New trends in the treatment of proximal humerus fractures

Biomechanical design optimization of proximal humerus locked plates: A review

BACKGROUND

Proximal humerus locked plates (PHLPs) are widely used for fracture surgery. Yet, non-union, malunion, infection, avascular necrosis, screw cut-out (i.e., perforation), fixation failure, and re-operation occur. Most biomechanical investigators compare a specific PHLP configuration to other implants like non-locked plates, nails, wires, and arthroplasties. However, it is unknown whether the PHLP configuration is biomechanically optimal according to some well-known biomechanical criteria. Therefore, this is the first review of the systematic optimization of plate and/or screw design variables for improved PHLP biomechanical performance.

METHODS

The PubMed website was searched for papers using the terms "proximal humerus" or "shoulder" plus "biomechanics/biomechanical" plus "locked/locking plates". PHLP papers were included if they were (a) optimization studies that systematically varied plate and screw variables to determine their influence on PHLP's biomechanical performance; (b) focused on plate and screw variables rather than augmentation techniques (i.e., extra implants, bone struts, or cement); (c) published after the year 2000 signaling the commercial availability of locked plate technology; and (d) written in English.

RESULTS

The 41 eligible papers involved experimental testing and/or finite element modeling. Plate variables investigated by these papers were geometry, material, and/or position, while screw variables studied were number, distribution, angle, size, and/or threads. Numerical outcomes given by these papers included stiffness, strength, fracture motion, bone and implant stress, and/or the number of loading cycles to failure. But, no paper fully optimized any plate or screw variable for a PHLP by simultaneously applying four well-established biomechanical criteria: (a) allow controlled fracture motion for early callus generation; (b) reduce bone and implant stress below the material's ultimate stress to prevent failure; (c) maintain sufficient bone-plate interface stress to reduce bone resorption (i.e., stress shielding); and (d) increase the number of loading cycles before failure for a clinically beneficial lifespan (i.e., fatigue life). Finally, this review made suggestions for future work, identified clinical implications, and assessed the quality of the papers reviewed.

CONCLUSIONS

Applying biomechanical optimization criteria can assist biomedical engineers in designing or evaluating PHLPs, so orthopaedic surgeons can have superior PHLP constructs for clinical use.

How do surgeons decide when to treat proximal humerus fractures with operative versus nonoperative management?

PURPOSE

The objective of this study was to determine the underlying factors that drive the decision for surgeons to pursue operative versus nonoperative management for proximal humerus fractures (PHF) and if fellowship training had an impact on these decisions.

METHODS

An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons Society to assess differences in patient selection for operative versus nonoperative management of PHF. Descriptive statistics were reported for all respondents.

RESULTS

A total of 250 fellowship trained Orthopaedic Surgeons responded to the online survey. A greater proportion of trauma surgeons preferred nonoperative management for displaced PHF fractures in patients over the age of 70. Operative management was preferred for older patients with fracture dislocations (98%), limited humeral head bone subchondral bone (78%), and intraarticular head split (79%). Similar proportions of trauma surgeons and shoulder surgeons cited that acquiring a CT was crucial to distinguish between operative and nonoperative management.

CONCLUSION

We found that surgeons base their decisions on when to operate primarily on patient's comorbidities, age, and the amount of fracture displacement when treating younger patients. Further, we found a greater proportion of trauma surgeons elected to proceed with nonoperative management in patients older than the age of 70 years old as compared to shoulder surgeons.

Effectiveness of locking compression plate for proximal humeral fracture in elderly patients without structural bone grafting: age group of 65-79 compared to 80 and above

PURPOSE

This study shows the effectiveness of locking compression plate for proximal humeral fractures in elderly patients over 80 years old without structural bone grafting compared age group of 65-79 (Group 1) with 80 and above (Group 2).

METHODS

This study included sixty-one patients who underwent using locking compression plate for proximal humeral fractures between April 2016 and November 2021. The patients were divided into two groups. The neck shaft angle (NSA) was checked at immediately after surgery, at 1 month and the final follow-up visit. The NSA changes in the two groups were compared using the independent t-test. In addition, multiple regression analysis was used to find out which factors affect NSA changes.

RESULTS

In group 1, the mean difference between NSA immediately after surgery and 1 month after surgery was 2.74°, and group 2 was 2.89°. In group 1, the mean difference in NSA for 1 month after surgery and at the last follow-up was 1.43°, and group 2 was 1.75°. No significant difference was observed in the NSA changes between two groups (p = 0.59, 0.173). Bone marrow density and four-part fracture type were significant difference in NSA changes (p = 0.003, 0.035). The disabilities of the arm, shoulder and hand scale (DASH scale), age, medical support, diabetes and three-part fracture type were no significant in NSA changes.

CONCLUSIONS

Using locking compression plate without structural bone grafting is a good option in elderly patients over 80 years old and can help achieve radiological results similar to patients which age group of 67-79.

A nationwide analysis of geriatric proximal humerus fractures: trends, outcomes, and cost

Background

In the USA, proximal humerus fractures (PHF) are the third most common fracture among the elderly. Although most geriatric PHF are treated conservatively, surgical management remains an option. This retrospective study compares annual trends, patient outcomes, and hospital costs between operatively and non-operatively managed geriatric PHF.

Methods

The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was queried from 2012 to 2015. Geriatric patients with PHF were identified and those who underwent operative or non-operative management were compared in trends, outcomes and costs.

Results

In total, 137 810 patients met inclusion criteria, of which 51 795 (37.6%) underwent operative management. The operative cohort was younger (76.6 vs 80.9, p<0.001) with a greater proportion of females (81.8% vs 77.6%, p<0.001). The operative cohort demonstrated less frailty and lower Elixhauser Comorbidity Scores (both p<0.001). The operative cohort was also more likely to be discharged home (30.4% vs 13.9%, p<0.001). There was no significant linear trend in age-adjusted and sex-adjusted proportions of operative versus non-operative geriatric PHF (p=0.071), but a positive linear trend was statistically significant for total cost of operative geriatric PHF (p<0.001). Multivariable analyses demonstrated similar overall complication rates between cohorts (OR 0.95, 95% CI 0.89 to 1.00; p=0.06), although surgical intervention increased length of stay (LOS) by 0.15 days (95% CI 0.03 to 0.27; p<0.001) and median cost of hospitalization by US$10 684 (95% CI US$10 384 to US$10 984; p<0.001).

Conclusions

This study identifies a positive linear trend in total cost of operatively managed geriatric PHF from 2012 to 2015. Operative management of geriatric PHF is associated with a similar overall complication rate and greater likelihood of being discharged home. Although non-operative management is associated with decreased LOS and hospital expenses, providers should consider surgical PHF treatment options when available and appropriate in the context of patient-focused outcomes, particularly long-term disposition after intervention.

Level of Evidence

This level IV retrospective study identifies.

Effect of Calcar Screw in Locking Compression Plate System for Osteoporotic Proximal Humerus Fracture: A Finite Element Analysis Study

This study proposes a finite element analysis (FEA) model for complex fractures at the osteoporotic proximal humerus and investigates the relevance of using a calcar screw in surgical treatments using this model. Two types of three-dimensional (3D) fracture models of patients with osteoporotic humerus were constructed reflecting the mechanical properties of the osteoporotic humerus, such as the Young’s modulus and Poisson’s ratio, and two load conditions mimicking the clinical environment were applied for simulation. Using the 3D models and the conditions, the FEA software calculated the concentration and distribution of stresses developing in the humerus, locking compression plate (LCP), and screws. Then, we evaluated and predicted the fixed state of a LCP system depending on whether the maximum stress value exceeded tensile strength. When axial force was applied, insertion of the calcar screw led to significant reduction of stress applied on screws in the fracture model having a medial gap by approximately 61%, from 913.20 MPa to 351.84 MPa. Based on the results, it was clearly confirmed that using of calcar screws improved the stability of a three-part fractures and simultaneously reinforced medial support.

Understanding postoperative rehabilitation preferences in operatively managed proximal humerus fractures: do trauma and shoulder surgeons differ?

BACKGROUND

Proximal humerus fractures (PHFs) are common, and their incidence is increasing as the population ages. Despite this, postoperative rehabilitation remains unstandardized and little is known about surgeon preferences. The aim of this study was to assess differences in postoperative rehabilitation preferences and patient education between orthopedic trauma and shoulder surgeons.

METHODS

An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons to assess differences in postoperative rehabilitation preferences and patient counseling. Descriptive statistics were reported for all respondents, trauma surgeons, and shoulder surgeons. Chi-square and unpaired 2-sample t tests were used to compare responses. Multinomial regression was used to further elucidate the influence of fellowship training independent of confounding characteristics.

RESULTS

A total of 293 surgeons completed the survey, including 172 shoulder and 78 trauma surgeons. A greater proportion of trauma surgeons preferred an immediate weightbearing status after arthroplasty compared to shoulder surgeons (45% vs. 19%, P = .003), but not after open reduction and internal fixation (ORIF) (62% vs. 75%, P = .412). A greater proportion of shoulder surgeons preferred home exercise therapy taught by the physician or using a handout following reverse shoulder arthroplasty (RSA) (21% vs. 2%, P = .009). A greater proportion of trauma surgeons began passive range of motion (ROM) <2 weeks after 2-part fractures (70% vs. 41%, P < .001). Conversely, a greater proportion of shoulder surgeons began passive ROM between 2 and 6 weeks for 2-part (57% vs. 24%, P < .001) and 4-part fractures (65% vs. 43%, P = .020). On multinomial regression analysis, fellowship training in shoulder surgery was associated with preference for a nonweightbearing duration of >12 weeks vs. 6-12 weeks after ORIF. Similarly, fellowship training in shoulder surgery was associated with increased odds of preferring a nonweightbearing duration of <6 weeks vs. no restrictions and >12 weeks vs. 6-12 weeks after arthroplasty. Training in shoulder surgery was associated with greater odds of preferring a nonweightbearing duration prior to beginning passive ROM of 2-6 weeks vs. <2 weeks or >6 weeks for 2-part fractures, but not 4-part fractures.

CONCLUSION

Trauma surgeons have a more aggressive approach to rehabilitation following operative PHF repair compared to shoulder surgeons regarding time to weightbearing status and passive ROM. Given the increasing incidence of PHFs and substantial variations in reported treatment outcomes, differences in rehabilitation after PHF treatment should be further evaluated to determine the role it may play in the outcomes of treatment studies.

Current Role of Reverse Total Shoulder Arthroplasty for Fractures of the Proximal Humerus

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

Minimum 2-year outcomes of reverse total shoulder arthroplasty for fracture: how does acute arthroplasty compare with salvage?

BACKGROUND

The objective of our study was to compare patient-reported outcome measures, range of motion (ROM), complication rates, and reoperation rates after reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures between patients treated acutely (≤30 days after injury), those treated after initial nonoperative treatment (>30 days after injury), and those treated after failed open reduction-internal fixation. Secondarily, we aimed to identify any patient-, injury-, or surgery-related factors independently associated with our response variables.

METHODS

We identified 576 patients who sustained a proximal humeral fracture treated with primary or revision shoulder arthroplasty between January 2003 and August 2018. The final cohort included 153 patients. Multivariable analysis was used to assess whether explanatory variables were associated with our response variables.

RESULTS

Initial nonoperative treatment compared with acute rTSA was associated with worse Shoulder Subjective Value (P = .04), Shoulder Pain and Disability Index score (P = .03), and Shoulder Pain and Disability Index disability subscale score (P = .03). Only depression was independently associated with worse visual analog scale pain score (P = .04). There was no significant difference in postoperative ROM between the initial treatment groups. Older age was associated with decreased ROM in all planes. Additionally, ipsilateral upper-extremity injury was associated with decreased active abduction (P = .03), and cemented humeral stems were associated with decreased passive abduction (P = .03). Initial nonoperative treatment was associated with increased complication rates (odds ratio, 3.65; 95% confidence interval, 1.11-12.01), and male sex was associated with higher rates of reoperation (odds ratio, 3.53; 95% confidence interval, 1.31-9.51).

CONCLUSIONS

Patients who undergo initial periods of nonoperative management have worse functional outcomes and higher complication rates than those who undergo acute rTSA for proximal humeral fractures. Patients who undergo rTSA after failed open reduction-internal fixation show no difference in patient-reported outcomes compared with those who undergo acute rTSA. In addition, male patients are at higher risk of reoperation, whereas older patients are at risk of decreased ROM. Patients with preoperative depression are at risk of increased pain at 2 years after surgery.

Anatomical study for the treatment of proximal humeral fracture through the medial approach

BACKGROUND

The treatment of complex 3- and 4-part proximal humeral fractures has been controversial due to numerous postoperative complications. With the further study of medial support and blood supply of humeral head, new techniques and conception are developing. The study aims to illustrate the medial approach of the proximal humeral fracture through cadaver autopsy.

METHOD

Upper limbs from 19 cadavers have been dissected to expose the shoulder joint. We selected the coracoid process as the bony reference. Vernier caliper will be used to measure the following data, including distance from coracoid process to circumflex brachial artery, distance between anterior humeral circumflex artery (ACHA) and posterior circumflex brachial artery (PCHA) and their diameters. Assessment included the characteristics of the vascular supply around the humeral head, identification of the structures at risk, quality of exposure of the bony structures, and feasibility of fixation.

RESULTS

The medial approach is appropriate in 86.84% anatomical patterns. Between the lower part of the shoulder capsule and the insertion of conjoined tendon, the bony surface exposed was limited by the interval between ACHA and PCHA. An interval of 2 to 3 cm (24.29 ± 3.42 mm) was available for medial plate. ACHA (49.35 ± 8.13 mm, 35.14-68.53 mm) and PCHA (49.62 ± 7.82 mm, 37.67-66.76 mm) were about 5 cm away from the coracoid process. Risk structures including ACHA and PCHA originate in common, PCHA originated from the deep brachial artery (DBA), the presence of perforator vessels, musculocutaneous nerve intersects with ACHA, the diameter of PCHA: ACHA < 1.5. In 13.15% anatomical patterns, this risk structure should be taken seriously.

CONCLUSION

The medial approach opens a new perspective in the optimal management of complex fractures of proximal humerus. Anatomical research proves that the medial approach is feasible. The interval between ACHA and PCHA is suitable for placement. Anatomical pattern and indication have been discussed, and we hypothesized that ACHA has been destroyed in complex PHFs. With further studies on the anatomy and mechanism of injury, the development of more clinical cases will be an important work of our institution in the future.

3D printing-assisted surgery for proximal humerus fractures: a systematic review and meta-analysis

AIM

This study aimed to assess the efficacy of three-dimensional (3D) printing to conventional surgeries in proximal humerus fractures (PHFs).

METHODS

Eight databases were comprehensively searched for data on clinical characteristics and outcomes, including operation time, time to bone healing, blood loss volume, number of intraoperative fluoroscopies, the reduction rate of anatomic proximal humeri, Constant scores, Neer rating, loss of humeral head height, and complications. These data were compared between 3D printing-assisted versus conventional surgeries to learn the efficacy of 3D printing-assisted surgery.

RESULTS

3D printing-assisted surgery outperformed conventional procedures in operation time, blood loss volume, time to the union of PHFs, number of fluoroscopies, the reduction rate of anatomic proximal humeri, Constant scores, Neer rating, and complications.

CONCLUSION

3D printing-assisted surgery improves operation time, anatomic healing, pain, and motion, with less harm to patients.

Imaging of traumatic shoulder injuries – Understanding the surgeon’s perspective

Imaging plays a key role in the assessment and management of traumatic shoulder injuries, and it is important to understand how the imaging details help guide orthopedic surgeons in determining the role for surgical treatment. Imaging is also crucial in preoperative planning, the longitudinal assessment after surgery and the identification of complications after treatment. This review discusses the mechanisms of injury, key imaging findings, therapeutic options and associated complications for the most common shoulder injuries, tailored to the orthopedic surgeon’s perspective.

Efficacy of Hemiarthroplasty vs. Locking Plate Fixation for Proximal Humerus Fractures: A Meta-Analysis

Background: Proximal humerus fractures are common in a clinic and account for ~6% of all adult fractures. Hemiarthroplasty (HA) or locking plate (LP) fixation is currently recommended for the treatment of complex proximal humerus fractures (PHFs); however, there is no uniform standard for optimal surgical treatment or functional recovery. We conducted a meta-analysis to compare the efficacy of LP and HA in the treatment of PHFs. Methods: Relative studies associated with HA and LP were searched in December 2020 in the PubMed, Embase, Cochrane Library, and OVID databases. The quality of the studies, functional outcomes (including the Constant-Murley score (CMS), American Shoulder and Elbow Surgeons Score (ASES), Simple Shoulder Test (SST), Short Form Health Survey (SF-12v2), complications, and reoperation rate were extracted and analyzed with the Stata 14.0 software. Results: A total of 958 patients from 12 studies were included in the meta-analysis, which showed that patients treated with LP had a significantly lower reoperation rate, a higher complication rate, and a higher CMS score than those treated with HA. There were no significant differences in ASES, SST, or SF-12v2 scores between treatment groups. Conclusions: Compared with HA, LP exhibited better clinical efficacy in some aspects. However, large sample and randomized, controlled studies are needed for further validation.

Minimally invasive fixation with modified palm tree technique for proximal humerus fractures: Outcomes in a series of 132 patients

INTRODUCTION

Various surgical techniques and implants are available for surgical treatment of significantly displaced proximal humerus fractures. We describe a minimally invasive technique using 3 curved wires, inserted in a retrograde fashion into the humeral head. These are aimed to diverge within the humeral head to provide three separate 3-point fixations to achieve good stability. We present the results of proximal humerus fractures managed with the modified palm tree technique.

METHODS

A retrospective analysis of data collected prospectively including demographics, radiographs, clinical outcomes, complications and revision surgery for patients treated with the palm tree technique was performed.

RESULTS

Between 1998 and 2017, 132 patients underwent fixation with this technique. Average age was 61.8 years. Fifty-Eight fractures were 2 part, 46 were three part and 28 were four part. Average follow up was 26 months. In three to four part fractures, a bone graft substitute block was used behind the humeral head fragment for structural support. There were 11 early revisions (8.3%). In 7 cases the fixation failed early and was revised to other implants like angular & locking plates (4), hemiarthroplasties (2) and reverse arthroplasty (1). In 4 cases the construct was revised to achieve better positioning of the wires. From the 125 remaining patients, 120 achieved union(96.8%). There were 3 painless fibrous non-unions and 2 painful non-unions requiring revision. The mean final Constant score was 75.5 and subjective shoulder value was 7.8/10. Nine patients (6.8%) developed avascular necrosis of the humeral head of which three patients were revised later to an arthroplasty.

CONCLUSION

This technique is a simple, minimally invasive technique which can be used for two, three and four part fractures with good functional outcomes and high union rates. No metalwork remains in the proximal humerus should another procedure like arthroplasty be required in case of avascular necrosis of the humeral head or fracture sequela.

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

BACKGROUND AND HYPOTHESIS

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Operative treatment of 2-part surgical neck type fractures of the proximal humerus in the elderly: Cement augmented locking plate PHILOS™ vs. proximal humerus nail multiloc®

INTRODUCTION

The purpose of this prospective randomized controlled clinical trial was to compare locked plating with intramedullary nailing in the treatment of displaced 2-part surgical neck type proximal humeral fractures in elderly patients.

PATIENTS AND METHODS

Patients ≥60 years of age with a displaced 2-part surgical neck type fracture of the proximal humerus were surgically treated and randomized for either augmented locking plate fixation Group LP or multiplanar intramedullary nailing Group IN. The primary outcome parameter was the Disabilities of the Shoulder, Arm and Hand (DASH) Score after 24 months. Secondary outcome parameters were the age- and gender adjusted Constant Murley Score (CS), the American Shoulder and Elbow Score (ASES), the Oxford Shoulder Score (OSS) and the Short Form 36 (SF-36) after 6 weeks, 3 months, 6 months, 12 and 24 months. Further parameters included the quality of fracture reduction as well as complications and revision surgeries. 60 patients with a mean age of 75±9.8 were included and longitudinally followed over 24 months (follow-up rate: 83.3%).

RESULTS

The mean DASH-Scores at 24 months was 32.6 ± 9.7 points in Group LP versus 37.8 ± 8.3 points in Group IN (p = 0.04). The mean Constant Murley Score at 24 months follow-up was 76.2 ± 7.7 points in Group LP compared to 72 ± 9.1 points in Group IN (p = 0.08). The ASES at 24 months follow-up was 75.1 ± 9 points in Group LP versus to 73.5 ± 8.9 in Group IN (p = 0.51). The OSS at 24 months was 43.7 ± 8.1 in Group LP compared to 38.2 ± 10 in Group IN (p = 0.03). The SF-36 at 24 months was 74.7 ± 12.5 in Group LP versus to 70.9 ± 12.8 in Group IN (p = 0.29). Screw cutting out was observed in n = 2 (6,7%) cases of Group LP, and in none of Group IN (p = 0.49). Revision surgery was necessary in n = 2 (6.7%) cases of Group LP and in two cases of Group IN (6.7%, p = 1).

CONCLUSION

Functional outcomes are similar at 2-years follow-up in locked plating with screw tip augmentation compared to intramedullary nailing. Both implants reached low complication- and revision rates for two-part surgical neck types fractures of the proximal humerus in patients ≥60 years, if anatomic fracture reduction and accurate implant position was obtained.

Glenohumeral joint lavage does not affect clinical outcomes in open reduction and internal fixation of displaced intracapsular proximal humeral fractures: a prospective, randomized, double-blinded trial

BACKGROUND

This prospective, randomized, and double-blinded trial evaluates the effect of intraoperative glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures.

METHODS

Between January 2016 and April 2018, 86 patients (mean age: 65.2 ± 16.3 years) with a displaced intracapsular proximal humeral fracture were treated by open reduction and internal fixation using locking plates. Patients were randomized to either locked plating followed by intraoperatively performed glenohumeral joint lavage (group L, n = 36) or locked plating without the lavage (group NL, n = 36). Functional outcome assessment included range of shoulder motion, strength, and the Constant score, obtained 6 weeks, 3 months, 6 months, and 12 months postoperatively. A total of 62 shoulders could be reviewed for final investigation (86% follow-up).

RESULTS

One year after open reduction and internal fixation, the mean Constant score was 70 ± 14 (group L, n = 31) compared with 73 ± 14 (group NL, n = 31, P = .272). The mean forward flexion and abduction in group L was 134 ± 33 and 128 ± 33 as compared with 139 ± 32 and 135 ± 32 in group NL, respectively (P = .538, P = .427). The mean external rotation was 40 ± 16 (group L) compared with 44 ± 16 (group NL) (P = .210). The overall complication rate was 9.6% and did not differ significantly between the groups (P = .321). In group L, there were 2 cases of avascular necrosis (6.5%) and 1 case of secondary displacement (3.2%). In group NL, 1 case of avascular necrosis (3.2%) and 1 case of secondary displacement were noted (3.2%, P = .742).

CONCLUSION

The results of this study do not demonstrate a need for glenohumeral joint lavage in open reduction and internal fixation of displaced intracapsular proximal humeral fractures with regard to shoulder function at 1-year follow-up.

Administration of Tranexamic Acid in Proximal Humeral Fractures

INTRODUCTION

This study aimed to analyze the efficacy of intravenous administration of tranexamic acid in complex proximal humeral fractures.

MATERIALS AND METHODS

Sixty-seven patients with displaced 3 and 4 part proximal humerus fractures were randomized into the control (n = 33) and TXA (n = 34) groups. Fifteen minutes before the skin incision, 15 mg/kg body weight of 0.9% sodium chloride solution or TXA was injected intravenously. Open reduction and internal fixation was conducted through a deltoid-pectoral approach with fixed angle locked plating (PHILOS) for all the patients. The patients were followed up 2 months after surgery. Total blood loss, blood test results, blood transfusion rate, and wound complications were analyzed between the two groups.

RESULTS

Significant differences were observed in intraoperative blood loss and postoperative blood loss during the first 24 h between the two groups. There were no significant differences in postoperative blood loss during the second 24 h, wound complication rates, blood transfusion rate and adverse side effects. And thromboembolic events related with the application of TXA were not noted in the TXA group.

CONCLUSION

Preoperative administration of tranexamic acid could reduce intraoperative and postoperative blood loss in patients with complex proximal humeral fractures.

LEVEL OF EVIDENCE

II, prospective comparative study.

Finite element analysis of an intramedulary anatomical strut for proximal humeral fractures with disrupted medial column instability: A cohort study

BACKGROUND

Lateral locking plate (LLP) fixation has gained popularity for the treatment of proximal humeral fractures (PHFs); however, complications can occur due to loss of the medial cortical buttress from fracture comminution.

MATERIALS AND METHODS

We designed a novel intramedullary anatomical medial strut with allograft bone (IAMSAB) using MIMICS software to specifically fill the intramedullary canal of the proximal humeral bone. We used finite element analysis to evaluate the biomechanical characteristics of a LLP, LLP-intramedullary fixation system (IFS), LLP-anatomical medial locking plate (AMLP), or the combined application of a LLP and IAMSAB (LLP-IAMSAB) fixation construct in patients with a PHF and an unstable medial column.

RESULTS

For axial or rotational loads, under (normal) Nor or osteoporotic (Ost) bone conditions, the LLP-IAMSAB fixation construct was significantly stiffer than the LLP-IFS fixation construct, and displacement at the fracture site after LLP-IAMSAB fixation was significantly less than after LLP or LLP-IFS fixation (P < 0.05). Stiffness of the LLP-IAMSAB and LLP-AMLP fixation constructs and displacement at the fracture site after LLP-IAMSAB and LLP-AMLP fixation were not significantly different. The IFS, AMLP, and IAMSAB shared the load in the LLP and decreased the risk of implant failure. There were no significant differences in von Mises stress and stress distribution after fixation with the LLP-IFS, LLP-AMLP, and LLP-IAMSAB constructs.

CONCLUSION

These data suggest that the IAMSAB can provide direct medial support or resistance to rotation and augment the biomechanics of the LLP. The combined application of the IAMSAB and LLP may achieve functional outcomes that are similar to the LLP-AMLP fixation construct.

A comparative retrospective study of locking plate fixation versus a dedicated external fixator of 3- and 4-part proximal humerus fractures: Results after 5 years

INTRODUCTION

Fractures of the proximal humerus (PHF) represent a common injury among orthopedic department; especially for three- and four-part fractures no consensus about the best treatment is still achieved. The aim of our study was to compare clinical and radiological outcomes in patients alternatively treated with plates and screws or external fixation system for a type III-IV proximal humerus fracture.

MATERIAL AND METHODS

Sixty-nine patients went surgery for type III-IV PHF between January 2011 and January 2014. According to the Neer classification, fractures were classified as type III in 50 cases (72,46%) and type IV in 19 cases (24,56%). 45 patients were treated with plates (65%) and 24 external fixators (35%). The patients' mean age was 62 years (range, 31-87 y). At five years, 60 patients (86,9%) were assessed using the visual analog scale (VAS) pain score, Constant Score (CS), the range of motion, and radiological evaluation. The CS at five years was the primary outcome measure. Results were evaluated and compared with the contralateral unaffected side to avoid bias related to different ages.

RESULTS

At the final follow up, we found no clinical differences when comparing the two procedures. Moreover, when age was considered as a variable, a significative difference of the CS was observed in the group of patients younger than 65 years treated with a plate (Plate Group Mean: 79; SD: +/- 15. Ex Fi Mean: 58; SD:+/- 4. P = 0,008). In the group of patients older than 65 years, the two procedures did not show significative differences in outcomes (Plate Group Mean: 69; SD: +/- 15. Ex Fi Mean: 63; SD:+/- 7. P = 0,032). External fixation procedure was overall associated with a reduction in blood loss, surgical time, length of hospital stay.

CONCLUSION

Percutaneous techniques have a long tradition in PHF treatment; the introduction of dedicated external fixation system has the advantage to improve the stability and allow early rehabilitation when compared to the classical pinning technique. In our experience, the indication elderly patients with osteoporosis and comorbidities may benefit by this type of mini-invasive surgery with low soft tissue damages.

Anatomic locking plates for complex proximal humeral fractures: anatomic neck fractures versus surgical neck fractures

BACKGROUND

Continued debate exists on the management of displaced 3- or 4-part proximal humeral fractures. Only a few studies have compared the efficacy of proximal humeral locking plates (PHLPs) for treating anatomic neck fractures (ANFs) and surgical neck fractures (SNFs).

METHODS

The medical data of 31 consecutive patients with displaced 4-part proximal humeral fractures treated with PHLPs between May 2013 and April 2015 were reviewed retrospectively. We divided the patients into the ANF and SNF groups and assessed the neck-shaft angle (NSA), sum of the screw tip-articular surface distance, and other parameters postoperatively at 3 days and at 12 months using shoulder radiographs. The Constant-Murley scores were assessed at 3 days, 12 months, and last follow-up.

RESULTS

The ANF group had a significantly lower mean age and significantly greater mean operative duration, estimated blood loss, and rate of bone grafting. Full or partial osteonecrosis of the humeral head developed in 7 patients and 1 patient in the ANF and SNF groups, respectively. Screw cutout and/or pullout complications occurred in 8 cases in the ANF group but not in the SNF group. In the ANF group, the values for NSA and the sum of the screw tip-articular surface distance changed significantly from 3 days to 12 months postoperatively. There were no significant correlations among the tested parameters.

CONCLUSION

ANFs resulted in more complications at a younger age than SNFs. ANF treatment using PHLPs is more prone to a decreased NSA and humeral head osteonecrosis and has poorer clinical outcomes than SNF treatment using PHLPs.

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.

Parametric Design Optimisation of Proximal Humerus Plates Based on Finite Element Method

Optimal treatment of proximal humerus fractures remains controversial. Locking plates offer theoretical advantages but are associated with complications in the clinic. This study aimed to perform parametric design optimisation of proximal humerus plates to enhance their mechanical performance. A finite element (FE) model was developed that simulated a two-part proximal humerus fracture that had been treated with a Spatial Subchondral Support (S3) plate and subjected to varus bending. The FE model was validated against in vitro biomechanical test results. The predicted load required to apply 5 mm cantilever varus bending was only 0.728% lower. The FE model was then used to conduct a parametric optimisation study to determine the orientations of inferomedial plate screws that would yield minimum fracture gap change (i.e. optimal stability). The feasible design space was automatically identified by imposing clinically relevant constraints, and the creation process of each FE model for the design optimisation was automated. Consequently, 538 FE models were generated, from which the obtained optimal model had 4.686% lower fracture gap change (0.156 mm) than that of the manufacturer's standard plate. Whereas its screws were oriented towards the inferomedial region and within the range of neck-shaft angle of a healthy subject. The methodology presented in this study promises future applications in patient-specific design optimisation of implants for other regions of the human body.

Comparison between minimally invasive plate osteosynthesis and open plating for proximal humeral fractures: a meta-analysis

AIM

We conducted this meta-analysis for comparing the efficacy and safety in proximal humeral fractures by treatment minimally invasive plate osteosynthesis and open plating.

METHODS

The potential academic literature were identified from the Cochrane Library, Springer, PubMed, Embase and ScienceDirect. Pooled data were analyzed by RevMan 5.1.

RESULTS

Seven studies marched with the inclusion criteria. Meta-analysis showed the significant differences in terms of blood loss, operative time, length of hospital stays and constant score between two groups. No significant differences were found in time to union, the union rate and complications.

CONCLUSION

Minimally invasive plate osteosynthesis in proximal humeral fractures provided significantly shorter operative times, length of hospital stays, less blood loss and better clinical outcomes without increasing complications.

Comparison of CFR-PEEK and conventional titanium locking plates for proximal humeral fractures: a retrospective controlled study of patient outcomes

BACKGROUND

Metal plates are the fixation devices used most frequently to proximal humeral fractures (PHFs). However, in recent years carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates have become increasingly common. This study compares the clinical and radiographic outcomes of 42 Neer three- and four-part PHFs treated with CFR-PEEK or metal (titanium) plates.

MATERIALS AND METHODS

Forty-two PHF patients were managed with CFR-PEEK plates (n = 21, males/females 9/12; mean age 57.4 years; mean follow-up 30.7 months; CFR-PEEK group) or metal plates (n = 21; males/females 7/14; mean age 55.8 years; mean follow-up 52.7 months; Metal group). Active shoulder mobility (anterior elevation, lateral elevation, external rotation, and internal rotation), the Constant-Murley Score, the Simple Shoulder Test Score, and the pain score were recorded. Preoperative computed tomography scans and X-rays were obtained. Postoperative fracture healing and displacement, tuberosity resorption and/or malposition, hardware position, and cortical thinning (CT) under the plate were assessed radiographically.

RESULTS

Shoulder mobility, clinical, and pain scores were similar in both patient groups. CT was significantly greater in CFR-PEEK patients (mean difference, 1.14 mm; p = 0.0003). In both groups, incomplete or poor calcar reduction was associated to a significantly higher complication rate, especially stiffness and muscle weakness (p = 0.016). The rate of tuberosity resorption was significantly higher in the Metal group (p = 0.040). Two patients required revision to a hemiarthroplasty (CFR-PEEK) and reverse arthroplasty (Metal group).

CONCLUSIONS

CFR-PEEK plates provide a viable alternative to conventional titanium plates in PHFs, ensuring similar clinical outcomes and a lower rate of tuberosity resorption, but they involve higher stress shielding under the plate.

The Augment of the Stability in Locking Compression Plate with Intramedullary Fibular Allograft for Proximal Humerus Fractures in Elderly People

Objective

The objective of this study was to compare the clinical outcomes and complications between the locking compression plate (LCP) and LCP with fibular allograft in the treatment of patients with displaced proximal humerus fracture (PHF) in elderly people.

Material and Methods

Between January 2010 and December 2013, a total of 97 elderly patients with displaced PHF were treated by LCP or LCP with fibular allograft, and finally 89 patients were included in our study. All the patients were divided into Group I (patients treated by LCP) and Group II (patients treated by LCP with fibular allograft). Function results were assessed by the disability of the arm, shoulder, and hand (DASH) score and Constant-Murley score (CMS), and complications were also recorded in each group.

Results

The average follow-up was 35.2 months (range, 24-48 months) in Group I and 33.5 months (range, 24-48 months) in Group II. DASH in patients of Group I was significantly higher than that in patients in Group II and patients of Group I had CMS scores significantly lower than patients in Group II (P<0.05). The rates of varus malunion, screw perforation, and loss of reduction>5mm were significantly higher in Group I than in Group II (P<0.05).

Conclusions

The present results showed that that patients treated by LCP with fibular allograft had a better functional outcome and a lower complication rate compared to patients treated by LCP alone. Suitable void filler in the proximal humerus for supporting the head fragment, medial cortical bone, and greater tuberosity might play a key role in reducing the incidence of the complications in elderly patients, especially with osteoporosis.

Biomechanical analysis of plate systems for proximal humerus fractures: a systematic literature review

BACKGROUND

Proximal humerus fractures are the third most common in the human body but their management remains controversial. Open reduction and internal fixation with plates is one of the leading modes of operative treatment for these fractures. The development of technologies and techniques for these plates, during the recent decades, promise a bright future for their clinical use. A comprehensive review of in vitro biomechanical studies is needed for the comparison of plates' mechanical performance and the testing methodologies. This will not only guide clinicians with plate selection but also with the design of future in vitro biomechanical studies. This review was aimed to systematically categorise and review the in vitro biomechanical studies of these plates based on their protocols and discuss their results. The technologies and techniques investigated in these studies were categorised and compared to reach a census where possible.

METHODS AND RESULTS

Web of Science and Scopus database search yielded 62 studies. Out of these, 51 performed axial loading, torsion, bending and/or combined bending and axial loading while 11 simulated complex glenohumeral movements by using tendons. Loading conditions and set-up, failure criteria and performance parameters, as well as results for each study, were reviewed. Only two studies tested four-part fracture model while the rest investigated two- and three-part fractures. In ten studies, synthetic humeri were tested instead of cadaveric ones. In addition to load-displacement data, three-dimensional motion analysis systems, digital image correlation and acoustic emission testing have been used for measurement.

CONCLUSIONS

Overall, PHILOS was the most tested plate and locking plates demonstrated better mechanical performance than non-locking ones. Conflicting results have been published for their comparison with non-locking blade plates and polyaxial locking screws. Augmentation with cement [calcium phosphate or poly(methyl methacrylate)] or allografts (fibular and femoral head) was found to improve bone-plate constructs' mechanical performance. Controversy still lies over the use of rigid and semi-rigid implants and the insertion of inferomedial screws for calcar region support. This review will guide the design of in vitro and in silico biomechanical tests and also supplement the study of clinical literature.

Calcar screw position in proximal humerus fracture fixation: Don't miss high!

INTRODUCTION

In locked plate fixation of proximal humerus fractures, the calcar is an important anchor point for screws providing much-needed medial column support. Most locking plate implants utilize a fixed-trajectory locking screw to achieve this goal. Consequently, adjustments of plate location to account for patient-specific anatomy may result in a screw position outside of the calcar. To date, little is known about the consequences of "missing" the calcar during plate positioning. This study sought to characterize the biomechanics associated with proximal and distal placement of locking plates in a two-part fracture model.

MATERIALS AND METHODS

This experiment was performed twice, first with elderly cadaveric specimens and again with osteoporotic sawbones. Two-part fractures were simulated and specimens were divided to represent proximal, neutral, and distal plate placements. Non-destructive torsional and axial compression tests were performed prior to an axial fatigue test and a ramp to failure. Torsional stiffness, axial stiffness, humeral head displacement and stiffness during fatigue testing, and ultimate load were compared between groups.

RESULTS

Cadavers: Proximal implant placement led to trends of decreased mechanical properties, but there were no significant differences found between groups. Sawbones: Distal placement increased torsional stiffness in both directions (p = 0.003, p = 0.034) and axial stiffness (p = 0.018) when compared to proximal placement. Distal placement also increased torsional stiffness in external rotation (p = 0.020), increased axial stiffness (p = 0.024), decreased humeral head displacement during fatigue testing, and increased stiffness during fatigue testing when compared to neutral placement.

DISCUSSION

The distal and neutral groups had similar mechanical properties in many cadaveric comparisons while the proximal group trended towards decreased construct stiffness.

RESULTS

from the Sawbones model were more definitive and provided further evidence that proximal calcar screw placements are undesirable and distal implant placement may provide improved construct stability.

CONCLUSION

Successful proximal humerus fracture reconstruction is inherent upon anatomic fracture reduction coupled with medial column support. Results from this experiment suggest that missing the calcar proximally is deleterious to fixation strength, while it is safe, and perhaps even desirable, to aim slightly distal to the intended target.

Hybrid blade and locking plate fixation for proximal humerus fractures: a comparative biomechanical analysis

BACKGROUND

Open reduction and internal fixation of proximal humerus fractures can be difficult to achieve adequate, complication free results due to osteopenia of the proximal humerus and unstable fracture patterns. This study aimed to compare the biomechanical properties of a novel hybrid fixed angle blade plate (Fx plate) with an established fixed angle locking plate (PHILOS plate).

METHODS

A two-part fracture was simulated in synthetic composite humeri by creating a transverse osteotomy and 10 mm fracture gap at the surgical neck. After treating the fractures with either an Fx plate or a PHILOS plate, humeral head was fixed and the shaft was displaced in a cantilever fashion. For elastic tests, loading was along the frontal and sagittal plane to achieve varus/valgus and extension/flexion, respectively. In plastic tests, loading was in a varus direction to determine the constructs' resistance to varus collapse.

RESULTS

In elastic tests, both construct types had higher peak load and stiffness in extension/flexion than varus/valgus. Fx plate constructs were significantly stiffer than PHILOS constructs in varus/valgus (mean: 7.590/6.900 vs. 6.609/6.091 N/mm; p < 0.001 for both) but significantly less stiff in extension/flexion (8.770/9.541 vs. 9.533/9.997 N/mm; p < 0.001 for extension, p < 0.05 for flexion). In varus plastic tests, significantly higher peak loads were reported for Fx plate than PHILOS (134.391 vs. 115.531 N; p < 0.001).

CONCLUSIONS

In this fracture gap model, humeri implanted with a novel Fx plate provided higher varus/valgus stiffness but lower extension/flexion stiffness than a more traditional proximal humeral locking plate design (PHILOS).

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.

Retrospective analysis of proximal humeral fracture-dislocations managed with locked plates

BACKGROUND

Fracture-dislocation is the extreme variant of injury to the proximal humerus that occurs more commonly in young adults as a result of high-velocity trauma. We evaluated the functional and radiologic outcome of fixation of proximal humeral fracture-dislocations with locked plates.

METHODS

This was a retrospective review of 33 proximal humeral fracture-dislocations in 29 patients with a mean age of 35 years (range, 19-60 years) treated by open reduction and internal fixation with locked plates between January 2009 and December 2013. The fracture-dislocation in 85% was the result of high-energy trauma resulting in 3- or 4-part fracture-dislocation. The fracture-dislocation was anterior in 27 and posterior in 6.

RESULTS

The average delay from injury to surgery was 7 days (range, 1-35 days), with a mean follow-up of 40 months (range, 24-66 months). All of the fractures united at an average of 15 weeks after surgery. At the final follow-up, the mean forward flexion was 129° (range, 100°-160°), and mean abduction was 128° (range, 100°-150°). The mean Constant score at the final follow-up was 78 points (range, 68-88 points). One case of complete osteonecrosis of the humeral head and 1 case of partial osteonecrosis of the humeral head were noted. Two cases of screw perforation of the humeral head were seen, with subsequent restricted range of motion improving after removal of the offending screws.

CONCLUSIONS

Most young patients with 3- and 4-part proximal humeral fracture-dislocations can achieve good functional outcome after fixation with locked plates.

The Deltoid Lift: A Comparison Study of Exposure Area in Proximal Humeral Approaches

BACKGROUND

Adequate exposure of the proximal humerus is necessary to address atypical or complex proximal humerus fractures and orthopedic tumors. Surgical management may be difficult through existing approaches due to their limited nature and the delicate neurovascular anatomy of the shoulder. The deltoid lift, a previously described extensile approach, can be incorporated into the surgeon's armamentarium as an alternative exposure to the proximal humerus. The objective of this study was to quantify and compare the humeral exposure achieved through the deltoid lift with the standard direct lateral deltoid-splitting, anterolateral acromial, and deltopectoral approaches in terms of surface area and exposure of key anatomic landmarks.

METHODS

Each approach was performed a minimum of 8 times on 18 cadaveric specimens. After identifying landmarks, exposure area of exposed humerus was quantified using digital images and ImageJ software.

RESULTS

The deltoid lift yielded an average exposure area of 46 cm². Comparison of the exposure area for the deltoid lift against each of the other approaches yielded statistical significance ( P < .01). The exposure provided was 2-folds greater than that of the next most extensive approach. All anatomic landmarks were directly visible through the deltoid lift as compared with the remaining approaches, through which only 1 landmark was directly visualized and only 2 of the 3 remaining were palpable through the approach.

CONCLUSIONS

The deltoid lift extensile surgical exposure to the proximal humerus provides the largest humeral exposure with the greatest visibility of landmarks relative to the 3 most widely utilized standard approaches.

Biomechanical evaluation of a novel dualplate fixation method for proximal humeral fractures without medial support

Background

Comminuted fractures of the proximal humerus are generally treated with the locking plate system, and clinical results are satisfactory. However, unstable support of the medial column results in varus malunion and screw perforation. We designed a novel medial anatomical locking plate (MLP) to directly support the medial column. Theoretically, the combined application of locking plate and MLP (LPMP) would directly provide strong dual-column stability. We hypothesized that the LPMP could provide greater construct stability than the locking plate alone (LP), locking plate combined with a fibular graft (LPSG), and locking plate combined with a distal radius plate (LPDP).

Methods

LP, LPMP, LPSG, and LPDP implants were instrumented into the finite element model of a proximal humeral fracture. Axial, shear, and rotational loads were applied to the models under normal and osteoporotic bone conditions. The whole simulation was repeated five times for each fixator. To assess the biomechanical characteristics, the construct stiffness, fracture micromotion, stress distribution, and neck-shaft angle (NSA) were compared.

Results

The LPMP group showed significantly greater integral and regional construct stiffness, and endured less von Mises stresses, than the other three fixation methods. The stresses on the lateral locking plate were dispersed by the MLP. The LPMP group showed the least change in NSA.

Conclusions

From the finite element viewpoint, the LPMP method provided both lateral and medial direct support. The LPMP system was effective in treating proximal humeral fracture with an unstable medial column.

The results of tension band rotator cuff suture fixation of locked plating of displaced proximal humerus fractures

INTRODUCTION

The purpose of this study was to assess 1-year outcomes of patients with displaced proximal humerus fractures who underwent treatment with locked plate fixation with rotator cuff suture augmentation.

METHODS

A total of 86 patients who had sustained 2, 3 and 4-part displaced proximal humerus fractures underwent locked plate fixation with multiple sutures placed in the cuff tendons. Clinical outcome variables included active forward elevation (AFE), active external rotation (AER), and Constant and American Shoulder and Elbow Surgeons (ASES) scores. Post-operative variables included the following complications: varus re-collapse, loss of fixation, osteonecrosis of the humeral head (AVN), screw cut out, hardware failure and infection.

RESULTS

Forty-one patients were available with minimum of 1-year follow-up. Mean AFE was 142±17.0° and AER was 41±13.0°. The overall complication rate was 14.6%, with osteonecrosis being the most common (12.2%). Of the 21 patients (51.2%) that initially had varus displacement, all but one maintained anatomic reduction and fixation. Mean ASES score was 78.2±20.0 and average Constant score was 72.7±17.6. Bivariate analyses demonstrated that pre-operative medial comminution (p=0.297) or varus collapse (p=0.95) were not associated with an increased likelihood of sustaining a complication.

CONCLUSIONS

Follow-up of patients in this series demonstrated a low overall complication rate and excellent functional outcomes. We believe suture augmentation of the rotator cuff can counteract varus forces on proximal humerus fractures fixed with locked plates, and should be performed routinely in displaced 2, 3 and 4 part fractures.

[Augmentation technique on the proximal humerus]

BACKGROUND AND OBJECTIVES

The treatment of osteoporotic fractures is still a challenge. The advantages of augmentation with respect to primary in vitro stability and the clinical use for the proximal humerus are presented in this article.

MATERIAL AND METHODS

In this study six paired human humeri were randomized into an augmented and a non-augmented group. Osteosynthesis was performed with a PHILOS plate (Synthes®). In the augmented group the two screws finding purchase in the weakest cancellous bone were augmented. The specimens were tested in a 3-part fracture model in a varus bending test.

RESULTS

The augmented PHILOS plates withstood significantly more load cycles until failure. The correlation to bone mineral density (BMD) showed that augmentation could partially compensate for low BMD.

CONCLUSION

The augmentation of the screws in locked plating in a proximal humerus fracture model is effective in improving the primary stability in a cyclic varus bending test. The targeted augmentation of two particular screws in a region of low bone quality within the humeral head was almost as effective as four screws with twice the amount of bone cement. Screw augmentation combined with a knowledge of the local bone quality could be more effective in enhancing the primary stability of a proximal humerus locking plate because the effect of augmentation can be exploited more effectively limiting it to the degree required. The technique of augmentation is simple and can be applied in open and minimally invasive procedures. When the correct procedure is used, complications (cement leakage into the joint) can be avoided.

Influence of Early Bisphosphonate Administration for Fracture Healing in Patients with Osteoporotic Proximal Humerus Fractures

BACKGROUND

Bisphosphonates are generally known to adversely affect fracture healing because they inhibit osteoclastic bone resorption. However, some authors argue that bisphosphonates have no adverse effect on the restoration of the mechanical integrity of long bones after fractures. It is unclear whether bisphosphonates can be initiated safely in patients with acute proximal humerus fractures. The aim of this study was to determine whether the early use of a bisphosphonate affects healing and outcomes of osteoporotic proximal humerus fractures treated with a locking compression plate.

METHODS

Between August 2004 and June 2013, a total of 82 osteoporotic patients who underwent locking plate fixation of proximal humerus fractures were enrolled retrospectively. The patients were divided into two groups according to the timing of the commencement of treatment with alendronate after surgery: group A (n = 34, initiation of the bisphosphonate treatment within two weeks after surgery) and group B (n = 48, control group, initiation of the treatment three months after surgery). Patients were assessed for radiographic union at 2, 6, 10, and 16 weeks, 6 months, and 1 year after surgery. Clinical assessments were performed using the Constant score and American Shoulder and Elbow Surgeons (ASES) score at 1 year after surgery.

RESULTS

No significant differences were observed between the two groups with respect to radiographic and clinical outcomes after locking plate fixation. All patients obtained fracture union, and the mean time to radiographic union was similar in group A and group B (6.3 and 6.6 weeks, respectively; p = 0.67).

CONCLUSIONS

This study shows that the early initiation of bisphosphonate treatment does not affect bone union or clinical outcomes in patients with an osteoporotic proximal humerus fracture treated by locking compression plate fixation.

Operative treatment of 2-part surgical neck fractures of the proximal humerus (AO 11-A3) in the elderly: Cement augmented locking plate Philos™ vs. proximal humerus nail MultiLoc®

Background

Proximal humeral fractures are with an incidence of 4–5 % the third most common fractures in the elderly. In 20 % of humeral fractures there is an indication for surgical treatment according to the modified Neer-Criteria. A secondary varus dislocation of the head fragment and cutting-out are the most common complications of angle stable locking plates in AO11-A3 fractures of the elderly. One possibility to increase the stability of the screw-bone-interface is the cement augmentation of the screw tips. A second is the use of a multiplanar angle stablentramedullary nail that might provide better biomechanical properties after fixation of 2-part-fractures. A comparison of these two treatment options augmented locking plate versus multiplanar angle stable locking nail in 2-part surgical neck fractures of the proximal humerus has not been carried out up to now.

Methods/Design

Forty patients (female/male, ≥60 years or female postmenopausal) with a 2-part-fracture of the proximal humerus (AO type 11-A3) will be randomized to either to augmented plate fixation group (PhilosAugment) or to multiplanar intramedullary nail group (MultiLoc). Outcome parameters are Disabilities of the Shoulder, Arm and Hand-Score (DASH) Constant Score (CS), American Shoulder and Elbow Score (ASES), Oxford Shoulder Score (OSS), Range of motion (ROM) and Short Form 36 (SF-36) after 3 weeks, 6 weeks, 3 months, 6 months, 12 and 24 months.

Discussion

Because of the lack of clinical studies that compare cement augmented locking plates with multiplanar humeral nail systems after 2-part surgical neck fractures of the proximal humerus, the decision of surgical method currently depends only on surgeons preference. Because only a randomized clinical trial (RCT) can sufficiently answer the question if one treatment option provides advantages compared to the other method we are planning to perform a RCT.

Trial registration

Clinical Trial (NCT02609906), November 18, 2015, registered retrospectively.

Long endomedullary nail in proximal third humeral shaft fractures

INTRODUCTION

Proximal humeral fractures with a spiral line of fracture extending from the humeral head to the diaphyseal region are increasing. Treatment for these fractures is comparable to that for shaft fractures. The purpose of this study was to evaluate the use of a new "Long" humeral nail for this type of lesion and identify the best distal locking.

MATERIALS AND METHODS

Forty-three patients treated with a Long Diphos Nail^® were selected for this study: main exclusion criteria were poor cognitive and responsive ability to physical therapy, four-part fracture requiring humeral head replacement, an isolated greater or lesser tubercle fracture and a head-splitting fracture. All patients were divided into two groups according to the distal locking (single or double) and clinically evaluated at 1, 3, 6 and 12 months after surgery. The following parameters were evaluated: fracture healing on radiographic images every month; level of pain with Visual Analogue Scale (VAS); recovery of shoulder function or ability to resume normal daily activities according to the Constant Scoring System (CSS); patient satisfaction; and complications, like fracture consolidation defect or delay. A statistical analysis was performed.

RESULTS

Improvements in pain, satisfaction and shoulder functional recovery were recorded. Patients reached fracture healing in two to six months. The mean healing time was better for double distal locking (p=0.04).There was a clinically greater difference (p=0.006) between the groups for the mean Constant score at 3 months follow-up, with better results for the double distal locking group. Complications were: one patient with a consolidation delay with a single distal locking screw breakage; it was necessary to remove the nail and perform a second treatment.

CONCLUSIONS

The results of the study indicate the efficacy of Long Diphos Nail^® in the treatment of fractures with a line of fracture extending to the proximal diaphyseal region. The features of a multiplane stabilisation above the fracture and a distal double locking may represent the key for a good fixation for 11-A2, A3 or B2 fractures with a long spiral line. A double distal locking reduces fracture micro-instability and so patients recover function and strength quicker because of less pain at the fracture site.

STUDY DESIGN

retrospective, cohort of cases.

LEVEL OF EVIDENCE

IV.

Outcome Analysis of Locking Plate Fixation in Proximal Humerus Fracture

INTRODUCTION

Proximal humerus fractures account for approximately 5% of all fractures. Stable minimally displaced fractures can be treated nonoperatively but the management of displaced fractures remain controversial with various modalities of treatment available. Locking plates provide stable fixation and enable early postoperative mobilization specially in osteoporotic proximal humerus fracture.

AIM

To evaluate the functional outcome of locking plate fixation and to compare the results of two approaches used for fixation.

MATERIALS AND METHODS

This prospective study was conducted at a tertiary level hospital between September 2011 to December 2013. PHILOS plates were used for internal fixation of displaced proximal humerus fractures Neer's type 2 part, 3 part and 4 part fractures on 26 patients (M/F ratio 1.36:1; mean age 46 years). According to Neer classification, 5,12 and 9 patients had displaced 2, 3 and 4 part fractures respectively. Deltopectoral and deltoid splitting approaches were used for fixation on 13 patients each. Functional outcome was assessed using Constant-Murley shoulder score. Graphpad software version 6.0 was used with Chi-square test and Fisher-exact test are used to compare data. The p-value< 0.05 is considered significant.

RESULTS

Of the 26 patients, all fractures united radiologically and clinically and average constant score at final follow-up was 72.5. At the final follow-up 8 patients had good score, 10 patients had moderate score, 6 patients had excellent outcome and 2 patients had poor outcome according to Constant score. Mean time to union was 12.3 weeks (9 -15 weeks). Four complications (15.4%) were encountered, 2 cases of varus malunion, 1 case of wound infection which required wound debridement and 1 case of screw cut-out in which screw removal was done. Mean constant score in delto splitting approach was 70.9 and 74 in deltopectoral group (p-value= 0.54). No significant difference existed in constant score in 2 approaches. No significant difference existed between groups in terms of complications (P > .05) and all fractures were united.

CONCLUSION

Our study demonstrates that locking plate fixation gives good functional outcomes in treatment of proximal humerus fractures. There was no significant difference in the two approaches used for exposure. Our results are comparable to various studies conducted by other authors which states that locking plates provide better functional and radiological outcomes as compared to other fixation methods like Tension band wiring, percutaneous K-wire fixation, non-locking plates, intramedullary nails.

Minimal Invasive Percutaneous Osteosynthesis for Elderly Valgus Impacted Proximal Humeral Fractures with the PHILOS

There is a growing concern about elderly valgus impacted proximal humeral fractures. The aim of this study was to evaluate the treatment and clinical outcomes following minimal invasive percutaneous plate osteosynthesis (MIPPO) with the proximal humeral internal locking system (PHILOS) for the treatment of elderly valgus impacted proximal humeral fracture. Between May 2008 and May 2012, 27 patients (average age 67.3, range 61–74) with valgus impacted proximal humeral fractures were enrolled in the study. The patients were treated with MIPPO using PHILOS-plate through the anterolateral delta-splitting approach. Rehabilitation exercises were done gradually. The NEER score and Constant-Murley score were used to evaluate shoulder function. All the patients were followed up by routine radiological imaging and clinical examination. There were 15 cases of II-part greater tuberosity fractures, 10 cases of III-part greater tuberosity fractures, and 2 cases of IV-part fractures according to the NEER classification. The surgery was successful in all patients with an average follow-up of 20.8 (range: 11–34) months. The fractures united in an average of 7.2 (6–14) weeks without implant loosening. According to NEER score, there were 17 excellent, 7 satisfactory, 2 unsatisfactory, and 1 poor. The mean Constant-Murley score was 89.4 ± 4.35. No complication including axillary nerve damage, postoperative nerve or vessel damage, infections, DVT, or death was observed. In conclusion, the MIPPO technique with the PHILOS through the anterolateral delta-splitting approach seems to be a safe and easy treatment for elderly valgus impacted proximal humeral fractures. A case-control study and longer follow-up time are needed.

The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial - a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults

BACKGROUND

Proximal humeral fractures account for 5-6% of all fractures in adults. There is considerable variation in whether or not surgery is used in the management of displaced fractures involving the surgical neck.

OBJECTIVE

To evaluate the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment of the majority of displaced fractures of the proximal humerus involving the surgical neck in adults.

DESIGN

A pragmatic parallel-group multicentre randomised controlled trial with an economic evaluation. Follow-up was for 2 years.

SETTING

Recruitment was undertaken in the orthopaedic departments of 33 acute NHS hospitals in the UK. Patient care pathways included outpatient and community-based rehabilitation.

PARTICIPANTS

Adults (aged ≥ 16 years) presenting within 3 weeks of their injury with a displaced fracture of the proximal humerus involving the surgical neck.

INTERVENTIONS

The choice of surgical intervention was left to the treating surgeons, who used techniques with which they were experienced. Non-surgical treatment was initial sling immobilisation followed by active rehabilitation. Provision of rehabilitation was comparable in both groups.

MAIN OUTCOME MEASURES

The primary outcome was the Oxford Shoulder Score (OSS) assessed at 6, 12 and 24 months. Secondary outcomes were the 12-item Short Form health survey, surgical and other shoulder fracture-related complications, secondary surgery to the shoulder or increased/new shoulder-related therapy, medical complications during inpatient stay and mortality. European Quality of Life-5 Dimensions data and treatment costs were also collected.

RESULTS

The mean age of the 250 trial participants was 66 years and 192 (77%) were female. Independent assessment using the Neer classification identified 18 one-part fractures, 128 two-part fractures and 104 three- or four-part fractures. OSS data were available for 215 participants at 2 years. We found no statistically or clinically significant differences in OSS scores between the two treatment groups (scale 0-48, with a higher score indicating a better outcome) over the 2-year period [difference of 0.75 points in favour of the surgery group, 95% confidence interval (CI) -1.33 to 2.84; p = 0.479; data from 114 surgery and 117 non-surgery participants] or at individual time points. We found no statistically significant differences between surgical and non-surgical group participants in SF-12 physical or mental component summary scores; surgical or shoulder fracture-related complications (30 vs. 23 respectively); those undergoing further shoulder-related therapy, either surgery (11 vs. 11 respectively) or other therapy (seven vs. four respectively); or mortality (nine vs. five respectively). The base-case economic analysis showed that, at 2 years, the cost of surgical intervention was, on average, £1780.73 more per patient (95% CI £1152.71 to £2408.75) than the cost of non-surgical intervention. It was also slightly less beneficial in terms of utilities, although this difference was not statistically significant. The net monetary benefit associated with surgery is negative. There was only a 5% probability of surgery achieving the criterion of costing < £20,000 to gain a quality-adjusted life-year, which was confirmed by extensive sensitivity analyses.

CONCLUSIONS

Current surgical practice does not result in a better outcome for most patients with displaced fractures of the proximal humerus involving the surgical neck and is not cost-effective in the UK setting. Two areas for future work are the setting up of a national database of these fractures, including the collection of patient-reported outcomes, and research on the best ways of informing patients with these and other upper limb fractures about initial self-care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN50850043.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 24. See the NIHR Journals Library website for further project information.

Clinic research on the treatment for humeral shaft fracture with minimal invasive plate osteosynthesis: a retrospective study of 128 cases

INTRODUCTION

Minimal invasive plate osteosynthesis (MIPO) is one of the most important techniques in the treatment for humeral shaft fractures. This study was performed to evaluate the efficacy of MIPO technique for the treatment for humeral shaft fractures.

MATERIALS AND METHODS

We retrospectively evaluated 128 cases with humeral shaft fractures that were treated with MIPO technique from March 2005 to August 2008. All the patients were followed up by routine radiological imaging and clinical examinations. Constant-Murley score and HSS elbow joint score were used to evaluate the treatment outcome.

RESULTS

The average duration of the surgery was 60 min (range 40-95 min) without blood transfusion. All fractures healed without infection. All cases recovered carrying angle except four cases with 10°-15° cubitus varus. After the average follow-up of 23 (13-38) months, satisfactory function was achieved according to Constant-Murley score and HSS elbow joint score. Constant-Murley score was 80 on average (range 68-91). According to HSS elbow joint score, there were 123 cases of excellent clinical outcome and five cases of effective outcome.

CONCLUSION

It seems to be a safe and effective method for managing humeral shaft fractures with MIPO technique.

Application of Additional Medial Plate in Treatment of Proximal Humeral Fractures With Unstable Medial Column: A Finite Element Study and Clinical Practice

The purpose of this study was to use finite element analysis to compare the biomechanical characteristics after lateral locking plate (LLP) or LLP with a medial anatomical locking plate (LLP-MLP) fixation of proximal humeral fractures with an unstable medial column.First, a 3-dimensional, finite element analysis model was developed. Next, LLP and LLP-MLP implants were instrumented into the proximal humeral fracture models. Compressive and rotational loads were then applied to the humerus model to determine the biomechanical characteristics. Both normal and osteoporotic proximal humerus fractures were simulated using 2 internal fixation methods each under 7 loading conditions. To assess the biomechanical characteristics, the construct stiffness, fracture micromotion, and stress distribution on the implants were recorded and compared.The LLP-MLP method provided both lateral and medial support that reduced the stress on the LLP and the amount of displacement in the fracture region. In contrast, the LLP method resulted in more instability in the medial column and larger magnitudes of stress. In osteoporotic bone, the LLP was more inclined to fail than LLP-MLP.The LLP-MLP method provides a strong support for the medial column and increases the stability of the region surrounding the fracture.

EPIDEMIOLOGICAL PROFILE OF PATIENTS WITH PROXIMAL HUMERUS FRACTURE TREATED AT HOSPITAL SÃO PAULO, BRAZIL

Objective: To analyze the epidemiological aspects of proximal humerus fractures and describe the profile of patients with proximal humerus fractures hospitalized and treated at Hospital São Paulo, between 2008 and 2013. Methods: Hospital records were retrospectively analyzed for surgically treated patients diagnosed with proximal humerus fracture. Age, gender, injury mechanism, length of hospital stay, performed treatment and associated diseases were considered. Results: From all patients studied, 52 were female at their sixth decade of life. As for the injury mechanism, fall from height was the main cause for women (88.46%) and for man it was motorcycle accidents (31.42%). Fixation with locked plate was the most frequently used treatment. Conclusion: Most patients were female in their fifth decade of life, injured mainly by fall from height. Fixation with locked plate was the most frequently used treatment and the patients were admitted for 7 days, on average. Level of Evidence II, Retrospective Study.

The Deltoid Lift: A Cadaveric Analysis and the Literature Review of a Novel Surgical Approach to the Proximal Humerus

Obtaining adequate exposure of the proximal humerus for anatomic reduction of complex intra-articular fractures or in the surgical treatment of tumor may be difficult. Here we describe a novel approach to the proximal humerus: the deltoid lift, and perform a cadaveric analysis objectively quantifying the exposure. The deltoid lift offers significantly greater exposure to the proximal humerus as compared with the deltopectoral approach.

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.

Long contoured locking plate fixation of traumatic proximal humeral fractures with distal extension

BACKGROUND

There is a paucity of data available with respect to outcome on long contoured locking plate fixation for proximal humerus fractures with distal fracture extension.

METHODS

Thirty-four patients with traumatic proximal humerus fractures with distal extension underwent fixation with long contoured locking plates. Twenty-five patients (74%) were included in the study: one patient died, two patients had unrelated illnesses resulting in them being unable to complete follow-up assessment and six were lost to follow-up. Patients' case notes and radiographs were retrospectively reviewed, and patients were contacted to assess functional outcome using the Visual Analogue Scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) score, Oxford Shoulder Score (OSS) and Stanmore Percentage of Normal Shoulder Assessment (SPONSA).

RESULTS

Mean follow-up was 27 months (range 11 months to 60 months). Mean pain at final follow-up was 3.6 [95% confidence interval (CI) = 2.5 to 4.8] with only four patients having residual pain greater than 5 on the VAS scale. Mean DASH score was 41.2 (95% CI = 32.0 to 50.4), mean OSS was 29.1 (95% CI = 24.3 to 33.9) and mean SPONSA was 63.9% (95% CI = 50.8 to 77.2). There was one wound infection. Three patients had non-unions that required bone grafting and revision internal fixation.

CONCLUSIONS

We feel long contoured locking plates represent a useful treatment option for complex proximal humerus fractures.