Deltoid-split approach versus deltopectoral approach for proximal humerus fractures: A systematic review and meta-analysis

An updated systematic review and meta‑analysis comparing deltoid‑split approach with deltopectoral approach for proximal humerus fractures

The present review and meta-analysis aimed to summarize the currently available data and to compare the important clinical and functional outcomes in patients with proximal humerus fractures who were treated using deltoid split (DS) or deltopectoral (DP) surgical approaches. The PubMed, EMBASE, Scopus and Cochrane Central Register of Controlled Trials databases were systematically searched for randomized controlled trials or observational studies that reported functional outcome data of patients with fracture of proximal humerus who were surgically treated using DS and DP approaches. A total of 14 studies were included in the present meta-analysis. The duration of surgery [min; weighted mean difference (WMD), -16.44; 95% CI, -(25.25-7.63)], amount of blood loss [ml; WMD, -57.99; 95% CI, -(102.74-13.23)] and time to bone union [weeks WMD, -1.66; 95% CI, -(2.30-1.02)] was comparatively lower in patients that underwent DS. There were no statistically significant differences in the pain and quality of life scores, range of movement and risk of complications between the DS and the DP groups. Patients in the DS group had improved shoulder function and constant shoulder score (CSS) at 3 months post-surgery (WMD, 6.36; 95% CI, 1.06-11.65). No differences were observed between the two groups in terms of CSS and disabilities of the arm, shoulder and hand scores at 12 and 24 months post-operatively. The activity of daily living (ADL) score was significantly improved in the DS group at 3 (WMD, 1.23; 95% CI, 0.40-2.06), 6 (WMD, 0.99; 95% CI, 0.72-1.25) and 12 months (WMD, 0.83; 95% CI, 0.18-1.47) after the surgery. The present results suggested that DS and DP surgical approaches were associated with similar clinical outcomes. The DS approach was associated with certain perioperative benefits, as well as reduced time to bone union, improved shoulder function in the early postoperative period and improved ADL scores. These benefits may be considered while choosing between these two surgical approaches.

Reverse shoulder arthroplasty for proximal humerus fractures: a comparison of the deltoid split and deltopectoral approaches

INTRODUCTION

Reverse shoulder arthroplasty (RSA) is a common treatment for three- and four-part proximal humerus fractures. RSA is commonly performed through a deltopectoral (DP) surgical approach; however, a deltoid split (DS) approach has been described. The purpose of this study was to compare the intraoperative and postoperative outcomes of patients undergoing RSA for proximal humerus fractures through a DP and DS approach.

MATERIALS AND METHODS

A retrospective study of patients who underwent RSA for proximal humerus fractures at our level 1 trauma center was performed. Patients were evaluated at a minimum 1-year follow-up. Intraoperative outcomes as well as patient-reported outcome measures (PROMs) were analyzed. Postoperative complications, reoperation rates, and radiographic outcomes were evaluated.

RESULTS

Sixteen patients were included in the DP group and 13 patients in the DS group. The average follow-up was 28.6 months in the DP group and 21.1 months in the DS group. There were no significant differences in patient demographics or injury characteristics. Operative time was significantly shorter in the DS group (103 min) compared to the DP group (123 min). Tuberosity repair was performed in 81.3% of patients in the DP group and 92.3% of patients in the DS group. No significant differences were found in PROMs at final follow-up. There were no significant differences in postoperative complications. Three patients in the DP group and one patient in the DS group required reoperation. Lastly, 81.8% of patients achieved tuberosity union in the DS group and 66.7% in the DP group; however, this did not reach statistical significance.

CONCLUSION

This study demonstrates that RSA for proximal humerus fractures performed through a DS or DP approach may result in similar intraoperative and postoperative outcomes, with no difference in reoperation or complication rates.

Plate osteosynthesis for proximal humerus fractures through a deltoid-split approach under traction in lateral decubitus position: preliminary results

Aim: We aimed to present deltoid split approach under traction in lateral decubitus position that we perform for the treatment of proximal humerus fractures (PHFs) and to present the preliminary surgical and clinical outcomes of our patients. Material and Method: Twelve patients who underwent plate osteosynthesis through a deltoid split approach under traction in lateral decubitus position between May 2019 and January 2021 were evaluated. Patient demographics, Neer classification, and time from injury to surgery were collected in all patients preoperatively. Radiation exposure time and operating time was recorded intraoperatively. Radiological outcomes were assessed, including time to union, and neck-shaft angle. Functional outcomes were evaluated using the Constant score at the minimum 12-month follow-up. Results: Twelve patients (5 male, 7 female) were evaluated with a mean age 58.6±10.7 years (range, 32 to 72 years) at the time of surgery. The mean follow-up period was 117.4±3.8 months). The mean operation time was 60.7±15.2 min (range, 44 to 92 min). The mean radiation exposure time was 6.1±3.0 s (range, 3.3 to 14.2 s). Fracture union was observed in all patients at mean 14.6±2.5 weeks (range, 8 to 20 weeks). The mean neck-shaft angle after the union was 134.5±3.4 degrees (range, 124 to 143 degrees). The mean Constant score was at the final follow-up was 76.4±8.7 (range, 63 to 90). Conclusion: Patient positioning in the lateral decubitus position under traction can be considered as a safe, reliable, and reproducible method in selected patients with PHFs.

Investigation of the Clinical Effect of New Shoulder Joint Abduction Frame in Humeral Fracture Patients after Arthroscopic Shoulder Surgery

Objective

This work is organized to analyze the clinical effects of new shoulder joint abduction frame on the bone metabolic markers, shoulder joint function, and visual analogue scale (VAS) of humeral fracture patients undergoing arthroscopic surgery.

Methods

118 patients with humeral fracture who planned to undergo shoulder surgery in our hospital from November 2018 to June 2021 were selected as the study objects and were divided into two groups according to the random number method, with 59 patients in each group. The patients in the two groups were subjected to arthroscopic shoulder surgery. New shoulder joint abduction frame was used for shoulder joint fixation in the abduction frame group, and sling was used for shoulder joint fixation in the sling group after surgery. The duration of fixation was 4-6 weeks. Finally, the prognostic indicators, complications, and serum bone metabolism levels in 4 and 6 weeks after surgery, shoulder joint function (Neer score), VAS score before surgery and after 3 and 6 months of surgery, and excellent or good rate of shoulder joint activity after 6 months of surgery were compared between the two groups.

Results

The postoperative fracture healing time and start time of shoulder joint training were shorter, and the humeral varus angle and femur height loss were smaller in the abduction frame group than in the sling group (P < 0.05). There was no significant difference in the total incidence of complications between the two groups (3.39% and 13.56%, respectively) (P > 0.05). After 4 or 6 weeks of surgery, the levels of serum osteoprotegerin (OPG) and carboxyterminal propeptide of type I procollagen (PICP) were increased but the levels of tartrate-resistant acid phosphatase-5B (TRAP-5B) were decreased in the two groups with more significant differences in the abduction frame group (P < 0.05). After 6 months of follow-up, 2 cases were lost to follow-up in the abduction frame group and 3 cases in the sling group. Neer scores were increased, while VAS scores were decreased in the two groups in the third or sixth months after surgery with significant differences in the abduction frame group (P < 0.05). The excellent or good rate of shoulder joint activity was 94.74% (54/57) in the abduction frame group, significantly higher than that in the sling group (80.36%; 45/56) (P < 0.05).

Conclusion

The fixation effect of new shoulder joint abduction frame is significant after arthroscopic surgery, and patients can carry out functional training as early as possible, which is helpful to promote fracture healing, relieve pain, and restore shoulder joint function with high safety.

Soft-Tissue Considerations in Shoulder Surgery in the Patient With Lymphedema

Lymphedema is a chronic, progressive, and often debilitating condition that results in swelling of the affected tissue. Secondary lymphedema is most commonly recognized by unilateral swelling of the ipsilateral extremity after the treatment of cancer. It is estimated that nearly 1.45 million women suffer from breast cancer-related lymphedema in the United States. The number of patients suffering from upper extremity lymphedema is expected to increase because multimodal treatment of breast cancer increases the long-term survival after diagnosis. Because this population ages, the likelihood of encountering a patient with concurrent lymphedema and shoulder pathology requiring orthopaedic intervention is likely to rise. A patient with an already edematous arm and/or impaired drainage of that arm is likely to have different and more complex intraoperative and postoperative courses than patients with normal lymphatic drainage. Although a lymphedematous arm should not preclude surgical intervention, there are considerations when approaching shoulder surgery in the setting of upper extremity lymphedema that may help mitigate complications and aid the patient in their orthopaedic recovery.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely, including in the use of surgery. This is an update of a Cochrane Review first published in 2001 and last updated in 2015.

OBJECTIVES

To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registries, and bibliographies of trial reports and systematic reviews to September 2020. We updated this search in November 2021, but have not yet incorporated these results.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults.  DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. We prepared a brief economic commentary for one comparison.

MAIN RESULTS

We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. Six comparisons were tested by 2 to 10 trials, the others by small single-centre trials only. Twelve studies evaluated non-surgical treatments, 10 compared surgical with non-surgical treatments, 23 compared two methods of surgery, and two tested timing of mobilisation after surgery. Most trials were at high risk of bias, due mainly to lack of blinding. We summarise the findings for four key comparisons below. Early (usually one week post injury) versus delayed (after three or more weeks) mobilisation for non-surgically-treated fractures Five trials (350 participants) made this comparison; however, the available data are very limited. Due to very low-certainty evidence from single trials, we are uncertain of the findings of better shoulder function at one year in the early mobilisation group, or the findings of little or no between-group difference in function at 3 or 24 months. Likewise, there is very low-certainty evidence of no important between-group difference in quality of life at one year. There was one reported death and five serious shoulder complications (1.9% of 259 participants), spread between the two groups, that would have required substantive treatment. Surgical versus non-surgical treatment Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures). There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants). There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year (EQ-5D (0: dead to 1: best quality): mean difference (MD) 0.01, 95% CI -0.02 to 0.04; 6 studies, 502 participants). There is low-certainty evidence of little between-group difference in mortality: one of the 31 deaths was explicitly linked with surgery (risk ratio (RR) 1.35, 95% CI 0.70 to 2.62; 8 studies, 646 participants). There is low-certainty evidence of a higher risk of additional surgery in the surgery group (RR 2.06, 95% CI 1.21 to 3.51; 9 studies, 667 participants). Based on an illustrative risk of 35 subsequent operations per 1000 non-surgically-treated patients, this indicates an extra 38 subsequent operations per 1000 surgically-treated patients (95% CI 8 to 94 more). Although there was low-certainty evidence of a higher overall risk of adverse events after surgery, the 95% CI also includes a slightly increased risk of adverse events after non-surgical treatment (RR 1.46, 95% CI 0.92 to 2.31; 3 studies, 391 participants). Open reduction and internal fixation with a locking plate versus a locking intramedullary nail Four trials (270 participants) evaluated surgical intervention for displaced fractures (63% were two-part fractures). There is low-certainty evidence of no clinically important between-group difference in shoulder function at one year (SMD 0.15, 95% CI -0.12 to 0.41; 4 studies, 227 participants), six months (Disability of the Arm, Shoulder, and Hand questionnaire (0 to 100: worst disability): MD -0.39, 95% CI -4.14 to 3.36; 3 studies, 174 participants), or two years (American Shoulder and Elbow Surgeons score (ASES) (0 to 100: best outcome): MD 3.06, 95% CI -0.05 to 6.17; 2 studies, 101 participants). There is very low-certainty evidence of no between-group difference in quality of life (1 study), and of little difference in adverse events (4 studies, 250 participants) and additional surgery (3 studies, 193 participants). Reverse total shoulder arthroplasty (RTSA) versus hemiarthroplasty There is very low-certainty evidence from two trials (161 participants with either three- or four-part fractures) of no or minimal between-group differences in self-reported shoulder function at one year (1 study) or at two to three years' follow-up (2 studies); or in quality of life at one year or at two or more years' follow-up (1 study). Function at six months was not reported. Of 10 deaths reported by one trial (99 participants), one appeared to be surgery-related. There is very low-certainty evidence of a lower risk of complications after RTSA (2 studies). Ten people (6.2% of 161 participants) had a reoperation; all eight cases in the hemiarthroplasty group received a RTSA (very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery. The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures. There is insufficient evidence from randomised trials to inform the choices between different non-surgical, surgical or rehabilitation interventions for these fractures.

Displaced proximal humerus fractures treated with ORIF via the deltoid interfascicular approach vs the deltopectoral approach: A prospective case-control study

BACKGROUND

The purpose of this study was to evaluate the clinical outcomes and complications of displaced proximal humeral fractures treated with proximal humeral internal locking system (PHILOS) plate fixation via a deltoid interfascicular (DI) vs a deltopectoral (DP) approach.

METHODS

This prospective case-control study was conducted with patients admitted to our hospital from May 2015 to June 2018 who suffered from unilateral displaced proximal humerus fractures. Patients were treated with PHILOS plate fixation via a DI (DI group) or DP approach (DP group). The clinical outcomes and complication data were collected for comparison between the 2 groups. The patients were followed up at 3, 6, and 12 months; and every 6 months thereafter. The patients' functional recoveries were evaluated according to the normalized Constant-Murley score, range of motion of the shoulder (flexion, abduction, external/internal rotation) and disabilities of the arm, shoulder and hand score.

RESULTS

A total of 77 patients, followed for an average of 15 ± 2.2months (range, 12-21), were enrolled (36 in DI group and 41 in DP group) for final analysis. No significant differences in age, sex, affected side, fracture type, injury mechanism or time from injury to operation were found between the 2 groups (all P > .05). The incision length, intra-operative blood loss, and duration of operation in the DI group were significantly less than those in the DP group, respectively (all P < .05). The functional outcomes assessed by the normalized Constant-Murley score and range of motion of flexion and internal rotation in the DI group were superior to those in the DP group at 3 and 6months after the operation (P < .05); however, no significant differences were observed at the 12-month and subsequent follow-ups (all P > .05). There was no significant difference in the range of shoulder external rotation and abduction during the postoperative follow-ups (P > .05). At the last follow-up, the mean disabilities of the arm, shoulder, and hand score was 14.0 (6.6) points in the DI group and 14.4 (6.9) points in the DP group (P = .793). Complications occurred in 1 patient in the DI group and 8 patients in the DP group (P = .049).

CONCLUSION

The current study demonstrates that DI approach is a safe and effective alternative for the treatment displaced proximal humerus fractures. The DI approach rather than DP approach was recommended when lateral and posterior exposure of the proximal humerus is required, especially when fixed with PHILOS plate.

Avaliação funcional do ombro após osteossíntese da fratura da tuberosidade maior: Há influência da luxação glenoumeral?

Objetivo Avaliar os resultados funcional e radiográfico pós-operatórios do ombro, em pacientes submetidos a sutura transóssea de fratura da tuberosidade maior (FTM) por acesso anterolateral, e a influência da luxação glenoumeral nesses resultados.

Métodos Realizou-se estudo retrospectivo e avaliação funcional (pela escala de Constant-Murley). Calculou-se a distância entre a tuberosidade maior e a superfície articular do úmero proximal (por meio de radiografia em incidência anteroposterior verdadeira) após a consolidação. Usou-se o teste Exato de Fisher para as variáveis independentes categóricas, e os testes tde Student ou de Mann-Whitney para as não categóricas.

Resultados Ao todo, 26 pacientes preencheram os critérios de inclusão. A associação de luxação glenoumeral com FTM foi observada em 38% da amostra. A média da pontuação na escala de Constant-Murley foi de 82,5 + 8,02. A presença de luxação associada não alterou o resultado funcional. A distância média da consolidação da tuberosidade maior do úmero em relação à superfície articular da cabeça umeral foi de 9 + 4,3 mm abaixo da linha articular da cabeça umeral. Pacientes com luxação associada evoluíram com redução menor, mas isso não influenciou na pontuação na escala de Constant-Murley.

Conclusão As FTMs submetidas ao tratamento cirúrgico com sutura transóssea evoluíram com bom resultado funcional. A presença de luxação dificultou a redução anatômica da tuberosidade maior. Entretanto, isso não influenciou na pontuação na escala de Constant-Murley.

Acromion-axillary nerve distance and its relation to the arm length in the prediction of the axillary nerve position: a clinical study

Background

Because of the broad anatomic variation in the course of the axillary nerve, several cadaveric studies have investigated the acromion-axillary nerve distance and its association with the humeral length to predict the axillary nerve location. This study aimed to analyze the acromion-axillary nerve distance (AAND) and its relation to the arm length (AL) in patients who underwent internal plate fixation for proximal humerus fractures.

Methods

The present prospective study involved 37 patients (15 female, 22 male; the mean age = 51 years, age range 19–76) with displaced proximal humerus fractures treated by open reduction and internal fixation. After anatomic reduction and fixation were achieved, the following parameters were measured in each patient before wound closure without making an extra incision or dissection: (1) the distance from the anterolateral edge of the acromion to the course of the axillary nerve was recorded as the acromion-axillary nerve distance and (2) the distance from the anterolateral edge of the acromion to the lateral epicondyle of the humerus was recorded as arm length. The ratio of AAND to AL was then calculated and recorded as the axillary nerve index (ANI).

Results

The mean AAND was 6 ± 0.36 cm (range 5.5–6.6), and the mean arm length was 32.91 ± 2.9 cm (range 24–38). The mean axillary nerve ratio was 0.18 ± 0.02 (range 0.16 to 0.23). There was a significant moderate positive correlation between AL and AAND (p = 0.006; r = 0.447). The axillary nerve location was predictable in only 18% of the patients.

Conclusion

During the anterolateral deltoid-splitting approach to the shoulder joint, 5.5 cm from the anterolateral edge of the acromion could be considered a safe zone to prevent possible axillary nerve injury.

Shoulder-specific Outcome after Proximal Humerus Fracture Influences Medium-term Overall Quality of Life

BACKGROUND

Surgical treatment of proximal humerus fracture is an established procedure. Postoperative complications have been shown to have a significant impact on shoulder-specific outcome. Little is known to date about an influence on injury-independent quality of life.

AIM OF THE WORK

The aim of this retrospective study is to analyse whether patients with a poor functional outcome after surgically treated proximal humerus fracture also show a reduced general quality of life in the medium term. Emphasis is placed on the analysis of patients with poor functional outcome due to postsurgical complications.

MATERIAL AND METHODS

Evaluation of all patients operated at one level 1 trauma centre with a proximal humerus fracture in the period 01.01.2005 to 31.12.2015 and follow-up using validated scores (Constant-Murley Score [CMS], EQ-5D). Two groups, group A with good outcome (∆CMS ≤ 15P.) and group B with poor outcome (∆CMS ≥ 16P.), were defined. Furthermore, descriptive variables including definition of a complication were defined in advance.

RESULTS

138 patients were included in the study (group A: 91, group B: 47). The mean follow-up was 93.86 months ± 37.33 (36-167). Group B had significantly more complications. Furthermore, patients with poor outcome regarding the shoulder (group B) were also found to have significantly lower EQ-VAS (78.9 ± 19.2 [20.0-100] vs. 70.4 ± 19.5 [15.0-98.0]; p = 0.008) and EQ index (0.91 ± 0.14 [0.19-1.00] vs. 0.82 ± 0.17 [0.18-1.00]; p < 0.001).

DISCUSSION

In conclusion, in the present study, the patients with poor outcome of shoulder function in CMS have significantly lower overall quality of life after a mean of more than 6 years of follow-up. The poor outcome was due to a significantly higher postoperative complication rate. This was independent of the fracture morphology present and the surgical procedure used.

Outcomes of plate osteosynthesis for displaced 3-part and 4-part proximal humerus fractures with deltopectoral vs. deltoid split approach

PURPOSE

Three part and four-part fractures of the proximal humerus offer challenges in reduction and plate fixation, with considerable debate about use of Deltoid splitting (DS) and Delto-pectoral (DP) approaches, especially when they involving the greater tuberosity. We prospectively compared the results using DS approach and DP approach in these cases, with special focus on functional outcomes, complications, and ease of tuberosity reduction.

MATERIALS AND METHODS

84 patients with three- and four-part proximal humerus fracture were alternately allocated the DP approach or DS approach for proximal humerus locking plate fixation. The outcome analysis was done by evaluating relative Constant score and ease of surgical reduction of greater tuberosity; radiological malunion was evaluated using Beredjiklian classification and complications were noted.

RESULTS

At mean follow-up of 23 months (19-48 months), the mean 'relative Constant score was 74.27 ± 8.19 in the DP group and 73.26 ± 8.02 in the DS group and the difference was statistically insignificant (p = 0.988). There was no significant difference with respect to shoulder ROM, abductor strength, radiological malunion or complications. However, the mean surgical time was significantly less (p value = 0.042) in DS group (65 ± 5 min) in comparison to DP group (92 ± 4.3 min); significantly less difficulties were documented by the surgeon in reducing the greater tuberosity in DS group(p value = 0.02).

CONCLUSION

Although surgical time was reduced and greater tuberosity reduction was easier in DS group, the other outcomes were similar; either surgical approach can be used based, and can be based on the experience and comfort level of the surgeon.

Reverse or Hemi Shoulder Arthroplasty in Proximal Humerus Fractures: A Single-Blinded Prospective Multicenter Randomized Clinical Trial

OBJECTIVES

To compare outcomes between hemiarthroplasty (HA) and reversed shoulder arthroplasty (RSA) as a treatment for dislocated 3-part and 4-part proximal humerus fractures in the elderly population.

DESIGN

Prospective multicenter randomized controlled trial.

SETTING

Three Level-1 trauma centers.

PATIENTS/PARTICIPANTS

This study included 31 patients of which 14 were randomized into the HA group and 17 into the RSA group.

INTERVENTION

Patients randomized to the HA group were treated with a cemented-stem Aequalis-fracture HA and patients randomized to the RSA group with a cemented-stem Aequalis-fracture RSA.

MAIN OUTCOME MEASUREMENTS

Primary outcomes consisted of range of motion and constant score. Secondary outcomes were the visual analog scale for pain, DASH score, SF-12 scores, and radiographic outcomes.

RESULTS

After 6 and 12 months of follow-up, RSA showed a significant higher anterior elevation (105 degrees vs. 80 degrees, P = 0.002 and 110 degrees vs. 90 degrees, P = 0.02, respectively) and constant score (60 vs. 41, P = 0.01 and 51 vs. 32, P = 0.05, respectively) compared with HA. There were no significant differences in external and internal rotation. Also, visual analog scale pain, DASH scores, SF-12 scores, and radiological healing of the tuberosities and heterotopic ossification did not show any significant differences between groups.

CONCLUSION

RSA showed significant superior functional outcomes for anterior elevation and constant score compared with HA for dislocated 3-part and 4-part proximal humerus fractures after short-term follow-up.

LEVEL OF EVIDENCE

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

Proximal humerus exposure with the inverted-L anterolateral deltoid flip approach, anterolateral deltoid splitting approach, and deltopectoral approach: A comparative cadaveric study

BACKGROUND

Reduction of the posterior aspect of proximal humerus fracture, such as far-retracted greater tuberosity or posterior articular head split fracture via a deltopectoral or deltoid splitting approach, is difficult and usually needs extensive dissection. The inverted-L anterolateral deltoid flip approach, which is developed from the deltoid splitting approach, accesses the proximal humerus via lateral deltoid flap lifting. This study compared the area and arc of surgical exposure to the proximal humerus of this proposed approach to existing approaches.

METHODS

Eleven cadaveric specimens were used. Deltopectoral and deltoid splitting approaches were carried out on the right and left shoulder, respectively. Soft tissue was retracted after completion of a surgical approach to expose the proximal humerus, and dot-to-dot marking pins were placed along the border of exposed area. An additional area with a full shoulder rotation was also marked on the deltopectoral side. An inverted-L deltoid flip approach was further carried out on a deltoid splitting side with a posterior extending incision along the acromion process and the deltoid detachment from the acromion process. The additional area of exposure was subsequently marked. All soft tissue around the proximal humerus was taken down, and the glenohumeral joint was disarticulated. Area of exposure and axial images were taken for further processing and measurement.

RESULT

An average distance of the axillary nerve from the acromion process of the deltoid splitting and the deltopectoral approaches were 49.15 mm and 57.35 mm, respectively (P < 0.05). The average area of exposure of the inverted-L deltoid flip, deltoid-splitting, deltopectoral, and deltopectoral with full rotation approaches were 2729.81mm², 1404.39mm², 1325.41mm², and 2354.78mm², respectively (P < 0.05). Mean arc of exposure lateral to bicipital groove of the inverted-L deltoid flip, deltoid splitting, deltopectoral, and deltopectoral with full rotation approaches were 151.75degrees, 105.02degrees, 61.68°, and 110.64°, respectively (P < 0.05).

CONCLUSION

The inverted-L anterolateral deltoid flip approach provides the most posterior access to the proximal humerus. However, it requires more soft tissue dissection and awareness of tension on the axillary nerve. This approach could be an alternative for displaced posterior head splits or far-retracted greater tuberosity proximal humerus fractures.

Deltopectoral Approach for Arthroplasty After Early Failed Proximal Humerus Fixation Via Deltoid Split Heals Uneventfully: A Case Report

CASE

A 57-year-old male carpenter sustained a 2-part displaced proximal humerus fracture of his nondominant arm with varus angulation after a fall down the stairs. Fifteen days postinjury, the patient underwent direct reduction and surgical fixation with an intramedullary cage implant via a deltoid split approach. Nine days postsurgery, the patient presented to the emergency department after another fall with failed fixation. Two weeks after index surgery, he was revised to a reverse total shoulder arthroplasty via a deltopectoral approach and healed both incisions uneventfully.

CONCLUSION

A deltopectoral approach performed acutely after a deltoid split approach for fracture can heal uneventfully.

Long head of biceps in proximal fractures of the humerus: an underestimated problem?

Background and aim of the work:

The long head of biceps (LHB) is one of the tendons of the rotator cuff that runs strictly close to the humeral head. In case of pathology, it can be responsible for pain and shoulder impairment: in such cases, surgical options include tenotomy or tenodesis. The management of LHB along with surgery of the rotator cuff or during shoulder prosthetic replacement has been widely discussed in the literature. Conversely, the possibility of acute impingement and incarceration of LHB in proximal humerus fractures, as well as its role in shoulder pain in outcomes of these fractures, has been poorly considered.

Methods:

The following aspects in the literature on LHB and proximal humerus fractures have been analysed: its management during fixation of fractures, the possibility of interference of the tendon with reduction of fractures or dislocations of the shoulder and its possible role in chronic pain after fixation of proximal humerus fractures.

Results:

LHB can be an obstacle in the reduction of fractures, dislocations and fracture-dislocations. Only a few papers take into account acute surgery to LHB (tenotomy or tenodesis); most of the studies on fixation of proximal humerus fractures simply ignore the problem of LHB. The tendon can be a source of pain and a cause of disability in sequelae of these fractures.

Conclusions:

LHB should be taken into consideration both in the acute phase of fractures of the proximal humerus and in the outcomes. Other studies are needed to better understand its optimal management during fracture surgery. (www.actabiomedica.it)