The use of a blade plate and autogenous cancellous bone graft in the treatment of ununited fractures of the proximal humerus

Operative treatment of nonunions in the elderly: Clinical and radiographic outcomes in patients at minimum 75 years of age

BACKGROUND

Limited information exists on nonunion treatment in the elderly. This retrospective study evaluates whether results of operative treatment of nonunion of the humerus or femur in patients aged ≥ 75 years are comparable to those in younger patients.

METHODS

We identified patients age ≥ 75 years with a nonunion of humerus or femur treated with open reduction and internal fixation. The Non-Union Scoring System was calculated. Complications, clinical outcome, and radiographic findings were assessed. Primary endpoint was nonunion healing. A literature review compared time to healing of humeral and femoral nonunion in younger populations.

RESULTS

We identified 45 patients treated for a nonunion of humerus or femur with > 12 months follow-up. Median age was 79 years (range 75-96). Median time to presentation was 12 months (range 4-127) after injury, median number of prior surgeries was 1 (range 0-4). Union rate was 100%, with median time to union 6 months (range 2-42). Six patients underwent revision for persistent nonunion and healed without further complications.

CONCLUSIONS

Using a protocol of debridement, alignment, compression, stable fixation, bone grafting and early motion, patients aged 75 years or older can reliably achieve healing when faced with a nonunion of the humerus or femur.

LEVEL OF EVIDENCE

IV.

[Three-dimensional finite element analysis of exo-cortical placement of humeral calcar screw for reconstruction of medial column stability]

Objective

To explore the biomechanical stability of the medial column reconstructed with the exo-cortical placement of humeral calcar screw by three-dimensional finite element analysis.

Methods

A 70-year-old female volunteer was selected for CT scan of the proximal humerus, and a wedge osteotomy was performed 5 mm medially inferior to the humeral head to form a three-dimensional finite element model of a 5 mm defect in the medial cortex. Then, the proximal humeral locking plate (PHILOS) was placed. According to distribution of 2 calcar screws, the study were divided into 3 groups: group A, in which 2 calcar screws were inserted into the lower quadrant of the humeral head in the normal direction for supporting the humeral head; group B, in which 1 calcar screw was inserted outside the cortex below the humeral head, and the other was inserted into the humeral head in the normal direction; group C, in which 2 calcar screws were inserted outside the cortex below the humeral head. The models were loaded with axial, shear, and rotational loadings, and the biomechanical stability of the 3 groups was compared by evaluating the peak von mises stress (PVMS) of the proximal humerus and the internal fixator, proximal humeral displacement, neck-shaft angle changes, and the rotational stability of the proximal humerus. Seven cases of proximal humeral fractures with comminuted medial cortex were retrospectively analyzed between January 2017 and December 2020. Locking proximal humeral plate surgery was performed, and one (5 cases) or two (2 cases) calcar screws were inserted into the inferior cortex of the humeral head during the operation, and the effectiveness was observed.

Results

Under axial and shear force, the PVMS of the proximal humerus in group B and group C was greater than that in group A, the PVMS of the internal fixator in group B and group C was less than that in group A, while the PVMS of the proximal humerus and internal fixator between group B and group C were similar. The displacement of the proximal humerus and the neck-shaft angle change among the 3 groups were similar under axial and shear force, respectively. Under the rotational torque, compared with group A, the rotation angle of humerus in group B and group C increased slightly, and the rotation stability decreased slightly. All the 7 patients were followed up 6-12 months. All the fractures healed, and the healing time was 8-14 weeks, with an average of 10.9 weeks; the neck-shaft angle changes (the difference between the last follow-up and the immediate postoperative neck-shaft angle) was (1.30±0.42)°, and the Constant score of shoulder joint function was 87.4±4.2; there was no complication such as humeral head varus collapse and screw penetrating the articular surface.

Conclusion

For proximal humeral fractures with comminuted medial cortex, exo-cortical placement of 1 or 2 humeral calcar screw of the locking plate outside the inferior cortex of the humeral head can also effectively reconstruct medial column stability, providing an alternative approach for clinical practice.

Prediction of Nonunion After Nonoperative Treatment of a Proximal Humeral Fracture

BACKGROUND

The prevalence of nonunion after a proximal humeral fracture (PHF) and the risk factors for its occurrence are poorly defined. We aimed to estimate the rate of nonunion in nonoperatively treated patients and to produce a clinical model for its prediction.

METHODS

Two thousand two hundred and thirty adult patients (median age, 72 years [range, 18 to 103 years]; 75.5% were female) with a PHF underwent assessment of fracture union using standard clinical evaluation and conventional radiographs. We assessed the prevalence of nonunion and measured the effect of 19 parameters on healing. Best statistical practices were used to construct a multivariate logistic regression model. The PHF assessment of risk of nonunion model (PHARON) was externally validated in a subsequent prospectively collected population of 735 patients, treated by the same protocol in our institution.

RESULTS

Overall, 231 (10.4%) of 2,230 patients developed nonunion. Only 3 (0.8%) of 395 patients with a head-shaft angle (HSA) of >140° developed nonunion; in this cohort, none of the measured candidate variables were independently predictive of nonunion on multivariate logistic regression analysis. In the larger cohort of 1,835 patients with an HSA of ≤140°, 228 (12.4%) developed nonunion. Decreasing HSA, increasing head-shaft translation (HST), and smoking were independently predictive of nonunion on multivariate analysis. The prevalence of nonunion was very low (1%) in the majority with both an HSA of >90° and HST of <50%, whereas the risk was much higher (83.7%) in the 8.3% with an HSA of ≤90° and HST of ≥50%. In both groups, the prevalence of nonunion was much higher in smokers.

CONCLUSIONS

The prevalence of nonunion after PHF is higher than previously reported. Most patients have favorable risk-factor estimates and a very low risk of this complication, but a smaller subgroup is at much higher risk. The risk can be accurately estimated with PHARON, using standard clinical assessment tools.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Repair of proximal humerus fracture nonunions using a standardized treatment algorithm: a case series

BACKGROUND

Nonunion of fractures about the proximal humerus represents a rare and complex problem. The purpose of this study was to evaluate the clinical and functional outcomes following proximal humerus fracture (PHF) nonunion repair using a plate and screw construct with a direct comparison to those experienced following operative fixation of acute PHF using a plate and screw construct.

METHODS

Two separate patient cohorts were included in this study. The first consisted of 16 patients diagnosed with a non-united PHF who underwent operative nonunion repair treated with a standard algorithmic approach. The comparison group consisted of 173 patients who achieved union following initial open reduction and internal fixation of an acute PHF treated with a proximal humerus locking plate construct. All patients had at least 12 months of postoperative follow-up. Outcomes were assessed for both groups using American Shoulder and Elbow Surgeons (ASES) scores, visual analog scale (VAS) pain scores, and postoperative shoulder range of motion (ROM). Statistical analyses were used to compare these outcome measures between the two cohorts.

RESULTS

The nonunion repair cohort consisted of eleven surgical neck nonunions and five nonunions of both the surgical neck and greater tuberosity. Ten patients had undergone surgical treatment for their original fracture, while six were initially treated non-operatively. All patients had Boileau type 3 sequelae of their proximal humerus fracture. Union was achieved in all patients at a mean of 5.4 months following nonunion repair. Complications included hardware failure requiring revision in two patients (12.5%) and avascular necrosis requiring conversion to anatomic total shoulder arthroplasty following union in one patient (6.3%). The nonunion repair and acute fracture cohorts did not differ with respect to mean ASES scores, VAS pain scores, or active shoulder ROM at any postoperative time point.

CONCLUSION

Surgical repair of PHF nonunion is a viable treatment strategy that can lead to consistent bony healing with outcomes comparable to those of patients who achieve fracture union following initial surgical repair of an acute proximal humerus fracture. Surgeons should be cognizant of mechanical considerations that may lead to early failure.

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

OBJECTIVES

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Augmentation of plate osteosynthesis for proximal humeral fractures: a systematic review of current biomechanical and clinical studies

INTRODUCTION

Secondary dislocation due to loss of fixation is the most common complication after plate fixation of proximal humeral fractures. A wide range of different techniques for augmentation has been described to improve the primary and secondary stability. Nevertheless, comparative analyses on the specific advantages and limitations are missing. Therefore, the aim of the present article was to systematically review and evaluate the current biomechanical and clinical studies.

MATERIALS AND METHODS

The databases of PubMed and EMBASE were comprehensively searched for studies on augmentation techniques for proximal humeral fractures using defined search terms. Subsequently, all articles identified were screened for eligibility and subdivided in either clinical or biomechanical studies. Furthermore, the level of evidence and study quality were assessed according the Oxford Centre for Evidence-Based Medicine and the Coleman Methodology Score, respectively.

RESULTS

Out of 2788, 15 biomechanical and 30 clinical studies were included. The most common techniques were structural allogenic or autologous bone grafting to enhance the medial support, metaphyseal void filling utilizing synthetic bone substitutes or bone grafts, and screw-tip augmentation with bone cement. Biomechanical data were available for structural bone grafting to enhance the medial support, void filling with synthetic bone substitutes, as well as for screw-tip augmentation. Clinical evidence ranged from level II-IV and study quality was 26-70/100 points. Only one clinical study was found investigating screw-tip augmentation. All studies included revealed that any kind of augmentation positively enhances mechanical stability, reduces the rate of secondary dislocation, and improves patients' clinical outcome. None of the studies showed relevant augmentation-associated complication rates.

CONCLUSIONS

Augmentation of plate fixation for proximal humeral fractures seems to be a reliable and safe procedure. All common techniques mechanically increase the constructs' stability. Clinically evaluated procedures show reduced complication rates and improved patient outcomes. Augmentation techniques seem to have the highest significance in situations of reduced bone mineral density and in high-risk fractures, such as 4-part fractures. However, more high-quality and comparative clinical trials are needed to give evidence-based treatment recommendations.

Joint-preserving treatment for type 3 sequelae following fracture of the proximal humerus with small head fragments

BACKGROUND

Although nonunions of the proximal humerus are rare, they cause significant disability to patients. Surgical reconstruction is challenging, especially with small and excavated head fragments. A promising surgical option is open reduction and stabilization using the Humerusblock device along with tension wires. The aim of this retrospective investigation was to evaluate the clinical and radiological results of this procedure.

MATERIALS AND METHODS

Fifteen patients with symptomatic surgical neck nonunions were treated with open reduction and internal fixation using the Humerusblock device without bone grafting. All patients showed a loss of bone stock, leading to excavated head fragments. The mean interval from injury to the described treatment was 6.2 months (range, 3.4-10.7). At a mean follow-up of 40.5 months, the Constant-Murley score was documented, pain and patient satisfaction were evaluated using a visual analogue scale, and x-rays were taken in two planes.

RESULTS

The patients' mean age was 69.7 years (range, 52-83). The mean Constant-Murley score improved from 24 points before surgery to 62 points at follow-up, which was an average of 80.8% of the score obtained for the contralateral arm. Radiological examination confirmed bony healing in 14 patients. All but one patient felt satisfied with the results. Three patients required revision surgery because of a hematoma, and early metal removal was performed in one patient because of infection.

CONCLUSION

Nonunions of humeral surgical neck fractures can be successfully treated by fixation using the Humerusblock device along with tension wires without the need for additional bone grafting. Especially in patients with flat, concave head fragments, this procedure remains a promising reconstructive option to arthroplasty.

LEVEL OF EVIDENCE

Level IV; Therapeutic retrospective case series.

Early outcomes of proximal humerus fracture fixation with locking plate and intramedullary fibular strut graft

Proximal humerus fractures are commonly encountered in elderly patients. Surgical treatment demonstrates high complication rates, including varus construct collapse and screw cutout. In this study, the authors evaluate the clinical outcome of locking plate fixation with intramedullary fibular strut graft augmentation as a primary surgical treatment in the prevention of early collapse and screw cutout. A total of 9 patients were evaluated. Surgery was performed for displaced proximal humerus fractures between April and December 2011. Patients were either class 2, 3, or 4, according to Neer classification. Mean patient age was 75.4 years. Preoperative and immediate, 6-week, and 3-month postoperative radiographs were evaluated. Head-shaft angles were measured to assess for varus collapse and displacement. Range of motion, complication rates, and functional recovery were also evaluated. Patients underwent open reduction and internal fixation with placement of an intramedullary fibular strut graft. Fixation was achieved with a Philos plate (Synthes, Oberdorf, Switzerland). Reduction and fixation were evaluated with radiographs. Passive exercises and range of motion were allowed immediately postoperatively, and all patients achieved active abduction and forward flexion 6 weeks postoperatively. Shoulder radiographs taken 12 weeks postoperatively revealed no loss of reduction or screw cutout. The introduction of the locking plate has improved outcomes. The addition of an intramedullary strut graft has shown improved preliminary results. Maintained reduction was observed in all 9 patients in the early postoperative period, and good functional motion was achieved. No incidence of screw cutout was recorded.

Reverse total shoulder replacement for nonunion of a fracture of the proximal humerus

Patients with pain and loss of shoulder function due to nonunion of a fracture of the proximal third of the humerus may benefit from reverse total shoulder replacement. This paper reports a prospective, multicentre study, involving three hospitals and three surgeons, of 35 patients (28 women, seven men) with a mean age of 69 years (46 to 83) who underwent a reverse total shoulder replacement for the treatment of nonunion of a fracture of the proximal humerus. Using Checchia’s classification, nine nonunions were type I, eight as type II, 12 as type III and six as type IV. The mean follow-up was 51 months (24 to 99). Post-operatively, the patients had a significant decrease in pain (p < 0.001), and a significant improvement in flexion, abduction, external rotation and Constant score (p < 0.001), but not in internal rotation. A total of nine complications were recorded in seven patients: six dislocations, one glenoid loosening in a patient who had previously suffered dislocation, one transitory paresis of the axillary nerve and one infection.

Reverse total shoulder replacement may lead to a significant reduction in pain, improvement in function and a high degree of satisfaction. However, the rate of complications, particularly dislocation, was high.

Cite this article: Bone Joint J 2014;96-B:1239–43.

Revision with plates of humeral nonunions secondary to failed intramedullary nailing

PURPOSE

The objective of this study was to evaluate the results achieved after revision with plates of humeral nonunions secondary to failed intramedullary nailing.

METHODS

We retrospectively evaluated 32 patients with humeral nonunions secondary to failed intramedullary nailing, treated by internal fixation with plates between 1998 and 2012. Nonunions were diaphyseal in 19 cases, they were located in the proximal humeral metaphysis in nine cases, and in the distal humeral metaphysis in four cases. There were 11 atrophic nonunions and 21 oligotrophic nonunions. Initial treatment was performed with static locked nails in 12 cases, nails with expansive locking systems in 11 cases, and using thin elastic nails in nine cases. The nails were placed antegrade in 18 cases and retrograde in 14 cases. Time between initial surgery and revision surgery averaged 14.5 months. In seven diaphyseal nonunions, the intramedullary nail was left in-situ. Bone graft was added in 25 cases.

RESULTS

Follow-up averaged 35 months. Union was achieved in all cases, after an average of 3.8 months. Disabilities of the Arm, Shoulder and Hand (DASH) score at last follow-up averaged 14 points, and Constant's score averaged 82 points. The analogue scale of pain averaged 0.8 points. Out of seven patients with radial nerve compromise, six recovered completely and one needed tendon transfers.

CONCLUSIONS

Revision with plates after failed intramedullary humeral nailing achieved union and good predictable objective and subjective results in all cases. Adequate implant selection and meticulous surgical technique are necessary to achieve successful osteosynthesis and bony union.

Proximal humeral nonunion treated with an intramedullary tantalum cylinder

Nonunion is uncommon after proximal humerus fracture surgery. There is no agreement about preferred method of treatment. Traditional approaches have included laterally based locking plates, autogenous grafting, and endosteal support to provide improved biomechanical stability. Open reduction and internal fixation (ORIF) of proximal humeral nonunion has been performed with various methods, including blade plates and bone grafting, as well as intramedullary support with autologous or allogenic grafts. Both malunion and nonunion have occurred after ORIF with locking plates. Endosteal support in the form of a fibular allograft incorporated into the locking plate construct can increase mechanical stability in selected cases. An ideal implant for proximal humeral nonunion provides medial column mechanical support and osteoconductive and osteoinductive properties. Porous intramedullary tantalum metal may play a role in nonunion surgery as an alternative to fibular allograft because of its versatility of use and salutary biological effects. It offers many material advantages for use in nonunion surgery. Tantalum is extensively porous (75%-80%), has a stiffness close to that of native bone, and offers the possibility of being a carrier for osteoinductive materials. It may also be suitable for patients who refuse allograft material. This article describes a 65-year-old woman with recalcitrant proximal humeral nonunion who was successfully treated with revision ORIF with intramedullary tantalum cylinder augmentation with a lateral-based locking plate and autogenous cancellous bone grafting. At 5-year follow-up, she had excellent motion and clinical and radiographic union.

Treatment of surgical neck nonunions of the humerus with locked plate and autologous fibular strut graft

OBJECTIVES

To determine whether using a fixed-angle locked plate plus a fibular strut autograft to treat humeral surgical neck nonunions can result in improved union.

PATIENTS AND METHODS

The study cohort included 5 females and 2 males with an average age of 58.4 years (range 45-76) who presented with atrophic nonunion of the surgical neck of the humerus. All patients underwent revision surgery with locked plating plus a nonvascularized autologous fibular strut bone graft. Clinical and radiological union was documented in all patients.

RESULTS

The mean time from initial trauma to last revision surgery was 20.1 ± 12.6 months (range 12-48). The average time between revision surgery and the date of union was 6.1 months (range 5-8). The average active forward flexion was 124° (range 70-160) at final follow-up. The Constant-Murley score increased from an average of 25.7 points preoperatively to 77.7 points postoperatively (p < 0.001). The average analog scale of pain decreased from 7.57 points (range 6-10) preoperatively to 0.57 points (range 0-2) postoperatively (p < 0.001).

CONCLUSIONS

Locked plate fixation and autologous fibular strut bone graft facilitated the successful treatment of humeral surgical neck nonunions.

Modern perspectives of open reduction and plate fixation of proximal humerus fractures

Recent innovations have greatly increased the range of proximal humeral fractures that are amenable to open reduction and plate fixation.The optimum technique for some of the more complex fracture patterns is not yet fully refined.This article aims to describe the recent advances in the treatment of complex proximal humeral fractures by open reduction and locking plate fixation, focusing particularly on the indications for surgery, the operative techniques, and the expected outcomes after treatment.

The treatment of established non-union of the proximal humerus using the Polarus locking intramedullary nail

INTRODUCTION

Non-union following fracture of the proximal humerus is not uncommon, particularly in the elderly. This can be associated with significant morbidity due to pain, instability and functional impairment. The Polarus device (Acumed) is a locked, antegrade intramedullary nail designed to stabilize displaced 2-, 3- and 4-part fractures of the proximal humerus. We report our experience with the Polarus nail for the treatment of established non-union of the proximal humerus.

MATERIALS AND METHODS

A total of 7 Polarus nails were inserted for the treatment of non-union of the proximal humerus between June 2000 and July 2007. Each fracture site was opened, debrided, stabilized with a Polarus nail and then grafted with autologous cancellous iliac crest bone. The time between injury and surgery ranged from 6 to 102 months. One patient had undergone previous fixation of her fracture using Rush intramedullary rods. All patients were females, and mean age at surgery was 63.6 years (range, 49-78 years). A retrospective review of notes and radiographs was carried out. Patients were reviewed at varying intervals postoperatively (range, 13-68 months) and assessed using the Constant shoulder-scoring system.

RESULTS

All un-united fractures progressed to union. There were no wound complications and no postoperative nerve palsies. Functional outcome was good, even in those cases with a long interval between injury and surgery. The mean Constant score was 63 (range, 54-81). Migration of a single proximal locking screw was seen in 2 patients, and these screws required removal at 5 and 12 months, respectively, postoperatively.

CONCLUSION

In our experience, a locked proximal humeral nail used in conjunction with autologous bone grafting is an excellent device for the treatment of proximal humerus non-unions.

Reconstructive surgical treatment without bone grafting in nonunions of humeral surgical neck fractures

OBJECTIVE

To evaluate reconstruction surgery without bone grafting in humeral surgical neck nonunions using either a blade plate or the "Humerusblock" implant in small head fragments.

DESIGN

Retrospective cohort study, Evidence-Based Medicine Level IV.

SETTING

Paracelsus Medical University Salzburg, Department of Traumatology and Sports Injuries.

PATIENTS

Fifty-five patients (mean age, 66.2 years) with symptomatic nonunion after humeral surgical neck fractures were subjected to surgical reconstruction.

INTERVENTION

In 45 patients, open reduction and internal fixation using a blade plate was performed (Group 1). In 10 patients, the Humerusblock device was used (Group 2), because the head fragment of each of these patients was too small for plating. In no patients was bone grafting used.

MAIN OUTCOME MEASUREMENTS

Shoulder function, level of pain, and bone healing.

RESULTS

After a mean follow-up time of 74 months, the overall mean Constant score improved from 30.4% preoperatively to 83.2% postoperatively. The improvement was from 30.5% to 85.3% in Group 1 and from 32.2% to 75.4% in Group 2, which represented statistically significant improvements for both groups (P < 0.01). Radiologic bone healing was achieved in 51 patients (93%). The overall complication rate was high, 15%, and complications included plate loosening, avascular head necrosis, persistent nonunion, and infection.

CONCLUSIONS

Nonunion of humeral surgical neck fractures can be successfully treated by surgical reconstruction without bone grafting using either a blade plate or the Humerusblock for small head fragments. However, an increased complication rate is associated with this challenging posttraumatic pathology.

[The use of blade plate and dynamic screw plate osteosynthesis]

Osteosynthesis in fracture treatment and in some reconstructive procedures with blade plates or dynamic screw systems was the standard procedure for several decades. In this review, the current options and concepts using blade plate osteosynthesis, stabilization of proximal and distal femur fractures and reconstructive procedures with the dynamic hip screw or the dynamic condylar blade are discussed. On the basis of a literature review, the present indications, results and region-specific complications are reported and discussed.Blade plates are used mainly in the context of reconstructive procedures, as well as in the treatment of pseudoarthroses. The Pauwel procedure in femoral neck non-unions is one of the best known indications. In contrast, the dynamic hip screw is the gold standard for stabilization of femoral neck and most pertrochanteric fractures, whereas the dynamic condylar screw is still an alternative to internal fixators for proximal and distal femoral fracture fixations.

Biomechanical evaluation of 3-part proximal humerus fractures: a cadaveric study

Proximal humerus fractures occur frequently, and treatment remains controversial. This study compares stiffness in axial loading for 3 methods of fixation (locking compression plate, standard (nonlocking) proximal humerus plate, and blade plate) in a 3-part proximal humerus fracture model. Twelve paired proximal humeri were obtained from embalmed human cadavers and separated into 3 groups. Osteotomies of the surgical neck and greater tuberosity were created to simulate a 3-part proximal humerus fracture. After fixation, constructs were axially loaded in 20 degrees of abduction for 200 cycles in an Instron materials testing machine (Norwood, Massachusetts). The blade plate (mean, 146.87+/-28.9 N/mm) demonstrated 29% more mean stiffness than the standard plate (mean, 113.0+/-22.3 N/mm; P=.19). The locking compression plate (mean, 130.71+/-39.2 N/mm) exhibited 15% greater stiffness compared to the standard plate in our 3-part model (P=.58). The blade plate demonstrated 12% greater stiffness than the locking compression plate (P=.64). There was no significant difference in mean stiffness between the fixed-angle devices and the standard plate. Future in vitro and clinical studies of plate devices for proximal humerus fractures would be worthwhile to determine the benefits and limitations of various implants for specific types of fractures, including clinical performance and cost of care.

Intraoperative distraction in the upper extremity

Intraoperative distraction aids in the restoration of length, facilitates reduction, assists in maintaining rotational alignment, and provides a temporary stable platform for definitive fixation of acute fractures, malunions, and nonunions. This technique has been described at length in the lower extremity; however, there is a paucity of literature regarding its use in the upper extremity. Distraction is the application of tension across a fracture site. Proximal and distal fixation may be achieved in several ways, with common instrumentation including the use of an external fixator set. Intraoperative distraction may be invaluable in the treatment of displaced fractures of the upper extremity. The objective of this paper was to detail the technique of intraoperative distraction in the surgical treatment of fractures of the clavicle, humerus, radius, and ulna.

Proximal humeral nonunions treated with fixed-angle locked plating and an intramedullary strut allograft

OBJECTIVE

To determine if the use of a fixed-angle locked plate plus an intramedullary allograft in the treatment of proximal humeral nonunions resulted in improved union.

DESIGN

Retrospective clinical analysis of patients' medical charts and radiographs.

SETTING

Clinical practice of senior authors.

PATIENTS/PARTICIPANTS

Eighteen patients who presented to the senior authors' clinic between 2001 and 2007 with clinical and radiographic evidence of symptomatic proximal humeral nonunions that were treated with the described method were included for analysis. Patients with severe humeral head bone loss, avascular necrosis, evidence of arthrosis, and less than 12-month clinical follow-up were excluded.

INTERVENTION

All patients with a symptomatic viable nonunion of the proximal humerus were treated with a fixed-angle locked plate and an intramedullary cortical allograft.

MAIN OUTCOME MEASUREMENT

Patients were followed until radiographic union was achieved, with this being the principle determinant of a successful outcome.

RESULTS

Radiographic union was achieved in 17 of 18 patients (94%). The average follow-up was 26.5 months (range 12-49 months). The average time from surgery to radiographic union was 5.4 months (range 2.5-8.8 months). There was 1 failure of fixation, and 2 patients developed transient neurologic sequelae. Range of motion measurements obtained from the most recent clinical follow-up were 115 degrees (range 20-180 degrees) active forward elevation, 37 degrees (range 0-70 degrees) passive external rotation, and active internal rotation was to the 10th thoracic vertebrae. American Shoulder and Elbow Surgeon scores improved from a level of 40 preoperatively to 81 postoperatively, and visual analog scale scores improved from 6.7 to 1.5.

CONCLUSION

Intramedullary strut allograft insertion combined with fixed-angle plating is an effective technique for treating viable nonunions of the proximal humerus and was successful in achieving union in 94% of our patients.

PSEUDARTHROSIS OF THE HUMERAL NECK: ANALYSIS OF THE RESULTS WHEN USING THE TECHNIQUE DESCRIBED BY WALCH ET AL

Objective: To evaluate bone healing and the patient's outcome after open reduction and internal fixation, when using the technique described by Walch et al, in 1996, which uses conventional intramedullary corticocancellous bone graft and internal fixation with plate and screws added by a tricortical intramedullary bone graft, also autologous. Methods: From July 1997 to May 2005, 14 patients were treated by this technique, 14 of these diagnosed with pseudoarthrosis of the humeral proximal end. One died at the early postoperative period due to pulmonary thromboembolism; therefore, 13 patients were re-evaluated. Results: The mean follow-up time was 51.4 months (ranging from 12 to 130 months). Four patients evolved with excellent results, four good and five fair results. Therefore, there were 61.5% of satisfactory results according to UCLA functional scale and no poor result. Twelve cases (92%) healed within 3.5 months in average. Conclusion: the surgical treatment of the nonunion of the surgical neck of the humerus using this technique showed an effective outcome with 92% of healing; excellent and good results in 61.5% of the cases, as well as satisfaction of all patients with their final results; nonunion resulting from two-part fractures had better results when compared with three-part fractures.

Management of proximal humeral nonunions and malunions

Surgical treatment of proximal humeral nonunions and malunions are technically challenging. Osteosynthesis with bone grafting for the treatment of nonunions is indicated in young, active patients with adequate bone stock in the proximal fragment and preservation of the glenohumeral articular surfaces. Corrective osteotomy may be a reasonable option for proximal humeral malunions in young patients without evidence of degenerative joint disease. Arthroplasty for proximal humerus nonunions and malunions has a guarded outcome because of limitations in shoulder motion, but pain relief is more consistently improved upon.

Interlocking intramedullary nailing for nonunion of the proximal humerus with the Straight Nail System

Nonunion of the proximal humerus is a challenging problem. Since 1996, we have performed interlocking intramedullary nailing for the treatment of proximal humeral nonunions with the Straight Nail System and bone grafting. The objective of this study was to investigate the clinical outcomes of this procedure in patients with proximal humeral nonunion. We investigated 14 consecutive patients (mean age, 74.3 +/- 8.7 years). One patient was excluded because of associated brachial plexus palsy. All but 2 were initially treated conservatively. Range-of-motion exercises were started 1 week after the operation. The mean follow-up period was 37.8 months. Union was achieved in all cases without any evidence of malunion. All patients had improved range of motion of the shoulder and were satisfied with the surgical results. Mean flexion of the shoulder was 122 degrees +/- 14 degrees, and mean external rotation was 35 degrees +/- 10 degrees. Interlocking intramedullary nailing with the Straight Nail System and bone grafting offered a successful method of stable internal fixation in these complex proximal humeral nonunion cases.

Proximal humeral fractures: a systematic review of treatment modalities

A systematic review was conducted of primary intervention of proximal humeral fracture, which is a common injury with significant morbidity. Keywords of proximal humeral fracture were entered into PubMed and Embase databases. Two evaluators reviewed abstracts from 1985 to 2004 for inclusion and exclusion criteria yielding 66 articles. These articles were evaluated independently for outcomes and quality of evidence using the Structured Effectiveness Quality Evaluation Scale and Sackett's Levels of Evidence. Patient characteristics and outcomes were recorded. The 66 studies included 2155 patients grouped by fracture types according to the Neer classification system. Studies differed by intervention, methods, outcome measures and results. Quality scores averaged 15/48; only 2 articles included randomized groups. Current studies typically lack randomization, comparators, and independent evaluation, with a resultant inability to produce clinical conclusions. Further research comparing primary treatment methods in a properly designed and controlled fashion is required, ideally using randomized controlled trials.

Humeral nonunion

Humerus fractures comprise 5% to 8% of all fractures. Although uncommon, nonunions can present a frustrating challenge to the orthopedic surgeon. Various risk factors that may predispose patients to nonunion include obesity, osteoporosis, alcoholism, smoking, poor bone quality, and scar tissue. Many methods of treatment have been described with various degrees of success. The rates of healing of humeral nonunions by traditional means of internal fixation with bone graft range from 70% to 92%, although in cases of infection, poorly vascularized beds, and open, segmental, or severely comminuted fractures, secondary bony healing may still be compromised.

Treatment of proximal humerus fractures

The majority of proximal humerus fractures are treated nonoperatively with good functional results. Multiple options exist for treating displaced fractures, without a clear advantage of any one method for a given fracture type. Goals include an adequate reduction and stable fixation to initiate early motion and rehabilitation. Decision-making should be based on patient and injury specifics and surgeon's experience. Various types of fixation, including plates, nails, or percutaneous pins, can maintain sufficient stability to promote shoulder mobility and function. Any of these methods will have few complications when undertaken with appropriate patient selection and careful surgical technique. Preliminary results of locking plates in the proximal humerus suggest that this is a favorable treatment option for displaced, comminuted proximal humerus fractures, which compares well with established methods. Locked plating may improve fracture stability in some complex patterns and facilitate early rehabilitation. It is possible that some fractures previously treated with hemiarthroplasty may be managed successfully with locking plates. Prospective study to assess the complications, outcomes, and cost effectiveness of nonoperative management compared to various surgical treatment options is warranted.

Unexpected high complication rate following internal fixation of unstable proximal humerus fractures with an angled blade plate

OBJECTIVES

The increasing number of fractures of the proximal humerus, especially in the elderly, carries with it the unsolved problem of the optimal treatment for the displaced or unstable fractures. The authors' goal was to analyze whether fixation with a bent valgus angled blade plate could improve the outcomes reported in the literature to date.

DESIGN

Prospective clinical study.

SETTING

Urban level 1 university trauma center.

PATIENTS

Over a 27-month period, 42 consecutive patients were treated for an unstable or displaced proximal humerus fracture.

INTERVENTION

Open reduction and internal fixation with a 90-degree cannulated angled blade plate prebent to 110 degrees.

MAIN OUTCOME MEASUREMENTS

Active follow-up for 1 year with assessment of objective and subjective functional results (ie, motion; strength; Constant score; Disabilities of the Arm, Shoulder, and Hand (DASH) score; and visual analog scale (VAS)) and radiographic assessment (reduction, alignment, necrosis, and nonunion).

RESULTS

Follow-up was completed for 86% of the patients, who achieved a mean Constant score of 66 points (82% of the contralateral side) with a mean forward flexion of 125 degrees and an average strength of 72% of the contralateral side. Low disability (mean DASH score 22) and pain values (mean VAS 2) were demonstrated after this type of stabilization. The overall complication rate was 33% (12/36), with protrusion of the blade into the glenohumeral articulation as the most frequent problem (8/36, 22%). The negative impact of an adverse event on subjective and objective outcomes was only significant for forward flexion (P = 0.02). Neither clinical outcome nor complication rate was different when compared to patients with regard to fracture type (3 versus 4 parts) or age (younger or older than 70 years).

CONCLUSIONS

Fixation of displaced proximal humeral fractures with an angled blade plate provided sufficient stability. Blade perforation into the humeral joint occurred in every fourth patient and was found to be the major reason for a high complication rate. In view of this major problem, the technique described here cannot be recommended, even though the absence of nonunions in our series seems to support the low invasiveness of this surgical approach.

Locking plates improve torsional resistance in the stabilization of three-part proximal humeral fractures

This study quantified the torsional resistance provided by locking plates and angled blade plates used to stabilize proximal humeral fractures. Three-part proximal humeral fractures were created in 6 pairs of cadaveric humeri. One specimen of each pair was reconstructed with a proximal humeral locking plate, whereas the other specimen was reconstructed with an angled blade plate. An external rotation torque, varying from 0 to 5 N-m, was applied to the humeral head until the head rotated 30 degrees or 10,000 loading cycles were applied. The mean initial torsional stiffness was significantly larger for the locking plates (0.99 N-m/degree) than for the blade plates (0.59 N-m/degree). For each pair, the maximum rotation was larger for the blade plate than for the locking plate. For this in vitro model of a reconstructed 3-part proximal humeral fracture, the locking plate provided better torsional fatigue resistance and stiffness than the blade plate.

New trends in the treatment of proximal humerus fractures

For complex proximal humeral fractures, most authors agree on the importance of anatomic reduction and stable fixation to allow early range of motion. Currently a variety of techniques are used such as K-wires, t-plates, and primary prosthesis among others. However, no current treatment guidelines have been established. Newer implants provide greater angular stability, better biomechanical properties, and enhanced anchorage in these complex injuries. These implants therefore have a potential for achieving better results in treating complex fractures. We discuss current treatment concepts and focus on biomechanics and early results of new implants designed to provide angular stability.

LEVEL OF EVIDENCE

Expert Opinion, Level V. See the Guidelines for Authors for a complete description of levels of evidence.

New implant designs for fracture fixation in osteoporotic bone

Screws are one of the limiting factors for fixation of implants, particularly in poor bone quality. A class of new implants with an implant-bone-interface optimized regarding load transition by increasing the peripheral area might improve the anchorage of implants in osteoporotic bone. However, the shape of these implants requires new technologies for insertion. The goal of the work presented here was to analyze the relevant parameters regarding implant geometry and to demonstrate the effect of new procedures for their insertion. The investigation was divided into three parts: 1) implant design optimisation, 2) efficiency of cortical bone ablation, and 3) implant insertion technology. Finite element analysis (FEA) was performed to investigate the influence of the number of lobes, the radius of the outer curvature and additional milling to remove any sharp changes of section around the lobe. Opening of the cortical bone with an Er:YAG laser was studied using calf cortex from 2 to 7 mm thickness. The effect of a) pulse energy and pulse duration, b) cortical thickness, c) wet or dry boundary conditions on volume and geometry of ablated bone, time required to penetrate the cortical bone and local bone tissue damage was quantified. Pneumatic and ultrasound based insertion were compared in the third experiment. The cortical bone was prepared in the following ways: a) no opening, b) predrilling of three holes (1 mm diameter each) and c) exact pre-cutting of the whole contour. Increasing the radius of the outer curvature from 2 to 5 mm reduces the peak stresses during loading in all planes in the implant as well as in the adjacent cortical bone by about 30-40%. An increase in the number of lobes from two to three decreases the mean peak stress by about 46% (alpha < 0.001) and the range between the minimal and maximal peak stresses for different loading directions by about 83%. Penetration of cortical bone with an Er:YAG laser was possible up to a cortical thickness of 6 mm with fewer than 100 pulses. The ablation rate per pulse increased more with increasing duration than with increasing energy. Signs of bone damage such as melting were only visible when high pulse energies and durations were used. Insertion of the prototype was possible with all devices, but only when the whole contour was cut out of the cortical bone. However, the use of the ultrasound vibrator led to heating up of the tissue fluid and subsequently to water evaporation and tissue damage. Insertion of the prototype was possible with both pneumatic vibrators, but only when the whole contour was cut out of the cortical bone. New implant designs may lead to reduced stress peaks in the surrounding bone and might be inserted with the help of new insertion technologies, namely laser cutting of cortical bone and pneumatic vibration. Further studies are required to optimize these technologies prior to clinical use.

Fixation principles in metaphyseal bone--a patent based review

Osteoporotic changes start in cancellous bone due to the underlying pathophysiology. Consequently, the metaphyses are at a higher risk of "osteoporotic" fracture than the diaphysis. Furthermore, implant purchase to fix these fractures is also affected by the poor bone quality. In general, researchers and developers have worked on three different approaches to address the problem of fractures to osteoporotic bone: adapted anchoring techniques, improved load distribution as well as transfer with angular stable screws, and augmentation techniques using bone substitutes. A patent-based review was performed to evaluate which ideas were utilized to improve fixation in osteoporotic, metaphyseal bone, especially in the proximal femur, and to analyze whether the concept had entered clinical use. Anchoring devices that are either extramedullary or intramedullary have a long clinical history. However, demanding surgical techniques and complications, especially in poor quality bone, are justification that such implants and their corresponding surgical techniques need to be improved upon. Expanding elements have been evaluated in the laboratory. The results are promising and the potential of this approach has yet to be fully exploited in the clinics. Internal fixators with angular stable screws open the door for many new anchorage ideas and have great potential for further optimization of load distribution and transfer. Augmentation techniques may improve anchorage in osteoporotic bone. However, the properties of bone substitute materials will need to be modified and improved upon in order to meet the demanding requirements. If we summarise the development process and the clinical use of implants to date, we have to clearly state that more factors than simply biomechanical advantage will determine the clinical success of a new fixation principle or a new implant. Instead, fracture treatment of patients with osteoporosis really needs an interdisciplinary approach!

Nonunions of the humerus

Humerus fractures comprise 5% to 8% of all fractures. Nonunions are uncommon, but when they occur, they present a challenge to the orthopaedic surgeon and often are debilitating to patients. There are risk factors that may predispose patients to nonunion. Many methods of treating these nonunions have been described with varying degrees of success. We review the literature concerning the treatment of proximal, midshaft, and distal humeral nonunions and describe our treatment protocol based on the literature.

Outcome of open reduction and internal fixation of surgical neck nonunions of the humerus

OBJECTIVE

The purpose of this study was to evaluate the results of open reduction and internal fixation of nonunions of the surgical neck of the humerus.

DESIGN

Retrospective review of patients who underwent operative treatment of a surgical neck of the humerus nonunion.

SETTING

Shoulder and elbow service at two university centers.

PATIENTS

Thirteen patients with a two-part nonunion of the surgical neck of the humerus who were treated with open reduction and internal fixation with bone graft with a minimum of 12 months' follow-up were included. Patients with avascular necrosis, posttraumatic arthritis, severe humeral head bone loss, or a nonunion of one of the two tuberosities were excluded.

INTERVENTION

Open reduction and internal fixation with either a blade plate or a T-plate and autogenous bone graft.

MAIN OUTCOME MEASURES

Medical records, operative reports, physical examination, and preoperative and postoperative radiographs were reviewed. Outcome was assessed using Neer's criteria for the evaluation of total shoulder arthroplasty, visual analogue pain scale, range of motion, and ability to perform activities of daily living.RESULTS The results were excellent in 11 patients, satisfactory in 1 patient, and poor in 1 patient. The 11 nonunions in patients with excellent results healed within 6 months. The patient with the poor result initially had a persistent nonunion and required revision, open reduction and internal fixation, and bone grafting. This patient healed and went on to have an excellent result at final follow-up. All fractures were healed at the time of this study. Pain scores decreased from an average of 4.2 preoperatively to 1.2 postoperatively on a 5-point pain scale. Forward elevation in the scapular plane improved from 24 degrees preoperatively to 144 degrees postoperatively. All patients but one were able to attain overhead elevation. All patients were able to perform activities of daily living, such as dressing, bathing, combing hair, and performing perineal care, at final follow-up. Overall satisfaction increased from an average of 1.0 to 9.4 on a 10-point visual analogue scale.

CONCLUSIONS

Open reduction and internal fixation with autogenous bone graft results in excellent outcomes even in patients >65 years old and patients with significant medical problems. This treatment method offers predictable fracture healing and has a low complication rate.

Results of treatment of infected humeral nonunions: the Mayo Clinic experience

Between 1987 and 2001, 15 infected humeral nonunions were treated of which nine were distal, four were proximal, and two were midshaft. One patient was lost to followup. The remaining 14 patients were followed up for a mean of 37 months (range, 8-156 months). All patients were treated with debridement and intravenous antibiotics. Ten patients had surgical attempts at achieving bony union: external fixation (four patients), plating (two patients), external fixation and plating (two patients), tension band wiring (one patient), and bone grafting with shoulder spica casting (one patient). Three patients were treated definitively with a functional brace because of low functional demands and one patient had resection arthroplasty followed by delayed total elbow arthroplasty. Of the 10 nonunions treated with surgical attempts at achieving bony union, only seven healed. None of those nonunions in patients treated with a functional brace healed. At final followup, 12 of 14 patients had minimal or no pain and two patients had moderate pain, both with ununited fractures. Complications included one seroma and two cases of posttraumatic elbow stiffness for which the patients required capsular release. This study documents the challenges in achieving bony union in the infected humeral nonunion in contradistinction to the predictable union rates reported for aseptic humeral nonunions. Although pain relief was predictable in most patients, functional results generally were poor and bony union was difficult to obtain.

Advances in the management of humeral nonunion

Approximately 10% of all long-bone fractures occur in the humerus. Although primary treatment usually is successful, humeral nonunion can lead to marked morbidity and functional limitation. Complications include joint contractures of the shoulder and elbow, especially with periarticular pseudarthrosis. Marked osteopenia or bone loss, or both, often occur after fracture and after failure to achieve union. Retained implants often break, impeding fixation and requiring removal. Soft-tissue deficits and incisions from the original injury or prior surgeries also may complicate reconstruction, as can intra-articular fractures and associated nerve palsies. Successful surgical management of humeral nonunion requires stable internal fixation that allows early joint motion and uses autogenous bone graft to promote healing. Contracture release and early joint motion are necessary to optimize function. Shoulder hemiarthroplasty and semiconstrained total elbow arthroplasty are viable options for irreversible joint damage. Advances in preoperative evaluation and surgical reconstruction have improved functional outcomes.