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Williamson J, Sakthivelnathan V, Seligson D. Use of light activated intramedullary device for revision of a proximal humerus fracture: a case study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-03980-0. [PMID: 38967689 DOI: 10.1007/s00590-024-03980-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 04/29/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Post-operative non-compliance is a risk factor for fracture fixation failure and presents a challenge for revision surgery planning. We present a patient who underwent revision surgery for a proximal humerus fracture with lateral locked plating augmented with a UV light activated intramedullary implant. CASE A 45-year-old woman with a history of alcoholism presented with a proximal humerus fracture. After undergoing open reduction internal fixation with a lateral locking plate, the patient suffered a fall secondary to delirium tremens. New radiographs demonstrated displacement of the fracture with failure of screws. Revision surgery consisting of removal of the initial construct as well as open reduction internal fixation via lateral locking plate, augmented with a UV-activated intramedullary cement implant, was performed. CONCLUSION This is the first case report describing the use of a UV-activated intramedullary cement implant to augment the use of lateral locked plating for proximal humerus fractures. This case illustrates the successful management using UV-activated intramedullary cement to augment fixation, specifically in a patient with risk factors and post-operative non-compliance that predispose to fixation failure.
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Affiliation(s)
- Jacob Williamson
- Department of Orthopaedic Surgery, The University of Louisville School of Medicine, 323 East Chestnut Street, Louisville, KY, 40202, USA.
| | - Vishaal Sakthivelnathan
- John Sealy School of Medicine, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - David Seligson
- Department of Orthopaedic Surgery, The University of Louisville School of Medicine, 323 East Chestnut Street, Louisville, KY, 40202, USA
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Lee E, Jeong HJ, Lee YS, Oh JH. The application of a dual-lead locking screw could enhance the reduction and fixation stability of the proximal humerus fractures: a biomechanical evaluation. Front Surg 2024; 11:1333670. [PMID: 38586241 PMCID: PMC10995320 DOI: 10.3389/fsurg.2024.1333670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 03/04/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Bicortical screw fixation, which penetrates and fixes the near and far cortex of bone, has been conventionally used to achieve compressive fixation for fracture using screws. Open reduction and internal fixation using the locking plate are widely used for treating proximal humerus fractures. However, minimal contact between the bone and the locking plate can lead to an insufficient reduction. Theoretically, a dual-lead locking screw with different leads for the screw head and body could enhance the reduction and fixation stability of fragments in proximal humeral fractures without bicortical fixation, and achieve additional compression at the bone-plate-screw interface. This study assessed the insertion mechanics of the lead ratio of the dual-lead locking screw and its effect on the fixation stability of the proximal humerus fracture. Methods A Multi-Fix® locking plating system composed of ∅ 3.5 mm locking screws and a locking plate was used to make a locked plating for Sawbone bone blocks and fourth-generation composite humeri. Two different types of Sawbone bone blocks were used to simulate the osteoporotic (10 PCF) and normal cancellous (20 PCF) bones. The lead of the screw head thread (L head ) was 0.8 mm, and that of the screw body (L body ) was 0.8, 1.25, 1.6, 2.0, and 2.4 mm, whose lead ratios (R lead = L body / L head ) were 1.0, 1.56, 2.0, 2.5, and 3.0, respectively. Results The dual-lead locking screw elevated the compression between the locking plate and the bone. The elevation in the compression due to the dual-lead thread became weaker for the cancellous bone when the lead of the screw body was more than twice that of the screw head. The plate/humerus compression with strong bone quality withstood higher dual-lead-driven compression. Discussion A dual-lead locking screw of L body = 1.25 mm (R lead = 1.56 ) is recommended for maximum rotational stability for the locked humerus plating. The screws with over L body = 1.6 mm (R lead = 2 ) have no advantage in terms of the failure torque and maximum torsional deformation. Any locking dual-lead screw with a body thread lead of <1.6 mm (R lead = 2 ) can be used without the risk of bone crush when surgeons require additional compression to the locked cancellous bone plating.
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Affiliation(s)
- Eunju Lee
- Department of BioMedical Engineering, School of BioMed Science, Daegu Catholic University, Gyoungbuk, Republic of Korea
| | - Hyeon Jang Jeong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Yeon Soo Lee
- Department of BioMedical Engineering, School of BioMed Science, Daegu Catholic University, Gyoungbuk, Republic of Korea
| | - Joo Han Oh
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
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Zdero R, Brzozowski P, Schemitsch EH. Biomechanical design optimization of proximal humerus locked plates: A review. Injury 2024; 55:111247. [PMID: 38056059 DOI: 10.1016/j.injury.2023.111247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/15/2023] [Accepted: 11/24/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Proximal humerus locked plates (PHLPs) are widely used for fracture surgery. Yet, non-union, malunion, infection, avascular necrosis, screw cut-out (i.e., perforation), fixation failure, and re-operation occur. Most biomechanical investigators compare a specific PHLP configuration to other implants like non-locked plates, nails, wires, and arthroplasties. However, it is unknown whether the PHLP configuration is biomechanically optimal according to some well-known biomechanical criteria. Therefore, this is the first review of the systematic optimization of plate and/or screw design variables for improved PHLP biomechanical performance. METHODS The PubMed website was searched for papers using the terms "proximal humerus" or "shoulder" plus "biomechanics/biomechanical" plus "locked/locking plates". PHLP papers were included if they were (a) optimization studies that systematically varied plate and screw variables to determine their influence on PHLP's biomechanical performance; (b) focused on plate and screw variables rather than augmentation techniques (i.e., extra implants, bone struts, or cement); (c) published after the year 2000 signaling the commercial availability of locked plate technology; and (d) written in English. RESULTS The 41 eligible papers involved experimental testing and/or finite element modeling. Plate variables investigated by these papers were geometry, material, and/or position, while screw variables studied were number, distribution, angle, size, and/or threads. Numerical outcomes given by these papers included stiffness, strength, fracture motion, bone and implant stress, and/or the number of loading cycles to failure. But, no paper fully optimized any plate or screw variable for a PHLP by simultaneously applying four well-established biomechanical criteria: (a) allow controlled fracture motion for early callus generation; (b) reduce bone and implant stress below the material's ultimate stress to prevent failure; (c) maintain sufficient bone-plate interface stress to reduce bone resorption (i.e., stress shielding); and (d) increase the number of loading cycles before failure for a clinically beneficial lifespan (i.e., fatigue life). Finally, this review made suggestions for future work, identified clinical implications, and assessed the quality of the papers reviewed. CONCLUSIONS Applying biomechanical optimization criteria can assist biomedical engineers in designing or evaluating PHLPs, so orthopaedic surgeons can have superior PHLP constructs for clinical use.
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Affiliation(s)
- Radovan Zdero
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada
| | - Pawel Brzozowski
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada.
| | - Emil H Schemitsch
- Orthopaedic Biomechanics Lab, Victoria Hospital, London, ON, Canada; Division of Orthopaedic Surgery, Western University, London, ON, Canada
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Ren H, Wu L, Zhang X, Jian Z, Yi C. The effect of integrity of lesser tuberosity-medial calcar on postoperative outcome in the proximal humeral fracture. J Orthop Surg Res 2023; 18:363. [PMID: 37194053 DOI: 10.1186/s13018-023-03851-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/10/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND In proximal humeral fractures, the medial calcar is often considered an important stabilizing structure. When the medial calcar is disrupted, some patients may have accompanying humeral lesser tuberosity comminution that has not been noticed. To investigate the impacts of comminuted fragments of lesser tuberosity and calcar on postoperative stability, CT results, number of fragments, cortical integrity, and the variation of neck-shaft angle were compared in patients with proximal humeral fractures. MATERIALS AND METHODS From April 2016 to April 2021, this study included patients with senile proximal humeral fractures diagnosed by CT three-dimensional reconstruction with lesser tuberosity fractures and medial column injuries. The number of fragments in the lesser tuberosity and the continuity of medial calcar were evaluated. Postoperative stability and shoulder function were evaluated by comparing changes in neck-shaft angle and the DASH upper extremity function score from 1 week to 1 year after the operation. RESULTS A total of 131 patients were included in the study, and the results showed that the number of fragments of the lesser tuberosity was related to the integrity of the medial cortex of the humerus. That is, when there were more than two lesser tuberosity fragments, the integrity of humeral medial calcar was poor. The positive rate of the lift-off test was higher in patients with lesser tuberosity comminutions 1 year after surgery. In addition, patients with more than two lesser tuberosity fragments and continuous destruction of the medial calcar had large variations in the neck-shaft angle, high DASH scores, poor postoperative stability, and poor recovery of shoulder joint function 1 year postoperatively. CONCLUSION The number of humeral lesser tuberosity fragments and the integrity of the medial calcar were associated with the collapse of the humeral head and the decrease in shoulder joint stability after the proximal humeral fracture surgery. When the number of lesser tuberosity fragments was greater than two and the medial calcar was damaged, the proximal humeral fracture had poor postoperative stability and poor functional recovery of the shoulder joint, which required auxiliary internal fixation treatment.
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Affiliation(s)
- Hanru Ren
- Department of Orthopaedics, Pudong Medical Center, Shanghai Pudong Hospital, Fudan University, No. 2800, Gongwei Road, Shanghai, 200120, China
| | - Lianghao Wu
- Department of Orthopaedics, Pudong Medical Center, Shanghai Pudong Hospital, Fudan University, No. 2800, Gongwei Road, Shanghai, 200120, China
| | - Xu Zhang
- Department of Orthopaedics, Pudong Medical Center, Shanghai Pudong Hospital, Fudan University, No. 2800, Gongwei Road, Shanghai, 200120, China
| | - Zhen Jian
- Department of Orthopaedics, Pudong Medical Center, Shanghai Pudong Hospital, Fudan University, No. 2800, Gongwei Road, Shanghai, 200120, China
| | - Chengqing Yi
- Department of Orthopaedics, Pudong Medical Center, Shanghai Pudong Hospital, Fudan University, No. 2800, Gongwei Road, Shanghai, 200120, China.
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Haws BE, Samborski SA, Karnyski S, Soles G, Gorczyca JT, Nicandri GT, Voloshin I, Ketz JP. Risk factors for loss of reduction following locked plate fixation of proximal humerus fractures in older adults. Injury 2023; 54:567-572. [PMID: 36424218 DOI: 10.1016/j.injury.2022.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/06/2022] [Accepted: 11/13/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE To identify characteristics associated with loss of reduction following open reduction and locked plate fixation (ORIF) of proximal humerus fractures in older adults and determine if loss of reduction affects patient reported outcomes (PROs), range of motion (ROM), and complication rates during the first postoperative year. METHODS Patients >55 years old who underwent proximal humerus ORIF were reviewed. Patient and fracture characteristics were recorded. Fixation characteristics were measured on the initial postoperative AP radiograph including humeral head height (HHH) relative to the greater tuberosity (GT), head shaft angle (HSA), screw-calcar distance, and screw tip-joint surface distance. Loss of reduction was defined as GT displacement >5 mm or HSA displacement >10° on final follow up radiographs. Patient, fracture, and fixation characteristics were tested for association with loss of reduction. Outcomes including ROM, visual analog scale pain and PROMIS scores, and complication/reoperation rates during the first postoperative year were compared between those with or without loss of reduction. RESULTS A total of 79 patients were identified, 23 (29.1%) of which had a loss of reduction. Calcar comminution (relative risk [RR]=2.5, 95% Confidence Interval [CI]=1.3-5.0, p<0.01), HHH <5 mm above GT (RR=2.0, CI=1.0-3.9, p = 0.048), and screw-calcar distance ≥12 mm (RR=2.1, CI=1.1-4.1, p = 0.03) were risk factors for loss of reduction. Upon multivariate analysis, calcar comminution was determined to be an independent risk factor for loss of reduction (RR=2.4, CI=1.2-4.7, p = 0.01). Loss of reduction led to higher complication (44% vs 13%, p<0.01) and reoperation rates (30% vs 7%, p<0.01), and decreased achievement of satisfactory ROM (>90° active forward flexion, 57% vs 82%, p = 0.02) compared to maintained reduction, but similar PROs. CONCLUSIONS Calcar comminution, decreased HHH, and increased screw-calcar distance are risk factors for loss of reduction following ORIF of proximal humerus fractures. These morphologic and technical factors are important considerations for prolonged reduction maintenance.
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Affiliation(s)
- Brittany E Haws
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA.
| | - Steven A Samborski
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - Steven Karnyski
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - Gillian Soles
- University of California, Davis, Department of Orthopaedic Surgery, Sacramento, CA, USA
| | - John T Gorczyca
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - Gregg T Nicandri
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - Ilya Voloshin
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
| | - John P Ketz
- University of Rochester Medical Center, Department of Orthopaedics, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
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OKUTAN AE. Plate osteosynthesis for proximal humerus fractures through a deltoid-split approach under traction in lateral decubitus position: preliminary results. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1166982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Aim: We aimed to present deltoid split approach under traction in lateral decubitus position that we perform for the treatment of proximal humerus fractures (PHFs) and to present the preliminary surgical and clinical outcomes of our patients.
Material and Method: Twelve patients who underwent plate osteosynthesis through a deltoid split approach under traction in lateral decubitus position between May 2019 and January 2021 were evaluated. Patient demographics, Neer classification, and time from injury to surgery were collected in all patients preoperatively. Radiation exposure time and operating time was recorded intraoperatively. Radiological outcomes were assessed, including time to union, and neck-shaft angle. Functional outcomes were evaluated using the Constant score at the minimum 12-month follow-up.
Results: Twelve patients (5 male, 7 female) were evaluated with a mean age 58.6±10.7 years (range, 32 to 72 years) at the time of surgery. The mean follow-up period was 117.4±3.8 months). The mean operation time was 60.7±15.2 min (range, 44 to 92 min). The mean radiation exposure time was 6.1±3.0 s (range, 3.3 to 14.2 s). Fracture union was observed in all patients at mean 14.6±2.5 weeks (range, 8 to 20 weeks). The mean neck-shaft angle after the union was 134.5±3.4 degrees (range, 124 to 143 degrees). The mean Constant score was at the final follow-up was 76.4±8.7 (range, 63 to 90).
Conclusion: Patient positioning in the lateral decubitus position under traction can be considered as a safe, reliable, and reproducible method in selected patients with PHFs.
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Koeppe J, Katthagen JC, Rischen R, Freistuehler M, Faldum A, Raschke MJ, Stolberg-Stolberg J. Male Sex Is Associated with Higher Mortality and Increased Risk for Complications after Surgical Treatment of Proximal Humeral Fractures. J Clin Med 2021; 10:2500. [PMID: 34198778 PMCID: PMC8201359 DOI: 10.3390/jcm10112500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 12/20/2022] Open
Abstract
AIMS The best surgical treatment of multi-fragmentary proximal humeral fractures in the elderly is a highly controversial topic. The aim of this study is to assess for sex-related differences regarding mortality and complications after reverse total shoulder arthroplasty (RTSA) and locking plate fixation (LPF). PATIENTS AND METHODS All patients from the largest German healthcare insurance (26.5 million policy holders) above the age of 65 years that were treated with LPF or RTSA after a multi-fragmentary proximal humerus fracture between January 2010 and September 2018 were included. Multivariable Cox regression models were used to assess the association of sex with overall survival, major adverse events and surgical complications. RESULTS A total of 8264 (15%) men and 45,707 (85%) women were followed up for a median time of 52 months. After 8 years, male patients showed significantly higher rates for death (65.8%; 95% CI 63.9-67.5% vs. 51.1%; 95% CI 50.3-51.9%; p < 0.001) and major adverse events (75.5%; 95% CI 73.8-77.1% vs. 61.7%; 95% CI 60.9-62.5%; p < 0.001). With regard to surgical complications, after adjustment of patient risk profiles, there were no differences between females and males after LPF (p > 0.05), whereas men showed a significantly increased risk after RTSA (HR 1.86; 95% CI 1.56-2.22; p < 0.001) with more revision surgeries performed (HR 1.76, 95% CI 1.46-2.12; p < 0.001) compared to women. CONCLUSION The male sex is an independent risk factor for death and major adverse events after both LPF and RTSA. An increased risk for surgical complications after RTSA suggests that male patients benefit more from LPF. Sex should be considered before making treatment decisions.
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Affiliation(s)
- Jeanette Koeppe
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstrasse 56, 48149 Muenster, Germany; (J.K.); (A.F.)
| | - J. Christoph Katthagen
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany; (J.C.K.); (M.J.R.)
| | - Robert Rischen
- Clinic for Radiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany;
| | - Moritz Freistuehler
- Medical Management Division—Medical Controlling, University Hospital Muenster, Niels-Stensen-Straße 8, 48149 Muenster, Germany;
| | - Andreas Faldum
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstrasse 56, 48149 Muenster, Germany; (J.K.); (A.F.)
| | - Michael J. Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany; (J.C.K.); (M.J.R.)
| | - Josef Stolberg-Stolberg
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building W1, 48149 Muenster, Germany; (J.C.K.); (M.J.R.)
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