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Adeyemo A, Bertha N, Perry KJ, Updegrove G. Implant Selection for Proximal Humerus Fractures. Orthop Clin North Am 2021; 52:167-175. [PMID: 33752838 DOI: 10.1016/j.ocl.2020.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Proximal humerus fractures (PHF) are a common orthopedic injury; however, their treatment remains largely controversial with evidence supporting a wide array of treatments. Although many injuries can be treated nonoperatively, there has been much debate about surgical management of PHF. A detailed review of the literature was performed relative to operative management options specifically related to implant choices. Although no definitive answers are available regarding best practice, there is literature to guide operative decision-making and implant selection based on both patient- and surgeon-specific factors.
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Affiliation(s)
- Adeshina Adeyemo
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA
| | - Nicholas Bertha
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA
| | - Kevin J Perry
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA
| | - Gary Updegrove
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA.
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Biomechanical analysis of plate systems for proximal humerus fractures: a systematic literature review. Biomed Eng Online 2018; 17:47. [PMID: 29703261 PMCID: PMC5923007 DOI: 10.1186/s12938-018-0479-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 04/18/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Proximal humerus fractures are the third most common in the human body but their management remains controversial. Open reduction and internal fixation with plates is one of the leading modes of operative treatment for these fractures. The development of technologies and techniques for these plates, during the recent decades, promise a bright future for their clinical use. A comprehensive review of in vitro biomechanical studies is needed for the comparison of plates' mechanical performance and the testing methodologies. This will not only guide clinicians with plate selection but also with the design of future in vitro biomechanical studies. This review was aimed to systematically categorise and review the in vitro biomechanical studies of these plates based on their protocols and discuss their results. The technologies and techniques investigated in these studies were categorised and compared to reach a census where possible. METHODS AND RESULTS Web of Science and Scopus database search yielded 62 studies. Out of these, 51 performed axial loading, torsion, bending and/or combined bending and axial loading while 11 simulated complex glenohumeral movements by using tendons. Loading conditions and set-up, failure criteria and performance parameters, as well as results for each study, were reviewed. Only two studies tested four-part fracture model while the rest investigated two- and three-part fractures. In ten studies, synthetic humeri were tested instead of cadaveric ones. In addition to load-displacement data, three-dimensional motion analysis systems, digital image correlation and acoustic emission testing have been used for measurement. CONCLUSIONS Overall, PHILOS was the most tested plate and locking plates demonstrated better mechanical performance than non-locking ones. Conflicting results have been published for their comparison with non-locking blade plates and polyaxial locking screws. Augmentation with cement [calcium phosphate or poly(methyl methacrylate)] or allografts (fibular and femoral head) was found to improve bone-plate constructs' mechanical performance. Controversy still lies over the use of rigid and semi-rigid implants and the insertion of inferomedial screws for calcar region support. This review will guide the design of in vitro and in silico biomechanical tests and also supplement the study of clinical literature.
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Laux CJ, Grubhofer F, Werner CML, Simmen HP, Osterhoff G. Current concepts in locking plate fixation of proximal humerus fractures. J Orthop Surg Res 2017; 12:137. [PMID: 28946902 PMCID: PMC5613450 DOI: 10.1186/s13018-017-0639-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 09/17/2017] [Indexed: 12/27/2022] Open
Abstract
Despite numerous available treatment strategies, the management of complex proximal humeral fractures remains demanding. Impaired bone quality and considerable comorbidities pose special challenges in the growing aging population. Complications after operative treatment are frequent, in particular loss of reduction with varus malalignment and subsequent screw cutout. Locking plate fixation has become a standard in stabilizing these fractures, but surgical revision rates of up to 25% stagnate at high levels. Therefore, it seems of utmost importance to select the right treatment for the right patient. This article provides an overview of available classification systems, indications for operative treatment, important pathoanatomic principles, and latest surgical strategies in locking plate fixation. The importance of correct reduction of the medial cortices, the use of calcar screws, augmentation with bone cement, double-plate fixation, and auxiliary intramedullary bone graft stabilization are discussed in detail.
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Affiliation(s)
- Christoph J Laux
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
| | - Florian Grubhofer
- Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Clément M L Werner
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hans-Peter Simmen
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Georg Osterhoff
- Department of Trauma Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
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Euler SA, Petri M, Venderley MB, Dornan GJ, Schmoelz W, Turnbull TL, Plecko M, Kralinger FS, Millett PJ. Biomechanical evaluation of straight antegrade nailing in proximal humeral fractures: the rationale of the "proximal anchoring point". INTERNATIONAL ORTHOPAEDICS 2017; 41:1715-1721. [PMID: 28497166 DOI: 10.1007/s00264-017-3498-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Varus failure is one of the most common failure modes following surgical treatment of proximal humeral fractures. Straight antegrade nails (SAN) theoretically provide increased stability by anchoring to the densest zone of the proximal humerus (subchondral zone) with the end of the nail. The aim of this study was to biomechanically investigate the characteristics of this "proximal anchoring point" (PAP). We hypothesized that the PAP would improve stability compared to the same construct without the PAP. METHODS Straight antegrade humeral nailing was performed in 20 matched pairs of human cadaveric humeri for a simulated unstable two-part fracture. RESULTS Biomechanical testing, with stepwise increasing cyclic axial loading (50-N increments each 100 cycles) at an angle of 20° abduction revealed significantly higher median loads to failure for SAN constructs with the PAP (median, 450 N; range, 200-1.000 N) compared to those without the PAP (median, 325 N; range, 100-500 N; p = 0.009). SAN constructs with press-fit proximal extensions (endcaps) showed similar median loads to failure (median, 400 N; range, 200-650 N), when compared to the undersized, commercially available SAN endcaps (median, 450 N; range, 200-600 N; p = 0.240). CONCLUSIONS The PAP provided significantly increased stability in SAN constructs compared to the same setup without this additional proximal anchoring point. Varus-displacing forces to the humeral head were superiorly reduced in this setting. This study provides biomechanical evidence for the "proximal anchoring point's" rationale. Straight antegrade humeral nailing may be beneficial for patients undergoing surgical treatment for unstable proximal humeral fractures to decrease secondary varus displacement and thus potentially reduce revision rates.
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Affiliation(s)
- Simon A Euler
- Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria. .,The Steadman Clinic, 181 West Meadow Drive, Suite 400, Vail, CO, 81657, USA. .,Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO, 81657, USA.
| | - Maximilian Petri
- The Steadman Clinic, 181 West Meadow Drive, Suite 400, Vail, CO, 81657, USA.,Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO, 81657, USA.,Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Melanie B Venderley
- Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO, 81657, USA
| | - Grant J Dornan
- Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO, 81657, USA
| | - Werner Schmoelz
- Department of Trauma Surgery and Sports Traumatology, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Travis Lee Turnbull
- Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO, 81657, USA
| | - Michael Plecko
- Unfallkrankenhaus Graz, Göstinger Str. 24, 8020, Graz, Austria
| | - Franz S Kralinger
- Department of Trauma Surgery, Wilhelminenspital, Montlearstr. 37, 1160, Vienna, Austria
| | - Peter J Millett
- The Steadman Clinic, 181 West Meadow Drive, Suite 400, Vail, CO, 81657, USA.,Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO, 81657, USA
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Fischer C, Frank M, Kunz P, Tanner M, Weber MA, Moghaddam A, Schmidmaier G, Hug A. Dynamic contrast-enhanced ultrasound (CEUS) after open and minimally invasive locked plating of proximal humerus fractures. Injury 2016; 47:1725-31. [PMID: 27242329 DOI: 10.1016/j.injury.2016.05.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 04/26/2016] [Accepted: 05/06/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Closed reduction and locked plate fixation of proximal humerus fractures with the minimally invasive deltoid-splitting approach intends to minimize soft tissue damage although axillary nerve injury has been reported. The aim of this study was to assess the deltoid muscle perfusion with dynamic contrast-enhanced ultrasound (CEUS) as novel technique and evaluate its relation to the functional and neurologic outcome after open (ORIF) and minimally invasive (MIPO) fracture fixation. PATIENTS AND METHODS 50 patients, 30 with deltopectoral ORIF and 20 with deltoid-splitting MIPO approach were examined 6-49 months after surgery. Only patients with a healthy, contralateral shoulder were selected. Shoulder function, satisfaction as well as psychosocial outcome were assessed with established scores (Constant, DASH, Simple Shoulder Test, ASES, SF-12). Electromyography (EMG) of the deltoid muscle was performed to determine axillary nerve damage. Ultrasound of both shoulders included CEUS and Power Doppler after deltoid muscle activation via active abduction for two minutes. RESULTS None of the examinations and scores showed significant differences between ORIF and MIPO patients, the psychosocial outcome was similar. The fracture types were equally distributed in both groups. The normalized Constant Score was 76.3±18.6 in the ORIF and 81.6±16.1 in the MIPO group (p=0.373). Deltoid muscle perfusion in CEUS and Power Doppler revealed no differences between both approaches. EMG excluded functionally relevant axillary nerve injuries. Compared with the contralateral shoulder, Constant- and ASES-Scores (p≤0.001 for both ORIF and MIPO) as well as the deltoid CEUS perfusion (ORIF p=0.035; MIPO p=0.030) were significantly worse for both approaches. CONCLUSIONS Convincing consensus of functional, ultrasonographic and neurologic examinations demonstrated comparable outcomes after deltopectoral and deltoid-splitting approach. The quantification of the deltoid muscle perfusion with CEUS indicates that the proclaimed benefits of the MIPO approach on soft tissue might not be as great as expected.
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Affiliation(s)
- Christian Fischer
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.
| | - Marion Frank
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Pierre Kunz
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Tanner
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Marc-André Weber
- Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Arash Moghaddam
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Gerhard Schmidmaier
- Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas Hug
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
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