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

Prediction of the Proximal Humerus Morphology Based on a Statistical Shape Model with Two Parameters: Comparison to Contralateral Registration Method

(1) Background: Complex proximal humerus fractures often result in complications following surgical treatment. A better understanding of the full 3D displacement would provide insight into the fracture morphology. Repositioning of fracture elements is often conducted by using the contralateral side as a reconstruction template. However, this requires healthy contralateral anatomy. The purpose of this study was to create a Statistical Shape Model (SSM) and compare its effectiveness to the contralateral registration method for the prediction of the humeral proximal segment; (2) Methods: An SSM was created from 137 healthy humeri. A prediction for the proximal segment of the left humeri from eight healthy patients was made by combining the SSM with parameters. The predicted proximal segment was compared to the left proximal segment of the patients. Their left humerus was also compared to the contralateral (right) humerus; (3) Results: Eight modes explained 95% of the variation. Most deviations of the SSM prediction and the contralateral registration method were below the clinically relevant 2 mm distance threshold.; (4) Conclusions: An SSM combined with parameters is a suitable method to predict the proximal humeral segment when the contralateral CT scan is unavailable or the contralateral humerus is unhealthy, provided that the fracture pattern allows measurements of these parameters.

Plate Fixation of Proximal Humerus Fractures: How to Get It Right and Future Directions for Improvement

PURPOSE OF REVIEW

Open reduction and internal fixation with locking plates (ORIF-LP) has been used for decades for the surgical management of proximal humerus fractures. Despite good outcomes have been widely published in the literature, unacceptably high rates of complications (up to 40%), many of them yielding poor outcomes and requiring reoperation (up to 25%), have also been reported, especially in elderly patients. Most common complications are related to implant failure, with intra-articular screw penetration as the most frequent and devastating.

RECENT FINDINGS

Advances in patient selection and surgical technique, and implementation of bone or cement augmentation, have been developed to hopefully decrease complication rates. Mayo-FJD Classification offers prognostic information that can aid in the decision-making process for proximal humeral fractures. Displaced valgus impacted fractures seem to be associated with well over a 10% rate of avascular necrosis after ORIF-LP. A principle-based and stepwise surgical technique combining anatomic reduction and a short screw configuration can provide good outcome in most patients, even the elderly, decreasing implant failures to less than 10%. Acrylic cement augmentation has the potential to further decrease implant failure rate to 1%. Reoperation rates are higher partly due to the need to remove hardware for painful subacromial conflict. However, no studies to date definitively demonstrated the superiority of ORIF-LP compared to non-operative treatment, intramedullary nailing, or reverse shoulder arthroplasty. ORIF-LP can provide good results for the surgical management of displaced proximal humerus fractures even in elderly patients provided adequate patient selection and a principle based and stepwise surgical technique, supplemented with bone graft or acrylic cement when needed. Poor outcomes and high complication and reoperation rates should be expected when these recommendations are not followed.

Treatment of Metaphyseal Defects in Plated Proximal Humerus Fractures with a New Augmentation Technique-A Biomechanical Cadaveric Study

Background and Objectives: Unstable proximal humerus fractures (PHFs) with metaphyseal defects-weakening the osteosynthesis construct-are challenging to treat. A new augmentation technique of plated complex PHFs with metaphyseal defects was recently introduced in the clinical practice. This biomechanical study aimed to analyze the stability of plated unstable PHFs augmented via implementation of this technique versus no augmentation. Materials and Methods: Three-part AO/OTA 11-B1.1 unstable PHFs with metaphyseal defects were created in sixteen paired human cadaveric humeri (average donor age 76 years, range 66-92 years), pairwise assigned to two groups for locked plate fixation with identical implant configuration. In one of the groups, six-milliliter polymethylmethacrylate bone cement with medium viscosity (seven minutes after mixing) was placed manually through the lateral window in the defect of the humerus head after its anatomical reduction to the shaft and prior to the anatomical reduction of the greater tuberosity fragment. All specimens were tested biomechanically in a 25° adduction, applying progressively increasing cyclic loading at 2 Hz until failure. Interfragmentary movements were monitored by motion tracking and X-ray imaging. Results: Initial stiffness was not significantly different between the groups, p = 0.467. Varus deformation of the humerus head fragment, fracture displacement at the medial humerus head aspect, and proximal screw migration and cut-out were significantly smaller in the augmented group after 2000, 4000, 6000, 8000 and 10,000 cycles, p ≤ 0.019. Cycles to 5° varus deformation of the humerus head fragment-set as a clinically relevant failure criterion-and failure load were significantly higher in the augmented group, p = 0.018. Conclusions: From a biomechanical standpoint, augmentation with polymethylmethacrylate bone cement placed in the metaphyseal humerus head defect of plated unstable PHFs considerably enhances fixation stability and can reduce the risk of postoperative complications.

Statistical Morphology and Fragment Mapping of Complex Proximal Humeral Fractures

Background and Objectives: Proximal humerus fractures (PHFs) are common in the elderly, but the treatment results are often poor. A clear understanding of fracture morphology and distribution of cortical bone loss is important for improved surgical decision making, operative considerations, and new implant designs. The aim of this study was to develop a 3D segmentation fracture mapping technique to create a statistical description of the spatial pattern and cortical bone loss of complex PHFs. Materials and Methods: Fifty clinical computed tomography (CT) scans of complex PHFs and their contralateral intact shoulders were collected. In-house software was developed for semi-automated segmentation and fracture line detection and was combined with manual fracture reduction to the contralateral template in a commercial software. A statistical mean model of these cases was built and used to describe probability maps of the fracture lines and cortical fragments. Results: The fracture lines predominantly passed through the surgical neck and between the tuberosities and tendon insertions. The superior aspects of the tuberosities were constant fragments where comminution was less likely. Some fracture lines passed through the bicipital sulcus, but predominantly at its edges and curving around the tuberosities proximally and distally. Conclusions: A comprehensive and systematic approach was developed for processing clinical CT images of complex fractures into fracture morphology and fragment probability maps and applied on PHFs. This information creates an important basis for better understanding of fracture morphology that could be utilized in future studies for surgical training and implant design.

Preventing varus collapse in proximal humerus fracture fixation: 90-90 dual plating versus endosteal fibular allograft strut

INTRODUCTION

Screw cut out and varus collapse are the most common complication of locked plate fixation of proximal humerus fractures. The purpose of this study was to compare dual plating and endosteal fibular allograft struts as augmentation strategies to prevent varus collapse.

MATERIALS AND METHODS

A trapezoidal osteotomy was created at the metaphysis to create a 2-part proximal humerus model in 18 paired shoulder specimens. Each specimen was assigned to group A, B, or C and was fixed with either a lateral locking plate, a lateral locking plate and anterior one-third tubular plate in an orthogonal 90/90 configuration, or a lateral locking plate with intramedullary fibular strut, respectively. The specimens were stressed in axial compression to failure. Displacement, elastic limit, ultimate load, and stiffness were recorded and calculated.

RESULTS

There was no difference in mean cyclic displacement between the three groups (0.71 mm vs 0.89 mm vs 0.61 mm for Group A, B, C, respectively). Lateral plating demonstrated the greatest absolute and relative displacement at the elastic limit (5.3 mm ± 1.5 and 4.4 mm ± 1.3) without significance. The elastic limit or yield point was greatest for fibular allograft, Group C (1223 N ± 501 vs 1048 N ± 367 for Group B and 951 N ± 249 for Group A) without significance.

CONCLUSIONS

Dual plating of proximal humerus fractures in a 90-90 configuration demonstrates similar biomechanical properties as endosteal fibular strut allograft. Both strategies demonstrate superior stiffness to isolated lateral locked plating.

Minimum 2-year results of the second-generation CFR-PEEK locking plate on the proximal humeral fracture

PURPOSE

The aim of this study was to analyse and compare the 24-month range of motion results of patients treated with CFR-PEEK2 versus conventional titanium plate osteosyntheses (TAL-P). We hypothesized similar clinical outcomes but a better range of motion in the CFR-PEEK2 group than the TAL-P group in the 2-year follow-up.

METHODS

This retrospective study analysing prospectively collected data included all patients that presented with a PHF and were treated with CFR-PEEK2 between November 2016 and April 2018. Follow-up was performed after a minimum of 24 months, evaluating the functional degree of movement functional scores, including the Subjective Shoulder Value (SSV) as well as an age- and sex-adapted Constant-Murley score (CMS). The 2-year results were compared to the results of a matched pair group comprising patients that were treated with TAL-P during the same period.

RESULTS

Of the 35 patients included (mean age: 61.2 [18-78] years), 30 (86%) patients completed the 24-month follow-up in the CFR-PEEK2-group. After 24 months, the mean CMS was 89.9 points (pt) (44.5-100 pt) and the mean SSV was 86.7% (35-100%). Compared to the matched-pair TAL-P cohort, the 24-month follow-up showed similar results (CMS: 88.6 pt. (40.5-100 pt.) [p = 0.9]; SSV: 76% (30-100%) [p = 0.05]). However, significantly better degrees of forward flexion and internal rotation as well as a better range of motion in abduction was recorded in patients treated with CFR-PEEK2 plates than TAL-P.

CONCLUSION

At the 24-month follow-up, patients who received treatment with CFR-PEEK2 compared to those that received TAL-P showed enhanced range of motion whilst having similar clinical scores.

Proximal humeral fracture locking plate fixation with anatomic reduction, and a short-and-cemented-screws configuration, dramatically reduces the implant related failure rate in elderly patients

Background

Multiple studies have reported an unacceptable implant-related complication rate in proximal humeral fractures treated with locking plates, particularly in older patients. Our objective was to compare the fracture fixation failure rates in elderly patients, after a dedicated technique for locking plate fixation with cement augmentation or without it.

Methods

A total of 168 open reduction and internal fixation with locking plates were performed for complex proximal humerus fractures by a single surgeon in 136 women and 32 men older than 65 years of age (average 76 years). Treatment groups included group 1 with noncemented screws (n = 90) and group 2 with cemented screws (n = 78). As per Mayo-FJD Classification, there were 74 (44%) varus posteromedial impaction, 41 (24%) algus impaction, 46 (28%) surgical neck, and 7 (4%) head dislocation injuries. A retrospective radiographic and a clinical analysis was performed.

Results

At a mean follow-up of 33 months, the implant failure rate was significantly lower in the cement augmentation group (1% vs. 8%, P = .03). The overall complication rate was 21% (25% group 1, 15% group 2; P = .1). Global avascular necrosis was associated with sustaining a valgus impacted fracture (P = .02 odds ratio 5.7), but not to augmentation. Partial avascular necrosis occurred only in patients treated with cemented screws (3.8%). The overall revision rate was 9% in both groups. Forward elevation was 126 ± 36 degrees and external rotation was 44 ± 19 degrees. The mean Constant score was 70 ± 15 in group 1 and 76 ± 15 in group 2 (P = .03).

Conclusion

Cement augmentation significantly decreased the rate of implant failure. Good results are expected for most patients treated with this technique.

Screw placement in two different implants for proximal humeral fractures regarding regional differences in bone mineral density: An anatomical study

BACKGROUND

The aim of this study was to investigate proximal humerus plating regarding drill depth and over penetration of the glenohumeral joint and to find a relation between these findings and different areas of bone mineral density (BMD) in the humeral head.

MATERIAL & METHODS

The study sample involved 45 upper extremities from human adult cadavers. Two different plates (HOFER; PHILOS) were applied to the proximal humerus. Each hole was drilled until the respective participant thought to have placed the drill bit subchondral. Next, penetration of the far cortex was conducted to determine the residual bone stock. Additionally, the point of screw penetration of the far cortex was identified for each hole of the plates and allocated to five regions with different bone mineral density as described by Tingart et al.

RESULTS

The screw penetration rate and the residual bone stock were compared within the 5 BMD regions. A significantly thicker residual bone stock was found at the central region (SD ± 13.1 mm) than in the anterior region (SD ± 9.5 mm) and in the posterior region (SD ± 8.5 mm). The anterior region revealed a significantly higher penetration rate than the posterior region (p = 0.01) and the central region (p = 0.03).

CONCLUSION

The anterior region of the humeral head was associated with a higher over penetration rate of the far cortex into the glenohumeral joint and a decreased bone stock after subchondral drilling representing a reduced bone mineral density (BMD).

LEVEL OF EVIDENCE

Cadaver Study.

Evaluation of screw placement in proximal humerus fractures regarding drilling manoeuvre and surgeon's experience

INTRODUCTION

Following proximal humeral plate osteosynthesis, mechanical complication rates ranging up to 40% have been reported. The study aims to determine the influence of surgeons' experience and the technique of drilling on the complication rate.

MATERIALS AND METHODS

The sample involved 45 cadaveric humeri. Six orthopaedic surgeons were divided into two groups with regard to their level of experience (novice versus expert group). On each humerus two different proximal humerus plates were applied. Drillings were performed either with a sharp or worn drill bit (to simulate either sharp or blunt drilling). The respective holes were drilled until the respective participant thought to have placed the drill bit subchondrally, followed by perforation of the cartilage of the humeral head. Both these values and cases of unintended penetration of the articular cavity were evaluated.

RESULTS

Fourteen holes (3.6%) were primary penetrated in the joint cavity in the worn-drill-bit-subgroup and 19 holes (5%) in the sharp-drill-bit-group. The latter had an average distance between the chosen subchondral position and the humeral articular surface of 8.3 mm and the worn-drill-bit-subgroup was at 10.6 mm. In the novice group 20 perforations (5.2%) of the joint space occurred and the mean interval between the chosen subchondral point and the humeral articular surface was 4.0 mm. The experienced surgeons showed a perforation rate of 3.4% and were at a mean of 14.9 mm. There were no significant differences regarding drilling manoeuvres and experience.

CONCLUSION

Although our results are satisfactory, they can be traced back to the relatively high interval between the respective chosen position of the drill bit and the humeral articular surface which may not guarantee screw stability during ORIF of all fracture patterns.

Stable osteosynthesis of cage in cage technique for surgical treatment of proximal humeral fractures

Background

The treatment of a displaced proximal humeral fracture is still a matter of controversy. The purpose of this study was to report outcomes at a long-term follow-up after fixation augmentation using peek (polyether-ether-ketone) cage and locking compression plate (LCP).

Methods

A total of 27 patients (average age 53.8 years, range 19–86 years) were treated with peek cage and LCP. All of them had a minimum radiographic and clinical follow-up of 1 years. Outcomes were assessed using the Constant-Murley score (CMS), disability of the arm, shoulder and hand (DASH) score. Complications were also recorded during follow-up.

Results

The average follow-up was 28 months (range 12–48 months). The mean functional outcomes were as follows: CMS, 73.3 (range 61–86); DASH, 45.9 (range 27–68). A total of 4 patients had complications: osteonecrosis developed in one patient, loss of reduction was observed in 1 patient and stiffness was occurred in two patients.

Conclusion

The use of peek cage and LCP has been a valuable option in the treatment of proximal humeral fractures. The complication rate was acceptable. Suitable void filler in the proximal humerus for reconstructing the medial column integrity attains mechanical stability in reducing the incidence of the complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01235-x.

[Application of suspensory external fixation technique in treatment of proximal humeral fracture]

Objective

To investigate the effectiveness of suspensory external fixation technique in treatment of proximal humeral fractures.

Methods

Between August 2013 and October 2018, 14 patients with proximal humeral fractures were treated with suspensory external fixation technique. There were 10 males and 4 females with an average age of 55.9 years (range, 43-76 years). There were 10 cases of falling injury and 4 cases of traffic accident injury. Among them, there were 9 cases of Neer type Ⅲ and 5 cases of Neer type Ⅳ. The time from injury to operation was 3-7 days (mean, 4.6 days). Nine cases were complicated with osteoporosis. The preoperative visual analogue scale (VAS) score was 6.1±1.2. The effectiveness was comprehensively evaluated by hospital stay, fracture healing time, removal time of external fixator, postoperative complications, VAS score, and Neer score of shoulder joint function.

Results

All operations were successfully completed, and the hospital stay was 6-14 days, with an average of 9.4 days. All the incisions healed by first intention, and no infection or other complications occurred. All patients were followed up 16-60 months (mean, 35.4 months). X-ray films examination showed that all fractures healed, the healing time was 4-7 months (mean, 4.9 months). The removal time of external fixator was 5-8 months (mean, 6.3 months). VAS scores were 1.5±0.8 at 1 month after operation and 1.0±0.9 at last follow-up, both of which were significantly improved when compared with preoperative score, the differences were significant between different time points ( P<0.05). Neer score of shoulder joint function was 75-100 (mean, 91.1); 9 cases were excellent, 4 cases were good, and 1 case was fair. The excellent and good rate was 92.9%. During follow-up, there was no adverse events such as acromion impingement, nonunion, or pseudoarthrosis.

Conclusion

For proximal humeral fractures, the suspensory external fixation technique is a simple and reliable treatment method that can significantly improve joint function.

Treatment options for proximal humeral fractures in the older adults and their implication on personal independence

BACKGROUND

No consensus exists on the optimal treatment of proximal humeral fractures (PHFx). Uncertainty about surgical treatment in the older adults using locking plates (e.g., PHILOS) has emerged, due to a high number of complications. This study aimed to assess the impact of non-operative versus operative treatment of a PHFx on the level of self-dependence in our older population.

METHODS

We included patients aged over 65 years with some level of self-dependence, treated at our hospital between 5/2011 and 4/2013 for isolated PHFx of AO subtypes A2, A3, and B1 for which either non-operative or surgical treatment using a PHILOS plate had been applied. The patients were questioned, examined, or interviewed via phone; AO fracture patterns and treatment were documented as well as level of self-dependence, complications, constant score (CSM), subjective shoulder value (SSV), quality of life (EQ-5D), and shoulder pain and disability index (SPADI).

RESULTS

Patients with PHFx of AO subtypes A2, A3, or B1 that were either treated non-operative (n = 50) or operative by insertion of the PHILOS plate (n = 63) were included. Operative-treated patients were 3.3 times as likely to lose some level of independence (95% CI 0.39-28, p = 0.271). Shoulder motion, strength, and functional outcomes tended to be lower in operative-treated patients, with adjusted differences of, - 11 CMS points (95% CI - 23 to 2), - 9 SPADI points (95% CI - 18 to 0), and - 6% in SSV (95% CI - 17 to 5). Quality-of-life EQ-5D utility index was similar in both groups (mean - 0.04; 95% CI - 0.18 to 0.10).

CONCLUSION

In our study population, non-operatively treated older adults with an AO type A2, A3, B1 fracture of the proximal humerus tended to have a high chance to return to their premorbid level of independence, compared to patients treated with a locking plate. A change in the treatment algorithm for these PHFx may be carefully considered and further investigated in clinical practice.

Advanced CT visualization improves the accuracy of orthopaedic trauma surgeons and residents in classifying proximal humeral fractures: a feasibility study

PURPOSE

Osteosynthesis of proximal humeral fractures remains challenging with high reported failure rates. Understanding the fracture type is mandatory in surgical treatment to achieve an optimal anatomical reduction. Therefore, a better classification ability resulting in improved understanding of the fracture pattern is important for preoperative planning. The purpose was to investigate the feasibility and added value of advanced visualization of segmented 3D computed tomography (CT) images in fracture classification.

METHODS

Seventeen patients treated with either plate-screw-osteosynthesis or shoulder hemi-prosthesis between 2015 and 2019 were included. All preoperative CT scans were segmented to indicate every fracture fragment in a different color. Classification ability was tested in 21 orthopaedic residents and 12 shoulder surgeons. Both groups were asked to classify fractures using three different modalities (standard CT scan, 3D reconstruction model, and 3D segmented model) into three different classification systems (Neer, AO/OTA and LEGO).

RESULTS

All participants were able to classify the fractures more accurately into all three classification systems after evaluating the segmented three-dimensional (3D) models compared to both 2D slice-wise evaluation and 3D reconstruction model. This finding was significant (p < 0.005) with an average success rate of 94%. The participants experienced significantly more difficulties classifying fractures according to the LEGO system than the other two classifications.

CONCLUSION

Segmentation of CT scans added value to the proximal humeral fracture classification, since orthopaedic surgeons were able to classify fractures significantly better into the AO/OTA, Neer, and LEGO classification systems compared to both standard 2D slice-wise evaluation and 3D reconstruction model.

Failure after proximal humeral fracture osteosynthesis: a one year analysis of hospital-related healthcare cost

Purpose

The issue of rising healthcare costs and limited resources is a topic of worldwide discussion over the last several decades. We hypothesized that failure of proximal humeral fracture osteosynthesis is presumed to be an important determinant in healthcare resources and related costs. The aim of this study was to calculate the total hospital-related healthcare cost of proximal humeral fracture osteosynthesis over one  year focusing on failure.

Methods

A total of 121 patients with a proximal humeral fracture treated by angular stable osteosynthesis were included in this retrospective study. All hospital-related healthcare costs were investigated. Five main hospital-related cost categories were defined: hospitalization cost, honoraria, day care admission, materials, and pharmaceuticals.

Results

A total healthcare cost of € 1,139,448 was calculated for the whole patient group. Twelve patients needed revision surgery due to complications or fixation-related failure. This failure rate alone costed € 190,809 of the healthcare resources. In other words, failure after proximal humeral fracture osteosynthesis costed 17% of the total healthcare expenditure inone year.

Conclusion

This study demonstrates that a high amount of hospital-related healthcare resources is spent because of failure after proximal humeral fracture osteosynthesis. Further research is necessary and should investigate on how to prevent failure. This is not only in the patient’s interest, but it is also of great importance for maintaining a healthy healthcare system.

Osteosynthesis of proximal humeral fractures: a 1-year analysis of failure in a Belgian level-1 trauma centre

PURPOSE

Proximal humeral fractures are the third most common fractures affecting the elderly. Angular stable osteosynthesis has become indispensable in the operative treatment. However, surgical fixation remains challenging. The aim of this retrospective study was to analyse the failure rate after osteosynthesis of proximal humeral fractures over a year in a level-1 trauma centre. Furthermore, parameters that are presumed to be related to osteosynthesis failure will be investigated and discussed.

METHODS

After meeting the exclusion criteria, 134 patients were operatively treated with angular stable osteosynthesis between January 2017 and January 2018 at the University Hospitals of Leuven.

RESULTS

Circa 16% of the proximal humeral osteosyntheses failed. Our study showed that the most significant parameter for osteosynthesis failure was smoking. The odds of failure were significantly lower if treated by a shoulder surgeon compared to another trauma surgeon in the plate and nail group combined.

CONCLUSION

The management of proximal humeral fracture osteosynthesis remains a controversial subject. In this retrospective analysis, a failure rate of 15.7% was calculated. Smoking is a statistically significant parameter related to osteosynthesis failure. The subspecialty of the treating trauma surgeon affected the failure rate significantly. A lower failure rate was noted after osteosynthesis by a shoulder surgeon compared to another trauma surgeon.

Axillary nerve elongation in humeral fracture plating: A cadaveric study for comparison between straight and helical Philos plates

Helical plating is a known concept in humeral fracture treatment. Attention should be paid to the axillary nerve when inserting a plate underneath the deltoid muscle. The purpose of this cadaveric study was to estimate axillary nerve stretching when introducing the plate.

METHODS

On 42 fresh frozen human humeri, an 8-, 10- and 12-hole Philos plate in a straight and a helical shape were compared measuring the maximum plate-bone-distance.

RESULTS

For all three plate lengths, the helical plates had a significantly lower plate-bone-distance.

CONCLUSION

Indirectly, this suggests a lower axillary nerve elongation and hence less chance of nerve damage.

Proximal humeral internal locking plate combined with a custom neutral-position shoulder and elbow sling for proximal humerus fractures: A randomized study

OBJECTIVES

The aim of this study was to investigate the effectiveness of the proximal humeral internal locking system (PHILOS) plate combined with a custom neutral-position shoulder and elbow sling for proximal humerus fractures.

METHODS

A total of 112 patients with proximal humerus fractures were assigned randomly into 2 groups. Group A (n = 56) was treated by open reduction and internal fixation (ORIF) with a PHILOS plate; group B (n = 56) was treated by ORIF with a PHILOS plate in combination with the use of a custom neutral-position shoulder and elbow sling for 30 days after surgery. The incidence of internal fixation failure, the Constant-Murley shoulder assessment, and Visual Analogue Scale (VAS) score were recorded and analyzed.

RESULTS

Patients included were followed up for an average of 15 months (range, 6-24 months). No significant differences were observed in mean VAS scores and mean Constant-Murley shoulder assessment scores at 1-day preoperative and postoperative day 3 between groups A and B. However, mean VAS scores and mean Constant-Murley shoulder assessment in group B were significantly improved when compared with group A at postoperative day 30 and the final follow-up. No cases of postoperative infection, loss of reduction, PHILOS break, or vascular nerve injury occurred in either group.

CONCLUSIONS

Proximal humerus fractures treated with the combination of the PHILOS and custom neutral-position shoulder and elbow sling for 30 days after operation was associated with a lower incidence of internal fixation failure. There was no increase in adverse events compared with open reduction and internal fixation with a PHILOS plate alone.

Biomechanical comparison of screw-based zones of a spatial subchondral support plate for proximal humerus fractures

Stabilisation of proximal humerus fractures remains a surgical challenge. Spatial subchondral support (S3) plate promises to overcome common complications associated with conventional proximal humerus plates. This study compared the biomechanical performance of S3 plate with a fixed-angle hybrid blade (Equinoxe Fx) plate and a conventional fixed-angle locking plate (PHILOS). The effects of removal of different S3 plate screws on the humeral stability were also investigated. A total of 20 synthetic left humeri were osteotomised transversely at the surgical neck to simulate a two-part fracture and were each treated with an S3 plate. Head screws were divided into three zones based on their distance from the fracture site. Specimens were divided into four equal groups where one group acted as a control with all screws and three groups had one of the screw zones missing. With humeral head fixed, humeral shaft was first displaced 5 mm in extension, flexion, valgus and varus direction (elastic testing) and then until 30 mm varus displacement (plastic testing). Load-displacement data were recorded to determine construct stiffness in elastic tests and assess specimens' varus stability under plastic testing. Removal of the screw nearest to the fracture site led to a 20.71% drop in mean elastic varus bending stiffness. Removal of the two inferomedial screw above it resulted in a larger drop. The proximal screw pair had the largest contribution to extension and flexion bending stiffness. Varus stiffness of S3 plate constructs was higher than PHILOS and Fx plate constructs. Stability of humeri treated with S3 plate depends on screws' number, orientation and location. Varus stiffness of S3 plate construct (10.54 N/mm) was higher than that of PHILOS (6.61 N/mm) and Fx (7.59 N/mm) plate constructs. We attribute this to S3 plates' thicker cross section, the 135° inclination of its screws with respect to the humeral shaft and the availability of pegs for subchondral support.

Influence of age, gender, and radiographic features on the deltoid splitting approach for surgical osteosynthesis in displaced proximal humerus fractures: a comparison study

BACKGROUND

The deltoid splitting approach has recently been widely adopted to facilitate less invasive procedures for proximal humerus fractures. However, there are still concerns regarding its effectiveness in aging people and in cases involving complex fractures. This study was conducted to evaluate the efficacy of a proximal humeral locking plate using the anterolateral deltoid splitting approach and to specifically examine the effect of patient age, gender, and fracture pattern on surgical outcomes.

METHODS

Forty-two cases of proximal humeral fractures treated using the deltoid splitting approach and locking plate fixation were reviewed. Outcome differences were evaluated in terms of age, gender distribution, and radiographic analysis based on the Neer Classification. The influence of the surgical approach was further investigated by age-matched paired analysis after subdividing patients into two age groups (younger than 60 years vs. older than 60 years; N = 21, in each group).

RESULTS

In total, 41 patients (98%) demonstrated fracture union. The average Constant score was 80.4. No significant differences were found between patients younger than 60 years, and the older patients. Higher mean scores were found in men than in women (p = 0.448) and in simple fractures than in complex fractures (p = 0.454), without any significant differences. Better postoperative functional outcomes were observed when the humeral head-neck angle was greater than 105°, with a significant difference (p = 0.000). Surgical complications were found in 16 patients (38%) without significant difference between two age groups (p = 0.268). The most common complication was screw penetration.

CONCLUSIONS

Anterolateral deltoid splitting using locking plate fixation provided a feasible alternative for surgery of proximal humerus fractures in different age groups and yielded comparable outcomes when the neck-shaft angle was properly restored. Surgeons must be cautious regarding potential complications, especially with screw penetration when using the locking plate through a less invasive approach.

TRIAL REGISTRATION

ISRCTN75494532 . Trial Date: 2017/01/31.

Treatment of comminuted proximal humeral fractures using locking plate with strut allograft

BACKGROUND

This study compared the radiologic outcome of fixation using locking plate only with fixation using locking plate with an endosteal strut allograft in the treatment of comminuted proximal humeral fracture.

METHODS

Among 52 patients with comminuted proximal humeral fracture, 32 patients underwent fixation with locking plate only, and 20 patients underwent fixation using locking plate with an endosteal strut allograft. The strut allograft was inserted into the intramedullary cavity of the humerus to support the humeral head and fixed with the locking plate. Immediate postoperative radiologic findings were compared with those of 6 months or more after the surgery, and loss of anatomic fixation was defined if the varus malalignment of neck-shaft angle (NSA) was more than 5° or if the change of humeral head height (HHH) was more than 3 mm.

RESULTS

In the locking plate-only group, 22 of 32 patients (69%) showed the change in NSA of more than 5°, with an average of 10.2°. The HHH change in 20 patients (62.5%) was more than 3 mm, with an average of 4 mm. Among 20 patients who underwent locking plate with the endosteal strut allograft, the average NSA and HHH change was 3° and 1 mm, respectively. Varus malalignment was evident in 2 patients (10%). The HHH change was more than 3 mm in 1 patient (5%).

CONCLUSION

Fixation using a locking plate with an endosteal strut allograft can be considered a reasonable option to maintain the anatomic reduction in elderly patients with comminuted proximal humeral fracture.

Clinical Effects of the Probing Method with Depth Gauge for Determining the Screw Depth of Locking Proximal Humeral Plate

Background. The use of locking plates has gained popularity to treat proximal humeral fractures. However, the complication rates remain high. Biomechanical study suggested that subchondral screw-tip abutment significantly increased the stability of plant. We present a simple method to obtain the proper screw length through the depth gauge in elderly patients and compared the clinical effects with traditional measuring method. Methods. 40 patients were separated into two groups according to the two surgical methods: the probing method with depth gauge and the traditional measuring method. The intraoperative indexes and postoperative complications were recorded. The Constant and Murley score was used for the functional assessment in the 12th month. Results. Operative time and intraoperative blood loss indicated no statistical differences. X-ray exposure time and the patients with screw path penetrating the articular cartilage significantly differed. Postoperative complications and Constant and Murley score showed no statistical differences. Conclusions. Probing method with depth gauge is an appropriate alternative to determine the screw length, which can make the screw-tip adjoin the subchondral bone and keep the articular surface of humeral head intact and at the same time effectively avoid frequent X-ray fluoroscopy and adjusting the screws.

Computational anatomy of the proximal humerus: An ex vivo high-resolution peripheral quantitative computed tomography study

BACKGROUND/OBJECTIVE

Spatial knowledge of the anatomy of the proximal humerus is critical for effective treatment, particularly in patients affected by fragility fractures. High-resolution peripheral quantitative computed tomography (HR-pQCT) imaging with medical image processing techniques enable three dimensional (3D) analysis of volumetric bone mineral density (vBMD) of bones of different sizes and shapes.

METHODS

To elucidate the bony anatomy and to create 3D reference data, we conducted a computerized HR-pQCT-based study in intact postmortem samples of the proximal humerus to highlight the anatomy with particular emphasis on the size, shape, and bone stock distribution pattern.Fifty-eight defrozen intact humerus samples from 28 female and 30 male donors, who were aged 61-98 years old (mean age ± standard deviation, 80.6 ± 9 years), were scanned in the proximal third using the extended standard HR-pQCT protocol. A 3D statistical bone and averaged bone density models with low, middle, and high total vBMDs were computed. We examined the 3D patterns of size and shape variations using principal component analysis, and the vBMD distributions and variabilities using volume-rendering and virtual bore probing.

RESULTS

The computer models revealed a highly variable bony anatomy in which size was the predominant variation in the first principal component (PC). In the second PC, we observed notable variabilities in the shape of the head and shaft inclination. A distinct 3D pattern of bone stock distribution was detected in which the lowest vBMD values were identified in the medullary cavity, middle values were identified in the central zone, and the highest values were identified in the cortex and humeral head-particularly in the subarticular zones. In the presence of bone loss, the vBMD values were ubiquitously decreased, but the pattern of 3D bone stock distribution was maintained.

CONCLUSION

The new anatomical 3D data that we acquired will improve the understanding of the normal bony anatomy of the proximal humerus. The extended HR-pQCT protocol and computer models may be used for other skeletal sites and used as 3D reference models that can be applied to systematically improve implant design and anchorage.

OSTEOSYNTHESIS OF PROXIMAL HUMERAL END FRACTURES WITH FIXED-ANGLE PLATE AND LOCKING SCREWS: TECHNIQUE AND RESULTS

Describe the results of proximal humeral fractures surgically treated with the Philos locking plate system.

METHOD

Between March 2003 and October 2004 we prospectively reviewed 24 of 26 patients with proximal humerus fractures treated with a Philos plate. The mean follow-up time was 12 months and the mean age of patients was 57 years. Six patients had four-part proximal humerus fractures, 11 patients had three-part proximal humerus fractures, and nine patients had two-part proximal humerus fractures. Clinical evaluation was performed using the University of California at Los Angeles (UCLA) criteria.

RESULTS

The mean UCLA score was 30 points (17-34). All fractures showed union. Three patients showed fracture union at varus position. The mean UCLA score for these patients was 27 points.

CONCLUSION

Osteosynthesis with Philos plate provides a stable fixation method with good functional outcome.

A scoping review of biomechanical testing for proximal humerus fracture implants

Background

Fixation failure is a relatively common sequela of surgical management of proximal humerus fractures (PHF). The purpose of this study is to understand the current state of the literature with regard to the biomechanical testing of proximal humerus fracture implants.

Methods

A scoping review of the proximal humerus fracture literature was performed, and studies testing the mechanical properties of a PHF treatment were included in this review. Descriptive statistics were used to summarize the characteristics and methods of the included studies.

Results

1,051 proximal humerus fracture studies were reviewed; 67 studies met our inclusion criteria. The most common specimen used was cadaver bone (87 %), followed by sawbones (7 %) and animal bones (4 %). A two-part fracture pattern was tested most frequently (68 %), followed by three-part (23 %), and four-part (8 %). Implants tested included locking plates (52 %), intramedullary devices (25 %), and non-locking plates (25 %). Hemi-arthroplasty was tested in 5 studies (7 %), with no studies using reverse total shoulder arthroplasty (RTSA) implants. Torque was the most common mode of force applied (51 %), followed by axial loading (45 %), and cantilever bending (34 %). Substantial testing diversity was observed across all studies.

Conclusions

The biomechanical literature was found to be both diverse and heterogeneous. More complex fracture patterns and RTSA implants have not been adequately tested. These gaps in the current literature will need to be addressed to ensure that future biomechanical research is clinically relevant and capable of improving the outcomes of challenging proximal humerus fracture patterns.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0627-x) contains supplementary material, which is available to authorized users.

Computerized Virtual Surgery Planning for ORIF of Proximal Humeral Fractures

The authors evaluated the effectiveness of computerized virtual planning for open reduction and internal fixation (ORIF) of proximal humeral fractures. Between June 2011 and July 2013, a total of 46 patients with proximal humeral fractures were included in the current study. Preoperatively, fracture data were obtained via computed tomography (CT) reconstruction. Based on the dataset obtained from CT scanning, the 3-dimensional model of fractures was constructed and virtual segmentation, restoration, and internal fixation were performed. All eligible cases were treated by ORIF with locking plates. Intraoperatively, operative time, blood loss, and fluoroscope frequency were recorded. Postoperatively, the curative effect was evaluated by quality of fracture restoration reconstruction and plate position. In addition, fracture healing time and complications were recorded in the follow-up period. Average operative time was 85.6 minutes, and intraoperative blood loss ranged from 60 to 150 mL. Postoperatively, 1 patient experienced avascular necrosis, and no cases of screw penetration or screw loosening were observed. The coincidence rate of plate position was 91.3% according to height and 95.7% based on the position of the intertubercular sulcus and greater tuberosity. At the end of the follow-up period, mean shoulder function score was 83.9 (range, 58-96). Eighty-seven percent of patients had an excellent or good outcome. Computerized virtual planning facilitated ORIF and showed good results for patients with complex proximal humeral fractures. It may be a favorable option for treating fractures of the proximal humerus.

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.

Bone properties of the humeral head and resistance to screw cutout

Surgical treatment of fractures involving the proximal humeral head is hampered by complications. Screw cutout is the major pitfall seen in connection with rigid plating. We have exploited a bony explanation for this phenomenon.

Open reconstruction of complex proximal metadiaphyseal fragility fractures of the humerus

PURPOSE

A proactive surgical and rehabilitation protocol was implemented to manage humeral fractures involving both the proximal end and shaft in an older patient population. Primary treatment goals were early return to function and reliable fracture union with minimal complications.

METHODS

From 2008 to 2012, 21 such operations were performed; 18 were considered "fragility" fractures based on mechanism, patient age, and evidence of osteopenia or osteoporosis. Open reduction and internal fixation (ORIF) was employed using direct reduction and fixation with a long periarticular locking plate. Physiotherapy was commenced 2 weeks postoperatively. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was used to assess functional outcome at a time point greater than 1 year postoperative.

RESULTS

The study group consisted primarily of elderly females (83% with a median age of 69 years) whom sustained complex metadiaphyseal proximal humeral fractures after simple mechanical fall (78%). Uneventful union occurred in all cases. Local complications included 1 case of partial radial nerve palsy, which had resolved completely by 1 year. No cases of infection were identified. Long-term return to functionality was evident with a median DASH score of 12 (mean = 21, standard deviation = 20, n = 13). Seventy five percent of patients reported minimal or no pain (question [Q] 24), and 75% achieved return of overhead function (Q6, 12, and 15).

CONCLUSION

Treatment of complex metadiaphyseal fragility fractures with anatomic reduction, fixed angle plating, and early physiotherapy returns the older patient to optimized functionality with minimal risk of complication. The DASH outcomes are equivalent to ORIF of isolated proximal humerus fractures and clinically indistinguishable from the general population.

Strength recovery after proximal humeral fractures treated with locking plate

PURPOSE

The aim of this study is to understand whether the isokinetic strength could be a valid objective data of functional recovery evaluating a group of patients with proximal humeral fractures treated with open reduction and internal fixation with locking plate comparing the clinical and functional recovery (isokinetic strength) with the not involved side.

METHODS

Seventy patients underwent surgery with locking plate placement for proximal humeral fractures. The strength of each patient's shoulders, both involved and not involved, was evaluated using isokinetic tests and Constant-Murley score. Finally, the study included 48 patients and the mean follow-up of 33 months.

RESULTS

The functional outcome showed no significant differences between operated and not operated shoulder.

CONCLUSIONS

This study shows that the assessment of the force can be supported by use of tools such as the evaluation with isokinetic machines with the advantage of having, in this way, an objective data on the functional recovery.

LEVEL OF EVIDENCE

III.

BIOMECHANICAL COMPARISON OF THE ROLE OF INLAY GRAFT IN PROXIMAL HUMERUS FRACTURE FIXED WITH CONVENTIONAL PLATE AND LOCKING PLATE

With a varus deformity, repairs of proximal humeral fractures frequently fail after screws pull out due to lack of medial support. Indirect intramedullary grafts have been used to prevent such complications. A biomechanical study was performed to investigate the role of an intramedullary bone peg (strut) in fractures fixed with conventional and locking plates.

Twenty artificial proximal humerus specimens were divided into four groups. Group 1 specimens were fixed with convention plates and group 2 specimens were fixed with the addition of a bone peg. Groups 3 and 4 specimens were fixed using locking plate and additional bone peg, respectively. All specimens were tested with a static loading test, and the axial stiffness and maximal load were recorded.

Locking plates with inlay graft were the most rigid of the four groups. When an intramedullary graft was introduced, the maximal load increased by more than 200%, whether conventional or locking plates were used. The maximal load of a conventional plate with inlay graft was more than twice of that of the locking plate only.

Indirect medial support acts as an anti-bending device, reducing the tension on the plate. It also decreases varus deformity and loosening of screws. Locking plate stabilize the plate-bone interface. Locking plate with indirect medial support is thus recommended for patients withsevere osteoporotic or medial comminuted proximal humeral fractures.

Mechanisms of failure of locked-plate fixation of the proximal humerus: acoustic emissions as a novel assessment modality

OBJECTIVES

Locking plates are the predominant implants used for proximal humerus fractures. Despite a preponderance of good clinical outcomes, failures continue to occur. The purpose of this study was to investigate the failure mechanism of locked proximal humeral plate fixation and its relationship with bone density and screw length.

METHODS

Human cadaveric humeri were subjected to cyclic bending loads after an unstable 2-part fracture (Orthopedic Trauma Association classification 11 A-3) was created and stabilized with a locking proximal humeral plate. Acoustic emission (AE) sensors were mounted on the specimens to detect fracture displacement and generation of microcracks. The data were analyzed to evaluate construct failure.

RESULTS

Eight of 10 locking plate constructs in cadaver specimens failed in varus collapse. The primary influences on failure were cancellous bone density and cancellous bone screw length. AE monitoring demonstrated patterns of microcrack progression, predominantly along the inferior screws. The progression trends according to AE were similar to their respective actuator displacement versus time curves.

CONCLUSIONS

Cancellous bone density and total cancellous screw depth penetration seem to be critical variables. Although the patients' bone density cannot be controlled, surgeons may decrease the risk of failure by maximizing the length of the screws within the cancellous bone. Analysis of microcrack formation revealed that failures begin at the midportion and tips of the inferior screws and at the bone-plate interface of the inferior screws.

Biomechanical evaluation of locking plate fixation of proximal humeral fractures augmented with calcium phosphate cement

OBJECTIVES

To evaluate the influence of calcium phosphate cement augmentation on failure of locking plate fixation of proximal humeral fracture fixation in a cadaveric fracture model.

METHODS

A 5-mm wedge osteotomy was created in each of 11 paired fresh-frozen human cadaveric humeri (age > 65 years). Specimens were randomly assigned to receive either locked plate fixation (group 1) or locked plate fixation with cement augmentation (group 2). Constructs were tested for axial stiffness, load to failure, and failure mode using a material testing machine.

RESULTS

Cement-augmented specimens resisted higher loads (1936 ± 609 N) in comparison to nonaugmented specimens (1373 ± 590 N) (P = 0.01). In group 1, varus displacement and glenohumeral screw perforation occurred in all cases. Varus displacement occurred in 2 cases in group 2, whereas glenohumeral screw perforation did not occur in any of the cases. Cement augmentation led to a significant increase in axial stiffness (P = 0.04).

CONCLUSIONS

Calcium phosphate cement-augmented locking plates enhanced fixation stability in proximal humeral fractures and reduced glenohumeral screw perforation in this 2-part cadaveric model. The ultimate advantage of this method remains to be determined in vivo.

Can the osteosynthesis with locking plates be a better treatment for unstable fractures of the proximal humerus?

PURPOSE

The purpose of this study is to review our experience with proximal humeral locking plates, including complications, functional outcomes, strength recovery and predictors of successful treatment.

METHODS

Seventy unstable proximal humeral fractures were treated with open reduction internal fixation (ORIF) with the use of locking proximal humerus plate. At an average follow-up of 31 months, the clinical and subjective outcomes were evaluated, and complication was analysed.

RESULTS

The average Constant score was 72. The mean disabilities of the arm, shoulder and hand score was 23. The average range of motion was as follows: mean range of anterior elevation and abduction 120°-150°; external rotation in abduction 64° and in adduction 44°; and internal rotation T12.

CONCLUSION

On the basis of the overall functional and clinical outcome obtained, it is possible to suggest that the ORIF of the proximal humerus fractures using locking plate represents a helpful option that can lead to a good clinical and functional outcome even in the most complex fractures.

Functional outcomes following locking plate fixation of complex proximal humeral fractures

The purpose of this study was to evaluate the functional outcome of patients with complex proximal humeral fractures fixated by locking plate technology. Eighty-nine patients (27 men, 62 women) older than 50 years with 3- and 4-part proximal humeral fractures were treated using locking plate fixation and followed up for more than 1 year. Functional outcomes were assessed by using the Disabilities of the Arm, Shoulder, and Hand (DASH) and Constant scores, and the complications were evaluated through physical and radiographic examinations. Mean DASH and Constant scores for all 89 patients were 19.6 and 66.6 points, respectively. No significant differences existed in the 2 scores between patients with 3- and 4-part fractures. Of the 71 patients without complications, 68 had an excellent functional outcome according to the DASH score, whereas 2 patients had an excellent outcome on the Constant score. For the 18 patients with complications, the functional outcomes were significantly poorer compared with patients without complications. According to the Constant score, all patients with complications were classified into a moderate or poor functional outcome, but the rate was 12% with the DASH score. In patients with 3- and 4-part proximal humeral fractures fixed with locking plate fixation, complications were the major cause of compromised functional outcomes. Based on these results, different conclusions would be reached when the functional outcome was assessed by using the DASH and Constant scores separately. Because the clinician-based Constant score may bias the results, patient-based assessments, such as the DASH score, are required for the evaluation of functional outcome after shoulder surgery.

The position and number of screws influence screw perforation of the humeral head in modern locking plates: a cadaver study

OBJECTIVES

Screw perforation of the humeral head in locking plate osteosynthesis occurs in up to 30% of cases. The current study compared different fixation possibilities (eg, number and position of screws) to reduce screw perforation in the humeral head.

METHODS

A humeral head fracture with a missing medial support was created in 30 fresh-frozen cadavers and fixed with a polyaxial locking plate (NCB PH; Zimmer, Warsaw, IN). The constructs were loaded with increasing force and the number of cycles until screw perforation was recorded. Four different fixation methods were tested: group 1 five screws with fixed angle, group 2 five screws in polyaxial position according to bone strength, group 3 three screws, and group 4 five screws with 1 as an inferomedial support screw.

RESULTS

More screws in the humeral head significantly increased the number of cycles before screw perforation. An inferomedial support screw further increased the number of cycles. Polyaxial screw placement compared with fixed-angle placement had no effect on the screw perforation phenomenon.

CONCLUSIONS

We recommend to position an inferomedial support screw, and at least 5 screws in the head fragment, when using a locking plate in proximal humerus fractures with disrupted medial hinge.

Locking plate for proximal humeral fracture in the elderly population: serial change of neck shaft angle

Background

We conducted this radiographic study in the elderly population with proximal humeral fracture aiming to evaluate 1) the serial changes of neck-shaft angle after locking plate fixation and 2) find relationship between change in neck shaft angle and various factors such as age, fracture pattern, severity of osteoporosis, medial support and initial reduction angle.

Methods

Twenty-five patients who underwent surgical treatment for proximal humeral fracture with locking plate between September 2008 and August 2010 are included. True anteroposterior and axillary lateral radiographs were made postoperatively and at each follow-up visit. Measurement of neck shaft angle was done at immediate postoperative, 3 months postoperative and a final follow-up (average, 11 months; range, 8 to 17 months). Severity of osteoporosis was assessed using cortical thickness suggested by Tingart et al.

Results

The mean neck shaft angles were 133.6° (range, 100° to 116°) at immediate postoperative, 129.8° (range, 99° to 150°) at 3 months postoperative and 128.4° (range, 97° to 145°) at final follow-up. The mean loss in the neck-shaft angle in the first 3 months was 3.8° as compared to 1.3° in the period between 3 months and final follow-up. This was statistically significant (p = 0.002), indicating that most of the fall in neck shaft angle occurs in the first three months after surgery. Relationship between neck shaft angle change and age (p = 0.29), fracture pattern (p = 0.41), cortical thickness (p = 0.21), medial support (p = 0.63) and initial reduction accuracy (p = 0.65) are not statistically significant.

Conclusions

The proximal humerus locking plate maintains reliable radiographic results even in the elderly population with proximal humerus fracture.

Benefits and harms of locking plate osteosynthesis in intraarticular (OTA Type C) fractures of the proximal humerus: a systematic review

INTRODUCTION

Locking plate osteosynthesis of proximal humeral fractures are widely recommended and used, even in complex intraarticular fracture patterns such as AO/OTA Type C fractures. We systematically reviewed clinical studies assessing the benefits and harms of osteosynthesis with angle stable plates in AO/OTA Type C fractures of the proximal humerus.

METHODS

We conducted an iterative search in PubMed, Embase, Cochrane Library, Web of Science, Cinahl, and PEDro in all languages from 1999 to November 2010. Eligible studies should study the outcome for Type C fractures after primary osteosynthesis with locking plate within two weeks of injury, and a follow-up period of six months or more. Patients should be evaluated with the Constant-Murley Score (CS). Two observers extracted data independently.

RESULTS

Twelve studies and 282 Type C fractures were included. Results were categorised according to study type and synthesised qualitatively. No randomised clinical trials were identified. Two comparative, observational studies reported a mean CS of 71 (relative to contralateral shoulder) and 75 (non-adjusted Constant Score) for Type C fractures. For all studies mean non-adjusted CS ranged from 53 to 75. Mean age- and sex-adjusted CS ranged from 60 to 88. Mean CS relative to the contralateral shoulder ranged from 71 to 85. The most common complications were avascular necrosis (range, 4-33%), screw perforations (range, 5-20%), loss of fixation (range, 3-16%), impingement (range, 7-11%) and infections range 4-19%. Reoperation rate ranged from 6 to 44%.

CONCLUSIONS

Insufficient study designs and unclear reporting preclude safe treatment recommendations. Complication and reoperation rates were unexpected high. Based on the studies included we cannot routinely recommend the use of locking plates in AO/OTA Type C fractures.

Comparison of two different locking plates for two-, three- and four-part proximal humeral fractures--results of an international multicentre study

PURPOSE

The aim of this study was to compare the functional outcome, quality of restoration, and complication rate after open reduction and internal fixation (ORIF) of displaced or unstable 2-, 3- and 4-part humeral fractures using two different locking plates.

METHODS

The data used in this analysis was prospectively collected in two large multicentre studies in 15 European Level 1 trauma centres. A total of 318 patients with proximal humeral fractures were treated with ORIF using either the locking proximal humerus plate (LPHP) or proximal humeral internal locking system (PHILOS). Outcome measurements included Constant and Neer scores, evaluation of local pain at the fracture site and complications, and radiographic assessment at one year.

RESULTS

At one year, the mean Constant scores (relative to the contralateral shoulder) improved significantly for both groups and were above 80% for 2-, 3-, and 4-part fractures. A significantly shorter surgical time, less pain at the fracture site, and better functional outcome was achieved by PHILOS-treated patients with 2-part fractures throughout the one-year follow-up month and with 3-part fractures at three months (p < 0.05). There was no difference between the treatment outcomes for 4-part fractures, and no difference in the complication rates (p > 0.05).

CONCLUSIONS

PHILOS and LPHP can be considered as useful implants for ORIF of displaced and unstable proximal humeral fractures. There was a slight advantage of the PHILOS system with regard to operative time and functional outcome, especially for the treatment of 2- and 3-part fractures.

Predicting failure after surgical fixation of proximal humerus fractures

BACKGROUND

Several studies reported high failures rates after internal fixation of proximal humerus fractures. Loss of reduction and screw cut-out are the most common reasons for revision surgery. Several risk factors for failure have been described in the literature. The aim of the present study was to assess risk factors for failure after surgical fixation of unstable proximal humerus fractures in a multivariate setup.

METHODS

Two different surgical techniques (PHILOS locking plate and Humerusblock) were used. In the PHILOS group, every kind of postoperative relative movement between the implant and the humeral head or shaft was defined as failure. In the Humerusblock group, postoperative movement between the humeral head and the shaft in terms of angulation or translational displacement was defined as failure. The following parameters were assessed: age, gender, cancellous bone mineral density (BMD) of the humeral head, fracture type, medial metaphyseal comminution, medial metaphyseal head extension, initial angulation of the humeral head in the frontal plane, initial anteversion of the humeral head, medial hinge displacement, maximum displacement of the tuberosities with respect to the head, surgical technique, anatomic reconstruction and restoration of the medial cortical support.

RESULTS

The following parameters were found to have a significant influence on the failure rate: age, local BMD, anatomic reduction, and restoration of the medial cortical support. The failure rate significantly increased with the number of risk factors.

CONCLUSION

Preoperative assessment of the local BMD and the patients' biological age as well as intraoperative anatomic reduction and restoration of the medial cortical support are the essentials for successful surgical fixation of proximal humerus fractures. Multifragmentary fracture patterns in old patients with low local BMD are prone for fixation failure. If the surgeon is not able to achieve anatomic reduction and restoration of the medial cortical support intraoperatively in this situation, adjustments such as augmentation or primary arthroplasty should be considered.

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.

Upper extremity periarticular fractures: when should they be fixed and when should they be replaced?

Periarticular fractures are common, especially in the elderly. Decision-making is dependent on fracture pattern as well as on patient- and surgeon-related factors.This article explores current concepts in decision-making for either reconstruction or primary prosthetic replacement of the proximal humerus. Selection criteria were relevance of data, number of cases greater than 20, and comparability of results.

Clinical longer-term results after internal fixation of proximal humerus fractures with a locking compression plate (PHILOS)

OBJECTIVES

The aim of this study was to investigate the subjective and objective longer-term outcomes after fracture fixation with the Proximal Humerus InterLocking OSteosynthesis (PHILOS) plate.

DESIGN

Minimum 4-year follow-up of a primary prospective cohort study.

SETTING

Single university trauma center.

PATIENTS/PARTICIPANTS

Sixty-four consecutively collected patients fulfilled the study criteria. Seven patients (11%) were lost to follow-up, resulting in 57 patients (65 ± 14 years).

INTERVENTION

Open reduction and internal fixation with the PHILOS® plate.

MAIN OUTCOME MEASUREMENTS

Standardized follow-up including functional outcome instruments (eg, Constant Murley score, Disabilities of the Arm, Shoulder and Hand), rate of complications, and secondary surgeries at 6, 12, and no less than 48 months (uni- and multivariate analysis; P < 0.05).

RESULTS

At the 4- to 6-year follow-up (median 5 years postinjury), patients on average achieved an 87% range of motion of the injured compared with the uninjured shoulder (eg, 133° ± 40° versus 152° ± 26° abduction). Objective and subjective outcome improved significantly during the overall follow-up, most of all in reoperated and younger patients (65 years and younger) and within the first postinjury year. We observed an overall reoperation rate of 29% and 10 patients (17.5%) demonstrated an insufficient result resulting from pain (greater than 3 visual analog scale) or restricted abduction (less than 90°) at longer-term follow-up. First, the need for revision surgery and, second, increasing age were found to be the most predictive factors for unsatisfactory results.

CONCLUSIONS

Fracture fixation with the PHILOS showed good to excellent longer-term results in three fourths of patients with outcome partially still improving after the first postoperative year.

New trends in fixation of proximal humeral fractures: a review

Surgical treatment of proximal humeral fractures continues to be a challenge especially in osteoporotic patients. Locking plates and intramedullary nails have been used with satisfactory results but the previous reported complications have not been substantially reduced. Most of the existing studies involve a small number of patients followed up for a rather short period of time. Since proximal humeral fractures constitute a heterogenous group of complex fractures in an even more heterogenous population, no single fixation method is a panacea. Choice of implant and method of fixation should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. Based on the findings of the existing clinical studies the authors propose a treatment algorithm.