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Ripoll T, Fairag R, Bonomo I, Gastaud O, Psacharopulo D. Axillary Artery Injuries Associated With Proximal Humerus Fractures: A Literature Review and a Proposal of a Novel Multidisciplinary Surgical Approach. Vasc Endovascular Surg 2024; 58:245-254. [PMID: 37823274 DOI: 10.1177/15385744231206834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Proximal humerus fractures (PHF) are common injuries that can lead to axillary artery injury, which carries the risk of not being identified during initial assessment. The aim of this study was to describe the management of suspected axillary artery injury associated with PHF according to our experience and to describe a new multidisciplinary surgical approach. METHODS This was a single-center retrospective study. A database was created for patients admitted for PHF to the emergency department of the Hospital of Cannes between October 2017 and October 2019. Patients admitted with PHF associated with suspected ipsilateral upper limb ischemia, and/or massive diaphysis displacement, and/or upper limb ipsilateral neurological deficits were included in this study. RESULTS In total, 301 patients diagnosed with PHF were admitted within these periods. Among these patients, 12 presented with suspected axillary artery lesions, of whom, 6 were included in the present study and treated according to our new approach. A description of these 6 cases, along with an extensive literature review is presented. CONCLUSION Based on our experience, the endovascular approach proposed for the management of axillary artery injury associated with proximal humerus fractures is effective, feasible and reproducible.
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Affiliation(s)
- Thomas Ripoll
- Service de Chirurgie Vasculaire, Centre Hospitalier de Cannes, Cannes, France
- Service de Chirurgie Orthopédique, Centre Hospitalier de Cannes, Cannes, France
| | - Rayan Fairag
- Service de Chirurgie Orthopédique, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Iris Bonomo
- Service de Gynécologie, Institut Bergonié, Bordeaux, France
| | - Olivier Gastaud
- Service de Chirurgie Orthopédique, Centre Hospitalier de Cannes, Cannes, France
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Schöbel T, Gemkow M, Wendler T, Schleifenbaum S, Löffler S, Theopold J, Hepp P. Primary stability in locking plate fixation for proximal humeral fractures may be increased by using an additional nail osteosynthesis in combination with locking plate osteosynthesis-A biomechanical comparison. Clin Biomech (Bristol, Avon) 2024; 114:106235. [PMID: 38552372 DOI: 10.1016/j.clinbiomech.2024.106235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Stability is regarded as an important factor for proper healing and avoiding secondary dislocation in osteoporotic fractures of the proximal humerus. Several surgical techniques have been proposed for treatment, including intramedullary nail osteosynthesis and locking plate fixation. This study introduces a novel approach that combines both techniques and compares its primary stability with conventional methods. METHODS The study involved 25 osteoporotic humeri with two-part fracture models, which were randomly assigned to locking-plate fixation, intramedullary nailing, or a combination of both techniques. The specimens were subjected to sinusoidal loading at 250 N in 20° abduction for 5000 cycles and then to quasi-static loading until failure. Fracture movement, failure mode, and failure load were measured and compared among the groups. FINDINGS The groups fixated with intramedullary nailing and the groups fixated with intramedullary nailing and locking plate fixation showed significantly lower fracture motion than the group using locking plate fixation only (p < 0.005) and significantly higher load to failure (p = 0.007 and p = 0.0062, respectively). There was no significant difference between the group using intramedullary nailing and the group using locking-plate fixation and intramedullary nailing in fracture movement or load-to-failure (p > 0.005). INTERPRETATION The results indicate that locking plate fixation provides less primary stability than intramedullary nailing or the combined of both techniques. This combined approach may offer advantages as a treatment for complex proximal humeral fractures in osteoporotic bone, and specific implants should be developed to ensure optimal treatment.
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Affiliation(s)
- Tobias Schöbel
- Department of Orthopedic, Trauma, and Plastic Surgery, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.
| | - Maximilian Gemkow
- Department of Orthopedic, Trauma, and Plastic Surgery, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.
| | - Toni Wendler
- Department of Orthopedic, Trauma, and Plastic Surgery, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany; ZESBO - Center for Research on Musculoskeletal Systems, Semmelweisstraße 14, 04103 Leipzig, Germany.
| | - Stefan Schleifenbaum
- Department of Orthopedic, Trauma, and Plastic Surgery, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany; ZESBO - Center for Research on Musculoskeletal Systems, Semmelweisstraße 14, 04103 Leipzig, Germany; Fraunhofer Institute for Machine Tools and Forming Technology, Nöthnitzer Straße 44, 01187 Dresden, Germany.
| | - Sabine Löffler
- Institute of Anatomy, University of Leipzig, Liebigstraße 13, 04103 Leipzig, Germany.
| | - Jan Theopold
- Department of Orthopedic, Trauma, and Plastic Surgery, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.
| | - Pierre Hepp
- Department of Orthopedic, Trauma, and Plastic Surgery, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.
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Ou Z, Feng Q, Peng L, Zhou M, Rai S, Tang X. Risk factors for osteonecrosis of the humeral head after internal fixation of proximal humeral fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2024; 144:31-40. [PMID: 37566131 DOI: 10.1007/s00402-023-05020-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/26/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Osteonecrosis of the humeral head (ONHH) is a severe complication after the internal fixation of proximal humeral fractures (IFPHF). The risk factors remain controversial though many studies have reported. In this research, meta-analysis was used to evaluate which surgeon-level factors can be modified to lower the risk and we hope to provide evidence-based support for preventing ONHH. METHODS Literature was retrieved from PubMed, Cochrane Library, Embase, Web of Science, and Scopus for eligible studies published up to January 2023. The pooled odds ratios (ORs) were calculated with their corresponding 95% confidence intervals (CIs) to evaluate. STATA 15.1 software was applied for data synthesis, sensitivity synthesis, and publication bias. RESULTS 45 articles were published between 2000 and 2022, and 2482 patients were finally included. All articles were observational research, with 7 case-control studies and 38 cohort studies, and the Newcastle Ottawa Scale (NOS) score ranged from 7 to 9. The pooled results suggested that age (OR 0.32, 95% CI 0.14-0.74, P = 0.01), reduction quality (OR 0.08, 95% CI 0.01-0.44, P = 0.00), fracture type (OR 0.44, 95% CI 0.25-0.78, P = 0.01), surgical approach (OR: 4.06, 95% CI 1.21-13.61, P = 0.02) and fixation implant (OR = 0.68, 95% CI = 0.34-1.33, P = 0.02) were risk factors for ONHH after IFPHF. According to sensitivity analysis, Begg (P = 0.42) and Egger (P = 0.68) tests, the results were stable and exhibited no publication bias. CONCLUSIONS The study showed that age, reduction quality, fracture type, surgical approach and fixation implant were risk factors for ONHH after IFPHF, while gender, varus or valgus, timely operation, injured side, and the existence of medial support have little influence on ONHH, as they could not be considered risk factors and still need further investigations.
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Affiliation(s)
- ZiXuan Ou
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - QiYuan Feng
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - LianQi Peng
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - MinQi Zhou
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Orthopaedics, Al Ahalia Hospital, Abu Dhabi, United Arab Emirates
| | - Xin Tang
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Contreras JJ, Meissner A, Valenzuela A, Liendo R, de Marinis R, Calvo C, Soza F. Straight antegrade humeral nailing and risk of iatrogenic injury of supraspinatus tendon footprint: An MRI study. Shoulder Elbow 2023; 15:72-80. [PMID: 37974613 PMCID: PMC10649480 DOI: 10.1177/17585732221150895] [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: 08/06/2022] [Revised: 12/18/2022] [Accepted: 12/28/2022] [Indexed: 11/19/2023]
Abstract
Background Straight antegrade humeral nailing (SAHN) is associated with excellent clinical results in proximal humerus fractures. The optimal entry point is the top of the humeral head. However, the anatomy is variable, and the entry point can affect supraspinatus tendon footprint (SSP-F) or fracture reduction. The aim of this study was to analyze the relationship between the SSP-F and SAHN entry point by analyzing magnetic resonance imaging (MRI) studies of the humerus. Methods In total 58 MRI studies of entire humerus were reviewed. The mean age was 51.6 ± 12.4 years, with 40 female patients. The distance between the SSP-F and the SAHN insertion point (critical distance: CD), the width of the footprint, and the neck-shaft angle (NSA) were measured. Univariate and multivariate analysis were performed. Results The mean CD was 7.51 mm ± 2.81 (0-12.9 mm) with 51.7% of proximal humerus "critical type" (CD <8 mm). The CD was found to be lower in females, with no difference found with varying age (62.5% "critical type"). CD correlated with NSA (linear regression). "Critical type" correlated with female gender and NSA (logistic regression). Discussion More than half of the humerus are "critical types" as to SAHN and may, therefore, be at risk for procedure-related complications.
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Affiliation(s)
- Julio J Contreras
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
- Shoulder and Elbow Unit, Instituto Traumatológico, Santiago, Chile
- Department of Orthopedics and Trauma, Universidad de Chile, Santiago, Chile
| | - Arturo Meissner
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
| | - Alfonso Valenzuela
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
| | - Rodrigo Liendo
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
| | - Rodrigo de Marinis
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
| | - Claudio Calvo
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
| | - Francisco Soza
- Shoulder and Elbow Unit, Pontifical Catholic University of Chile, Santiago, Chile
- Department of Orthopedics and Trauma, Pontifical Catholic University of Chile, Santiago, Chile
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Henkelmann R, Hepp P, Mester B, Dudda M, Braun PJ, Kleen S, Zellner J, Galler M, Koenigshausen M, Schildhauer TA, Saier T, Trulson I, Dey Hazra RO, Lill H, Glaab R, Bolt B, Wagner M, Raschke MJ, Katthagen JC. Assessment of Complication Risk in the Treatment of Proximal Humerus Fractures: A Retrospective Analysis of 4019 Patients. J Clin Med 2023; 12:jcm12051844. [PMID: 36902631 PMCID: PMC10003238 DOI: 10.3390/jcm12051844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/22/2023] [Accepted: 02/21/2023] [Indexed: 03/03/2023] Open
Abstract
(1) Background: The treatment of proximal humeral fractures (PHFs) is debated controversially. Current clinical knowledge is mainly based on small single-center cohorts. The goal of this study was to evaluate the predictability of risk factors for complications after the treatment of a PHF in a large clinical cohort in a multicentric setting. (2) Methods: Clinical data of 4019 patients with PHFs were retrospectively collected from 9 participating hospitals. Risk factors for local complications of the affected shoulder were assessed using bi- and multivariate analyses. (3) Results: Fracture complexity with n = 3 or more fragments, cigarette smoking, age over 65 years, and female sex were identified as predictable individual risk factors for local complications after surgical therapy as well as the combination of female sex and smoking and the combination of age 65 years or older and ASA class 2 or higher. (4) Conclusion: Humeral head preserving reconstructive surgical therapy should critically be evaluated for patients with the risk factors abovementioned.
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Affiliation(s)
- Ralf Henkelmann
- Department of Orthopedics, Trauma and Plastic Surgery, Division of Arthroscopic and Special Joint Surgery/Sports Injuries, University of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
- Correspondence: ; Tel.: +49-341-9717300
| | - Pierre Hepp
- Department of Orthopedics, Trauma and Plastic Surgery, Division of Arthroscopic and Special Joint Surgery/Sports Injuries, University of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Bastian Mester
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Marcel Dudda
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Philipp-Johannes Braun
- Department of Trauma and Orthopaedic Surger, BG Hospital Unfallkrankenhaus Berlin gGmbH, Warener Straße 7, 12683 Berlin, Germany
| | - Sebastian Kleen
- Department of Trauma and Orthopaedic Surger, BG Hospital Unfallkrankenhaus Berlin gGmbH, Warener Straße 7, 12683 Berlin, Germany
| | | | - Michael Galler
- Department of Trauma Surgery, Caritas Hospital St. Josef, Landshuter Strasse 65, 93053 Regensburg, Germany
| | - Matthias Koenigshausen
- Department of General and Trauma Surgery, University Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | - Thomas A. Schildhauer
- Department of General and Trauma Surgery, University Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | - Tim Saier
- Department of Trauma Surgery, BG Trauma Center Murnau, 82418 Murnau, Germany
| | - Inga Trulson
- Institute for Laboratory Medicine, German Heart Center, Technical University of Munich, Lazarettstraße 36, 80636 Munich, Germany
| | - Rony-Orijit Dey Hazra
- Department for Orthopaedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169 Hannover, Germany
| | - Helmut Lill
- Department for Orthopaedic Surgery and Traumatology, DIAKOVERE Friederikenstift, Humboldtstr. 5, 30169 Hannover, Germany
| | - Richard Glaab
- Department of Traumatology, Cantonal Hospital Aarau, 5001 Aarau, Switzerland
| | - Basil Bolt
- Department of Traumatology, Cantonal Hospital Aarau, 5001 Aarau, Switzerland
| | - Marcus Wagner
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), Leipzig University, Härtelstraße 16-18, 04107 Leipzig, Germany
| | - Michael J. Raschke
- Department for Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Jan Christoph Katthagen
- Department for Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
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Connelly JW, Meltzer JH, Tapscott DC, Molino J, Green A, Scott Paxton E. Short-term clinical and radiographic outcomes in patients treated with a modern intramedullary nailing system for 2-part proximal humerus fractures. Injury 2023; 54:561-566. [PMID: 36435642 DOI: 10.1016/j.injury.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 10/26/2022] [Accepted: 11/06/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The optimal surgical treatment of displaced proximal humerus fractures (PHFs) remains controversial. There are advocates for both open reduction and internal fixation with plate and screws (ORIF) and intramedullary nailing (IMN). The purpose this study was to evaluate the early-term clinical and radiographic outcomes of IMN for isolated, displaced 2-part surgical neck PHFs using a modern, straight nail system and to determine the effect of preoperative patient and fracture characteristics on outcome. METHODS This was a case series of 23 patients with displaced 2-part surgical neck PHFs who were treated with ORIF using a straight IMN with minimum follow-up of 1 year (mean 2.5 years [range, 1.1-4.6]). Patients were identified retrospectively and contacted for measurement of active range of motion (AROM) and patient reported outcome measures (PROMs) including the American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and Single Assessment Numeric Evaluation (SANE), EuroQol-5D (EQ-5D), and Visual Analog Scale Pain score (VAS Pain). Plain radiographs were evaluated to assess the quality of the reduction and failure of fixation. Complications and reoperations were identified. RESULTS Reduction was anatomic in 12 (52%) patients, acceptable in 9 (39%), and 2 (9%) were malreduced. There were no differences in reduction quality based on sex (p = 0.37), age at surgery (p = 0.68), calcar comminution (p = 0.68), number of screws in the head (p = 0.99), or medial hinge disruption (p = 0.06). At final follow-up, the mean ASES score was 92 ± 10, OSS was 45 ± 4, SANE was 93 ± 7, EQ-5D of 0.85 ± 0.17, and VAS Pain was 0 ± 1. The mean active forward flexion was 143° ± 16°, active external rotation was 68° ± 20°, and internal rotation was T11 ± 4 vertebrae. Two (9%) patients underwent reoperation and 2 (9%) patients experienced clinical failure not requiring reoperation. CONCLUSIONS Straight IMN is a reliable treatment for displaced 2-part surgical neck PHFs with excellent radiographic and clinical outcomes in early follow-up. The implant facilitated anatomic or acceptable alignment of the fracture in the vast majority of patients.
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Affiliation(s)
- James W Connelly
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Riverside, Providence, RI, United States.
| | - Jourdan H Meltzer
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Riverside, Providence, RI, United States
| | - David C Tapscott
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Riverside, Providence, RI, United States
| | - Janine Molino
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Riverside, Providence, RI, United States; Lifespan Biostatistics Core, Rhode Island Hospital, Providence, RI, United States
| | - Andrew Green
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Riverside, Providence, RI, United States
| | - E Scott Paxton
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, Riverside, Providence, RI, United States
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Bue M, Bright E, Thillemann TM, Mosegaard SB, Hansen TB, Klebe T, Mechlenburg I, Stilling M. Osteoporosis does not affect bone mineral density change in the proximal humerus or the functional outcome after open reduction and internal fixation of unilateral displaced 3- or 4-part fractures at 12-month follow-up. J Shoulder Elbow Surg 2023; 32:292-301. [PMID: 35998782 DOI: 10.1016/j.jse.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 06/17/2022] [Accepted: 07/07/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this prospective study was to investigate bone mineral density (BMD) changes in the proximal humerus of the shoulder during a healing period of 12 months after displaced 3- or 4-part proximal humerus fractures treated with open reduction and internal fixation (ORIF) with an anatomic angular stable locking plate and the influence on fracture healing and functional outcomes. METHODS In a prospective multicenter study, 36 patients (29F and 7M, age range: 38-83) with unilateral displaced 3- or 4-part proximal humerus fractures were included for ORIF. Dual-energy x-ray absorptiometry for osteoporosis status was employed. Postoperative and 6-week, 3-, 6-, and 12-month shoulder radiographs and dual-energy x-ray absorptiometry of the shoulder with BMD measures in 4 templated regions of interest (ROIs) were performed. Functional outcomes, Western Ontario Osteoarthritis of the Shoulder index, Constant score, visual analog scale pain (VAS), and 36-Item Short Form Survey, were collected. RESULTS A total of 17 of 36 patients had osteoporosis. We found no differences in BMD changes, functional outcomes, radiology, or need for revision surgery between the osteoporosis and nonosteoporosis groups. The BMD values gradually declined from baseline to 3-month follow-up in all 4 ROIs of the operated shoulders. All 4 ROIs in the operated shoulder presented with a reduction in BMD at 3, 6, and 12 months compared with baseline, whereas no significant BMD changes were seen in the healthy shoulder during the study period. The functional outcomes displayed an increase in Constant score from 3 to 12 months, but a decrease in domains of the 36-Item Short Form Survey from preinjury to 12 months (physical functioning, general health, and bodily pain). Preinjury and 12-month Western Ontario Osteoarthritis of the Shoulder index, VAS pain at rest, and VAS pain at activity were comparable. CONCLUSION BMD changes appeared swiftly in the proximal humerus, after the treatment of displaced 3- or 4-part fractures with ORIF, particularly affecting the proximal diaphysis of the humerus. Shoulder function was restored to preinjury levels for most of the patients. Osteoporosis may not be regarded as a contraindication for the treatment of displaced 3- or 4-part fractures with ORIF.
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Affiliation(s)
- Mats Bue
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Elisabeth Bright
- Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Theis Muncholm Thillemann
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Sebastian Breddam Mosegaard
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Orthopaedic Surgery, University Clinic for Hand, Hip and Knee Surgery, Holstebro Regional Hospital, Holstebro, Denmark
| | - Torben Bæk Hansen
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Orthopaedic Surgery, University Clinic for Hand, Hip and Knee Surgery, Holstebro Regional Hospital, Holstebro, Denmark
| | - Thomas Klebe
- Department of Orthopaedic Surgery, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Inger Mechlenburg
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Maiken Stilling
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Orthopaedic Surgery, University Clinic for Hand, Hip and Knee Surgery, Holstebro Regional Hospital, Holstebro, Denmark.
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The Role of Intramedullary Nailing for Proximal Humerus Fractures: What Works and What Does Not. Curr Rev Musculoskelet Med 2023; 16:85-94. [PMID: 36626085 PMCID: PMC9889584 DOI: 10.1007/s12178-022-09816-w] [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] [Accepted: 12/06/2022] [Indexed: 01/11/2023]
Abstract
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.
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Evaluation of the Multiple Assessment Subjective Shoulder Score (MASSS). A pilot study. Orthop Traumatol Surg Res 2022; 108:103313. [PMID: 35537681 DOI: 10.1016/j.otsr.2022.103313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 01/18/2022] [Accepted: 02/08/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION This study compares an entirely patient reported modification of the Constant-Murley Score (CS) (the Multiple Assessment Subjective Shoulder Score [MASSS]), with the CS in symptomatic patients with non-instability shoulder pathology. HYPOTHESIS The hypothesis is that the sub scores and overall score of the MASSS will be well correlated and in high agreement to the corresponding scores of the CS. MATERIALS AND METHODS The MASSS, the CS and adjusted-CS (a-CS) were administered to 74 patients. The MASSS replaced the strength and ROM domains of the CS with SANE scores. Correlations, differences, agreement, test-retest reliability, and internal consistency were assessed using Pearson's R test, paired t-test, Bland-Altman method, intraclass correlations (ICC) and Cronbach's alpha. RESULTS Correlation between MASSS and CS (0.834) and a-CS (0.824) were excellent. Total MASSS (54.0) was higher than CS (41.8) (p<0.001) and a-CS (47.8) (p<0.05). MASSS strength and ROM domains were higher than those of the CS (Strength: 13.4 v 5.3 [p<0.001], ROM: 24.8 v 20.8 [p<0.001]. There was a floor effect for the strength domain of the CS (46.7% minimum score), but not the MASSS (0% minimum score). MASSS internal consistency (0.626-0.734) was better than the CS (0.401-0.643). Test re-test reliability of the total MASSS (ICC 0.93) and the strength (ICC 0.90) and ROM (ICC 0.86) domains was excellent. DISCUSSION The MASSS has several advantages over the CS. Although the correlation of the total MASSS with the CS and a-CS was high, there was poor agreement in the strength and the ROM domains and therefore the MASSS value is not interchangeable with the CS, but rather should be considered as an alternative. LEVEL OF EVIDENCE II; Prospective cohort study.
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10
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Wang H, Liu Y, Wang D, He Y, Yao P, Lu T, Zhou J. Predictive Indicators for Complications of Proximal Humerus Fractures Treated with Locking Plate or Intramedullary Nail Fixation. Orthop Surg 2022; 14:2109-2118. [PMID: 35924701 PMCID: PMC9483087 DOI: 10.1111/os.13421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/26/2022] [Accepted: 06/26/2022] [Indexed: 12/02/2022] Open
Abstract
Objective The purpose of this study was to evaluate the best placement of calcar screws in proximal humerus fracture surgeries. Methods This retrospective cohort study included clinical and radiographic outcomes of 98 patients treated with proximal humerus fracture surgeries between January 2017 and June 2020. Demographic data of patients were obtained from medical records. The surgical and radiographic results were also collected: operation time, blood loss, time to surgery, fibular allograft, disruption of medial region hinge, Neer classification, and recovery of medial support. Patients were allocated into two groups: the locking plate group (n = 65) and the intramedullary nail group (n = 33). In this study, we proposed new predictive indicators, named horizontal ratio (HR) and vertical ratio (VR), to quantify the placement of calcar screws in these two groups. A receiver operating characteristic (ROC) analysis was conducted to display the accuracy of these indicators. Shoulder activity, visual scale analog (VAS) score, and Constant score were performed to evaluate postoperative clinical outcomes at 1 year follow‐up. Results In the multivariate logistic regression analysis, only time to surgery and effective medial support were considered statistically significant factors of postoperative complications (p < 0.05). Significant differences were observed between medial support and postoperative complications both in the locking plate group and the intramedullary nail group (p < 0.05). Only the vertical ratio of locking plate (VRLP) was a statistically significant predictor of postoperative complications (p < 0.05). The area under curve was calculated to assess the predictive value of VRLP, which came to 0.84. In addition, a ROC analysis found quantifiable thresholds of the VR was 0.1713 as measures to avoid postoperative complications in the locking plate fixation. Conclusion In locking plate fixation, the incidence of postoperative complications increased significantly when the VR of calcar screws greater than 0.1713, which was beneficial to surgeons to place calcar screws.
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Affiliation(s)
- Hanzhou Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Yang Liu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Dong Wang
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Yuanming He
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Peifeng Yao
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Tianchao Lu
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Junlin Zhou
- Department of Orthopedic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
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11
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Willauschus M, Schram L, Millrose M, Rüther J, Loose K, Bail HJ, Geßlein M. Specific Radiologic Risk Factors for Implant Failure and Osteonecrosis of the Humeral Head after Interlocking Nailing with the Targon PH + of Proximal Humeral Fractures in a Middle to Old Population. J Clin Med 2022; 11:jcm11092523. [PMID: 35566649 PMCID: PMC9103667 DOI: 10.3390/jcm11092523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Operative management of proximal humeral fractures is still challenging. While antegrade nailing has become a valid option in fracture fixation, risk factors for adverse events, and failure have not been sufficiently clarified. Methods: All patients of a single trauma center undergoing surgery for proximal humeral fractures with the Targon PH+ nail between 2014 and 2021 were evaluated retrospectively. This included complications, revisions, and failures. Pre- and postoperative radiographic imaging were assessed regarding fracture’s complexity, anatomic reduction, reconstruction of the medial hinge, metaphyseal head extension, and fixation of the implant in the calcar region. Follow-up was at a minimum of 12 months. Results: A total number of 130 patients with a mean age of 74.5 years (range 63−94, SD ± 8.2) are included in this study. Two- and three-part fractures were found in 58 patients, while 14 patients showed four-part fractures. Overall, a complication rate of 34.2% and an implant failure rate of 15.4% was found. Four-part fractures showed a significantly higher complication rate than two- and three-part fractures. Four-part fractures also showed significantly higher revisions (p = 0.005) and implant failures (p = 0.008). The nonsufficient anatomical reduction was found to be a risk factor for complications (p < 0.0001), implant failures (p < 0.0001), and later humeral head osteonecrosis (p < 0.0001). Insufficiently reconstructed medial hinges (p = 0.002) and a metaphyseal head extension of under 8 mm (p = 0.005) were also demonstrated as risk factors for osteonecrosis of the humeral head. Conclusions: Four-part fractures in an elderly population show high complication, revision, and implant-failure rates. Therefore, demonstrated radiologic risk factors should be evaluated for improvements. Anatomical reduction and fixation near the calcar proved to be vital for successful antegrade nailing of complex fractures. To prevent osteonecrosis of the humeral head, reconstruction of the medial hinge and metaphyseal head extension should be evaluated.
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Affiliation(s)
- Maximilian Willauschus
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, 90419 Nuremberg, Germany; (L.S.); (J.R.); (K.L.); (H.J.B.); (M.G.)
- Correspondence:
| | - Linus Schram
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, 90419 Nuremberg, Germany; (L.S.); (J.R.); (K.L.); (H.J.B.); (M.G.)
| | - Michael Millrose
- Department of Trauma Surgery and Sports Medicine, Garmisch-Partenkirchen Medical Centre, 82467 Garmisch-Partenkirchen, Germany;
| | - Johannes Rüther
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, 90419 Nuremberg, Germany; (L.S.); (J.R.); (K.L.); (H.J.B.); (M.G.)
| | - Kim Loose
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, 90419 Nuremberg, Germany; (L.S.); (J.R.); (K.L.); (H.J.B.); (M.G.)
| | - Hermann Josef Bail
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, 90419 Nuremberg, Germany; (L.S.); (J.R.); (K.L.); (H.J.B.); (M.G.)
| | - Markus Geßlein
- Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, 90419 Nuremberg, Germany; (L.S.); (J.R.); (K.L.); (H.J.B.); (M.G.)
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12
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Frodl A, Eberbach H, Senbaklavaci Ö, Schmal H, Jaeger M. Fracture dislocation of the humerus with intrathoracic humeral head fragment - A case report and review of the literature. Trauma Case Rep 2022; 37:100592. [PMID: 35005168 PMCID: PMC8718900 DOI: 10.1016/j.tcr.2021.100592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2021] [Indexed: 11/30/2022] Open
Abstract
We present a rare case of humeral fracture dislocation with intrathoracic humeral head fragment. A 74-year old female was transferred to a major trauma facility after falling on her arm while gardening. An intrathoracic humeral head fragment was diagnosed after initial imaging. In correspondence with the department of thoracic surgery, the decision was made to remove the intrathoracic fragment thoracoscopically and succeed with a reverse total shoulder arthroplasty.
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Affiliation(s)
- A Frodl
- Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany
| | - H Eberbach
- Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany
| | - Ö Senbaklavaci
- Department of Thoracic Surgery, Freiburg University Hospital, Freiburg, Germany
| | - H Schmal
- Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany.,University Hospital Odense, Dep. Of Orthopedic Surgery, Sdr. Boulevard 29, 5000 Odense C, Denmark
| | - M Jaeger
- Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany
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13
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Gumina S, Candela V, Cacciarelli A, Iannuzzi E, Formica G, Lacarbonara W. Three-part humeral head fractures treated with a definite construct of blocked threaded wires: finite element and parametric optimization analysis. JSES Int 2021; 5:983-991. [PMID: 34766074 PMCID: PMC8568808 DOI: 10.1016/j.jseint.2021.06.007] [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] [Indexed: 11/18/2022] Open
Abstract
Background Mini open reduction and percutaneous fixation of three-part humeral head fracture with blocked threaded wires has demonstrated functional results similar to locking plates or intramedullary nails but with significantly lower major complication rate. In the context of three-part humeral head fractures, we performed a parametric optimization through a finite element analysis of a recently published construct to verify if the encouraging clinical results can be supported by a more rigorous investigation from a mechanical viewpoint. Materials and Methods The 2-dimensional geometry of a three-part proximal humerus fracture synthetized with a system of blocked threaded wires was created. Tension/bending/shear and compression load tests were simulated. A parametric optimization analysis was performed considering four design parameters (height of wire couples; wire material; interdistance between two wires). Eighteen simulations were carried out. Additional analyses were performed also considering a varying diameter of the external rod. Results Four points where the largest gap occurs and three points associated with the highest stress concentration were considered. As per the tension/bending/shear loading, a slight gap increase was observed in two different points (8.494 μm; 7.540 μm), while a slight decrease was detected along the greater tuberosity fracture line (1.445 μm). The maximum von Mises stress up to 64.4 MPa was achieved in the humeral head. As per the compression loading, the gap increased along the greater tuberosity fracture line (1.445 μm; 7.545μm); the maximum von Mises stress attains the value of 64.42 MPa. The smallest gap distance (15.37μm) and the lowest von Mises stress (51.51 MPa) were obtained in two different alternative constructs. The diameter of the external rod had no significant effect. Conclusions The studied construct is biomechanically valid; it only allows micromovements (one-thousandth of the characteristic humerus size) that are not able to cause humeral head rotation and translation. Furthermore, the construct generates acceptable pressure stresses on sensible areas of the fractured humeral head. Compared to the original construct, we propose to space the pair of horizontal wires for the great tuberosity by at least 1 cm.
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Affiliation(s)
- Stefano Gumina
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences, Sapienza University of Rome, Istituto Clinico Ortopedico Traumatologico (ICOT), Latina, Italy
| | - Vittorio Candela
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences, Sapienza University of Rome, Istituto Clinico Ortopedico Traumatologico (ICOT), Latina, Italy
- Corresponding author: Vittorio Candela, MD, Department of Anatomy, Histology, Legal Medicine and Orthopedics, University of Rome, Piazzale Aldo Moro 5, 00185, Rome, Italy.
| | - Arianna Cacciarelli
- Department of Structural Engineering, Sapienza University of Rome, Rome, Italy
| | - Eleonora Iannuzzi
- Department of Structural Engineering, Sapienza University of Rome, Rome, Italy
| | | | - Walter Lacarbonara
- Department of Anatomical, Histological, Forensic Medicine and Orthopaedics Sciences, Sapienza University of Rome, Istituto Clinico Ortopedico Traumatologico (ICOT), Latina, Italy
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14
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Boyer P, Couffignal C, Bahman M, Mylle G, Rousseau MA, Dukan R. Displaced three and four part proximal humeral fractures: prospective controlled randomized open-label two-arm study comparing intramedullary nailing and locking plate. INTERNATIONAL ORTHOPAEDICS 2021; 45:2917-2926. [PMID: 34554308 DOI: 10.1007/s00264-021-05217-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of this study was (1) to compare clinical and radiological outcomes of 3- and 4-part proximal humeral fractures using either IMN or LP (2) and to report complications related to each technique. METHODS A prospective controlled randomized open-label two-arm study was performed. Ninety-nine consecutive adult patients with a 3- and 4-part displaced acute proximal humeral fractures were randomized to be treated with IMN (n = 49) or LP (n = 50). Constant, ASES and SST scores were recorded by the surgeon. Range of motion was evaluated. A visual analog scale (VAS) was used to assess shoulder pain. Complications and revision surgeries were reported. RESULTS Eighty-five patients were analyzed, nine were lost, and five died during the follow-up period. The mean age was 73.7 years (± 13.3,, and the mean follow-up was 66 months (± 13.5). At last follow-up, VAS was lower in the IMN group (0.9 (± 1.1) vs. 1.9 (± 1.7), p = 0.001). The median Constant score was significantly higher in the IMN group (81.6 (± 10.9) points) vs. in the LP group (75.6 (± 19.5) points) (p = 0.043), and ASES score was also significantly higher in the IMN group (86.3 (± 9.5) vs. 75.2 (± 19.6), p = 0.001). There was no difference in the range of motion or SST scores between the two groups. Complications were seen higher in the LP group (9 (21%) vs. 22 (52%), p = 0.003). Revision surgery was higher in the LP group (37% vs. 21%). CONCLUSION Satisfactory results were accomplished in both groups according to the reported clinical outcomes. Complication and revision rates were higher in LP group.
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Affiliation(s)
- Patrick Boyer
- Orthopaedic Surgery Department, Université de Paris, Hôpital, Bichat 46 Henri Huchard, 75018, Paris, France
| | - Camille Couffignal
- Clinical Research, Biostatistics and Epidemiology Department, AP-HP, Hôpital Bichat, F-75018, Paris, France
| | - Mohammad Bahman
- Alrazi Hospital, University of Kuwait, Al Sabah Medical Area, Kuwait, Kuwait
| | - Guy Mylle
- Clinique Hartmann, Neuilly Sur Seine, France
| | - Marc-Antoine Rousseau
- Orthopaedic Surgery Department, Université de Paris, Hôpital, Bichat 46 Henri Huchard, 75018, Paris, France
| | - Ruben Dukan
- Orthopaedic Surgery Department, Université de Paris, Hôpital, Bichat 46 Henri Huchard, 75018, Paris, France.
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Adeyemo A, Bertha N, Perry KJ, Updegrove G. Implant Selection for Proximal Humerus Fractures. Orthop Clin North Am 2021; 52:167-175. [PMID: 33752838 DOI: 10.1016/j.ocl.2020.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Proximal humerus fractures (PHF) are a common orthopedic injury; however, their treatment remains largely controversial with evidence supporting a wide array of treatments. Although many injuries can be treated nonoperatively, there has been much debate about surgical management of PHF. A detailed review of the literature was performed relative to operative management options specifically related to implant choices. Although no definitive answers are available regarding best practice, there is literature to guide operative decision-making and implant selection based on both patient- and surgeon-specific factors.
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Affiliation(s)
- Adeshina Adeyemo
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA
| | - Nicholas Bertha
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA
| | - Kevin J Perry
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA
| | - Gary Updegrove
- Department of Bone and Joint, Penn State Milton Hershey Medical Center, 30 Hope Drive, Building A; PO Box 859, Hershey, PA 17033, USA.
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16
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Proximal humeral nail for treatment of 3- and 4-part proximal humerus fractures in the elderly population: effective and safe in experienced hands. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:769-777. [PMID: 33211233 DOI: 10.1007/s00590-020-02832-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Optimal treatment of 3- and 4-part proximal humerus fractures (PHFs) remains controversial. Although commonly recommended for less comminuted PHFs, the outcomes of treatment with proximal humerus nailing (PHN) are more equivocal. The purpose of this study was to report on radiographic and clinical outcomes of patients undergoing PHN fixation of 3- and 4-part PHFs at minimum one-year follow-up. Our hypothesis was that the findings would demonstrate satisfactory radiographic and clinical outcomes, with low rates of complications and revision surgeries. METHODS Between 2008 and 2016, 121 patients with comminuted, low-energy, osteoporotic, PHFs underwent fixation via Targon PHN (Aesculap, Tuttlingen, Germany). Of these, 60 patients met inclusion and exclusion criteria and were included in this analysis (mean age 72; range 65-85). All completed a minimum 1-year follow-up (range 12.5-82 months). Patients with 3-part PHFs were compared to patients with 4-part PHFs. Clinical, radiographic, and functional outcomes were assessed at postoperative visits. Patient reported outcomes included pain, the American Shoulder and Elbow Surgeons (ASES) score and the Simple Shoulder Test (SST). Radiographic union and revision and complication rates were assessed. RESULTS Overall, 37 (62%) fractures were classified as Neer 3 and 23 (38%) were classified as Neer 4. Both groups achieved similar postoperative range of motion. Patients with 3-part fractures reported significantly lower postoperative pain (0.76 ± 1.8 vs. 1.65 ± 2.2, p = 0.0047). Patients with 3-part fractures reported significantly better ASES scores (82.4 ± 19.2 vs. 70.8 ± 21.9, p = 0.02) and non-statistically significant higher SST scores (8.4 ± 3.2 vs. 7.43 ± 3.8, p = 0.14). Adequate fracture union was achieved in 53 fractures (88.3%). Three patients (5%) had varus malunion or greater tuberosity displacement, one (1.7%) had mechanical failure, and three (5%) had radiographic evidence of avascular necrosis. Between groups, there was no difference in failure rates. CONCLUSION Proximal humeral nails can successfully be used by experienced surgeons in fixation of comminuted and displaced proximal humeral fractures in selected patients with osteoporosis. While patients with both 3- and 4-part fractures demonstrate fracture union with satisfactory outcomes, patients with 3-part fractures demonstrate significantly higher postoperative functional scores.
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Huntley SR, Lehtonen EJ, Robin JX, Arguello AM, Rouleau DM, Brabston EW, Ponce BA, Momaya AM. Outcomes of surgical fixation of greater tuberosity fractures: A systematic review. Orthop Traumatol Surg Res 2020; 106:1119-1126. [PMID: 32933866 DOI: 10.1016/j.otsr.2020.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 04/01/2020] [Accepted: 05/27/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Isolated greater tuberosity fractures account for up to a fifth of all proximal humeral fractures. There have been several retrospective cohort studies and case series reporting outcomes after treatment of this pathology. This study aims to report on the clinical outcomes of surgically treated isolated greater tuberosity fractures, as well as diagnostic workup and complications associated with fracture fixation. METHODS A systematic review was performed under PRISMA guidelines to identify studies that reported the results or clinical outcomes of isolated greater tuberosity fracture. The searches were performed using MEDLINE through PubMed, the Elsevier Embase database, and the Cochrane Database of Systematic Reviews. RESULTS Sixteen studies met inclusion criteria comprising 345 patients and 345 shoulders. The mean age was 52.9 years and mean follow-up was 3.4 months. The mean postoperative American Shoulder and Elbow Surgeon Score, the most frequently utilized patient reported outcome measure across studies, was 90.1% of ideal maximum. All studies used standard shoulder radiographs in their initial workup and most commonly referred to a minimum of 5mm displacement as an indication for surgery. Fifty five percent of patients were treated using open fixation and 35.9 with arthroscopic fixation. Ninety three percent of patients were able to return to work. A total of fifty-two (15.1%) complications were reported in the included studies. CONCLUSIONS The current literature describes overall satisfactory functional outcomes and minimal occupational morbidity following either open or arthroscopic fixation of isolated greater tuberosity fractures despite a notable rate of complications. LEVEL OF EVIDENCE IV, systematic review.
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Affiliation(s)
- Samuel R Huntley
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Eva J Lehtonen
- University of Alabama at Birmingham, Birmingham, AL, United States
| | | | | | - Dominique M Rouleau
- Faculty of Medicine, université de Montréal, 2900, boulevard Edouard-Montpetit, H3T 1J4 Montréal, QC, Canada; Hôpital du Sacré-Cœur, C2095-5400, boulevard Gouin O., H4J 1C5 Montréal, QC, Canada
| | | | - Brent A Ponce
- University of Alabama at Birmingham, Birmingham, AL, United States
| | - Amit M Momaya
- University of Alabama at Birmingham, Birmingham, AL, United States.
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Lorenz G, Schönthaler W, Huf W, Komjati M, Fialka C, Boesmueller S. Complication rate after operative treatment of three- and four-part fractures of the proximal humerus: locking plate osteosynthesis versus proximal humeral nail. Eur J Trauma Emerg Surg 2020; 47:2055-2064. [PMID: 32448941 DOI: 10.1007/s00068-020-01380-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/24/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE There is still disagreement regarding the optimal surgical treatment of three- and four-part fractures of the proximal humerus. The aim of this monocentric, retrospective study was to compare the complication rate of internal fixation with a locking plate versus proximal humeral nailing after a one-year follow-up. METHODS From 2005 to 2016, 292 patients suffered a fracture of the proximal humerus and were treated surgically at our level-I trauma center. According to the inclusion criteria, 50 patients were included in this study: 19 of these (11 three-part fractures and 8 four-part fractures) were treated with a proximal humeral nail (HN) and 31 (12 three-part fractures and 19 four-part fractures) with a locking plate (LP) osteosynthesis. Classification was performed according to the Hertel classification. At a 1-year follow-up, the complication rate of the two treatment methods was compared. RESULTS Twenty patients (40%) suffered at least one complication. Of these, six patients (12%) were treated with a HN and 14 (28%) with a LP (p = 0.39). The most frequent complication was screw perforation (22%), followed by non-union (16%). Humeral head necrosis (10%) occurred only in the LP cohort. One wound infection occurred in a patient treated with a HN. Four-part fractures were treated more frequently with a LP. However, the difference was non-significant in this sample (p = 0.186). CONCLUSIONS The results of our study provide some evidence that in terms of complication rate, both treatment options are comparable for internal fixation of three- and four-part fractures of the proximal humerus. The type of fracture seems to be decisive for the choice of implant.
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Affiliation(s)
- Greta Lorenz
- Department of Trauma Surgery, AUVA Trauma Center Vienna Meidling, Kundratstraße 37, 1120, Vienna, Austria.
| | - Wolfgang Schönthaler
- Department of Trauma Surgery, AUVA Trauma Center Vienna Meidling, Kundratstraße 37, 1120, Vienna, Austria
| | - Wolfgang Huf
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Micha Komjati
- Department of Trauma Surgery, AUVA Trauma Center Vienna Meidling, Kundratstraße 37, 1120, Vienna, Austria
| | - Christian Fialka
- Department of Trauma Surgery, AUVA Trauma Center Vienna Meidling, Kundratstraße 37, 1120, Vienna, Austria
| | - Sandra Boesmueller
- Department of Trauma Surgery, AUVA Trauma Center Vienna Meidling, Kundratstraße 37, 1120, Vienna, Austria
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Abstract
Proximal humeral fractures are a commonly encountered injury; however, no consensus has been reached for the ideal treatment. Current surgical fixation options include plate, plate with fibular strut allograft, intramedullary fixation, pinning, suture constructs, and external fixation. Each of these options possesses distinct advantages and disadvantages. With the evolution of implant design, a greater understanding of the mechanisms of failure of fixation, and the ability to preserve fracture biology, the management of proximal humeral fractures with intramedullary fixation has become an accepted treatment option. From a biomechanical perspective, intramedullary fixation may have advantages over laterally based fixation, in particular with fractures associated with significant calcar comminution. The ability to insert the implant from a superior starting point may help preserve vascular supply to the humeral head and tuberosities. With reported outcomes comparable with the aforementioned techniques and an evolving understanding of fracture characteristics and failures of fixation, intramedullary fixation represents an alternative treatment option for proximal humeral fractures with specific fixation and biologic advantages.
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20
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Panagiotopoulou VC, Varga P, Richards RG, Gueorguiev B, Giannoudis PV. Late screw-related complications in locking plating of proximal humerus fractures: A systematic review. Injury 2019; 50:2176-2195. [PMID: 31727401 DOI: 10.1016/j.injury.2019.11.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2019] [Indexed: 02/07/2023]
Abstract
Locking plating is a common surgical treatment of proximal humeral fractures with satisfactory clinical results. Implant-related complications, especially screw-related, have been reported, however, the lack of information regarding their onset, used surgical technique, complexity of the fracture, bone quality etc., prevents from understanding the causes for them. The aim of this systematic review is to identify the potential risk factors for late screw complications by gathering information about the patient characteristics, comorbidities, fracture types, surgical approaches and implant types. A PubMed search was performed using humerus, fractures, bone and locking as keywords in clinical papers written in English. All abstracts and manuscripts on distal or humerus shaft fractures, and those on proximal humerus fractures without any or with only iatrogenic complications were excluded. One hundred studies met the inclusion criteria, resulting in 33% of the reported cases having at least one complication, with 11% of all complications being screw-related. Most of the latter were secondary screw perforations and screw cut-outs, being predominantly linked to poor bone quality, while screw loosening and retraction were found less frequently as a result of locking mechanism failure. Overall, the amount of information for complications was limited and screw perforation was the most frequent screw-related complication, mostly reported in female patients older than 50 years, following four-part or AO/OTA type C fractures and detected four weeks postoperatively. The sparse information in the literature could be an indicator that the late screw complications might have been under-reported and under-described, making the understanding of the screw-related complications even more challenging.
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Affiliation(s)
- Vasiliki C Panagiotopoulou
- AO Research Institute Davos, Davos, Switzerland; School of Chemical and Processing Engineering, Engineering Building, University of Leeds, UK.
| | - Peter Varga
- AO Research Institute Davos, Davos, Switzerland
| | | | | | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
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21
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Erdle B, Izadpanah K, Eberbach H, Zwingmann J, Jaeger M, Südkamp N, Maier D. [Primary fracture protheses and reverse shoulder arthroplasty in complex humeral head fractures : An alternative to joint-preserving osteosynthesis?]. DER ORTHOPADE 2019; 47:410-419. [PMID: 29632973 DOI: 10.1007/s00132-018-3570-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The surgical management of complex humeral head fractures has adapted dynamically over the course of the last decade. The primary use of reverse shoulder arthroplasty in elderly patients has gained in relevance due to promising short and middle-term results. Long-term results, however, are still pending. The appliance of anatomical hemiarthroplasty, on the other hand, has lost in significance in favour of osteosynthesis and reverse shoulder arthroplasty. INDICATIONS This review article follows the question as to under which circumstances primary fracture arthroplasty reflects an alternative or even a preference to joint-preserving osteosynthesis in the treatment of complex proximal humeral fractures. It also specifies spectrums of indications for anatomical hemiarthroplasty and reverse shoulder arthroplasty.
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Affiliation(s)
- B Erdle
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland.
| | - K Izadpanah
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland
| | - H Eberbach
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland
| | - J Zwingmann
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland
| | - M Jaeger
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland
| | - N Südkamp
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland
| | - D Maier
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Straße 55, 79106, Freiburg, Deutschland
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22
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Shi X, Liu H, Xing R, Mei W, Zhang L, Ding L, Huang Z, Wang P. Effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture: an update systematic review and meta-analysis. J Orthop Surg Res 2019; 14:285. [PMID: 31470878 PMCID: PMC6717341 DOI: 10.1186/s13018-019-1345-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 08/22/2019] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Xiaoqing Shi
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Hao Liu
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Runlin Xing
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Wei Mei
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Li Zhang
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Liang Ding
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Zhengquan Huang
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China
| | - Peimin Wang
- Department of Orthopedic Trauma, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Hospital of Traditional Chinese Medicine, 155 Hanzhong Road, PO Box 210029, Nanjing, China.
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23
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Dimitriou D, Waldmann S, Antoniadis A, Liebhauser M, Helmy N, Riede U. Early locking plate removal following open reduction and internal fixation of proximal humeral fractures could prevent secondary implant-related complications. J Orthop 2019; 17:106-109. [PMID: 31879485 DOI: 10.1016/j.jor.2019.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 06/04/2019] [Indexed: 11/26/2022] Open
Abstract
Introduction Proximal humeral fracture is a common cause of morbidity in the elderly and poses a challenge for the orthopedic surgeon. Open reduction and internal fixation (ORIF) with a locking plate is associated with high rate of secondary implant-related complications (IRC). Early implant removal could potentially reduce the risk of IRC and further improve the outcome in relatively asymptomatic patients. The purpose of this study was to evaluate the clinical and radiologic outcomes following implant removal. Methods A total of 56 patients with an average age of 63 ± 13 years and a mean follow-up of 29 months were evaluated retrospectively following removal of a locking plate in the proximal humerus. Postoperative functional outcomes were evaluated with the Constant-Score, Subjective shoulder value and Quick-DASH score. Results Early implant removal resulted in high functional outcomes with 96% of the patients reporting an improvement of their shoulder function following implant removal. No intraoperative complications were reported. Avascular necrosis (AVN) of the humeral head occurred in 12.5% of the patients, but no secondary screw cut-out was reported. Conclusion Early implant removal might be a safe option to avoid secondary IRC with significant subjective functional improvement also in asymptomatic patients. Although early implant removal cannot reverse the process of AVN, it could potentially prevent secondary IRC and subsequent glenohumeral cartilage destruction.
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Affiliation(s)
- Dimitris Dimitriou
- Department of Orthopaedics Bürgerspital Solothurn, Schöngrünstrasse 38, CH-4500, Solothurn, Switzerland
| | - Soeren Waldmann
- Department of Orthopaedics Bürgerspital Solothurn, Schöngrünstrasse 38, CH-4500, Solothurn, Switzerland
| | - Alexander Antoniadis
- Department of Orthopaedics Bürgerspital Solothurn, Schöngrünstrasse 38, CH-4500, Solothurn, Switzerland
| | - Martin Liebhauser
- Department of Orthopaedics Bürgerspital Solothurn, Schöngrünstrasse 38, CH-4500, Solothurn, Switzerland
| | - Naeder Helmy
- Department of Orthopaedics Bürgerspital Solothurn, Schöngrünstrasse 38, CH-4500, Solothurn, Switzerland
| | - Ulf Riede
- Department of Orthopaedics Bürgerspital Solothurn, Schöngrünstrasse 38, CH-4500, Solothurn, Switzerland
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24
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Chelli M, Levy Y, Lavoué V, Clowez G, Gonzalez JF, Boileau P. The "Auto-Constant": Can we estimate the Constant-Murley score with a self-administered questionnaire? A pilot study. Orthop Traumatol Surg Res 2019; 105:251-256. [PMID: 30876713 DOI: 10.1016/j.otsr.2018.11.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 11/19/2018] [Accepted: 11/28/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The Constant score, allows an objective and subjective assessment of the shoulder function. It has been proven to have a poor interobserver reliability for some of its aspects and is not usable as a remote assessment tool. HYPOTHESIS The Constant-Murley functional shoulder score can be assessed with a self-administered questionnaire. METHODS We conducted a prospective continuous study in a shoulder-specialized service. For each patient seen in consultation or hospitalized for a shoulder pathology, a self-administered questionnaire was delivered, and a clinical examination was performed by a surgeon. The questionnaire, in French language, was composed of checkboxes only, with pictures preferred over text for most items. Correlations with surgeon examination were assessed with the intraclass correlation coefficients, differences with the paired t-test. RESULTS One hundred consecutive patients were analyzed. Correlation between the two scores was excellent (0.87), as were the range of motion and the pain subscores (0.85 and 0.78), good for the activity (0.69) and fair for the strength (0.57). The mean total score was 3 points lower for the self-administered questionnaire (CI95 [-5; -1]; p<0.01). Activity and pain were not significantly different (-0.4/20 and -0.3/40; p>0.05) but pain and force were slightly different (+0.8/15; -3.0/25; p<0.01). CONCLUSION The Auto-Constant questionnaire in French is an excellent estimator of the Constant score, and of its pain and mobility sub-scores. It is less accurate for the evaluation of the strength, but differences between sub-scores compensate and allow its use in daily practice. LEVEL OF PROOF II, Prospective continuous clinical series.
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Affiliation(s)
- Mikaël Chelli
- Institut Universitaire Locomoteur et du Sport, University Hospital of Nice, 06000 Nice, France.
| | - Yohann Levy
- Institut Universitaire Locomoteur et du Sport, University Hospital of Nice, 06000 Nice, France
| | - Vincent Lavoué
- Institut Universitaire Locomoteur et du Sport, University Hospital of Nice, 06000 Nice, France
| | - Gilles Clowez
- Institut Universitaire Locomoteur et du Sport, University Hospital of Nice, 06000 Nice, France
| | - Jean-François Gonzalez
- Institut Universitaire Locomoteur et du Sport, University Hospital of Nice, 06000 Nice, France
| | - Pascal Boileau
- Institut Universitaire Locomoteur et du Sport, University Hospital of Nice, 06000 Nice, France
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25
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Plath JE, Kerschbaum C, Seebauer T, Holz R, Henderson DJH, Förch S, Mayr E. Locking nail versus locking plate for proximal humeral fracture fixation in an elderly population: a prospective randomised controlled trial. BMC Musculoskelet Disord 2019; 20:20. [PMID: 30630465 PMCID: PMC6329164 DOI: 10.1186/s12891-019-2399-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/02/2019] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Johannes E Plath
- Department of Trauma, Orthopaedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Christian Kerschbaum
- Department of Trauma, Orthopaedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Tobias Seebauer
- Department of Trauma, Orthopaedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Rainer Holz
- Department of Trauma, Orthopaedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | | | - Stefan Förch
- Department of Trauma, Orthopaedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Edgar Mayr
- Department of Trauma, Orthopaedic, Plastic and Hand Surgery, University Hospital of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
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26
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Wang JQ, Jiang BJ, Guo WJ, Zhao YM. Serial changes in the head-shaft angle of proximal humeral fractures treated by placing locking plates: a retrospective study. BMC Musculoskelet Disord 2018; 19:420. [PMID: 30497479 PMCID: PMC6267827 DOI: 10.1186/s12891-018-2349-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 11/19/2018] [Indexed: 11/24/2022] Open
Abstract
Background Although the proximal humeral fractures (PHFs) treated with locking plate have been well applied, there are few studies concerning on the serial HSA changes after locking plate placement. The purpose of this retrospective study was to explored the clinical significance of serial HSA changes after surgery. Methods We retrospectively analyzed the clinical data of 122 patients between January 2012 to December 2016 in our hospital. The serial change of the HSA and Neer’s score of 122 patients were recorded and analyzed. Then, we evaluated the HSA changes affected functional recovery in conjunction with medial support (MS). Moreover, multivariable linear regression analysis was performed to identify any potential confounding factors that may influence functional recovery. Results Of 146 patients, 122 (50 males and 72 females) patients were finally enrolled in our study. Our preliminary data suggested that the most decrease of HSA occurred in the period of 1 to 3 months (p < 0.001) postoperatively, and functional recovery was significantly related with the change of HSA (R2 = 0.647, p < 0.001). The presence of MS plays an important role in maintaining postoperative HSA and restoring function. Moreover, Neer type 4 fracture, the difference between the postoperative HSA (on the injured side) and that of the uninjured side (the ΔHSA), and the HSA change to the end of follow-up were all significantly associated with functional recovery. Conclusions Serial HSA changes were evident in PHF patients in whom locking plates had been inserted; it is essential to maintain reduction for 1–3 months postoperatively. MS is important in this context and surgeons must maximally restore MS. Furthermore, the functional outcome tended to improve when the HSA of the injured side was restored to a value close to that of the uninjured side.
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Affiliation(s)
- Ji-Qi Wang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, Zhejiang, 325000, China
| | - Bing-Jie Jiang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, Zhejiang, 325000, China
| | - Wei-Jun Guo
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, Zhejiang, 325000, China
| | - You-Ming Zhao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, 109# Xue Yuan Xi Road, Wenzhou, Zhejiang, 325000, China.
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27
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Li M, Wang Y, Zhang Y, Yang M, Zhang P, Jiang B. Intramedullary nail versus locking plate for treatment of proximal humeral fractures: A meta-analysis based on 1384 individuals. J Int Med Res 2018; 46:4363-4376. [PMID: 30270807 PMCID: PMC6259395 DOI: 10.1177/0300060518781666] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective The optimal surgical intervention on the treatment for proximal humeral
fractures (PHFs) remains uncertain. The aim of this study was to evaluate
clinical outcomes following fixation of PHFs by intramedullary nails or
locking plates Methods The Cochrane Library, PubMed, EMBASE, China Knowledge Resource Integrated
(CNKI), Chongqing VIP and Wanfang databases were systematically searched for
studies published between January 01, 1996 and December 31, 2016 that
investigated intramedullary nail vs. locking plate in the
surgical treatment of PHFs. A meta-analysis examined incision length, blood
loss, operation time, fracture healing time, Constant scores and
post-operative complications. The methodological and evidence quality were
also assessed by MINORS and GRADE system. Results From the original 1024 references, 20 studies involving 1384 patients met the
eligibility criteria. Analyses showed that intramedullary nails were
superior to locking plates in incision length, peri-operative bleeding time,
operation time and fracture healing time. However, there were no differences
between treatments in Constant score or post-operative complications. Conclusion Although the evidence quality was poor, the results suggest that compared
with locking plates, intramedullary nails may be a better choice for the
repair of PHFs.
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Affiliation(s)
- Ming Li
- 1 Department of Trauma Rescue and Treatment Centre, Peking University People's Hospital, Beijing, China.,2 Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Yanhua Wang
- 2 Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Yupeng Zhang
- 3 Department of Orthopaedics and Spinal Surgery, Binzhou Centre hospital, Binzhou, China
| | - Ming Yang
- 2 Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Peixun Zhang
- 2 Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Baoguo Jiang
- 1 Department of Trauma Rescue and Treatment Centre, Peking University People's Hospital, Beijing, China.,2 Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, China
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28
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Oppebøen S, Wikerøy AKB, Fuglesang HFS, Dolatowski FC, Randsborg PH. 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. J Orthop Surg Res 2018; 13:197. [PMID: 30092807 PMCID: PMC6085712 DOI: 10.1186/s13018-018-0906-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 08/02/2018] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Sjur Oppebøen
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway.
| | - Annette K B Wikerøy
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Hendrik F S Fuglesang
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Filip C Dolatowski
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Per-Henrik Randsborg
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway
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29
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Sun Q, Ge W, Li G, Wu J, Lu G, Cai M, Li S. Locking plates versus intramedullary nails in the management of displaced proximal humeral fractures: a systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2017; 42:641-650. [PMID: 29119298 DOI: 10.1007/s00264-017-3683-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 10/27/2017] [Indexed: 01/03/2023]
Abstract
PURPOSE To compare the clinical outcome and complications of locking plates versus intramedullary nails in patients with displaced proximal humeral fractures. Our hypothesis was that there would be no difference between these two implants with regard to clinical outcome and complications. METHODS We performed a systemic review of PubMed, EMBASE, Clinical Trials Registry, Cochrane Central Register of Controlled Trials and Google Scholar to identify all relevant randomized controlled trials, prospective and retrospective comparative studies on April 26, 2017. The studies of locking plates compared to intramedullary nails in patients with displaced proximal humeral fractures were included. We conducted a meta-analysis of shoulder functional scores, range of motion, pain scores, and complications. RESULTS This meta-analysis included 13 comparative studies with 958 patients (529 in the locking plate group and 429 in the intramedullary nail group). A significantly greater external rotation (MD = 9.67; 95% CI, 4.22-15.12; P = 0.0005) and a significantly higher penetration rate (RR = 1.75; 95% CI, 1.11-2.77; P = 0.02) were observed in the locking plate group compared with the intramedullary nail group. Constant-Murley scores, DASH scores and total complication rate were comparable between the two groups. Moreover, there were no significant differences in forward elevation, VAS scores, and other complications. CONCLUSIONS Current evidence indicates that locking plates and intramedullary nails have similar performance in terms of the functional scores and total complication rate. No superior treatment was suggested between locking plates and intramedullary nails for displaced proximal humeral fractures.
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Affiliation(s)
- Qi Sun
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China
| | - Wei Ge
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China
| | - Gen Li
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China
| | - Jiezhou Wu
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China
| | - Guanghua Lu
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China
| | - Ming Cai
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China
| | - Shaohua Li
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China.
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Gracitelli MEC, Malavolta EA, Assunção JH, Ferreira Neto AA, Silva JS, Hernandez AJ. Locking intramedullary nails versus locking plates for the treatment of proximal humerus fractures. Expert Rev Med Devices 2017; 14:733-739. [PMID: 28792243 DOI: 10.1080/17434440.2017.1364624] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Proximal humerus fractures (PHF) are common fractures and are the third most common type of fractures among older adults. The most commonly used implants include the locking plate and the locking intramedullary nail. Areas covered: The aim of this study is to perform a literature review of biomechanical and clinical studies that compare the locking plate and intramedullary nail for PHF osteosynthesis. Expert commentary: Twelve clinical studies and seven biomechanical studies were identified that met this criterion. The findings of this review showed that intramedullary nailing and locking plate fixation yielded similar functional results, but with contrasting complication rates. The biomechanical studies showed controversial results, with most of the studies demonstrating better biomechanical properties for the intramedullary nail. Different types of intramedullary nail for PHF have different characteristics, with curvilinear nails presenting a higher risk of complications.
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Affiliation(s)
- Mauro E C Gracitelli
- a Department of Orthopedics and Traumatology, School of Medicine , University of São Paulo , Sao Paulo , Brazil
| | - Eduardo A Malavolta
- a Department of Orthopedics and Traumatology, School of Medicine , University of São Paulo , Sao Paulo , Brazil
| | - Jorge H Assunção
- a Department of Orthopedics and Traumatology, School of Medicine , University of São Paulo , Sao Paulo , Brazil
| | - Arnaldo A Ferreira Neto
- a Department of Orthopedics and Traumatology, School of Medicine , University of São Paulo , Sao Paulo , Brazil
| | - Jorge S Silva
- a Department of Orthopedics and Traumatology, School of Medicine , University of São Paulo , Sao Paulo , Brazil
| | - Arnaldo José Hernandez
- a Department of Orthopedics and Traumatology, School of Medicine , University of São Paulo , Sao Paulo , Brazil
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