The importance of inferomedial support in the hot air balloon technique for treatment of 3-part proximal humeral fractures

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Self-made dentation hook plate associated with hot-air balloon technique on treatment of Mutch or type isolated greater tuberosity fractures of humerus]

Objective

To observe effectivness and safeness of self-made dentation hook plate associated with hot-air balloon technique in treating Mutch Ⅰ or Ⅱ type isolated greater tuberosity fractures of humerus.

Methods

Between January 2016 and December 2018, 15 patients with Mutch Ⅰ or Ⅱ type greater tuberosity fractures were treated with self-made dentation hook plate associated with hot-air balloon technique. There were 9 males and 6 females with an average age of 45.1 years (range, 29-62 years). The injury causes included falling injury in 9 patients and traffic accident injury in 6 patients. According to Mutch classification, 4 cases were MutchⅠ type and 11 cases were Mutch Ⅱ type. There were 7 cases with anterior dislocation of shoulder. The time from injury to operation was 2-10 days (mean, 4.5 days).

Results

All 15 patients were followed up 8-16 months, with an average of 13.5 months. There was no infection of incision, loss of reduction of fracture block, delayed union or nonunion. The average time of fracture union was 6.5 months (range, 4-8 months). One patient had axillary paralysis at 1 day after operation, and was treated with nutritional nerve therapy, the symptoms disappeared after 2.5 months. Three patients had slight subacromial impingement. After fracture healing, the hook plate was taken out in advance, and the pain and abnormal noise disappeared during shoulder abduction. At last follow-up, Costant-Murley score used to evaluate shoulder joint function was 88-100, with an average of 96.8; 8 cases were excellent, 7 cases were good, and the excellent and good rate was 100%. The internal fixator was removed after 8-16 months after the secondary operation with no re-fracture occurred.

Conclusion

The self-made dentation hook plate associated with hot-air balloon technique is a safe and reliable method for the treatment of Mutch Ⅰ or Ⅱ type isolated greater tuberosity fracture of humerus.

Fixation of 4-part fractures of the proximal humerus: Can we identify radiological criteria that support locking plates or IM nailing? Comparative, retrospective study of 107 cases

INTRODUCTION

No objective criteria exist to help surgeons choose between IM nailing and plate fixation for 4-part fractures of the proximal humerus. The goal of this study was to identify radiological criteria that would make one technique a better choice than the other.

MATERIAL AND METHODS

This was a comparative, multicentre, retrospective study of 54 cases of antegrade nailing and 53 cases of plating performed between 1st January 2009 and 31 December 2011 for 4-part fractures of the proximal humerus. All patients had a minimum radiological and clinical follow-up of 18 months. The functional outcomes were evaluated using the weighted Constant score; a poor result was defined as a weighted Constant score<70%. The following radiological criteria were evaluated during the preoperative assessment and at the last follow-up: initial displacement and reduction of humeral head and tuberosities; morphology of the medial column (i.e. calcar comminution, posteromedial hinge, size of metaphyseal head extension); occurrence of avascular necrosis (AVN).

RESULTS

After an average follow-up of 42 months, the weighted Constant scores and rate of poor outcomes were 77% and 48% in the nail group and 81% and 38% in the plate group, respectively (ns). The humeral head was reduced into an anatomical position, valgus or varus in 57%, 30% and 13% of cases in the nail group, and 58%, 29% and 13% in the plate group, respectively. The tuberosities healed in an anatomical position in 72% of nail cases and 70% of plate cases (ns). Only the presence of a medial hinge preoperatively had an effect on the functional outcomes in the nail and plate groups: the weighted Constant scores (P=0.05) and rate of poor outcomes (P=0.02) were 82% and 52% in the nail group and 97% and 9% in the plate group, respectively. The complication rates were comparable: the rates of AVN and articular screw penetration were 17% and 11% in the nail group, and 15% and 11% in the plate group, respectively. The surgical revision rate was 18.5% in the nail group and 30% in the plate group.

CONCLUSION

If the medial hinge is preserved, we recommend locking plate fixation. In other cases, either technique can be used as long as the general rules of internal fixation are applied: reduction of the tuberosities, varus correction and stabilization of the calcar area.

LEVEL OF EVIDENCE

IV, retrospective study.

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

Background

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

Materials and methods

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

Results

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

Conclusions

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

Level of evidence

Level IV, Systematic review.

Is there any advantage in placing an additional calcar screw in locked nailing of proximal humeral fractures?

BACKGROUND

The objective of this study was to evaluate the biomechanical effect of an additional unlocked calcar screw compared to a standard setting with three proximal humeral head screws alone for fixation of an unstable 2-part fracture of the surgical neck.

HYPOTHESIS

The additional calcar screw improves stiffness and failure load.

METHODS

Fourteen fresh frozen humeri were randomized into two equal sized groups. An unstable 2-part fracture of the surgical neck was simulated and all specimens were fixed with the MultiLoc(®)-nail. Group I represented a basic screw setup, with three locked head screws and two unlocked shaft screws. Group II was identical with a supplemental unlocked calcar screw (CS). Stiffness tests were performed in torsional loading, as well as in axial and in 20° abduction/20° adduction modes. Subsequently cyclic loading and load-to-failure tests were performed. Resulting stiffness, displacement under cyclic load and ultimate load were compared between groups using the t-test for independent variables (α=0.05).

RESULTS

No significant differences were observed between the groups in any of the biomechanical parameters. Backing out of the CS was observed in three cases.

DISCUSSION

The use of an additional unlocked calcar screw does not provide mechanical benefit in locked nailing of an unstable 2-part fracture of the surgical neck.