcomes and requiring reoperation (up to 25%), have also been reported, especially in elderly patients. Most common complications are related to implant failure, with intra-articular screw penetration as the most frequent and devastating. RECENT FINDINGS Advances in patient selection and surgical technique, and implementation of bone or cement augmentation, have been developed to hopefully decrease complication rates. Mayo-FJD Classification offers prognostic information that can aid in the decision-making process for proximal humeral fractures. Displaced valgus impacted fractures seem to be associated with well over a 10% rate of avascular necrosis after ORIF-LP. A principle-based and stepwise surgical technique combining anatomic reduction and a short screw configuration can provide good outcome in most patients, even the elderly, decreasing implant failures to less than 10%. Acrylic cement augmentation has the potential to further decrease implant failure rate to 1%. Reoperation rates are higher partly due to the need to remove hardware for painful subacromial conflict. However, no studies to date definitively demonstrated the superiority of ORIF-LP compared to non-operative treatment, intramedullary nailing, or reverse shoulder arthroplasty. ORIF-LP can provide good results for the surgical management of displaced proximal humerus fractures even in elderly patients provided adequate patient selection and a principle based and stepwise surgical technique, supplemented with bone graft or acrylic cement when needed. Poor outcomes and high complication and reoperation rates should be expected when these recommendations are not followed.
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Affiliation(s)
- Antonio M Foruria
- Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery, Autónoma University, Fundación Jiménez Díaz University Hospital, Avenida Reyes Católicos 2, Madrid, Spain.
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Furuhata R, Tanji A, Oki S, Kamata Y. Influence of Proximal Humeral Cortical Bone Thickness on the Radiographic Outcome After Osteosynthesis of Proximal Humeral Fractures: Propensity Matching Score Analysis. Geriatr Orthop Surg Rehabil 2023; 14:21514593231198645. [PMID: 37645438 PMCID: PMC10460996 DOI: 10.1177/21514593231198645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023] Open
Abstract
Introduction Osteoporosis can affect the surgical outcomes of proximal humeral fractures in older people. Recently, the cortical bone thickness of the proximal humerus on plain radiograph has been proposed to reflect local osteoporosis of the proximal humerus; however, its effect on the surgical outcome of proximal humeral fractures remains unclear. The purpose of this study is to investigate the influence of cortical bone thickness on postoperative radiographic outcomes after osteosynthesis for proximal humeral fractures. Materials and Methods We retrospectively identified 190 patients (≥50 years) who underwent osteosynthesis with an intramedullary nail or plate for proximal humeral fractures. The patients were categorized into 2 groups according to the cut-off value of an average proximal humerus cortical bone thickness of 6 mm on plain radiographs: patients with and without local osteoporosis. After propensity score matching, we compared the incidence of postoperative radiographic complications between the 2 groups. We also performed subgroup analyses of outcomes in a subgroup of patients who underwent intramedullary nailing and those who underwent plate fixation. Results Propensity score matching yielded 60 patients in each group. No significant difference in complication rates was observed between the 2 groups. However, in the intramedullary nailing subgroup, the incidence of reduction loss was significantly higher in patients with local osteoporosis than in those without local osteoporosis (51.7% vs 14.3%, P = .002). Discussion The proximal humeral cortical bone thickness had no significant effect on the overall radiographic outcome; however, reduction loss after intramedullary nailing was susceptible to local osteoporosis of the proximal humerus. Conclusion Our study suggests that plate fixation is advantageous in preventing postoperative reduction loss in patients with lower cortical bone thickness.
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Affiliation(s)
- Ryogo Furuhata
- Department of Orthopaedic Surgery,Ashikaga Red Cross Hospital, Ashikaga-shi, Japan
| | - Atsushi Tanji
- Department of Orthopaedic Surgery,Ashikaga Red Cross Hospital, Ashikaga-shi, Japan
| | - Satoshi Oki
- Department of Orthopaedic Surgery, Saiseikai Utsunomiya Hospital, Utsunomiya-shi, Japan
| | - Yusaku Kamata
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Meguro-ku, Japan
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Jhamnani R, Dhanda MS, Surana A. Study of Functional Outcome and Postoperative Complications Among Proximal Humerus Fracture Patients Treated With Proximal Humerus Internal Locking System (PHILOS) Plating. Cureus 2023; 15:e42411. [PMID: 37637540 PMCID: PMC10447996 DOI: 10.7759/cureus.42411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
Background Proximal humerus fractures comprise nearly 4%-5% of all fracture types and nearly 25% of fracture humerus. These fractures are commonly seen in the elderly population (people aged 60 years or more). The best way to treat elderly people who have three- or four-part fractures of the proximal humerus is debatable, with many in favour of prosthetic humeral head replacements. This study aimed to assess the functional outcome of proximal humerus fractures managed with a proximal humerus locking plate and to investigate the incidence of complications in these patients. Methodology This retrospective study included 32 cases of proximal humerus fractures managed surgically at a tertiary care teaching hospital in Rajasthan between July 2016 to July 2022 with a proximal humerus internal locking system (PHILOS) plate. NEER scoring system was used to categorise the fractures. Functional assessment was done using Constant Murley's shoulder score. Constant Murley shoulder score was graded as failure (0-69 points), unsatisfactory (70-79), satisfactory (80-89), and excellent (90-100). Subjects having metastatic and pathological fractures; associated fractures in the ipsilateral limb; having major nerve injury and cases of open fracture were excluded from this study. Results The mean age was 54.5±6.4 years. Of the total 32 cases of proximal humerus fractures, 12 cases of two-part fractures received an excellent grade, compared to seven cases of three-part fractures. Three two-part fracture cases and two three-part fracture cases all received satisfactory grades. Excellent results (score > 89) were noticed in 62.5% (n = 20) of the instances, satisfactory results (scoring 80-89) in 21.87% (n=7), poor results (score 70-79) in 9.38% (n=3), and failure results (score 70) in 6.25% (n=2). In 65.6% of cases, follow-up showed no complications. Shoulder stiffness and malunion (9.38%) were the most frequent consequences, followed by avascular necrosis (6.25%). Conclusions Based on the findings of this retrospective study, it can be opined that PHILOS plaiting appears to be a secure option for proximal humerus fracture cases. It offers solid fixation, prompt mobilisation, and excellent functional outcomes as observed in this study. Additionally, very few post-operative complication rates again support our conclusion.
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Affiliation(s)
- Rohit Jhamnani
- Orthopaedics, Pacific Medical College and Hospital, Udaipur, IND
| | - Manjeet Singh Dhanda
- Orthopaedics, Shaheed Hassan Khan Mewati (SHKM) Government Medical College, Nuh, IND
| | - Avinash Surana
- Preventive Medicine, Infantry Division, 14 Coprs, Bareilly, IND
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Dewarrat A, Terrier A, Barimani B, Vauclair F. Comparison of the ALPS and PHILOS plating systems in proximal humeral fracture fixation - a retrospective study. BMC Musculoskelet Disord 2023; 24:371. [PMID: 37165381 PMCID: PMC10170861 DOI: 10.1186/s12891-023-06477-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 04/29/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Open reduction and plate osteosynthesis are considered as a successful technique for the treatment of proximal humerus fracture (PHF) despite high complication rates. The objective of our study was to review the clinical outcome and complications of the Anatomic Locking Plate System (ALPS) and compare it to the Proximal Humeral Internal Locking System (PHILOS). Our hypothesis was that ranges of motion (ROM) were superior and complication rates were lower with ALPS. METHODS Twenty patients treated with ALPS for PHF were retrospectively compared to 27 patients treated with PHILOS. Union, ROM and complications were clinically and radiologically assessed at 6 weeks, 3, 6, 12 and 18-24 months post-operatively. RESULTS Mean age was 52 ± 14 in the ALPS group and 58 ± 13 in the PHILOS group. Last follow-ups were conducted at a mean of 20.6 ± 4.8 months. Mean shoulder abduction was superior with ALPS by 14° (p-value = 0.036), 15° (p-value = 0.049), and 15° (p-value = 0.049) at 3, 6, and 12 months respectively. Mean shoulder external rotation was superior with ALPS by 11° (p-value = 0.032), 15° (p-value = 0.010) and 12° (p-value = 0.016) at 6 weeks, 3 and 6 months respectively. At the end of the follow-up, ROM remained better with ALPS, but not significantly. Complication rates over 21 months reached 20% with ALPS and 48% with PHILOS (p-value = 0.045). Implant removal rates reached 10% with ALPS and 37% with PHILOS (p-value = 0.036). Avascular necrosis was the only cause for hardware removal in the ALPS group. CONCLUSION The ALPS group showed better clinical outcomes with faster recovery in abduction and external rotation, although no difference in ROM remained after 21 months. Additionally, the complications rate was lower at last follow up. In our experience, the ALPS plating system is an effective management option in some PHF.
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Affiliation(s)
| | - Alexandre Terrier
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
- Laboratory of Biomechanical Orthopedics, Ecole Polytechnique Fédérale de Lausanne (EPFL), Station 9, 1015, Lausanne, Switzerland
| | - Bardia Barimani
- Division of Orthopedic Surgery, McGill University, Montreal, QC, Canada
- University of Toronto, Toronto, Canada
| | - Frédéric Vauclair
- University of Lausanne, Lausanne, Switzerland
- Department of Orthopaedics and Traumatology, Lausanne University Hospital, Lausanne, Switzerland
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Lanzetti RM, Gaj E, Berlinberg EJ, Patel HH, Spoliti M. Reverse Total Shoulder Arthroplasty Demonstrates Better Outcomes Than Angular Stable Plate in the Treatment of Three-part and Four-part Proximal Humerus Fractures in Patients Older Than 70 Years. Clin Orthop Relat Res 2023; 481:735-747. [PMID: 36383078 PMCID: PMC10013660 DOI: 10.1097/corr.0000000000002480] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Proximal humeral fractures are traditionally treated with open reduction and internal fixation (ORIF), but reverse total shoulder arthroplasty (RTSA) has emerged as an increasingly popular treatment option. Although ORIF with angular locking plates is a common treatment for proximal humerus fractures, prior reports suggest high failure and complication rates. Although RTSA has become an increasingly popular option for complex proximal humeral head fractures given its low complication rates, there are concerns it may lead to limited postoperative ROM. Thus, the optimal treatment for patients older than 70 years from a functional and radiographic perspective remains unclear. QUESTIONS/PURPOSES (1) In patients older than 70 years with three-part and four-part proximal humerus fractures, does RTSA result in better functional outcome scores (Constant, American Shoulder and Elbow Surgeons [ASES], and DASH scores) than ORIF with a locking plate? (2) Does RTSA result in greater ROM than ORIF? (3) Does RTSA result in a lower risk of complications than ORIF? (4) In patients with either procedure, what are the rates of negative radiographic outcomes in those treated with ORIF (such as malunion, bone resorption, malalignment, or avascular necrosis) or those with RTSA (such as resorption, notching, and loosening)? (5) At a minimum of 2 years of follow-up, does ORIF result in a greater number of revision procedures than RTSA? METHODS Between January 1, 2013, and June 30, 2018, we treated 235 patients for a proximal humeral fracture. We considered only patients without previous ipsilateral fracture or surgery, other fractures, or radial nerve injuries; age older than 70 years; and patients without neurologic disease or cognitive dysfunction as potentially eligible. Sixty-nine percent (162 patients) of the patients were eligible; a further 31% (73 patients) were excluded because 18% (13 of 73 patients) did not meet the inclusion criteria, 62% (45 patients) underwent nonoperative treatment, and 21% (15 patients) declined to participate. Patients were nonrandomly allocated to receive RTSA if they had supraspinatus Goutallier/Fuchs Grade 3 or 4 atrophy or ORIF if they had supraspinatus Goutallier/Fuchs Grade 1 or 2 atrophy. This left 81 patients who were treated with RTSA and another 81 patients who were treated with ORIF. Among the 81 patients treated with RTSA, 11% (nine patients) were lost to the minimum study follow-up of 2 years or had incomplete datasets, leaving 89% (72 patients) for analysis. Among the 81 patients treated with ORIF, 19% (15 patients) were lost before the minimal study follow-up of 2 years or had incomplete datasets, leaving 82% (66 patients) for analysis. The median follow-up for both groups was 53 months (range 24 to 72 months). The mean age was 76 ± 2.9 years in the RTSA group and 73 ± 2.9 years in the ORIF group. In the RTSA group, 27 patients had a three-part fracture and 45 patients had a four-part fracture. In the ORIF group, 24 patients had three-part fractures and 42 patients had four-part fractures (p = 0.48). Shoulder function was assessed using functional outcome questionnaires (ASES, DASH, and Constant) and active ROM measurements. A surgical complication was defined as any instance of dislocations, fractures, adhesive capsulitis, nerve injuries, or surgical site infections. Radiographic outcomes after ORIF (malunion, tuberosity resorption, or avascular necrosis) and RTSA (notching and osteolysis) were assessed. In calculating the revision rate, we considered unplanned revision procedures only. RESULTS Compared with patients treated with ORIF, patients treated with RTSA had superior improvements in Constant (85.0 ± 7.0 versus 53.0 ± 5.0; mean difference 32 [95% CI 30 to 34]; p < 0.01), ASES (46.3 ± 3.7 versus 30.0 ± 3.5; mean difference 16 [95% CI 15 to 18]; p < 0.01), and DASH scores (40.5 ± 4.2 versus 30.5 ± 2.6; mean difference 10 [95% CI 9 to 11]; p < 0.01). The mean elevation was 135° ± 7° for patients with RTSA and 100° ± 6° for patients with ORIF (mean difference 35 o [95% CI 33 to 37]; p < 0.01). The mean abduction was 131° ± 7° for patients with RTSA and 104° ± 6° for those with ORIF (mean difference 27 o [95% CI 25° to 29°]; p < 0.01). The mean external rotation was 85° ± 5° for patients with RTSA and 64° ± 5° for those with ORIF (mean difference 21° [95% CI 19° to 23°]; p < 0.01). The mean internal rotation was 45° ± 6° for patients with RTSA and 40° ± 6° for those with ORIF (mean difference 5° [95% CI 3° to 7°]; p < 0.01). The risk of complications was not different between patients with ORIF and those with RTSA (5% [three of 66] versus 1% [one of 72]; relative risk 3.3 [95% CI 0.3 to 30.7]; p = 0.30). Among patients with ORIF, 8% had varus malunions (five of 66), 6% had resorption of the greater tuberosity (four of 66), and 2% had avascular necrosis of the humeral head (one of 66). In the RTSA group, 24% (17 of 72 patients) demonstrated reabsorption of periprosthetic bone and 79% of patients (57 of 72) exhibited no notching. The risk of revision was not different between the RTSA and ORIF groups (0% [0 of 72] versus 9% [six of 66]; relative risk 0.07 [95% CI 0.0 to 1.2]; p = 0.07). CONCLUSION In patients older than 70 years with three-part and four-part proximal humerus fractures, primary RTSA resulted in better patient-reported outcome scores and better ROM than ORIF with an angular stable locking plate. Our findings might help surgeons decide between internal fixation and arthroplasty to surgically treat these injuries in older patients. Although RTSA seems to be a preferable treatment modality in view of these findings, longer follow-up is required to evaluate its longevity compared with ORIF with an angular locking plate. Dissimilar to ORIF, which is generally stable once healed, arthroplasties are at a continued risk for loosening and infection even after healing is complete. LEVEL OF EVIDENCE Level II, therapeutic study.
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Affiliation(s)
- Riccardo Maria Lanzetti
- Orthopaedics and Traumatology Unit, Department of Emergency and Acceptance, San Camillo-Forlanini Hospital, Rome, Italy
| | - Edoardo Gaj
- San Andrea Hospital, University of Rome “Sapienza,” Rome, Italy
- Ospedale Israelitico di Roma, Rome, Italy
| | - Elyse J. Berlinberg
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Harsh H. Patel
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Marco Spoliti
- Orthopaedics and Traumatology Unit, Department of Emergency and Acceptance, San Camillo-Forlanini Hospital, Rome, Italy
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Neudeck R, Daferner MP, Fleischhacker E, Helfen T, Gilbert F, Böcker W, Ockert B, Siebenbürger G. Mid-term functional outcome (minimum 24 months, mean 4 years) after locking plate osteosynthesis for displaced fractures of the proximal humerus in 557 cases. Injury 2023:S0020-1383(23)00289-9. [PMID: 37012129 DOI: 10.1016/j.injury.2023.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/16/2023] [Accepted: 03/23/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND The best surgical management of displaced proximal humeral fractures remains a matter of considerable debate. This study presents mid-term functional outcome (median 4 years) after locking plate osteosynthesis for displaced proximal humeral fractures. METHODS Between February 2002 and December 2014 1031 patients with 1047 displaced proximal humeral fractures were treated by open reduction and locking plate fixation with the same implant and received consecutive prospective follow up at least 24 months after surgical treatment. Clinical follow-up consisted of Constant Murley score (CS), Disabilities of the Arm, Shoulder and Hand score (DASH), and Short Form 36 questionnaire (SF-36). Complete follow-up could be performed in 557 (53.2%) cases, with a mean follow-up of 4.0 ± 2.7 years. RESULTS Of 557 patients (67% women; mean age at time of osteosynthesis: 68.3 ± 15.5 years) absolute CS of all patients 4 ± 2.7 years after surgery was 68.4 ± 20.3 points. Normalized CS according to Katolik was 80.4 ± 23.8 points, and CS in percentage to the contralateral side (%CS) was 87.2 ± 27.9%. DASH score was at 23.8 ± 20.8 points. Osteosynthesis related complications (secondary displacement, screw cutout, avascular necrosis (n = 117 patients) were associated with lower functional scores (mean CS was 54.5 ± 19.0 p.; nCS 64.5 ± 22.9 p.;%CS 71.2 ± 25.0%; DASH score 31.9 ± 22.4 p.). The SF 36 was 66.5 points in the case cohort and a vitality mean of 69.4 points. Patients with a complication showed lower results (SF 36 56.7; vitality mean 64.9 points). CONCLUSIONS Overall, patients following locking plate osteosynthesis of displaced proximal humeral fractures showed good to moderate outcomes four years after surgery. Mid-term functional outcomes correlate significantly with those at 1 year postoperatively. Furthermore, there is a significant negative correlation of midterm functional outcome with the occurrence of complications. LEVEL OF EVIDENCE Level III, prospective nonconsecutive patients.
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Affiliation(s)
- Rouven Neudeck
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, Munich 81377, Germany
| | | | - Evi Fleischhacker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, Munich 81377, Germany
| | - Tobias Helfen
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, Munich 81377, Germany
| | - Fabian Gilbert
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, Munich 81377, Germany
| | - Wolfgang Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, Munich 81377, Germany
| | - Ben Ockert
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, Munich 81377, Germany
| | - Georg Siebenbürger
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Marchioninistr. 15, Munich 81377, Germany.
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Siebenbürger G, Neudeck R, Daferner MP, Fleischhacker E, Böcker W, Ockert B, Helfen T. It Is Always the Same—A Complication Classification following Angular Stable Plating of Proximal Humeral Fractures. J Clin Med 2023; 12:jcm12072556. [PMID: 37048639 PMCID: PMC10095119 DOI: 10.3390/jcm12072556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/19/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023] Open
Abstract
Introduction: The aim of this study was to create a novel complication classification for osteosynthesis-related complications following angular stable plating of the proximal humerus subsuming the influence of these complications on clinical outcome in relation to fracture morphology and consequent revision strategies. A total of 1047 proximal humerus fractures with overall 193 osteosynthesis-associated complications (24.5%) were included. The following complication types could be clarified: complication Type 1 is defined by mild varus (<20°) or valgus displacement of the humeral head without resulting in a screw cutout through the humeral head cortex. Type 2a is defined by varus displacement (<20°) of the humeral head associated with screw cutout through the humeral head cortex. Type 2b complication is limited to displacement of the greater tuberosity, lesser tuberosity, or both tuberosities. Complication Type 2c is defined by severe varus dislocation (>20°) of the humeral head with screw cutout at the humeral head cortex. Complication Type 3 describes a displacement of the angular stable plate in the humeral shaft region with associated shaft-sided screw cutout, while the position of the humeral head remains static. Complication Type 4 is characterized by the occurrence of AVN with or without glenoidal affection (4a/b). Clinical outcome according to the constant score was mainly affected by type 2–4, leading to a deteriorated result. Depending on the type of complication, specific revision strategies can be considered. Additionally, more complex fracture patterns fostered the incidence of complications.
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Affiliation(s)
- Georg Siebenbürger
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munchen, Germany
- Correspondence:
| | - Rouven Neudeck
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munchen, Germany
| | | | - Evi Fleischhacker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munchen, Germany
| | - Wolfgang Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munchen, Germany
| | - Ben Ockert
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munchen, Germany
| | - Tobias Helfen
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, 81377 Munchen, Germany
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Rischen R, Köppe J, Stolberg-Stolberg J, Freistühler M, Faldum A, Raschke MJ, Katthagen JC. Treatment Reality of Proximal Humeral Fractures in the Elderly-Trending Variants of Locking Plate Fixation in Germany. J Clin Med 2023; 12:jcm12041440. [PMID: 36835975 PMCID: PMC9963188 DOI: 10.3390/jcm12041440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 01/26/2023] [Accepted: 02/01/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND The surgical treatment of proximal humeral fractures (PHFs) with locking plate fixation (LPF) in the elderly is associated with high complication rates, especially in osteoporotic bone. Variants of LPF such as additional cerclages, double plating, bone grafting and cement augmentation can be applied. The objective of the study was to describe the extent of their actual use and how this changed over time. METHODS Retrospective analysis of health claims data of the Federal Association of the Local Health Insurance Funds was performed, covering all patients aged 65 years and older, who had a coded diagnosis of PHF and were treated with LPF between 2010 and 2018. Differences between treatment variants were analyzed (explorative) via chi-squared or Kruskal-Wallis tests. RESULTS Of the 41,216 treated patients, 32,952 (80%) were treated with LPF only, 5572 (14%) received additional screws or plates, 1983 (5%) received additional augmentations and 709 (2%) received a combination of both. During the study period, relative changes were observed as follows: -35% for LPF only, +58% for LPF with additional fracture fixation and +25% for LPF with additional augmentation. Overall, the intra-hospital complication rate was 15% with differences between the treatment variants (LPF only 15%, LPF with additional fracture fixation 14%, LPF with additional augmentation 19%; p < 0.001), and a 30-day mortality of 2%. CONCLUSIONS Within an overall decrease of LPF by approximately one-third, there is both an absolute and relative increase of treatment variants. Collectively, they account for 20% of all coded LPFs, which might indicate more personalized treatment pathways. The leading variant was additional fracture fixation using cerclages.
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Affiliation(s)
- Robert Rischen
- Clinic for Radiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
- Correspondence: ; Tel.: +49-251-83-47302
| | - Jeanette Köppe
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstrasse 56, 48149 Muenster, Germany
| | - Josef Stolberg-Stolberg
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany
| | - Moritz Freistühler
- Medical Management Division—Medical Controlling, University Hospital Muenster, Niels-Stensen-Straße 8, 48149 Muenster, Germany
| | - Andreas Faldum
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstrasse 56, 48149 Muenster, Germany
| | - Michael J. Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany
| | - J. Christoph Katthagen
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany
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A Standardized Operative Protocol for Fixation of Proximal Humeral Fractures Using a Locking Plate to Minimize Surgery-Related Complications. J Clin Med 2023; 12:jcm12031216. [PMID: 36769863 PMCID: PMC9917760 DOI: 10.3390/jcm12031216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/22/2023] [Accepted: 01/29/2023] [Indexed: 02/05/2023] Open
Abstract
The current literature suggests that up to 55% of complications after plate osteosynthesis treatment for patients with proximal humerus fractures are attributed to the surgical procedure. The hypothesis of this study was that a standardized surgical protocol would minimize surgery-related adverse events. This prospective cohort study included 50 patients with a mean age of 63.2 (range 28-92) years treated by one single surgeon using a previously published standardized surgical protocol. Clinical and radiological follow-up examinations were conducted for up to 24 months using Constant-Murley Score (CS), Subjective Shoulder Value (SSV) and radiographs in true anteroposterior, axial and y-view. Finally, CS was 73.9 (standard deviation [SD]: 14.0) points (89% compared to the uninjured shoulder), and SSV was 83.3% (SD: 16.7) at two years of follow-up. Postoperative radiologic evaluation revealed no primary surgical-related or soft-tissue-related complications (0%). The main complications were secondary, biological complications (20%), largely represented by avascular necrosis (8%). Eight patients underwent revision surgery, mainly for implant removal. In addition, a total of four patients were revised using a hemiarthroplasty (n = 2), reverse shoulder arthroplasty (n = 1) or re-osteosynthesis. The use of our standardized surgical technique on proximal humerus fractures improves fixation with regard to primary stability and prevents primary, surgical-technique-related complications. The subjective grading of a high level of difficulty surgery was associated with more complications.
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Connelly JW, Meltzer JH, Tapscott DC, Molino J, Green A, Scott Paxton E. Short-term clinical and radiographic outcomes in patients treated with a modern intramedullary nailing system for 2-part proximal humerus fractures. Injury 2023; 54:561-566. [PMID: 36435642 DOI: 10.1016/j.injury.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 10/26/2022] [Accepted: 11/06/2022] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- James W Connelly
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Riverside, Providence, RI, United States.
| | - Jourdan H Meltzer
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Riverside, Providence, RI, United States
| | - David C Tapscott
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Riverside, Providence, RI, United States
| | - Janine Molino
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Riverside, Providence, RI, United States; Lifespan Biostatistics Core, Rhode Island Hospital, Providence, RI, United States
| | - Andrew Green
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Riverside, Providence, RI, United States
| | - E Scott Paxton
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Riverside, Providence, RI, United States
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Kimmeyer M, Schmalzl J, Rentschler V, Jessen M, Gerhardt C, Lehmann LJ. Functional results and unfavorable events after treatment of proximal humerus fractures using a new locking plate system. BMC Musculoskelet Disord 2023; 24:63. [PMID: 36694169 PMCID: PMC9872058 DOI: 10.1186/s12891-023-06176-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/18/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Proximal humerus fractures are often treated with a fixed-angle titanium plate osteosynthesis. Recently, plates made of alternative materials such as carbon fibre-reinforced polyetheretherketone (CFR-PEEK) have been introduced. This study presents the postoperative results of patients treated with a CFR-PEEK plate. METHODS Patients with proximal humerus fractures treated with a CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) were included. In follow-up examination, age and gender adjusted Constant-Murley Score (ACS), Subjective Shoulder Value (SSV), Quick Disabilities of the Arm, Shoulder and Hand Score (QDASH) and pain score (Visual Analog Scale (VAS)) were analyzed. General condition at follow-up was measured by European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L). Range of motion was recorded. In addition, radiographs at follow-up, unfavorable events and revision rate were analyzed. RESULTS In total, 98 patients (66.0 ± 13.2 years, 74 females, 24 males) were reexamined. Mean follow-up was 27.6 ± 13.2 months. There were 15 2-part, 28 3-part and 55 4-part fractures. The functional scores showed good results: SSV 83.3 ± 15.6%, QDASH 13.1 ± 17.0 and ACS 80.4 ± 16.0. A 4-part-fracture, head split component, nonanatomic head shaft reposition and preoperative radiological signs of osteoarthritis were significant negative predictors for poorer clinical scores. Unfavourable events were observed in 27 patients (27.6%). Revision surgery was performed in 8 (8.2%) patients. Risk factors for an unfavourable event were female gender, age of 50 years and older, diabetes, affected dominant hand, 4-part fracture, head split and preoperative radiological signs of osteoarthritis. CONCLUSION There are several advantages of the CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) such as the polyaxial screw placement and higher stability of locking screws. In summary, the CFR-PEEK plate osteosynthesis is a good alternative with comparable clinical results and some biomechanical advantages. Proximal humerus fractures show good clinical results after treatment with a CFR-PEEK plate. The revision rate and the risk of unfavorable events are not increased compared to conventional titanium plate osteosynthesis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Michael Kimmeyer
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeuserstr. 18, 76135 Karlsruhe, Germany
| | - Jonas Schmalzl
- grid.411760.50000 0001 1378 7891Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, Oberduerrbacher Str. 6, 97080 Wuerzburg, Germany
| | - Verena Rentschler
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeuserstr. 18, 76135 Karlsruhe, Germany
| | - Malik Jessen
- grid.6936.a0000000123222966Department of Trauma Surgery, University Clinic Rechts Der Isar, Technical University Munich, Ismaninger Str. 22, D-81675 Munich, Germany
| | - Christian Gerhardt
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeuserstr. 18, 76135 Karlsruhe, Germany
| | - Lars-Johannes Lehmann
- Department of Traumatology, Hand Surgery and Sports Medicine, ViDia Clinics Karlsruhe, Steinhaeuserstr. 18, 76135 Karlsruhe, Germany
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Park SG, Seok HG. Proximal Humerus Fractures Treated Using Locking Plate: A Comparison Between Anatomical Reduction and Valgus Bent Locking Plate Fixation After Valgus Reduction. Indian J Orthop 2022; 56:2153-2159. [PMID: 36507195 PMCID: PMC9705637 DOI: 10.1007/s43465-022-00740-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 08/30/2022] [Indexed: 02/04/2023]
Abstract
Introduction Plate osteosynthesis is preferred for the treatment of proximal humerus fractures (PHFs). However, applying the locking plate flush against the bone may lead to varus malreduction and medial displacement of the humeral head. We hypothesized that slight valgus reduction and valgus bent locking plate fixation against potential varus deformation would yield better results than the traditional plate fixation. Methods We retrospectively reviewed patients with PHFs treated with locking plate fixation between March 2014 and July 2019. We evaluated changes in the neck-shaft angle (NSA) and humeral head height, as well as the development of complications postoperatively. Clinical outcomes were measured at 1-year post-surgery and at the last follow-up using the American Shoulder and Elbow Surgeons, the Disabilities of the Arm, Shoulder and Hand, and the Constant-Murley scores. Results A total of 58 patients with PHFs were enrolled in this study. They were divided into the valgus-aligned group (n = 28) and the anatomical group (n = 30). According to radiographic evaluation, immediate postoperative NSA was significantly greater in the valgus-aligned group. Moreover, the NSA measured at the last follow-up was significantly greater the valgus-aligned group. In contrast, the NSA became considerably more varus-aligned in the anatomical group. Conclusion The appropriate valgus reduction and valgus bending plate fixation could lead to better short-term results and improve the ability of proximal humerus locking plates to prevent varus collapse and fixation failure. Level of Evidence Level III, retrospective cohort design.
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Affiliation(s)
- Sam-Guk Park
- Department of Orthopedic Surgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170 Hyeonchung-ro, Nam-gu, Daegu, 42415 Republic of Korea
| | - Hyun-Gyu Seok
- Department of Orthopedic Surgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170 Hyeonchung-ro, Nam-gu, Daegu, 42415 Republic of Korea
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Tarallo L, Micheloni GM, Giorgini A, Lombardi M, Limone B, Catani F, Porcellini G. Anatomically reduced fixation should always be considered when treating B and C proximal epiphyseal humeral fractures. J Orthop Traumatol 2022; 23:51. [PMID: 36334166 PMCID: PMC9637075 DOI: 10.1186/s10195-022-00668-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 09/21/2022] [Indexed: 11/07/2022] Open
Abstract
Background Proximal humeral fractures are commonly observed in elderly patients. Management of these injuries is controversial. Literature comparing locking plate fixation, arthroplasty, and conservative treatments show no clear advantages for any of these management strategies. Thus far, no study has considered anatomically reduced fractures obtained after locking plate treatment. To clarify the best surgical procedure in middle-aged patients, we considered outcomes and major complications leading to surgical revision following an anatomically reduced fracture fixed with locking plate and reverse shoulder arthroplasty (RSA) in the treatment of type B/C fractures in patients between 50 and 75 years of age. Methods This is a retrospective study including 59 patients between 50 and 75 years of age with type B/C proximal humeral fracture treated with RSA or with locking plate fixation (resulting in an anatomical reduction) between January 2010 and December 2018. Preoperative radiographs and computed tomography (CT) were evaluated in all patients. Clinical and radiologic follow-up was performed using range of motion (ROM), the Constant–Murley Score (CMS), the Oxford Shoulder Score (OSS), the Simple Shoulder Test (SST), the Subjective Shoulder Value (SSV), and visual analog scale (VAS). Major complications were considered. Results In the plate fixation group, ROM, CMS, SST, and VAS were higher than in the RSA group. Lower complication rates compared with the literature were observed in both groups. Anatomically reduced fracture fixed with plate and screw could outperform RSA in terms of outcome. In second-level centers where traumatology is performed by surgeons with great expertise in upper limb trauma, the choice between plate fixation and reverse arthroplasty should be made during surgery. Conclusion Anatomically reduced fractures showed better outcomes compared with RSA in type B/C fractures. Surgeons should always try to perform a reduction of the fracture in order to understand if a plate fixation could be feasible. If it is impossible to perform an anatomical reduction, we suggest to consider RSA. This is a retrospective observational study.
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Affiliation(s)
- Luigi Tarallo
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
| | - Gian Mario Micheloni
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
| | - Andrea Giorgini
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
| | - Martina Lombardi
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
| | - Beatrice Limone
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
| | - Fabio Catani
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
| | - Giuseppe Porcellini
- grid.7548.e0000000121697570Department of Orthopaedic Surgery, University of Modena and Reggio-Emilia, Via del Pozzo 71, 41125 Modena, Italy
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Role of Fibular Allograft in Proximal Humerus Fractures: A Systematic Review. J Orthop Trauma 2022; 36:e425-e430. [PMID: 35580343 DOI: 10.1097/bot.0000000000002404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To analyze the outcomes and complication rates of fibular allografts (FA) as an augmentation technique for proximal humeral fractures and determine their appropriate indications. DATA SOURCES English- and Spanish-language articles in PubMed, MEDLINE, Embase, Web of Science (Core Collection), and Google Scholar databases were systematically reviewed with the Preferred Reporting Items for Systematic Reviews guidelines on April 10, 2020. STUDY SELECTION Studies of patients with proximal humeral fractures treated primarily with FA and locking compression plates and with a minimum follow-up of 6 months were included, and presenting results with standardized clinical scales, radiological values, and operative complications. DATA EXTRACTION Two authors independently extracted data from the selected studies with a standardized data collection form. Subsequently, each extracted data set was consolidated on the agreement of authors. DATA SYNTHESIS From the initial screening of 361 articles, 5 case series and 6 retrospective cohort studies were included. A meta-analysis was not performed. CONCLUSIONS FA improved the clinical and radiological results, thereby reducing complications. The optimal indication for this procedure may be a 4-part fracture with medial column disruption in younger adults. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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25
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Hung CY, Yeh CY, Wen PC, Yeh WL, Lin SJ. The effect of medial calcar support on proximal humeral fractures treated with locking plates. J Orthop Surg Res 2022; 17:467. [PMID: 36307815 PMCID: PMC9617439 DOI: 10.1186/s13018-022-03337-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background Studies have reported mixed results on the importance of medial calcar support for the treatment of proximal humeral fractures. The purpose of this study was to compare radiographic and functional outcomes of patients who had displaced proximal humeral fractures with varying levels of medial support. Methods We performed a retrospective comparative cohort study. The study was conducted at a Level III trauma center in Taiwan. Seventy patients with proximal humeral fractures were collected retrospectively from 2015 to 2019. Only patients with two-, three-, or four-part types (Neer type I, II, or III) of displaced proximal humeral fractures were included in this study. However, patients with head-split fracture patterns, shoulder dislocation, prior shoulder trauma, and poor fracture reduction present in postoperative films were excluded. We assessed the radiographic outcomes, including the reduction score and amount of impaction in the humeral head. The functional outcome was evaluated based on the Constant score. Results Patients were grouped into the intact medial calcar group and the medial calcar deficiency group. In a subgroup analysis, the group with intact medial support had a significantly lower amount of impaction and a higher Constant score compared with the medial calcar deficiency group. Additionally, the groups with intact medial support had a nonsignificant difference in the Constant score between the affected side and the contralateral side. Conclusion The amount of impaction and the reduction score in the humeral head at the 12-month radiographic follow-up were significantly higher in the group with medial support deficiency. However, the reduction score after surgery exhibited no difference. This implies that the inherent nature of medial comminution of proximal humeral fracture may lead to inferior radiographic outcomes.
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Affiliation(s)
- Chun-Yu Hung
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Yunlin, Taiwan.,Department of Orthopaedic Surgery, Jen-Ai Hospital, Taichung, Taiwan
| | - Chia-Yi Yeh
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Po-Chong Wen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Yunlin, Taiwan
| | - Wen-Ling Yeh
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Orthopaedic Surgery, Lotung Poh-Ai Hospital, Yilan, Taiwan
| | - Shih-Jie Lin
- Department of Orthopaedic Surgery, New Taipei Municiple TuCheng Hospital, Chang Gung Memorial Hospital, New Taipei City, Taiwan. .,Department of Chemical Engineering, National Tsing Hua University, Hsinchu, Taiwan.
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Miltenberg B, Masood R, Katsiaunis A, Moverman MA, Puzzitiello RN, Pagani NR, Menendez ME, Salzler MJ, Drager J. Fracture dislocations of the proximal humerus treated with open reduction and internal fixation: a systematic review. J Shoulder Elbow Surg 2022; 31:e480-e489. [PMID: 35605847 DOI: 10.1016/j.jse.2022.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/11/2022] [Accepted: 04/18/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The treatment of proximal humerus fracture dislocations can be challenging given the extensive injury to the proximal humeral anatomy and increased risk of devascularization of the humeral head often seen in these injuries. The purpose of this study is to undertake a systematic review of the literature on the functional outcomes, rate of revision, and short- and long-term complications for proximal humerus fracture dislocations treated with open reduction and internal fixation (ORIF). METHODS The PubMed and OVID Embase databases were queried for literature reporting on proximal humerus fracture dislocations treated with ORIF. Data including study design, patient demographics, functional outcomes, and complications were recorded. RESULTS Twelve studies including 294 patients with Neer type 2-, 3-, or 4-part proximal humerus fracture dislocations met the criteria for inclusion. The mean patient age was 53.4 years (19-89 years) with an average follow-up of 2.9 years (1.15-4.9 years). At the final follow-up, the mean Constant score was 73.2 (52-87.3) and the mean Disabilities of the Arm Shoulder and Hand score was 26.6 (17.5-32). Avascular necrosis was observed in 20.0% (0%-82.3%) and nonunion was observed in 3.0% (0%-7.7%) of patients. Conversion to arthroplasty was observed in 10.7% (5%-20%) and a total reoperation was observed in 35.6% (11.8%-89.1%) of patients in studies explicitly reporting these outcomes. In addition to conversion to arthroplasty, common causes of reoperation were revision ORIF (5.2%) and hardware removal (22.2%). CONCLUSION Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates. This information can be used to counsel patients and set expectations about the potential for further surgeries.
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Affiliation(s)
| | - Raisa Masood
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, MA, USA
| | | | | | | | - Nicholas R Pagani
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, MA, USA
| | - Mariano E Menendez
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Matthew J Salzler
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, MA, USA
| | - Justin Drager
- Department of Orthopedic Surgery, Tufts Medical Center, Boston, MA, USA.
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Using the Greater Tuberosity as a Reference for Placement of Proximal Humerus Plates Leads to a High Rate of Calcar Screw Malposition. J Orthop Trauma 2022; 36:525-529. [PMID: 35436241 DOI: 10.1097/bot.0000000000002377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Achieving calcar fixation is critical to minimize the failure of proximal humerus fractures repaired with proximal humeral locking plates (PHLPs). Many operative technique manuals reference the greater tuberosity (GT) for plate placement. The objective of this study was to examine the accuracy of calcar screw placement when PHLPs were placed based on distance from the GT. METHODS Twenty cadaveric specimens were acquired representing a height distribution across the US population. Thirteen different PHLPs were applied. A drill bit was placed through the designated calcar screw hole and measured on radiographs, with the inferior 25% of the head representing an ideal placement. RESULTS Three hundred fifty constructs were studied. In 28% of the specimens, the calcar screw was misplaced. In 20% of the specimens, it was too low, whereas in 8%, it was too high. The calcar screw missed low in 30% of patients shorter than 5 feet, 5.5 inches versus 8% of taller patients ( P = 0.007). It missed high in 13% of taller patients versus 2% of shorter patients ( P = 0.056). Calcar screws in variable-angle plates missed 0% of the time, whereas those in fixed-angle plates missed 36% of the time ( P = 0.003). CONCLUSIONS Placement of PHLPs based on distance from the GT results in unacceptable position of the calcar screw 28% of the time and up to 36% in fixed-angle plates. This could be further compounded if the GT is malreduced. Current technique guide recommendations result in an unacceptably high rate of calcar screw malposition.
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Warnhoff M, Jensen G, Lill H, Ellwein A. [Current trends in reverse fracture arthroplasty]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:690-698. [PMID: 35861875 DOI: 10.1007/s00113-022-01211-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 06/15/2023]
Abstract
The reliable results of reverse arthroplasty have made this the preferred treatment method for non-reconstructable proximal humeral fractures. The individual consideration of the patient and the morphological features of the fractures are essential. Computed tomography (CT) images provide crucial information on the perfusion of the humeral head relevant for the prognosis and treatment. In this context a differentiation must be made between hard and soft criteria against a reconstruction. Tuberosities should be reduced whenever possible, because reverse arthroplasty with healed tuberosities provides a better range of motion and more strength for external rotation and anteversion, less complications and longer survival rates. In recent years the trend has been towards anatomical designs of prostheses with a humeral inclination of 135°. Revision rates for primary fracture prostheses are overall low with instability as the main reason for revision surgery, followed by periprosthetic fractures and infections. Reverse fracture arthroplasty has comparable or better clinical results compared to conservative treatment, osteosynthesis for geriatric patients, hemiarthroplasty and prosthesis implantation by elective surgery. Reverse arthroplasties, which were implanted in conditions of fracture sequelae, did not achieve significantly poorer clinical outcome at mid-term follow-up and can significantly improve shoulder function.
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Affiliation(s)
- M Warnhoff
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Deutschland.
| | - G Jensen
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Deutschland
| | - H Lill
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Deutschland
| | - A Ellwein
- Klinik für Orthopädie und Unfallchirurgie, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169, Hannover, Deutschland
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29
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Wang H, Liu Y, Wang D, He Y, Yao P, Lu T, Zhou J. Predictive Indicators for Complications of Proximal Humerus Fractures Treated with Locking Plate or Intramedullary Nail Fixation. Orthop Surg 2022; 14:2109-2118. [PMID: 35924701 PMCID: PMC9483087 DOI: 10.1111/os.13421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/26/2022] [Accepted: 06/26/2022] [Indexed: 12/02/2022] Open
Abstract
Objective The purpose of this study was to evaluate the best placement of calcar screws in proximal humerus fracture surgeries. Methods This retrospective cohort study included clinical and radiographic outcomes of 98 patients treated with proximal humerus fracture surgeries between January 2017 and June 2020. Demographic data of patients were obtained from medical records. The surgical and radiographic results were also collected: operation time, blood loss, time to surgery, fibular allograft, disruption of medial region hinge, Neer classification, and recovery of medial support. Patients were allocated into two groups: the locking plate group (n = 65) and the intramedullary nail group (n = 33). In this study, we proposed new predictive indicators, named horizontal ratio (HR) and vertical ratio (VR), to quantify the placement of calcar screws in these two groups. A receiver operating characteristic (ROC) analysis was conducted to display the accuracy of these indicators. Shoulder activity, visual scale analog (VAS) score, and Constant score were performed to evaluate postoperative clinical outcomes at 1 year follow‐up. Results In the multivariate logistic regression analysis, only time to surgery and effective medial support were considered statistically significant factors of postoperative complications (p < 0.05). Significant differences were observed between medial support and postoperative complications both in the locking plate group and the intramedullary nail group (p < 0.05). Only the vertical ratio of locking plate (VRLP) was a statistically significant predictor of postoperative complications (p < 0.05). The area under curve was calculated to assess the predictive value of VRLP, which came to 0.84. In addition, a ROC analysis found quantifiable thresholds of the VR was 0.1713 as measures to avoid postoperative complications in the locking plate fixation. Conclusion In locking plate fixation, the incidence of postoperative complications increased significantly when the VR of calcar screws greater than 0.1713, which was beneficial to surgeons to place calcar screws.
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Affiliation(s)
- Hanzhou Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Yang Liu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Dong Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Yuanming He
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Peifeng Yao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Tianchao Lu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Junlin Zhou
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
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Braman JP, Nyangacha TN, Knudsen ML. Endosteal plating in proximal humerus fractures: a novel technique and alternative to fibular strut allograft for medial column support. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:350-353. [PMID: 37588868 PMCID: PMC10426668 DOI: 10.1016/j.xrrt.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Hypothesis The purpose of this retrospective study is to investigate the clinical and radiographic outcomes associated with the use of a standard metal plate as an endosteal implant in combination with a lateral locking plate to treat 4 patients with displaced proximal humerus fractures. Methods A retrospective case series study design was utilized, and the medical records of 4 patients with displaced, 3-part proximal humerus fractures treated using this technique between January 2019 and July 2021 were reviewed for this study. The mean age was 52 years (range, 44-57 years). The radiographic outcome of interest was humeral neck-shaft angle preoperatively, intraoperatively, and at the latest follow-up. The average follow-up duration was 62 weeks (range, 12-161 weeks). Results All fractures healed without loss of reduction or neurovascular deficits. Avascular necrosis was not observed in the 2 patients with sufficient follow-up time to make such an evaluation. The average neck-shaft angles preoperatively, intraoperatively, and at the latest follow-up were 104.8°, 139.8°, and 137°, respectively. Conclusion Locking plate technology augmented with an endosteal plate provided stable reduction and restoration of physiologic alignment in a small number of patients with displaced proximal humerus fractures. This construct creates a second column of fixation, providing medial column support, and could be removed in the event of a future revision to a reverse shoulder arthroplasty.
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Affiliation(s)
- Jonathan P. Braman
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | | | - Michael L. Knudsen
- Division of Shoulder, Elbow and Sports Medicine, Columbia University Medical Center, New York, NY, USA
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Handoll HH, Elliott J, Thillemann TM, Aluko P, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2022; 6:CD000434. [PMID: 35727196 PMCID: PMC9211385 DOI: 10.1002/14651858.cd000434.pub5] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely, including in the use of surgery. This is an update of a Cochrane Review first published in 2001 and last updated in 2015. OBJECTIVES To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registries, and bibliographies of trial reports and systematic reviews to September 2020. We updated this search in November 2021, but have not yet incorporated these results. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults. DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. We prepared a brief economic commentary for one comparison. MAIN RESULTS We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. Six comparisons were tested by 2 to 10 trials, the others by small single-centre trials only. Twelve studies evaluated non-surgical treatments, 10 compared surgical with non-surgical treatments, 23 compared two methods of surgery, and two tested timing of mobilisation after surgery. Most trials were at high risk of bias, due mainly to lack of blinding. We summarise the findings for four key comparisons below. Early (usually one week post injury) versus delayed (after three or more weeks) mobilisation for non-surgically-treated fractures Five trials (350 participants) made this comparison; however, the available data are very limited. Due to very low-certainty evidence from single trials, we are uncertain of the findings of better shoulder function at one year in the early mobilisation group, or the findings of little or no between-group difference in function at 3 or 24 months. Likewise, there is very low-certainty evidence of no important between-group difference in quality of life at one year. There was one reported death and five serious shoulder complications (1.9% of 259 participants), spread between the two groups, that would have required substantive treatment. Surgical versus non-surgical treatment Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures). There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants). There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year (EQ-5D (0: dead to 1: best quality): mean difference (MD) 0.01, 95% CI -0.02 to 0.04; 6 studies, 502 participants). There is low-certainty evidence of little between-group difference in mortality: one of the 31 deaths was explicitly linked with surgery (risk ratio (RR) 1.35, 95% CI 0.70 to 2.62; 8 studies, 646 participants). There is low-certainty evidence of a higher risk of additional surgery in the surgery group (RR 2.06, 95% CI 1.21 to 3.51; 9 studies, 667 participants). Based on an illustrative risk of 35 subsequent operations per 1000 non-surgically-treated patients, this indicates an extra 38 subsequent operations per 1000 surgically-treated patients (95% CI 8 to 94 more). Although there was low-certainty evidence of a higher overall risk of adverse events after surgery, the 95% CI also includes a slightly increased risk of adverse events after non-surgical treatment (RR 1.46, 95% CI 0.92 to 2.31; 3 studies, 391 participants). Open reduction and internal fixation with a locking plate versus a locking intramedullary nail Four trials (270 participants) evaluated surgical intervention for displaced fractures (63% were two-part fractures). There is low-certainty evidence of no clinically important between-group difference in shoulder function at one year (SMD 0.15, 95% CI -0.12 to 0.41; 4 studies, 227 participants), six months (Disability of the Arm, Shoulder, and Hand questionnaire (0 to 100: worst disability): MD -0.39, 95% CI -4.14 to 3.36; 3 studies, 174 participants), or two years (American Shoulder and Elbow Surgeons score (ASES) (0 to 100: best outcome): MD 3.06, 95% CI -0.05 to 6.17; 2 studies, 101 participants). There is very low-certainty evidence of no between-group difference in quality of life (1 study), and of little difference in adverse events (4 studies, 250 participants) and additional surgery (3 studies, 193 participants). Reverse total shoulder arthroplasty (RTSA) versus hemiarthroplasty There is very low-certainty evidence from two trials (161 participants with either three- or four-part fractures) of no or minimal between-group differences in self-reported shoulder function at one year (1 study) or at two to three years' follow-up (2 studies); or in quality of life at one year or at two or more years' follow-up (1 study). Function at six months was not reported. Of 10 deaths reported by one trial (99 participants), one appeared to be surgery-related. There is very low-certainty evidence of a lower risk of complications after RTSA (2 studies). Ten people (6.2% of 161 participants) had a reoperation; all eight cases in the hemiarthroplasty group received a RTSA (very low-certainty evidence). AUTHORS' CONCLUSIONS There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery. The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures. There is insufficient evidence from randomised trials to inform the choices between different non-surgical, surgical or rehabilitation interventions for these fractures.
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Affiliation(s)
- Helen Hg Handoll
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, UK
- Department of Orthopaedics and Trauma, The University of Edinburgh, Edinburgh, UK
| | - Joanne Elliott
- Division of Musculoskeletal and Dermatological Sciences, The University of Manchester, Manchester, UK
| | - Theis M Thillemann
- Department of Orthopaedics, Shoulder and Elbow Unit, Aarhus University Hospital, Aarhus N, Denmark
| | - Patricia Aluko
- National Institute for Health Research (NIHR) Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
| | - Stig Brorson
- Centre for Evidence-Based Orthopaedics, Zealand University Hospital and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Chloros GD, Prodromidis AD, Wilson J, Giannoudis PV. Fracture fixation in extremity trauma with carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates: evidence today. Eur J Trauma Emerg Surg 2022; 48:2387-2406. [PMID: 34487201 PMCID: PMC9192460 DOI: 10.1007/s00068-021-01778-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/15/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE To compare the CFR-PEEK plates with conventional plates in fracture fixation with regards to clinical and radiological outcomes and complications. METHODS A systematic literature search was conducted in four online databases independently by two reviewers using the Cochrane methodology for systematic reviews. The identified relevant studies were assessed against predetermined inclusion/exclusion criteria. Independent data extraction and assessment of risk of bias and study quality was carried out. RESULTS Nine studies (patient n = 361) out of 6594 records were included for analysis: 2 RCTs (n = 63), 3 prospective cohort studies (n = 151), and 4 retrospective cohort studies (n = 147). Studies were grouped per anatomic area of fixation. Four studies (n = 200) examined fixation of proximal humerus fractures. Two studies (n = 74) examined fixation of distal radius fractures. Two studies (n = 53) assessed outcomes of fixation of distal femur fractures. One study (n = 87) assessed the outcomes of fixation of ankle fractures. All nine studies reported very high union rates (from 91% in distal femur to 100% in upper limb) for the CFR-PEEK plate groups and low complication rates. There was no significant difference in clinical outcomes, and rate of complications as compared to the conventional plate groups. CONCLUSION CFR-PEEK plates have high union rates in extremity fracture fixation similar to conventional plates with comparable good clinical outcomes and a very low and comparable rate of complications. Considering their advantages, CFR-PEEK plates seem to be valid alternative to conventional plating.
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Affiliation(s)
- George D Chloros
- Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds, UK
| | - Apostolos D Prodromidis
- Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds, UK
| | - Jo Wilson
- Invibio Biomaterial Solutions Ltd, Hillhouse International, Thornton-Cleveleys, Lancashire, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds, UK.
- NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK.
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Saber AY, Said UN, Abdelmonem AH, Elsayed H, Taha M, Hussein W, Al-Hashimi K, El-Omar O, Elbeshbeshy M. Surgical Fixation of Three- and Four-Part Proximal Humeral Fractures Using the Proximal Humeral Interlocking System Plate. Cureus 2022; 14:e25348. [PMID: 35774694 PMCID: PMC9236683 DOI: 10.7759/cureus.25348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction The management of proximal humeral fractures ranges greatly from conservative management to surgical treatment. For those fractures requiring surgical treatment, internal fixation is the primary method. The aim of internal fixation is to achieve rigid fracture fixation until union occurs, return of shoulder range of motion, and minimise intra-and postoperative complications. The aim of this study was to evaluate the results of the Proximal Humeral Interlocking System Plate (PHILOS) used for the treatment of three-and four-part proximal humeral fractures. Materials and methods This study included 30 patients with a mean age of 54 years (range 20-80 years). Results were checked post-operatively with standard radiographs and clinical evaluation according to the Constant-Murley shoulder score. All patients were followed up for 12 months. Results Union was achieved in all patients with a mean neck/shaft angle of 130° (range 108°-150°). The mean Constant-Murley score at the final follow-up was 82.28 (range 67-96) correlating with good results. No patients developed an intraoperative or postoperative vascular injury, wound complications, or avascular necrosis of the humeral head. Conclusion Our study has shown that the surgical treatment of three- and four-part proximal humeral fractures with the use of the PHILOS plate leads to a good functional outcome. It has also demonstrated the PHILOS plate and is an effective system for fracture stabilisation provided the correct surgical technique is used with awareness of potential hardware complications.
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Patch DA, Reed LA, Hao KA, King JJ, Kaar SG, Horneff JG, Ahn J, Strelzow JA, Hebert-Davies J, Little MTM, Krause PC, Johnson JP, Spitler CA. Understanding postoperative rehabilitation preferences in operatively managed proximal humerus fractures: do trauma and shoulder surgeons differ? J Shoulder Elbow Surg 2022; 31:1106-1114. [PMID: 35143996 DOI: 10.1016/j.jse.2021.12.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 12/21/2021] [Accepted: 12/25/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal humerus fractures (PHFs) are common, and their incidence is increasing as the population ages. Despite this, postoperative rehabilitation remains unstandardized and little is known about surgeon preferences. The aim of this study was to assess differences in postoperative rehabilitation preferences and patient education between orthopedic trauma and shoulder surgeons. METHODS An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons to assess differences in postoperative rehabilitation preferences and patient counseling. Descriptive statistics were reported for all respondents, trauma surgeons, and shoulder surgeons. Chi-square and unpaired 2-sample t tests were used to compare responses. Multinomial regression was used to further elucidate the influence of fellowship training independent of confounding characteristics. RESULTS A total of 293 surgeons completed the survey, including 172 shoulder and 78 trauma surgeons. A greater proportion of trauma surgeons preferred an immediate weightbearing status after arthroplasty compared to shoulder surgeons (45% vs. 19%, P = .003), but not after open reduction and internal fixation (ORIF) (62% vs. 75%, P = .412). A greater proportion of shoulder surgeons preferred home exercise therapy taught by the physician or using a handout following reverse shoulder arthroplasty (RSA) (21% vs. 2%, P = .009). A greater proportion of trauma surgeons began passive range of motion (ROM) <2 weeks after 2-part fractures (70% vs. 41%, P < .001). Conversely, a greater proportion of shoulder surgeons began passive ROM between 2 and 6 weeks for 2-part (57% vs. 24%, P < .001) and 4-part fractures (65% vs. 43%, P = .020). On multinomial regression analysis, fellowship training in shoulder surgery was associated with preference for a nonweightbearing duration of >12 weeks vs. 6-12 weeks after ORIF. Similarly, fellowship training in shoulder surgery was associated with increased odds of preferring a nonweightbearing duration of <6 weeks vs. no restrictions and >12 weeks vs. 6-12 weeks after arthroplasty. Training in shoulder surgery was associated with greater odds of preferring a nonweightbearing duration prior to beginning passive ROM of 2-6 weeks vs. <2 weeks or >6 weeks for 2-part fractures, but not 4-part fractures. CONCLUSION Trauma surgeons have a more aggressive approach to rehabilitation following operative PHF repair compared to shoulder surgeons regarding time to weightbearing status and passive ROM. Given the increasing incidence of PHFs and substantial variations in reported treatment outcomes, differences in rehabilitation after PHF treatment should be further evaluated to determine the role it may play in the outcomes of treatment studies.
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Affiliation(s)
- David A Patch
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Logan A Reed
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Scott G Kaar
- Department of Orthopaedic Surgery, Saint Louis University, St Louis, MO, USA
| | - John G Horneff
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jason A Strelzow
- Department of Orthopaedic Surgery, The University of Chicago, Chicago, IL, USA
| | - Jonah Hebert-Davies
- Department of Orthopedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Milton T M Little
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Peter C Krause
- Department of Orthopaedic Surgery, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Joseph P Johnson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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Lazzari BJ, Yoo CJ, Kamson AO, Muzio AE, Lippe RW. Hawkins wiring for three-part fractures of the proximal humerus: A case series. Trauma Case Rep 2022; 38:100614. [PMID: 35146108 PMCID: PMC8819121 DOI: 10.1016/j.tcr.2022.100614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 11/25/2022] Open
Abstract
Three-part proximal humerus fractures in the elderly continue to be difficult to surgically treat. We evaluated the Hawkins wiring (HW) technique, which utilizes figure-of-eight tension band wiring, to treat three-part proximal humerus fractures involving the greater tuberosity. Currently, there is a paucity of data detailing patient outcomes and radiographic follow-up of this technique. The purpose of this case series is to evaluate patient reported outcomes and radiographic follow-up for fractures treated with this technique. Over two years, six patients at our institution underwent HW to treat three-part proximal humerus fractures. Average DASH and Oxford Shoulder scores (OSS) were 20.4 (range, 1-40) and 40 (range, 33-46) respectively. All patients had satisfactory return of function after surgery. Radiographic union was achieved in all six patients and there were no reported complications. HW technique is an efficacious treatment for three-part proximal humerus fractures in elderly patients.
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Affiliation(s)
- Bradley J. Lazzari
- Corresponding author at: 4300 Londonderry Rd, Harrisburg, PA 17109, United States of America.
| | - Charlie J. Yoo
- Department of Orthopedic Surgery, UPMC Harrisburg, Harrisburg, PA, United States of America
- Orthopedic Institute of Pennsylvania, Camp Hill, PA, United States of America
- UPMC Pinnacle, 4300 Londonderry Rd, Harrisburg, PA 17109, United States of America
| | - Anthony O. Kamson
- Department of Orthopedic Surgery, UPMC Harrisburg, Harrisburg, PA, United States of America
- Orthopedic Institute of Pennsylvania, Camp Hill, PA, United States of America
- UPMC Pinnacle, 4300 Londonderry Rd, Harrisburg, PA 17109, United States of America
| | - Anna E. Muzio
- Department of Orthopedic Surgery, UPMC Harrisburg, Harrisburg, PA, United States of America
- Orthopedic Institute of Pennsylvania, Camp Hill, PA, United States of America
- UPMC Pinnacle, 4300 Londonderry Rd, Harrisburg, PA 17109, United States of America
| | - Ronald W. Lippe
- Department of Orthopedic Surgery, UPMC Harrisburg, Harrisburg, PA, United States of America
- Orthopedic Institute of Pennsylvania, Camp Hill, PA, United States of America
- UPMC Pinnacle, 4300 Londonderry Rd, Harrisburg, PA 17109, United States of America
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Skura B, Glazier MT, Schuette HB, Passias BJ, Chang IR, Verre J, Mehta S, Taylor BC. The Corkscrew Technique for Removing a Fibular Strut Allograft From the Proximal Humerus. Cureus 2022; 14:e23233. [PMID: 35449668 PMCID: PMC9012660 DOI: 10.7759/cureus.23233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/05/2022] Open
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Luciani P, Procaccini R, Rotini M, Pettinari F, Gigante A. Angular stable plate versus reverse shoulder arthroplasty for proximal humeral fractures in elderly patient. Musculoskelet Surg 2022; 106:43-48. [PMID: 32504451 DOI: 10.1007/s12306-020-00669-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 05/26/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Treatment of complex proximal humeral fractures in the elderly is a challenge and reverse shoulder arthroplasty (RTSA) is now an important alternative to open reduction internal fixation (ORIF) with angular stable plate. The purpose of this study is to compare clinical and radiological outcomes of RTSA and ORIF in the elderly. METHODS We retrospectively analyzed patients treated for three- or four-part displaced fractures of the proximal humerus. Range of motion, disabilities of the arm, shoulder and hand (DASH) and Constant scores were recorded. X-ray exam in three projections completed the clinical observation at follow-up. RESULTS Forty-eight patients were enrolled after a mean follow-up of 37 months: 22 RTSA and 26 ORIF. Mean age at trauma was 74 years. Compared with RTSA patients, ORIF patients had significantly higher mean external rotation (28° vs. 14°) and better results in modal internal rotation (hand at D7 vs. hand at L5-S1). No significant differences were seen in DASH and Constant scores. Avascular necrosis and loss of reduction with varus dislocation of the humeral head were the most frequent causes of revision surgery in ORIF (34.6%) while the revision rate of the RTSA was 9.1%. CONCLUSION In this study, both treatments showed good clinical outcomes, but RTSA resulted in lower revision rate than ORIF. Even if external and internal rotation in RTSA patients were worse than ORIF, they did not affect the patient's quality of life. So, the reverse arthroplasty seems to be a more reliable treatment.
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Affiliation(s)
- P Luciani
- Clinical Orthopaedics, Department of Clinical and Molecular Science, Marche Polytechnic University, Via Tronto 10/A, 60126, Ancona, Italy.
| | - R Procaccini
- Clinical Orthopaedics, Department of Clinical and Molecular Science, Marche Polytechnic University, Via Tronto 10/A, 60126, Ancona, Italy
| | - M Rotini
- Clinical Orthopaedics, Department of Clinical and Molecular Science, Marche Polytechnic University, Via Tronto 10/A, 60126, Ancona, Italy
| | - F Pettinari
- Clinical Orthopaedics, Department of Clinical and Molecular Science, Marche Polytechnic University, Via Tronto 10/A, 60126, Ancona, Italy
| | - A Gigante
- Clinical Orthopaedics, Department of Clinical and Molecular Science, Marche Polytechnic University, Via Tronto 10/A, 60126, Ancona, Italy
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Current Role of Reverse Total Shoulder Arthroplasty for Fractures of the Proximal Humerus. J Orthop Trauma 2022; 36:e98-e105. [PMID: 34294668 DOI: 10.1097/bot.0000000000002238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.
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Oldrini LM, Feltri P, Albanese J, Marbach F, Filardo G, Candrian C. PHILOS Synthesis for Proximal Humerus Fractures Has High Complications and Reintervention Rates: A Systematic Review and Meta-Analysis. Life (Basel) 2022; 12:life12020311. [PMID: 35207598 PMCID: PMC8880552 DOI: 10.3390/life12020311] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose: The aim of this study was to quantify the rate of complications and reinterventions in patients treated with PHILOS plate for proximal humerus fractures (PHFs) synthesis. Methods: A comprehensive literature search was performed on the PubMed, Web of Science, Embase, and Cochrane databases up to 7 October 2021. Studies describing medium and long-term complications in PHF synthesis using the PHILOS plate were included. A systematic review and meta-analysis were performed on complications and causes of reinterventions. Assessment of risk of bias and quality of evidence was performed with the Downs and Black’s “Checklist for Measuring Quality”. Results: Seventy-six studies including 4200 patients met the inclusion criteria. The complication rate was 23.8%, and the main cause was screw cut-out (4.1%), followed by avascular necrosis (AVN) (3.1%) and subacromial impingement (1.5%). In patients over 55 years, the complication rate was 29.5%. In the deltopectoral (DP) approach the complication rate was 23.8%, and in the delto-split (DS) it was 17.5%, but no difference between the two approaches was seen when considering the type of fracture. The overall reintervention rate was 10.5% in the overall population and 19.0% in older patients. Conclusions: Proximal humerus synthesis with a PHILOS plate has high complications and reintervention rates. The most frequent complication was screw cut-out, followed by humeral head AVN and subacromial impingement. These results need to be further investigated to better understand both the type of patient and fracture that is more at risk of complications and reintervention and to compare pros and cons of the PHILOS plate with respect to the other solutions to manage PHFs.
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Affiliation(s)
- Lorenzo Massimo Oldrini
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900 Lugano, Switzerland; (L.M.O.); (J.A.); (F.M.); (G.F.); (C.C.)
| | - Pietro Feltri
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900 Lugano, Switzerland; (L.M.O.); (J.A.); (F.M.); (G.F.); (C.C.)
- Correspondence:
| | - Jacopo Albanese
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900 Lugano, Switzerland; (L.M.O.); (J.A.); (F.M.); (G.F.); (C.C.)
| | - Francesco Marbach
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900 Lugano, Switzerland; (L.M.O.); (J.A.); (F.M.); (G.F.); (C.C.)
| | - Giuseppe Filardo
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900 Lugano, Switzerland; (L.M.O.); (J.A.); (F.M.); (G.F.); (C.C.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Via Buffi 13, 6900 Lugano, Switzerland
| | - Christian Candrian
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, 6900 Lugano, Switzerland; (L.M.O.); (J.A.); (F.M.); (G.F.); (C.C.)
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Via Buffi 13, 6900 Lugano, Switzerland
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Davey MS, Hurley ET, Anil U, Condren S, Kearney J, O'Tuile C, Gaafar M, Mullett H, Pauzenberger L. Management options for proximal humerus fractures - A systematic review & network meta-analysis of randomized control trials. Injury 2022; 53:244-249. [PMID: 34974908 DOI: 10.1016/j.injury.2021.12.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/10/2021] [Accepted: 12/12/2021] [Indexed: 02/02/2023]
Abstract
AIMS The purpose of this study is to systematically review the randomized controlled trials on the various treatment options that can be utilized in the management of displaced proximal humerus fractures. MATERIALS & METHODS Based on the PRISMA guidelines, three independent reviewers performed a systematic review of the literature. Randomized control trials (RCTs) focusing on the outcomes of the following interventions in the management of PHFs were considered for inclusion; (1) non-operative or conservative (NOC) management, (2) open reduction and internal fixation (ORIF), (3) intra-medullary nailing (IMN), (4) shoulder hemi-arthroplasty (HA), and (5) reverse shoulder arthroplasty (RSA). Network meta-analyses were performed using R and studies were ranked according to their P-score. RESULTS Our study included 13 RCTs. RSA had improvements in abduction, constant score, flexion, as well as lowest rates of malunion and osteonecrosis when compared to other management modalities (P-Score = 0.9786, P-Score = 0.9998, P-Score = 0.9909, P-Score = 0.9590 and P-Score = 0.8042 respectively). HA was found to have improvements in health-related quality of life scores when compared to other management modalities (P-Score = 0.9672). ORIF had the highest improvement in quick disability of arm, shoulder and hand scores and visual analogue scale scores (P-Score = 0.8209 and P-Score = 0.7155 respectively). NOC was found to have the lowest rate of conversion to surgical intervention, with RSA having the lowest rate of surgical interventions (P-Score = 0.9186 and P-Score = 0.7497 respectively). DISCUSSION & CONCLUSION RSA offers satisfactory improvements in clinical and functional outcomes when compared to other non-operative and operative treatment options in the management of carefully selected proximal humerus fractures, with a minimal revision rate when compared to other surgical management modalities. LEVEL OF EVIDENCE I - Systematic Review & Meta-Analysis of Randomized Control Trials.
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Affiliation(s)
- Martin S Davey
- Sports Surgery Clinic, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Eoghan T Hurley
- Sports Surgery Clinic, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland; New York University Langone, New York, NY, United States of America
| | - Utkarsh Anil
- New York University Langone, New York, NY, United States of America
| | | | - Jack Kearney
- Royal College of Surgeons in Ireland, Dublin, Ireland
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Kong LP, Yang JJ, Wang F, Liu FX, Yang YL. Minimally invasive open reduction of greater tuberosity fractures by a modified suture bridge procedure. World J Clin Cases 2022; 10:117-127. [PMID: 35071511 PMCID: PMC8727274 DOI: 10.12998/wjcc.v10.i1.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/04/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Most greater tuberosity fractures can be treated without surgery but some have a poor prognosis. The surgical procedures for avulsion fractures of the humeral greater tuberosity include screw fixation, suture anchor fixation, and plate fixation, all of which have treatment-associated complications. To decrease surgical complications, we used a modified suture bridge procedure under direct vision and a minimally invasive small incision to fix fractures of the greater tuberosity of the humerus.
AIM To investigate the clinical efficacy and outcomes of minimally invasive modified suture bridge open reduction of greater tuberosity evulsion fractures.
METHODS Sixteen patients diagnosed between January 2016 and January 2019 with an avulsion-type greater tuberosity fracture of the proximal humerus and treated by minimally invasive open reduction and modified suture bridges with anchors were studied retrospectively. All were followed up by clinical examination and radiographs at 3 and 6 wk, 3, 6 and 12 mo after surgery, and thereafter every 6 mo. Outcomes were assessed preoperatively and postoperatively by a visual analog scale (VAS), the University of California Los Angeles (UCLA) shoulder score, the American Shoulder and Elbow Surgeon score (ASES), and range of motion (ROM) for shoulders.
RESULTS Seven men and nine women, with an average age of 44.94 years, were evaluated. The time between injury and surgery was 1-2 d, with an average of 1.75 d. The mean operation time was 103.1 ± 7.23 min. All patients achieved bone union within 3 mo after surgery. VAS scores were significantly decreased (P = 0.002), and the mean degrees of forward elevation (P = 0.047), mean degrees of abduction (P = 0.035), ASES score (P = 0.092) were increased at 3 wk. The UCLA score was increased at 6 wk (P = 0.029) after surgery. The average degrees of external rotation and internal rotation both improved at 3 mo after surgery (P = 0.012 and P = 0.007, respectively). No procedure-related deaths or incision-related superficial or deep tissue infections occurred.
CONCLUSION Modified suture bridge was effective for the treatment of greater tuberosity evulsion fractures, was easier to perform, and had fewer implants than other procedures.
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Affiliation(s)
- Ling-Peng Kong
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong Province, China
| | - Juan-Juan Yang
- Department of Radiotherapy, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan 250117, Shandong Province, China
| | - Fu Wang
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong Province, China
| | - Fan-Xiao Liu
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong Province, China
| | - Yong-Liang Yang
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, Shandong Province, China
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KOKKALIS ZINONT, BAVELOU EKATERINI, PAPANIKOS EFSTRATIOS, PANAGOPOULOS ANDREAS, MEGAS PANAGIOTIS. AVOIDING COMPLICATIONS OF LOCKING PLATING FOR PROXIMAL HUMERUS FRACTURES. J Long Term Eff Med Implants 2022; 32:73-81. [DOI: 10.1615/jlongtermeffmedimplants.2022040229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Müller M, Greve F, Crönlein M, Zyskowski M, Pesch S, Biberthaler P, Kirchhoff C, Beirer M. Reconstruction or replacement? A challenging question in surgical treatment of complex humeral head fractures in the elderly. Arch Orthop Trauma Surg 2022; 142:3247-3254. [PMID: 34432097 PMCID: PMC9522728 DOI: 10.1007/s00402-021-04124-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/12/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Surgical treatment of complex humeral head fractures in the elderly is challenging due to osteoporotic bone, comorbidities and reduced compliance. The treatment strategy (reconstruction versus replacement) should allow for a functional aftercare and result in a high patient satisfaction. Major complications leading to surgical revision are crucial and should be avoided. The purpose of this study was to analyse the major complication rate leading to surgical revision and the patient-based outcome in complex humeral head fractures of the elderly population treated either using locking plate fixation (LCP) or reversed total shoulder arthroplasty (rTSA). MATERIALS AND METHODS All patients older than 65 years surgically treated due to a four-part fracture of the proximal humerus between 2003 and 2015 were enrolled in our retrospective study. Major complications and revision rates were recorded and functional outcome was assessed using the Munich Shoulder Questionnaire (MSQ) allowing for qualitative self-assessment of the Shoulder Pain and Disability Index (SPADI), of the Disability of the Arm, Shoulder and Hand (DASH) score and of the Constant Score. RESULTS A cohort of 103 patients with a mean age of 73.4 ± 6.2 years suffering from four-part fractures of the humeral head were enrolled. 63 patients were treated using the LCP fixation compared to 40 rTSAs. There were no significant differences in the patient-reported functional outcome. The revision rate was significantly higher in the LCP group (10/63; 15.9%) compared to the rTSA group (1/40; 2.5%). Reasons for revision were avascular head necrosis, cut-out of screws, secondary dislocation of the greater tuberosity and hypersensitivity to metal. CONCLUSIONS Reversed total shoulder arthroplasty and locking plate fixation are both established surgical procedures for the management of complex proximal humerus fractures in the elderly leading to similar functional results. However the revision rate in the rTSA group was significantly lower. Primary rTSA should, therefore, be favoured in multimorbid elderly patients with an increased complication risk to avoid repeated anaesthesia.
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Affiliation(s)
- M. Müller
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - F. Greve
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - M. Crönlein
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - M. Zyskowski
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - S. Pesch
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - P. Biberthaler
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - C. Kirchhoff
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
| | - M. Beirer
- grid.6936.a0000000123222966Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, 81675 München, Germany
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Dankl L, Schmoelz W, Hoermann R, Euler S. Evaluation of mushroom-shaped allograft for unstable proximal humerus fractures. Arch Orthop Trauma Surg 2022; 142:409-416. [PMID: 33355717 PMCID: PMC8843909 DOI: 10.1007/s00402-020-03715-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 12/06/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Proximal humerus fractures are common injuries of the elderly. Different treatment options, depending on fracture complexity and stability, have been recommended in the literature. Particularly for varus displaced fractures with a lack of medial support, and patients suffering from osteoporosis, structural allografts can be used to enhance the stability of the construct. An individually shaped allograft has been suggested in the literature and investigated in a clinical setting. However, biomechanical properties have yet to be evaluated. MATERIALS AND METHODS Twenty-four fresh-frozen humeri and 12 femoral heads were obtained, and an unstable three-part fracture of the humeral head was simulated. Fracture fixation was achieved by using a locking plate in both groups. In the test group, a mushroom-shaped allograft was tailored out of a femoral head to individually fit the void inside the humeral head. Specimens were fitted with a 3D motion analysis system and cyclically loaded with a stepwise increasing load magnitude in a varus-valgus bending test until failure or up to a maximum of 10,000 load cycles. RESULTS The mushroom group reached a significantly higher number of load cycles (8342; SD 1,902; CI 7133-9550) compared to the control group (3475; SD 1488; CI 2530-4420; p < 0.001). Additionally, the test group showed significantly higher stiffness values concerning all observational points (p < 0.001). CONCLUSION This mushroom-shaped allograft in combination with a locking plate significantly increased load to failure as well as stiffness of the construct when exposed to varus-valgus bending forces. Therefore, it might be a viable option for surgical treatment of unstable and varus displaced proximal humerus fractures to superiorly prevent loss of reduction and varus collapse.
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Affiliation(s)
- Lukas Dankl
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Werner Schmoelz
- Department of Orthopaedics and Traumatology, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Romed Hoermann
- Division Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Simon Euler
- Trauma and Orthopedic Surgery, Sanatorium Kettenbruecke der Barmherzigen Schwestern GmbH, Innsbruck, Austria
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Biomechanical study of Proximal humeral fracture fixation: Locking plate with medial support screw vs. locking plate with intramedullary fibular graft. Clin Biomech (Bristol, Avon) 2021; 90:105510. [PMID: 34673363 DOI: 10.1016/j.clinbiomech.2021.105510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the biomechanical properties of two different fixation constructs in varus collapse proximal humerus fracture, locking plate with medial support screw and locking plate with intramedullary fibular graft. METHODS We used 8 pairs of undamaged fresh-frozen humen cadaveric humeri and fibula from patients ranging in age from 62 to 81 years. We simulated a proximal humerus fracture with medial comminution using wedge shaped osteotomy. One group was fixed with locking plate with medial support screws, the other group with locking plate with intramedullary fibular graft. Biomechanical test was carried out using servohydraulic material testing system. We measured displacement of specimens under cyclic load test, maximum failure load, initial stiffness, and mode of failure under increasing load test. FINDINGS Under cyclic loading, the displacement of the specimen was significantly less in the locking plate with fibular strut graft group than in the locking plate with medial support screws group. (p = 0.012) Under increasing load test, the Locking plate with fibular strut graft group showed higher values in both maximum failure load and initial stiffness than the Locking plate with medial support screws group, and this was statistically significant. (p = 0.012, p = 0.001). INTERPRETATION In biomechanical study, the locking plate with fibular strut graft showed significantly better results in all of the maximum failure load, initial stiffness, and gap depletion compared to the locking plate with medial support screws. LEVEL OF EVIDENCE Level IV.
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Proximal humeral fractures treated with an intramedullary cage and plate: clinical and radiographic outcomes at a minimum of 1 year postoperatively. J Shoulder Elbow Surg 2021; 30:2786-2794. [PMID: 34022366 DOI: 10.1016/j.jse.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 05/01/2021] [Accepted: 05/02/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal humeral fractures are common injuries. Although certain fracture types may benefit from surgery including open reduction-internal fixation (ORIF), the optimal method for fixation is unclear. Newer implant designs that improve healing by minimizing hardware failure and recurrent fracture displacement may optimize clinical outcomes. METHODS Over a 27-month period, 37 consecutive patients with proximal humeral fractures were treated by a single surgeon with a lateral humeral plate through which an intramedullary nitinol cage was inserted. Additional screws were placed through the tuberosities and cage as required. Fractures were classified by both the Neer classification and angulation or displacement in the coronal plane. At most recent follow-up, radiographic results, patient-reported outcome measurements, range of motion, complications, and reoperations were recorded. RESULTS Thirty-one patients had a minimum of 1 year of clinical and radiographic follow-up. The average follow-up period was 91 weeks. By use of the Neer classification, there were 4 two-part, 21 three-part, and 6 four-part fractures. Twenty-one fractures were displaced in valgus and 10 in varus. Outcome measurements at most recent follow-up demonstrated an average American Shoulder and Elbow Surgeons score of 68; Single Assessment Numeric Evaluation score of 70; Quick Disabilities of the Arm, Shoulder and Hand score of 27; Veterans RAND-12 Physical Component Score of 37 and Mental Component Score of 51; Constant score of 55; Patient-Reported Outcomes Measurement Information System score of 29; and Oxford Shoulder Score of 23. Average active range of motion showed forward elevation of 134°, abduction of 91°, external rotation with the arm at the side of 30° (range, -10° to 60°), and internal rotation with the arm at the side to L1 (range, T6-S4). There were 11 complications (35%), including 2 cases of axillary nerve neurapraxia that resolved and 4 cases of avascular necrosis (13%). Unplanned reoperations were performed in 6 patients (19%). One patient underwent revision for loose hardware removal, 1 patient underwent revision ORIF after a fall, and 4 patients required component removal and revision to shoulder arthroplasty. No screw cutout or varus head collapse occurred. CONCLUSION The management of proximal humeral fractures remains challenging. Our results demonstrate similar fracture healing, clinical improvement, and complication rates compared with conventional ORIF with screws and a side plate. At 1 year of follow-up, there were low rates of recurrent fracture displacement and screw cutout. There was a higher-than-expected rate of avascular necrosis as compared with other studies using a similar fixation construct. Larger studies and longer follow-up may demonstrate decreased rates of revision surgery and superior outcomes. Additional studies may determine whether this fixation method is superior to others for proximal humeral fractures.
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Foruria AM, Martinez-Catalan N, Valencia M, Morcillo D, Calvo E. Proximal humeral fracture locking plate fixation with anatomic reduction, and a short-and-cemented-screws configuration, dramatically reduces the implant related failure rate in elderly patients. JSES Int 2021; 5:992-1000. [PMID: 34766075 PMCID: PMC8568824 DOI: 10.1016/j.jseint.2021.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Multiple studies have reported an unacceptable implant-related complication rate in proximal humeral fractures treated with locking plates, particularly in older patients. Our objective was to compare the fracture fixation failure rates in elderly patients, after a dedicated technique for locking plate fixation with cement augmentation or without it. Methods A total of 168 open reduction and internal fixation with locking plates were performed for complex proximal humerus fractures by a single surgeon in 136 women and 32 men older than 65 years of age (average 76 years). Treatment groups included group 1 with noncemented screws (n = 90) and group 2 with cemented screws (n = 78). As per Mayo-FJD Classification, there were 74 (44%) varus posteromedial impaction, 41 (24%) algus impaction, 46 (28%) surgical neck, and 7 (4%) head dislocation injuries. A retrospective radiographic and a clinical analysis was performed. Results At a mean follow-up of 33 months, the implant failure rate was significantly lower in the cement augmentation group (1% vs. 8%, P = .03). The overall complication rate was 21% (25% group 1, 15% group 2; P = .1). Global avascular necrosis was associated with sustaining a valgus impacted fracture (P = .02 odds ratio 5.7), but not to augmentation. Partial avascular necrosis occurred only in patients treated with cemented screws (3.8%). The overall revision rate was 9% in both groups. Forward elevation was 126 ± 36 degrees and external rotation was 44 ± 19 degrees. The mean Constant score was 70 ± 15 in group 1 and 76 ± 15 in group 2 (P = .03). Conclusion Cement augmentation significantly decreased the rate of implant failure. Good results are expected for most patients treated with this technique.
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Affiliation(s)
- Antonio M Foruria
- Fundación Jiménez Díaz University Hospital at Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery Department, Madrid, Spain
| | - Natalia Martinez-Catalan
- Fundación Jiménez Díaz University Hospital at Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery Department, Madrid, Spain
| | - María Valencia
- Fundación Jiménez Díaz University Hospital at Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery Department, Madrid, Spain
| | - Diana Morcillo
- Fundación Jiménez Díaz University Hospital at Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery Department, Madrid, Spain
| | - Emilio Calvo
- Fundación Jiménez Díaz University Hospital at Shoulder and Elbow Reconstructive Surgery Unit, Orthopedic Surgery Department, Madrid, Spain
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A nomogram for predicting reduction loss risk after locking plate fixation for proximal humeral fractures. Injury 2021; 52:2947-2951. [PMID: 34399985 DOI: 10.1016/j.injury.2021.07.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 07/20/2021] [Accepted: 07/27/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of our study was to determine the risk factors for reduction loss in patients with proximal humeral fractures after locking plate fixation and establish a nomogram prediction model. METHODS We retrospectively analyzed the clinical data of proximal humeral fractures patients who had been surgically treated for locking plate in our institution from January 2016 to December 2018. Perioperative information was obtained through the electronic medial record system, univariate and multivariate analyzes were performed to determine the risk factors of reduction loss, and a nomogram model was constructed to predict the risk of reduction loss. The predictive performance and consistency of the model were evaluated by the consistency coefficient (C-index) and the calibration curve, respectively. RESULTS 115 patients were finally enrolled in our study. Multivariate analysis results showed that age, fracture classification, medial comminution, and calcar screw status were independent risk factors for reduction loss. The accuracy of the contour map for predicting transfusion risk was 0.944. CONCLUSION We found a correlation between reduction loss and age, fracture classification, medial comminution, and calcar screw status after locking plate fixation for proximal humeral fractures patients. Our nomogram is helpful for clinicians to identify high-risk patients, early intervention and reduce the incidence of reduction loss.
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Shin MJ, Kim H, Kim DM, Park D, Jeon IH, Koh KH. Role of inferomedial supporting screws for secondary varus deformity in non-osteoporotic proximal humerus fracture: A biomechanical study. Arch Orthop Trauma Surg 2021; 141:1517-1523. [PMID: 33051712 DOI: 10.1007/s00402-020-03627-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate the effect of a medial support screw through a proximal humerus fracture. For this purpose, we verified whether the biomechanics are different according to the position of the screw while using the same number of screws. In addition, we tried to verify whether the insertion of additional inferomedial screws would make a difference in stability. MATERIALS AND METHODS Twenty-four proximal humerus bones were included in the study. A two-part fracture was created and fixed using a locking plate. Cyclic loading and load-to-failure test were applied to three groups: group A (proximal 6 screws + calcar screws), group B (proximal 6 screws), and group C (proximal 4 screws + calcar screws). Interfragmentary gaps were measured following cyclic loading and compared. The failure was defined when the bone breakage or medial gap closing was observed during ultimate failure load applied. The load-to-failure, maximum displacement, stiffness, and yield load were recorded and compared. RESULTS The interfragmentary gap was differently reduced by 0.29 ± 0.14 mm, 0.73 ± 0.25 mm, and 0.53 ± 0.09 mm following 1000 cyclic loading for groups A, B, and C, respectively. The load-to-failure was 945.22 ± 101.02 N, 941.40 ± 148.90 N, and 940.58 ± 91.78 N in groups A, B, and C, respectively. The stiffness of group A (214.76 ± 34.0 N/mm) was superior when compared to that of group C (171.12 ± 23.0 N/mm; p = 0.025). The maximum displacement prior to failure, yield load, showed no significant difference between comparative groups. CONCLUSION Our study did not show any additional biomechanical effects with the use of inferomedial supporting screws in non-osteoporotic proximal humerus fracture, besides making the fracture-plate construct stiff. The role of the inferomedial supporting screw was also unclear. However, the groups that used increased screw fixation and inferomedial screw insertion seemed to be more resistant to cyclic loading.
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Affiliation(s)
- Myung Jin Shin
- Department of Orthopedic Surgery, College of Medicine, Asan Medical Center, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hyojune Kim
- Department of Orthopedic Surgery, College of Medicine, Asan Medical Center, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Dong Min Kim
- Department of Orthopedic Surgery, College of Medicine, Asan Medical Center, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Dongjun Park
- Department of Orthopedic Surgery, College of Medicine, Asan Medical Center, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - In-Ho Jeon
- Department of Orthopedic Surgery, College of Medicine, Asan Medical Center, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kyoung Hwan Koh
- Department of Orthopedic Surgery, College of Medicine, Asan Medical Center, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Lari A, Alherz M, Jarragh A. A torque induced iatrogenic fracture of the humeral shaft in proximal humeral fracture plating - A case report and biomechanical perspectives. Ann Med Surg (Lond) 2021; 68:102615. [PMID: 34381603 PMCID: PMC8339138 DOI: 10.1016/j.amsu.2021.102615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 07/25/2021] [Accepted: 07/25/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Proximal humerus fractures are common amongst the elderly and osteoporotic cohorts. Common treatment methods include proximal locking plates. In this case, we describe an iatrogenic fracture of the proximal humeral shaft during screw insertion under power. Similar cases have not been described previously in open reduction and internal fixation of a proximal humerus fracture. Further, we focus particularly on precautionary measures that aim to avoid such complications that may lead to considerable morbidity. Case presentation We describe a case of a 65 year old osteoporotic female who underwent open reduction internal fixation of a proximal humerus fracture complicated by an unusual iatrogenic humeral fracture at the level of insertion of the distal screw, likely secondary to inserting the proximal locking screws under power. Conclusion In this case, we explore the possible factors leading to the fracture and precautionary measures to avoid them. The rate of iatrogenic intraoperative fractures are likely underreported and have not been described in open reduction and internal fixation of an existing fracture. The underlying factors that may predispose to such complications have not been previously described in similar cases. This case serves as a warning of an unanticipated complication and describes the potential biomechanical factors involved. Proximal humerus fractures are common in the elderly and osteoporotic cohorts. Iatrogenic fractures intraoperatively during open reduction internal fixation have not been reported in orthopedic trauma. Care should be taken to avoid excessive energy/torque at screw sites while using electric drivers. The biomechanical precautions during fixation should be visited and more extensively described to avoid similar incidents.
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Affiliation(s)
- Ali Lari
- AlRazi Orthopedic Hospital, AlSabah Medical Region, Kuwait
| | | | - Ali Jarragh
- Department of Orthopedic Surgery, Jaber Alahmed Alsabah Hospital, South Surra, Kuwait
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