Intramedullary nailing of the proximal humerus: evolution, technique, and results

Intramedullary versus locking plate fixation for proximal humerus fractures: indications and technical considerations

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Intramedullary Nailing Technique for Proximal Humeral Fractures Using a Straight Antegrade Nail with Locking Tuberosity Fixation

Background

Intramedullary straight nail fixation of proximal humeral fractures using a locking mechanism provides advantages compared with plating, including (1) less soft-tissue dissection, which preserves periosteal blood supply and soft-tissue attachments; (2) improved construct stability for comminuted fractures or osteopenic bone; and (3) shorter operative time for simpler fractures.

Description

The patient is placed in the beach-chair position with the head of the bed elevated approximately 45°. The fracture is reduced with use of closed or percutaneous methods, ideally, or with an open approach if required. Temporary fragment fixation with percutaneous Kirschner wires can be utilized. A 1-cm incision is made just anterior to the acromioclavicular joint, overlying the zenith of the humeral head and in line with the diaphysis. A guide-pin is then placed through this incision and is verified to be centrally located and in line with the humeral diaphysis on fluoroscopic views. The guide-pin is advanced into the diaphysis. A cannulated 9-mm reamer is inserted over the guide-pin to create a starting position. The nail is then inserted, with adequate fragment reduction maintained until the proximal nail portion is buried under the subchondral humeral head. The proximal screw trajectory and alignment are checked fluoroscopically. The proximal locking screws are pre-drilled and inserted first using percutaneous drill sleeves through the radiolucent targeting jig. The screw is inserted through the guide and is advanced into the nail until appropriately seated. This process is then repeated for the other proximal screws as necessary. Finally, the distal diaphyseal screws are pre-drilled and inserted in a similar percutaneous fashion using the jig, and the jig is removed. Final orthogonal images are obtained. Copious irrigation of the incisions is performed and they are closed and dressed with a sterile dressing. The operative arm is placed in an abduction sling.

Alternatives

Alternative treatment options for proximal humeral fractures include nonoperative treatment with use of a sling, percutaneous reduction and internal fixation with Kirschner wires, open reduction and internal fixation with a locking plate and screw construct, hemiarthroplasty, and anatomic or reverse total shoulder arthroplasty1.

Rationale

The presently described technique for proximal humeral fracture fixation using a straight, antegrade, locking nail allows for minimal soft-tissue disruption, preserving vascularity and soft-tissue support and achieving angularly stable fixation in often osteopenic bone. The superior and in-line entry point avoids complications of rotator cuff injury and/or subacromial impingement. The proximal locking screws avoid complications of screw penetration or migration. This technique is appropriate for surgically indicated Neer 2-, 3-, and 4-part humeral fractures, including in elderly patients, when the humeral head fragment remains viable1-5.

Expected Outcomes

Based on available Level-III and IV evidence using this technique, patients should expect recovered motion and the ability to perform daily activities independently, with a mean active elevation of 132° to 136°1,4,6, external rotation of 37° to 52°1,4,6, and internal rotation to L31. Pain scores improved significantly from preoperatively to postoperatively, with a mean pain score of 1.4 on the visual analogue scale3,4,6. Patient-reported outcomes were good to excellent, with Single Assessment Numerical Evaluation (SANE) scores of 80% to 81%1,6, mean Constant scores from 71 to 811,3,4,6, and high rates of patient satisfaction (97% satisfied or very satisfied)4. Studies also demonstrated good to excellent fracture healing, with no tuberosity migration and low rates of nonunion (0% to 5%)1,6 and humeral head necrosis (0% to 4%)1,4. Revision rates ranged from 10.5% to 16.7%4,6.

Important Tips

The starting position of the guide-pin must be central and at the zenith of the humeral head on the anteroposterior Grashey and the scapular Y views, and the guide-pin must be aligned with the diaphysis prior to advancing it.Failure to bluntly dissect the percutaneous incisions risks injury to the axillary nerve.Verify correct version of the nail prior to drilling any screws, to avoid incorrect version and potential loss of functional rotation.

Acronyms and Abbreviations

ABD = abductionAP = anteroposteriorCT = computed tomographyER = external rotationFF = forward flexion (forward elevation)IR = internal rotationSANE = Single Assessment Numerical EvaluationSSV = Subjective Shoulder ValueVAS = Visual Analogue Scale.

Lateral minimally invasive plate osteosynthesis (MIPO) with long PHILOS for proximal metaphyseal-diaphyseal humeral fracture: surgical techniques and a clinical series

The minimally invasive plate osteosynthesis (MIPO) for proximal metaphyseal-diaphyseal humeral fracture is an effective alternative treatment with satisfactory outcomes. In this study, we described the surgical techniques and clinical results using MIPO via a lateral approach and long PHILOS plate fixation in 23 patients. All fractures were successfully united within a mean union time of 13.5 weeks (range 9-18). There was no iatrogenic radial nerve palsy. The deltoid power was grade 5 in all patients, except for 2 patients who had associated brachial plexus injury and gunshot injury at the deltoid muscle. The mean Constant-Murley score was 85.6 (range 16-98) and DASH score was 12.1 (range 1.7-85). Based on these findings, the lateral MIPO with long PHILOS plate fixation could be an alternative for the proximal metaphyseal-diaphyseal fractures of the humeral shaft.

Technical Tips for Reduction and Stable Fixation of Proximal Humerus Fractures

The surgical treatment of proximal humerus fractures, though common, is associated with surprisingly high complication rates upward of 34%. Obtaining a reduction and placing a stable fixation can be challenging because many fractures treated surgically are comminuted and occur in osteoporotic bone. Nevertheless, innovations in technique and implant design are mitigating some failures. These innovations include the use of fibular strut allograft and other fixation adjuncts, the correct placement of calcar screws and other locking fixation, and having a systematic approach to reduction and intraoperative imaging to ensure the restoration of anatomy. This review and accompanying video highlight various technical strategies to maximize the success of surgical treatment for these challenging injuries.

Influence of Proximal Humeral Cortical Bone Thickness on the Radiographic Outcome After Osteosynthesis of Proximal Humeral Fractures: Propensity Matching Score Analysis

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.

Intramedullary nailing versus cemented plate for treating metastatic pathological fracture of the proximal humerus: a comparison study and literature review

BACKGROUND

Pathological fracture of the humerus causes severe pain, limited use of the hand, and decreased quality of life. This study aimed to compare the outcomes of intramedullary nailing and locking plate in treating metastatic pathological fractures of the proximal humerus.

METHODS

This retrospective comparison study included 45 patients (22 male, 23 female) with proximal humerus metastatic pathological fractures who underwent surgical treatment between 2011 and 2022. All data were collected from medical records and were analyzed retrospectively. Seventeen cases underwent intramedullary nailing plus cement augmentation, and 28 cases underwent locking plate plus cement augmentation. The main outcomes were pain relief, function scores, and complications.

RESULTS

Among 45 patients with mean age 61.7 ± 9.7 years, 23 (51.1%) had multiple bone metastases, and 28 (62.2%) were diagnosed with impending fractures. The nailing group had significantly lower blood loss [100 (60-200) versus 500 (350-600) ml, p < 0.001] and shorter hospital stay (8.4 ± 2.6 versus 12.3 ± 4.3 days, p < 0.001) than the plating group. Average follow-up time of the nailing group was 12 months and 16.5 months for the plating group. The nailing group had higher visual analog scale (VAS) scores than the plating group, indicating greater pain relief with nailing [7 (6-8) versus 6 (5-7), p = 0.01]. Musculoskeletal Tumor Society functional scores [28 (27-29) versus 27 (26.5-28.5), p = 0.23] were comparable between groups. No complications, local recurrence, or revision surgery were reported until the last follow-up in either group. However, one case in the plating group had a humeral head collapse and fragmentation without needing revision surgery.

CONCLUSIONS

Intramedullary nailing with cement augmentation is a viable option for treating proximal humerus metastatic pathological fracture, providing rigid fixation and better pain relief resulting in earlier mobility to optimize functional outcomes. Less invasive procedure with less blood loss and shorter hospital stay also benefits patients. Level of evidence Level II. Trial registration statement Not applicable.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reduction of geometric misfit in straight antegrade humeral nailing by evaluating the effect of entry point angulation using a three-dimensional computational analysis

BACKGROUND

Straight antegrade intramedullary nails are generally inserted utilising the apex as the surgical entry point in accordance with the mechanical axis of the bone. Our objective is to optimise the bone-nail fit in intramedullary nailing by subjecting the surgical entry point to varying angulations in both the mediolateral and anterior-posterior directions via a quantitative fit assessment in each configuration to identify the optimal angulation, defined as the angulation with the lowest occurrence of thin-out to improve nail fitting within the humerus.

METHODS

Computed tomography (CT) scans from 10 cadaveric humeri models were used to generate three-dimensional bone models. The centreline profile of each humerus model was determined by dividing the humerus into multiple slices and identifying its respective centroid. The guidewire and nail models were then established and inserted into the humerus using the apex as the standard entry point. The bone-nail fit was measured utilising three fit quantification parameters: thin-out distance, nail protrusion volume into the cortical shell and deviation distance (top, middle, bottom) between the nail's longitudinal axis and medullary cavity centroid.

FINDINGS

Results revealed a statistically significant association between angulation and occurrence of thin-out (p < .001) and showed that the optimally angulated entry point resulted in decreased cortical breach across the nail insertion depth compared to the standard entry point.

INTERPRETATION

Our findings suggested that the current straight nail design may require further modifications to optimise the nail trajectory within the medullary canal by decreasing the bone-nail geometric mismatch to potentially maximise its working length.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Comparison of surgical efficacy of locking plates and interlocking intramedullary nails in the treatment of proximal humerus fractures

Background

The objective of this study was to evaluate the efficacy of locking plates versus interlocking intramedullary nails in the treatment of proximal humerus fractures to provide clinical data support and theoretical guidance.

Methods

Patients with proximal humerus fracture from the Third hospital of Shijiazhuang city and Third hospital of Hebei medical university and from January 2017 to June 2019 were selected, included and divided into the locking plate group and the interlocking intramedullary nail group according to the intervention received. Information pertaining to the perioperative period (operation time, hospital stay, blood loss, etc.) of patients in both groups was collected. VAS pain scores, shoulder activity Constant-Murley scores and postoperative complications were documented. The perioperative data of the two groups were compared, and P < 0.05 was considered statistically significant.

Results

A total of 64 patients were enrolled, including 36 patients in the locking plate group, with a mean age of 61.3 ± 13.9 years, while the mean age of the interlocking intramedullary nail group was 65.6 ± 11.2 years. There was no statistical difference in gender, affected side, injury mechanism and Neer classification between the two groups (P > 0.05). However, the average operation time of the locking plate group was shorter than that of the interlocking nail group (84.9 ± 11.7 vs. 102.6 ± 22.1 min, P = 0.00), and the intraoperative blood loss of the locking plate group (137.4 ± 16.8 ml) was higher than that of the interlocking nail group (72.5 ± 10.5 ml, P = 0.00). There was no significant difference in the VAS score and Constant-Murley score between these two groups at the final follow-up.

Conclusion

Interlocking intramedullary nails are more minimally invasive than locking plates, but fracture reduction and fixation take longer. There was no significant difference in pain and shoulder function scores between the two internal fixation strategies for the treatment of proximal humerus fracture.

Humeral shaft fracture: Outcomes of percutaneous antegrade intramedullary nailing using the long Telegraph® nail with dynamic distal locking

INTRODUCTION

Antegrade intramedullary nailing (IMN) in humeral shaft fracture (HSF) has been abandoned by certain orthopedic surgeons due to rotator cuff injury caused by curved nails, and to unreliable anatomical results. The purpose of this study was to report outcomes of straight percutaneous intramedullary nailing with dynamic distal locking in HSF.

HYPOTHESIS

Percutaneous antegrade intramedullary nailing using a long straight nail with dynamic distal locking improves radiological and functional outcome in HSF.

MATERIAL AND METHODS

A retrospective study was carried out, between january 2008 and june 2018, about 76 consecutive patients undergoing straight percutaneous antegrade IMN with dynamic distal locking for isolated closed displaced HSF. Eighteen patients were excluded; 36 were reviewed in June 2018 to assess Constant score.

RESULTS

There were 35 women and 23 men, with a mean age of 53years. All fractures were closed: 36 type A, 16 type B and 6 type C according to the AO/OTA classification. Healing was achieved in 97% of cases, at a mean 13±3weeks. There were no cases of infection or secondary nerve injury. The mean Constant score was 78±13.

DISCUSSION

Surgical treatment of humeral shaft fractures is a subject of discussion, without any consensus. Based on our experience, percutaneous antegrade IMN with dynamic distal locking improves anatomical and functional outcomes, provided that the surgical technique is mastered, which requires a learning curve.

LEVEL OF EVIDENCE

IV, retrospective study.

Blocking screw augmentation in intramedullary nailing for displaced surgical neck fractures of the proximal humerus

A displaced surgical neck fracture can be a good indication for antegrade intramedullary nailing. However, nail insertion may result in malreduction and translational displacement of the humeral head fragment because of muscle traction and size discrepancies between the diameters of the medullary canal and the intramedullary nail. We used blocking screw augmentation in 20 fractures with residual medial displacement of the distal fragment after nail insertion to anatomically reduce displacement of the fracture and to maintain the reduced position before bone union. A blocking screw was placed percutaneously at the lateral side of the canal. Next, a straight intramedullary nail was reinserted medial to the blocking screw. Finally, the nail was locked both proximally and distally. All cases showed bone union without fixation failure at the time of the final follow-up. Blocking screw augmentation with intramedullary nailing is feasible for the treatment of humeral surgical neck fractures and is thought to be helpful for fracture reduction during surgery and stable fixation after surgery.

Third-generation intramedullary nailing for displaced proximal humeral fractures in the elderly: quality of life, clinical results, and complications

INTRODUCTION

Antegrade insertion of third-generation intramedullary nail (IMN) has been shown to provide excellent results in young patients for treatment of displaced two-part surgical neck fracture. In elderly patients, osteoporosis makes internal fixation problematic and frequently contributes to failed fixation and poor clinical results. The purpose of this study was to report the health-related quality of life (HRQoL), functional results, and postoperative complications obtained with straight third-generation antegrade nailing of proximal humerus fractures (PHFs) in elderly patients.

METHODS

A retrospective review of 32 patients aged 80 y.o. or older presenting a two-part or three-part PHFs treated with a straight IMN with a minimum follow-up of 12 months. Results assessed included 1) radiographic measures 2) clinical data: Charlson Comorbidity Index (CCI), VAS, range of motion (ROM), Individual Relative Constant score (IRC), Simple Shoulder Test (SST) and 3) Health-related Quality of life (HRQoL) with the EQ-5D index/EQ-VAS.

RESULTS

Mean age was 82.1 (range 80-90) and mean follow-up was 45.6 months (range 16-53 months) with 91% of female patients and a mean CCI 4.6. 81% were two-part surgical neck fractures and 19% were three-part greater tuberosity fractures. The mean neck-shaft angle (NSA) at final follow-up was 132º ± 17.9º. 15.6% underwent hardware removal because of subacromial impingement and one patient (3%) was revised to RSA because of severe secondary fracture displacement. Mean IRC was 67,7 ± 30, the mean SST and VAS-Pain were 8.1 ± 3.1 and 3.2 ± 3.2, respectively, and the mean EQ-5D/EQ-VAS were 0.40 ± 0.33/64.2 ± 8.9. At last review, mean active forward flexion, abduction, and external rotation were 115º ± 35º, 100º ± 35º, and 20º ± 15º, respectively.

CONCLUSION

Appropriate selection of fracture and proper operative technique with a third-generation nail result in good functional results and good HRQol with a low complication rate in elderly population.

Outcomes of Mini-Invasive Arthroscopic Arthrolysis Combined with Locking Screw and/or Intramedullary Nail Extraction after Osteosynthesis of the Proximal Humerus Fracture

Data on the effectiveness of arthroscopic arthrolysis and extraction of osteosynthetic material after osteosynthesis of the proximal humerus in patients with persisting problems are rare and insufficient. In this study, we performed arthroscopic arthrolysis and extraction of fixation screws, and, where protruding, extraction of the nail in 34 patients with problems persisting 12 months after osteosynthesis of the proximal humerus using an intramedullary nail. The effectiveness of the treatment was assessed using the Constant-Murley shoulder score and forward flexion difference between the treated arm and the contralateral one. A median increase of 16 points in CMS score and 30 degrees reduction in the arm forward flexion difference was recorded 12 months after the arthroscopy. The improvement was significantly higher in the patient group with intramedullary nail extraction (however, this group had worse pre-operative values and the screw was only extracted where likely to cause problems). The median time to heal was 11 weeks; no serious peri- or post-procedural complications occurred. Mini-invasive arthroscopic arthrolysis combined with extraction of osteosynthetic material proved to be a safe and effective method for treatment of patients after osteosynthesis of the proximal humerus using an intramedullary nail with persisting pain and/or mobility limitation.

Secondary radial neuropathy after closed intramedullary nailing of humeral shaft fractures. Results over a 10-year period

Background. Retrospective study to examine secondary radial nerve palsy after humeral shaft fixation with closed locked intramedullary nailing. Materials and methods. Patients were identified from the hospitals’ registration systems for humeral shaft fractures, nerve lesions, plating, nailing and external fixation during a 10-year period from January 2007 to December 2016. All radial nerve lesions were registered and followed-up in patient files. Results. 89 patients with locked intramedullary nailing were available for an outpatient follow-up. Mean age was 67 years at the time of injury. 72 fractures were non-pathological. Of these, 31 were nonunions. 28, 61 and zero were identified in the proximal, middle and distal thirds of the humeral shaft respectively. 76 procedures were closed and 13 were with open reduction. Six radial nerves had nerve exploration. Eight patients developed immediate postoperative radial nerve palsies. Of these, six developed after closed surgery, two after nerve exploration. Of seven available patients with a radial nerve palsy, six of these remitted. Two patients were later surgically explored. One patient out of 89 sustained a verifiable permanent radial nerve paralysis. Conclusions. In this study, the risk of a radial nerve palsy was 7.9 % with closed locked intramedullary nailing. This study suggests that exploration of the radial nerve is not necessary routinely in order to prevent radial nerve lesions when performing closed intramedullary nailing for humeral shaft fractures in adults with a preoperative normal radial nerve function. Level of Evidence : Level IV.

Newer generation straight humeral nails allow faster bone healing and better functional outcome at mid-term

Purpose

Although proximal and diaphyseal humerus fractures are frequent, the optimal management remains controversial. Antegrade nailing prevents further damage to the soft tissues and to the vascularization, but it has been associated with postoperative shoulder pain and dysfunction. During the latest years a straight nail design was developed to minimize these problems.

Methods

A total of 243 patients who had undergone surgery for antegrade intramedullary humeral nailing between January 2013 and July 2018 in A. Gemelli Trauma Center were divided into two groups according to the nail design used: straight nail group (S-group) and curvilinear nail group (C-group). Clinical data were collected using assessment forms (SF12-v2, Quick-DASH, ASES and Constant-Murley). Radiographic bone healing was assessed with RUST score at 30, 90 and 180 days after surgery.

Results

The S-group was made up of 128 patients with a mean age of 59 ± 19 (range 18–97) and a mean follow-up of 46 ± 9 months. The C-group was made up of 115 patients with a mean age of 53 ± 16 (range 18–88) and a mean follow-up of 51 ± 8 months. The S-group had a mental component summary (MCS) score of 54.3 ± 7.7 and a physical component summary (PCS) score of 46 ± 10.2, the C-group had a MCS score of 50.9 ± 8.4 and a PCS score of 44.1 ± 7.4. Quick-DASH and ASES were respectively 18.8 ± 4.3 and 78.6 ± 8.2 in the S-group, 28.3 ± 11.6 and 72.1 ± 13.5 in the C-group with statistical significance. Constant-Murley score was 73.9 ± 9.1 in the S-group (76% of the contralateral healthy side) and 69.4 ± 10.4 in the C-group (73% of the contralateral healthy side). The radiographic union score in the S-group was 4.1 ± 0.3 at 30 days after surgery, 7 ± 0.8 at 90 days and 10 ± 1.2 at 180 days, while in the C-group it was 4.2 ± 0.4 at 30 days, 6.4 ± 0.7 at 90 days and 9 ± 0.9 at 180 days.

Conclusion

Newer generation straight nails allow a faster bone healing and better functional outcome at mid-term follow up.

Level of evidence III.

MutiLoc Nail Versus Philos Plate in Treating Proximal Humeral Fractures: A Retrospective Study Among the Alderly

Background

Proximal humeral fractures (PHFs) account for 4–5% of all fractures in the elderly. There is still a controversy among the treatments in the displaced PHFs. Our aim was to explore the clinical outcome of PHFs with the treatment of MultiLoc nail or Philos plate in the elderly patients.

Methods

A total of 82 sustained elderly patients with PHFs were finally recruited between Dec 2016 and Dec 2017. 34 patients were treated with MultiLoc nail and 48 patients were treated with Philos plate. The demographics, fracture types, blood loss, operation time, union time, postoperative complications, visual analog scores (VASs), Constant scores, American Shoulder and Elbow Scores (ASESs), and neck-shaft-angle (NSA) between the two groups were compared.

Results

No differences were observed in the demographics, fracture types, VAS, Constant scores, and ASES scores between the two groups at final follow-up. Compared with the plate group, the blood loss, operation time, and union time were significantly lower in the nail group (all P < .05). The rate of general complications was 54.17% in the plate group, which was higher than that in the nail group (26.47%, P = .01). Three patients experienced reoperation in the plate group (3/48; 6.25%), but none in the nail group. Although there were no significant differences in intraoperative NSA between the two groups, the NSA at final follow-up in the nail group was much higher than the plate group (137.55 ± 5.53°vs 134.47 ± 5.92°, P = .02).

Conclusions

Multiloc intramedullary nail showed the similar effectiveness of final VAS, final Constant scores, and ASES scores in PHFs treatment with Philos plate. However, MultiLoc nail is superior to Philos plate in blood loss, operation time, complications, reoperation rate, and the change of NSA.

Differences in soft tissue damage using a percutaneous versus open approach for antegrade straight humeral nailing: a quantitative and qualitative anatomical study

BACKGROUND

Percutaneous insertion of third-generation straight humeral nails is a recent alternative to the conventional open method. Rather than splitting, retracting and subsequently repairing the supraspinatus fibers to visualize the humeral head entry site, the percutaneous approach utilizes a cannulated awl to enter the intramedullary canal through the supraspinatus fibers without visualizing internal shoulder structures. Despite recent evidence demonstrating satisfactory outcomes in the percutaneous method, the potential for iatrogenic injury to the rotator cuff and other shoulder structures is not fully understood.

MATERIALS AND METHODS

We performed an anatomical study of 46 shoulders in 23 cadavers to compare damage caused to internal shoulder structures between the open and percutaneous techniques. Dimensions and morphologies of supraspinatus and humeral head perforations were recorded.

RESULTS

The percutaneous technique produced greater latitudinal tearing (p = 0.002) and less longitudinal tearing (p < 0.001) of muscle fibers, however there was no difference in supraspinatus hole area (p = 0.748). The long head biceps tendon was within 3 mm of the bone entry hole in 13 (28%) shoulders, with one shoulder in the open group exhibiting full tendon transection.

CONCLUSIONS

Percutaneous insertion of intramedullary nails using a cannulated awl appears to produce similar soft tissue and bone entry site morphology as compared to the conventional open technique. The percutaneous method was associated with slightly greater latitudinal tearing, however the effects of this remain to be clarified through clinical studies. External rotation should be avoided during instrumentation to reduce the risk of biceps tendon transection.

Implant Selection for Proximal Humerus Fractures

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.

Arthroscopic intramedullary nailing of humeral fractures through the rotator interval

INTRODUCTION

Antegrade nailing of humeral fractures is a proven technique with well-documented results. The standard surgical approach requires incision of the supraspinatus tendon to insert a nail, which comes with the risk of damaging the rotator cuff. The aims of this study were to describe a new surgical technique for arthroscopic humeral nailing that does not require opening the rotator cuff and to report the clinical and radiological outcomes of this technique.

MATERIALS AND METHODS

This was a single center, retrospective study of patients who had a humeral shaft or surgical neck fracture at our hospital in 2017 and underwent antegrade intramedullary nailing by arthroscopy. The nail was introduced through the rotator interval without opening the rotator cuff. All were reviewed at 1-year postoperative: clinical examination (joint range of motion and Constant score) plus AP and lateral radiographs of the shoulder.

RESULTS

Eighteen patients (12 women, 6 men) with a mean age of 65.4 years (37-84) were included retrospectively. One patient died during the follow-up period thus 17 patients were available for analysis. At the 1-year follow-up, the mean forward flexion was 152.1° (90-180), the mean external rotation was 56.1° (30-80), the mean absolute Constant score was 73.9 (54-88) points and the mean adjusted Constant score was 93.5 (67-100) points. Bone union was achieved in 16/17 patients (94%) with 1 patient experiencing a nonunion. There were no complications.

CONCLUSION

Arthroscopic antegrade nailing of humeral shaft and surgical neck fractures through the rotator interval yields good clinical and radiological results in our hands. This new, rotator cuff-sparing technique is a viable option for treating humeral fractures by arthroscopy.

LEVEL OF EVIDENCE

IV; retrospective study without control group.

Effectiveness of reverse total shoulder arthroplasty for primary and secondary fracture care: mid-term outcomes in a single-centre experience

BACKGROUND

The introduction of reverse total shoulder arthroplasty (RSA) as a treatment option in complex proximal humeral fractures, has significantly extended the surgical armamentarium. The aim of this study was to investigate the mid-term outcome following fracture RSA in acute or sequelae, as well as salvage procedures. It was hypothesized that revision RSA (SRSA) leads to similar mid-term results as primary fracture treatment by RSA (PRSA).

METHODS

This retrospective study describes the radiological and clinical mid-term outcomes in a standardized single-centre and Inlay design. Patients who underwent RSA in fracture care between 2008 and 2017 were included (minimum follow-up: 2 years, minimum age: 60 years). The assessment tools used for functional findings were range of motion (ROM), Visual Analogue Scale, absolute (CS) plus normative Constant Score, QuickDASH, and Subjective Shoulder Value. All adverse events as well as the radiological results and their clinical correlations were statistically analysed (using p < .05and 95% confidence intervals).

RESULTS

Following fracture RSA, 68 patients were included (mean age: 72.5 years, mean follow-up: 46 months). Forty-two underwent primary RSA (PRSA), and 26 underwent revision RSA (SRSA). Adverse advents were observed in 13% (n = 9/68). No statistically significant results were found for the scores of the PRSA and SRSA groups, while the failed osteosynthesis SRSA subgroup obtained statistically significantly negative values for ROM subzones (flexion: p = .020, abduction: p = .020). Decreased instances of tubercle healing were observed for the in PRSA group relative to the SRSA group (p = .006). The absence of bony healing of the tubercles was related to significant negative clinical and subjective outcomes (all scores: p < .05, external rotation: p= .019). Significant postoperative improvements were evaluated in the SRSA group (CS: 23 to 56 at mean, p = .001), the time from index surgery to operative revision revealed no associations in functional findings.

CONCLUSIONS

RSA is an effective option in severe shoulder fracture management with predictable results for salvage as well as first-line treatment. Promising mid-term functional results, reasonable implant survival rates, and high patient satisfaction can be achieved.

LEVEL OF EVIDENCE

Level III.

Effects of arthroscopic pancapsular release for proximal humeral fractures treated with intramedullary nailing: a retrospective study

Background

Proximal humeral fractures are one of the most common fractures in adults. Some patients treated operatively have restriction in range of motion (ROM) after surgery. This study aimed to evaluate arthroscopic pancapsular release in patients with severe stiffness after treatment with intramedullary nailing for proximal humeral fractures.

Methods

This study included 12 patients (7 women and 5 men) who underwent arthroscopic pancapsular release in the beach-chair position between May 2015 and February 2018. Intraoperative findings were recorded, and ordinary (with scapulothoracic motion) and true (without scapulothoracic motion) glenohumeral ROMs were measured with a goniometer. The American Shoulder and Elbow Surgeons shoulder score, Shoulder Rating Scale score of the University of California, Los Angeles scoring system, and Constant score were compared before and after the release. The Wilcoxon signed rank and Mann-Whitney U tests were used to analyze data.

Results

The average age of the patients was 65.1 years (standard deviation, 9.5 years), and the mean follow-up period after the release was 30.6 months (standard deviation, 11.7 months). All ROMs on the affected side after surgery were significantly greater than those before surgery in all directions. However, ROMs in forward flexion, lateral elevation, and external rotation with the arm at the side and at 90° of forward flexion on the affected side postoperatively were significantly lower than those on the unaffected side. All scores were significantly greater after surgery than before surgery.

Conclusion

Arthroscopic pancapsular release is effective for patients with proximal humeral fractures treated with intramedullary nailing.

Operative Management of Proximal Humerus Nonunions in Adults: A Systematic Review

OBJECTIVES

To characterize the literature on operative interventions for proximal humerus nonunions in adults. Second, to identify prognostic factors associated with outcomes for locked plate open reduction and internal fixation (ORIF).

DATA SOURCES

PubMed, EMBASE, MEDLINE, Scopus, and Cochrane databases were searched for articles from 1990 to 2020.

STUDY SELECTION

Studies reporting outcomes of proximal humerus nonunions managed with ORIF, hemiarthroplasty (HA), total shoulder arthroplasty (TSA), or reverse TSA (RTSA) were included. Studies failing to stratify outcomes by treatment or fracture sequelae were excluded.

DATA EXTRACTION

Two authors independently extracted data and appraised study quality using MINORS score.

DATA SYNTHESIS

Descriptive statistics were reported. Outcomes for ORIF and arthroplasty groups were not compared due to differing patient populations.

CONCLUSIONS

Thirty-seven articles were included, representing 508 patients (246 ORIF, 137 HA/TSA, and 125 RTSA). Patients managed by ORIF were younger with simpler fracture patterns than those managed by arthroplasty. Regarding ORIF, locked plates achieved highest union rates (97.0%), but clinical outcomes were comparable with all plate fixation constructs [forward flexion (FF): 123-144°; external rotation: 42-46°; Constant score: 75-84]. Complication and reoperation rates for ORIF were 26.0% and 14.6%, respectively. Furthermore, subgroup analysis of locked plate ORIF demonstrated shorter consolidation time with initial conservative fracture management (4.3 vs. 6.0 months) and autograft use (3.9 vs. 5.5 months). With arthroplasty, RTSA demonstrated greater forward flexion (109.4° vs. 97.2°) but less external rotation (16.5° vs. 36.8°) than HA/TSA. Complication and reoperation rates were 18.2% and 10.9% for HA/TSA and 21.6% and 14.4% for RTSA, respectively.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

In vitro evaluation of the tension band suture method for proximal humerus fracture treatment

Background

Proximal humeral fractures are common, and more than half occur in patients over 65 years of age. Operative treatment may be recommended for displaced, complicated fractures; however, surgery may lead to displacement of the greater tuberosity or humeral head. Supplemental tension band sutures have been recommended to prevent such a complication. In this study, we investigate the best combination of suture, washer, and threading angle for proximal humeral fractures from a mechanical view.

Methods

The mechanical durability of 18 combinations of suture materials (Fiberwire, Ethibond, and Surgilon), threading washers (ring washer, disc washer), and threading angles (15 or 45°) were examined via a cyclic loading test.

Results

The most durable combination in the cyclic loading test consisted of threading the Fiber Wire to the washer ring using only one hole (ring washer-1) at 45°. In contrast, the most vulnerable combination was threading Ethibond to the washer disc at 15°. Breakage of all suture materials occurred at the suture-washer interface, and no failure or loosening of the knots was observed. FiberWire gradually eroded until the loss of equilibrium; whereas the rupture of Ethibond and Surgilon occurred suddenly.

Conclusions

From a mechanical viewpoint, we demonstrated that applying a supplemental tension band suture using FiberWire with a single-hole ring washer threaded at a wider angle is recommended.

Locking Plates versus Locking Intramedullary Nails Fixation of Proximal Humeral Fractures Involving the Humeral Shaft: A Retrospective Cohort Study

Background

For proximal humeral fractures (PHFs), locking intramedullary nails and locking plates have been widely used. However, few reports have been published on the therapy of complex PHFs accompanying humeral shaft fractures. Therefore, we performed this research to analyze the effectiveness of locking intramedullary nails and locking plates in the management of proximal humeral fractures involving the humeral shaft.

Material/Methods

We retrospectively reviewed 40 cases diagnosed with proximal humeral fractures involving the humeral shaft fixed with either locking intramedullary nails or locking plates with at least of 2 years’ follow-up. Clinical data were obtained from the medical records. Follow-up data included the Constant-Murley score, American Shoulder and Elbow Surgeons score (ASES), visual analog scale score (VAS), and the relative strength of the supraspinatus and deltoid muscles.

Results

In total, 19 locking plate patients and 21 locking intramedullary nail patients were analyzed. The average follow-up period was 35 months in the locking plate group and 34 months in the locking intramedullary nail group. There were obvious differences in the intraoperative blood loss, time of operation, and the length of operative incision between the 2 groups (p<0.05). There were no significant differences between the groups in Constant-Murley score, ASES, VAS, or the relative strength of supraspinatus and deltoid muscles.

Conclusions

For PHFs involving the humeral shaft, both locking plates and locking intramedullary nails can achieve satisfactory functional results in the long-term follow-up assessment. The locking intramedullary nail group was superior with regards to intraoperative blood loss, time of operation, and length of incision.

How to improve the outcomes of surgically treated proximal humeral osteoporotic fractures? A narrative review

Proximal humeral fractures (PHF) are the third most common non-vertebral fragility fractures after hip and distal radius. It still controversial which treatment might be more appropriate, and surgically treated outcomes depends also on an appropriate technique. In order to clarify surgical indications, tips and pitfall a narrative review was conducted. Pinning, external fixation, plating and internal fixators has each one its advantages and disadvantages. During the procedure an appropriate use of the fixation device and handling of the soft tissue might be associated with better outcomes. Calcar comminution, varus angulation, medial dislocation of the shaft, fracture-dislocation are factors that could lead to choose a replacement. Hemiarthroplasty and reverse total shoulder arthroplasty are the most common prosthesis used in PHF. The restoration of humeral length and tuberosities might lead to an improvement in clinical outcomes and prosthesis survivorship.

Clinical and radiographic outcomes after antegrade intramedullary nail fixation of humeral fractures

INTRODUCTION

Humerus fractures are frequent, accounting for about 3-4% of all fractures in adults. Treatment for fractures of the diaphyseal and proximal meta-epiphyseal regions remains controversial: there is no unanimity in the scientific community about the superiority of surgical treatment over non-surgical treatment and which is the best between possible surgical treatments. Among the choices for surgical treatment the most commonly used implants are the locking-compression plate and the intramedullary nailing. The purpose of this study was to perform a clinical and radiographic follow-up in patients who underwent surgical procedures for reduction and osteosynthesis of proximal or diaphyseal humeral fractures by means of anterograde intramedullary nailing with a straight-shaped nail.

PATIENTS AND METHODS

A clinical and radiographic follow-up was performed in 56 patients who underwent surgical procedures for reduction and osteosynthesis of proximal or diaphyseal humeral fractures by means of antegrade intramedullary nailing using Synthes MultiLoc® system. Clinical data were collected using subjective quality of life assessment forms (SF12-v2), quality of life related to specific disabilities assessment forms (Quick-DASH, ASES score, WORC) and objective functional assessment forms (Constant-Murley score). The radiographic Follow-Up was performed at 30, 90 and 180 days from the date of the surgery.

RESULTS

Almost all patients were able to return to a satisfactory quality of life, comparable with the one before the traumatic episode. The functional results were assessed as excellent or good with almost complete recovery of the range of motion and moderate recovery of strength. The residual pain encountered was moderate or zero. The average QuickDASH score was 17.7 ± 4.3 (range 9.1 - 27.3). The average ASES score was 73.8 ± 8.1 (range 58.3 - 88.3). The average WORC score was 543.3 ± 100 [74% ± 4.8%] (range 310 - 740). The mean Constant-Murley score was 69.6 ± 4.6 (range 61 - 84). All patients had a fair or good consolidation of the fracture on radiographic examinations. The calculated RUST score was 4.2 ± 0.4 (range 4-5) 30 days after surgery, 6.1 ± 0.9 (range 4- 8) 90 days after surgery and 9.8 ± 1.5 (range 7-12) to 180 days after surgery. No major complications were found.

CONCLUSIONS

Treatment of the diaphyseal and proximal meta-epiphyseal humeral fractures with antegrade intramedullary nail provides excellent subjective and objective clinical results and good radiographic results. However, clinical studies with larger number of patients and longer follow-up are necessary.

Antegrade intramedullary nailing in proximal humeral fractures: results of 23 cases

Introduction:

the metaepiphyseal fractures of the proximal humerus represent 5% of all fractures and mainly affect elderly patients. The type of treatment remains controversial. This retrospective study aimed to evaluate the clinic and radiographic results of 23 patients affected by two or three fragments fractures of the proximal humerus with or without metaphyseal extension treated with antegrade intramedullary nailing.

Materials and Methods:

all patients were clinically evaluated using the “Constant score” (CS) and individual satisfaction was assessed with a visual scale (VS). Moreover, the fracture’s healing process and the neck shaft angle (NSA) were assessed radiographically.

Results:

the mean follow-up was 72 months (24-120). Clinical evaluation and individual satisfaction were positive in most cases (mean CS 79,39 and VS 3,17). Worse results were observed in patients over 65 years.

Discussion:

among the different surgical options intramedullary nailing ensures good fracture stability and high consolidation rate. The entry point through the rotator cuff is of main importance as well as proximal nail positioning and choice of the locking screws length. In this study the functional results of the shoulder were worse in the elderly, who were supposed to have already a degenerated rotator cuff.

Conclusions:

antegrade intramedullary nailing should be considered a valid therapeutic option in this type of fractures. The surgical technique may influence functional results, as consequence of iatrogenic damage of the rotator cuff. (www.actabiomedica.it)

Indications and results of osteosynthesis for proximal humerus fragility fractures in elderly patients

Proximal humerus fractures (PHF) are common injuries in the elderly population. Conservative treatment is indicated for undisplaced and stable fractures, which account for almost 80% of the cases. More complex fracture patterns might need surgery, with a wide variety of indication criteria and surgical techniques described in the literature. Surgical treatment should be reserved for patients in good clinical conditions, autonomous in daily living activities and able to adhere to postoperative rehabilitation protocols. In the elderly population with severe osteoporosis, cognitive impairment and clinical comorbidities, the risk of surgical failures is high. In these patients, the choice between surgical and conservative treatment, as well as for the type of procedure, is even more difficult, with no general consensus in the literature. Final indication is usually conditioned by surgeon’s experience and preference. Two independent reviewers (B.H and G.G) independently extracted studies on proximal humeral fractures. All selected studies were screened independently (B.H and G.G) based on title and abstract. Then the full text of any article that either judged potentially eligible was acquired and reviewed again. Any disagreement was resolved by discussing the full text manuscripts. Aim of the present paper is to review the literature about indications and results of osteosynthesis for proximal humerus fragility fractures in the elderly population.

Rotator cuff integrity and shoulder function after intra-medullary humerus nailing

INTRODUCTION

Antegrade percutaneous intra-medullary nailing (IMN) has a poor reputation in the treatment of humerus fractures. The aim of the present study was to assess rotator cuff integrity and shoulder function after IMN in humerus fracture.

HYPOTHESIS

Third-generation humeral nails (straight, small diameter, with locked screws) conserve rotator cuff tendon integrity and avoid the shoulder stiffness and pain incurred by 1st generation (large diameter, without self-blocking screw) and 2nd generation nails (curved, penetrating the supraspinatus insertion on the greater tuberosity).

METHODS

Forty patients (26 female, 14 male; mean age, 60 years (range, 20-89 years)) with displaced humeral fracture (23 proximal humerus, 17 humeral shaft) underwent IMN using a 3rd generation nail (34 Aequalis™ (Tornier-Wright), 6 MultiLoc™ (Depuy-Synthes)). Mean clinical, radiologic and ultrasound follow-up was 8 months (range, 6-18 months); 22 patients agreed to postoperative CT scan.

RESULTS

There were no revision surgeries for rotator cuff repair or secondary bone displacement. Mean Adjusted Constant Score (ACS) was 93±22% and the Subjective Shoulder Value (SSV) 77±18%. Elevation was 140±36°, external rotation 48±22° and internal rotation was to L3. Ultrasound found: 5 supraspinatus tendon lesions (12.5%) (2 full and 3 deep partial tears) without functional impact (ACS) 91% without vs. 107% with tear; (p=0.12); 2 of the deep partial tears involved excessively lateral and high nail positioning. Eight patients (20%) had painful tendinopathy of the long head of the biceps (LHB) tendon associated with significantly impaired functional scores (ACS 65% vs. 100%; p<0.001); and 4 cases of technical error: 3 of anterior LHB screwing in the groove, and 1 of LHB irritation due to an excessively long posterior screw.

CONCLUSION

Supraspinatus tendon lesions following IMN with a 3^rd-generation humeral nail were rare (12.5%) and asymptomatic; prevalence was not higher than in the general population in the literature (16%). LHB tendinopathy was frequent (20%) and symptomatic, and due to technical error in half of the cases.

LEVEL OF EVIDENCE

IV, retrospective study.

Early displacement of two part proximal humerus fractures treated with intramedullary proximal humeral nail

Introduction

Proximal humerus nails (PHN) are commonly used for the treatment of simple proximal humerus fractures, and have a reported malunion rate of about 10%. The surgeons who used PHN in one medical institution have noticed a high rate of fracture re-displacement in the early post-operative period. This study's aim is to evaluate the rate of secondary displacement and malunion of patients treated for two part proximal humerus fractures with an angle-stable PHN (MultiLoc), and to assess possible risk factors for this secondary displacement.

Methods

A retrospective study comprised of 25 consecutive patients with 2 part surgical neck or metaphysis displaced proximal humerus fracture, treated with PHN between the years 2014-2017. Results assessed included radiographic measures (neck-shaft angle) and clinical data: range of motion (ROM) and functional scores (Constant, DASH, SSV). A univariate regression analysis was used to assess possible risk factors for secondary displacement.

Results

Mean age was 66.6 (range 17-93), and mean follow up was 20 months (range 6-40). Mean neck shaft angle (NSA) changed from 139.1° post operatively to 122.6° at last follow up, with 6 patients (24%) having a NSA change larger than 20°. Two patients (8%) ended up with NSA less than 90°, defined as malunion. The deltoid tuberosity index was found to correlate with the degree of displacement (-0.41, p = 0.04).

Conclusions

PHN for simple displaced proximal humerus fractures was associated with fair clinical results but an unacceptable rate secondary displacement. The deltoid tuberosity index was found to correlate with the degree of this secondary displacement.

Medial Buttress Plating for Humerus Fractures With Unstable Medial Column

The purpose of this study was to report surgical tips and techniques on the use of additional medial buttress plate fixation in proximal humeral fractures with unstable medial column restoration after lateral locking compression plate fixation. Between April 2011 and January 2017, 17 patients with medial cortical deficiency were treated using this technique. The average follow-up period was 30 (range, 12-81) months. Successful fracture healing was achieved in all 17 cases. The mean neck-shaft angle change was 1.33 degree (range, 0-7.4 degree). Anterior glenoid rim erosion occurred in 1 patient. No avascular necrosis of the humeral head or significant loss of reduction, and no implant failure or screw perforation occurred. In the first part of this study, we described in detail the indications and surgical technique applied to these fractures. In the second part, we reviewed the clinical and radiographic outcomes of these patients. Supplemental medial buttress plate fixation after lateral locking compression plate fixation was effective in preventing varus collapse and implant failure for proximal humeral fractures with an unstable medial column.

Effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture: an update systematic review and meta-analysis

BACKGROUND

To evaluate the effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture (PHF).

METHODS

China National Knowledge Infrastructure (CNKI), Chinese Scientific Journals Database (VIP), Wan-fang database, Chinese Biomedicine Database (CBM), PubMed, EMBASE, Web of Science, and Cochrane Library were searched until July 2018. The eligible references all show that the control group uses locking plates to treat PHF, while the experimental group uses intramedullary nails to do that. Two reviewers independently retrieved and extracted the data. Reviewer Manager 5.3 was used for statistical analysis.

RESULTS

Thirty-eight retrospective studies were referred in this study which involves 2699 patients. Meta-analysis results show that the intramedullary nails in the treatment of proximal humeral fractures are superior to locking plates in terms of intraoperative blood loss, operative time, fracture healing time, postoperative complications, and postoperative infection. But there is no significance in constant, neck angle, VAS, external rotation, antexion, intorsion pronation, abduction, NEER, osteonecrosis, additional surgery, impingement syndrome, delayed union, screw penetration, and screw back-out.

CONCLUSIONS

The intramedullary nail is superior to locking plate in reducing the total complication, intraoperative blood loss, operative time, postoperative fracture healing time and postoperative humeral head necrosis rate of PHF. Due to the limitations in this meta-analysis, more large-scale, multicenter, and rigorous designed RCTs should be conducted to confirm our findings.

TRIAL REGISTRATION

PROSPERO CRD42019120508.

Evidence-based algorithm to treat patients with proximal humerus fractures-a prospective study with early clinical and overall performance results

BACKGROUND

On the basis of patients' demands, bone quality, and fracture type, we developed an evidence-based treatment algorithm for proximal humerus fractures (PHF) that includes all treatment modalities from open reduction and internal fixation, hemiprosthesis, to reverse total shoulder arthroplasty. This study was done to assess its feasibility and early clinical outcome.

MATERIALS AND METHODS

Patients with isolated PHF in 2014 and 2015 were included in this prospective study. The quality of life (EQ-5D) and the level of autonomy before injury were recorded. The fractures were classified and local bone quality was measured. When possible, patients were treated according to the algorithm. Radiographic and clinical follow-up-Constant score, subjective shoulder value, and EQ-5D-took place after 3 months and 1 year. The rate of unplanned surgery was analyzed.

RESULTS

A total of 192 patients (mean age 66 years; 58 male, 134 female) were included. Of these, 160 (83%) were treated according to the algorithm. In total, 132 patients were treated conservatively, 36 with open reduction and internal fixation and 24 with reverse total shoulder arthroplasty or hemiarthroplasty. Generally, the mean EQ-5D before trauma and 1 year after treatment was equal to 0.88 to 0.9 points. After 1 year, the overall mean relative Constant score was 95% and mean subjective shoulder value 84%. Unplanned surgery was necessary in 21 patients.

CONCLUSION

This comprehensive algorithm is designed as a noncompulsory treatment guideline for PHF, which prioritize the patient's demands and biology. The high adherence proves that it is a helpful tool for decision making. Furthermore, this algorithm leads to very satisfying overall results with low complication and revision rates.

"90/90" Plating of proximal humerus fracture-a technical note

INTRODUCTION

While locking plates have markedly improved fixation of proximal humerus fractures, a cohort of fractures remains difficult to treat. This cohort has been identified as fractures with marked medial comminution and varus deformity. Loss of reduction and fixation failure are the most frequently reported complications for this cohort. We report the use of an orthogonal 1/3 tubular plate to augment the proximal humerus locking plate.

METHODS

The subject underwent osteosynthesis for a four-part proximal humerus fracture with medial comminution. Fixation was performed within 24 h of injury. Standard deltopectoral approach exposed the fracture. Sutures were sited to control the tuberosities and cuff. Initial reduction was held with a K-wire and augmented with a three-hole 1/3 tubular plate. Proximal humerus locking plate was sited in standard fashion including locked medial support screws. Reduction was confirmed both clinically and with intra-operative radiography.

RESULTS

The technique provided satisfactory results. At 6 months, the fracture had fully united with no loss of reduction. At 1 year, the patient had excellent range of motion.

CONCLUSION

The use of a 1/3 tubular plate to augment fixation of proximal humerus fractures with medial comminution may provide a simple, reproducible, and cost-effective method to decrease loss of reduction and subsequent malunion.

Displaced humeral surgical neck fractures: classification and results of third-generation percutaneous intramedullary nailing

BACKGROUND

The high rates of complications and reoperations observed with the early designs of first-generation (unlocked) and second-generation (bent design) humeral intramedullary nail (IMNs) have discouraged their use by most surgeons. The purpose of this study was to report the results of a third-generation (straight, locking, low-profile, tuberosity-based fixation) IMN, inserted through a percutaneous approach, for the treatment of displaced 2-part surgical neck fractures.

METHODS

We performed a retrospective review of 41 patients who underwent placement of a third-generation IMN to treat a displaced 2-part surgical neck fracture (AO/OTA type 11A3). The mean age at surgery was 57 years (range, 17-84 years). After percutaneous insertion through the humeral head, the IMN was used as a reduction tool. Static locking fixation was achieved after axial fracture compression ("back-slap" hammering technique). Patients were reviewed and underwent radiography with a minimum of 1 year of follow-up; the mean follow-up period was 26 months (range, 12-53 months).

RESULTS

Preoperatively, 3 types of surgical neck fractures were observed: with valgus head deformity (Type A = 8 cases), shaft translation without head deformity (Type B = 19 cases), or with varus head deformity (Type C = 14 cases). At final follow-up, all fractures went on to union, and the mean humeral neck-shaft angle was 132° ± 5°. We observed 2 malunions and 1 case of partial humeral head avascular necrosis. No cases underwent screw migration or intra-articular penetration. At last review, mean active forward elevation was 146° (range, 90°-180°) and mean external rotation was 50° (range, 20°-80°). The mean Constant-Murley score and Subjective Shoulder Value were 71 (range, 43-95) and 80% (range, 50%-100%), respectively.

CONCLUSIONS

Antegrade insertion of a third-generation IMN through a percutaneous approach provides a high rate of fracture healing, excellent clinical outcome scores, and a low rate of complications. No morbidity related to the passage of the nail through the supraspinatus muscle and the cartilage was observed. The proposed A, B, and C classification allows choosing the optimal entry point for intramedullary nailing.

Locking nail versus locking plate for proximal humeral fracture fixation in an elderly population: a prospective randomised controlled trial

Background

Proximal humeral fractures (PHFs) are the third most common fracture in older patients. The purpose of the study was to prospectively evaluate the outcomes of PHF fixation with a locking blade nail (LBN) or locking plate (PHILOS) osteosynthesis in a homogeneous elderly patient population.

Methods

Inclusion criteria were an age > 60 years and the capacity to give informed consent. Patients with isolated tuberosity fractures, previous trauma or surgery, advanced osteoarthritis, fracture dislocation, pathological fractures, open fractures, neurological disorders, full-thickness rotator cuff tears, fracture line at the nail entry point or severely reduced bone quality intra-operatively were excluded.

Eighty one patients with PHFs were randomised to treatment using LBN or PHILOS. Outcome measures comprised Constant score, age and gender adjusted Constant score, DASH score, VAS for pain, subjective overall condition of the shoulder (1–6) and active shoulder range-of-motion in flexion and abduction. Plain radiographs were obtained in two planes. All data were collected by an independent observer at 3, 6 and 12 months postoperatively.

Results

Thirteen patients were excluded intra-operatively due to rotator cuff tears, fracture morphology or poor bone-quality. Of the remaining 68 patients, 27 in the LBN and 28 in the PHILOS group completed the full follow-up. Mean age at surgery was 75.6 years and the majority of PHFs were three-part fractures (49 patients). Baseline demographics between groups were comparable.

All outcome measures improved between assessments (p < 0.001). The LBN group showed improved DASH scores as compared to PHILOS at 12 months (p = 0.042) with fewer incidences of secondary loss of reduction and screw cut-out (p = 0.039). A total of 29 complications (in 23 patients) were recorded, 13 complications (in 12 patients) in the LBN group and 16 complications (in 11 patients) in the PHILOS group (p = 0.941). No significant inter-group difference was observed for any other outcome measures, nor was fracture morphology seen to be associated with clinical outcome or complication rate.

Conclusions

At short-term follow-up, LBN osteosynthesis yielded similar outcomes and complication rates to PHILOS plate fracture fixation in an elderly patient population, though with a significantly lower rate of secondary loss of reduction and screw cut-out.

Registration trial

No. DRKS00015245 at Deutsches Register Klinischer Studien, registered: 22.08.2018, retrospectively registered.

Inferomedial cortical bone contact and fixation with calcar screws on the dynamic and static mechanical stability of proximal humerus fractures

BACKGROUND

This study aimed to explore the effect of retaining inferomedial cortical bone contact and fixation with calcar screws on the dynamic and static mechanical stability of proximal humerus fractures treated with a locking plate.

METHODS

Twelve Synbone prosthetic humeri (SYNBONE-AG, Switzerland) were used for a wedge osteotomy model at the proximal humerus, in four groups. In the cortex contact + screw fixation group and cortex contact group, the inferomedial cortical bone contact was retained. In the screw fixation group and control group, the inferomedial cortical bone contact was not retained. Calcar screw fixation was implemented only in the screw fixation groups. The dynamic and static mechanical stability of the models were tested with dynamic fatigue mechanics testing, quasi-static axial compression, three-point bending, and torsion testing.

RESULTS

The cortex contact + screw fixation group showed the longest fatigue life and the best stability. There was 35% difference in fatigue life between the cortex contact + screw fixation group and the cortex contact group, 43%between the cortex contact + screw fixation group and screw fixation group, and 63% between the cortex contact + screw fixation group and screw fixation group (P < 0.01). The cortex contact + screw fixation group showed the best axial compressive stiffness, bending stiffness, and torsion stiffness; these were successively decreased in the other three groups (P < 0.01).

CONCLUSION

Retaining inferomedial cortical bone contact and fixation with two calcar screws maintained fracture stability with the highest strength and minimum deformation. Of the two methods, restoration of the inferomedial cortical bone support showed better dynamic and static biomechanical properties than placement of calcar screws alone.

Six-year experience with antegrade intramedullary nail for the treatment of proximal and diaphyseal humeral fractures

BACKGROUND

Proximal and shaft humeral fractures are very common worldwide; surgical treatment can be a viable option to reduce limb immobilization and to allow the patient an earlier return to daily activities. The aim of our study was to evaluate the outcomes of patients treated with intramedullary nail in our Institute from January 2010 to December 2016.

MATERIALS AND METHODS

This is an observational cohort study. Inclusion criteria were: traumatic proximal and diaphyseal humeral fractures treated with antegrade nail; a minimum follow-up of 6 months. We evaluated the fracture healing time, the functional recovery (using the Constant score) and postoperative complications (need of blood transfusion, infections and need of re-intervention). The t test was used for statistical analysis.

RESULTS

Ninety-five patients were included (20 proximal and 75 diaphyseal fractures). Bone callus formation was evident a mean of 57 days after surgery. In all patients, there was an improvement in the functional recovery over time, but those younger than 65 years had better outcomes. The type of fracture and patients' gender did not affect these results at one and 6 months of follow-up. In 18 cases, blood transfusions were needed; infections never occurred; finally, revision surgery was performed in 10 cases (two reverse total shoulder arthroplasties, one open reduction and internal fixation with plate and screws and seven nail removals for intolerance).

CONCLUSION

In our study, intramedullary nail proved to be a minimally invasive technique with a rapid improvement in range of motion, an earlier rehabilitation and acceptable pain.

Comparison of CFR-PEEK and conventional titanium locking plates for proximal humeral fractures: a retrospective controlled study of patient outcomes

BACKGROUND

Metal plates are the fixation devices used most frequently to proximal humeral fractures (PHFs). However, in recent years carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates have become increasingly common. This study compares the clinical and radiographic outcomes of 42 Neer three- and four-part PHFs treated with CFR-PEEK or metal (titanium) plates.

MATERIALS AND METHODS

Forty-two PHF patients were managed with CFR-PEEK plates (n = 21, males/females 9/12; mean age 57.4 years; mean follow-up 30.7 months; CFR-PEEK group) or metal plates (n = 21; males/females 7/14; mean age 55.8 years; mean follow-up 52.7 months; Metal group). Active shoulder mobility (anterior elevation, lateral elevation, external rotation, and internal rotation), the Constant-Murley Score, the Simple Shoulder Test Score, and the pain score were recorded. Preoperative computed tomography scans and X-rays were obtained. Postoperative fracture healing and displacement, tuberosity resorption and/or malposition, hardware position, and cortical thinning (CT) under the plate were assessed radiographically.

RESULTS

Shoulder mobility, clinical, and pain scores were similar in both patient groups. CT was significantly greater in CFR-PEEK patients (mean difference, 1.14 mm; p = 0.0003). In both groups, incomplete or poor calcar reduction was associated to a significantly higher complication rate, especially stiffness and muscle weakness (p = 0.016). The rate of tuberosity resorption was significantly higher in the Metal group (p = 0.040). Two patients required revision to a hemiarthroplasty (CFR-PEEK) and reverse arthroplasty (Metal group).

CONCLUSIONS

CFR-PEEK plates provide a viable alternative to conventional titanium plates in PHFs, ensuring similar clinical outcomes and a lower rate of tuberosity resorption, but they involve higher stress shielding under the plate.

Straight proximal humeral nailing: Risk of iatrogenic tendon injuries with respect to different entry points in anatomical specimens

BACKGROUND

The purpose of the study was to evaluate the relationship of implant-related injuries to the adjacent anatomical structures in a newer generation straight proximal humeral nail (PHN) regarding different entry points. The proximity of the proximal lateral locking-screws of the MultiLoc proximal humeral nail (ML PHN) may cause iatrogenic tendon injuries to the lateral edge of the bicipital humeral groove (BG) as reference point for the tendon of the long head of biceps brachii (LBT) as well as the lateral insertion of the infraspinatus tendon (IST).

MATERIALS AND METHODS

The study comprised n = 40 upper extremities. Nail application was performed through a deltoid approach and supraspinatus tendon (SSP) split with a ML PHN. All tests were performed in three different entry points. First nail (N1) - standard position in line with the humeral shaft axis; second nail (N2) - a more lateral entry point; third alternative (N3) - medial position, centre of the humeral head. After nail placement, each specimen was screened for potential implant-related injuries or worded differently hit rates (HR) to the BG and the IST. The distances to the anatomical structures were measured and statistically interpreted.

RESULTS

The observed iatrogenic IST injury rate was 17.5% (n = 7/40) for N1, 5% (n = 2/40) for N2 and 62.5% (n = 25/40) for N3, which was statistically significantly higher (p < 0.001). Regarding the BG, the evaluated HR was 7.5% (n = 3/40) for both N1 and N2. Only the nail placed in the head centre (N3) showed an iatrogenic injury rate of 20% (n = 8/40) (p < 0.062). No statistically significant association between humeral head size and the HR could be observed (head diameter: IST: p = 0.323, BG: p = 0.621; head circumference: IST: p = 0.167; BG: p = 0.940). For the IST and BG, all distances in nail positions N1 and N2 as well as N2 and N3 differ statistically significant (p < 0.001).

CONCLUSIONS

An entry point for nail placement in line or slightly laterally to the humeral shaft axis - but still at the cartilage - should be advocated.

The Augment of the Stability in Locking Compression Plate with Intramedullary Fibular Allograft for Proximal Humerus Fractures in Elderly People

Objective

The objective of this study was to compare the clinical outcomes and complications between the locking compression plate (LCP) and LCP with fibular allograft in the treatment of patients with displaced proximal humerus fracture (PHF) in elderly people.

Material and Methods

Between January 2010 and December 2013, a total of 97 elderly patients with displaced PHF were treated by LCP or LCP with fibular allograft, and finally 89 patients were included in our study. All the patients were divided into Group I (patients treated by LCP) and Group II (patients treated by LCP with fibular allograft). Function results were assessed by the disability of the arm, shoulder, and hand (DASH) score and Constant-Murley score (CMS), and complications were also recorded in each group.

Results

The average follow-up was 35.2 months (range, 24-48 months) in Group I and 33.5 months (range, 24-48 months) in Group II. DASH in patients of Group I was significantly higher than that in patients in Group II and patients of Group I had CMS scores significantly lower than patients in Group II (P<0.05). The rates of varus malunion, screw perforation, and loss of reduction>5mm were significantly higher in Group I than in Group II (P<0.05).

Conclusions

The present results showed that that patients treated by LCP with fibular allograft had a better functional outcome and a lower complication rate compared to patients treated by LCP alone. Suitable void filler in the proximal humerus for supporting the head fragment, medial cortical bone, and greater tuberosity might play a key role in reducing the incidence of the complications in elderly patients, especially with osteoporosis.

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

Background

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

Methods

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

Results

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

Conclusion

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

Time-dependent differences in management and microbiology of orthopaedic internal fixation-associated infections: an observational prospective study with 229 patients

OBJECTIVES

Little information has been published on orthopaedic internal fixation-associated infections. We aimed to analyse time-dependent microbiology, treatment, and outcome.

METHODS

Over a 10-year period, all consecutive patients with internal fixation-associated infections at the University Hospital of Basel, were prospectively followed and clinical, microbiological and outcome data were acquired. Infections were classified as early (0-2 weeks after implantation), delayed (3-10 weeks), and late (>10 weeks).

RESULTS

Two hundred and twenty-nine patients were included, with a median follow-up of 773 days (IQR 334-1400). Staphylococcus aureus was the most prevalent pathogen (in 96/229 patients, 41.9%). Enterobacteriaceae were frequent in early infections (13/49, 26.5%), whereas coagulase-negative staphylococci (36/92, 39.1%), anaerobes (15/92, 16.3%) and streptococci (10/92, 10.9%) increased in late revisions. Failure was observed in 27/229 (11.7%). Implants were retained in 42/49 (85.7%) in early, in 51/88 (57.9%) in delayed, and in 9/92 (9.8%) in late revisions (p < 0.01). Early revisions failed in 6/49 (12.2%), delayed in 9/88 (10.2%), and late in 11/92 (13.0%) (p 0.81). Debridement and retention failed in 6/42 (14.3%) for early, in 6/51 (11.8%) for delayed, and in 3/9 (33.3%) for late revisions (p 0.21). Biofilm-active antibiotic therapy tailored to resistance correlated with improved outcome for late revisions failure (6/72, 7.7% versus 6/12, 50.0%; p < 0.01) but not for early revisions failure (5/38, 13.2% versus 1/11, 9.1%; p 1.0).

CONCLUSIONS

Treatment of internal fixation-associated infections showed a high success rate of 87-90% over all time periods. Implant retention was highly successful in early and delayed infections but only limited in late infections.

Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient

Introduction:

Proximal humerus fractures are common in the elderly. The evaluation and management of these injuries is often controversial. The purpose of this study is to review recent evidence and provide updated recommendations for treating proximal humerus fractures in the elderly.

Methods:

A literature review of peer-reviewed publications related to the evaluation and management of proximal humerus fractures in the elderly was performed. There was a focus on randomized controlled trials and systematic reviews published within the last 5 years.

Results:

The incidence of proximal humerus fractures is increasing. It is a common osteoporotic fracture. Bone density is a predictor of reduction quality and can be readily assessed with anteroposterior views of the shoulder. Social independence is a predictor of outcome, whereas age is not. Many fractures are minimally displaced and respond acceptably to nonoperative management. Displaced and severe fractures are most frequently treated operatively with intramedullary nails, locking plates, percutaneous techniques, or arthroplasty.

Discussion:

Evidence from randomized controlled trials and systematic reviews is insufficient to recommend a treatment; however, most techniques have acceptable or good outcomes. Evaluation should include an assessment of the patient’s bone quality, social independence, and surgical risk factors. With internal fixation, special attention should be paid to medial comminution, varus angulation, and restoration of the calcar. With arthroplasty, attention should be paid to anatomic restoration of the tuberosities and proper placement of the prosthesis.

Conclusion:

A majority of minimally displaced fractures can be treated conservatively with early physical therapy. Treatment for displaced fractures should consider the patient’s level of independence, bone quality, and surgical risk factors. Fixation with percutaneous techniques, intramedullary nails, locking plates, and arthroplasty are all acceptable treatment options. There is no clear evidence-based treatment of choice, and the surgeon should consider their comfort level with various procedures during the decision-making process.

Current concepts in locking plate fixation of proximal humerus fractures

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.

A Simple Procedure for the Evaluation of Bone Vitality by Staining with a Tetrazolium Salt

Presently, no intra-operative method for a direct assessment of bone vitality exists. Therefore, we set out to test the applicability of tetrazolium-based staining on bone samples. The explanted femoral heads of 37 patients were used to obtain either cancellous bone fragments or bone slices. Samples were stained with 2,3,5-triphenyl-2H-tetrazolium chloride (TTC) or 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (thiazolyl blue, MTT) at different times (one to twelve hours) after explantation. Staining was quantified either spectrophotometrically after extraction of the dyes or by densitometric image analysis. TTC-staining of cancellous bone fragments and bone slices, respectively, indicated the detectability of vital cells in both types of samples in a window of up to six hours after explantation. Staining intensity at later time-points was indistinguishable from the staining of untreated samples or sodium azide treated samples, which represent dead cells. In contrast, MTT-staining of bone slices revealed intense unspecific staining, which obscured the evaluation of the vitality of the samples. The lack of a detectable increase of colour intensity in TTC-stained bone samples, which were treated more than six hours after explantation, corresponds to reduced fracture healing. The described simple procedure could provide a basis for an intraoperative decision by the orthopaedic surgeon.