MIPO of proximal humerus fractures through an anterolateral acromial approach. Is the axillary nerve at risk?

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.

A novel surgical approach and technique and short-term clinical efficacy for the treatment of proximal humerus fractures with the combined use of medial anatomical locking plate fixation and minimally invasive lateral locking plate fixation

BACKGROUND AND HYPOTHESIS

The typical anterolateral approach is widely used to treat proximal humerus fractures with lateral locking fixation. However, lateral fixation cannot completely avoid medial reduction loss and varus deformity especially in the cases of an unstable medial column. We present a novel medial surgical approach and technique together with a minimally invasive lateral locking plate to fix proximal humerus fractures with an unstable medial column.

MATERIALS AND METHODS

We performed an anatomical study and reported 8 cases of proximal humerus fractures with unstable medial columns treated with plate fixation through a minimally invasive anterolateral approach and medial approach. All surgeries were performed by the same single surgeon. Patients were followed clinically and radiographically at 1, 3, 6, and 12 months postoperatively.

RESULTS

There was a safe region located at the medial part of the proximal humerus just beneath the articular surface. An anatomical medial locking proximal humerus plate could be placed in the medial column and did not affect the axillary nerve, blood supply of the humeral head, or stability of the shoulder joint. Successful fracture healing was achieved in all 8 cases. The function and range of motion of the shoulder joint were satisfactory 24 months postoperatively, with an average Constant score (CS) of 82.8. No reduction loss (≥ 10° in any direction), screw cutout, nonunion, or deep infection occurred.

CONCLUSIONS

The combined application of medial anatomical locking plate fixation and minimally invasive lateral locking plate fixation is effective in maintaining operative reduction and preventing varus collapse and implant failure in proximal humerus fractures with an unstable medial column.

Neurotization of isolated axillary nerve palsy in a teenage patient

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Isolated axillary nerve palsy is a very rare condition, resulting most often from shoulder dislocation, motor vehicle accidents or iatrogenic injury.

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Loss of shoulder sensibility and abduction are the mean symptoms. And Electromyography (EMG) test helps to confirm the diagnoses.

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Long head triceps branch transfer to the axillary nerve is a good surgical procedure.

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Favorable results are associated with young age, early intervention time and adequate rehabilitation.

Background and aim

The aim of this article was to study isolated axillary nerve injury, his etiologies, symptomatology and treatment via nerve transfer or neurotization.

Methods

We describe the procedure of long head triceps radial branch transfer to the axillary nerve motor branch in adolescent patient with right deltoid muscle palsy and shoulder anesthesia following a motorcycle crush six months ago.

Results

Total recovery of the shoulder sensibility, abduction and extension at one-year follow-up, and patient returned progressively to his normal live and sports activities without any functional effect on the donor muscle.

Conclusion

The advantages of the axillary nerve transfer are demonstrated through many publications. It is a good therapeutic option if it concerned a young patient and practiced at early time followed by adequate rehabilitation.

Effect of surgical approaches on deltoid innervation and clinical outcomes in the treatment of proximal humeral fractures

Objectives

This study aims to investigate the effects of deltopectoral and anterolateral acromial approaches commonly used in open reduction-internal fixation of proximal humeral fractures on the clinical outcomes, and axillary nerve damage through electrophysiological assessment.

Patients and methods

Forty-eight patients (22 males, 26 females; mean age 47.9±13.2 years; range, 22 to 73 years) diagnosed with Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) type 11 proximal humeral fractures who underwent osteosynthesis with anatomical locking plates in our hospital between January 2015 and June 2016 were prospectively examined. The patients were divided into two groups according to either the deltopectoral or anterolateral deltoid-split surgical approach used. Clinical outcomes were evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH) scores and Constant-Murley scores (CMS) obtained at three- and 12-month follow-up visits. Needle electromyography (EMG) was performed for the electrophysiological assessment of the deltoid muscle.

Results

There were no significant differences between the groups in terms of demographic data, follow-up times, and complications. DASH scores and CMS obtained postoperatively at three months (p=0.327 and p=0.531, respectively) and 12 months (p=0.324 and p=0.648, respectively) revealed no significant differences. In addition, the two groups did not significantly differ with respect to the presence of EMG abnormalities (p=0.792). Avascular necrosis of the humeral head was detected in only two patients from the deltopectoral group.

Conclusion

Deltopectoral and anterolateral approaches do not differ regarding the presence of postoperative EMG abnormalities and functional outcomes. Surgeons can thus adopt either approach. However, dissection without damaging the soft tissue should be performed in both approaches.

Late screw-related complications in locking plating of proximal humerus fractures: A systematic review

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.

A new risk to the axillary nerve during percutaneous proximal humeral plate fixation using the Synthes PHILOS aiming system

BACKGROUND

Percutaneous aiming arms have been developed to minimize injury during placement of submuscular proximal humerus plates. The purpose of this study was to determine the risk of axillary nerve injury during percutaneous proximal humeral plate fixation using the Synthes PHILOS aiming system.

METHODS

By use of 10 fresh-frozen cadavers (20 shoulders), a 3.5-mm locking compression proximal humeral plate was fixated percutaneously to the humerus through a lateral deltoid-splitting approach using the PHILOS aiming guide. Dissection of the axillary nerve was then carried out, and measurements of its relation to the screw holes in row A through row G of the plate were taken. The lateral acromion-to-axillary nerve distance was also measured.

RESULTS

The axillary nerve traversed row D in every shoulder, whereas it crossed over row C in 11 shoulders and both holes in row E in 16 shoulders. The closest distance to the axillary nerve achieved was 4.5 mm, corresponding to the distal (left) screw in row B. A significant negative correlation was found for the distance from the nerve to the closest proximal and distal screws (row B and row G, respectively) in both right shoulders (ρ = -0.797; 95% confidence interval, -0.916 to -0.548) and left shoulders (ρ = -0.615; 95% confidence interval, -0.831 to -0.237).

CONCLUSION

The axillary nerve traverses rows C, D, and E of the proximal humeral plate using the PHILOS aiming system. Importantly, our study is the first to demonstrate that the axillary nerve crosses over row C. Left-sided plate screws also came in closer proximity to the axillary nerve than right-sided plate screws.

[Reduction techniques for minimally invasive stabilization of proximal humeral fractures]

OBJECTIVE

The aim of surgical stabilization of proximal humerus fractures is to restore the anatomical relations between the greater and lesser tubercle, to reconstruct the joint and preserve the vascular supply of the fragments.

INDICATIONS

Approximately 80% of proximal humeral fractures can be treated conservatively. Surgical treatment is indicated based on the fracture pattern, patient-related factors and the risk of avascular head necrosis. Two-part fractures with a metaphyseal comminution zone and 3/4-part fractures can benefit from near to anatomic reconstruction depending on the patient's demands and bone quality. Minimally invasive stabilization procedures allow for an anatomical reconstruction in the majority of fresh proximal humeral fractures with or without a proximal shaft fracture, provided that intraoperative traction allows the fracture to be aligned axially in the image intensifier by ligamentotaxis. Indirect, combined with direct reduction maneuvers, allow for an almost anatomical reconstruction, despite minimal invasive approaches.

SURGICAL TECHNIQUE

Beach chair position. The arm is held in a pneumatic articulating traction device. Evaluation of the indirect reduction potential by ligamentotaxis with visualization of the alignment of the head fragments in relation to the shaft by traction, abduction/adduction, flexion/extension and rotation. The traction device and a foam roll in the axilla to neutralize the tension of the pectoralis major and teres major muscles while simultaneously adducting the elbow hold the reduction. Insufficient reduction of the fragments requires additional direct reduction maneuvers. Opening of the bursa and fixation of the rotator cuff with sutures to adjust reposition. A 2.5 mm-threaded K‑wire is inserted into the head fragment as a joystick. Under protection of the axillary nerve, the plate is inserted under protection of the axillary nerve. Temporary fixation of the plate with Kirschner wires for positioning the plate 5-8 mm below the greater tubercle and 2-3 mm laterally of the sulcus of the long biceps tendon and subsequent radiographic control. Reduction of the shaft against the plate with a cortex screw. The threaded K‑wire in the head can be used to adjust the varus and valgus alignment and to achieve adequate support of the calcar. Finally, complete the osteosynthesis with angular stable screws.

POSTOPERATIVE MANAGEMENT

Immediate active assisted exercise in the shoulder under physiotherapeutic supervision. Temporary immobilization for patient comfort. Standard active and resistive mobilization after the first clinical and radiological checkup 6 weeks after surgery. Further radiological checks after 3 and 6 months and 1 year. No routine plate removal.